“Rosemary, we found a recent citation of your research”, is a message I receive from ResearchGate whenever there is a new citation to my work! One message was another citation to one of my early papers (Eustace & Ilagan, 2010), which was the report of a concept analysis of HIV disclosure, published in the Journal of Advanced Nursing. Noteworthy is that this message was a report of the 50th citation to that paper. In the world of knowledge generation, this was particularly exciting news because I realized the impact the paper had for other scholars.  What I didn’t realize was the magnitude of influence the paper had in advancing nursing knowledge. This led me to some random thoughts on who exactly are these authors who cited my work and what was the context of their citations of my paper? A brief review of the citations and literature about the topic indicated that majority were from papers published in non-nursing journals and authored by non-nursing scholars. In addition, I found that some publications from nursing that examined closely related concepts did not cite my work. This surprised me but increased my curiosity about what all of this meant to me as a nursology scholar.

During a recent search of literature, I found an inspiring article by Rodgers et al. (2018) about the limitations of concept analysis. They underscored the importance of “moving knowledge development beyond the level of ‘concept analysis’ to developing a clear linkage to the resolution of problems in the discipline” (p. 451).  I asked myself, how can we do that? Do we have the theoretical and methodological knowledge to do that?  If we do, why are we still “stuck” on concept analysis per se?

These questions prompted me to reflect on my concept analysis of HIV disclosure (Eustace & Ilagan, 2010). I asked myself, what has been done to move beyond the concept analysis of HIV disclosure during the intervening years? A search for the citations using the Semantic Scholar impact search engine (https://www.semanticscholar.org) revealed that one replication of my concept analysis has been published (Kanyamura, Ncube, Mhlanga, & Zvinavashe 2016). Surprisingly, although the impact of the publication indicated was highly influential to others work, especially for background data, the impact of the analysis findings was very limited (see Figure 1). What this meant to me was that there was no indication of linkage of the concept analysis results with knowledge development. Inasmuch as this finding is consistent with Rodgers et al.’s (2018) concern that concept analyses are not being extended to resolve disciplinary problems, how, can we help nurse scholars advance science in this area? Is there a way?

Figure 1: Semantic Scholar Impact Output for the concept of HIV Disclosure by Eustace and Ilagan (2010)

One way forward is to develop clear guiding structures for nursing knowledge development as an essential step in closing the gaps between theory, research, and practice (Marrs & Lowry (2006). To help find a solution, I turned to the well-known approach of Conceptual-Theoretical-Empirical (CTE) structures in nursing that have been advocated for many years by Dr Jacqueline Fawcett (e.g. Fawcett, 1988; Fawcett, 2012). So, where do we start? I propose that nurse scholars consider the following 3 critical steps:

Step 1: Nurse Scholars need to examine where a nursing concept of interest is derived from within our nursing models/theories. For example, the case of the concept of HIV disclosure can be situated within the nursing model of HIV Disclosure developed by Bairan et al. (2007) (i.e. relationship model). It is important for the nurse scholar to indicate the purpose of the concept analysis: is there a need for clarification, development, or refinement or is there little or no literature about the concept? These queries will guide the scholar to the appropriate concept analyses methods. The selection of HIV disclosure, in my case was the lack of a clear definition and a broader perspective of the HIV disclosure process in both the Bairan et al. (2007) model and in other HIV disclosure models (e.g. disease progression (Kalichman, 1995 ); consequences model (Serovich, 2001).

Step 2: Nurse Scholars need to develop a conceptual theoretical empirical (CTE) structure for linking concept analyses to the next step in theory generation. As described by Fawcett and Gigliotti (2001), theory generation studies usually proceed from the “conceptual model directly to the empirical research methods and the data obtained is analyzed creating a new middle range theory” (p. 342). Thus, the CTE structure should direct the nurse scholar to the relevant literature for the concept analysis, which will be summarized and synthesized to identify the antecendents, attributes and consequences of the new descriptive middle-range theory of the concept of interest (see Figure 2 for an example of the CTE structure for the concept analysis of HIV Disclosure). The “C” in the CTE structure represents the HIV Disclosure Conceptual Model by Bairan et al. (2007). The “T” represents the specific concept to be analyzed, which is “HIV disclosure.” The E of the CTE structure indicates the empirical research methods used to generate the antecendents, attributes and consequences of the studied concept, as explained in Walker and Avant’s (2019) approach to concept analysis.

