Are We Ready to Utilize Concept Analyses To Advance Nursology? Could This Be a Way Forward?

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

Figure2

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 21st 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 Nursing70, 1207-1208.

Eustace, R. W., & Ilagan, P. R. (2010). HIV disclosure among HIV positive individuals: A concept analysis. Journal of Advanced Nursing66, 2094-2103.

Fawcett, J. (1988). Conceptual models and theory development. Journal of Obstetric, Gynecologic, & Neonatal Nursing17, 400-403.

Fawcett, J. (2013a). Thoughts about conceptual models and measurement validity. Nursing Science Quarterly26, 189-191.

Fawcett, J. (2013b). Thoughts about multidisciplinary, interdisciplinary, and transdisciplinary research. Nursing Science Quarterly26, 376-379.

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd 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 AnalysisJournal 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 Quarterly19, 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 Scholarship50, 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 Quarterly14, 158-163.

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

Opportunities for Advancing Nursing Knowledge: A Personal Journey of Appreciation

24 years ago while completing the first baccalaureate nursing degree program offered in Tanzania, East Africa at Muhimbili University of Health and Allied Sciences (MUHAS); I sat in a nursing theory class trying to grasp concepts and principles that shape nursing as a professional discipline (i.e. the grand and middle range nursing theories and models). Surprisingly, most of the concepts I learned mirror concepts I have since encountered in my academic career as a graduate student and nurse scholar. For instance, self-care concepts in chronic disease management mirror concepts in Orem’s self-care theory; concepts in interprofessional models mirror concepts in nursing interpersonal and interactional theories (e.g. Imogene King’s theory and Peplau’s theory); Systems thinking concepts mirror concepts in Roy’s conceptual model  and Betty Neumann’s conceptual model; concepts in psychotherapeutic approaches mirror concepts in the nursing humanistic theories (e.g. relational and caring concepts) and concepts in the acculturation theories (e.g. Gordon’s theory, John Berry’s theory) mirror those in Leininger’s cultural care theory. These are just a few examples on how rich nursing theoretical underpinnings play a key role guiding health care actions and outcomes in addition to the medical disease-centered perspective.  In this case, I think we need to strategically revisit the existing models, refine and adapt them to our changing health care environments as well as develop new approaches and educational models that have an impact on health outcomes of interest.

This critical reflective query originates from a quote I read in the 2010 Institute of Medicine Future of Nursing: Focus on Nursing Education Research Brief stating that, “New approaches and educational models must be developed to respond to burgeoning information in the field. For example, fundamental concepts that can be applied across all settings and in different situations need to be taught, rather than requiring rote memorization” (p2). This statement made me think further: Have we adequately synthesized the existing key concepts and principles? Is it time to re-visit the nursing metaparadigm concepts? What new concepts do we need to develop and how can we develop them? Which concepts and principles of the disciplines should we teach in undergraduate vs graduate nursing programs to avoid rote memorization? Are we at risk of re-inventing wheels of nursing knowledge? Have we been instrumental in advancing implementation science to promote “empirical and practical generalizability” of nursing theories and models? 

A memorable photo of the burn patient I cared for in the surgical ward.

Let me flashback on my personal educational and career journey to make the case: I was trained to understand and embrace the art and science of nursing within the realities of closing my own personal knowledge gap on nursing theory (didactic), research and practice.  My first taste of nursing knowledge application and development started when I was assigned to take care of a burn patient for my clinical case study assignment during my medical-surgical clinical rotation. As a BSN prepared student, the ‘why” of what we do as nurses was emphasized.  In this case, the nursing action of “turning and repositioning patients every two hours to prevent pressure sores” opened new insights on my nursing knowledge application beyond just doing a task. I was intrigued by the Braden scale for predicting pressure sores risk developed by Drs. Barbara Braden and Nancy Bergstrom from a conceptual schema that attributed key determinants of pressure ulcers from current evidence–intensity and duration, tissues tolerance of the skin, and supporting structure or pressure (Braden & Bergstrom, 1987). I continued my inquiry by completing my fourth year BSN capstone project on the topic of pressure sores in the medical and surgical population. Moreover, as part of my training, I was introduced to a course on principles of teaching and learning in our curriculum. Nursing students were expected to learn how to write up a philosophy in teaching, practice and research. Learning about philosophy helped me appreciate the importance of nursing values, beliefs, the different ways of knowing and different approaches to nursing education and practice that continue to shape our discipline to this day. I can truly attest to Bruce, Reitz and Lim’s (2014) statement that: “Philosophy is not only understood as relevant but vital to our discipline and professional practice (p. 70).

