INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Understanding paradigms used for nursing research

Kathryn Weaver BN MN PhD RN
EQUIPP Postdoctoral Fellow, Faculty of Nursing, University of Alberta, Alberta, Canada; and Assistant Professor, Faculty of
Nursing, University of New Brunswick Fredericton, New Brunswick, Canada

Joanne K. Olson PhD RN

Professor, Faculty of Nursing, University of Alberta, Alberta, Canada

Accepted for publication 4 May 2005

Correspondence: W E A V E R K . & O L S O N J . K . ( 2 0 0 6 ) Journal of Advanced Nursing 53(4), 459–469

Kathryn Weaver, Understanding paradigms used for nursing research
International Institute for Qualitative Aims. The aims of this paper are to add clarity to the discussion about paradigms
Methodology,
for nursing research and to consider integrative strategies for the development of
Faculty of Nursing,
nursing knowledge.
University of Alberta,
6-10 University Extension Centre,
Background. Paradigms are sets of beliefs and practices, shared by communities of
8303-112 Street, researchers, which regulate inquiry within disciplines. The various paradigms are
Edmonton, characterized by ontological, epistemological and methodological differences in
Alberta T6G 2T4, their approaches to conceptualizing and conducting research, and in their contri-
Canada. bution towards disciplinary knowledge construction. Researchers may consider
E-mail: kweaver@unb.ca these differences so vast that one paradigm is incommensurable with another.
Alternatively, researchers may ignore these differences and either unknowingly
combine paradigms inappropriately or neglect to conduct needed research. To
accomplish the task of developing nursing knowledge for use in practice, there is a
need for a critical, integrated understanding of the paradigms used for nursing
inquiry.
Methods. We describe the evolution and influence of positivist, postpositivist,
interpretive and critical theory research paradigms. Using integrative review, we
compare and contrast the paradigms in terms of their philosophical underpinnings
and scientific contribution.
Findings. A pragmatic approach to theory development through synthesis of
cumulative knowledge relevant to nursing practice is suggested. This requires that
inquiry start with assessment of existing knowledge from disparate studies to
identify key substantive content and gaps. Knowledge development in under--
researched areas could be accomplished through integrative strategies that preserve
theoretical integrity and strengthen research approaches associated with various
philosophical perspectives. These strategies may include parallel studies within the
same substantive domain using different paradigms; theoretical triangulation to
combine findings from paradigmatically diverse studies; integrative reviews; and
mixed method studies.
Conclusion. Nurse scholars are urged to consider the benefits and limitations of
inquiry within each paradigm, and the theoretical needs of the discipline.

Keywords: integrative review, nursing theory, paradigms, philosophy, research

methods

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K. Weaver and J.K. Olson

producing that knowledge. Paradigms are lenses for viewing

Introduction
and interpreting significant substantive issues to the disci-
Paradigms are patterns of beliefs and practices that regulate pline. Issues deemed worthy of pursuit are prioritized; others
inquiry within a discipline by providing lenses, frames and are suppressed (Cheek 2000). Paradigms are also frames that
processes through which investigation is accomplished. The hold the vocabulary, theories and principles, as well as the
need to clarify the paradigms of nursing research has been presuppositions and values related to an inquiry (Thompson
identified as one of the top 10 issues facing the discipline 1985, Moccia 1988, Bunkers et al. 1996). We further define
(Colorado Nursing Think Tank 2001). Working to achieve paradigms as sets of philosophical underpinnings from which
further clarity will enable nurse researchers to structure specific research approaches (e.g. qualitative or quantitative
inquiry, making explicit the philosophical assumptions methods) flow.
underlying their methodological choices. The purpose of Paradigms are established by communities of scholars with
this paper is to examine the paradigms used in nursing shared beliefs about the nature of reality and knowledge
research and to make recommendations about conducting construction (Jacob 1989, Hinshaw 1996). They are human
disciplinary inquiry. To achieve this purpose, we explore the constructions categorized by differences in beliefs and values
evolution and influence of the various research paradigms on (Hamilton 1994). As such, paradigms can be neither proved
nursing theoretical and disciplinary development, and we nor disproved (Moccia 1988, Guba 1990). This may create
present ontological, epistemological, and methodological doubt about how best to initiate inquiry. According to Kuhn
similarities and differences among positivist, postpositivist, (1970), all disciplinary research is conducted within para-
interpretive and critical theory paradigms. The goals of digms. The approaches to inquiry open to a researcher within
inquiry, place of theory in the research process, and nature a particular paradigm are defined by the paradigm itself
of knowledge sought within each paradigm are described. (Laudan 1977).
We recommend a pragmatic approach to conducting disci- The paradigms that have been used for nursing
plinary inquiry and we suggest integrative strategies that research are positivist, postpositivist, interpretive and crit-
clarify the theoretical perspective most needed to build ical social theory. The positivist paradigm arose from a
disciplinary knowledge. philosophy known as logical positivism, which is based on
rigid rules of logic and measurement, truth, absolute
principles and prediction. Postpositivism has emerged in
Background
response to the realization that reality can never be
completely known and that attempts to measure it are
Defining research paradigms
limited to human comprehension. The interpretive para-
The task of clarifying the paradigms used for nursing research digm emphasizes understanding of the meaning individuals
is complicated by semantic confusion between the terms ascribe to their actions and the reactions of others.
‘paradigm’, ‘disciplinary matrix’, ‘research tradition’ and The critical social theory paradigm is concerned with
‘worldview’. Kuhn (1970) uses the term ‘paradigm’ (p. 10) to the study of social institutions, issues of power and
describe a heuristic framework for examining the natural alienation, and envisioning new opportunities (Gillis &
sciences and ‘disciplinary matrix’ (p. 182) for social sciences. Jackson 2002).
Laudan (1977) defines a ‘research tradition’ as the ‘set of It is widely held that adherence to one paradigm
general assumptions about the entities and processes in a predetermines the direction of theory development for a
domain of study, and…the appropriate methods to be used discipline, ultimately delimiting knowledge available for
for investigating the problems and constructing the theories utilization in practice. The different types of knowledge
in that domain’ (p. 81). Kikuchi (2003) equates paradigm required for nursing practice may be constructed from single
with an individual’s perceived ‘worldview’. It is beyond the or multiple modes of inquiry. Fawcett et al. (2001) advocated
scope of this paper to differentiate extensively between these for multiple modes of inquiry to meet nursing’s knowledge
various terms to determine if they all describe the same needs. Van der Zalm and Bergum (2000) illuminated the
phenomenon. We will use the term ‘paradigm’ – despite empirical, moral, aesthetic, personal and socio-political
criticism of its ambiguous and inconsistent use – as it has contributions to knowledge that arise from using a single
been most often understood and applied by nurse scholars mode of inquiry. Rather than uncritically prescribing single
(e.g. Allen et al. 1986). or multiple modes of inquiry, we support basing research on
We understand paradigms to be mechanisms to bridge a a clearer, more integrated understanding of the paradigms
discipline’s requirements for knowledge and its systems for used for nursing inquiry.

