Examining the State of the Medicine: Hospital Readmissions

Subject: Nursing
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As methods for analyzing concepts have proliferated in nursing, a critical method ological issue has arisen. Analytic techniques for examining conceptual meaning have incorporated varied strategies for advancing the concept under the rubric of concept analysis, concept development, and theory building. The authors argue that this evo lution has created methodological confusion. Following a discussion of a conceptu alization of concepts and concept-theory-truth linkages, methods of concept analysis are critiqued in terms of the purpose and the nature of the findings produced by analy ses using both traditional and emergent methods. The authors argue that concept analysis is a process of strategic examination of the scientific literature that results in an integrated perspective of the state of the science, or what is known about the concept. In contrast, concept advancement refers to techniques that emphasize the synthesis of new or deeper knowledge that is relevant to the discipline. The authors conclude that disentangling concept analysis from techniques for concept advance ment is critical to enhancing the utility of concept-based research in nursing.

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Over the past several decades, multiple methods of concept analysis have been developed and applied in nursing. These techniques have provided nursing researchers with much needed analytic processes to examine the conceptual understanding of phenomena of interest to nursing science. Such con ceptual understanding guides translational research that in turn directs the devel opment of evidence-based practice. Thus, phenomena-concepts-practice are inherently linked in the science of nursing.

The proliferation of methods of concept analysis has resulted in a critical method ological issue: Is concept analysis synonymous with concept advancement? In this article, we review the commonly employed techniques of concept analysis and the products of such analyses to set the scene for a deeper discussion of concept advancement techniques. We conclude that concept analysis is ideally employed to determine the state of the science; the point from which the concept may be strategically advanced toward a higher level of scientific utility.

Types of Concepts

What are concepts? Before launching a discussion of analytic techniques, it is useful to describe a conceptualization of concepts. Concepts are mental abstractions or units of meaning derived to represent some aspect or element of the human experience (Chinn & Kramer, 1995; King, 1988). It is important to keep in mind that concepts are manifested in phenomena but that they never assume a concrete form; a concept is a mental image, not the thing or behavior itself (Walker & Avant, 1995). For example, the classic exercise of asking students to play word games involving a thing (e.g., What is a table?) attempts to draw their thinking into abstraction to demonstrate how a concept is a unit of meaning rather than a material entity that appears before them.

Concepts are second-order expressions; they package complex sensible or precognitive meaning with cognitive processing into some form of categorical meaning (Merleau-Ponty, 1998). Concepts are brought forth through language; they are embedded in discourse (see Merleau-Ponty, 1998; Rodgers, 2000a; or Walker & Avant, 1995). Concepts are not purely a scientific endeavor; rather concept formation is a natural human process that occurs through being in the world with others.

But there is an important differentiation of concepts that is critical to this discussion. Ordinary or everyday concepts are not the same as scientific concepts (for this discussion, see Mitcham, 1999; Morse, 2000; Rodgers, 2000a). Ordinary concepts are those used by people in everyday life. They have a common meaning, which may be implicit but is understandable within that cultural unit. Ordinary definitions of concepts are found in the dictionary. They change over time to reflect common usage, for example, “soccer mom” or “globalization” now carry conceptual meanings that have evolved through usage. Twenty or 30 years ago, these concepts would have been meaningless.

Scientific concepts are a different entity in that a degree of precision is required in order for the conceptual label to encompass a unit of meaning that is used consistently within a scientific discipline. These concepts require a more specific or narrow definition so that those using the conceptual unit in scientific endeavors are clearly using it in the same way, with the same meaning, so that findings are meaningfully understood (Morse, 2000). The concern of science with the specification of concept usage is reflected in the issues of construct validity. Conceptual clarity is necessary for solid theoretical integration (Knafl & Deatrick, 2000). Therefore, scientific concepts are more precise meaning units that when linked together propositionally form a theoretical representation of reality.

