Another condition for theoretical development in a discipline is to identify, acknowledge, and accept or transcend the paradoxes that may be related to theory development. Living with para- doxes in a discipline is as effective in the development of its theories as confronting the paradoxes, making a choice, and then moving on with the business of developing the discipline. What is not effective is to pretend there is only one view or to be immobilized by the paradox, and to make resolving it the focus rather than the means.
A commitment to theory development was made in nursing by the American Nursing Associ- ation in the mid-1960s. However, the debates related to nursing theory may have delayed the process. Much has been written and debated about nursing theory and about the differences for practice between nursing theories and nonnursing theories. Other debates centered around
CHAPTER 7 Sources, Resources, and Paradoxes for Theory 125 whether nursing needs theory in nursing, of nursing, or for nursing. Others developed a rather strong case for the lack of need of practice theory. Still others showed that nurses borrow all the- ory. Another group of debaters demonstrated that other practice fields have no theory of their own, and therefore nursing’s quest for theories is an unwarranted one.
Theory is not a status symbol or a special honorary card that nursing needs to remain in the halls of academia or to achieve professional status. Theory provides the mechanism from which we can organize our observations, focus our inquiry, and communicate our findings. Theory helps to explain, describe, and predict the range of phenomena of interest to nurses that are central in meeting the identified goals and in highlighting gaps in our knowledge. Instead of getting on with the business of developing theories related to our substantive area of practice and advancing nurs- ing knowledge, a good part of two decades (1960–1980) has been spent debating whether nurses are capable of developing theories, whether they should develop theories, and whether theories are even necessary to nursing. On the whole, the theories that were developed in nursing have not been developed further or refined. (There are some exceptions; for example, Roy has been sys- tematic in developing her theory and in proposing refinements and theoretical propositions. See Chapter 13 for an analysis of Roy’s ideas and for citations.)
In general, theories have become subjects of debate about whether they are philosophies, the- ories, concepts, metaparadigms, paradigms, grand theories, or, even worse, not theories at all.
From all these debates, more concepts have evolved to describe theoretical thinking in nursing, such as conceptual frameworks, theoretical models, and conceptual models. This evolution only managed to add considerably to the confusion of nurses. The muddle may have delayed the sea- soned theoreticians and researchers in their attempts at knowledge development; it has kept the novice from getting involved in the process of theory building; it has confused those outside the discipline, who have not understood what nurses are quibbling about; and it has stood in the way of nurses understanding, contributing to, and improving patient care.
In this section, historical examples of the confusion in the discipline, as related to its theoret- ical development, are identified and discussed. Only two of the paradoxes that have been the sub- ject of debates in the past are analyzed. These paradoxes were selected for three reasons: they transcend time; their influence on the level of development of theoretical nursing during the 1970s to 1990s is hypothesized to be profound; and understanding these two paradoxes through careful analyses can be useful for analyzing and understanding other contemporary and future paradoxes.
These paradoxes symbolize a significant period in the development of the theoretical aspects of the nursing discipline. The full meanings of these debates and their roles in enhancing or con- straining the intellectual environment in the discipline have not yet been fully extracted. By reflecting on the meanings of each side of the debates, students of theory and theory development may be able to develop some insights and some visions about forces and constraints in theory development.
Conceptual Models Versus Theory
In one of the first theory classes in the United States, taught at the University of California, Los Angeles in the late 1960s, Dorothy Johnson classified the conceptualizations of nursing that existed at that time as nursing models. It appears that, since then, terms such as models, frame- works, or theories have been used freely and interchangeably to refer to any conceptualization of nursing reality. An example of a common usage of models is when one is used to denote that the study of a system B is based on the study of a system A, and that all parts of system B correspond to all parts of system A. Then, it is said that B is modeled after A, but it does not say that any causal relationship exists between A and B. It only means that some of system A’s properties are in system B. It also means that the properties of system B that are different from system A’s prop- erties need to be identified. Therefore, modeling denotes similarities in most of the pattern and order and in some of the properties. In other words, “when one system is a model of another, they resemble one another in form and not in content” (Kaplan, 1964, p. 263).
Although this is the common use, there are different types of models. The physical model duplicates the form and structure but differs in scale; the miniature train and the baby doll who
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cries, laughs, and sucks are examples of physical models. They are replicas; in other words, laws that govern the original are obeyed by the model. The semantic model is built by using similar sym- bols and could be called a conceptual analogue. We use semantic models when we reduce our hypothesis to statistical symbols for the purpose of analysis. A widely used model in nursing is the formal model. To develop formal models, we resort to deductive logic, deducing from the original theory by using the central components and crucial relationships as a model for data gathering. For- mal models exhibit the same properties in components and the same structure, but the context may be different. For example, we may use an epidemiologic theory of disease transmission with its com- ponents of incubation, contagiousness, and quarantine to describe how nursing theories are transmit- ted. Whereas correspondence in the formal model is theoretical, abstract correspondence exists between theoretical ideas and empirical observations in the interpretive model. Data may be inter- preted using an old theory. The model for interpretation combines both data and the old theory.
