Advances in Nursing ScienceVol. 41, No. 3, pp. 293–302Copy.docx

Advances in Nursing Science
Vol. 41, No. 3, pp. 293–302
Copyright c© 2018 Wolters Kluwer Health, Inc. All rights
reserved.
The Nursing Knowledge Pyramid
A Theory of the Structure of Nursing
Knowledge
Veronica B. Decker, DNP, PMHCNS-BC, MBA; Roger M.
Hamilton, PhD
A theory of the structure of nursing knowledge is proposed.
Using retroductive reasoning
to build upon an existing theory, the goal of the Nursing
Knowledge Pyramid is to integrate
disparate forms of nursing knowledge into a comprehensive,
coherent, and useful structure
to enhance the learning, development, automation, and
accessibility of nursing knowledge.
Education uses are discussed. Key words: machine knowledge,
nursing knowledge, tacit
knowledge, theory
N URSES must have the required knowl-edge, skills, and
attitudes necessary to
take actions that will achieve optimal patient
outcomes. When it comes to the knowledge
part of a nurse’s job, an important question is
how the nursing knowledge base should be
structured so that it is most useful to nurses
in practice. Knowledge structures are impor-

tant for nursing practice because they shape
nursing behavior.1
However, nursing knowledge, like knowl-
edge in other disciplines, is not a single depos-
itory of well-ordered knowledge,2 and long
ago Donaldson and Crowley3 encouraged
nurse authors to seek a means of explicating
the nursing discipline’s body of knowledge.
More than 30 years later, the problem was
still challenging, as Kim1 concluded that
having a unifying framework for epistemo-
Author Affiliations: University of Central Florida
College of Nursing, Orlando (Dr Decker); and
Consultant, Mt Dora, Florida (Dr Hamilton).
The author declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this editorial.
Correspondence: Veronica B. Decker, DNP, PMHCNS-
BC, MBA, University of Central Florida College of Nurs-
ing, 12201 Research Pkwy, Ste 300, Orlando, FL 32826
([email protected]).
DOI: 10.1097/ANS.0000000000000204
logical discussions about nursing knowledge
was critical. Addressing this need, in this
article, we present an overview of a unifying
theory of the structure of nursing knowledge,
the Nursing Knowledge Pyramid (NKP)
(Figure 1).
Science uses 3 kinds of reasoning: de-

duction, induction, and retroduction.4 Sim-
ply stated, deduction is top-down, general-to-
specific reasoning; induction is bottom-up,
specific-to-general reasoning; and retroduc-
tion is the improvement of existing theories.1
In the NKP, moving from bottom to top is de-
ductive whereas moving from top to bottom
is inductive. Retroductive reasoning improves
existing theory wherever it is appropriate and
is best illustrated in Figure 2.
As shown in Figure 2 (left), the current
highest-level organizing structure of nursing
knowledge may be the Structural Holarchy of
Contemporary Nursing Knowledge (hereafter
“holarchy”).5(p4) Fawcett called the holarchy a
theory of the structure of nursing knowledge.
It consists of a metaparadigm, philosophies,
conceptual models, theories, and empirical in-
dicators in a holarchy organized by decreasing
levels of abstraction. Using retroductive rea-
soning, we build upon this theory to create an
alternative theory—the NKP (Figure 2, right).
We do so because we hypothesize that the
NKP structure better supports the learning,
development, automation, and accessibility
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized
reproduction of this article is prohibited.
293
mailto:[email protected]

294 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER
2018
Statements of Significance
What is known to be true or assumed
to be true about this topic:
• Nursing knowledge structures
shape nursing practice.
• The highest-level organizing
structure for nursing knowledge
may be the Structural Holarchy
of Contemporary Nursing
Knowledge, a theory consisting
of a metaparadigm, philosophies,
conceptual models, theories, and
empirical indicators arranged in a
holarchy organized by
decreasing levels of abstraction
What this article adds:
• Using retroductive reasoning, the
proposed NKP builds upon the
Structural Holarchy of
Contemporary Nursing
Knowledge to provide an
alternative theory of the
structure of nursing knowledge
• The NKP theory may better
support the learning,
development, automation, and
accessibility of nursing