Completing my Carnegie African Diaspora Fellowship (CADFP) at MUHAS in 2017. Top: Group photo with nursing students and faculty at the MUHAS scientific conference

Later, as part of my graduate studies, I was exposed to concept analysis methods and how to evaluate and apply theories/models to a problem of interest. My graduate education provided me with a great foundation in nursing knowledge grounded within the health promotion and preventive care paradigms at the individual, family, population, community and systems levels of practice (i.e., MS Community/Public Health Clinical Nurse Specialist, MS and PhD in Family Science (focus on Family Life Education and Consultation).  Armed with this knowledge, I was successful in completing a concept analysis paper in my nursing theory class (Eustace & Ilagan, 2010), evaluated the family socio-ecological theory for my family theory class, and applied Berry’s acculturation theory in my doctoral dissertation to study acculturative stress (Eustace, 2007, 2010). Additionally, I learned how to appreciate the difference between conceptualization and operationalization of variables (concepts) across studies and disciplines.

Group photo with nursing students enrolled in the community/public health course. Invited guest lecture to teach concepts and principles of health promotion theories and models.

Overall, this knowledge has been instrumental in my nursing career as a nurse educator and scholar. I continue to learn and try to understand key concepts of interest to further my research agenda in the field of family nursing and how it impacts chronic disease prevention and risk reduction outcomes: “HIV/AIDS family interventions” (Eustace, 2013), “family health nursing intervention” (Eustace, Gray & Curry, 2015),  “male involvement” (Eustace, 2018) and “family nursing” (Eustace, in press). I am currently in the process of conceptualizing a “Family Health Strength-Based Socio-Ecological Model of Breast Cancer in Sub-Saharan Africa” (Eustace, Nyamhanga & Lee, 2018) to guide my international collaborative research agenda. This model is grounded in the theoretical foundations for nursing of families: the Bioecological systems theory (Bronfenbrenner & Lerner, 2004) and Strength based-nursing (SBN) approach (Gottlieb & Gottlieb, 2017).

An inspirational reunion with my undergraduate dean and mentor –a pioneer of the BSN program in Tanzania, Professor Pauline P. Mella, (middle) with her sponsor Dr Eileen Stuart-Shor at the 2016 American Academy of Nursing Conference

Along the way, I must give credit to my professors early on in my nursing career as well as faculty mentors and external reviewers who have inspired me in the utilization of nursing theories and the process of theorizing nursing knowledge. I wish all nursing students today are exposed to these kind of learning and critical reflective discovery opportunities in their undergraduate or graduate studies.  Similarly, I wish junior and mid-level career nurses interested in nursing theories and the process of theorizing nursing knowledge have access to qualified educators and mentors.

Therefore, the following question remains to be answered: As a community of nurse scholars and practitioners, how are we strategic in building our capacity to meet the demands of developing a generation of nurses who will advance nursing knowledge as part of the future of nursing?  We need a well-trained and competent nurse educator and mentor workforce that is capable of offering the next generation of nurses (i.e., LPNs, RNs, DNPs, PhDs) and nursing paraprofessionals (e.g., nursing assistants, community health workers, and traditional attendants) the opportunity to learn and translate nursing knowledge that will impact health outcomes of interest.  For example, a nursing workforce with expertise in theory who will teach nursing theory and serve on dissertation and doctoral project committees, nursing research grant applications and nursing practice committees. If that were to happen, we will need proactive and revolutionary nurse scholars and leaders to lead the way in the areas of nursing education, nursing research, evidence based-practice, and policy-making as part of the future of nursing.