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Integrative literature reviews and meta-analyses Understanding paradigms used for nursing research

representative samples (Bunkers et al. 1996), technical clin-

Evolution of paradigms for nursing research
ical knowledge about specific interventions (Horsfall 1995),
Since the time of Nightingale, nursing has been concerned and predictive theories for at-risk individuals and populations
with acquiring theoretical knowledge for application to (Norbeck 1987).
practice. Initially, nursing borrowed theories from other
disciplines to meet its practice needs (Meleis 1997). Early Interpretive
theoretical ideas unique to nursing were derived mainly from The Heideggerian view of the nature of being-in-the-world
clinical observations, personal knowledge and philosophical and of humans as self-interpreting has spurred the evolution
thinking (Kirkevold 1997). These early nursing perspectives of the interpretive paradigm (Holmes 1996, Appleton & King
were useful for articulating the nature of nursing and guiding 1997). In this paradigm, intersubjectivity (mutual recogni-
practice but less useful for guiding nursing research (Hinshaw tion) between researcher and research participants is fostered
1999). The evolution of nursing as a professional discipline and valued (Dzurec 1989, Horsfall 1995). Phenomena are
necessitated the establishment of a scientific research base studied through the eyes of people in their lived situations.
(Wuest 1994, Donaldson & Crowley 1997/1978) to increase The unitary nature of person-with-environment is congruent
disciplinary credibility. with the individualized, holistic practice espoused by the
The effort to increase credibility has been influenced by nursing discipline (Drew & Dahlberg 1995). Examples of
factors within and external to nursing. Internally, attention nursing theories developed within the interpretive paradigm
has been directed towards developing a specialized know- are Parse’s (1992) Human Becoming, based on the insepar-
ledge base that could be taught to students and used to ability of humans and their environments, and Leininger’s
distinguish professional education from technical training. (1988) Transcultural Nursing, concerned with culturally
Externally, nursing has struggled to differentiate itself from competent care for people of similar or different cultures.
medicine and to develop the knowledge to respond to
changing societal needs (e.g. technological advances, in- Critical social theory
creased scope of nursing practice). To develop a scientific Critical social theory, inspired by the writings of Marx, Hab-
base for nursing and to seek professional status in esteemed ermas and Freire, includes feminist, grassroots and emanci-
medical and academic institutions, nurse researchers at first patory movements. It is concerned with countering oppression
followed the dominant positivist paradigm (Cull-Wilby & and redistributing power and resources (Maguire 1987, Lutz
Pepin 1987, Nagle & Mitchell 1991). et al. 1997). A critical theory perspective assumes that truth
exists as ‘taken for granted’ realities shaped by social, political,
Positivism cultural, gender and economic factors that over time are con-
Positivism, referred to as the received view, uses scientific sidered ‘real’ (Ford-Gilboe et al. 1995). Within the critical
method to develop general abstract laws describing and theory paradigm, research becomes a means for taking action
predict patterns in the physical world (Suppe & Jacox 1985). and a theory for explaining how things could be (Maguire
Theory is established deductively through formal statistical 1987). Process, not product is emphasized (Thorne 1999).
testing of hypotheses (Lincoln & Guba 1985). Objective A desired focus is praxis, or the combination of reflection and
generalizable theory is sought via stringent control of con- action to effect transformation (Mill et al. 2001).
textual variables. The influence of positivism can be seen in
the conceptual models of Orem and Roy (Nagle & Mitchell
Method
1991, Barrett 1992) and in such tools as nursing diagnoses
and practice standards (Dzurec 1989, Drew & Dahlberg Integrative review of the literature describing the various
1995). paradigms was conducted using Ganong’s (1987) method of
analysis. This method was selected because it provides a
Postpositivism structured, practical approach to identifying and understand-
Research in the postpositivist paradigm continues the posi- ing relevant themes and differences in a body of literature.
tivist emphasis on well-defined concepts and variables, con- The method consists of (a) formulating questions for the
trolled conditions, precise instrumentation and empirical review, (b) making decisions about what to review,
testing (Guba & Lincoln 1994). Objective knowledge is (c) organizing the characteristics of the literature reviewed
sought through replication. The postpositive paradigm is and (d) evaluating the reliability of ideas, arguments and
judged appropriate for the study of nursing questions findings. The questions we formulated were: What are the
requiring systematically gathered and analysed data from similarities and differences in the assumptions underlying the