knowledge and therefore may
better support nursing practice.
• As one exemplar, nurse
educators and nursing students
should consider using the NKP as
a powerful cognitive tool for
organizing the teaching and
learning of nursing knowledge.
of nursing knowledge and therefore will be
more useful to nurses.
For example, we propose that all nurs-
ing knowledge can be categorized using the
NKP. That is, every component of nursing
knowledge should be locatable in the NKP,
regardless of the knowledge source. Whether
a piece of knowledge is an entry into a
database table, a blood pressure reading, a
theory, or a nurse’s intuition, if the NKP
is truly exhaustive, the knowledge should
map to some component(s) of the pyramid.
Once the piece of knowledge is located on
the pyramid, whether it is a new idea or an
old one, the nurse then seeks to fill out each
block of the pyramid to create a deep, ratio-
nal, coherent, well-developed idea. This pro-
cess leads to the learning of existing knowl-
edge, the development of new knowledge,
and the automation of all but intuitive knowl-
edge. The details are provided later, however,
think of the NKP as the building blocks of
knowledge, from the most abstract to the
most concrete.

To determine how to organize our discus-
sion, we first need to decide which available
theory template, which we call a meta-theory
in this article, is appropriate. To leverage the
integrity of the holarchy as much as possi-
ble, we adapted the Fawcett and DeSanto-
Madeya analysis and evaluation nursing theory
organizing framework as our meta-theory, as
shown in the Table.5 Therefore, the NKP the-
ory analysis overview (part 3) is analyzed ac-
cording to its definition, scope, content, and
context. External critics can then evaluate the
theory according to the evaluation structure
of the Table meta-theory (part 4).
ANALYSIS
Definition of a theory
A theory is “the creative and rigorous
structuring of ideas that projects a tenta-
tive, purposeful, and systematic view of
phenomenon.”6(p255) Since Fawcett described
her holarchy, upon which we build the NKP,
as a theory of the structure of nursing knowl-
edge, so shall we. It is a grand theory in scope
and a descriptive theory in purpose. Overall,
our purpose is to build a more useful structure
of nursing knowledge.
Theory scope
Kim1 identified 4 levels of theory in
decreasing levels of scope: grand, meso,
middle-range, and micro. Grand theories

further develop a particular aspect of a
Nursing Knowledge Pyramid 295
Figure 1. The Nursing Knowledge Pyramid.
conceptual model.5 A specific kind of con-
ceptual model with a specific purpose is a
discipline boundary metaparadigm (without
the “-”), which places a boundary on the
phenomenon of interest.5 Our selected nurs-
ing discipline boundary conceptual model,
the Metaparadigm of Nursing, consists of the
4 concepts (the “nouns” bounding a disci-
pline) of nursing, human beings, health, and
environment.5 Because the NKP addresses
the structure of knowledge required to en-
act optimal nursing actions, the NKP devel-
ops the concept of nursing. The NKP theory
can, therefore, be classified as a grand theory.
Theory context
The phenomenon of interest is the struc-
ture of nursing knowledge at its most inclu-
sive, most comprehensive level. It has rele-
vance to what the profession knows and what
a nurse knows. Epistemology is the branch of
philosophy related to the nature and extent
of human knowledge, that is, a system of jus-

tified true beliefs.7 The guiding philosophy
of the NKP is epistemological coherentism,
which is a foundational theory that is based
on justifications and implies that for a belief
to be justified, the range of beliefs it is based
on must cohere with one another.”7 The se-
lections for the abstraction levels of the NKP
will visibly support each other if they are log-
ically coherent.
Theory content
Our purpose is to propose a nursing knowl-
edge framework that facilitates the learn-
ing, development, automation, and accessi-
bility of nursing knowledge by retroductively
enhancing the holarchy theory it is based on.
As shown in Figure 2 (right), the NKP the-
ory enhanced the holarchy theory through
6 innovations: (1) added the tacit knowledge
2018
Figure 2. The Structural Holarchy of Contemporary Nursing
Knowledge (left)5(p4) and the Nursing Knowledge
Pyramid (right). The shaded areas represent common
components. From Fawcett and DeSanto-Madeya.5 Used
with permission.
abstraction level; (2) surfaced the database

abstraction-level idea from the narrative to the
diagram; (3) reversed the level-of-abstraction
direction; (4) added knowledge meta-types;
(5) wrapped the abstraction levels in a pyra-
mid metaphor; and (6) added knowledge
groups. As Wallis reminds us: “The creation
of each theory requires a tradeoff between
simplicity, generality, and accuracy.”2(p82) Al-
though the NKP diagram is more complex
than the holarchy diagram, our goal in the
NKP diagram is to hit a cognitive “sweet
spot” by increasing its self-explanatory con-
tent without making it overly complex, which
discourages comprehension.6 Readers will
need to refer to Figure 2 (right), as the follow-
ing sections briefly describe the major con-
cepts of the NKP and the rationales for these
changes to the holarchy.
Abstraction levels
Tacit knowledge
The discipline of nursing is concerned with
what the nurse knows but has not been made
explicit. Tacit knowledge is the naturally oc-
curring intuitive or prescient knowledge that
is accessible to nurses but cannot be articu-
lated. Intuition refers to the ability to quickly
appraise the situation and act without con-
scious reasoning and has been proposed as
an important explanatory concept that influ-
ences nursing practice.1 Prescient knowledge
knows what is going to happen before it hap-
pens. For example, a nurse’s “gut feeling” may

