Within nursing, the patient's perception is recognized as the patient's reality. How does this way of knowing in nursing fit within an objective or subjective paradigm of the world? Explain your reasoning. 1 page, 2 sources.
see attached artcticles, if you prefer to use them.
ONCOLOGY NURSING FORUM • VOL. 43, NO. 2, MARCH 2016 245
Marie Flannery, PhD, RN, AOCN®
Explicit Assumptions About Knowing
Conceptual Foundations is a new column for Oncology Nursing Forum (ONF) that focuses on the frameworks that underpin research and practice initiatives. The purpose of this inaugural column is to provide an overview of what conceptual frameworks are, related terms, the role of conceptual frameworks in the research process, and why these frameworks matter. The majority of articles published in ONF are research manuscripts. Readers include student nurses, practicing oncology nurses, nurse managers, advanced practice on- cology nurses, nurse scientists, and people in other disciplines who are interested in patients with cancer. In the guidelines for ONF articles, peer reviewers are asked to address the conceptual model/ theory (if needed) that is included in the manuscript. For all who read, apply, and create knowledge, un- derstanding the conceptual frame- work underlying a research study is an essential skill to master. The conceptual framework may be ex- plicitly identified by the author or may be implicit. If not specifically stated, the reader must detect the underlying assumptions that form a conceptual foundation.
Definitions and Related Terms
What is a conceptual framework? Concept is defined as “an abstract or generic idea generalized from
Marie Flannery, PhD, RN, AOCN®, Associate Editor CONCEPTUAL FOUNDATIONS
Flannery is a research assistant professor in the School of Nursing at the University of Rochester Medical Center in New York.
No financial relationships to disclose.
Key words: concept; theory; framework; model; oncology
ONF, 43(2), 245–247.
particular instances” (“Concept,” n.d., para. 1). Framework is de- fined as “the basic structure of something: a set of ideas or facts that provide support for some- thing” or “a supporting structure” (“Framework,” n.d., para. 1). Taken together, a conceptual framework consists of specified abstract ideas that are joined in an identified structure. Conceptual frameworks identify what is important in un- derstanding a phenomenon and provide guidance for relationships. No universally accepted definition exists for conceptual framework, and the term is sometimes used interchangeably with conceptual model, theoretical framework, and theory (Powers & Knapp, 2011).
Many terms are related to con- ceptual frameworks (see Table 1). Epistemology is a branch of philosophy that studies “how we know” and the justification of knowledge claims. Varying epis- temologic philosophic traditions have emphasized different aspects and views of knowledge, certainty, and truth, and have provided dif- fering interpretations of theory and concepts. Empirical philosophic traditions influence much of the current research and emphasize the systematic observation of real- ity through sensory observation (Powers & Knapp, 2011). Worldview refers to a general orientation or set of beliefs about how the world operates. Paradigm, a term coined by philosopher Thomas Kuhn,
246 VOL. 43, NO. 2, MARCH 2016 • ONCOLOGY NURSING FORUM
also refers to a system of beliefs about knowledge, often specific to a discipline. Theory is a term with many definitions; in the research realm, a scientific theory includes a set of statements or principles that explain phenomena. A theory is one type of a conceptual frame- work that always will include at least two concepts and at least one relational statement. Of note, not all conceptual frameworks will qualify as a theory. A model refers to a graphic representation; it may be a two-dimensional diagram or a three-dimensional mock-up. A con- ceptual model is a diagram or draw- ing of the conceptual framework.
A conceptual framework may be reflected in the worldview, ma- jor paradigm, or general orienting framework of the author. A con- ceptual model may be referenced or drawn in the article. A theory
may be referenced and explained. A conceptual framework may not be explicitly stated but may be discern- ible to the reader by the author’s stated and unstated assumptions. Specifically, the reader may be able to discern the framework used by what is studied, how it is studied, and what is measured. What is not included in the study also may be an indication of the implied framework. A concept that may seem vital to a clinician or researcher but was not included in the study may reflect its relative lack of prominence in the author’s conceptual framework.