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paradigms used for nursing research? What is the significance working within interpretive and critical theory paradigms
of paradigms to theory and disciplinary knowledge develop- have considered observations as subjective, ‘value relative’, or
ment? What are the consequences in choosing one paradigm ‘value mediated’ (Lincoln & Guba 1985). In addition,
for nursing research over others? researchers in the interpretive paradigm have sought inter-
We addressed these questions through study of the theor- subjectivity or shared subjective awareness and understanding
etical and philosophical literature. Using the keywords within the research relationship. Methodologies associated
research paradigm, research tradition, disciplinary matrix, with each paradigm reflected the ontological underpinnings of
worldview, nursing knowledge, positivism, postpositivism, relativism or realism and epistemological underpinnings of
interpretive, and critical social theory, material was identified objectivity, subjectivity or intersubjectivity. For example, the
from the computerized databases for nursing, allied health, participatory action research approach of critical social theory
medical and educational literature (e.g. CINAHL, Medline, was developed to reveal hidden power imbalances, learn how
Pubmed, EBSCO and ERIC). Primary sources were identified people subjectively experience problems, and make this
by reviewing the reference lists of the retrieved material. We knowledge publicly available.
did not limit the search to a specific timeframe as the history We further examined the paradigms to distinguish differ-
of nursing research and nursing science has been short. The ences in the goals of inquiry, nature of knowledge sought,
sample consisted of 72 journal articles and chapters published and the place of theory in the research process. With the
in English. overall aim of creating good science, the goals of research
To organize the characteristics of the literature reviewed within each paradigm varied. The goals of positivist and
and to determine the current state of knowledge, we postpositivist paradigm research were control and prediction
constructed a table using as columns the categories for (Allen et al. 1986, Guba & Lincoln 1994); the goal of
comparison that emerged from the reading and as rows the interpretive research was understanding (Ford-Gilboe et al.
individual paradigms (see Table 1). Critical analysis was 1995) and that of critical theory was emancipation (Maguire
completed by identifying underlying assumptions, examining 1987). Theoretical knowledge of truth as an absolute entity
the logic of explanations, evaluating the content of each work was sought in the positivist paradigm, and truth as a probable
in light of previous work, and clustering results. We carried value was sought in the postpositivist paradigm (Guba &
out what Kirkevold (1997) defines as a synopsis review in Lincoln 1994, Letourneau & Allen 1999). Practical knowl-
that we clarified and portrayed systematized information edge to help understand or change the social world was the
about each paradigm without attempting to unify the focus of interpretive and critical theory paradigms. This type
alternative theoretical positions. of knowledge, co-constructed between researchers and
research participants, was subject to continuous revision
(Campbell & Bunting 1991, Kim 1999). In the positivist and
Findings
postpositivist paradigms, theory was established deductively.
The positivist focus was on verifying hypotheses and
Comparing and contrasting the paradigms
replicating findings (Lincoln & Guba 1985, Morse & Field
The philosophical underpinnings of the positivist, postposi- 1995); the postpositivist focus was on falsifying hypotheses
tivist, interpretive and critical theory paradigms of nursing (Guba & Lincoln 1994). In the interpretive paradigm, theory
research were assessed for similarities and differences. The emerged inductively – hypotheses were formulated and tested
interpretive paradigm differed ontologically from the others to generate theory, and established theory was used to
because it is based on relativism, a view of truth as composed explain the data (Lincoln & Guba 1985, Morse & Field
of multiple local and specific realities that can only be 1995). Theory and knowledge in the critical social theory
subjectively perceived (Allen et al. 1986, Guba 1990). Posit- paradigm were closely linked in that theory made shared
ivist, postpositivist and critical theory paradigms are based on meanings of social interactions explicit and illuminated
realism, a view of truth as universal and independent of human embedded barriers to autonomy and responsibility (Allen
perception of it. Postpositivist and critical theory paradigms et al. 1986, Mill et al. 2001).
are based on the assumption that this universal truth may not
be accessible to everyone (Allen et al. 1986, Guba & Lincoln
Significance of paradigms to nursing theory development
1994). Positivist and postpositivist paradigms differed episte-
mologically from the others in their assumption that observa- The evolution of multiple paradigms has sparked extensive
tions can be objective and either ‘value free’ or ‘value neutral’ debate over the need to determine if one, a combination of
(Norbeck 1987, Schumaker & Gortner 1992). Researchers several, or any at all is best for nursing research. We assessed

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Table 1 Paradigms used for nursing research

Contributions Limitations

Positivist
Generalizability of findings beyond a particular sample (Baker Context stripping limits application to practice (Schumaker &
et al. 1998) Gortner 1992)
Produces description and prediction (Allen et al. 1986, Labonte Explanation as well as description and prediction needed to guide
& Robertson 1996) nursing intervention (Schumaker & Gortner 1992)
Objectivity enhances credibility. Only directly observable ‘Value free’ observations impossible as observations based on
theoretical entities held to exist; researcher role is detachment perception, a function of prior knowledge and experience (Schu-
(Allen et al. 1986, Guba & Lincoln 1994, Clark 1998) maker & Gortner 1992, Playle 1995). Scientists may ensure the
status quo (Gould 1981)
Attempts to discover universal truth through verification Absolute truth is rarely if ever established (Chinn 1985)
(Lincoln & Guba 1985, Gortner 1993)
Belief that scientific methods used to investigate the physical Humans seen as extensions of nature described via causal mechanical
world can be used to investigate the social world (Feyerabend laws (Kleynhaus & Cahill 1991). Ignores possibility that humans
1990) actively construct their social world and knowledge (Blummer 1969)
Postpositivist
Recognizes fallacies of verification. Seeks to falsify hypotheses Knowledge claims represent probabilities about human phenomena
(Gortner 1993) and establish probable truth (Maguire 1987) rather than universal governing laws (Letourneau & Allen 1999)
Attempts holism by including subjective states (Schumaker & Neglects ‘whole’ person by studying parts (Pearson 1990, Nagle &
Gortner 1992) and multiple perspectives and stakeholders Mitchell 1991). Does not make explicit how the views of patients as
(Letourneau & Allen 1999) stakeholders are drawn into the research process
Powerful, i.e. attracts funding (Guba & Lincoln 1994, Cheek Theory development controlled by others outside of discipline. Power
2000) influences what can and will be known (Dzurec 1989)
Encourages precision, caution and scepticism (Gortner 1993). Conformity with peers within postpositivist paradigm may lead to
Credibility through conformity with judgment of peers becoming ‘pot-bound’
(Letourneau & Allen 1999)
Logical for study of phenomena such as genetic issues and No ‘cookbook’ techniques for achieving balance of heterogeneous
epidemiology (Norbeck 1987). Defines boundaries of nursing qualitative and quantitative methods (Letourneau & Allen 1999,
separately from social sciences (Drew 1988, Gortner 1993) p. 627)
Interpretive
Inquiry is means for articulating, appreciating, and making May ignore ecological, historical, and risk factors (Gortner 1993)
visible the voices, concerns and practices of research
participants (Benner 1994)
Focus is subjectivity and intersubjectivity (Dzurec 1989, Loss of objectivity limits ability to discriminate patterns that are
Drew & Dahlberg 1995, Horsfall 1995) fundamental to humans (Allen 1985)
Truth viewed as multiple realities that are holistic, local, and Less explanatory power as infinite number of interpretations are
specific (Ford-Gilboe et al. 1995) possible for a given phenomenon (Berger & Luckmann 1966)
Seeks understanding, shared meaning, and embedded meaning Theorizing limited because the human state is not objectified outside
(Allen & Jensen 1996) of the lived experience and present (Gortner 1993)
Meaning is constructed in the researcher–participant interaction Discomfort with the uncertainty of the ever-changing nature of
in the natural environment (Guba & Lincoln 1994, Ford- knowledge
Gilboe et al. 1995, Hinshaw 1999)
Critical social theory
Exposes oppression through understanding shared meanings of Emphasizes rationality while excluding feelings despite the
political, social, historical and cultural practices that impede emancipatory potential of feelings (Campbell & Bunting 1991)
equal participation (Ludz et al. 1997)
Theory and practice closely linked. Research goes beyond If researchers know ahead of time that social action is needed, then do
description towards action to change inequities (Mill et al. 2001) not need research to justify this (Gortner 1993)
Ensures representation of diverse and under-represented views The one who critiques is part of the culture being critiqued which
(Gortner 1993, Wuest 2000) suggests complicity (Reed 1995)
Practitioners can develop tacit knowledge from practice via Practitioners may not see themselves as researchers or theorists and
criticism and reflection (Fawcett et al. 2001) practice as data (Tolley 1995)
Research process characterized by continual redefinition of Focus on problems defined by oppressed groups and collective
problems and by cooperative interaction between researchers humanity. May exclude the individual and personal level. Some
and those whose environment is being researched research team members may have more power than others
(Campbell & Bunting 1991)