inform an intervention decision, but the nurse
Table. Example of a Meta-Theoretical
Structure Outline
1. Name (source): Framework for Analysis
and Evaluation of Nursing Theories5(p311)
2. Definition of meta-theory
3. Analysis
Step 1: Theory scope
Step 2: Theory context
Step 3: Theory content
4. Evaluation
Step 1: Significance
Step 2: Internal consistency
Step 3: Parsimony
Step 4: Testability
Step 5: Empirical adequacy
Step 6: Pragmatic adequacy
may not be able to articulate the source of that
feeling. Tacit knowledge is inherently disor-
ganized. If it became consciously organized,
it could be articulated and become explicit
knowledge.

We believe tacit knowledge is important
to any exhaustive typology of nursing knowl-
edge. It is placed at the bottom of the pyra-
mid because all knowledge is rooted in tacit
knowledge.8
Philosophies
Philosophies are the epistemological, onto-
logical, aesthetic, logical, metaphysical, and
ethical claims of a discipline. In other words,
they are the broad perspective for practice, re-
search, and scholarship9 and the foundation
for any theory development.10
Paradigms/conceptual models
The next level of the NKP reflects a
philosophical stance11 and addresses the
paradigms and conceptual models that pro-
vide alternative ways to view the subject mat-
ter of a discipline and the central concepts
of a discipline. Fawcett and DeSanto-Madeya
defined conceptual models as:
A set of relatively abstract and general concepts
that address the phenomena of central interest to
a discipline, the propositions that broadly describe
those concepts, and the propositions that state rel-
atively abstract and general relations between two
or more of the concepts.5(p13)
Theories
There are 4 kinds of types or purposes
of theories: descriptive, explanatory, predic-

tive, and prescriptive.1 Descriptive theories
are the most basic of theories and describe
the essence of the phenomenon under study:
its concepts, properties, and dimensions.12
Here, the phenomenon is the structure of
nursing knowledge and the theory was cre-
ated through a critical evaluation of the
holarchy—specifically examining its empir-
ical and pragmatic adequacy—and finding
opportunities for improvement. Addressing
these inadequacies led to the NKP descriptive
theory.
Empirical indicators
Empirical indicators are the second from
the highest tier in the NKP and bring forth
the lower abstraction levels into the real
world. Empirical indicators measure concepts
and are the basis for evidence-based practice.
More specifically:
An empirical indicator is defined as a very concrete
and specific real-world proxy for a middle-range
theory concept—an actual instrument, experimen-
tal condition, or procedure that is used to observe
or measure a middle-range theory concept. The in-
formation obtained from empirical indicators typi-
cally is called data.5(p17)
Databases
The data in nursing knowledge can be
found in databases—organized collections of
data. This level recognizes the reality that

the nursing knowledge base is distributed be-
tween humans and machines. In the NKP, the
term “databases” are used as a general term to
denote explicit or original nursing knowledge
that resides on machines.
Fawcett and DeSanto-Madeya5 mention
“patient databases” and “computer informa-
tion systems” as part of the holarchy empiri-
cal indicators abstraction-level narrative. This
approach may be problematic because they
group nonempirical indicator knowledge un-
der the empirical indicator label. For exam-
ple, while typical real-world empirical indica-
tors (eg, a patient’s blood pressure readings
over a week) can be stored in a database,
other kinds of databases exist that do not con-
tain empirical indicators. Would collections
of nursing theories, nursing interventions, or
nursing decision-making strategies be empiri-
cal indicators? We think not. And what would
you call the data generated by an empirical
study that is stored in a database table but
has not yet been analyzed and interpreted? It
is nursing knowledge, but it is not tacit hu-
man knowledge and is not yet explicit human
knowledge. These are examples of a different
kind of knowledge, which we call machine
knowledge, discussed later.
Also, collections of data have their own
emergent knowledge, distinct from individual

