The first step in understanding theories and frameworks is to become familiar with theoretical terms and their application. These terms are concept, relational statement, conceptual model, theory, middle-range theory, and study framework.
A concept is a term that abstractly describes and names an object, a phenomenon, or an idea, thus providing it with a distinct identity or meaning. As a label for a phenomenon or a composite of behavior or thoughts, a concept is a concise way to represent an experience or state (Meleis, 2012). Concepts are the basic building blocks of theory (Figure 8-1). An example of a concept is the term “anxiety.” The concept brings to mind a feeling of uneasiness in the stomach, a rapid pulse rate, and troubling thoughts about future negative outcomes. Another example of a concept is patient, which denotes a person receiving healthcare services. Think about all the different ways that people receive health care. In many of these settings, the recipients are called patients. The concept of patient encompasses millions of people from widely divergent nationalities, health conditions, and living situations, all of whom share the common characteristic of receiving care.
FIGURE 8-1 Concepts, relational statements, and theories.
Concepts can vary in their levels of abstraction. At high levels of abstraction, concepts that naturally cluster together are called constructs. For example, a construct associated with the concept of anxiety might be “emotional responses.” Within the same construct, hope, anger, fear, and optimism could be identified. Another construct is health care, which includes the concepts of treatment, prevention, health promotion, palliative care, and rehabilitation, to name a few.
A relational statement is the explanation of the connection between or among concepts (Fawcett & DeSanto-Madeya, 2013; Walker & Avant, 2011). Relational statements provide the structure of a framework (see the middle section of Figure 8-1). Clear relational statements are essential for constructing an integrated framework that guides the development of a study’s objectives, questions, and hypotheses. The types of relationships described determine the study design and indicate the types of statistical analyses that may be used to answer the research question. Mature theories, such as physiological theories, have measurable concepts and clear relational statements that can be tested through research.
A conceptual model, one type of which is known as a grand theory, is a set of highly abstract, related constructs. A conceptual model broadly explains phenomena of interest, expresses assumptions, and reflects a philosophical stance. Nurse scholars have expended time and effort to debate the distinctions among definitions of theory, conceptual model, conceptual framework, and theoretical framework (Chinn & Kramer, 2015; Fawcett & DeSanto-Madeya, 2013; Higgins & Moore, 2000; Meleis, 2012). For example, Watson’s theory of caring (1979) has been identified as a meta-theory (Higgins & Moore, 2000), a theory (Meleis, 2012), a philosophy (Alligood, 2010), and a conceptual model (Fitzpatrick & Whall, 2005). Most of nursing’s grand theories, such as Watson’s, are global and offer theoretical, almost philosophical, explanations of what nursing should be, and what the vital parts of nursing should entail. They are explanations of nursing as a whole. In this textbook, we use the terms “conceptual model” l and “conceptual framework” interchangeably. We have deliberately chosen not to contribute to the scholarly debate, but to provide the information needed to use concepts, relational statements, and theories.
A theory consists of a set of defined concepts and relational statements that provide a structured way to think about a phenomenon (see the portion of Figure 8-1 below the lowest dashed line). Theories are developed to describe, explain, or predict a phenomenon or outcome (Goodson, 2015). As discussed earlier, relational statements clarify the relationship that exists between or among concepts. It is the individual statement within a theory that is tested through research, not the entire theory. Thus, identifying and categorizing the statements (relationships among the concepts) within the theory are critical to the research endeavor: one or more of these relationships forms the basis of the study’s framework.
Scientific theories are those for which repeated studies have validated relationships among the concepts (Goodson, 2015). These theories are sometimes called laws for this reason. Although few nursing and psychosocial theories have been validated to this extent, physiological theories have this level of validation through research and can provide a strong basis for nursing studies.
Middle-range theories present a partial view of nursing reality. Proposed by Merton (1968), a sociologist, middle-range theories are less abstract and address more specific phenomena than do the grand theories (Peterson, 2009). They apply directly to practice, with a focus on explanation of the specifics of condition, symptom, diagnosis, or process, and on implementation. They differ from grand theories because they are concerned with aspects of nursing, not its totality. Because of the narrower focus, middle-range theories can provide a framework to guide a research study.
Middle-range theories may be developed from grand theories in nursing through substruction. For example, Pickett, Peters, and Jarosz (2014) identified Orem’s Theory of Self Care (2001) as a grand theory that was applicable to weight management. Pickett et al. (2014, p. 243) “deduced from the assumptions and concepts of the theory” to construct their middle-range theory of weight management. Middle-range theory may also be developed inductively from research findings, such as grounded theory studies. Others emanate from practice, or from existent theory in related fields. Whatever their source, middle-range theories are sometimes called substantive theories because they are more concrete than grand theories.
A research framework is the theoretical structure guiding a specific study. One way to describe the research framework is to present a map or diagram of its concepts and relational statements. Diagrams of research frameworks are conceptual maps (Fawcett, 1999; Newman, 1979, 1986). A conceptual map summarizes and integrates visually the theoretical structure of a study. A narrative explanation allows us to grasp the essence of a phenomenon in context. A research framework should be supported by references from the literature. The framework may have been derived from research findings or be an adaptation of a theory, so the literature is available to support the explanation. If the framework has emerged from clinical experiences, a search of the literature may reveal supporting studies or theories. Frameworks vary in complexity and accuracy, depending on the available body of knowledge related to the phenomena being described.
