Abstract
This column presents a scholarly dialogue with Dr. Lorraine O. Walker. As a co-author of the book Strategies for Theory Construction in Nursing (Walker & Avant, 2019), first published in 1983 and now in its 6th edition, Dr. Walker has made substantial contributions to advancing nursing knowledge and nursing practice. Furthermore, she has dedicated herself to the scientific inquiries into the motherhood transition with its implications for maternal and infant health. In this scholarly dialogue, she shares her expectations of concept analysis for the nursing discipline, along with her new research endeavors and the future of nursing as a science and discipline. It will guide nurse scholars to the world of nursing as a science.
Dr. Lorraine O. Walker is invited for the scholarly dialogue to present her views on nursing, express her thoughts on the contribution of concept analysis to the nursing discipline, and share her current research with the readers of Nursing Science Quarterly. Dr. Walker is a renowned scholar in the areas of concept and theory development and an expert in the motherhood transition, including its implications for maternal and infant health. She is a co-author of a famous book, Strategies for Theory Construction in Nursing (Walker & Avant, 2019), on theory development strategies that is in its 6th edition, and she has published over 150 scholarly publications. Dr. Lorraine Walker is the Luci B. Johnson Centennial Professor in Nursing of The University of Texas at Austin. She earned a diploma in nursing from Holy Cross Central School of Nursing, South Bend, Indiana; an MS in nursing and an EdD in philosophy of education from Indiana University, Bloomington, Indiana; and an MPH in maternal-child health from the University of Alabama at Birmingham. She was inducted into Delta Omega, the National Public Health Honor Society, in 2008 and the International Nurse Researcher Hall of Fame, Sigma Theta Tau International at the 28th International Nursing Research Congress in 2017. She is a fellow of the American Academy of Nursing and the Society of Behavioral Medicine.
Dr. Walker, thank you so much for participating in the scholarly dialogue to share your thoughts on the nursing discipline and your recent studies with the readers. It is an honor to have this opportunity to dialogue with you.
I am very honored to participate in this scholarly dialogue.
Since the book Strategies for Theory Construction in Nursing was first published in 1983, it has highlighted the contributions of concept analysis and theory construction in nursing. I believe the book is written based on your understanding of nursing as a practice discipline. Could you please explain your understanding of nursing?
This question is so interesting because the title of my dissertation at Indiana University was Nursing as a Discipline. So, I feel like I am going back many years to the dissertation, trying to identify, even then and still today, what a practice discipline is. Specifically in nursing, we are drawn to understanding, or we are guided by two specific things, particularly by our nursing metaparadigm, which initially articulated the ideas of person, health, environment, and nursing (Fawcett, 1984). Although they sound like isolated concepts, there have been themes identified as related to those concepts. Often, when one steps back and thinks about the scope of the nursing discipline, those metaparadigm concepts become a guidepost for us. The other component of nursing as a practice discipline is its social mandate. In fact, it is probably our social mandate that takes us to the nursing metaparadigm, bringing those two together. In nursing and education as practice disciplines, having a lot of parallels between them, there seem to be both theoretical and practical components, such as knowledge and skills that people need. The philosophical component in nursing is very much guided by our social mandate, and it is explicated particularly in the theoretical component. What are the phenomena of concern to the discipline? Many of our early nurse theorists gave us some guidance. Despite the fact that they had different answers in relation to this, they brought forth enduring concepts, which I will talk about a little bit later.
Nursing has certainly changed a lot, but ironically, what we found during COVID time was that many of our initial strategies were ones that Florence Nightingale would have used. We may think that so much has changed, but there may be enduring elements that have certainly evolved but are stable, defined both from a theoretical standpoint and our practical skills as well. As we learned in COVID, we were back in Nightingale’s era, in basic care of the person in the environment. So, I think nursing science fits in this theoretical and practice component, and nursing science intersects with both the theoretical part and the practice part. Nursing science is drawing on theories or has contributed to expanding or modifying nursing theories. Also, nursing science is contributing to the practice component as we come to understand nursing interventions more clearly. Therefore, nursing science cuts across both our theoretical as well as the practice components of the discipline.