2018
pieces of knowledge. For example, knowl-
edge discovery techniques such as data min-
ing and text mining can uncover hidden
knowledge by looking for patterns and rela-
tionships within the data and text, thereby
generating new knowledge. This knowledge-
producing function of machine knowledge
may be hidden behind the empirical indica-
tors label in the holarchy, but it is not explicit.
Note that although not all explicit knowl-
edge needs to be databased to be useful, do-
ing so makes knowledge useable by pow-
erful automated analytical tools and widely
accessible to nursing stakeholders. For ex-
ample, the scholarly nursing journal Nurse
Education Today and many other journals
encourage authors to enable readers to link
to the actual data sets referenced in their
articles.13
This level of the NKP is placed at the apex
because the contents of the databases depend
on the knowledge in the lower levels of ab-
straction, and is more specific than the lower
levels. This type of knowledge will become
more important as the field of nursing infor-
matics grows and more nursing knowledge is
databased and made more accessible.
Knowledge meta-types

Why does the NKP have a line down the
middle? The substance at each level of abstrac-
tion is important and so is its form. Except for
the inherently disorganized tacit knowledge
level, the vertical line in the NKP diagram di-
vides each abstraction level into 2 parts: (1)
an overarching structure (the “meta-” on the
left side, of which there can be more than 1 to
select from [hence the “1 . . . n” subscript]);
and (2) the substance in that structure (the
examples on the right side, of which there
can also be more than 1 to select from). The
Table shows an outline of a “meta-” (left side)
at the theories level, which is adapted from
Fawcett and DeSanto-Madeya.5
To avoid confusion, note that at the level
of paradigm/conceptual models, a “meta-
paradigm” is not the same as a “meta-
paradigm.” We use the “meta-” prefix to in-
dicate a structure and “meta” (without the
“-”) to refer to a higher abstraction level
within an example, such as the Metaparadigm
of Nursing. Kim1 noted the importance of
both metatheorizing and substantive theoriz-
ing to more richly develop nursing knowl-
edge. Meta-types provide an ideal structure
for discussing the examples, acting as a qual-
ity control, so they are located next to, and
immediately accessible to, the examples in
the NKP. They also provide the ability to
compare, contrast, and evaluate examples sys-
tematically (eg, comparing 2 theories). Al-
though Fawcett and DeSanto-Madeya5 exten-

sively discuss model and theory frameworks
in their book, they are only tangentially asso-
ciated with the holarchy theory, which does
not include frameworks. Because we believe
these frameworks are valuable components
of the nursing knowledge base, we have in-
cluded them as an integral part of the NKP
theory and brought them forward in the NKP
diagram.
Knowledge groups
The NKP theory groups the vertical abstrac-
tion knowledge levels into tacit knowledge,
explicit knowledge, and machine knowledge
(Figure 3). As discussed previously, tacit
knowledge is the naturally occurring, but inar-
ticulable, intuitive, and prescient knowledge
that is accessible to each nurse individually.
Explicit knowledge is the declarative, proce-
dural, conditional, and structural knowledge
deliberately accessible to nurses that can be
articulated. Machine knowledge is explicit or
original knowledge that resides on machines
such as computers.
There are at least 2 reasons for creating
knowledge groups: (1) they provide cogni-
tive scaffolding for learning the abstraction
levels; and (2) they provide an entry into
the pyramid for the discipline of knowledge
development. To illustrate this, by adapting
the SECI (socialization-externalization-
combination-internalization) knowledge
conversion model,14 Figure 3 shows how
knowledge can be converted and developed

Figure 3. The Nursing Knowledge Pyramid translated for
knowledge development.
from one knowledge group to another using
the strategy exemplars shown. For example,
tacit knowledge can be converted to explicit
knowledge by using externalization strate-
gies such as interviews and questionnaires.
Likewise, machine knowledge can be con-
verted to explicit human knowledge through
knowledge discovery techniques such as data
mining and text mining.
Pyramid metaphor
Why use a metaphor? We recognized an
opportunity to create a metaphor as a cogni-
tive tool to enhance the teaching and learn-
ing of nursing knowledge. Educational re-
search shows that students excel when the
teacher’s teaching styles are congruent with
their learning styles.15 The Kolb Learning
Style Inventory classifies learners into 4 dis-
tinct styles: divergers, assimilators, converg-
ers, and accommodators.16 Most first-year un-
dergraduate nursing students, as measured by
the Kolb Learning Style Inventory, have ei-

