Janice M. Morse
Why is a raven like a writing desk?
—Lewis Carroll (1865/2010, p. 82)
Conceptual comparison is a method used to delineate allied concepts. It may be used if you suspect that a single concept label is being applied to several allied (or slightly different) concepts, it may be used when a number of concepts compete to explain or account for a single phenomenon, or it may be used when a researcher suspects that a concept has subtly undergone changes during the process of application—that is, as it has been used over a period of time, or has been used in different contexts, for instance, adopted into different disciplines and these different contexts have given it a different form. Conceptual comparison is therefore a method identifying small but important changes within or between allied concepts; it is a way to develop conceptual precision.
THE PATTERNS AND USES OF CONCEPT COMPARISON
Concept comparison may be used for different patterns of comparison. We discuss the major types here and, with examples, later in this chapter.
Several Concepts Compete for the Same Phenomenon
Concept comparison enables us to explore, compare, and delineate competing concepts: that is, to examine two or more concepts competing for the same phenomenon. Often these concepts have a lay label and a scientific label that both describe the same phenomenon. For instance, we may consider “being there” and “presence” to be overlapping concepts. This is diagrammed in Figure 19.1(a).
The Concept Has Undergone Changes as It Has Been Used
The second reason to use concept comparison is if you suspect that the concept has become unstable over time and to determine if the concept has changed or gradually been altered with use (see Figure 19.1b). This method is usually used with scientific concepts, which are supposedly clearly defined in operational definitions. The definitions of scientific concepts remain constant over time. Yet sometimes they may be altered gradually over time, or used in slightly different ways from study to study. Researchers may be unaware that the concept has been altered, yet examination of its use in research may reveal that subtle but important changes have occurred.
The Concept Is Used Differently in Different Contexts
Sometimes the concept acquires different forms in different contexts or may change with different applications. An example of such a change is the different forms acquired when a concept is used in different disciplines. Concept comparison enables us to determine if different forms of a concept are indeed a single concept or rather several allied concepts masquerading under a single concept label. (Figure 19.1c).
Several Allied Concepts May Actually Be the Same Concept
Sometimes allied concepts may actually be different concept names for the same concept, so that a broad concept may account for many types or forms. The same attributes are present in the two or more allied concepts, but these attributes are present in different strengths; thus the two concepts are actually different forms of the same concept (see Figure 19.1d). An example of this is the concept of hope, which comes in many different forms: In Chapter 16 we discuss hoping against hope, hoping for a chance for a chance, provisional hope, and incremental hope. But there are many other kinds of hope, and we asked you to consider if high hopes, unrealistic hope, and false hope were kinds of hope, allied concepts, or different concepts. Another example would be three terms that are frequently used in nursing: “watching over,” “being there,” or “presence.” Are these the same concept, allied concepts, or different concepts?
At times, two similar concepts may actually represent slightly different forms of a similar concept—and are “true” allied concepts. These concepts may share one or more attributes and it is this that makes them similar, and they may be associated in different ways—within the concept but at a lower level of abstraction, as a component of the larger concept, or nesting. However, as an allied concept represents a different (albeit associated) phenomenon, it is delineating and clarifying these differences that makes an important contribution.
Patterns of Relationships of Allied Concepts
Embedded, More Specialized Concepts
The first pattern of relationship with allied concepts is when a horizontal concept has “lower level” concepts embedded in it. The example given earlier in this text was the horizontal concept of suffering, with “more specialized” and contextualized concepts within it. For instance within suffering we may have the concept of grieving, bereavement, sorrow, and so forth, which may be considered types of suffering.
• Components, parts of the whole: These allied concepts may be a part of the larger concept. The example we discuss in Chapter 35 is “enduring,” which may be considered the first stage (or part) of suffering. Enduring may be explored as a concept in itself, or we may explore suffering, which consists of two (allied) subconcepts, enduring and emotional suffering.
• Clustering or neighboring concepts: These are concepts that account for closely associated concepts. An example may be to differentiate suffering from depression. In this chapter, we illustrate this process by delineating concepts that all account for nursing insight: intuition, emotional empathy, and inference.