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the utility of a unitary, pluralist, or anti-paradigmatic approaches, in denying social contexts and intersubjectivity
approach to guide inquiry through identification of each within research relationships, may perpetuate technically-
paradigm’s contributions and limitations. oriented practice (Horsfall 1995). Positivism has tended to be
inconsistent with holistic practice in its denial of unobserv-
Contributions able values, including spiritual aspects and relationships
Different benefits to nursing theory development were asso- within complex socio-political, ecological environments. Its
ciated with various research studies within the postpositivist, claims of producing value free observations and discovering
interpretive and critical theory approaches. Nursing research universal truth are questionable. The major criticism of
conducted within the postpositivist paradigm contributed to postpositivism is its reduction of people to parts and its
health promotion, illness prevention and professional edu- dehumanization of them to scores and percentages for
cation. For example, through postpositivist quantitative in- statistical analyses.
quiry, Faye and Yarandi (2004) identified that African Research within the interpretive paradigm has tended to
American women were at greater risk of depression because ignore the influence of biological factors and social structures
of lower income, lesser education and residency in rural on individual action. The loss of objectivity (e.g. multiple
committees. Treat-Jacobson and Lindquist (2004) found the interpretations of multiple realities, non-objectification of the
intensity of exercise required to receive functional benefit human state) has limited theorizing. The interpretive
following cardiac bypass surgery to be less than many people approach can be criticized for its underlying assumptions
realized. A study of the knowledge and attitudes of nurses about all being equal. Critical theory, shown to value the
caring for patients with AIDS (Walusimbi & Okonsky 2004) collective above the individual, has tended to demean
provided baseline data from which to determine appropriate participants asked to respond to shared, pre-existing social
educational interventions for nurses. orders they had no part in creating. Critical theory research-
Nursing research conducted in the interpretive paradigm ers have been criticized for their complicity in being part of
involved different qualitative methods to gain in-depth and the culture they critiqued and for suppressing findings
detailed description, understanding and explanation of incompatible with their beliefs.
ordinary occurrences as experienced by those in the field.
For example, Austin et al. (2003) used a hermeneutic
Unitary paradigm
phenomenological approach to understand the experiences
of nurses attempting to address ethical concerns in patient Those who have embraced a unitary or a single paradigm
care within health institutional environments. Through par- approach for nursing research have asserted that incommen-
ticipant observation fieldwork, Ellefsen and Kim (2004) surable ontological and epistemological differences among
obtained information about how nurses view, interpret and the paradigms required choosing one over the others for
receive the meanings of clinical situations. These findings specific research projects. In this way, the set of beliefs about
using the interpretive paradigm research have identified health, relationships of person with environment and goal of
specific strategies nurses use with patients that can inform nursing knowledge expressed in the paradigm were preserved
and improve nursing practice. (Mitchell & Pilkington 1999). Donaldson and Crowley
Researchers conducting inquiry in the critical social theory (1997/1978) have explained that a discipline is characterized
paradigm have made it their responsibility to raise awareness by ‘a unique perspective, a distinct way of viewing all
of social problems and to ensure that the voices and phenomena, which ultimately defines and limits the nature of
perspectives of marginalized people are heard. In keeping its inquiry’ (p. 242). While they have articulated the need for
with this mandate, Georges (2002) called for greater exam- an overarching framework of values agreed to by members of
ination of the context of social and political inequities creating the discipline, clearly Donaldson and Crowley have not
and sustaining suffering. Bermann (2003) described the need explicitly recommended establishment of a single research
for researchers who work with children, in which empower- perspective. The overarching framework for nursing inquiry
ment is a goal, to acknowledge power imbalances in research could endorse research approaches within diverse paradigms
relationships and to enable children to shape the interviews. (Northrup 1992, Reed 1995).

Limitations of the paradigms Paradigmatic plurality

Our review revealed limitations associated with each para- Proponents of paradigmatic plurality (combination of several
digm (see Table 1). Positivist and postpositivist research paradigms) have argued that knowledge developed from one

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perspective could complement knowledge developed from interpretative paradigm inquiry has enabled nurses to develop
another (Leddy 2000). They recommended harnessing the insights into unique individual responses within clinical
processes and products from multiple paradigms to meet situations that could improve the care of those involved
nursing demands for knowledge for practice (i.e. scientific (Van der Zalm & Bergum 2000). Knowledge constructed via
knowledge, professional judgment in the form of personal critical social theory has benefited people collectively by
knowledge of clients, humanistic connection, and clinical uncovering and transforming oppressive situations (Mill et al.
experience to aid ethical decision-making). Rolfe (1998) 2001).
provided the example of a nurse who found scientific We identify a trend in the literature towards using multiple
knowledge helpful to determine patient status. However, paradigms for nursing research (e.g. Cull-Wilby & Pepin
such knowledge could not direct the nurse about how to 1987, Monti & Tingen 1999). We do not support anti-
respond when a patient asked if he was dying. ‘In a discipline paradigmatic nursing inquiry because of its potential to
that deals with human beings, it is perhaps not feasible that exclude important topics not researchable from all paradigm
only one theory should explain, describe, predict, and change perspectives. We are concerned that its ‘top down’ applica-
all the discipline’s phenomena’ (Meleis 1997, p. 77). tion of general principles to particular cases may limit
knowledge construction to existing conceptualizations.

