A response to Risjord’s (2009) article, reconceptualizing concept analysis was unavoidable given the centrality and power of concepts in work of nurses and the life of clients. We are encouraged to see debate in JAN about concept clarification and the place of concepts in the development and structure of theories. However, we assert that the ghettoization of qualitative nursing science and the argument against concept ‘contextualization’ within the nursing literature is not only inaccurate but perilous.
Risjord endeavours to elucidate both the epistemological and ontological foundation of concept analysis within nursing. He reviews and critiques the historical progression of concept analysis methods within nursing beginning with Wilson and ending with Hupcey and Penrod. This critique and discussion focuses on the ‘contextualism’ of concepts and associated ontological and epistemological outcomes. For Risjord concepts are bound within ‘moderate realism’. He states that concepts are ‘contextualized’ only by theory and that concurrently these theories can be true or false only if the concepts represent objects ‘independent of the mind’. Risjord goes on to propose a new organization of concept analysis into scientific/theoretical concept analysis and colloquial concept analysis. Our critique of Risjord’s arguments focuses on the dilemma of theoretically contextualized concepts, the problem of moderate realism as an ontology for concept analysis and the misconstrued separation of theoretical/scientific and colloquial concept analysis.
Risjord’s assertion that concepts are solely contextualized by theory continues to ignore both how concepts are created and the affect of and needed intricacy of this creation. All of the major epistemologies in nursing recognize that knowledge to varying extents is bound by the context in which it is created (Forbes et al. 1999). Acknowledging this premise, any empirical knowledge related to nursing, including conceptual analyses, is bound to some degree by context. Risjord’s contention that concepts are only contextualized by the theory in which they are employed represents a purely realist viewpoint, one that privileges the creation and utilization of objective knowledge/probable truth. It is as if Risjord is blind to the fact that their has been a disciplinary ontological and epistemological shift in nursing science away from a unitary realist view to an accepted recognition that in each of the nursing epistemologies (post-positivist, interpretive or critical) knowledge is bound in context (Forbes et al. 1999).
Risjord proposes a theoretical construction of concept analysis that produces what he contends are clear ‘scientific’ concepts. This method focuses on an objective review of the ‘scientific’ uses of the concept. Missing in this method is the recognition that the initial creation and subsequent evolution of the concept is bound not in the context of a theory but in the context of the historical and social meaning of the original exploration of the concept (Wuest 1994). By proposing that concepts are only contextualized by theory, Risjord mistakenly distorts both the structure and meaning of concepts ignoring the relative nature of this type of knowledge (Duncan et al. 2007).
Concepts are central to many elements of post-positivist research including theory development (Paley 1996). They are integral in the creation and testing of nursing theory. However, to reduce their creation and utilization within the discipline of nursing to merely a key element of post-positive research belies the complexity of not only the construction, but the actual utilization of concepts within nursing. Concepts provide knowledge for nurses guiding practice and, in particular, patient care (Duncan et al. 2007). Risjord attempts to remedy this contradiction through his separation of concept analysis into scientific/theoretical and colloquial forms. For Risjord, this separation is bound in the difference between ‘scientific’ or theoretical concept analysis associated with measurement, and ‘colloquial’, by inference non-scientific qualitative methods of concept analysis. He asserts that qualitative research findings are bound in the context of the participants and that this type of knowledge is important to nursing practice but labels this method of concept analysis as ‘colloquial’/non-scientific and only valuable as a potential knowledge source. Risjord substantiates his argument by stating that the information gained through qualitative, understood as ‘colloquial’ inquiry is ‘fluid and vague’ (p. 689), and, hence, unsuitable as ‘scientific’ or theoretical concept analysis’. This uninformed idea fits with his traditional realist ontology critiqued earlier.
Most regrettably, Risjord’s position demonstrates his ignorance of qualitative nursing science. This form of nursing research, an established form of inquiry that is scientific and methodologically sound (Morse 2004, 2006), provides otherwise unattainable theoretical evidence essential for nursing praxis. His support of the hierarchal nature of scientific nursing research paradigms disregards the accepted norm that both qualitative and quantitative evidence are inextricably bound in context and that nursing is best served by epistemological diversity not traditional ontological divisions (Ford-Gilboe et al. 1995). Risjord’s position also ignores the importance of understanding the emic perspective within nursing knowledge and theory (Thorne 1999).
We argue that while concepts bound in one context may not apply to other contexts, the idea of objective universal concepts merely helps simplify theory development and testing and may complicate the implementation of concepts into nursing practice (Stevenson 2005). This misguided understanding also sets up a simplistic and linear relationship between concepts, theory and reality that does not recognize what conceptual knowledge actually denotes; knowledge that cannot be separated from the context of its creation. Theory that recognizes the type of contextualism that we have proposed may have a reduction in the universality of its scope but may better guide nursing practice and patient care bound in emic perspective.
We propose that Risjord’s understanding of theory may fit with what is better labelled as grand theory (Stevenson 2005). This type of theory corresponds best with the realist ideal of objective ‘detached’ research (Stevenson). The detached nature and attempt to create universality inherent in grand theory produces an inability to represent the complex social phenomena inherent within nursing (Stevenson). Stevenson hypothesizes that nursing would be better served by midrange theory that, while less universal, captures the complexity and context inherent within the discipline. Qualitative research allows the researcher to engage with participants experiencing the complex context bound reality. For Stevenson, the detached nature of concepts that are universal and only contextualized by theory creates a separation from reality and nursing practice that supports a long standing gap between nursing theory and practice.
The specious nature of the debate that Risjord presents equating realism and contextualism is perhaps best illustrated by the praxis application of the concept compliance/adherence/concordance described in our initial article. This concept was a construction of healthcare providers to operationalize and then ‘measure’ the pill-taking behaviour of individuals with primary hypertension (Sackett et al. 1975). Subsequent universal application of compliance as the way to define patient/client behaviour in relation to prescribed medical regimes is now an accepted reality (Chatterjee 2006, Bisonnette 2008). This diffusion is, in part at least, based on the implicit ontological assumptions espoused by Risjord; the possibility of a constructed ‘mind-independent reality’ (p. 688) that is bound solely by a theoretical context. Such thinking has resulted in a ‘conceptual mire’ around the concept of compliance (Lehane & McCarthy 2009) and, more importantly, a ill-informed and/or destructive interpretation of client behaviours. The history of this concept alone, illustrates that conceptual analysis and theory construction divorced from contextual reality is morally indefensible (Thorne 1999).