ther a diverger or assimilator learning style.17
Divergers have a strong imagination, are
aware of meanings and values, and have a
good ability to generate ideas, whereas assim-
ilators have a strong ability to create theo-
retical ideas and like to reason inductively.17
When a learner is a diverger or assimilator,
presenting a metaphor (such as the NKP) to
the learner is an effective instructional strat-
egy that promotes learning.18 Furthermore,
when the content to be learned is either
declarative knowledge (eg, remembering the
NKP levels or remembering the definition of a
theory) or procedural knowledge (eg, remem-
bering how to substruct a study, discussed
later), then the instructional strategy of
presenting a metaphor is again recommended
to promote learning.19 This is not surpris-
ing because metaphors can convey declar-
ative, procedural, and conditional kinds of
knowledge, and a metaphor can have pow-
erful effects on long-term recall.19 Because a
2018
metaphor structure helps a novice integrate
new information into existing knowledge,18

it is a powerful instructional tool.19
Why use a pyramid metaphor? Chinn
and Kramer write that “structural forms
are powerful devices for shaping our
perceptions”6(p194) and can convey “mean-
ing of a whole beyond the formative
elements.”6(p131) Specifically, the pyramid
form can convey broad-to-specific and
complex-to-simple properties.6 These are the
emergent properties of the NKP. For exam-
ple, one quality of a pyramid is that of having
a firm foundation. Here, to follow the phi-
losophy of epistemological coherentism men-
tioned earlier, each level “rests upon” and
is explicitly linked to the underlying levels
to create a strong, unified, logical, broad-to-
narrow abstraction whole. That is also why
the NKP reverses the abstraction levels of the
holarchy—to reinforce the idea of building a
solid, coherent foundation.
USING THE NURSING KNOWLEDGE
PYRAMID
Chinn and Kramer assert that “an important
theory is forward looking; usable in practice,
education, and research; and valuable for cre-
ating a desired future.”6(pp206-207) The NKP can
support nursing practice, education, and re-
search in many ways. This section highlights
2 uses for nursing education.
A vehicle for integrating new knowledge
The NKP provides valuable scaffolding for

learning the nursing knowledge base. In ad-
dition to learning the definitions of the NKP
concepts (eg, paradigm, theory), building a
complete coherent pyramid for any nurs-
ing knowledge is a powerful motivator and
learning experience, as selecting from the
available entities (eg, philosophies, theories)
at each abstraction level requires familiarity
with those entities in the nursing literature.
Nurse educators may want to consider requir-
ing new students to learn the NKP early in
their curriculum to help them integrate new
nursing knowledge, clarify their thinking, and
through meta-types, spur them to higher stan-
dards of scholarship in all their communica-
tions.
A vehicle for relating theory to research
Theoretical substruction uses relationship
diagrams to tie nursing theory to nursing prac-
tice by making the implicit assumptions of a
research study explicit, such as connecting
research questions to analysis.20 Substruction
has been used to assess the logical consistency
of theoretical structures, designs, and analy-
ses; to examine research literature; to plan the
research process; to facilitate grant writing;
and to theoretically derive variables for study
from abstract concepts.21 In the NKP (see
Figure 1), conventional theoretical substruc-
tion occurs at the line between the theories
and empirical indicators levels. However, if
substruction was utilized for transitioning
between all NKP abstraction levels, this

proposed deep substruction process can be
a vehicle for operationalizing the previously
discussed philosophy of epistemological co-
herentism throughout the NKP. As we use the
term in this article, deep substruction is nearly
identical to Fawcett and DeSanto-Madeya’s
C-T-E (concept-theory-empirical indicators)
process, which is a system for translating
nursing knowledge into research, educa-
tion, and practice.5 Both processes attempt
to explicitly show the logical transitions
between the abstraction levels. However,
deep substruction additionally uses the new
abstraction levels, uses the new “metas,”
and requires a concept map as minimal
output.
For example, Figure 4 illustrates how deep
substruction can be used to succinctly char-
acterize and assess the coherence of the as-
sumptions in a research study. In this case, a
piloted study was completed where patients
with cancer who self-reported distress were
recommended psychosocial coping str-
ategies.22 Starting at the bottom of the di-
agram and following the arrows upward
Figure 4. An example of the Nursing Knowledge Pyramid
translated for the deep substruction of a study. Used