When concepts appear similar, the trick is deciding if you are working with the same concept (in different forms) or allied concepts. A student once said, “It is time to get out our conceptual scalpels” (Antasia Wycoff, personal communication). Our task in concept clarification is to sort out (or to clarify) murkiness in our discipline and attack these puzzles. Dictionaries will not help with this task. Dictionaries often use the definition of one concept to define the allied concept.
CONCEPT COMPARISON AS A METHOD
Briefly, conceptual comparison is an active process of comparing the definitions and the significant dimensions (attributes and boundaries) of each concept. These conceptual dimensions are then compared between each allied concept to ensure comprehensive understanding of the differences in the way each allied concept is applied. Alternatively, the attributes of each competing concept are compared and contrasted. Then, from this analysis, comparison continues by asking analytic questions, and identifying significant attributes of a concept, thus enabling the researcher to determine what is unique and what is common between these concepts. (This step is the same as that used in pragmatic utility [Chapter 18], except that you are working with two or more concepts.) The boundaries of each allied concept are compared, to determine if the scope of each concept is similar.
Extending the Strategies of Pragmatic Utility
Constant comparison uses the principles and procedures of pragmatic utility described in Chapter 18. While pragmatic utility has been recommended for use with partially mature concepts, when comparing concepts you may find the following exceptions.
The Inclusion of Scientific Concepts
The concept concerned may be a scientific concept rather than a lay concept. Recall that the reason against using pragmatic utility for scientific concepts is that scientific concepts are fully developed when they are introduced: The definition is clear and standardized (as an operational definition), the attributes are clearly articulated, and the boundaries set. Therefore, nothing may be learned from analyzing such a concept.
However, when comparing concepts, we find ourselves looking at subtle and small changes in the same concept. Now, there is nothing wrong with a concept changing: indeed, lay concepts are constantly changing from being introduced to going “out of fashion.” A scientific concept also should be changed if it can be improved. (Notice that I said, “should be changed,” meaning that the change should be deliberate.) But we may elect to study a particular scientific concept because we suspect that the form of the concept has changed subtly over time. These changes may occur from use, acquired by one researcher after another working in different contexts and with different methods, or through debate, confusion, and disagreement between users. Concept comparison allows for the comparison of suspected differences in the form of the same concept, using the techniques of pragmatic utility. By this time, the concepts will have appeared in a large number of articles and be used by many researchers. Concept comparison allows us to compare a scientific concept as it was originally developed, and to look for variation as it has been used over time, comparing the concept as it was developed with the presently used “new version.”
Involving Immature Concepts
Occasionally, when comparing several competing concepts, you may find that the concepts involved are not all at the same level of maturity. Some of the concepts involved in the comparison (especially when used to examine competing concepts) may be immature, and there is little literature available describing these concepts. In this case, continue using pragmatic utility, but note the scarcity of literature for one or more of the concepts as a limitation. Excluding them altogether will result in a greater threat to the validity of your analysis. Alternatively, you may introduce the immature concepts after your examination of the analytic questions and compare them broadly at that point.
PATTERNS OF CONCEPT COMPARISON
Comparing Several Concepts Competing for the Same Phenomenon
Often, several concepts compete for the same phenomenon (Figure 19.2). We may call these terms “similes” or allied concepts, but often the terms need to be clarified, and often one is preferred over the other to advance the discipline. For example, we are not certain if nursing “presence” is the same as “being with,” and both appear in the literature. These two concepts closely resemble each other; one may be slightly different, and may appear to more closely resemble the phenomenon. Our task would be to determine the differences and the similarities between each of the concepts. At this stage of our research we do not examine the phenomenon itself—that is the task of qualitative inquiry.
Concepts that compete to explicate nursing insight
As an example of the use of concept clarification for competing concepts, we examine the concepts that nurses use to explain nurses’ ability to assess a patient condition, or to recognize a patient’s state, or an impending crisis, without the patient verbally reporting his or her symptoms, feelings, or need, and before the signs of deterioration are detected on patient monitors. These nurses have the ability to “read” the patient cues, and have the insight to comprehend their meaning (Morse, Miles, Clark, & Doberneck, 1994).
