Confirmation and validation of empiric knowledge in practice
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Practice is goal directed. Clinical testing of theory is therefore essential. Choose your theory—it does not hold in all circumstances. The professional must not be just a simple user of theory, but a developer, a tester and expander of theory. Not for the purpose of scholarship, but for intelligent practice.
Rosemary Ellis (1969, p. 1435)
In this quote, Rosemary Ellis reaffirms that the reason for testing, confirming, and validating theory in practice is that practitioners hold visions and goals for the individuals they care for as well as for the profession in general. Although this statement almost seems trite, how often are theories deliberately examined in relation to practice? There are many things that can interfere with the deliberate confirmation and validation of theory in practice, but current trends in practice and education have the potential to significantly strengthen the confirmation and validation of theory in practice. These trends include the focuses on evidence-based practice and translational research as well as growing emphasis on the development of research approaches that specifically address the challenges of practice.
The current focus on evidence-based practice is important, but we raise a caution that it is not enough to be a user of evidence or of theory as Ellis states. Rather, if we are to believe Ellis, practitioners—especially those with advanced degrees—are expected to be developers, testers, and expanders of theory. This can occur as evidence is used, evaluated, and integrated into theoretic structures that have potential for use in relation to visions and goals across the settings in which nurses practice. This chapter addresses the deliberative confirmation and validation of empiric knowledge in practice settings so that nursing’s goals can continue to be approached and met.
To underscore Ellis’s contribution, the development of empiric knowledge (e.g., theories, formal descriptions for a practice discipline) requires deliberative confirmation and validation in the practice setting to assess the value of theoretic knowledge for moving toward significant nursing goals. The use of the word deliberative means that confirmation and validation processes must be reasoned, thoughtful, and carefully designed.
The practice-based deliberative confirmation and validation of empiric knowledge contributes to the development of scientific competence among nurses, which in turn enhances the quality of nursing care. It involves assessing the extent to which empiric knowledge is useful for guiding practice. Practice-based approaches to the deliberative confirmation and validation of empiric knowledge further contribute to empiric knowledge development as outcomes are shared within the discipline. Research methods are required, and practice-based research findings contribute valuable information to the development of empiric knowledge and theory.
The confirmation and validation of empiric knowledge in practice require the use of clinical settings to do the following (1) substantiate, modify, and propose evidence to guide the development of practice-relevant research and theory; 2) refine conceptual meaning; and 3) assess and evaluate the soundness of theoretic relationships.
By practice, we mean the experiences that a nurse encounters during the process of caring for people. Some experiences are those of the client, whereas others are those of the nurse; some are interactive, and some are environmental. These experiences occur in many settings, but, when they occur in the context of the provision of nursing care, they are considered part of nursing practice.
In this chapter, we address specific ways in which practicing nurses contribute to empiric knowledge development processes and the ways in which empiric knowledge development processes contribute to practice. We suggest ways that evidence-based practice and the practice confirmation and validation of empiric knowledge (including theory) provide direction for the further development of theoretically grounded practice approaches. We discuss important dimensions of refining conceptual meaning that can be accomplished only in the context of practice. We propose guidelines for confirming and validating theoretic relationships in practice. We also offer methodologic guidelines for confirming and validating theoretic relationships and outcomes in practice.
Theory- and evidence-based practice
The confirmation and validation of empiric knowledge in practice settings are important processes that can substantiate or refute current evidence and provide direction for the modification of evidence on which practice can be based. We maintained in Chapter 9 that the linking of theory with research is important. We believe that best practices in nursing are based on evidence that is not only grounded in sound, research-linked theory but that also takes into account a philosophic perspective that is consistent with a wholistic view of nursing knowledge. A strong and viable link between theory, research, and practice is vital to quality nursing care as well as to the ongoing development of the knowledge of the discipline.
The current professional trend to embrace evidence-based practice as a standard for professional nursing has the potential to significantly influence how empiric knowledge and theory are used and developed in relation to practice. However, a view of “evidence” that is narrowly defined as research evidence alone leaves a substantial gap in the foundation that is needed for nursing (Porter, 2010). As Betts (2009) claims, many concerns must be addressed so that the best nursing care is provided. These include both philosophic and theoretic perspectives in addition to the evidence provided by empiric research. We would add that the best nursing care requires a practical perspective that considers the broad context within which evidence is used.