with permission from Decker and Weller-Ferris.23
through each of the abstraction levels, the
situation-driven psychosocial coping strategy
recommendations in the Decker Cancer Cop-
ing Rulebase (top of the diagram) were gen-
erated initially as tacit knowledge (bottom of
the diagram) accumulated from the first au-
thor’s 30 years of experience as an oncology
nurse aligned with evidence-based practice.23
These rules were compiled in a book and
constituted her prescriptive microtheory of
cancer coping—the Decker Theory of Cancer
Coping. To bridge the logical gap between
the Decker Theory of Cancer Coping and
her tacit knowledge, supporting philosophies
and paradigms were then found in the nurs-
ing literature and concept-mapped where ap-
propriate. To operationalize the Decker The-
ory of Cancer Coping, empirical indicators
were found and used in the study as shown.
To automate these prescriptions (databases
level), the treatment recommendations in the
book were combined with the self-report in-
strument values to generate a collection of
“If-Then” rules and collected in a rulebase
(a type of database). Specifically, the “Ifs”
were the patient responses to the psychomet-
rically sound Distress Thermometer and Prob-
lem List instrument and the “Thens” were
the psychosocial coping strategy recommen-
dations and local referrals based upon pa-
tient responses.24 This logic was then pro-
grammed into an automated tablet computer

application that was the centerpiece of a dis-
tress management program. The tablet com-
puter application received the instrument
self-reported input from the patient, used ex-
pert system reasoning (a type of artificial in-
telligence designed to mimic the reasoning of
an expert) based on the patient responses to
determine the recommendations, and printed
out reports to the provider and the patient.
The distress management program was then
piloted in a small oncology clinic.22 Data anal-
ysis suggested the program was feasible, safe,
and significantly effective. The NKP concept
map in Figure 4 helps the reader understand
the study by explaining the assumptions of
the study succinctly and enables the eval-
uation of their logical coherence. In addi-
tion to requiring familiarity with the nursing
2018
knowledge base, as a learning strategy, cre-
ating high levels of structural knowledge
through semantic networks such as concept
maps enhances comprehension of content,
domain-specific problem-solving, and reten-
tion of material.18
SUMMARY

How knowledge is structured is important
to any discipline, and the NKP theory pro-
vides a unifying framework for nursing knowl-
edge at the highest level of abstraction. Kim
reminds us that “multiple theories are not only
useful but also necessary.”1(p13) Using retro-
ductive reasoning, we applied 6 innovations
to an existing theory to develop a new theory.
Nurses and nurse educators should consider
using the NKP as a powerful cognitive tool to
facilitate the learning, development, automa-
tion, and accessibility of nursing knowledge,
thereby increasing the probability of nursing
success.
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River, NJ: Prentice Hall; 1991.
20. Wolf ZR, Heinzer MM. Substruction: illustrating the
connections from research question to analysis. J
Prof Nurs. 1999;15(1):33–37.
21. McQuiston CM, Campbell JC. Theoretical substruc-
tion: a guide for theory testing research. Nurs Sci Q.
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22. Decker VB, Howard GS, Holdread H, Decker BD,
Hamiltn RM. Piloting an automated distress manage-
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23. Decker VB, Weller-Ferris L. Coping With Cancer: A
Patient Pocket Book of Thoughts, Advice and Inspi-
ration for the Ill. Pittsburgh, PA: Oncology Nursing
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Comprehensive Cancer Network distress managem-
ent guidelines. http://www.nccn.org/professionals/
physician gls/pdf/distress.pdf. Updated 2014. Ac-
cessed 2014.
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f
ONCOLOGY NURSING FORUM • VOL. 43, NO. 2, MARCH
2016 245
Marie Flannery, PhD, RN, AOCN®
Explicit Assumptions About Knowing
Conceptual Foundations is a new column for Oncology Nursing

Forum (ONF) that
focuses on the frameworks that
underpin research and practice
initiatives. The purpose of this
inaugural column is to provide
an overview of what conceptual
frameworks are, related terms,
the role of conceptual frameworks
in the research process, and why
these frameworks matter. The
majority of articles published in
ONF are research manuscripts.
Readers include student nurses,
practicing oncology nurses, nurse
managers, advanced practice on-
cology nurses, nurse scientists,
and people in other disciplines
who are interested in patients with
cancer. In the guidelines for ONF
articles, peer reviewers are asked
to address the conceptual model/
theory (if needed) that is included
in the manuscript. For all who read,
apply, and create knowledge, un-
derstanding the conceptual frame-
work underlying a research study
is an essential skill to master. The
conceptual framework may be ex-
plicitly identified by the author or
may be implicit. If not specifically
stated, the reader must detect the
underlying assumptions that form
a conceptual foundation.
Definitions and Related Terms

