Concepts

The phenomenon termed social support introduced earlier is a concept. A concept is the basic element of a theory. Each concept in a theory needs to be defined by the theorist. The definition of a concept might be detailed and complete, or it might be vague and incomplete and require further development (Chinn & Kramer, 2011). Theories with clearly identified and defined concepts provide a stronger basis for a study framework.

Two terms closely related to concept are construct and variable. In more abstract theories, concepts have very general meanings and are sometimes referred to as constructs. A construct is a broader category or idea that may encompass several concepts. For example, a construct for the concept of social support might be resources. Another concept that is a resource might be household income. At a more concrete level, terms are referred to as variables and are narrow in their definition. Thus a variable is more specific than a concept. The word variable implies that the term is defined so that it is measurable and suggests that numerical values of the term are able to vary (are variable) from one instance to another. The levels of abstraction of constructs, concepts, and variables are illustrated with an example in Figure 7-1.

A variable related to social support might be emotional support. The researchers might define emotional support as a study subject’s rating of the extent of emotional encouragement or affirmation that he or she receives during a stressful time. The measurement of the variable is a specific method for assigning numerical values to varying amounts of emotional social support. Subjects would respond to questions on a survey or questionnaire about emotional support and their individual answers would be reported as scores. For example, the Functional Social Support Questionnaire has a three-item subscale that measures perceived emotional support (Broadhead, Gehlbach, de Gruy, & Kaplan, 1988; Mas-Expósito, Amador-Campos, Gómez-Benito, & Lalucat-Jo, 2011). One of the items was “People care what happens to me,” and the others addressed whether the respondent felt loved and received praise for doing a good job (Broadhead et al., 1988, p. 722). If the Functional Social Support Questionnaire was used by researchers in a study, the subjects’ answers to the three items would be added together as the total score. The subjects’ total scores on the three questions would be the measurement of the variable of perceived emotional support. (Chapter 10 provides a detailed discussion of measurement methods.)

Defining concepts allows consistency in the way the term is used. Concepts from theories have conceptual definitions that are developed by the theorist and differ from the dictionary definition of a word. A conceptual definition is more comprehensive than a denotative (or dictionary) definition and includes associated meanings that the word may have. A conceptual definition is referred to as connotative, because the term brings to mind memories, moods, or images, subtly or indirectly. For example, a conceptual definition of home might include feelings of security, love, and comfort, which often are associated with a home, whereas the dictionary definition is narrower and more specific—home is a dwelling in which a group of people who may or may not be related live. Some of the words or terms that are used frequently in nursing language have not been clearly defined. Terms used in theory or research need connotative meanings based on professional literature. Connotative definitions are clear statements of the concepts’ meaning in the particular theory or study.

The conceptual definition that a researcher identifies or develops for a concept comes from a theory and provides a basis for the operational definition. Remember that in quantitative studies, each variable is ideally associated with a concept, conceptual definition, and operational definition. The operational definition is how the concept can be manipulated, such as an intervention or independent variable, or measured, such as a dependent or outcome variable (see Chapter 5). Conceptual definitions may be explicit or implicit. It is important that you identify the researcher’s conceptual definitions of study variables when you critically appraise a study. Nichols, Rice, and Howell (2011) conducted a study with 73 overweight children who were 9 to 11 years old to examine the relationships among anger, stress, and blood pressure. Although the researchers did not identify the conceptual definitions in the report of the study, the definitions can be extracted from the study’s framework. The implicit conceptual definition and operational definition for one concept in the study, trait anger, are presented in Table 7-1. Conceptual and operational definitions of variables are described in detail in Chapter 5.

Relational Statements

A relational statement clarifies the type of relationship that exists between or among concepts. For example, in the study just mentioned, Nichols and colleagues (2011) proposed that high levels of trait anger were related to high blood pressure in overweight children. They also proposed that high blood pressure was influenced by patterns of anger expression and stress. In regard to the effects of stress on blood pressure, they provided more detail about how stress affected blood pressure by describing the relationships among the corticotropin-releasing factor, stress response, rate and stroke volume of the heart, cardiac output, and constriction of the blood vessels that result in changes in blood pressure. The statements of the physiological processes explaining the connections between stress and blood pressure were also relational statements. Figure 7-2 is the diagram that the researchers provided to display the relationships of their framework.