The notion that nursing conceptualizations are conceptual models evolved out of ideas repre- senting two different assumptions. In the nursing theory course developed by Johnson in the 1960s, the idea that nursing conceptualizations were modeled after guiding paradigms (systems, adaptation, developmental, and symbolic interaction) was introduced. Other writings and analyses were based on the same premise of guiding paradigms. The second idea, that of models, was based on interpretive models and assumed that nursing is the reality, and that each of the existing conceptualizations model that reality at different levels of isomorphism. Early designations of nursing thought correspond to the first idea, that conceptualizations are formally modeled after other conceptual schemata (Riehl and Roy, 1974), and later designations correspond to the second idea, that conceptualizations are based on interpretive models (Fawcett, 1995; Fitzpatrick and Whall, 1989).
Use of models also differs in another respect. In some usage, models correspond more to reality: they are less abstract than theories; they contain all variables of the subject matter; and they describe reality more fully. Theories describe fewer variables and are more abstract, but they also correspond more or less to reality (Kaplan, 1964). Others considered models as simplified forms of reality. Chin (1961) defined model as “a constructed simplification of some part of real- ity that retains only those features regarded as essential for relating similar processes whenever and wherever they occur” (p. 201).
Conceptual models and theories have been used synonymously (Dickoff and James, 1968), or definitions for one were used for the other: a set of concepts that are interrelated into a coherent whole and a set of propositions. Johnson (1968a) viewed a model as an “invention of the mind for a purpose” that “is drawn from reality and pertains to reality, but it does not constitute reality” (p. 2).
Both sets of definitions could be used to define one or the other; that is, conceptual framework or theory.
Further confusion has arisen because of other interchangeable terms. Conceptual frameworks have been used by some interchangeably with conceptual models and by others interchangeably with theory. Fawcett (1989), among others, dismissed the matter by equating conceptual frame- work with conceptual model and blamed the difference on semantics. Dickoff and James (1968) defined theory as a mental image being invented for the purpose of describing, relating, and pre- dicting a desired situation. To them, theories are conceptual frameworks; they do not differentiate between the two.
Some attempts have been made to differentiate between theory and conceptual models on such criteria as level of abstraction, degree of explication, level of specificity, types of linkage, and degree to which concepts and assumptions are interdefined (Fawcett, 1989; Fitzpatrick and Whall, 1989; Klein and Hill, 1972, cited in Rodman, 1980). They argued that conceptual frameworks (or models, as they are used interchangeably) are more abstract than theories. They represent a global view of a field—its main concepts and propositions—and therefore provide the blueprint for prac- tice, education, and research (Johnson, 1968a).
Whether conceptual frameworks are necessary steps in the process of developing theories has also been debated. Some contend that the conceptual framework is a stepping stone toward theory development (Hill and Hansen, 1960; Nye and Berardo, 1966), a view that has been adopted by
CHAPTER 7 Sources, Resources, and Paradoxes for Theory 127 some in nursing (Fawcett, 2005). Others question the necessity of conceptual frameworks for development of theory and argue that conceptual frameworks are neither necessary steps nor likely to promote or hinder theory development (Rodman, 1980).
The interchangeable use of the different concepts such as conceptual frameworks, models, and theories to describe the same thing has been a problem to the pure semanticists in the field.
The attempt to differentiate between them has frequently taken on the dimension of splitting hairs and has only added to the confusion. It is just such confusion that may have contributed to the slow progress and, at times, stilted theory development in nursing and has led to an almost exclu- sive preoccupation with method and process rather than content and consequences. Instead of addressing the central issues in providing quality care to clients, we have had to debate and defend the methodology for theory development. Theorizing is a painstakingly long process, the results of which may be minimized by relegating them to the level of “it is only a conceptual framework.”
This, in itself, may decrease the impact of the conceptualizations and may make the framework (or the theoretical model) less significant. The discipline using only conceptual frameworks tends to be regarded as pretheoretical and, as a result, nursing’s contribution to knowledge about patient care processes and outcomes are minimized.
There are other disadvantages to the preference of using conceptual frameworks and models when the use of theory would have been much clearer. One such disadvantage could be under- stood by examining analogous situations—one in which conceptual frameworks and models were used before the use of theory, and one in which theories were used from the outset.
Sociology, particularly family sociology, has been unique in believing that conceptual mod- els are distinct from theories. Sociologists have maintained, and nursing scholars have begun to agree, that conceptual models provide a step in the development of theory. However, modern soci- ologists have since questioned the wisdom of using a conceptual framework to denote the results of theorizing. The skeptics in sociology have pointed out numerous examples in which conceptual frameworks have resulted in theorizing that lacked specification and definition and the slow process of developing propositions for testing (Rodman, 1980).
Conversely, physical and natural sciences do not use conceptual frameworks and models as steps toward development of theory. Instead, they may use the term developing theory versus tested theory. Notice that many theories (genetic fat theory of obesity, cholesterol theory of car- diovascular diseases, psychoanalytical theory of neurosis) are at different levels of abstraction and different levels of sophistication and have different scopes, different levels of clarity, and varying degrees of understandable definitions; however, they are all called theories.