The emergence of proposals for practice-based evidence—rather than evidence-based practice—highlights the need to take a view of evidence that considers the context of practice. Practice-based evidence is an approach that acknowledges the importance of the environment of practice to the determination of practice recommendations. Practice-based evidence values knowledge that is generated from practice as compared with knowledge that conforms to hierarchies of evidence and that is created apart from the context of practice. Although some evidence-based recommendations are reasonable, many are not. For example, evidence may support providing multiple individualized sessions to teach families how to best communicate with a family member who has had a stroke. Such evidence-based recommendations make sense, but they are likely not practical in a busy health care setting. Thus, practice-based evidence is not decontextualized, universal knowledge; in fact, it is quite the opposite (Fox, 2003; Horn & Gassaway, 2007; Porter, 2010; Simons, Kushner, Jones, & James, 2003).
DiCenso, Guyatt, and Ciliska (2005) proposed a definition of evidence-based practice that we favor because it requires meaningful connections between theory, research, and practice, and it acknowledges that a comprehensive range of situational factors needs to be taken into consideration for evidence-based practice to be accomplished. For these authors, evidence-based practice integrates best research evidence, health care resources, patient preferences and actions, clinical settings and circumstances, and the clinician’s judgment with regard to clinical decision making (pp. 4-5). Thus, evidence-based practice is not simply the use of research in practice, as it is sometimes characterized. Evidence-based practice requires the consideration of an array of circumstances, including concerns that arise from aesthetic, personal, ethical, and emancipatory knowing. Nursing’s focus on evidence-based practice and the use of the best research evidence has the potential to promote the linking of theory, research, and practice. Furthermore, if evidence-based practice as described by DiCenso, Guyatt, and Ciliska (2005) is taken seriously, evidence that is increasingly more suitable for practice will emerge.
For researchers, a significant challenge related to evidence-based practice is the development of knowledge regarding questions that are clinically important and the completion of research in a way that will generate evidence that is usable in practice. This will require communication between researchers and clinicians in a way that has been largely absent in the past. Such communication has the potential to integrate the roles of nurse researcher and nurse clinician.
As clinicians strive to locate the best research evidence that is appropriate to managing care and then attempt to use that knowledge given the limitations of the practice environment, the extent to which research evidence is available and usable will become more obvious. The difficulties and benefits of various methodologic approaches with regard to generating empiric research evidence will be made visible. As clinicians discover well-conceived and well-carried-out research evidence that requires, for example, the use of assessment tools that are impractical clinically, researchers will begin to understand the importance of considering how research is conducted. The importance of structuring clinically important concepts into meaningful theoretic relationships and then assessing those relationships in ways that allow clinicians to make use of findings in practice will become clearer.
Evidence-based practice also has the potential to illuminate areas in which even well-conceived and well-developed evidence cannot be easily used because of lack of resources, patient or client considerations, and other contextual factors. Research evidence may be appropriate for practice, and concepts in relationship may have been operationalized and assessed in a way that makes them well suited for use in practice. However, features of context (e.g., nurse–patient ratios, insurance reimbursement patterns, institutional policies that involve security) may make it difficult to use that best evidence in practice. These situations bring to light the need for emancipatory knowledge to create a care context that will allow and encourage the use of best evidence and the need for researchers to consider such features of context during the research process.
The emergence of the Doctorate of Nursing Practice (DNP) as the basic educational credential for advanced nursing practice is well under way. This trend has significant potential to strengthen the linkages between theory, research, and practice in a way that supports evidence-based practice. The DNP was conceptualized as a path to prepare nurses to contribute to the development of nursing knowledge by implementing the science developed by nurse researchers and to develop and integrate nursing practices on the basis of theory (“The essentials of doctoral education for advanced nursing practice,” 2006). When these practitioners begin to implement research findings and theory-based nursing practices in the face of expectations for evidence-based practice, the nature of the evidence that is needed and subsequent implications for research and empiric knowledge development should become increasingly evident. Although the effect of the DNP on nursing practice remains to be seen, these practitioners have the potential to markedly affect how research, theory, and practice are linked to facilitate evidence-based practice.