Thank you so much for sharing and clarifying your understanding of nursing as a practice discipline. Many PhD students in nursing and nurse scholars conduct concept analysis guided by the book, Walker and Avant’s (2019) Strategies for Theory Construction in Nursing, as a preliminary study prior to pursuing nursing science. Could you explain what you mean by nursing concept?
This is really a challenge. First of all, when talking about nursing concepts, I do want to acknowledge Dr. Kay Avant, who passed away this past June in 2025. Anytime I am talking about concepts or concept analysis, I feel like I am left to flounder because she was really the expert in concept analysis. I very much cherish the conversations she and I had over time, and I draw on our conversations very much because she was really the one who brought the depth related to concept analysis.
Defining a nursing concept is as difficult as trying to define nursing itself. I think it has been called elusive by Sally Thorne (2015) while she was talking about the nature of the core disciplinary knowledge in nursing. So, we will try to hit on a few defining aspects of it. Most of all, I think a nursing concept needs to be congruent with our nursing metaparadigm. It needs to fit somewhere within the very broad scope of the nursing metaparadigm, which is also evolving, not static in time. Also, a nursing concept needs to fit within our broad social mandate of nursing. Within that, I think there is a great deal of flexibility as to what could be a nursing concept. When trying to understand an evolving concept, it is important to look back and ask if it does fit within the metaparadigm and the social mandate of nursing.
More specifically, the American Nurses Association (ANA, 2021) provided a new and updated definition of nursing. Though it is broadly defined, the ANA’s new nursing definition can be used as a benchmark, giving us guidance as to where the nursing concept fits in and as a framework to identify nursing concepts. It is difficult to identify nursing concepts versus functional or multidisciplinary concepts that are used across disciplines. It is not that there is distinctive nursing knowledge, but there certainly is knowledge that is more likely to be really relevant to nursing and less so to other professions. This may be an elusive attempt to avoid giving a definite answer to this. Each person needs to do the dialogue with the nursing metaparadigm and the definition of nursing: How do I make the case for this? Just for myself, if I am ever asked, can I actually explain it to others?
Yes, when we choose a nursing phenomenon for concept analysis, it should be a nursing concept, which is abstract and valuable enough to pursue further nursing sciencing. I understand that nurse scholars need to ensure a nursing concept is derived from the nursing definition or metaparadigm.
Yes, also we can make the case for why it fits, so it may not be the most abstract concept, like a midlevel concept, but it should make sense. The other thing I want to add is that not every concept for the foundation of a nursing dissertation needs concept analysis because concept analysis specifically is related to where there is a lack of clarity about the definition of something. So, a concept analysis is warranted only when there is a lack of clarity. For instance, if you are using some theoretical work and the theorist has provided a clear and adequate definition, then I don’t see the need to actually do an additional concept analysis because concept analysis is really meant to clarify where there is confusion or lack of clarity.
So, you focus on the lack of clarity as the need for concept analysis.
Yes.
There are different perspectives on whether concept analysis is guided by a unique nursing theoretical framework, or it can be based on a broader context of knowledge development related to nursing practice. Could you share your thoughts and perspectives on the nursing theory–guided concept analysis?
Thank you for this question. One of the things to remember is that everything we focus on is selected based on our assumptions. We could select many things. Then, what is the focus that we choose to have when we look at a phenomenon? I will give an example of this. I was interested in maternal empathy and happened to be looking at a videotape of a mother-infant interaction. It was a feeding interaction, and often during the period, mothers will talk to the baby or make comments. I was trained particularly to look at facial expressions to observe whether there was a matching of eye contact between mother and baby, so I was very much looking at it from a behavioral interaction standpoint. I was also looking at the same videotape with a colleague who was trained in psychodynamic theory. We did not discuss the video but watched it together. At the end, we compared our notes, and I was astounded to see my colleague talk all about symbolic things she noticed in the comments the mother made, which had implications in terms of psychodynamic theory. I was looking at all the behavioral cues between mothers and babies. If you compared our two descriptions of what occurred in that videotape, they would be completely different.