To be sure, some differences exist between models, conceptual frameworks, and theory. A model has to model another entity, whereas a theory may or may not model other properties, struc- tures, or functions. Conceptual frameworks may present a set of discrete concepts that are not as interrelated and linked in sets of propositions as we expect from theory. However, this varies, based on the level of development of the theory. Models tend to evoke the idea of empirical posi- tivism mixed with rationalism as a guiding philosophy or a goal, rather than the tool it ought to be.
Functions attributed to models as frameworks or directives for the development of research, frameworks for the generation of a hypothesis, guides for data collection, or depositories for research findings or the further development of theory are the same functions attributed to theory.
It is not entirely clear that nursing theorists, in using different labels for their conceptualiza- tions, have done so in any systematic way. For example, in a 1983 text, eight theorists used four different labels when referring to their conceptualizations: theory, model, science, and paradigm (Clements and Roberts, 1983). Others used theory to describe their conceptualizations, and then developed and/or isolated one part of these conceptualizations and defined it as conceptual frameworks and another part that was labeled a theory (King, 1995a, 1995b). The similarities and the differences in degree of specificity, level of abstraction, and number of concepts and propositions are not always consistent with the labels. One option for using these conceptualiza- tions is to attach the label preferred by the theorist; another option is to use whatever label the user prefers, as long as a definition and rationale are given. Some literature could always be found to document any of the uses.
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The perspective of this text is to minimize the differences between conceptual models, frame- works, and theories, and to relegate most of these differences to semantics and the confusion cre- ated by the many nursing scientists and theoreticians who have been educated in a multitude of fields. The rationale for taking this perspective is not to argue for a new position or to initiate a debate, but rather to cast some doubt on the significance of the differences between theories and conceptual models.
“Theory” is sufficient to describe the conceptualizations that have been proposed by our the- orists. The three related aspects claimed to differentiate between theory and conceptual model are definitions, interrelationships, and level of abstraction. The first two, which state that concepts should be defined and interrelated, are considered in the present perspective as a necessity for both theory and conceptual models. The third aspect, level of abstraction, remains an important consid- eration. Because theories could be classified as grand, middle-range, or single domain, based on the number of phenomena that the theory addresses, the number of propositions, and the opera- tional level of the definitions, the present perspective proposes this schema to classify nursing the- ory, rather than to relegate the classification system to such different labels as conceptual model, framework, metaparadigm, paradigm, and theory.
Although this perspective is proposed to enhance a common language across disciplines and to divert energy into development and progress in theoretical nursing rather than into circular debates, the final choice of a label is a personal matter and depends on the purpose for which the label is applied. Just as role theory has been proposed and used as a concept, a framework, a model, or a theory in research, practice, and administration in a number of disciplines, and just as the user may consider role theory from a cultural, structural, or intra-actionist perspective, nursing theories could also be used in the same way. The manner and the goal of the utilization may help determine the appropriate label.
Based on the perspective proposed here, nursing theory is defined as an articulated and com- municated conceptualization of invented or discovered reality pertaining to nursing for the pur- pose of describing, explaining, predicting, or prescribing nursing care. Nursing theory is developed to answer central domain questions.
Nursing Theory Versus Borrowed Theory
Some old debates endure. Among them are the concerns and meaning of borrowed theories (Fawcett, 2000). For some time now, nurses have been involved in a debate over the types of the- ory that ought to be developed. They have taken either practice or basic theory positions. Each side has developed a good case as to why one or the other type is possible. The significance of tak- ing one or the other position lies in the idea that the practice theory position encourages forging ahead with theory development, and the borrowed theory position discourages nurses from partic- ipating in the seemingly futile attempt to develop theories, when theories that exist in other disci- plines could easily be borrowed and used to explicate nursing phenomena.
The proponents and supporters of the development of practice theory in nursing (Dickoff et al., 1968; Jacox, 1974; Johnson, 1968a; Wald and Leonard, 1964) view nursing theory as a conceptual framework invented by the theorist for the ultimate purpose of creating situations to meet desired, preferred end results. Therefore, the ultimate goal for theory development in nursing is to produce a change in a nursing client or a nursing situation that is desired by the nurse or the client. Dickoff and James (1968, p. 200) called this a situation-producing theory.
This is a fourth-level theory; theories at other levels are invented and articulated with the pur- pose of ultimately leading to this level. The first level is factor isolating, a level where theories help delineate and describe a phenomenon. The second level is a correlating theory, where factors or concepts are related to depict theories, and the third level is a situation in which theories permit prediction and allow the promotion or inhibition of nursing care. Each of these levels brings the theorist closer to the goals of nursing that are demonstrated in prescriptive theories, or by the situation-producing level of theory, the fourth level. The development of fourth-level theory is congruent with the purpose of the profession, which ought to be action-oriented, as opposed to only academically oriented. Nurses are shapers, not just observers, of reality.