Frameworks for Research       Patricia Liehr and Mary Jane SmithFrom Practice to Research       To be introduced to framew...
theory in practice and beginning plans to use the theory to guide her thesis research. Attentivelyembracing story proposes...
interactions. This inductive process often generates the questions, which are most cogent for enhancingpatient well-being....
their conclusion(s) when using inductive reasoning; likewise, you will not always find a clear picture ofthe structure gui...
research questions and accompanying hypotheses. The inputs they identify are elder and family-caregiver characteristics. T...
influence health. The middle level on the ladder includes the frameworks, theories and concepts theresearcher uses to arti...
The middle of the ladder: Frameworks, theories and concepts       It is important to consider the middle of the ladder of ...
the purpose of explaining or predicting. A theory is like a blueprint, a guide for modeling a structure. Ablueprint depict...
than the person-environment mutual process described by Rogers.       If a researcher is using Roger’s theory to guide pla...
applicable…” (p. 159).     The theory of attentively embracing story, introduced in the beginning of this chapter as one, ...
more concrete level on the ladder, then it falls into micro-theory.Frameworks for researchThe critical thinking decision p...
research, the Double ABC-X Model of Family Adaptation. Although not a nursing theory, the Model  of Family Adaptation is a...
practice with families. Sometimes, frameworks from very different disciplines, such as physics or art,may be relevant. It ...
planning with elders, Applied Nursing Research 13:19-28, 2000.        Chinn PL, Kramer MK: Theory and nursing: a systemati...
Science Quarterly 10(4):171-174, 1997.       Rogers, ME: Nursing: Science of unitary, irreducible human beings: Update 199...
Table 1: Issues affecting BP change and related research questionsIssues                                              Rese...
well-being        construct incorporating              well-being   General Well-Being                  mental/psychologic...
Figure 4: Critical Thinking Decision Path      Guided by a view of the world the researcher uses:                highest l...
Figure 1 Attentively Embracing Story       Connecting with Self-in-Relation                               personal history...
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Liehr class

  1. 1. Frameworks for Research Patricia Liehr and Mary Jane SmithFrom Practice to Research To be introduced to frameworks for research, put yourself in the shoes of Kate and thoughtfullylisten to her story by attending to the message it brings for the practicing nurse wishing to critique,understand and do research. Kate works in a coronary care unit (CCU). She has worked in this unit fornearly three years, since she graduated with a baccalaureate degree in nursing. She has grown morecomfortable over time and now believes that she can readily manage whatever comes her way with thecomplexities of patient care in the CCU. Recently, she has been observing the pattern of blood pressure(BP) change when healthcare providers enter a patient’s room. This observation began when Katenoticed that one of her patients a 62 year old African-American woman who had continuous arterialmonitoring, had dramatic increases in BP, as much as 100%, each time the healthcare team made roundsin the CCU. Furthermore, this elevated BP persisted after the team left her room and slowly decreased toreach pre-round levels within the following hour. Conversely, the same patient, when visited by thenurse manager on her usual daily rounds, engaged calmly in conversation and was often left with lowerBP when the nurse-manager moved on to the next patient. Kate thought about what was happening andadjusted her work so that she could closely observe the details of this phenomenon over several days. Team rounds were led by the attending cardiologist and included nurses, pharmacists, socialworkers, medical students and nursing students. The nurse-manager’s visit occurred one-on-one. Duringteam rounds the patient was discussed and occasionally, she was asked to respond to a question abouther history of heart disease or her current experience of chest discomfort. Participants took turnslistening to her heart and students responded to questions related to her case. During the nurse managerconversation, the patient had the nurse’s attention. In fact, the nurse usually sat and spent time. Katenoticed that the nurse manager was especially attentive to the patient’s experience. She spent timetalking to the patient about how her day was going, what she was thinking about while lying in bed andwhat feelings were surfacing as she began to consider how life would be when she returned home. Kate decided to talk to the nurse manager about her observation. The nurse manager, Alison, waspleased that Kate had noticed these BP changes associated with interaction. She told Kate that she, too,noticed these change during her 8 year experience of working in CCU. Her observation led her to atheory, which seemed applicable to the observation. As a first year Master’s student Alison learned thetheory, attentively embracing story (Smith & Liehr, 1999; Liehr & Smith, 2000). She was applying the
  2. 2. theory in practice and beginning plans to use the theory to guide her thesis research. Attentivelyembracing story proposes that intentional nurse-client dialogue, which engages the human story, enablesconnecting with self-in-relation to create ease (Figure 1). As depicted by the theory model, the centralconcept of the theory is intentional dialogue. It is what Kate had first observed when she noticed Alisoninteracting with the patient. Alison was there with full attention, following the patient’s lead andpursuing what mattered most to the patient. Alison seemed to get a lot of information in a short time andthe patient seemed willing to share things, which she wasn’t sharing with other people. According to the theory, each of the three concepts, intentional dialogue, connecting with self-in-relation, and creating ease are intricately connected. So, when Kate observed intentional dialogue, shealso observed connecting with self-in-relation as the patient reflected on her