The first step is to identify the concepts in the literature accounting for this phenomenon. Three of the concepts were considered partially mature: intuition, emotional empathy, and inference. “Knowing” was considered an immature, lay concept. Those that were scientific concepts were: countertransference, compathy, and embodiment. Following the examination of the concepts’ definitions, these immature and scientific concepts were placed aside until the partially mature concepts were examined further.
Table 19.1 lists the definitions of each of the concepts. These definitions are derived from a “composite” definition. Displaying the definitions this way enables the researcher (and the reader) to quickly see significant differences in the concepts.
Some of the definitions refer to cognitive processes, others to emotional, and yet others refer to a mixture of both. Countertransference was described as emotional/physical. Which of the concepts occur to one quickly, instantaneously, with conscious thought? Did some concepts imply more certainty to assess the patient’s condition/experience than others?
The next step is to identify analytic questions that will enable you to distinguish between concepts. From a close reading of the literature, the following analytic questions associated with preconditions, the process of insight, and the outcomes, were identified.
• Is the concept a part of human experience?
• Is the concept a gift, talent, or special ability?
• Is the concept influenced by the nurse’s personal past?
• Is a previous relationship with the patient necessary for the concept to “work?”
• Can the experience of insight be taught or enhanced in the classroom or in the workplace?
The process of insight:
• Do nurses use emotional, cognitive, or physical responses with the concept?
• At what level of consciousness do nurses use the concept?
• At what level does identification with the patient, occur within the nurse—is it psychological or vicariously physical?
• Is the concept used to describe a process or a produce?
• Is the experience accurate in terms of predicting patient outcomes?
• Is the concept positive or negative for patient care?
The next step is to take a large (very large) sheet of paper and draw a matrix. Place these analytic questions in the first column (one per row). Across the first row, name the major author in the group for each major concept (in this case, authors for intuition, emotional empathy, and inference).
Working systematically, ask each author the analytic question, recording his or her answer on your matrix. Maintain control by placing direct quotations in quotation marks with the page number, noting the author, year, and page number.
Once this is completed, synthesize each group of responses. The results for this project are presented in Table 19.2. Any difference between concepts—and similarities—should be immediately apparent.
Delineating/Developing the Concepts
In Table 19.3 we show the conceptual attributes of intuition, emotional empathy, and inference. Commonalities are evident: all are for the relief of distress; all provide a nursing intervention. However, the process by which the nurse responds is very different. Intuition and emotional empathy both use the nurses’ emotional response and response subconsciously, whereas inference uses clinical knowledge. In addition, the outcomes and the perceived “success” of each, are also different with inference the most tolerant of error. However, difference in reporting were also different. Benner and Tanner (1987), when reporting on nurses’ interviews about intuition, had not reported instances in which the intuition was incorrect—on instances in which the nurse, based on intuition, had called a code and the patient had subsequently not coded.
Despite the cognitive overlap of these three concepts, there are distinct differences within each concept according to their epistemological origin, which impact on the interpretation, translation, and utilization of the concepts. Further, when concepts are borrowed from other disciplines, often their meaning subtly changes, so that two authors discussing the same concept may be using diverse meanings. We noted that:
… there were distinct differences relating to the epistemological origins and/or to the nursing interpretation, translation, adoption, and utilization of the concepts; this divergence of use is a problem for nursing. At times, the fact that these concepts were removed from their theoretical contexts and/or theoretical origins is not discussed. This borrowing has serious ramifications because, in the process of transfer, the meaning subtly changes. Thus, two authors may be apparently discussing the same concept yet applying diverse meanings to the same concept. For example, Benner and Tanner (1987) use the concept “intuition” to describe a model of skill acquisition as developed by Dreyfus and Dreyfus (1980), whereas Gerrity (1987) uses the concept of intuition as a personality trait as described by Jungian psychoanalysts … Because these differences have not been made explicit and because the same label is used for both meanings, these two theoretical interpretations of the same concept and the resulting research have been merged and are treated equivalently in the nursing literature. This conceptual sloppiness is a problem that requires urgent attention. (Morse et al., 1994, p. 249)
None of the authors writing about these concepts have suggested that nurses actually use two or even three of the concepts simultaneously—the concepts are distinct, and the competition between them is in the accounting for the phenomenon. Even though the process of instantaneous assessment without patients’ verbal complaint or changes in the vital signs on the monitor is still an important part of care, none of the concepts are adequately developed as to be incorporated into nursing theory or clinical teaching, and this problem remains. It is not a problem of monitoring, but in the interpretation of the behaviors of those being monitored. In 1994, we concluded by suggesting that as none of the concepts accurately included nurses’ prediction of a patient coding from a “look that patients get” prior to a code (Benner & Tanner, 1987) then perhaps we should transfer our attention to conducting research using subliminal theory. Research could then be conducted by actually coding patient’s expressions and looking for signs of this particular expression, rather than continually interviewing nurses (which appears to be a dead-end path to this inquiry). Such research would be clinically useful for assessment, and be suitable for teaching in the classroom, but to my knowledge, this has not been done.