I think it illustrates our decision to select is based on many assumptions in our training, so in that sense, what we choose to focus on, in a sense, may not be theory-guided, but is at least guided by our training and our experiences. I particularly want to notice and share my understanding that concept analysis really arose from the analysis of ordinary language, for instance, not from scientific language. Now, practice language can be in between these. Sometimes a concept could evolve in care based on dialogue between different clinicians, so they are talking about something that may not be a scientific concept yet, but it is something in practice they are noticing, coming out of their daily experiences. It could be almost like an intermediate point between ordinary language and scientific language. Scientific language is clarified through a different process or rules rather than what we would have for ordinary language. I don’t know if this is really helpful in clarifying this, but I think it is important to think about whether we come with assumptions that direct us to focus on certain things. Further, what is important is to have an awareness of what your assumptions are and to understand whether the concept is coming from the standpoint of ordinary language analysis or science. If it is coming from the standpoint of science, you may rather choose to do a qualitative study in which you look to see and use qualitative methods to understand the phenomenon. However, if it is a concept in ordinary language, then you are going to look at the uses. Aspects of concept analysis have evolved; for example, now people often do systematic reviews to help them understand those uses. Concept analysis has not remained static in terms of its methods.
Another component that I think is important in concept analysis is the model case, which isn’t just something you do at the end. It is something like your guidepost. You engage in this internal dialogue: Do the descriptions of the model case demonstrate all the defining attributes of the concept? Are there some parts I could eliminate? Are there some things missing? Do they apply to other things because they are so general? Although we laid it out in steps, particularly Dr. Avant did, and she made it very clear, one thing about concept analysis is that it is an iterative process, and I think the model case is essential. Now, whether the model case comes from a theoretical origin or a practical origin, it can help differentiate and ensure that attributes, antecedents, and consequences are defined accurately. If everybody agreed that you could have something else added or somewhat more related, then your example would not be the model case. Having an internal dialogue, going back and forth between potential attributes and the model case is important. Otherwise, if you are simply analyzing a concept, how do you make your decision about what the defining attributes are? It becomes arbitrary. I have recently noticed that we may have multiple analyses of the same concept, and yet none of them reference each other, and they have slightly different references. We might say that is because everything is changing, or it is because the process was not as thorough as it could have been. That was just a few observations, and this is a conversation that Dr. Avant and I have had several times. So, you know, Dr. Avant is actually present here with us, too.
Dr. Walker, you mentioned that the knowledge developed through a concept analysis can be tentative and changing because scientific and general knowledge changes so quickly, even though the structured process of concept analysis is a rigorous and formal process with scientific procedures. Would you please elaborate more on the tentativeness of concepts?
I love this question, but it is so complex. I am reminded of the Greek philosopher, Heraclitus, who said you never step in the same river twice. How do we understand the dialogue between change and constancy? One of the points I would like to make is that, to an extent, if a concept is initially derived by induction of our generalizations from experiences, we may make a mistake of confusing what I think Aristotle called accidental characteristics and essential characteristics of something. It is an interesting distinction. The example I want to give is if we say a defining attribute of swans is being white, but when we go to Australia, we are startled to see black swans. It illustrates that, to a degree, it depends on the range of observations we have made in relation to a concept. If we have had a more restricted vision of a concept or one just purely within our own culture or realm, we may say the concept needs to change when we look in other places; is it that the concept itself needs to be changed, or that the process of evolving the concept has been too limited from the very beginning?