experience in the moment;and, creating ease, when she saw lowered BP as the nurse-manager left the room. Alison and Kateshared an understanding that there was a relationship between patient-health care provider interactionand BP. They discussed several possible issues, which might be affecting this relationship. Theyidentified research questions related to each issue (Table 1). You may be able to think of other issues,which could generate a research question contributing to understanding of the relationship betweenpatient-health care provider interaction and BP. The list developed by Kate and Allison only serves as areflection of the complexity of the relationship. The list highlights the fact that the relationship cannot beunderstood with one study but a series of studies may enhance understanding and offer suggestions forchange. For instance, a thorough understanding may lead to testing of different approaches forconducting team rounds. Practice-theory-research links There are several important aspects of frameworks for research embedded in the story of Kateand Alison. First, it is important for the reader to notice the links between practice, theory and research.Each is intricately connected with the other to create the knowledge base for the discipline of Nursing.(Figure 2). Theory is a set of interrelated concepts, which provides a systematic view of a phenomenon.Theory guides practice and research; practice enables testing of theory and generates questions forresearch; research contributes to theory-building, and selecting practice guidelines. So, what is learnedthrough practice, theory and research interweaves to create the knowledge fabric of the discipline ofNursing. From this perspective, each reader is in the process of contributing to the knowledge base ofthe discipline. For instance, if you are practicing, you can use focused observation (Liehr, 1992) just asKate did, to consider the nuances of situations, which matter to patient health. Kate noticed the changein BP occurring with interaction and systematically began to pay close attention to the effect of varying
  3. 3. interactions. This inductive process often generates the questions, which are most cogent for enhancingpatient well-being. Approach to science Another major theme of the story of Kate and Alison can be found in each nurse’s way ofapproaching the phenomenon of the relationship between health care provider-patient interaction andBP. Each nurse was using a different approach for looking at the situation, but both were systematicallyevaluating what was observed. This is the essence of science…systematic collection, analysis andinterpretation of data. Kate was using inductive reasoning, a process of starting with details ofexperience and moving to a general picture. Inductive reasoning involves the observation of a particularset of instances that belong to and can be identified as part of a larger set. (Feldman, 1998). Alison toldKate that she, too, had begun with inductive reasoning and now was using deductive reasoning, aprocess of starting with the general picture, in this case the theory of attentively embracing story, andmoving to a specific direction for practice and research. Deductive reasoning uses two or more relatedconcepts, that when combined, enable suggestion of relationships between the concepts (Feldman,1998). Inductive and deductive reasoning are basic to frameworks for research. Inductive reasoning isthe pattern of “figuring out what’s there” from the details of the nursing practice experience. Inductivereasoning is the foundation for most qualitative inquiry (Chapter 9). Research questions related to theissue of the meaning of experience for the patient (Table1) can be addressed with the inductivereasoning of qualitative inquiry. Deductive reasoning begins with a structure, which guides one’ssearching for “what’s there”. All but the last two research questions listed in Table 1 would be addressedwith the deductive reasoning of quantitative inquiry. Given Alison’s use of deductive reasoning guided by the theory of attentively embracing story, itcan be assumed that she has read and critiqued the literature on theoretical frameworks, and has chosenattentively embracing story as a theoretical framework to guide her Master’s thesis research. In order forKate to move on in her thinking about research to study the way changes in blood pressure are related tohealthcare provider-patient interaction, she needs to become well versed on the importance of theoreticalframeworks. As she reads the literature and reviews research studies, she will critique the theoreticalframeworks guiding those studies. In doing the critiquing of existing frameworks, she will develop theknowledge and understanding needed to choose an appropriate framework for research. As a beginning,Kate is reading this chapter, recognizing herself as a critiquer of nursing research.HELPFUL HINTInvestigators may not always provide a detailed explicit statement of the observation(s) that led them to
  4. 4. their conclusion(s) when using inductive reasoning; likewise, you will not always find a clear picture ofthe structure guiding the study when deductive reasoning has been used.Frameworks as structure for research Whether evaluating a qualitative or a quantitative study, it is wise to look for the framework,which guided the study. Generally, when the researcher is using qualitative inquiry and inductivereasoning methods, the critiquer will find the framework at the end of the manuscript in the discussionsection (See Chapter 9). From the findings of the study, the researcher builds a structure for movingforward. In the study on bone marrow transplantation in the appendix C (Cohen & Ley, 2000), theresearchers obtained stories about what it was like to have a bone marrow transplant. These stories wereanalyzed and the findings were synthesized at the theoretical level. The researchers moved fromparticulars of the bone marrow transplant experience to a general structure of concepts, which includedfears, losses, hopes and a sense of transitioning through a life-altering event. These concepts weredescribed in the context of the subjects’ stories and relevant literature, creating a conceptual structure,which could be modeled. A model is a symbolic representation of a set of