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This difference in types of concepts (ordinary vs. scientific) is important to concept analysis techniques. Scientific endeavors rely on more precisely defined concepts (Mitcham, 1999; Morse, 2000). When ordinary or implied meanings of concepts are used to build theory in scientific enterprises, the waters are muddied (e.g., see Hupcey, Penrod, Morse, & Mitcham, 2001). For example, when considering trust in nurse-patient relationships, is my conceptualization of trust the same as the next reader’s? Is trust different from reliance? If so, how? It is important for conceptual units of scientific theory to be explicit in their representation of precise meaning of an element of human experience. In this article, we assert that the scientific understanding of a concept is the concern of concept analysis, not ordinary conceptual meaning. This is not to say that ordinary meaning has no merit in scientific work, rather this form of data is relevant to concept advancement techniques, not concept analysis.

Concepts-Theory Linkages

Often, as scientific units of meaning, concepts are described as building blocks of theory (Fawcett, 1978), triggering images of a brick and mortar wall. Using this analogy, the theory is built block by block as a process of stacking and securing concepts together. This view is problematic in that the linkages between concepts are presented as linear, a rather simplistic approach. For example, a “block” (concept) on the first course of the “wall” (theory) may be integrally linked with a “block” on the third course—yet the two don’t touch or link in any way except to support the “wall” (theory). Thus, this representation is inadequate in illustrating the complex integration of concepts important to nursing and other sciences concerned with human experiences or behaviors.

Hemple (1966) offers a different concept-theory analogy in his work in natural science, describing concepts as the “knots in a network of systematic interrelationships” (p. 94). Extending this analogy, the theory could be represented as a tapestry of interwoven, knotted conceptual threads (Penrod & Hupcey, 2005). Thus, no single strand (i.e., concept) in the tapestry (i.e., theory) stands apart from the others in a meaningful way. To pull one conceptual thread from the tapestry produces a piece of string or thread (i.e., the concept) that no longer reveals its accent or color within the larger pattern (i.e., conceptual meaning).

The tapestry analogy is useful to emphasize the importance of strong, well-integrated concepts for supporting theory. However, there is a deeper implication in this analogy that warrants some consideration: concepts are assigned meaning through placement within the context of theory. If we were to examine only red threads pulled from different tapestries, we could analyze the characteristics of threads themselves; however, the contribution of these threads to each tapestry lies in the contrast and intricacies developed when the red thread is knotted and woven with other strands in the larger work. That is, concepts cannot be analyzed irrespective of their theoretical frame. Paley (1996) has argued that concepts must be examined within the niches created in specific theories integrating those concepts. He asserts that the most meaningful way to clarify concepts is to examine the theories in which the concepts are embedded. We agree with Paley and have further asserted that the power of concept analysis (and subsequently, methods of advancing the concept) is to identify the existing theoretical strands and, ultimately, to tie and retie the conceptual knots to form a stronger, more coherent tapestry of nursing theory (Penrod & Hupcey, 2005).

Concepts that are of concern to the caring sciences, including nursing, are embedded in complex tapestries of behavioral, cognitive and emotive meaning (e.g., theories). It is difficult, if not impossible, to untangle the discrete thread of a concept from this tapestry of meaning. Therefore, attempts to isolate a concept in the process of analysis become an artificial endeavor. We cannot isolate concepts that are inherently linked in abstract meaning without in some way limiting the utility of analysis for understanding complex human experiences. From a practical perspective, this means that the scientific literature that precisely orders or interprets ordinary conceptual meaning must be analyzed for explicit and implicit meaning during the analytic process. The implicit meaning may be derived through an analysis of the positioning of concepts in a theoretical frame or by linguistic cues. We assert that scientific concepts cannot be critically analyzed if pulled from or isolated from the broader theoretical landscape without seriously compromising the value of the analytic product. In other words, processes of concept analysis must examine multiple theoretical frames to derive insights regarding conceptual meaning that transcend specific theoretical bounds and ring true to the human construction of meaning with the degree of precision required in scientific endeavors.

Far too often, manuscripts related to concept analyses describe the literature surrounding a word label without ever addressing the scientific meaning of the concept in any depth. In these papers, there is an obvious lack of conceptual thinking as the author processes mounds of literature from a narrow and restricted perspective. Available methods of concept analysis may be easily misconstrued to permit such superficial analysis, especially those that prescribe the concoction of contrived cases to support the analysis. Often, these model cases suffer an obvious lack of depth and the derived conceptualization is unable to capture the meanings inherent to complex human experiences (for further discussion, see Hupcey, Morse, Lenz, & Tasón, 1996). Such endeavors fall short of truly determining scientific meaning in a way that permits an understanding of the state of the science surrounding the concept.