The relational statements are what are tested through research. The researcher obtains data for the variables that represent the concepts in the study’s framework and analyzes the data for possible significant relationships among the variables using specific statistical tests. Testing a theory involves determining the truth of each relational statement in the theory. As more researchers provide evidence about the relationships among concepts, the accuracy or inaccuracy of the relational statements is determined. Many studies are required to validate all the relational statements in a theory.

In theories, propositions (relational statements) can be expressed at various levels of abstraction. Theories that are more abstract (grand nursing theories) contain relational statements that are called general propositions (Grove et al., 2013). Stating a relationship in a more narrow way makes the statement more concrete and testable and results in a specific proposition. Specific propositions in less abstract frameworks (middle range theories) may lead to hypotheses. Hypotheses are developed based on propositions from a grand or middle range theory that comprise the study’s framework. Hypotheses, written at a lower level of abstraction, are developed to be tested in a study. Statements at varying levels of abstraction that express relationships between or among the same conceptual ideas can be arranged in hierarchical form, from general to specific. Table 7-2 provides three examples of relationships between two concepts that are written as general propositions, specific propositions, and hypotheses. The first general proposition includes the constructs of enduring personality traits and physiological responses and could be applied to enduring personality traits, such as determination or self-confidence. In this case, the specific proposition indicates that the enduring personality trait is trait anger and the physiological response is blood pressure. The hypothesis proposes a specific relationship between trait anger and blood pressure that was tested in the study (Nichols et al., 2011).

Grand Nursing Theories

Early nurse scholars labeled the most abstract theories as conceptual models or conceptual frameworks. For example, Roy (Roy & Andrews, 2008) described adaptation as the primary phenomenon of interest to nursing in her model. This model identifies the elements considered essential to adaptation and describes how the elements interact to produce adaptation and thus health. In contrast, Orem (Orem & Taylor, 2011) presents her descriptions of health phenomena in terms of self-care, self-care deficits, and nursing systems. Both these theories have been called conceptual models.

What can be confusing is that other scholars do not label Roy’s and Orem’s writings as conceptual models, but classify them as grand nursing theories (Peterson & Bredow, 2009). Because of this lack of agreement, we will use the term grand nursing theories in this book to describe the nursing theories that are more abstract. We will reserve the term model to refer to a diagram that graphically presents the concepts and relationships of a framework being used to guide a study. Table 7-3 lists several well-known grand nursing theories, with a brief explanation.

Building a body of knowledge related to a particular grand nursing theory requires an organized program of research and a group of scholars. The Roy Adaptation Model (RAM) has been used as the basis for studies for over 25 years. The Roy Adaptation Association is a group of researchers who “analyze, critique, and synthesize all published studies in English based on the RAM” (Roy, 2011, p. 312). The Society of Rogerian Scholars continues to conduct studies and develop knowledge related to Martha Rogers’ Science of Unitary Human Beings (http://www.societyofrogerianscholars.org/index.html). The International Orem Society publishes a journal, Self-Care, Dependent-Care, & Nursing, to disseminate research and clinical applications of Dorothea Orem’s theory of self-care. These are examples of researchers who maintain a network to communicate with each other and other nurses about their work with a specific theoretical approach.

Middle Range and Practice Theories

Middle range theories are less abstract and narrower in scope than grand nursing theories. These types of theories specify factors such as a patient’s health condition, family situation, and nursing actions and focus on answering particular practice questions (Alligood & Tomey, 2010). Middle range theories are more closely linked to clinical practice and research than grand nursing theories and therefore have a greater appeal to nurse clinicians and researchers. They may emerge from a grounded theory study, be deduced from a grand nursing theory, or created through a synthesis of theories on a particular topic. Middle range theories also can be used as the framework for a study, thus contributing to the validation of the middle range theory (Peterson & Bredow, 2009). Table 7-4 lists some of the middle range theories currently being used as frameworks in nursing studies. These published middle range theories have clearly identified concepts, definitions of concepts, and relational statements and are referred to as substantive theories. These theories are labeled as substantive because they are closer to the substance of clinical practice. For example, clinical practice involves nursing actions to help the patient be comfortable. Kolcaba and Kolcaba (1991) analyzed the concept of comfort. They defined comfort as the state of relief, ease, and transcendence that is experienced in the physical, psychospiritual, environmental, and social contexts of a person. From that concept analysis, a middle range theory of comfort was developed that is applicable to practice and research. “According to the theory, enhanced comfort strengthens recipients….to engage in activities necessary to achieving health and remaining healthy” (Kolcaba & DiMarco, 2005, p.189).

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