Conceptual Frameworks and the Research Process
In the guidelines for manuscripts submitted to ONF, reviewers are asked to critique the use of con- ceptual frameworks in two specific
components of the manuscript. The literature review and discussion section guidelines specifically ask reviewers to consider the concep- tual framework or theory (if need- ed) that is used in the manuscript.
However, the integration of a con- ceptual framework actually threads and weaves through all compo- nents of the research process. The orienting framework or worldview provides a specific lens as to how an area of study is seen and how a clinical problem is identified. The choice of a theory or conceptual framework provides structure for the content that is included in the background and literature review. The framework or theory may be specifically discussed and a figure of the conceptual model included. The conceptual framework influ- ences the choice of method, set- ting, sample, instruments, proce- dures, and analysis strategies. The reviewer (and reader) often looks for a sense of coherence, logical consistency, and logical flow in a research study. The integration of a conceptual framework through all phases of the research process can provide a sense of coherence. For example, if the conceptual frame- work specifies that both patient and caregiver experiences are criti- cal to understanding the clinical issue, one might choose to conduct a descriptive longitudinal study conducted in the home setting; include patients and caregivers in the sample; include open-ended in- terviews, in addition to structured questionnaires, as measurement modalities; and include dyadic eval- uation techniques in the analysis.
The discussion section may in- clude comments on whether the conceptual framework worked or was helpful in the study, if the framework was supported or incon- sistent with study findings, or what revisions to the framework may be needed. Similarly, any practice implications and knowledge trans- lation may be influenced by the
TABLE 1. Terminology and Definitions for Conceptual Frameworks and Related Terms
Concept Abstract idea; building blocks of theory
A conceptual framework consists of specified abstract ideas that are joined together in an identified structure. Conceptual frame- works identify what is important in understanding a phenomenon and how the important ideas fit together and are related to one another.
Empirical Originating in or based on observation or experience
Epistemology A philosophy of knowledge that includes an understanding of “how we know” and a justification of knowledge claims
Model Graphic or symbolic representation of a phenomenon
Paradigm Patterns or systems of beliefs about science and knowledge pro- duction that may be discipline-specific
Theory A set of statements or principles devised to explain a group of facts or phenomena, particularly one that has been repeatedly tested or is widely accepted and can be used to make predictions about natural phenomena; a set of interrelated concepts that guide thinking; an idea or set of ideas that is intended to explain facts or events, the general principles or ideas that relate to a particular subject
Worldview “A global pattern of beliefs that constitute a school of thought and its attendant knowledge claims” (Powers & Knapp, 2011, p. 203)
Note. Based on information from “Concept,” n.d.; “Framework,” n.d.; Powers & Knapp, 2011.
ONCOLOGY NURSING FORUM • VOL. 43, NO. 2, MARCH 2016 247
guiding paradigm of the conceptual framework. Reviewers and readers want the description of the con- ceptual framework to be clear and understandable. The framework or theory generally feels to be the best fit and most meaningful when it is integrated throughout the study and manuscript and does not come across as a framework that was “tacked on” as an afterthought.
Conceptual frameworks are as- sociated with a wide range of re- search designs. In the case of an intervention study, the conceptual framework or theory establishes the required components for the intervention and proposes how they will work. In a study model- ing relationships or explaining an outcome, the conceptual frame- work determines what factors will be examined and the nature or valence of the relationship. In a descriptive study, a conceptual model provides guidance on what characteristics are necessary to include in the description. When a theory is presented or hypotheses are proposed, the statement of the important concepts and their struc- tural relationships is very clear.