concepts, which is created to depictrelationships. Figure 1 is the model of attentively embracing story. It represents the nurse-clientconnection through the rhythmical symbol labeled intentional dialogue. The model depicts process bylinking the concepts through nurse-client dialogue with arrows, which link to each other. This modelcould be the basis for deductive reasoning. An example of a deductive question, which could be derivedfrom the model, is:What is the difference in salivary cortisol (an indicator of ease) for cancer patients who engage withparticipants (connecting with self-in-relation) in a nurse-led (intentional dialogue) cancer support group? HELPFUL HINT When an investigator has used a deductive approach, the theoretical framework should be described to substantiate how the research question emerged. When the researcher is using quantitative inquiry and deductive reasoning methods, the critiquerwill find the framework at the beginning of the paper before a discussion of study methods. In the studyof a model for discharge planning for elders with heart failure in the appendix of this book, Bull,Hansen and Gross (2000) present a model, which they have derived from a broader evaluationperspective. Their model, which depicts inputs, process and outputs, is a framework for structuring the
  5. 5. research questions and accompanying hypotheses. The inputs they identify are elder and family-caregiver characteristics. The process is the partnership model, which proposes that discharge planningbe a collaborative interaction between professionals, patients and family caregivers. The partnershipmodel is the intervention administered to the experimental group in their research. The outputs oroutcomes they measure are: health status satisfaction, perception of care continuity, difficulties ofmanaging care and resource use for both the elderly patient and the family caregiver. The researchershave identified questionnaires or medical record sources, which will bring these outcomes to ameasurable level. Their model and the related literature lead Bull, Hansen and Gross (2000) tohypothesize that (p.20):1. scores on perceived health will be different for clients in the intervention and control cohorts;2. client satisfaction with discharge planning, perceptions of care continuity, preparedness and difficulties managing care will differ for the intervention and the control cohorts;3. caregiver’s response to care-giving will be different for the experimental and control cohorts; and,4. resource use will be different for the control and intervention cohorts.The researchers have used deductive reasoning to move from their model, which they substantiated withliterature, to the hypotheses (See Chapter 3), or best guesses about what they will find. Their model hasprovided a framework to guide their research from theory to hypotheses. They have moved from theabstract to the concrete, in contrast to Cohen and Ley’s (2000) movement from the concrete experienceof bone marrow transplant to the abstract structure of the concepts. The ladder of abstraction The ladder of abstraction is a way for the critiquer to gain a perspective when reading andthinking about frameworks for research. When critiquing the framework of a study, imagine a ladder(Figure 3). The highest level on the ladder includes beliefs, assumptions, what is sometimes called theworldview of the researcher. Although the worldview is not always explicitly stated in a manuscript, it isthere. In the study on outcomes of anger (Mahon, Yarcheski & Yarcheski, 2000) (See appendix B), theresearchers hold beliefs that there is a relationship between mind and body, and that emotions do indeed
  6. 6. influence health. The middle level on the ladder includes the frameworks, theories and concepts theresearcher uses to articulate the problem, purpose and structure for research. Mahon, Yarcheski andYarcheski (2000) study the problem of positive and negative outcomes of anger in early adolescents.The purposes described by the authors were to examine symptom patterns and diminished well-being asnegative outcomes of trait and state anger; and vigor and willingness to change as positive outcomes oftrait and state anger. Using the literature they create frameworks of the positive and negative outcomesof state and trait anger. These frameworks, which are presented as models, guide their research studyand are based on Spielberger’s theory of anger. The negative outcomes framework depicts relationshipsbetween the concepts of state anger, trait anger, diminished well-being and symptom patterns. Thepositive outcomes framework outlines links between state anger, trait anger, vigor and willingness tochange. These frameworks were derived from the literature and constructed by the researchers in orderfor them to logically structure their study. This “middle of the ladder” position of frameworks, theories and concepts moves to a lower rungwhere the empirical is located. The empirical is about that which can be observed through the senses.The empirical includes the variables, which are measured and described in quantitative research studiesand the story that is described in qualitative studies. Table 2 outlines the concepts with their conceptualdefinitions and the accompanying variables with their operational definitions from the Mahon,Yarcheski and Yarcheski (2000) study. A conceptual definition is much like a dictionary definition, conveying the general meaning ofthe concept. However, the conceptual definition goes beyond the general language meaning found in thedictionary by defining the concept as it is rooted in the theoretical literature. The operational definitionspecifies how the concept will be measured….what instruments will be used to capture the variable. Inlooking closely at the language used to describe conceptual and operational definitions (Table 2), thecritiquer will notice that operational definitions are lower on the ladder of abstraction than conceptualdefinitions. The language of the operational definition is closer to the ground. HELPFUL HINT Some reports of research embed conceptual definitions in the literature review. It is wise for the critiquer to seek and find the conceptual definitions so that the logical fit between the conceptual and operational definitions can be determined.