What is a conceptual framework?
Concept is defined as “an abstract
or generic idea generalized from
Marie Flannery, PhD, RN, AOCN®, Associate Editor
CONCEPTUAL FOUNDATIONS
Flannery is a research assistant professor in the
School of Nursing at the University of Rochester
Medical Center in New York.
No financial relationships to disclose.
Flannery can be reached at [email protected]
.Rochester.edu, with copy to editor at [email protected]
ons.org.
Key words: concept; theory; framework; model;
oncology
ONF, 43(2), 245–247.
doi: 10.1188/16.ONF.245-247
particular instances” (“Concept,”
n.d., para. 1). Framework is de-
fined as “the basic structure of
something: a set of ideas or facts
that provide support for some-
thing” or “a supporting structure”
(“Framework,” n.d., para. 1). Taken
together, a conceptual framework
consists of specified abstract ideas
that are joined in an identified
structure. Conceptual frameworks
identify what is important in un-

derstanding a phenomenon and
provide guidance for relationships.
No universally accepted definition
exists for conceptual framework,
and the term is sometimes used
interchangeably with conceptual
model, theoretical framework, and
theory (Powers & Knapp, 2011).
Many terms are related to con-
ceptual frameworks (see Table
1). Epistemology is a branch of
philosophy that studies “how
we know” and the justification of
knowledge claims. Varying epis-
temologic philosophic traditions
have emphasized different aspects
and views of knowledge, certainty,
and truth, and have provided dif-
fering interpretations of theory and
concepts. Empirical philosophic
traditions influence much of the
current research and emphasize
the systematic observation of real-
ity through sensory observation
(Powers & Knapp, 2011). Worldview
refers to a general orientation or
set of beliefs about how the world
operates. Paradigm, a term coined
by philosopher Thomas Kuhn,
246 VOL. 43, NO. 2, MARCH 2016 • ONCOLOGY NURSING
FORUM

also refers to a system of beliefs
about knowledge, often specific to
a discipline. Theory is a term with
many definitions; in the research
realm, a scientific theory includes
a set of statements or principles
that explain phenomena. A theory
is one type of a conceptual frame-
work that always will include at
least two concepts and at least
one relational statement. Of note,
not all conceptual frameworks will
qualify as a theory. A model refers
to a graphic representation; it may
be a two-dimensional diagram or a
three-dimensional mock-up. A con-
ceptual model is a diagram or draw-
ing of the conceptual framework.
A conceptual framework may
be reflected in the worldview, ma-
jor paradigm, or general orienting
framework of the author. A con-
ceptual model may be referenced
or drawn in the article. A theory
may be referenced and explained.
A conceptual framework may not be
explicitly stated but may be discern-
ible to the reader by the author’s
stated and unstated assumptions.
Specifically, the reader may be able
to discern the framework used by
what is studied, how it is studied,
and what is measured. What is not
included in the study also may be an

indication of the implied framework.
A concept that may seem vital to a
clinician or researcher but was not
included in the study may reflect
its relative lack of prominence in
the author’s conceptual framework.
Conceptual Frameworks
and the Research Process
In the guidelines for manuscripts
submitted to ONF, reviewers are
asked to critique the use of con-
ceptual frameworks in two specific
components of the manuscript. The
literature review and discussion
section guidelines specifically ask
reviewers to consider the concep-
tual framework or theory (if need-
ed) that is used in the manuscript.
However, the integration of a con-
ceptual framework actually threads
and weaves through all compo-
nents of the research process. The
orienting framework or worldview
provides a specific lens as to how
an area of study is seen and how a
clinical problem is identified. The
choice of a theory or conceptual
framework provides structure for
the content that is included in the
background and literature review.
The framework or theory may be
specifically discussed and a figure

of the conceptual model included.
The conceptual framework influ-
ences the choice of method, set-
ting, sample, instruments, proce-
dures, and analysis strategies. The
reviewer (and reader) often looks
for a sense of coherence, logical
consistency, and logical flow in a
research study. The integration of
a conceptual framework through all
phases of the research process can
provide a sense of coherence. For
example, if the conceptual frame-
work specifies that both patient
and caregiver experiences are criti-
cal to understanding the clinical
issue, one might choose to conduct
a descriptive longitudinal study
conducted in the home setting;
include patients and caregivers in
the sample; include open-ended in-
terviews, in addition to structured
questionnaires, as measurement
modalities; and include dyadic eval-
uation techniques in the analysis.
The discussion section may in-
clude comments on whether the
conceptual framework worked
or was helpful in the study, if the
framework was supported or incon-
sistent with study findings, or what
revisions to the framework may
be needed. Similarly, any practice
implications and knowledge trans-
lation may be influenced by the