Anti-paradigmatic inquiry
Discussion
An argument for anti-paradigmatic inquiry has been put
forward by Kikuchi (2003). She recommended studying only Nursing’s obsession with the paradigm debate has occupied
questions that all participants could answer, and approaching much space in the literature. Failure to build the nursing
questions in ‘piece-meal’ (p. 13) fashion. We agree that knowledge base comprehensively has been assumed to result
research conducted as a public enterprise towards which all from the lack of a consensual overarching framework for
members of a discipline can work may help to enlarge the conducting research. Yet nursing has not pursued ‘integration
disciplinary body. However, we are concerned that such of nursing research from the level of a conceptual framework
research might limit rather than expand the pursuit of some for a particular study to the level of more general theories and
of the types of knowledge needed for nursing practice (e.g. ultimately to that of a unified body of nursing knowledge’
emic perspectives, narratives, issues of power and control). (Donaldson & Crowley 1997/1978, p. 237). We must,
We also question whether this anti-paradigmatic stance is therefore, ask ourselves and our discipline if the current state
representative of the positivist paradigm, in which research of fragmentation of nursing knowledge has been the result of
questions are either limited to those that can be posed in limited nursing inquiry in which individual studies were not
terms of independent and dependent variables (Dzurec 1989) related to one another, or if it has been the result of research
or to variables whose existence can be directly verifiable emanating from an individual paradigm, a collective para-
(Schumaker & Gortner 1992, Clark 1998). digm, or no paradigm at all.

Addressing the paradigms debate Pragmatic approach to evaluating disciplinary inquiry and
theory development
In order for nursing to resolve the paradigm debate, we
believe that nurses must come together and address the In research, the purpose and the question guide inquiry and
thoughtful questions raised by Barrett (1992). These ques- knowledge development (e.g. Burns & Grove 2001, Morse &
tions are concerned with which paradigmatic philosophy best Richards 2002). The choice of a research paradigm and method
reflects nursing values, what processes could be used to are also guided by the current state of knowledge about a
pursue a unified disciplinary path, who will determine the one particular area of nursing. For example, within a positivist or
right approach, and who will relinquish their own commit- postpositivist paradigm a randomized controlled study cannot
ment for the sake of unity. Based on our consideration of the be conducted if the variables to be controlled have not first been
literature, we could not justify choosing one paradigm over defined. There is no need for interpretive paradigm inquiry if
others when most can inform different aspects vital to we already know what is being hypothesized and what we are
nursing practice. Theory arising from postpositivist paradigm apt to find. The participatory action research of the critical
inquiry has yielded prescriptive or situation-producing the- social paradigm is inappropriate if the knowledge sought is
ory, such as interventions for managing specific health or merely shared views, without opportunity to engage in action
illness threats (Gortner 1993). Theory generated through to address domination and power inequities.

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In addition, two ideas must be kept in mind when disparate studies. Critical analysis or review and critical
considering the choice of research paradigm. The first is that appraisal are modes of inquiry that integrate the literature.
scholars often restrict research questions to those that can They can help to determine if research within a single
studied within the paradigms with which the scholars align paradigm is sufficient to meet practice demands. To critically
themselves. The second is that not all paradigms are afforded analyse or review means to examine the existing literature on
equal credibility. Legitimacy is conferred by certain groups a particular topic, determining weaknesses in the research or
(e.g. funding and publication review boards) who regulate inconsistencies in findings (Kirkevold 1997). This can identify
what constitutes valid research. Pursuing inquiry in one gaps in available knowledge, areas where existing knowledge
paradigm may further the interests of a dominant stakehold- is untrustworthy, and areas requiring further information
er, while diverting energies away from developing sensitive before conclusions can be drawn. The findings from critical
methodologies and unique research interests needed for analysis or review can assist nurse clinicians to judge if the
nursing (Horsfall 1995). knowledge base is solid enough for practical application.
To reduce these potential sources of bias, it seems necessary Critical appraisal involves exploration of pragmatic utility
to determine criteria and a process for evaluating disciplinary (Morse 2000), and synthesizes key substantive content to
inquiry. A measure of the effectiveness of an inquiry is its direct inquiry towards areas that need development. Over-
problem-solving ability or usefulness to those involved (Lau- loaded or under-researched areas impinging on and influen-
dan 1977). It is also recommended that nursing research cing practice can thereby be opened up (Horsfall 1995).
priorities be situational-specific and practice-based (Dickoff & Critical appraisal can help to explicate the sociopolitical
James 1968, Im & Meleis 1999). Moreover, the basic concern historical context within which health and illness problems
of all nursing research is to improve the health and wellbeing are developed and addressed.
of the people studied (Ford-Gilboe et al. 1995, Warms & Following critical assessment of the literature, nursing
Schroeder 1999). Thus, theory development in nursing must knowledge may need to be developed in under-researched or
support service to people and the health of society. underdeveloped areas. This reopens the issue of which
We believe that nursing inquiry may be effectively paradigm to use. As previously discussed, the purpose of
evaluated through a pragmatic approach. The term pragma- the inquiry, in conjunction with the state of knowledge
tism is derived from the Greek word for action, from which development in the substantive area, should guide paradigm
the words ‘practice’ and ‘praxis’ originate (Barnhart 1995, selection. A pluralist approach may have greater utility to
James 1907/1998). Pragmatism is determining the value of an nursing because it holds that research from various para-
idea by its outcome in practice and conduct (James 1907/ digms can contribute to the development of knowledge
1998). A pragmatic approach stresses critical analysis of needed for nursing practice.
facts, applications and outcomes rather than abstraction and How best to utilize a pluralist approach to inquiry and
verbal solutions (James 1907). This approach can move subsequent theory development without violating the philo-
nursing beyond the boundaries and restrictions of a single sophical underpinnings of the individual paradigms is not
paradigm towards theory construction tailored to fit partic- well described in the literature. One strategy is to design a
ular situations (Doane 2003). Surely the tenets of pragmatism research programme comprised of parallel studies within the
(i.e. commitment to what works in practice, appreciation of same substantive domain, using different paradigms. This
plurality, and desire for integrated results) are relevant to preserves the theoretical and philosophical clarity of each
nursing? Nurse clinicians have identified that theory–practice tradition (Mitchell & Pilkington 1999). Follow-up integrative
gaps exist when theory does not address diverse practice techniques, such as conceptual triangulation of research
demands (e.g. Hanchett 2001). A pragmatic approach calls findings (Foster 1997) and integrative review (Kirkevold
for theory to be designed and tested in practice. This could 1997), could then be implemented to synthesize knowledge
counter passive acceptance of inquiry conducted for reasons from the separate research studies. Conceptual triangulation
other than to improve the health and comfort of those whom is a procedure for combining findings from paradigmatically
nursing serves. A pragmatic approach could stimulate inquiry diverse studies in such a way as to safeguard individual study
that complements one paradigm with another. designs. It involves integrating findings from research com-
pleted in different paradigms after considering threats to
rigour and examining the strength of the evidence (Foster
Strategies to develop nursing knowledge
1997). Integrative review enables integration of relevant
We suggest that inquiry should start with assessment of the information from isolated studies into a comprehensive
existing theoretical base containing findings from diverse, account (Kirkevold 1997). Additionally, mixed methods