When a Conceptual Framework Is Not Stated
Sometimes, perhaps often, an author does not explicitly identify his or her conceptual framework. However, clues often exist as to the underlying assumptions the author holds about the topic under study. In the introduction and background, the author provides information on what factors are important. These
factors often translate into the con- cepts that may reflect the operating framework for the author. This may be evident from past research that is cited and how the clinical issue is described. The instruments used in the research also provide informa- tion on the conceptual framework. For example, if the concept of self- efficacy is measured in a study, one can infer that self-efficacy is an important part of the unstated conceptual framework for under- standing the phenomenon being examined. Without an explicit state- ment of the conceptual framework, the reader or reviewer only can at- tempt to identify what concepts the author thought were important and what the assumed relationships were. Each person has assump- tions about what is important, how things may be related, and what counts as evidence. The use of a conceptual model makes these un- derlying assumptions explicit.
Conceptual frameworks are im- portant because they underlie ev- ery study and article. Frequent- ly used analogies for conceptual frameworks are that they are maps or blueprints. The blueprint tells the overall structure of relation- ships (framework) and the materi- als (concepts) that will be used in the design. Attention to conceptual frameworks is essential to building science. In addition to the facts and information about the focus of a study, knowledge about the success or failure of a conceptual framework or theory can provide
Authorship Opportunity Conceptual Foundations pro- vides readers with an overview of the role of conceptual frame- works in the research process. Materials or inquiries should be directed to Associate Editor Ma- rie Flannery, PhD, RN, AOCN®, at [email protected] ester.edu.
understanding for other situations and future research. Insight into the underlying mechanism of why or how something works (or did not) is examined in light of the proposed relationships of the framework or theory. For example, a conceptual framework for symptom manage- ment can be used for many differ- ent symptoms. As the conceptual framework is developed and refined, insight is gained into what needs to be included in effective symptom management interventions. The use of a conceptual framework or theory can advance understanding of multiple clinical problems.
Future columns wil l review specific theories and conceptual frameworks as they apply to oncol- ogy nursing and clinical problems for individuals with cancer.
Concept. (n.d.). In Merriam-Webster.com. Re- trieved from http://www.merriam-webster .com/dictionary/concept
Framework. (n.d.). In Merriam-Webster.com. Retrieved from http://www.merriam -webster.com/dictionary/framework
Powers, B.A., & Knapp, T.R. (2011). Diction- ary of nursing theory and research (4th ed.). New York, NY: Springer.
Copyright of Oncology Nursing Forum is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Advances in Nursing Science Vol. 41, No. 3, pp. 293–302 Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.
The Nursing Knowledge Pyramid A Theory of the Structure of Nursing Knowledge
Veronica B. Decker, DNP, PMHCNS-BC, MBA; Roger M. Hamilton, PhD
A theory of the structure of nursing knowledge is proposed. Using retroductive reasoning to build upon an existing theory, the goal of the Nursing Knowledge Pyramid is to integrate disparate forms of nursing knowledge into a comprehensive, coherent, and useful structure to enhance the learning, development, automation, and accessibility of nursing knowledge. Education uses are discussed. Key words: machine knowledge, nursing knowledge, tacit knowledge, theory
N URSES must have the required knowl-edge, skills, and attitudes necessary to take actions that will achieve optimal patient outcomes. When it comes to the knowledge part of a nurse’s job, an important question is how the nursing knowledge base should be structured so that it is most useful to nurses in practice. Knowledge structures are impor- tant for nursing practice because they shape nursing behavior.1
However, nursing knowledge, like knowl- edge in other disciplines, is not a single depos- itory of well-ordered knowledge,2 and long ago Donaldson and Crowley3 encouraged nurse authors to seek a means of explicating the nursing discipline’s body of knowledge. More than 30 years later, the problem was still challenging, as Kim1 concluded that having a unifying framework for epistemo-
Author Affiliations: University of Central Florida College of Nursing, Orlando (Dr Decker); and Consultant, Mt Dora, Florida (Dr Hamilton).
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publi- cation of this editorial.
Correspondence: Veronica B. Decker, DNP, PMHCNS- BC, MBA, University of Central Florida College of Nurs- ing, 12201 Research Pkwy, Ste 300, Orlando, FL 32826 ([email protected]).
logical discussions about nursing knowledge was critical. Addressing this need, in this article, we present an overview of a unifying theory of the structure of nursing knowledge, the Nursing Knowledge Pyramid (NKP) (Figure 1).
