Joumal of Advanced Nursing, 1995, 22,188-192

Continuing the dialogue: a response to Draper'scritique of Fawcett's ^Conceptual models andnursing practice: the reciprocal relationship'

Steven Kahn PhD RNAdjunct Assistant Professor

and Jacqueline Fawcett PhD FAANProfessor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania,USA

Accepted for publication 20 September 1994

KAHN S & FAWCETT J (1995) foumal of Advanced Nursing 22,188-192Continuing the dialogue a response to Draper's critique of Fawcett's'Conceptual models and nursmg practice the reciprocal relationship'In their response to Draper's (1993) critique of Fawcett's (1992) paper'Conceptual models and nursing practice the reciprocal relationship', theauthors argue that Draper's cntique is flawed They point out that Draper fails toacknowledge the diversity withm the positivist movement, makes logical leaps,and fails to acknowledge Fawcett's long-standing distinction between middle-range theones and conceptual models and her discussions ofthe differences mthe criteria to be used when evaluating conceptual models and theories

Knowledge and understanding are perhaps best advancedthrough contmumg dialogue and debate This paper rep-resents the continuation of a dialogue m the form of aresponse to Draper's (1993) cnbque of Fawcett's (1992)paper, 'Conceptual models and nursing pracbce tbereciprocal relabonship'

Fawcett (1992) contends that there is a reciprocalrelationship between conceptual models and nursmg prac-tice, such that conceptual models provide a structure fornursmg pracbce, and tbe outcomes of nursing pracbceprovide evidence for determination of the credibility ofconceptual models Draper (1993) contends that Fawcett'sview of the reciprocal relationship is located 'withm theintellectual tradibon of posibvism' and that 'the standardsof evidence upon which some of her arguments are basedare not compatible with the practice of posibvist socialscience, with the result that [Fawcett's] paper is internallyinconsistent' We now contend that Draper's cribque isflawed m a number of respects, most notably m his appar-ent lack of awareness of the diversity within tbe posibvistmovement, his leaps in logic, and his failure to acknowl-edge Fawcett's long-standmg distmcbon between middle-Correspondence Dr/ Fawcett 720 Middle Turnpike Storrs, CT 06268,

USA

range theones and conceptual models and her discussionsof the differences in criteria to use when eveduatmgconceptual models and theories (e g Fawcett 1984, 1989,Fawcett & Downs 1986)

DISTINCTIONS BETWEEN CONCEPTUALMODELS AND THEORIES

Although Draper (1993) acknowledges that Fawcett 'haspublished widely and mfluentially', his critique did notbenefit from those writings Rather, Draper bases much ofhis argument on points tbat are more appropriate to thediscussion of the relabvely specific and concrete formu-labons known as middle-range theories than to tbe abstractand general formulabons known as conceptual modelsof nursmg

The distmction between conceptual models and theoriesIS peirbcularly salient when one considers the number ofsteps required before empincal tesbng can occur A con-ceptual model cannot be tested directly because its globalconcepts and proposibons are not empmcally measurableMore specific and concrete concepts and propositions haveto be denved firom the conceptual model, that is, a middle-range theory must be formulated Those more concreteconcepts then must be defined m mesisurable ways, and

188 © 1995 Blackwell Science Ltd

Continuing the dialogue

hypotheses statmg specific, observable relabonships mustbe denved from the proposibons of the theory, pnor toempmcal testmg

Recognibon ofthe unpossibihty of direct empmcal testsof conceptual models led Fawcett to label the 'goodness'of conceptual models as credibihty and the 'goodness' oftheones as empmcal adequacy (Fawcett & Downs 1986)More specifically, theones are exammed to determine theextent to which they meet the cntenon of empmcaladequacy, whereas conceptual models are examined todetermine the extent to which they meet the cntenon ofcredibility

The empirical adequacy critenon

The cntenon of empmcal adequacy requires theoreticalclaims to be congruent with empmcal evidence derivedfrom research The mterpretabon of tests of hypotheses isespecially important when examining the empincaladequacy of a middle-range theory The logic of scienbficinference dictates that if the empmcal data do not conformto the hypothesized expectabon, it may be appropnate toconclude that the hypothesis is false Conversely, if theempmcal data conform to the expectabon stated by thehjrpothesis, then it may be appropnate to tentativelyaccept the h5rpothesis as empirically adequate, but notvalidated

This cnterion, then, emphasizes the view that the aimof research is not to determine the absolute truth, orvalidity, of theones, but rather to determine the degree ofconfidence warranted by the best empirical evidence