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2006 Blackwell Publishing Ltd

Integrative literature reviews and meta-analyses Understanding paradigms used for nursing research

confusion and perhaps intolerance and competition. To

What is already known about this topic understand better the paradigms used for nursing research
• Nursing knowledge has been developed from a variety and to begin to resolve the tension between unitary, plural-
of research approaches within multiple paradigms. istic and anti-paradigmatic perspectives, we have examined
• The need to clarify the paradigms used for nursing the philosophical underpinnings and knowledge development
research is an important issue facing the discipline. within individual paradigms and assessed the pragmatic
• Individual research paradigms, while serving to protect utility. No single paradigm emerged as unequivocally super-
the integrity and rigor of knowledge construction ior to another for nursing research. Rather, knowledge
within a scientific community, may define and restrict resulting from research within each paradigm was sought
approaches to inquiry. and valued for its contribution in describing, interpreting,
explaining and predicting the complexity of human health
experiences and illness responses. Critical assessment of the
What this paper adds existing theoretical base will help nurses adequately to
• Critical analysis of the research approaches within understand and address nursing’s knowledge needs. We
various research paradigms does not justify choosing recommend pluralistic approaches that maintain the individ-
one paradigm over others. ual theoretical perspectives of each paradigm because such
• The discipline’s task of developing knowledge may be approaches protect the integrity and rigour of knowledge
enhanced through the use of integrative strategies that construction, thus insuring a more worthwhile and valuable
maintain the theoretical perspectives of individual contribution to disciplinary development. The practice of
research paradigms. situating research within paradigms, as well as the knowledge
• An anti-paradigmatical approach to research may limit resulting from research processes, must be considered in the
disciplinary knowledge development. light of their ability to advance the social mission of nursing:
to enhance health and wellbeing and alleviate suffering.
studies (i.e. using quantitative and qualitative methods from
different paradigms in a single study) can help to accumulate
Author contributions
knowledge without crossing paradigmatic boundaries if
researchers clarify in advance the contribution of each KW contributed to study conception, design and drafting of
paradigm (Morse 1991). We think these strategies could the manuscript; KW and JO contributed to critical revisions
help to reduce theory–research–practice discrepancies be- of the manuscript for important intellectual content; JO
cause they respect theoretical perspectives. supervised the study.
Pluralistic integrative approaches can suggest important
new lines of research, empowering researchers to address
References
problems which cannot be resolved satisfactorily by adher-
ence to inquiry within a single paradigm. These approaches Allen D. (1985) Nursing research and social control: alternative
can be undertaken by communities of scholars who, as models of science that emphasize understanding and emancipation.
Hinshaw (1996) has predicted, will continue the growth of Image: Journal of Nursing Scholarship 17(2), 58–64.
Allen M.N. & Jensen L.A. (1996) Knowledge development in nur-
the nursing knowledge base through critique, constructive
sing. In Canadian nursing. Issues and perspectives (Kerr J.R. &
criticism and challenge of ideas. With attention to theoretical MacPhail J., eds), Mosby, St Louis, pp. 85–104.
perspectives, we contend that findings within multiple para- Allen D., Benner P. & Diekelmann N.L. (1986) Three paradigms for
digm can be integrated to increase the cumulative knowledge nursing research: Methodological implications. In Nursing
needed for the substance of our discipline and to provide Research Methodology: Issues and Implementation (Chinn P., ed.),
Aspen, Rockville, MD, USA, pp. 23–38.
relevant research-based knowledge to clinical nurses.
Appleton J.V. & King L. (1997) Constructivism: a naturalistic
methodology for nursing inquiry. Advances in Nursing Science
20(2), 13–22.
Conclusion
Austin W., Bergum V. & Goldberg L. (2003) Unable to answer the
Integrative review of the major paradigms used for nursing call of our patients: mental health nurses’ experience of moral
research has allowed us to identify issues that potentially distress. Nursing Inquiry 10(3), 177–183.
Baker C., Norton S., Young P. & Ward S. (1998) An exploration of
limit theory and disciplinary development. Embracing differ-
methodological pluralism in nursing research. Research in Nursing
ent paradigms for nursing research, while responding to the and Health 21, 545–555.
need for knowledge to direct nursing practice, had introduced