The purpose of listing this 1994 research in this volume was to illustrate the process of conducting concept comparison. However, nurse researchers are still exploring intuition using concept development methods with little progress, or by conducting interview research—which also has serious limitations for understanding this type of question. A systematic review by Rew (2004) concluded that most studies were of descriptive–exploratory design and have remained at that level for “more than 20 years” (p. E24). The microanalytic observational study has not been conducted.
What are we doing about this as a discipline? Research agendas established by federal agencies or foundations do not approach such a basic clinical problem—nor, indeed, do they call for any research problems that are at the core of nursing processes. Tanner (2006) reviewed the research to teaching clinical judgment, but in her article, clinical judgment remains dependent on reflective practice. Without developing a new approach to this research, educators have a difficult time teaching clinical judgment, as do students to learn the skills. Expert nursing remains the purview of mentors, learning by trial and error, and mysterious, unidentified assessment processes (see Paley, 1996, 1997, 2006).
The Concept Has Undergone Changes as It Has Been Used: Conceptual Drift
Pragmatic utility is a strategy that may be used for comparing a concept as it was developed with the way the concept is currently used. It may be used for scientific concepts, so that it is relatively easy to locate the publications that first introduced the concepts, and later publications that cited the original authors, and use the concept in current research, looking for subtle changes in the meaning or use of the concept (see Figure 19.3).
The problem is that the authors using the concept use the original definition and cite the author who originally introduced the concept, yet may be unaware that they are not using the concept as it was intended.
Do not forget that concepts are dynamic. However, scientific concepts are not supposed to be “informally dynamic.” If scientific concepts change (and they may), any modification is supposed to occur purposefully, with supporting theoretical rationale, experimentation, measurement, and debate.
THE EXAMPLE: THE CONCEPTUAL COHESION OF SOCIAL SUPPORT
Judith E. Hupcey
When the concept of social support was introduced by Caplan (1974), Cobb (1976), and Cassel (1976), social support was not suddenly “invented,” introducing new types of supportive relationships. Rather, the identification of the concept changed our perception of, and renamed, what was previously—and clumsily—called “caring friendship, community cohesion, or unconditional positive regard” (Tilden, 1985). However, as soon as social support was introduced, the significance of social support was recognized, but it had different research purposes in different disciplines. Hupcey (1998a) noted that for medical sociologists it became the rationale for exploring social networks; for psychologists the connection between social relations and coping in illness; and for nursing, the link between family/significant others, meeting patient needs and the outcomes of illness.
Not only did the various contexts in which social support was used change the definitions and meaning of social support, but so did the ways those researchers used the concept. Some researchers adhered to the original definition and used the concept accordingly; some researchers used the original definition, but examination of their research showed that they were actually operationalizing it other than the way it was intended, and yet others modified the definition.
Suspecting such changes, Hupcey (1998a) proceeded by first examining the original definitions of the concept. When concepts are first introduced, there is often a period of debate and modification to the definition. She then listed the definitions that were presented by each author, and examined them by comparing them with the original definitions, and the components of each definition, and examined their attributes (characteristics) looking for commonalties and differences. From this, analytic questions were developed:
1. Was the relationship between the supporter and the recipient specified?
2. What were the recipients’ perceptions of the outcomes of social support?
3. Was the type of support specified?
4. Did the definitions exclude material aid?