TABLE 1. Terminology and Definitions for Conceptual
Frameworks
and Related Terms
Term Definition
Concept Abstract idea; building blocks of theory
Conceptual
framework
A conceptual framework consists of specified abstract ideas that
are joined together in an identified structure. Conceptual frame-
works identify what is important in understanding a
phenomenon
and how the important ideas fit together and are related to one
another.
Empirical Originating in or based on observation or experience
Epistemology A philosophy of knowledge that includes an
understanding of
“how we know” and a justification of knowledge claims
Model Graphic or symbolic representation of a phenomenon
Paradigm Patterns or systems of beliefs about science and
knowledge pro-
duction that may be discipline-specific
Theory A set of statements or principles devised to explain a
group of
facts or phenomena, particularly one that has been repeatedly
tested or is widely accepted and can be used to make predictions
about natural phenomena; a set of interrelated concepts that

guide thinking; an idea or set of ideas that is intended to explain
facts or events, the general principles or ideas that relate to a
particular subject
Worldview “A global pattern of beliefs that constitute a school
of thought and
its attendant knowledge claims” (Powers & Knapp, 2011, p.
203)
Note. Based on information from “Concept,” n.d.;
“Framework,” n.d.; Powers &
Knapp, 2011.
ONCOLOGY NURSING FORUM • VOL. 43, NO. 2, MARCH
2016 247
guiding paradigm of the conceptual
framework. Reviewers and readers
want the description of the con-
ceptual framework to be clear and
understandable. The framework
or theory generally feels to be the
best fit and most meaningful when
it is integrated throughout the
study and manuscript and does not
come across as a framework that
was “tacked on” as an afterthought.
Conceptual frameworks are as-
sociated with a wide range of re-
search designs. In the case of an
intervention study, the conceptual
framework or theory establishes
the required components for the

intervention and proposes how
they will work. In a study model-
ing relationships or explaining an
outcome, the conceptual frame-
work determines what factors will
be examined and the nature or
valence of the relationship. In a
descriptive study, a conceptual
model provides guidance on what
characteristics are necessary to
include in the description. When a
theory is presented or hypotheses
are proposed, the statement of the
important concepts and their struc-
tural relationships is very clear.
When a Conceptual Framework
Is Not Stated
Sometimes, perhaps often, an
author does not explicitly identify
his or her conceptual framework.
However, clues often exist as to the
underlying assumptions the author
holds about the topic under study.
In the introduction and background,
the author provides information on
what factors are important. These
factors often translate into the con-
cepts that may reflect the operating
framework for the author. This may
be evident from past research that
is cited and how the clinical issue is
described. The instruments used in
the research also provide informa-

tion on the conceptual framework.
For example, if the concept of self-
efficacy is measured in a study,
one can infer that self-efficacy is
an important part of the unstated
conceptual framework for under-
standing the phenomenon being
examined. Without an explicit state-
ment of the conceptual framework,
the reader or reviewer only can at-
tempt to identify what concepts the
author thought were important and
what the assumed relationships
were. Each person has assump-
tions about what is important, how
things may be related, and what
counts as evidence. The use of a
conceptual model makes these un-
derlying assumptions explicit.
Conclusion
Conceptual frameworks are im-
portant because they underlie ev-
ery study and article. Frequent-
ly used analogies for conceptual
frameworks are that they are maps
or blueprints. The blueprint tells
the overall structure of relation-
ships (framework) and the materi-
als (concepts) that will be used in
the design. Attention to conceptual
frameworks is essential to building
science. In addition to the facts
and information about the focus
of a study, knowledge about the

success or failure of a conceptual
framework or theory can provide
Authorship Opportunity
Conceptual Foundations pro-
vides readers with an overview
of the role of conceptual frame-
works in the research process.
Materials or inquiries should be
directed to Associate Editor Ma-
rie Flannery, PhD, RN, AOCN®,
at [email protected]
ester.edu.
understanding for other situations
and future research. Insight into the
underlying mechanism of why or
how something works (or did not)
is examined in light of the proposed
relationships of the framework or
theory. For example, a conceptual
framework for symptom manage-
ment can be used for many differ-
ent symptoms. As the conceptual
framework is developed and refined,
insight is gained into what needs to
be included in effective symptom
management interventions. The
use of a conceptual framework or
theory can advance understanding
of multiple clinical problems.
Future columns wil l review
specific theories and conceptual
frameworks as they apply to oncol-
ogy nursing and clinical problems

for individuals with cancer.
References
Concept. (n.d.). In Merriam-Webster.com. Re-
trieved from http://www.merriam-webster
.com/dictionary/concept
Framework. (n.d.). In Merriam-Webster.com.
Retrieved from http://www.merriam
-webster.com/dictionary/framework
Powers, B.A., & Knapp, T.R. (2011). Diction-
ary of nursing theory and research (4th
ed.). New York, NY: Springer.
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