2006 Blackwell Publishing Ltd 467

K. Weaver and J.K. Olson

Barnhart R.K. (ed.) (1995) The World Book Dictionary 2 (L–Z). Faye G. & Yarandi H.N. (2004) Depression among Southern rural
World Book Inc., Chicago. p. 1635. African American women: a factor analysis of the Beck Depression
Barrett E.A. (1992) Disciplinary perspective: united or diversified? Inventory-II. Nursing Research 53, 251–259.
Response: diversity reigns. Nursing Science Quarterly 5, 155–157. Feyerabend P. (1990) Farewell to Reason. Verso, London, England.
Benner P. (1994) The tradition and skill of interpretive phenomenology Ford-Gilboe M., Campbell J. & Bermann H. (1995) Stories and
in studying health, illness, and caring practices. In Interpretive numbers: Coexistence without compromise. Advances in Nursing
Phenomenology: Embodiment, Caring, and Ethics in Health and Science 18(1), 14–26.
Illness (Benner P., ed.), Sage, Thousand Oaks, CA, pp. 99–127. Foster R.L. (1997) Addressing epistemologic and practical issues in
Berger P.L. & Luckmann T. (1966) The Social Construction of multimethod research: A procedure for conceptual triangulation.
Reality. Doubleday, New York. Advances in Nursing Science 20(2), 1–12.
Bermann H. (2003) Getting critical with children – empowering Ganong L.H. (1987) Integrative reviews of nursing research.
approaches with a disempowered group. Advances in Nursing Research in Nursing and Health 10, 1–11.
Science 26(2), 102–113. Georges J.M. (2002) Suffering: toward a contextual praxis. Advances
Blummer H. (1969) Symbolic Interactionism: Perspectives and in Nursing Science 25(1), 79–86.
Method. Prentice Hall, Englewood Cliffs, NJ, USA. Gillis A. & Jackson W. (2002) Introduction to nursing research. In
Bunkers S.S., Petardi L.A., Pilkington F.B. & Walls P.A. (1996) Research for Nurses: Method and Interpretation (Gillis A. &
Challenging the myths surrounding qualitative research in nursing. Jackson W., eds), F. A. Davis, Philadelphia, pp. 3–36.
Nursing Science Quarterly 9, 33–37. Gortner S.R. (1993) Nursing’s syntax revisited: a critique of philos-
Burns N. & Grove S.K. (2001) The Practice of Nursing Research. ophies said to influence nursing theories. International Journal of
W.B. Saunders, Philadelphia. Nursing Studies 30, 477–488.
Campbell J. & Bunting S. (1991) Voices and paradigms: perspectives Gould S.J. (1981) The Mismeasure of Man. Penguin, London, Eng-
on critical and feminist theory in nursing. Advances in Nursing land.
Science 13(3), 1–15. Guba E.C. (1990) The alternative paradigm dialogue. In The Para-
Cheek J. (2000) Setting the parameters. In Postmodern and Post- digm Dialogue (Guba E.C., ed.), Sage, Newbury Park, CA, USA,
structural Approaches to Nursing Research (Cheek J., ed.), Sage, pp. 17–30.
Thousand Oaks, CA, USA, pp. 1–15. Guba E.C. & Lincoln Y. (1994) Competing paradigms in qualitative
Chinn P. (1985) Debunking myths in nursing theory and research. research. In Handbook of Qualitative Research (Denzin N.K.
Image – The Journal of Nursing Scholarship 172, 45–49. & Lincoln Y., eds), Sage, Thousand Oaks, CA, USA, pp. 105–
Clark A.M. (1998) The qualitative-quantitative debate: moving from 117.
positivism and confrontation to post-positivism and reconciliation. Hamilton D. (1994) Traditions, preferences, and postures in applied
Journal of Advanced Nursing 27, 1242–1249. qualitative research. In Handbook of Qualitative Research
Colorado Nursing Think Tank (2001) JAN Forum: saving the dis- (Denzin N.K. & Lincoln Y., eds), Sage, Thousand Oaks, CA, USA,
cipline – top 10 unfinished issues to inform the nursing debate in pp. 60–69.
the new millennium. Journal of Advanced Nursing 35, 138. Hanchett M. (2001) Where is the theory to support infusion nursing?
Cull-Wilby B.L. & Pepin J.I. (1987) Toward a coexistence of para- Journal of IV Nursing 24(1), 56–60.
digms in nursing knowledge development. Journal of Advanced Hinshaw A.S. (1996) Research. Research traditions – a decade of
Nursing 12, 515–521. progress. Journal of Professional Nursing 12, 68.
Dickoff J. & James P. (1968) A theory of theories: a position paper. Hinshaw A.S. (1999) Evolving nursing research traditions: influen-
Nursing Research 17, 197–203. cing factors. In Handbook of Clinical Nursing (Hinshaw A.S.,
Doane G.H. (2003) Through pragmatic eyes: philosophy and Feetham S.L. & Shaver J.F., eds), Sage, Thousand Oaks, CA, USA,
the re-sourcing of family nursing. Nursing Philosophy 4(1), 25–32. pp. 19–30.
Donaldson D.M. & Crowley D.M. (1997/1978) The discipline of Holmes C.A. (1996) The politics of phenomenological concepts in
nursing. In Perspectives on Nursing Theory (Nicoll L., ed.), nursing. Journal of Advanced Nursing 24, 579–587.
Lippincott. (Original work published 1978 in Nursing Outlook, Horsfall J.M. (1995) Madness in our methods: nursing research,
26, 113–120), Philadelphia, pp. 235–246. scientific epistemology. Nursing Inquiry 2, 2–9.
Drew B.J. (1988) Devaluation of biological knowledge. Image – The Im E. & Meleis A.I. (1999) Situation-specific theories: philosophical
Journal of Nursing Scholarship 20, 25–27. roots, properties, and approach. Advances in Nursing Science
Drew N. & Dahlberg K. (1995) Challenging a reductionistic paradigm 22(2), 11–24.
as a foundation for nursing. Journal of Holistic Nursing 13, 332–345. Jacob E. (1989) Qualitative research: a defense of tradition. Review
Dzurec L.C. (1989) The necessity for and evolution of multiple of Educational Research 59, 229–235.
paradigms for nursing research: a poststructuralist perspective. James W. (1907) What Pragmatism Means. Lecture 2 in Pragmatism:
Advances in Nursing Science 11(4), 69–77. A New Name for Some Old Ways of Thinking, Longman, Green
Ellefsen B. & Kim H.S. (2004) Nurses’ construction of clinical situ- & Co., New York, pp. 17–32. Retrieved from http://spartan.ac.
ations: a study conducted in an acute-care setting in Norway. brocku.ca/~Iward/James/James_1907/James_1907_02.html on
Canadian Journal of Nursing Research 36, 114–131. 30 September 2003.
Fawcett J., Watson J., Neuman B., Walker P. & Fitzpatrick J.J. James W. (1998) Truth is established on pragmatic grounds.
(2001) On nursing theories and evidence. Journal of Nursing In Classic Philosophical Questions, 9th edn (Gould J.A., ed.),
Scholarship 33(2), 115–119. Prentice Hall, Upper Saddle River, NJ, USA, pp. 375–383.