  7. 7. The middle of the ladder: Frameworks, theories and concepts It is important to consider the middle of the ladder of abstraction, where concepts, theories andframeworks are located. Pretend to look at the middle section through a magnifying glass so that what islocated there can be distinguished and clarified. Concepts, theories and frameworks can be compared toeach other from the perspective of abstraction, concepts being the lowest on the ladder and frameworkshighest. However, some concepts are closer to the ground than others. The same is true for theories andframeworks. For instance, the concept of pain relief is closer to the ground than the concept of caring.The idea of varying levels of abstraction within the middle of the ladder will be emphasized in thesection addressing theories but it has relevance for concepts and frameworks as well. Concepts A concept is an image or symbolic representation of an abstract idea. Chinn and Kramer (1999)define a concept as a “complex mental formulation of experience”. Concepts are the major componentsof theory and convey the abstract ideas within a theory” (p. 252). Already, the reader has beenintroduced to several concepts, such as trait and state anger, well-being and vigor. The concepts of thetheory of attentively embracing story, intentional dialogue, connecting with self-in relation and creatingease, have been defined and their relationship has been modeled for the reader. Each concept creates amental image, which is explained further through the conceptual definition. For instance, pain is aconcept and when it comes to mind, it means something based on experience. The experiential meaningof the concept is different for the child who had just fallen off a bike, or the elderly person withrheumatoid arthritis or the doctorally prepared nurse who is studying pain mechanisms using an animalmodel. These definitions and associated images of the concept of pain incorporate different experientialand knowledge components…all with the same label, pain. Therefore, it is important to know themeaning of the concept for the person. In the case of the critiquer, it is important to know the meaningthat the researcher gives to the concepts in a research study. As outlined in Table 2, Mahon, Yarcheskiand Yarchesi (2000) very clearly defined the concepts of interest in their study. Theories A theory is a set of interrelated concepts, which structure a systematic view of phenomena for
  8. 8. the purpose of explaining or predicting. A theory is like a blueprint, a guide for modeling a structure. Ablueprint depicts the elements of a structure and the relation of each element to the other, just as a theorydepicts the concepts, which compose it and the relation of concepts with each other. Chinn and Kramer(1999) define a theory as an “expression of knowledge….a creative and rigorous structuring of ideas thatproject a tentative, purposeful, and systematic view of phenomena.” (p. 258). Theories are located on theladder of abstraction relative to their scope. An often-used label in nursing is Grand Theory, whichsuggests a broad scope, covering major areas of importance to the discipline. Grand theories arose at atime when nursing was addressing its nature, mission and goals (Im & Meleis, 1999). Therefore, it ishistorically important. However, the importance of grand theory extends beyond history to haveimplications for guiding the discipline today and in the future. For the purpose of introducing thecritiquer to theory as a framework for nursing research, grand theory, midrange theory and micro-rangetheory will be discussed. As is suggested by the names of these theory categories, grand theories arehighest and micro-range theories are lowest in level of abstraction. Grand Theory Theories unique to nursing help the discipline define how it is different from other disciplines.Nursing theories reflect particular views of person, health, environment and other concepts thatcontribute to the development of a body of knowledge specific to nursing’s concerns (Feldman, 1998).Grand theories are all-inclusive conceptual structures, which tend to include views on person, healthand environment to create a perspective of nursing. This most abstract level of theory has established aknowledge base for the discipline and is critical for further knowledge development in the discipline. There are several well-known nursing theorists whose grand theories have served as a basis forpractice and research. Among these theories are Rogers’ (1990; 1992) science of irreducible humanbeings; Orem’s (1995) theory of self-care deficit; Neuman’s theory of health as expandingconsciousness (1997); Roy’s adaptation theory (1991); Leininger’s culture care diversity anduniversality theory (1996); King’s goal attainment theory (1997); and, Parse’s theory of humanbecoming (1997). Each of these grand theories addresses the phenomena of concern to nursing from adifferent perspective. For example, Rogers views the person and the environment as energy fieldscoextensive with the universe. So, she recognizes the person-environment unity as a mutual process. Incontrast, King (1997) distinguishes the personal system, from the interpersonal and social systems,focusing on the interaction between the systems, and the interaction of the systems with theenvironment. So, for King, person and environment are interacting as separate entities. This is different