Science uses 3 kinds of reasoning: de- duction, induction, and retroduction.4 Sim- ply stated, deduction is top-down, general-to- specific reasoning; induction is bottom-up, specific-to-general reasoning; and retroduc- tion is the improvement of existing theories.1
In the NKP, moving from bottom to top is de- ductive whereas moving from top to bottom is inductive. Retroductive reasoning improves existing theory wherever it is appropriate and is best illustrated in Figure 2.
As shown in Figure 2 (left), the current highest-level organizing structure of nursing knowledge may be the Structural Holarchy of Contemporary Nursing Knowledge (hereafter “holarchy”).5(p4) Fawcett called the holarchy a theory of the structure of nursing knowledge. It consists of a metaparadigm, philosophies, conceptual models, theories, and empirical in- dicators in a holarchy organized by decreasing levels of abstraction. Using retroductive rea- soning, we build upon this theory to create an alternative theory—the NKP (Figure 2, right). We do so because we hypothesize that the NKP structure better supports the learning, development, automation, and accessibility
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294 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2018
Statements of Significance
What is known to be true or assumed to be true about this topic:
• Nursing knowledge structures shape nursing practice.
• The highest-level organizing structure for nursing knowledge may be the Structural Holarchy of Contemporary Nursing Knowledge, a theory consisting of a metaparadigm, philosophies, conceptual models, theories, and empirical indicators arranged in a holarchy organized by decreasing levels of abstraction
What this article adds: • Using retroductive reasoning, the
proposed NKP builds upon the Structural Holarchy of Contemporary Nursing Knowledge to provide an alternative theory of the structure of nursing knowledge
• The NKP theory may better support the learning, development, automation, and accessibility of nursing knowledge and therefore may better support nursing practice.
• As one exemplar, nurse educators and nursing students should consider using the NKP as a powerful cognitive tool for organizing the teaching and learning of nursing knowledge.
of nursing knowledge and therefore will be more useful to nurses.
For example, we propose that all nurs- ing knowledge can be categorized using the NKP. That is, every component of nursing knowledge should be locatable in the NKP, regardless of the knowledge source. Whether a piece of knowledge is an entry into a database table, a blood pressure reading, a theory, or a nurse’s intuition, if the NKP
is truly exhaustive, the knowledge should map to some component(s) of the pyramid. Once the piece of knowledge is located on the pyramid, whether it is a new idea or an old one, the nurse then seeks to fill out each block of the pyramid to create a deep, ratio- nal, coherent, well-developed idea. This pro- cess leads to the learning of existing knowl- edge, the development of new knowledge, and the automation of all but intuitive knowl- edge. The details are provided later, however, think of the NKP as the building blocks of knowledge, from the most abstract to the most concrete.
To determine how to organize our discus- sion, we first need to decide which available theory template, which we call a meta-theory in this article, is appropriate. To leverage the integrity of the holarchy as much as possi- ble, we adapted the Fawcett and DeSanto- Madeya analysis and evaluation nursing theory organizing framework as our meta-theory, as shown in the Table.5 Therefore, the NKP the- ory analysis overview (part 3) is analyzed ac- cording to its definition, scope, content, and context. External critics can then evaluate the theory according to the evaluation structure of the Table meta-theory (part 4).
Definition of a theory
A theory is “the creative and rigorous structuring of ideas that projects a tenta- tive, purposeful, and systematic view of phenomenon.”6(p255) Since Fawcett described her holarchy, upon which we build the NKP, as a theory of the structure of nursing knowl- edge, so shall we. It is a grand theory in scope and a descriptive theory in purpose. Overall, our purpose is to build a more useful structure of nursing knowledge.