In summary, an emphasis on evidence-based practice is much broader than the application of research in practice. Evidence-based practice has the potential to strengthen the linkages between theory and other empiric knowledge forms with practice. It also requires communication among nurses in a variety of roles. Specifically, embracing evidence for practice that arises from strong links between theory, research, and practice has potential to do the following:
• Strengthen the practitioner’s and the researcher’s ability to collaborate when framing important practice issues and the clinical questions that need to be addressed (Chesla, 2008)
• Improve the skills of practitioners with regard to determining the quality and limitations of research evidence and then synthesizing that research (Copnell, 2008; Fawcett & Garity, 2008)
• Support a decision-making infrastructure and the development of a database that is appropriate for the context of nursing practice (Burkhart & Androwich, 2009; Porter, 2010)
• Make visible the challenges that are inherent in using knowledge developed outside of the realm of practice (Canam, 2008)
• Provide researchers with information about the types of knowledge structures that are required to meet health care goals (Doane & Varcoe, 2008; Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Porter, 2010)
• Create approaches to developing theory that is relevant in practice (Doane, Browne, Reimer, MacLeod, & McLellan, 2009)
• Bring to light contextual factors related to resources and settings that affect evidence-based practice (Chesla, 2008)
• Energize theory and research practices that are intended to address social issues, such as health-care disparities and cultural diversity (Betts, 2009; Chesla, 2008; Chung, Cimprich, Janz, & Mills-Wisneski, 2009);
• Enhance the potential for academic researchers and clinicians in all disciplines to work together, share roles, and ultimately dissolve the distinctions among research, practice, and theory (Lenz, 2007; Ryan, 2009)
When evidence is developed with the use of research processes that are sensitive to the context and goals of practice, the transformation of practice is possible. The processes that we next describe for confirming and validating empiric theory and knowledge are significant approaches to the development of evidence for best nursing practices.
Refining conceptual meaning
Nursing concepts come from the experience of practicing nursing. Practicing nurses who reflect on the nature of their experiences and who systematically communicate their reflections make significant contributions to confirming and validating empiric knowledge. Researchers who are primarily involved in knowledge development benefit from the ideas of nurses who practice clinically. Everyone does not participate equally in all of the processes required for the development of empiric knowledge. Some researchers—but not all—do engage in practice. Some practicing nurses—but not all—conduct research. Many nurses who do engage in both practice and research find the experiences to be rewarding and beneficial. Regardless, each person participates in the collective endeavor to develop nursing knowledge.
Empiric concepts are formed from nursing practice by observing, naming, and making sense of what happens. The processes described in Chapter 7 for creating conceptual meaning can be used to systematically document reflections on your experiences from which you can derive a tentative conclusion about the experience that you might want to study. If you are practicing in a clinical setting, your thinking will be grounded in nursing practice, and you have a rich resource from which to explore conceptual meanings. After you have tentatively described your phenomenon of interest, you can turn to activities for the refinement of conceptual meaning. There are four practice-dependent activities that are required to refine conceptual meaning: identifying empiric indicators, differentiating similar concepts, identifying new concepts, and identifying conceptual and diagnostic criteria.
Identifying empiric indicators
Practice provides essential evidence that is used to select empiric indicators for abstract concepts. The experiences of practice can challenge existing theoretic conceptualizations, and they can reveal hunches that have not yet been linked to a particular concept or theory. The basic question is, “What have I experienced that can be linked to the abstract concept x?”
Anxiety is a good example of such an experience. Suppose that a wide range of behaviors observed in practice are described in a theory as manifestations of the concept of anxiety. These behaviors might include the wringing of the hands, being silent and refusing to talk, talking excessively, laughing, crying, sweating, eating compulsively, not eating, or lacking an appetite. Tools have been constructed that assess the concept of anxiety with the use of these empiric indicators. In your practice, you might observe that these ideas do not always fit and that they in fact sometimes contradict one another. When you work with individuals who are anxious, you notice that they tend to behave in ways that are not consistent with the theoretic concept. There are some behaviors that you almost never observe, whereas others that are commonly experienced are not taken into account by the theory. Because anxiety as an abstract idea does convey something that you know exists, it might be helpful if you could better identify it, understand how it works, and determine how people experience it differently. As you draw on your experience, new ideas begin to emerge from the empiric behaviors that you have noticed.
Differentiating similar concepts
Concepts that are similar yet different might share certain empiric indicators, and differentiating them may be difficult. If knowing the difference between them is important in practice, practice can provide the empiric information and conceptual insights required to distinguish them. This purpose becomes critical when you realize that errors can be made when assigning meaning to a person’s experience. For example, you might have been taught that certain behaviors are manifestations of anxiety on the basis of a popular theory of anxiety. You have integrated research evidence, theory, and your experience to make expert clinical judgments about how to help anxious people reduce their anxiety and improve their function, but your approach does not seem to be as effective as you think it should be. One problem might be that the behaviors are not indicative of anxiety but rather associated with fear. Your challenge is to begin to conceptualize anxiety more clearly, to understand what else might be happening, and to begin to find ways to differentiate between the experiences of anxiety and fear. As you question and challenge the conceptualization and the conclusions that you draw from it, you will form a basis for restructuring the concepts and form new or revised concepts that better represent nursing experience.
Identifying new concepts
Creating conceptual meaning is a process that can lead to the identification of new concepts. Model, borderline, related, and contrary cases that come from practice reflect the richness and complexity of practice. As you reflect deliberatively on these situations, your insights can lead to new ideas that contribute to the formation of new concepts. See the example in Box 10-1.