  9. 9. than the person-environment mutual process described by Rogers. If a researcher is using Roger’s theory to guide plans for a study, the research question willreflect different values than if the researcher is using King. The researcher using Roger’s theory mightstudy the relationship of therapeutic touch, to other phenomena which reflect a valuing for energy fieldsand pattern appreciation, while the one using King might study outcomes related to nurse-patient sharedgoals or other phenomena related to interacting systems. It is important for the critiquer to realize thatone grand theory is not better than another. Rather, these varying perspectives allow the nurse-researcherto select a framework for research, which facilitates movement of concepts of interest down the ladderof abstraction to the empirical level, where they can be measured as study variables. What is mostimportant about the use of theoretical frameworks for research is the logical connection of the theory tothe research question and the study design. Midrange Theory Mid-range theory is a focused conceptual structure, which synthesizes practice-research intoideas central to the discipline. Merton (1968), who has been the original source for much of Nursing’sdescription of mid-range theory, says that mid-range theory lie between everyday working hypothesesand all-inclusive grand theories. The critiquer might notice that Merton’s view of the “middle” allowsfor a great deal of space…between grand theories and hypotheses. This expansive view of the “middle”has been noted and efforts have been made to more clearly articulate the middle, as well as distinguishthe characteristics of midrange theory. Liehr and Smith (1999), in a ten year review of nursing literatureusing specific criteria, identified 22 midrange theories. Following the suggestion of Lenz (1996), theyconsidered the scope of the 22 midrange theories and grouped the 22 into high-middle, middle-middleand low-middle categories using the theory names (Table 3). The critiquer will recognize that thegroupings move from a higher to a lower level of abstraction. Because midrange theories are lower inlevel of abstraction than grand theories, they offer a more direct application to research and practice. Asthe level of abstraction decreases, translation into practice and research simplifies. In their conclusion,Liehr and Smith (1999) recommend that nurses thoughtfully construct midrange theory weaving practiceand research threads to create a whole fabric, which is meaningful for the discipline. Hamric, Spross andHanson (2000) in their text on advanced nursing practice call midrange theories to the attention ofadvanced practice nurses: “Middle-range theories address the experiences of particular patient populations or a cohort of people who are dealing with a particular health or illness issue……Because middle range theories are more specific in what they explain, practitioners often find them more directly
  10. 10. applicable…” (p. 159). The theory of attentively embracing story, introduced in the beginning of this chapter as one, which Kate was using to guide her practice and research, is a middle range theory. The theory was generated from nursing practice and research experience (Smith & Liehr, 1999). Micro-range theory Micro-range theory is a linking of concrete concepts into a statement that can be examined in practice and research. Higgins and Moore (2000) distinguish two levels of micro- range theory, one of higher level abstraction than the other. Micro-range theory at the higher level of abstraction, they suggest, is closely related to midrange theory, comprised of a limited number of concepts and applicable to a narrow issue or event (Higgins & Moore, 2000) The low- middle theory in Table 3 may fit this category. Hypotheses are an example of low abstraction micro-range theories. The critiquer will recall that a hypothesis is a best guess or prediction about what one expects to find. Chinn and Kramer (1999) define a hypothesis as a “tentative statement of relationship between two or more variables that can be empirically tested” (p. 254). Higgins and Moore (2000) emphasize the value of micro-range theory, noting that the “particularlistic approach is invaluable for scientists and practitioners as they work to describe, organize and test their ideas” (p 181). As you read this text, you could articulate a micro-range theory at the level of a hypothesis. In the beginning of the Chapter, Kate formulated a hypothesis about the relationship between patient-health care provider interaction and blood pressure. Although Kate didn’t label her idea as a hypothesis, it was a best guess based on observation. If you would take a minute to think about it, some experience from nursing practice, which has provoked confusion, could be stated as a hypothesis. A mismatch between what is known or commonly accepted as fact and what one experiences creates a hypothesis-generating moment. Every nurse has hypothesis- generating moments. Cultivating these moments requires noticing them, focusing observation to untangle details, and allowing time for creative thinking and dialogue (Liehr, 1992), leading to possibilities for creating low level micro-range theory…. or hypotheses. HELPFUL HINTThe critiquer of research will find mixed messages about levels and placement of theory. While oneauthor labels a particular theory “grand”, another author will label the same theory “midrange”. Thecritiquer can read the theory carefully and place it on the ladder of abstraction. If the theory is at the