Kim1 identified 4 levels of theory in decreasing levels of scope: grand, meso, middle-range, and micro. Grand theories further develop a particular aspect of a
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Nursing Knowledge Pyramid 295
Figure 1. The Nursing Knowledge Pyramid.
conceptual model.5 A specific kind of con- ceptual model with a specific purpose is a discipline boundary metaparadigm (without the “-”), which places a boundary on the phenomenon of interest.5 Our selected nurs- ing discipline boundary conceptual model, the Metaparadigm of Nursing, consists of the 4 concepts (the “nouns” bounding a disci- pline) of nursing, human beings, health, and environment.5 Because the NKP addresses the structure of knowledge required to en- act optimal nursing actions, the NKP devel- ops the concept of nursing. The NKP theory can, therefore, be classified as a grand theory.
The phenomenon of interest is the struc- ture of nursing knowledge at its most inclu- sive, most comprehensive level. It has rele- vance to what the profession knows and what a nurse knows. Epistemology is the branch of
philosophy related to the nature and extent of human knowledge, that is, a system of jus- tified true beliefs.7 The guiding philosophy of the NKP is epistemological coherentism, which is a foundational theory that is based on justifications and implies that for a belief to be justified, the range of beliefs it is based on must cohere with one another.”7 The se- lections for the abstraction levels of the NKP will visibly support each other if they are log- ically coherent.
Our purpose is to propose a nursing knowl- edge framework that facilitates the learn- ing, development, automation, and accessi- bility of nursing knowledge by retroductively enhancing the holarchy theory it is based on. As shown in Figure 2 (right), the NKP the- ory enhanced the holarchy theory through 6 innovations: (1) added the tacit knowledge
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296 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2018
Figure 2. The Structural Holarchy of Contemporary Nursing Knowledge (left)5(p4) and the Nursing Knowledge Pyramid (right). The shaded areas represent common components. From Fawcett and DeSanto-Madeya.5 Used with permission.
abstraction level; (2) surfaced the database abstraction-level idea from the narrative to the diagram; (3) reversed the level-of-abstraction direction; (4) added knowledge meta-types; (5) wrapped the abstraction levels in a pyra- mid metaphor; and (6) added knowledge groups. As Wallis reminds us: “The creation of each theory requires a tradeoff between simplicity, generality, and accuracy.”2(p82) Al- though the NKP diagram is more complex than the holarchy diagram, our goal in the NKP diagram is to hit a cognitive “sweet spot” by increasing its self-explanatory con- tent without making it overly complex, which discourages comprehension.6 Readers will need to refer to Figure 2 (right), as the follow- ing sections briefly describe the major con- cepts of the NKP and the rationales for these changes to the holarchy.
The discipline of nursing is concerned with what the nurse knows but has not been made explicit. Tacit knowledge is the naturally oc- curring intuitive or prescient knowledge that
is accessible to nurses but cannot be articu- lated. Intuition refers to the ability to quickly appraise the situation and act without con- scious reasoning and has been proposed as an important explanatory concept that influ- ences nursing practice.1 Prescient knowledge knows what is going to happen before it hap- pens. For example, a nurse’s “gut feeling” may inform an intervention decision, but the nurse
Table. Example of a Meta-Theoretical Structure Outline
1. Name (source): Framework for Analysis and Evaluation of Nursing Theories5(p311)
2. Definition of meta-theory 3. Analysis
Step 1: Theory scope Step 2: Theory context Step 3: Theory content
4. Evaluation Step 1: Significance Step 2: Internal consistency Step 3: Parsimony Step 4: Testability Step 5: Empirical adequacy Step 6: Pragmatic adequacy
Nursing Knowledge Pyramid 297
may not be able to articulate the source of that feeling. Tacit knowledge is inherently disor- ganized. If it became consciously organized, it could be articulated and become explicit knowledge.