Some things may be changing as there are scientific advances, and thus we literally have new discoveries. Certainly, the treatments of many conditions are now evolving dramatically as we look at changes. For instance, there is the evolution in terms of cancer care using immunotherapies. Previously, those were like hypotheses at best, even if we thought about that before. Now, our knowledge has changed, and our care has changed. However, there are other components that have remained constant, particularly within nursing. I would think certain things, such as the experience of human compassion. It may be expressed slightly differently in other cultures, but there is some constancy in the experience of human compassion. I don’t think I have any definitive answers to deal with this, but it is important not to confuse the limitations of our generalizations. If it is a concept based on what we have seen thus far, we call it the process of induction. If we go to Australia, we may see black swans and realize it is not the nature of swans that has changed; rather, what has actually changed is our evolved understanding of swans.
So, I can understand that concept analysis can also be influenced by the scholar’s own perspectives and experiences.
Exactly.
Then, what do you think the primary purposes of concept analysis are?
I think there are two ways. Dr. Avant and I had discussions around this. And even here, I think a couple of things about them are in print (Walker & Avant, 2005). For instance, if it is a student’s activity, a teacher might use concept analysis just to have students clarify some of their ideas about practice concepts. That can be a very useful learning experience for a student. Just the idea of thinking, looking at the literature, and realizing that they can do something to clarify a concept can contribute to practice. One important thing is that using concept analysis is a teaching strategy to encourage critical thinking and improve analytic skills in general. However, to warrant publication, concept analysis in some way should contribute to the discipline. There should be implications for it with a reason or a larger purpose for doing a concept analysis than merely doing the concept analysis.
This has been one of the critiques in the literature of concept analysis that many persons who have published their concept analysis do not use it in further scholarly work. Why didn’t it lead to something else with a larger purpose in the discipline (see review by Rodgers et al., 2018)? In that case, the burden falls on the reviewers for concept analysis manuscripts and editors. They should be sure to urge authors to take the next steps to implications. I mean, this could be the foundation for designing a nursing intervention, because you have clarified this concept, and now you have some intervention strategies that you can use based on this. If there is an unclear concept, you need to clarify it, and while using the clarification, you further develop the empirical referents leading to an instrument, or a measurement scale. So, it is important to ask, what is the larger purpose? What are the implications for science? I don’t think the concept analysis should be undertaken as an isolated activity because the contribution of the concept analysis is limited, so many people have actually criticized concept analysis for that reason. If it does not contribute to nursing discipline in a larger way, it may not warrant publication. I am sorry to say, a well-written paper in itself does not make a contribution to the discipline if it does not lead us to the next step. If the implications are missing, as a result, it sits there and leads other people to say concept analysis is really disappointing, as nothing ever happened with it. I am looking for the next step that the author takes because sometimes people do a concept analysis with the reason of personal growth in their understanding. There is nothing wrong with using a concept analysis as a means of personal growth in your understanding of a concept; however, for publication and disciplinary reasons, we want a concept analysis to lead more toward goals within the discipline.
I agree with you. The concept analysis itself is not research or sciencing, but when scholars move on to nursing science with what they found with concept analysis, they can contribute to nursing knowledge development.
Yes, exactly.
Is there anything further you would like to add about the contribution of concept analysis to the nursing discipline?
Well, I think the other area, and this is where Dr. Avant would, I think, strongly make the case. Concept analysis can contribute to two other things. One is theory development. Sometimes I have seen that people have done a concept analysis, but they have not identified the antecedents or the consequences of the concept. If you look at it, you can have the beginnings of what I would call a small theoretical model based on the concept analysis. It has the antecedents, core concepts, attributes, and consequences identified so that it can actually be a whole beginning framework for theory development. The other thing that Dr. Avant also pointed out was that concept analysis can help find nursing diagnoses. Some people find nursing diagnoses helpful, and others do not. In my experience, some of the nursing diagnoses have come directly from practice, and as a result, doing a concept analysis has led to the clarification of the nursing diagnosis.