  11. 11. more concrete level on the ladder, then it falls into micro-theory.Frameworks for researchThe critical thinking decision path (Figure 4) takes the critiquer through the thinking of a researcherwho is about to begin doing research. It is reasonable for the critiquer to expect to find some but notall of the phases of decision-making addressed in a research manuscript. Beginning with the view ofthe world, the highest rung on the ladder of abstraction, the researcher is inclined to approach aresearch problem from a perspective of inductive or deductive reasoning. If going in the direction ofinductive reasoning, the researcher will generally not present a framework before beginningdiscussion of the methods. This is not to say that literature will not be reviewed before introducingmethods. As an example, consider the Cohen and Ley (2000) manuscript in Appendix C. The authorsprovide a brief overview of the increasing prevalence of bone marrow transplant as a treatment forcancer and they describe several studies which examined dimensions of life for persons undergoingtransplant. The point of their literature review is to establish a case for doing the research they arereporting. They do not provide a framework for the study because they are planning an inductiveapproach to study the problem. Their intent is to be free of the structures, which may limit what theylearn; and, to be open to the experience of the person who is living through a bone marrow transplant. Referring back to Figure 4, if one’s view of the world guides deductive reasoning, the researcherwill go in one of two directions; a choice will be made between a conceptual or a theoreticalframework. The critiquer will notice when reading the theory literature that these terms are usedinterchangeably (Chinn & Kramer, 1999). However, in this case, each term is being distinguishedfrom the other on the basis of whether the researcher is creating the structure or whether the structurehas already been created by someone else. Generally, each of these terms refers to a structure, whichwill provide guidance for research. If it is a conceptual framework, it is a structure of conceptsand/or theories which are pulled together as a map for the study. If it is a theoretical framework, it isstructure of concepts which exists in the literature, a ready-made map for the study To better understand these differences, refer to the manuscript by Mahon, Yarcheski andYarcheski (2000) in Appendix B. These authors create a conceptual framework for their studyincorporating Spielberger’s anger theory with the four concepts, well-being, symptom patterns, vigor,and willingness to change. This framework is shared as a model and the critiquer is able to follow thelogic of the study by referring to the conceptual framework. In contrast, the manuscript by LoBiondo-Wood, Williams and Kouzekanani (2000) (Appendix D) uses a theoretical framework to guide their
  12. 12. research, the Double ABC-X Model of Family Adaptation. Although not a nursing theory, the Model of Family Adaptation is a tested structure, which some would label a midrange theory. The authors focus on one piece of the Model, the post-crisis period, which includes the five concepts, pile-up, existing new resources, coping, perception of stressor and adaptation. Each of these concepts is presented with clear indication of how it was measured in this sample of mothers of transplant children. The Double ABC-X Model of Family Adaptation logically guides the choice of variables and measures. Instead of creating a structure, these authors used a theoretical framework, which already existed in the literature. HELPFUL HINTWhen researchers use conceptual frameworks to guide their studies, you can expect to find a system ofideas, synthesized for the purpose of organizing thinking and providing study direction. From the perspective of the critical thinking decision path outlined in Figure 4, theoreticalframeworks can be grand, midrange or micro-range theories. Whether the researcher is using aconceptual or theoretical framework, conceptual and then operational definitions will emerge from theframework. The decision path (Figure 4) moves down the ladder of abstraction from the philosophicalto the empirical level, tracking thinking from the most abstract to the least abstract for the purposes ofplanning a research study. Critiquing the framework The framework for research provides guidance for the researcher as study questions are fine-tuned, methods for measuring variables are selected and analyses are planned. Once data are collectedand analyzed, the framework is used as a base of comparison. Did the findings coincide with theframework? If there were discrepancies, is there a way to explain them using the framework? Thecritiquer of research needs to know how to critically appraise a framework for research (FrameworkCritiquing Criteria box-end of chapter). The first question posed is whether a framework is presented. Sometimes, there may be astructure guiding the research but a diagrammed model is not included in the manuscript. The readermust then look for the study structure in the narrative description of the study concepts. When theframework is identified, it is important to consider its relevance for nursing. The framework doesn’thave to be one created by a nurse but the importance of its content for nursing should be clear. Thequestion of how the framework depicts a structure congruent with nursing should be addressed. Forinstance, although the Double ABC-X Model was not created by a nurse, it is clearly related to nursing