Food for thought: Why don’t we have clear standards to measure how nursing theoretical concepts and principles are integrated into nursing program curricula as part of our accreditation systems, as part of magnets status applications, and as part of nursing research agenda? Will taking this “backward step (to revisit our standards) as a way forward” be asking for too much from our leaders? Should we do this? How should we do this? If we should not do this, why not?  I welcome readers of nursology.net to reflect and share their thoughts on these epistemological issues and practical challenges in the comments section of this blog.

References

Braden, B., & Bergstrom, N. (1987). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 12(1), 8-16.

Bronfenbrenner, U. & Lerner, R. M. (EdS.) (2004). Making human beings human: Biological perspective on human development. Thousand Oaks, CA: Sage Publications.

Bruce, A., Rietze, L., & Lim, A. (2014). Understanding Philosophy in a Nurse’s World: What, Where and Why? Nursing and Health, 2(3), 65-71. doi: 10.13189/nh.2014.020302

Eustace, R.W (in press). Family Nursing. Macmillan Encyclopedia of Families, Marriages, and Intimate Relationships,

Eustace, R.W. (2018) Male Involvement: An Evolving Global Cross-Cultural Concept inFamily-Centered Health Care. NCFR Report, Family Focus: Families and Cultural Intersections, p 4.

Eustace, R. W. (2010). Factors Influencing Acculturative Stress among International Students: From the International Students’ Perspectives. Germany: VDM Verlag Dr. Muller Aktiengesellschaft & Co. KG.

Eustace, R. W. (2007). Factors influencing acculturative stress among international students in the United States (Doctoral dissertation, Kansas State University).

Eustace, R. W. (2013). A discussion of HIV/AIDS family interventions: implications for family‐focused nursing practice. Journal of Advanced Nursing, 69(7), 1660-1672.

Eustace, R.W. (1994). The prevalence of pressure sores in the Medical surgical patients at Muhimbili Medical Center (Undergraduate Research Report). Muhimbili University of Health and Allied Sciences.

Eustace, R.W, Gray, B. & Curry. D. (2015). The meaning of family nursing intervention: what do acute care nurses think? Research and theory for nursing practice, 29(2), 125.

Eustace, R. W., & Ilagan, P. R. (2010). HIV disclosure among HIV positive individuals: a concept analysis. Journal of Advanced Nursing, 66(9), 2094-2103.

Eustace, R. W., Nyamhanga, T. Lee, E. (2018). A Discussion of Social Determinants of Breast Cancer among Women in Tanzania: Advantages, Gaps and Future Directions in Family Scholarship. The 2018 Annual NCFR Conference, San Diego, California, November 7-10, 2018

Gottlieb, L. N., & Gottlieb, B. (2017). Strengths-Based Nursing: A Process for Implementing a Philosophy into Practice. Journal of family nursing, 23(3), 319-340.

Institute of Medicine (US). Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2010). The future of nursing: Focus on nursing education. Washington, DC: National Academies Press. http://www.nationalacademies.org/hmd/ ~/media/  Files/Report %20Files/2010/The-Future-of-Nursing/Nursing%20Education %202010%20Brief.pdf

Interested In Contributing To Nursology.Net?: The Innovative Way Of Promoting Global Exchange Of Nursing Knowledge

Dr. Eustace is a member of the Nursology.net management team!

Nursology.net exists to provide a way for you, the reader, to get your research out to a broad, global audience!  We are increasingly challenged to find new ways of improving population health outcomes by ensuring quality nursing care for all (Fawcett, Amweg, Legor, Kim, & Maghrabi, 2018). As the largest segment of the health care workforce, the nursing profession is positioned to lead and advance health as well as transform health care systems (IOM, 2011).

With this charge in hand, contemporary nursing scholars need to be in the forefront of advancing the profession and promoting a better understanding of the contributions of nursing knowledge in health care through scholarly development of nursing science. Although there has always been hiccups or outright aversion of nursing theory development within the profession, this is about to change as more nurses are called to lead the way to deal with the 21st century health challenges that need an informed nursing workforce (All‐Party Parliamentary Group on Global Health, 2016).