Concept-Truth Linkages

We believe that the power of concept analysis lies in identifying how a concept works within existing theories in order to derive a theoretical definition of the meaning ascribed to that concept. This definition of meaning derived from the contextual basis of the science (that is, theories) represents the “state of the science.” This assertion is rooted in our metaphysical perspectives of truth or reality, primarily ontology. On one hand, the truth could be conceived as an absolute value that can be discovered through precise scientific endeavors. On the other hand, the truth can be conceived as construction of those who experience a given phenomenon at a given point in time. Somewhere between these two endpoints of a continuum, there is a middle ground—a stance that accepts the power of the human experience in formulating conceptual meaning that is subsequently clarified through language expounding that meaning within a specific theoretical context for scientific use.

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Kikuchi’s (2003) interpretation of moderate realism embraces a quest for understanding reality focusing on probable truth rather than absolute truth. Concepts are abstracted through a cognitive process that is based on percepts (formed through perceptions along with memory and imagination). Concepts are, therefore, “grounded in reality or empirically derived” (p. 12). Context becomes critical as the individual is situated in a set of circumstances that influences percepts and the abstraction of concepts. Yet the convergence of what is known through a rigorous examination of these multiple contextually based conceptions reveals the probable truth that is embraced by moderate realists. Moderate realism asserts, “reality exists independent of the human mind” (p. 12), supporting a notion that probable truth transcends individual experience.

Using the tapestry analogy, concept analysis centers on following and pulling selected conceptual threads in multiple tapestries of meaning. The insights gleaned through each examination (now new threads of the meaning) are then rewoven or reknotted and tied into a new tapestry of meaning for that concept. The theoretical tapestry represents the probable truth revealed through an examination of multiple, and often, divergent contextual conceptualizations of concepts grounded in empirical, human experiences.

This is the position that we adopt in this series of papers. Through techniques of concept analysis, conceptual insights are isolated and examined. These insights are then integrated into a summative view of the state of the science surrounding the concept of interest. Since concepts are the backbone of theory in practice (that is, concepts help nurses to organize meaning to understand complex human experiences and behaviors in ways that influence the practice of nursing) such work is a critically important scientific endeavor.

Given this perspective, we propose that it is time to clarify methodological approaches to concept analysis and concept advancement. Concept analysis is a means for identifying scholars’ best efforts at establishing the probable truth as reflected in the scientific literature. In this case, the label “scientific literature” refers to scholarly works pertaining to the concept of interest, including empirical, theoretical, and philosophical writings. The goal of concept analysis is to establish the state of the science. As such, concept analysis has the potential to serve as an essential method of inquiry in progressive nursing science, not merely as an academic exercise. We believe that the findings of a critical concept analysis provide evidence for determining the most appropriate means for subsequently advancing the concept. In essence, concept advancement techniques progressively build the concept by explicating implicit meaning into more abstract theoretical formulations that transcend contextual conceptions. Such clarification of methods supports an evolutionary turn toward praxis by uniting nursing research, theory, and practice in a way that, we believe, could advance the science of nursing significantly.

Traditional Approaches to Concept Analysis

A number of approaches are used to guide the process of “concept analysis” in nursing. It is important to note, however, that the terms describing the overarching analytic processes, purposes for using such techniques, and the nature of the findings produced by each method differ. Ultimately these factors affect the critical examination of the concept and may result in analytic findings that do not truly reflect the state of the science. Others have critiqued common techniques of concept analysis (for example, see Hupcey, Morse, Lenz, & Tasón, 1996). For clarity, we provide a brief overview of the approaches described by: Wilson (1963), Walker and Avant (1995), Chinn and Kramer (1995), Rodgers (2000b), and Schwartz-Barcott and Kim (2000) (further delineated by Schwartz-Barcott, Patterson, Lusardi, & Farmer, 2002). Our focus in this review centers on the purpose, process, and products of these methods.