The credibility cnterion

The credibility cnterion requires evidence of the socialublity, social congruence, and social significance ofa con-ceptual model Judgements about those social aspects ofthe conceptual model require a review of all publicabonsand presentabons by the author of the conceptual model,as well as those by other nurses who have used themodel

Social utilityThe evaluabon of social ublity first considers the specialeducabon required to apply the conceptual model Morespecifically, although authors of conceptual models cer-tamly stnve to wnte and to discuss their work clearly andconcisely (Gormack & Reynolds 1992), the abstract andgeneral nature of nursmg models and the special vocabu-lary of each one typically require collegiate or contmmngeducabon for mastery In addibon, special trainmg inmterpersonal and psychomotor skills may be necessary toapply the model m climcal situabons (Magee 1994) Theconceptual model is considered credible if the nurse cangam a full imderstandmg of the content of the conceptual

model as well as the mterpersonal and psychomotor skillsnecessary to apply it

Second, the evaluabon of social ublity considers thefeasibihty of implementing clmical protocols denved fromthe conceptual model and related theones m nursing prac-bce The conceptual model is considered credible if thelmplementabon of such protocols is feasible FeasibilityIS detemuned by evaluating the human and matenalresources needed to establish the model-based nursmgacbons as customary pracbce (Magee 1994) Requisiteresources include the bme required to leam andimplement the protocols, the number, iype, and experbseof personnel needed for their applicabon, and the fundsfor contmumg education, salanes, equipment and proto-col-tesbng procedures

Third, the evaluabon of social ublity requiresconsideration of the extent to which the conceptual modelIS actually used to guide nursmg research, educabon,admmistrabon, and pracbce The conceptual model is con-sidered credible if it is generahzable to the design of nurs-ing studies, the construction of educational programmesand admmistrabve structures, and to the care of peoplewho require nursing

Social congruenceSocial congruence refers to the compabbility of conceptualmodel-based nursing acbvibes with the expectabons con-cernmg nursing pracbce, of the pabent, the community,and the health care system (Magee 1994) In particular, thepabent's and the community's culturally determmedexpectabons, as well as vanous health care team members'discipline-onented expectabons, with regard to appro-pnate areas of assessment, relevant goals and outcomesand appropnate nursmg lntervenbons, must be taken intoaccount (Aggleton & Chalmers 1985, Jones 1989, McLane1983) Furthermore, the expectations based on the systemof health care delivery in vanous countnes should be con-sidered (Cormack & Reynolds 1992)

The conceptual model is considered credible if relevantnursmg acbvibes are congruent with the expectabons ofpabents, communibes, and health care teams

Social significanceEvaluation of social significance requires a judgement tobe made with regard to the social value of a conceptualmodel, with emphasis placed on the effect of the use of aconceptual model on patients' health status (Magee 1994)'This cntenon,' accordmg to Johnson (1974), 'recogmzesthat a professional service is a highly valued one becauseIt IS cnbcal to people m some way' The social significanceof a conceptual model can be detemuned by informal andformal methods

The informal method of determmmg sociad sigmficanceIS accomphshed m three phases First, prototypeconceptual-theorebcal systems of nursmg knowledge are

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S Kahn and J Fawcett

developed for each climcai speciality area or each nursmgdepartment and for vanous patient populations Next, anmdividualized system of knowledge is developed by eachnurse for each patient Nursing care then is camed out maccordance with the nursmg process of the selected con-ceptual model, which is amplified by logically congruentmiddle-range theones Fmally, the results of theevaluation of the process provide data that may be usedto detemune the credibility of the conceptual model Theconceptual model is considered credible if patient out-comes are m accordance with expectations If, however,patient outcomes are not in accordance with expect-ations, the credibility of the conceptual model must bequestioned

The formal method of determining social significance isaccomplished by examining the findings of researchgmded by conceptual-theoretical-empincal systems ofnursing knowledge First, using an approach adapted fromwork by Silva (1986), the infiuence of the conceptualmodel on the research process is evaluated in relation tothe follovnng issues

1 The conceptual model of nursing is explicitly identifiedas the underlying guide for the research

2 The conceptual model of nursing is discussed msufficient breadth and depth for the relationshipbetween the model and the study purpose and researchquestion(s) to be clear

3 The linkages between conceptual model concepts andpropositions and middle-range theory concepts andpropositions are stated explicitly

4 The methodology of the study reflects the conceptualmodel

a The study subjects are drawn from a population thatIS appropnate for the unique focus of the concep-tual model

b The mstruments are appropnate empmcal mdicatorsof conceptual model concepts

c. The study design clearly reflects the unique focus ofthe conceptual model

d The data analysis techmques are m keepmg with theunique focus of the conceptual model