As a profession, I believe, we are transforming and our approaches are evolving.  Although our contributions might seem to be undervalued and in many cases our capacity to work to our full potential may be hindered, we are the only ones who can reverse this trajectory and advocate for the discipline, our patients, families and communities. We are the most trusted profession in health care systems. We have vast experience in theory construction methodologies and have significantly contributed to concepts related to nursing and health care.

Unfortunately, most of our preliminary work is not known to many nurses within the discipline and between disciplines. The impact of nursing on quality, access and cost of treatment is not new (All‐Party Parliamentary Group on Global Health, 2016). We need to take such positive outcomes and strive to make sure our contributions to public health policy and decision making are shared widely through various venues including peer-reviewed publications, professional organizations and innovative websites. These venues are critical for information exchange as well as advancing nursing knowledge.

Nursology.net is an innovative website that provides a venue to promote global exchange of nursing knowledge in the 21st century. Through Nursology.net, nurses are encouraged to contribute by sharing their work on how they have constructed a nursing theory, how they have tested nursing theoretical underpinnings in the empirical world and the impact of their outcomes on nursing practice, education and/or health policy. This process of knowledge sharing provides a timely channel for “meta-theory”- the study of ourselves to – re-examine the strengths and weakness of our theorizing processes. This is highly needed in the discipline to clarify the domain of nursing, guide nursing research and practice (Jairath, Peden-McAlpine, Sullivan, Vessey & Henly, 2018; Lor, Backonja, & Lauver, 2017).

Although we are very limited in systematic reviews related to summarizing theoretical evidence or theoretical meta-analyses (e.g. Wolf., & France, 2017), and we are not well structured in disseminating our knowledge outside nursing circles, we can close the gaps by becoming CHAMPIONS for better ways of sharing and learning from good nursing practice and from our own research locally, nationally and at the global-level (All‐Party Parliamentary Group on Global Health, 2016).  So, where can you start? The answer is Nursology.net.  

And why should you care about disseminating your findings on Nursology.net?

You should care because the construction of nursing knowledge can only continue to evolve as long as we share how we utilize and/or refine what we know about the theoretical underpinnings related to the art and science of nursing and how we contribute to the profession, the healthcare environment, targeted population and ultimately population health outcomes over time. Nurse scholars or student nurses should strive to share their findings on how they make deductive and inductive conclusive augments on their phenomena of interest by sharing their work as Practice, Education/theory, Research/Theory, Policy/Theory or Quality Improvement/Theory exemplars. (Note: there are forms on each of the main “Exemplar” sections that you can use to share your work!)

Are you interested in contributing your research work to Nursology.net? If YES, please follow the attached quick guide to get started! Become a CHAMPION FOR ADVANCING NURSING KNOWLEDGE!!  (Download a PDF of the flow chart here)

References

All‐Party Parliamentary Group on Global Health. (2016). Triple Impact: How Developing Nursing Will Improve Health, Promote Gender Equality and Support Economic Growth. Retrieved from http://www.who.int/hrh/com-heeg/digital-APPG_triple-impact.pdf

Fawcett, J., Amweg, L. N., Legor, K., Kim, B. R., & Maghrabi, S. (2018). More Thoughts About Conceptual Models and Literature Reviews: Focus on Population Health. Nursing science quarterly, 31(4), 384-389.

Institute of Medicine (US) (2011). Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Jairath, N. N., Peden-McAlpine, C. J., Sullivan, M. C., Vessey, J. A., & Henly, S. J. (2018). Theory and Theorizing in Nursing Science: Commentary from the Nursing Research Special Issue Editorial Team. Nursing research, 67(2), 188-195.

Lor, M., Backonja, U., & Lauver, D. R. (2017). How Could Nurse Researchers Apply Theory to Generate Knowledge More Efficiently?. Journal of Nursing Scholarship, 49(5), 580-589.

Wolf, Z. R., & France, N. E. (2017). Caring in Nursing Theory. International Journal for Human Caring, 21(2), 95-108.