So, you think concept analysis can contribute to nursing discipline through the development of theory and the clarification of nursing diagnoses.
I know in the US, nursing diagnosis is not as popular, but it is a part of the ICD-10. So, it does try to document the phenomena that nurses are seeing as important in their practice.
Walker and Avant’s concept analysis has been expanded from Wilson’s classic concept analysis, and there are diverse approaches to concept analysis in nursing. What do you think is the most unique part of Walker and Avant’s concept analysis method?
Well, I would say that it was probably one of the first works that put what was there within a nursing context. Wilson’s work was there, but often students need to have things put in the context of their area of study. So, the goal that Kay Avant and I had in the theory development book was to make it a primer for students, when it was originally written, maybe even today. If students are coming from a heavy practice environment, thinking theoretically about their practice is something that they haven’t had the opportunity, or just time, to do. So, by putting it in relatively clear-cut process with a simple methodology, we aimed to give them a bridge to move into the world of nurses thinking of themselves as nurse scientists or nurse theorists. In that regard, I think it was an important bridge, and certainly the concept analysis strategies that people are using now have evolved and are evolving. I remember what Dr. Avant mentioned; rather than just looking at all different uses of a concept, many people are now starting to use systematic reviews to identify those uses, so they are bringing a higher-level methodology to it.
Many nursing scholars conduct concept analysis, as you said, to bridge and proceed to nursing research as a nurse scientist with concrete definitions and understanding of the concept related to the main research topic. I would like to know more about your expectations for utilizing concept analysis in nursing. How do you expect nursing students or emerging scholars to use concept analysis?
I think they should be guided at the very beginning to think about a larger purpose for the concept analysis, not only to conduct a concept analysis but to have guidance from their mentors about why they are doing concept analysis and what its implications are. Sometimes students may not see the next step and may need guidance. So, I think that is one expectation, not so much of the expectation for students, but actually the expectation for the mentors of the students. When they do concept analysis for the first time, students are learners, not experts, so they need guidance to know that there must be some kind of implications, where concept analysis can be used, and how it makes a difference. There may be the burden that falls not so much on students but on the faculty as well as the mentors who are guiding students.
Thank you so much for your specific and detailed information on concept analysis, helping me understand concept analysis more than if I just read the book alone. Now, I would like to change topics and ask you about your current scholarly endeavors. Can you please share your recent research interests with the readers of Nursing Science Quarterly?
I have actually gone back. There is a saying: I went on a journey, and I came around the corner and found I was where I had started at the very beginning. That is kind of what has happened to me. Many years ago, I was really interested in the stress process and how that affected mothers. I recently found some old data that I had in a very large computer printout. I had to key it all again, and I knew what it was. I found that I was able to blend it with another dataset. I found that I had the beginnings for actually doing more than I had ever thought with this one project that I had done some time ago. I was able to pick that up and deal with the whole stress process. I had the good wisdom at that time to include questions where mothers could write in their own comments about what their stressors were and how they coped with them. It has taken me to a whole new area of looking at postpartum-specific stressors, but as defined by mothers, not as defined by general scales such as stress scales or anxiety scales. My prior work was more quantitative in nature, but by trying to blend the two together, I have become a proponent of mixed methods.
Particularly in terms of understanding interventions for a group, I have been influenced by the fact that there is a methodology called positive deviance, which takes as a starting point that people at the local level can often solve their own problems (Marsh et al., 2004). It may not be everyone who is able to solve the problems, but within a patient population or a group, especially when they may lack resources or advantages, a few may still be thriving even in difficult circumstances. The theory of positive deviance takes us to the investigation of those individuals to see what solutions have worked even under conditions of adversity.