468
2006 Blackwell Publishing Ltd

Integrative literature reviews and meta-analyses Understanding paradigms used for nursing research

Kikuchi J.F. (2003) Nursing knowledge and the problem of world- Morse J.M. & Richards L. (2002) Readme First for a User’s Guide to
views. Research & Theory for Nursing Practice 17, 7–17. Qualitative Methods. Sage, Thousand Oaks, CA, USA.
Kim H.S. (1999) Critical reflective inquiry for knowledge develop- Nagle L. & Mitchell G.J. (1991) Theoretical diversity: evolving
ment in nursing practice. Journal of Advanced Nursing 29, 1205– paradigmatic issues in research and practice. Advances in Nursing
1212. Science 14(1), 17–25.
Kirkevold M. (1997) Integrative nursing research – an important Norbeck J. (1987) In defense of empiricism. Image – The Journal of
strategy to further the development of nursing science and nursing Nursing Scholarship 19, 28–30.
practice. Journal of Advanced Nursing 25, 977–984. Northrup D.T. (1992) A united perspective within nursing. Nursing
Kleynhaus A.M. & Cahill D. (1991) Paradigms for chiropractic Science Quarterly 5, 154–155.
research. Chiropractic Journal of Australia 21(3), 102–107. Parse R.R. (1992) Human becoming: Parse’s theory of nursing.
Kuhn T.S. (1970) The Structure of Scientific Revolutions. University Nursing Science Quarterly 5, 35–42.
of Chicago Press, Chicago. Pearson A. (1990) Nursing: From whence to where? Deakin Uni-
Labonte R. & Robertson A. (1996) Delivering the goods, showing versity Press, Victoria, Australia.
our stuff: the case for a constructivist paradigm for health pro- Playle J.F. (1995) Humanism and positivism in nursing: contradic-
motion research and practice. Health Education Quarterly 23, tions and conflicts. Journal of Advanced Nursing 22, 979–984.
431–447. Reed P.G. (1995) A treatise on nursing knowledge development for
Laudan L. (1977) From theories to research traditions. In Progress the 21st century: Beyond postmodernism. Advances in Nursing
and its Problems: Toward a Theory of Scientific Growth (Laudan Science 17(3), 70–84.
L., ed.), University of California Press, Berkeley, pp. 70–120. Rolfe G. (1998) Nursing knowledge. In Expanding Nursing
Leddy S.K. (2000) Toward a complementary perspective on world- Knowledge (Rolfe G., ed.), Butterworth Heinemann, Oxford,
views. Nursing Science Quarterly 13, 225–233. pp. 7–39.
Leininger M.M. (1988) Leininger’s theory of nursing: cultural care Schumaker K.L. & Gortner S.R. (1992) (Mis)conceptions and
diversity and universality. Nursing Science Quarterly 1, 152–160. reconceptions about traditional science. Advances in Nursing
Letourneau N. & Allen M. (1999) Post-positivistic critical multip- Science 14(4), 1–11.
lism: a beginning dialogue. Journal of Advanced Nursing 30, 623– Suppe F. & Jacox A.K. (1985) Philosophy of science and the devel-
630. opment of nursing theory. In Annual Review of Nursing Research
Lincoln Y. & Guba E. (1985) Postpositivism and the naturalist 3 (Fitzpatrick H.W.J., ed.), Springer, New York, pp. 241–265.
paradigm. In Naturalistic Inquiry, Sage, London, pp. 14–46. Thompson J.L. (1985) Practical discourse in nursing: going beyond
Ludz K.F., Jones K.D. & Kendall J. (1997) Expanding the praxis empiricism and historicism. Advances in Nursing Science 7(4),
debate: contributions to clinical inquiry. Advances in Nursing 59–71.
Science 20(2), 23–31. Thorne S.E. (1999) Ideological implications of paradigm discourse.
Lutz K., Jones K. & Kendall J. (1997) Expanding the praxis debate: Nursing Inquiry 6, 123–131.
contributions to clinical inquiry. Advances in Nursing Science Tolley K. (1995) Theory from practice for practice: Is this a reality?
20(2), 23–31. Journal of Advanced Nursing 21, 184–190.
Maguire P. (1987) Doing Participatory Research. University of Treat-Jacobson D. & Lindquist R.A. (2004) Functional recovery and
Massachusetts, Amherst, MA, USA. exercise behaviour in men and women 5 to 6 years following
Meleis A.I. (1997) Theoretical Nursing: Development & Progress. coronary artery bypass graft (CABG) surgery. Western Journal of
Lippincott, Philadelphia. Nursing Research 26(5), 479–496.
Mill J.E., Allen M.N. & Morrow R.A. (2001) Critical theory: critical Van der Zalm J.E. & Bergum V. (2000) Hermeneutic-phenomenol-
methodology to disciplinary foundations in nursing. Canadian ogy: providing lived knowledge for nursing practice. Journal of
Journal of Nursing Research 33, 109–127. Advanced Nursing 31, 211–218.
Mitchell G.L. & Pilkington F.B. (1999) Research issues: a dialogue Walusimbi M. & Okonsky J.G. (2004) Knowledge and attitudes of
on the comparability of research paradigms – and other theoretical nurses caring for patients with HIV/AIDS in Uganda. Applied
things. Nursing Science Quarterly 12, 283–289. Nursing Research 17(2), 92–99.
Moccia P. (1988) A critique of compromise: beyond the methods Warms C.A. & Schroeder C.A. (1999) Bridging the gulf between
debate. Advances in Nursing Science 10(4), 1–9. science and action: the ‘new fuzzies’ of neopragmatism. Advances
Monti E.J. & Tingen M.S. (1999) Multiple paradigms of nursing in Nursing Science 22(2), 1–10.
science. Advances in Nursing Science 21(4), 64–80. Wuest J. (1994) Professionalism and the evolution of nursing as a
Morse J.M. (1991) Approaches to qualitative-quantitative meth- discipline: a feminist perspective. Journal of Professional Nursing
odological triangulation. Nursing Research 40, 120–123. 10, 357–367.
Morse J.M. (2000) Exploring pragmatic utility: concept analysis by Wuest J. (2000) Concept development situated in the critical para-
critically appraising the literature. In Concept Development in digm. In Concept Development in Nursing: Foundations, Tech-
Nursing: Foundations, Techniques, and Applications (Rodgers B.L. niques, and Applications (Rodgers B.L. & Knafl K.A., eds), W. B.
& Knafl K.A., ed.), W.B. Saunders Company, Philadelphia, Saunders, Philadelphia, pp. 369–386.
pp. 333–352.
Morse J. & Field P. (1995) Qualitative Research for Health Profes-
sionals. Sage, Thousand Oaks, CA, USA.

2006 Blackwell Publishing Ltd 469