We believe tacit knowledge is important to any exhaustive typology of nursing knowl- edge. It is placed at the bottom of the pyra- mid because all knowledge is rooted in tacit knowledge.8
Philosophies are the epistemological, onto- logical, aesthetic, logical, metaphysical, and ethical claims of a discipline. In other words, they are the broad perspective for practice, re- search, and scholarship9 and the foundation for any theory development.10
The next level of the NKP reflects a philosophical stance11 and addresses the paradigms and conceptual models that pro- vide alternative ways to view the subject mat- ter of a discipline and the central concepts of a discipline. Fawcett and DeSanto-Madeya defined conceptual models as:
A set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe those concepts, and the propositions that state rel- atively abstract and general relations between two or more of the concepts.5(p13)
There are 4 kinds of types or purposes of theories: descriptive, explanatory, predic- tive, and prescriptive.1 Descriptive theories are the most basic of theories and describe the essence of the phenomenon under study: its concepts, properties, and dimensions.12
Here, the phenomenon is the structure of nursing knowledge and the theory was cre- ated through a critical evaluation of the holarchy—specifically examining its empir- ical and pragmatic adequacy—and finding opportunities for improvement. Addressing these inadequacies led to the NKP descriptive theory.
Empirical indicators are the second from the highest tier in the NKP and bring forth the lower abstraction levels into the real world. Empirical indicators measure concepts and are the basis for evidence-based practice. More specifically:
An empirical indicator is defined as a very concrete and specific real-world proxy for a middle-range theory concept—an actual instrument, experimen- tal condition, or procedure that is used to observe or measure a middle-range theory concept. The in- formation obtained from empirical indicators typi- cally is called data.5(p17)
The data in nursing knowledge can be found in databases—organized collections of data. This level recognizes the reality that the nursing knowledge base is distributed be- tween humans and machines. In the NKP, the term “databases” are used as a general term to denote explicit or original nursing knowledge that resides on machines.
Fawcett and DeSanto-Madeya5 mention “patient databases” and “computer informa- tion systems” as part of the holarchy empiri- cal indicators abstraction-level narrative. This approach may be problematic because they group nonempirical indicator knowledge un- der the empirical indicator label. For exam- ple, while typical real-world empirical indica- tors (eg, a patient’s blood pressure readings over a week) can be stored in a database, other kinds of databases exist that do not con- tain empirical indicators. Would collections of nursing theories, nursing interventions, or nursing decision-making strategies be empiri- cal indicators? We think not. And what would you call the data generated by an empirical study that is stored in a database table but has not yet been analyzed and interpreted? It is nursing knowledge, but it is not tacit hu- man knowledge and is not yet explicit human knowledge. These are examples of a different kind of knowledge, which we call machine knowledge, discussed later.
Also, collections of data have their own emergent knowledge, distinct from individual
298 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2018
pieces of knowledge. For example, knowl- edge discovery techniques such as data min- ing and text mining can uncover hidden knowledge by looking for patterns and rela- tionships within the data and text, thereby generating new knowledge. This knowledge- producing function of machine knowledge may be hidden behind the empirical indica- tors label in the holarchy, but it is not explicit.
Note that although not all explicit knowl- edge needs to be databased to be useful, do- ing so makes knowledge useable by pow- erful automated analytical tools and widely accessible to nursing stakeholders. For ex- ample, the scholarly nursing journal Nurse Education Today and many other journals encourage authors to enable readers to link to the actual data sets referenced in their articles.13
This level of the NKP is placed at the apex because the contents of the databases depend on the knowledge in the lower levels of ab- straction, and is more specific than the lower levels. This type of knowledge will become more important as the field of nursing infor- matics grows and more nursing knowledge is databased and made more accessible.
Why does the NKP have a line down the middle? The substance at each level of abstrac- tion is important and so is its form. Except for the inherently disorganized tacit knowledge level, the vertical line in the NKP diagram di- vides each abstraction level into 2 parts: (1) an overarching structure (the “meta-” on the left side, of which there can be more than 1 to select from [hence the “1 . . . n” subscript]); and (2) the substance in that structure (the examples on the right side, of which there can also be more than 1 to select from). The Table shows an outline of a “meta-” (left side) at the theories level, which is adapted from Fawcett and DeSanto-Madeya.5
To avoid confusion, note that at the level of paradigm/conceptual models, a “meta- paradigm” is not the same as a “meta- paradigm.” We use the “meta-” prefix to in-
dicate a structure and “meta” (without the “-&#x
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