Wilson (1963) introduced a method of examining concepts that involved discussion of 11 considerations: questions of concept; ‘right answers’; model cases; contrary cases; related cases; borderline cases; invented cases; social context; underlying anxiety (of the researcher); practical results; and results in language. This ambitious discourse endures as a classic reference in concept analysis literature. While Wilson’s intent was not to delineate a method of concept analysis, this analytic process serves as the basis for many methods of concept analysis in nursing.

Although Wilson (1963) described the purpose of his work as, “set[ting] forth a framework through which one can build an understanding of the essential meaning of a concept in varied contexts” (p. 93), he also stated that “the analysis of concepts is essentially an imaginative process; certainly it is more of an art than a science” (p. 33). This emphasis on the process or the art of exploring concepts overshadows the notion of a product. A Wilsonian analysis enhances critical thinking processes but does not necessarily produce documentation of a scientific examination of a concept (i.e., a product). Herein arises the difficulty in applying this method to scientific endeavors; while the art of the image contributes to the derivation of the scientific conceptualization, the influence of imaginative processes often precludes the “evidence” found in the literature that reflects the essential meaning of the concept within a scientific context (especially complex behavioral concepts, like trust or uncertainty). The difficulty with Wilson’s text is that, while insightful and very comprehensive, it fails to prepare one to embark on a methodological analysis of the state of the concept in the science (reflected soundly in the literature).

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Walker and Avant (1983, 1988, 1995) describe concept analysis as a technique of concept development that is used when the concept is unclear, outmoded, or unhelpful. This method adapts Wilson’s work into an eight-step process: select a concept; determine aims or purposes of analysis; identify uses; determine defining attributes; construct a model case; construct borderline/ related/ contrary/ invented and illegitimate cases; identify antecedents and consequences, and define empirical referents. Both qualitative and quantitative techniques are prescribed within this process. The purpose of this technique is described as theory development. The products of the process include clear and precise theoretical and operational definitions for use in research (1995, p. 46), thus supporting the achievement of the purpose. Concepts are defined as evolving (“change over time,” 1995, p. 37) within a constructivist perspective. “The best one can hope for from a concept analysis is to capture the critical elements of it at the current moment in time” (1995, p. 37). While this approach to concept analysis is perhaps, in our experience, the most commonly used in nursing, this method often fails to produce an analysis of the concept that reaches the degree of insight implied by the authors. Of primary concern, how does the researcher come to know that the concept is unclear, outmoded, or unhelpful without a full analytic review of the state of the science?

Chinn and Kramer’s (1991, 1995; Chinn & Jacobs, 1983, 1987) approach to concept analysis is an adaptation of the work of Wilson and Walker and Avant. They assert that the primary purpose of concept analysis is the development of theory. Their technique focuses on five steps: select a concept; clarify the purpose; identify data sources; explore context and values; and formulate criteria. It is interesting to note their emphasis on constructed exemplary cases and the inclusion of diverse data sources including popular literature, visual images, and people. The purpose of the analytic process described by these scholars is to identify, clarify, and examine the word label, the phenomenon represented by the label, and the values, feelings, and attitudes that are associated with both the symbol and the phenomenon. The product of this process is considered to be tentative in nature and subject to alteration and change as new evidence becomes available. This method extends analysis beyond the state of science into the personal and societal realms. While we agree that such conceptualizations (the personal and the societal) are critical to advancing a concept to capture the empirical essence of the human experience, we do not believe that these realms of meaning are appropriate to discerning the probable truth exposed in the scientific literature.

Rodgers (1993, 2000b) described an ‘Evolutionary View’ of concept analysis that is embedded in the cycle of concept development. The purpose of concept analysis is “clarification of the concept and its current use, and uncovering the attributes of the concept as a basis for further development” (2000b, p. 83). In this method, Rodgers attempted to move beyond the essential features of a concept to capture “the dynamic nature of concepts, changing with both time and context” (2000b, p. 99). The process in this form of concept analysis was designed around the dynamic (not static) perspective of a concept: identifying the concept; choosing the setting and sample (literature); collecting and managing the data; analyzing the data; identifying a model case; interpreting the results, and identifying implications. The product of analysis (or results) is described as a heuristic device to provide “the clarity necessary to create a foundation for further inquiry and development” (2000b, p. 84). Emphasizing the cyclic nature of concept development even further, Rodgers (1993) said,