5 The data are mterpreted m terms of evidence regardingthe middle-range theory that was derived from or linkedwith the conceptual model

6 Discussion of the study results mcludes conclusionsregarding the empirical adequacy of the middle-rangetheory and the credibility of the conceptual model

The systematic examination of these issues is especiallyimportant because some researchers do httle more thancite a particuleur conceptual model in the study report(Silva 1987) If an investigator deals satisfactorily withthese SIX issues, the determination of credibility may pro-ceed to a companson of the research findings with the

propositions ofthe conceptual-theoretical system of nurs-mg knowledge that was used to gmde the research If theresearch findmgs support the empmcal adequacy of thetheory, then it is likely that the conceptual model is cred-ible If, however, the research findings do not support thehypothesized expectations, both the empmcal adequacyof the theory and the credibility of the conceptual modelmust be questioned

The application of the credibility cntenon is necessaryto avoid the danger of uncntical acceptance and adoptionof conceptual models, which could easily lead to their useas ideologies Indeed, cntical reviews of the evidenceregarding the credibility of each conceptual model mustbe encouraged, and acceptance of work that is 'fashionable,well-trodden or simply available m the nursmg library'(Gnnnell 1992) must be avoided The ultimate aim of theapplication ofthe credibility cntenon is to asceitam whichconceptual models are appropriate for use m whichclinical settings and with which patients

FLAWS IN DRAPER'S CRITIQUE

Draper's (1993) pnmary argument is that Fawcett (1992) isinconsistent He claims that Fawcett believes m lettmg evi-dence accumulate to confirm the validity of a theory Morespecifically. Draper makes the following claims

1 Fawcett is a positivist2 A positivist believes that the scientific validity of a

theory is established through Popperian falsificationattempts

3 Fawcett adheres to a verificatiomst methodology forestabhshing nursing theones, and

4 consequently, the theones are not scientific m thepositivistic sense

5 Therefore, Fawcett is mconsistent m adhenng toposihvistic assumptions

The flaws m this argument are that

1 Fawcett has not been shown to be a positivist2 Although Draper's contention would place Fawcett's

position withm the venficatiomst approach, Fawcettdoes not adhere to a verificatiomst methodology

3 Not all positivists believe m falsification as the road toscientific validity

4 Therefore, one can not conclude that Fawcett isinconsistent

It IS mstructive to examine the fiaws m Draper's argu-ment m some detail, for they illustrate some importantfeatures of positivism Let us consider the fiaws

Falsification and positivism

Draper spends much tune and effort trying to elucidate thenature of positivism through its history Actually, it is

190 © 1995 Blackwell Science Ltd, Joumal ofAdvanced Nursing, 22,188-192

continuing the dialogue

qiute difficult to typify all the mdividuals smce Gomtewho have been known as posihvists Draper quotes anumber of philosophers who professed an affinity for thescientific methods associated with 17th century physicsand who, consequently, beheved m mechanism and caus-ality and mamtamed that all knowledge of the world isdiscovered by experimental manipulation of vanablesHowever, at least some 20th century positivists did notaccept mechanism and causahon and did not adhere to astnct mterpretahon of expenmentahon as the examinationof the effect of the manipulation of independent vanableson dependent vanables (Ayer 1946, Gamap 1967)

Furthermore, a review of the publications of 20th cen-tury posihvists reveals that falsificahon is not the preferredmethodology of cdl posihvists In fact. Popper offered hismethodology to overcome Hume's problem of mduction,which plagued his positivist colleagues In contrast, positi-vists such as Ayer (1946), Gamap (1967) and Reichenbach(1951) struggled to make the venficatiomst programmework

Fawcett is not a positivist or a venficationist

It IS instnichve to pomt out that much of the work of theposihvists was a reachon to the reliance on theology andmetaphysics as ways to knowledge, pnor to and dunngthe 17th century These non-empincal approaches led tomuch mhumamty and suffenng, as well as to some bizarretheones about the natural world The posihvist movementcan be seen as a reachon to what the posihvists consideredpernicious bias and subjechvity The posihvists hoped toovercome such subjectivity hy lethng the facts speak forthemselves Theorists could then decide between compet-mg theories by lookmg at the facts This approach is basedon the assumption that the percephon of the facts remainsmdependent of the theones (and m our case the concep-tual models) m queshon Draper himself relies m part onthis issue to typify positivism