  13. 13. practice with families. Sometimes, frameworks from very different disciplines, such as physics or art,may be relevant. It is the responsibility of the author to clearly articulate the meaning of the frameworkfor the study and to link the framework to nursing. Once the meaning and nursing-relatedness are articulated, the critiquer will be able to determinewhether the framework is appropriate to guide the research. For instance, if a researcher is studyingstudents’ response to the stress of being in the clinical setting for the first time and presents a frameworkof stress related to recovery from chronic illness….something is the matter. This is a blatant mismatch,which generally won’t occur. However, subtle versions of mismatch will occur. So, the critiquer willwant to look closely at the framework to determine if it is “on target” and the “best fit” for the researchquestion and proposed study design. Next, focus on the concepts being studied. Does the reader know which concepts are beingstudied, how they are defined and translated into measurable variables? Is there literature to support thechoice of concepts? Concepts should clearly reflect the area of study; for example, using the generalconcept of stress when anxiety is more appropriate to the research focus creates difficulties in definingvariables and determining methods of measurement. These issues have to do with the logicalconsistency between the framework, the concepts being studied and the methods of measurement. Allalong the way, from view of the world to operational definitions (Figure 4), the critiquer is evaluatingfit. Consider once more the paper by LoBiondo-Wood, Williams and Kouzekanani (2000) (AppendixD). The authors provide a logically consistent link between the Double ABC-X Model of FamilyAdaptation; the concepts diagrammed in the post-crisis phase of the model; and, the measures used toaddress each concept. Finally, the critiquer will expect to find a discussion of the findings as they relateto the model. This final point enables evaluation of the framework for use in further research. It maysuggest necessary changes to enhance the relevance of the framework for continuing work. So, it is aplace for letting others know where one will go from here. Evaluating frameworks for research requires skill, which can only be acquired through repeatedcritique and discussion with others who have critiqued the same manuscript. The novice critiquer ofresearch must be patient as these skills are developed. With continuing education and a broaderknowledge of potential frameworks, one builds a repertoire of knowledge to judge the foundation of aresearch study….the framework for research.nREFERENCES Bull, MJ, Hanson, HE & Gross, CR: A professional-patient partnership model of discharge
  14. 14. planning with elders, Applied Nursing Research 13:19-28, 2000. Chinn PL, Kramer MK: Theory and nursing: a systematic approach, ed 5, St Louis, 1999,Mosby. Cohen, MZ & Ley, CD: Bone marrow transplantation: The battle for hope in the face of fear.Oncology Nursing Forum, In press. Hamric, AB, Spross, JA & Hanson CM:Advanced Nursing Practice, Philadelphia, 2000,Saunders. Higgins, PA & Moore, SM: Levels of theoretical thinking in nursing, Nursing Outlook48(4):179-183, 2000. Im E. & Meleis AI: Situation-specific theories: Philosophical roots, properties and approach.Advances in Nursing Science 22(2):11-24, 1999. King IM: King’s theory of goal attainment in practice, Nursing Science Quarterly 10(4):180-185,1997. Leininger, MM. Culture care theory. Nursing Science Quarterly 9(2):71-78, 1996. Lenz, E: Middle range theory-Role in research and practice, In Proceedings of the sixthRosemary Ellis scholar’s retreat, Nursing science implications for the 21 st century. Cleveland Ohio:Frances Payne Bolton School of Nursing, Case Western Reserve University, 1996. Liehr, P: Prelude to research, Nursing Science Quarterly, 5(3):102-103, 1992. Liehr P. & Smith MJ: Using story to guide nursing practice, International Journal of HumanCaring 4(2):13-18, 2000. Liehr P. & Smith MJ: Middle range theory: Spinning research and practice to create knowledgefor the new millennium, Advances in Nursing Science 21(4):81-91, 1999. LoBiondo-Wood, G, Williams, L & Kouzekanani K: Family adaptation to a child’s transplant:Pretransplant phase, Progress in Transplantation, In press. Mahon NE., Yarcheski, A & Yarcheski: TJ. Positive and negative outcomes of anger in earlyadolescents, Research in Nursing and Health 23:17-24, 2000. Merton RK: On sociological theories of the middle range. In Social Theory and Social Structure.New York, 1968, Free Press. Newman, MA: Evolution of the theory of health as expanding consciousness, Nursing ScienceQuarterly 10(1):22-25, 1997. Orem, DE: Nursing: Concepts of practice, ed 5, St. Louis, 1995, Mosby. Parse, RR: Transforming research and practice with the human becoming theory, Nursing
  15. 15. Science Quarterly 10(4):171-174, 1997. Rogers, ME: Nursing: Science of unitary, irreducible human beings: Update 1990. In E. Barrerr(Ed). Visions of Rogers’ science-based nursing, New York, 1990, National League for Nursing. Rogers, ME: Nightingale’s notes on nursing: Prelude to the 21st century, In Notes on nursing:What it is and what it is not. Commemorative Ed. Philadelphia, 1992, Lippincott Roy C. & Andrews HA: The Roy adaptation model: The definitive statement, Norwalk, 1991,Appleton & Lange. Smith, MJ & Liehr, P: Attentively embracing story: A middle range theory with practice andresearch implications, Scholarly Inquiry for Nursing Practice 13(3):3-27,1999.