I do not consider the attributes of a concept to be a fixed set of necessary and sufficient conditions or an essence. Consequently, this cluster of attributes may change, by convention or by purposeful redefinition, over time to maintain a useful, applicable, and effective concept. (p. 75)

The evolutionary approach challenges an essentialist position on concepts. This method of concept analysis is based on a complex, intellectually rigorous integration of more contemporary philosophical positions. Such complexity makes it difficult to disentangle the process of concept analysis as separate and discrete from concept development. Application of this method has been more limited than more traditional forms of concept analysis (e.g., Walker & Avant), perhaps because it challenges our philosophical interpretation of concepts or perhaps because it depicts concepts as such dynamic entities that are difficult to grasp for scientific examination and use.

Schwartz-Barcott and Kim (1986, 1993, 2000) described their “Hybrid Model,” which was originally developed in a doctoral course to merge philosophy of science, sociology, and field research into a three-phase approach to concept analysis: theoretical work (based in the literature); fieldwork (based on empirical data); and analytical work (integrating the final product). Schwartz-Barcott and Kim (2000) described this process in terms of concept development and analysis with the implicit purpose of fortifying the “building blocks of a theory” (2000, p. 130) for ultimate integration. This method moves concept analysis from an academic mental exercise into the realm of clinically based fieldwork, thus making an important contribution methodologically. However, the basis of the fieldwork (i.e., the theoretical work) remains underdeveloped. The method does not formulate a strong analysis of the state of the science from which to launch appropriate and well-focused fieldwork. Recently, Schwartz-Barcott and colleagues (2002) clarified their fieldwork strategies into three distinct pathways for clarifying and establishing theoretical congruence between a concept and clinical settings: theoretical selectivity; theoretical integration; and theory creation. The resultant products of the procedural application of the refined pathways are yet to be seen.

Emergent Perspectives on Concept Analysis

Despite the fact that the aforementioned methods of concept analysis were available and used in nursing, their application to phenomena of concern to nursing had varying degrees of success (Morse, Hupcey, Mitcham, & Lenz, 1996). In a critical response to these methods, a series of papers on concept analysis published by Morse and colleagues (Hupcey et al., 1996; Morse, 1995; Morse, Hupcey, et al., 1996; Morse, Mitcham, Hupcey, & Tasón, 1996) presented new perspectives on concept analysis. One of the insightful notions regarding concept analysis was the need to establish “criteria for the evaluation of the level of maturity of concepts” (Morse, Mitcham, et al., p. 387). Maturity was defined as a concept which “is well-defined, has clearly described characteristics, delineated boundaries, and documented preconditions and outcomes” (Morse, Mitcham, et al., 1996, p. 387). The evaluation of conceptual maturity was based on four broad philosophical principles, epistemological, pragmatic, linguistic, and logical (Morse, Hupcey, et al., 1996). The epistemological principle sets criteria for conceptual definitions and differentiation. The pragmatic principle addresses criteria surrounding utility and fit of conceptualizations. The linguistic principle centers on consistency and appropriateness of use. And finally, the logical principle develops criteria for examination of theoretical integration with other concepts. Thus, this series of papers provides an analytic lens through which the truth-value of current conceptualizations may be examined.

We believe that the principles described by Morse and colleagues (Hupcey et al., 1996; Morse, 1995; Morse, Hupcey, et al., 1996; Morse, Mitcham, et al., 1996) reveals the best estimate of probable truth evident in the scientific literature. The application of these analytic criteria has the potential to produce a principle-based examination of the concept as it appears in the scientific literature; however, use to date has been limited. From our experience, we have come to discover that the entanglement of analysis and advancement techniques muddles analytic processes, resulting in novice analysts wallowing in data and wondering when, or if, they will ever be finished with the project. Further, in order to address operational difficulties, we have clarified strategies for applying these principles in a concept analysis (Penrod & Hupcey, 2005). Yet, one thing is clear: principle-based concept analysis is a complex method and demands that the researcher analyzes scientific meaning (not everyday notions) and thinks critically (not imaginatively).