Fawcett, however, does not agree vnth that approachInstead, drawing from Popper's (1965) and Kuhn's (1970)epistemology, Fawcett maintains that all perceptions andobservahons are coloured by the conceptual frame of refer-ence, 1 e the conceptual model, from which we view theworld Thus, the world cannot be perceived mdependentlyfrom a conceptual model and observations cannot be madeoutside of some conceptual model The positivist'sprogramme of lettmg the facts decide between theonescollapses if this is true, because there are no independ-ent 'facts' If for no other reason, then, Fawcett cannot beconsidered a posihvist

This point has many ramificahons One is that what cancount as a countennstance to the conceptual model has tobe something that the model would predict For some,posihvists mcluded, this would appear to be beggmg thequeshon Draper (1993) seems to believe, and accepts the

idea, that the world can be observed mdependently fromtheones, as his example of bleeding and purging wouldmdicate In the example. Draper cnhcizes these medicaltreatments because they were t)ased on the madequatehumoral theory He claims that we now have a more accu-rate knowledge base of modem physiology to rely on Hisclaim would mdicate that there is some unparhal way todecide between theones and that is, of course, what theposiUvist program is about

Moreover, although Draper (1993) bases much of his cn-tique on issues conceming the validity of conceptualmodels, the previous discussion reveals that Fawcett, mfact, does not use the term 'validity' in her discussionsIndeed, Fawcett has deliberately eschewed the use thisterm because of its association with the philosophicaltenets of positivism Moreover, despite Draper's claims tothe contrary, Fawcett is not a posihvist, she does not sub-scnbe to venficahomsm, and she does not seek to validatetheones Rather, her wntings have always reflected herEillegiance with Popper's (1965) methodology of falsifi-cation (see especially, Fawcett & Downs 1986)

Fawcett is not inconsistent

One cannot conclude that Fawcett (1992) is mconsistentThat follows from the fact that Draper (1993) failed todemonstrate that Fawcett is not scientific in her own senseIn particular. Draper finds problematic the reciprocalrelahonship between theory and observahon or practiceThis IS cunous because it is the posihon of those whooppose positivism, including Hanson (1958) and Kuhn(1970) In fact, even Popper (1965) maintained that allobservations are made vnthin a 'frame of reference, [an]honzon of expectations', and that 'Observahon is alwaysselective It needs a chosen task object, a definite task, anmterest, a point of view, a problem' (Popper 1965) Morespecifically, one cannot observe the world withoutobserving it through some conceptual frame of reference,the observations, m tum, can affect the frame of referenceThat IS, of course, the exact pomt that Fawcett (1992) made

OTHER FLAWS IN DRAPER'S CRITIQUE

Draper (1993) maintains that Fawcett's claim that a con-ceptual model can be considered credible if pahent out-comes are congruent with the expectations raised by themodel 'is essenhally circulsur, because it neglects the pos-sibility that the outcomes would he inadequate whenjudged against extemally denved cntena' He also main-tains that Fawcett's claim that data from quality assurancereviews can be used for evidence regarding credibility iscircular In both mstances. Draper fails to take mto accountthe possibihty that Fawcett, drawmg from Kuhn (1970),views vanous conceptual models as incommensurableGonsequently, the rules of evidence exist only within the

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S Kahn and J Pawcett

conceptual model In fact, Fawcett subscnbes to themcommensurabUity viewpomt and has clearly stated thatexternal compansons of conceptual models should not bemade (eg Fawcett 1989)

Furthermore, Draper (1992) charges that Fawcett'retreats into vagueness when faced by the possibility ofnegabve answers' from evaluabons of conceptual model-based nursmg care by the recipients of that care In thisinstance. Draper fails to appreciate the importance ofbasing nursmg care on a perspecbve that is shared by bothnurse and pabent, and ignores Fawcett's (1992) statementthat 'Negabve answers may mdicate a lack of credibilitybut also may indicate that the recipient of care was notfully informed oJ the services that are associated with themodel' [italics added] In fact, Fawcett is committed, onboth ethical and pragmabc grounds, to estabhshmgcontracts between pabents and nurses that mclude anagreement regardmg the conceptual basis for the nursingcare to be given

CONCLUSION

In conclusion, we have shown that Fawcett (1992) adoptsa consistent lme of thought throughout her paperFawcett's posibon is that it is impossible to make 'objec-bTe' observabons, because all observabons are madewithm the context of some conceptual model Choice of aconceptual model must, therefore, be gmded by rules otherthan those of venficabon from 'objecbve' data The rules,accordmg to Fawcett, are explicated as the cntenon ofcredibility

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