Building on your initial knowledge of these theoretical terms, the next sections will revisit each one and provide additional description of analyzing concepts, statements, and theories.
Concepts are often described as the building blocks of theory: useful, in an amorphous sort of way, but difficult to tack down because of their abstractness. To make a concept concrete, the researcher must identify how it can be measured. The concept’s operational definition is a statement of how it will be measured (see Chapters 3 and 6). A concept made measurable is referred to as a variable. The word variable implies that the values associated with the term can vary from one instance to another. A variable related to anxiety might be “palmar sweating,” which the researcher can measure by assigning a numerical value to the amount of sweat on the subject’s palm. In Chapter 3, substruction was described in relation to linking concepts and variables when designing a study. To review this principle and provide examples, Figure 8-2 shows examples of the links among constructs, concepts, and variables. On the left of the figure is the template of the construct-to-variable continuum. The other two sets of shapes are examples of a construct, concept, and variable. Notice that a concept may have multiple ways of being measured. For example, to measure anxiety, a researcher may assess palmar sweating, ask subjects to complete the State-Trait Anxiety Scale, or observe subjects and complete a checklist of behaviors such as pacing, wringing of hands, and verbalizing concerns.
FIGURE 8-2 Substruction of constructs, concepts, and variables.
Defining concepts allows us to be consistent in the way we use a term in practice, apply it to theory, and measure it in a study. A conceptual definition differs from the denotative (or dictionary) definition of a word. A conceptual definition (connotative meaning) is more comprehensive than a denotative definition because it includes associated meanings the word may have. For example, a connotative definition may associate the term fireplace with images of comfort and warmth, whereas the denotative definition would be a rock or brick structure in a house designed for burning wood. Conceptual definitions may be found in theories, but can also be established through concept synthesis, concept derivation, or concept analysis (Walker & Avant, 2011).
In nursing, many phenomena have not yet been identified as discrete entities. Recognizing, naming, and describing these phenomena are critical steps to understanding the process and outcomes of nursing practice. In your clinical practice, you may notice a pattern of behavior or find a pattern or theme in empirical data and select a name to represent the pattern. The process of describing and naming a previously unrecognized concept is concept synthesis. Nursing studies often involve previously unrecognized and unnamed phenomena that must be named and carefully defined, so that study readers can understand their meanings and functions. Smith, Swallow, and Coyne (2015) conducted a concept synthesis of family-centered care and partnership-in-care. They reviewed 30 studies that used one or both of the concepts to find common elements. They integrated the shared elements into a framework of pediatric nurses’ involvement with families of children with long-term health conditions.
Concept derivation may occur when the researcher or theorist finds no concept in nursing to explain a phenomenon (Walker & Avant, 2011). Concepts identified or defined in theories of other disciplines can provide insight. In concept derivation, a concept is transposed from one of field of knowledge to another. If a conceptual definition is found in another discipline, it must be examined to evaluate its fit with the new field in which it will be used. The conceptual definition may need to be modified so that it is meaningful within nursing and consistent with nursing thought (Walker & Avant, 2011). For example, Manojlovich and Sidani (2008) identified four attributes of dose through concept analysis: purity, amount, frequency, and duration. Using these attributes, they examined the literature of medicine and behavioral therapy to derive a dose concept relevant to nurse staffing. Purity as a component of nurse dose was defined as concentration of nursing knowledge on a hospital unit. Amount was defined as the “total number of nurses available to provide care” (p. 315). The authors also provided definitions of frequency and duration in terms of nurse staffing and linked each aspect of nurse dose to patient outcomes. These attributes of nurse staffing could be helpful in developing an outcomes study. Concept derivation is a creative process that can be fostered by thinking deeply and having a willingness to learn about processes and theories in other disciplines.
Concept analysis is a strategy that identifies a set of characteristics essential to defining the connotative meaning of a concept. Several approaches to concept analysis have been described in the nursing and health care literature. Because the approaches have varying philosophical foundations and products, nurse theorists and researchers must select the concept analysis approach that best suits their purposes in a specific situation (Table 8-1). A frequently used approach to concept analysis is the process proposed by Walker and Avant (2011). The procedure guides the scholar to explore the various ways the term is used and to identify a set of characteristics that clarify the range of objects or ideas to which that concept may be applied (Walker & Avant, 2011). These essential characteristics, called defining attributes or criteria, provide a means to distinguish the concept from similar concepts and provide a foundation for determining whether an instrument has construct validity (see Chapters 10 and 16). Clinicians analyze concepts as a means to improve practice, such as Robson and Troutman-Jordan (2014) who analyzed the concept of cognitive reframing as a nursing intervention. Nurses can use cognitive reframing to help patients and their families change their perception of a diagnosis or situation to a more positive view. A more positive view may promote behavior change and well-being (Robson & Troutman-Jordan, 2014).