  16. 16. Table 1: Issues affecting BP change and related research questionsIssues Research questionsNumber of people in patient’s room Is there a difference in BP for patients in CCU when interacting with one person as compared to interacting with two people or a group of three or more people?Involvement of patient For the patient in CCU, what is the relationship between BP and the amount of time spent listening to the healthcare team’s discussion of personal qualities during routine rounds? What is the effect of nurse-patient intentional dialogue on BP within the hour after the dialogue?Continuing effect of experience on BP over the What is the BP pattern of patients in CCU from thenext hour beginning of routine healthcare rounds until 1 hour after the completion of rounds?Content of dialogue What is the relationship between issues discussed during intentional dialogue and BP?Meaning of experience for the patient What is the patient experience of being the object of routine healthcare rounds? What is the patient experience of sharing what matters with a nurse while in the CCU?BP: blood pressureCCU: coronary care unitTable 2 Concepts and Variables: Conceptual and Operational DefinitionsConcept Conceptual Variable Operational Definition DefinitionTrait anger Disposition of individuals to Trait anger Spielberger Trait anger scale perceive a wide range of situations as frustrating or annoying, tending to respond to 10 items that assesses how angry such situations with elevations one generally feels in state anger. (p. 17)State anger Emotional state marked by State anger Spielberger State anger scale subjective feelings that vary in intensity from mild annoyance 10 items that assesses how angry or irritation to intense fury and one is feeling right now range (p. 17)General Holistic, multidimensional General Short version of Adolescent
  17. 17. well-being construct incorporating well-being General Well-Being mental/psychological, physical questionnaire and social dimensions (p. 18) 39 items that assess the social, physical, and mental dimensions of well-beingSymptom Physical, psychological and Symptom Symptom Pattern Scalepatterns psychosomatic patterns (p.18) patterns 17 items that measure physical, psychological and psychosomatic manifestations of psychological distressVigor Mood or vigorousness, Vigor- Vigor-activity subscale of the ebullience and high energy (p. activity Profile of Moods States 19) 8 item adjective checklist used to measure vigorInclination to Seeking new and different Change Change subscale of thechange experiences, readily changing Personality Research Form-E opinions or values in different circumstances, and adapting 16 true-false items assessing readily to changes in the inclination to change environment (p. 19)Mahon, Yarcheski & Yarcheski, 2000Table 3: Middle range theory by level of abstractionHigh middle Middle middle Low middleCaring Uncertainty in illness Hazardous secrets and reluctantly taking chargeFacilitating growth and Unpleasant symptoms Affiliated individuation as adevelopment mediator of stressInterpersonal perceptual Chronic sorrow Women’s angerawarenessSelf-transcendence Peaceful end of life Nurse-midwifery careResilience Negotiating partnerships Acute pain managementPsychological adaptation Cultural brokering Balance between analgesia and side effects Nurse expressed empathy and Homelessness-helplessness patient distress Individualized music intervention for agitation Chronotherapeutic intervention for post-surgical painLiehr & Smith, 1999
  18. 18. Figure 4: Critical Thinking Decision Path Guided by a view of the world the researcher uses: highest level of discourse Deductive reasoning or Inductive reasoningto create a structure to identify a structure to begin to pieceto guide research to guide research together data to addressConceptual Theoretical Framework a research questionFramework Grand theory Midrange theory Micro-range theory The researcher poses the research question & the conceptual definitions of study variables and lowest level uses operational definitions to articulate of discourse measurement of the study variables
  19. 19. Figure 1 Attentively Embracing Story Connecting with Self-in-Relation personal history reflective awareness Intentional DialogueNurse true presence querying emergence Person Creating Ease re-membering disjointed story moments flow in the midst of anchoring