Figure2: Conceptual-Theoretical-Empirical Structure for Linking Concept Analyses to Theory Generation

Step 3.  Nurse Scholars need to utilize the findings from the concept analyses to advance nursing knowledge by using the results of the concept analysis to develop/refine theory constructs, develop instruments and then progress to explanatory and predictive theories by linking other concepts of the conceptual model to theory concepts.  So how can scholars use the descriptive middle range theory from the concept analyses to advance existing theory/model development?  Figure 3 provides a CTE structure for a hypothetical study of linking the concept analysis of HIV disclosure to advance the HIV disclosure model by Bairan et al. (2007). The vital step within the CTE structure is the re-evaluation process of the theory of which I have named the “theory refinement” process. In the HIV disclosure example, the original guiding conceptual model by Bairan et al. (2007) needs to be refined utilizing the antecedents, attributes and consequences derived from the concept analysis of the HIV disclosure concept. Scholars should utilize the results of the analysis to assess the adequacy of the constructs of the HIV disclosure model and propose directions for further empirical inquiry to determine the theory’s credibility in clinical practice and advancing the discipline.

Figure 3 – A hypothetical Conceptual-Theoretical-Empirical Structure for the HIV Disclosure Concept Analysis by Eustace et al. (2010)

Here are some epistemological considerations if we choose to move forward with this approach:

1. How can we best approach T in the CTE structure? In this case, how should nursology theorists guide scholars on how to systematically develop constructs from the descriptive middle range theory to be utilized in refining the concept for the existing theory/model?
2. What strategic and systematic approaches should we employ to retrieve, summarize, and synthesize the evidence for concept analyses, report findings and, lastly evaluate empirical studies on the concept analyses -theory generation linkage? How can we standardize the documentation process during knowledge dissemination? For example, documenting the specific date ranges when evidence was retrieved, dates when the publication was received, revised, accepted, published online and in the journal.
3. How should we move forward in designing shared CTE structures that are empirically adequate in nursing situations (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). For instance, how can we generate a global nursing HIV theory model and also contribute to knowledge development of a global interprofessional HIV Disclosure model?

 

A Call to Action:

ARE YOU READY to end what Draper (2014) calls the “intellectual dead end” (p. 1208) of concept analyses in nursing? If so, join me in articulating and advocating for approaches that facilitate the use of concept analyses as the starting point for advancing nursing knowledge. Developing nursology focused CTE structures that link concept analyses to other relevant practice phenomena are timely and very much needed to meet the demands of the complex 21^st health care delivery systems. I welcome any comments or suggestions from nursologist around the world on how we can better address this ongoing concern as we think about advancing nursing science for the Future of Nursing 2030.

References

Bairan, A., Taylor, G. A. J., Blake, B. J., Akers, T., Sowell, R., & Mendiola Jr, R. (2007). A model of HIV disclosure: Disclosure and types of social relationships. Journal of the American Academy of Nurse Practitioners, 19, 242-250.

Draper, P. (2014). A critique of concept analysis. Journal of Advanced Nursing, 70, 1207-1208.

Eustace, R. W., & Ilagan, P. R. (2010). HIV disclosure among HIV positive individuals: A concept analysis. Journal of Advanced Nursing, 66, 2094-2103.

Fawcett, J. (1988). Conceptual models and theory development. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 17, 400-403.

Fawcett, J. (2013a). Thoughts about conceptual models and measurement validity. Nursing Science Quarterly, 26, 189-191.

Fawcett, J. (2013b). Thoughts about multidisciplinary, interdisciplinary, and transdisciplinary research. Nursing Science Quarterly, 26, 376-379.

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3^rd ed.). Philadelphia, PA: F. A. Davis.

Kalichman, S. C. (1995). Understanding AIDS: A guide for mental health professionals.  Washington, DC: American Psychological Association.

Kanyamura, D., Ncube, B., Mhlanga, M., & Zvinavashe, M. (2016). HIV Disclosure: Concept Analysis.  Journal of Research in Pharmaceutical Science, 3(4), 1-4.

Marrs, J. A., & Lowry, L. W. (2006). Nursing theory and practice: Connecting the dots. Nursing Science Quarterly, 19, 44-50.

Rodgers, B. L., Jacelon, C. S., & Knafl, K. A. (2018). Concept analysis and the advance of nursing knowledge: State of the science. Journal of Nursing Scholarship, 50, 451-459.

Serovich J.M. (2001). A test of two HIV disclosure theories. AIDS Education Prevention, 13(4), 355–364

Villarruel, A. M., Bishop, T. L., Simpson, E. M., Jemmott, L. S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163.

Walker, L. O., & Avant, K. C. (2019). Strategies for theory construction in nursing. New York, NY: Pearson Education Inc.