Given these diverse approaches to concept analysis, it is not surprising that the potential contribution of concept analyses on the evolution of nursing science has been constrained. We believe that some of the limitations in the utility of the product of concept analyses are related to how nurse researchers and educators think about concept analysis. For example, while all of the approaches discussed above are somehow related (and taught) under the rubric of concept analysis, analytic terms are confused and entangled within broader concept-based research techniques, including concept development, creating conceptual meaning, and theory building. Data collection/fieldwork appears to be premature in some approaches: how can the researcher proceed with fieldwork strategically until a thorough understanding of the state of the science is fully established? Therefore, clarifying the principles underlying concept analysis is a logical first step in addressing these methodological limitations.

First, we assert that the purpose of concept analysis is to determine the state of the science (or best estimate of probable truth) surrounding a concept of interest. Thus, concept analyses are concerned with scientific literature, not creative imagination, art forms, fiction, interview data, or any other form of representation. Second, the process of concept analysis is primarily at the level of integration, not synthesis. The researcher must engage in a thorough and thoughtful analysis of what is known by examining the implicit and explicit assumptions cited in the scientific literature (i.e., scholarly works pertaining to the concept of interest, including empirical, theoretical, and philosophical writings). Concept analysis is more than an organization of findings; the integrated perspective produces a higher-level understanding of the concept of interest. In other words, when theoretical frameworks are examined for meaning and contextual boundaries are transcended, the evidence of probable truth is revealed. Therefore, the product of concept analysis is some form of a summary of the state of the science that reveals the scientific community’s best estimate of probable truth, given the evidence portrayed in the extant literature. While this product certainly contributes to the science of nursing, it is not a form of concept advancement; it is an analysis of what is known.

In our view, principle-based concept analysis (Penrod & Hupcey, 2005) provides a useful and meaningful framework for determining the global state of the science (or probable truth) surrounding a concept. However, the real value of this the emergent method lies in the evidence culled to support the summative conclusions (truth-value) related to each principle rather than on an assigned word label that denotes the degree of maturity (e.g., immature vs. partially mature). The notion of conceptual maturity is a significant contribution to understanding concepts, but the label that connotes a level of maturity is insufficient for determining the most appropriate techniques for concept advancement.

This is an important methodological distinction. Concept analysis is an integration of what is known, not an evaluation of the quality or maturity of the concept. Concept advancement is not driven by the label denoting the level of maturity; rather, gaps in understanding identified through comprehensive principle-based concept analysis are the most significant findings that direct subsequent concept-based inquiries.

Principle-based concept analysis requires the researcher to focus on evidence found in the scientific literature, not constructed cases, imaginative exploration, or hypo-thetical exemplars. Through the integration of insights derived from a principle-based examination of the scientific literature, the researcher should be able to derive a summative paragraph (or theoretical definition) on what is known in order to expose gaps or inconsistencies in current thinking. This enables the researcher to strategically progress toward a deeper examination of divergent views to advance a better explication of probable truth.

Principle-based concept analysis appears to provide the most comprehensive examination of the concept within theoretical frames of reference documented in the scientific literature. By applying the overarching principles based in the philosophy of science, the analyst is forced to take a much broader stance in an examination of theory, research, and philosophy papers; but most importantly, the analysis is based on the scientific literature (not lay literature or other forms of representation). This analysis reveals the state of the science and must be based on the literature of the selected disciplines.

Yet, even the application of such a comprehensive analytic technique will only provide us with a perspective of the state of the science, that is, the baseline understanding that enables the researcher to determine how to strategically advance the concept of interest by addressing identified gaps or inconsistencies. Concept analysis is the initial step in concept advancement; analysis must precede efforts at advancement. Analysis of a concept clarifies what is known of the concept at that time. As such, concept analysis can be used to estimate the probable truth revealed in the scientific literature as a first step in enhancing the knowledge base of the discipline. Such delimitation of analytic processes focuses the researcher on scientific perspectives of reality that can then be further developed through processes of concept advancement.


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Offprints. Requests for offprints should be directed to Judith E. Hupcey, EdD, CRNP, School of Nursing, The Pennsylvania State University, 600 Centerview Drive, Hershey, PA 17033. E-mail: [email protected]