I try to understand the ways that people figure out in their context ways to manage and find solutions not so much from a theoretical base, though I broadly do use the Lazarus and Folkman’s framework (1984) for how stress is an interaction between the person and their environment, which would also probably fit a lot with Sister Callista Roy’s framework. Combining the Lazarus and Folkman and positive deviance guided me to study specific stressors and how people may devise their own solutions. Thus, we’ve looked at not only stressors but how people actually cope. I am not sure whether this is a new breakthrough, especially in terms of foci for interventions, because many interventions draw on existing psychological theories, such as cognitive behavioral therapy or interpersonal therapies, but there are potential solutions that some parents or persons have already devised and are already using. It is always quite interesting to just listen to people tell their stories in this regard.
You may pay more attention to the person and environment to understand the person’s unique solutions to manage stress. I think it is a very interesting study and appreciate for sharing. Lastly, I would like to ask about your hopes and dreams for nursing, and your vision for how nursing will move forward.
I have got three wishes that I would like to mention. One of which is that I would love to see a textbook about nursing science. The textbook would not be about research methods but about the findings with key concepts of a science or the evidence-based practice to reflect the work that nurses have done. If you were a student in psychology, you would study the basic concepts of psychology. Do we have a book that is really called nursing science? Nurse scientists do a lot of interdisciplinary work, and I certainly want to honor that work. However, I would like to see a book from nursing’s unique angle of vision. I think Sally Thorne (2015) used the wording of the distinctive angle of vision.
My second wish is based on what a student shared long time ago. She was traveling and happened to be asked at one point, “Why and what are you studying?” The student was asked that question by a kind of official person, and she answered, “I am studying nursing science.” She was asked then, “What is nursing science?” She shared that she did not know how to answer that. I thought we needed to have an answer for that question, because it can also occur in an interdisciplinary team. As they go around the table and come to nursing and ask, “What is nursing’s contribution?” The nurse must have an answer for that, and it shouldn’t just be coordinating everybody else. There is more to nursing than coordination. Even as nursing is elusive, everybody still has to figure out the answer to that question. I would like to have something that is nursing science–based as an answer to that question, for example, see Pickler’s (2025) answer.
The third wish that I think about is possibilities of how we tie the past to the present and to the future. I did a piece a while ago, and I think it was called “Gifts of Wise Women” (Walker, 2020). It was a reflection on key ideas that I had come to see as enduring ideas from major nurse theorists. In doing that, I focused on some of those enduring ideas, and I hope I will carry them forward. One of them is human dignity, and that was in the work of Ernestine Wiedenbach (1964). We treat all with respect, so that respect, in terms of human dignity, is one of our core concepts that we always take with us in practice. Another one from the work of Ida Jean Orlando (1961), who focused on communication, applying principles from psychiatric nursing into interactions. I call that the gift of dialogue, which is being authentically present in the nurse-patient relationship. Another is from Sister Callista Roy. Although we often focus on her adaptation model (Roy & Andrews, 2008), I particularly want to focus on her identification of context, because it is weaving knowledge of culture and situational factors into care. If we do public health nursing and make home visits, we see the larger context, and all of a sudden, the care looks really different. Experiencing of understanding context, we do weave context into plans of care.
Dorothy Johnson (1980) had the wisdom to talk about a behavioral system way of being, which was a unique contribution. Trying to identify how patient care was different from the organizational management piece or the medical piece, she particularly emphasized helping people to achieve balance in daily living, what she called subsystems, focusing on the idea of balance. I think many people in academia say they are looking for work-life balance. What is that? I would tell them to read Dorothy Johnson’s work. I think it gives some really interesting ideas. Surely, Dorothea Orem’s (2001) idea of self-care has really transformed care in nursing, so that it is supportive care of people’s health needs as well as their well-being. It is sometimes confused with the idea that the patients do it for themselves, and that’s not what self-care means for Dorothea Orem. I think sometimes we don’t realize it, and I made that mistake at least initially, until I actually heard her speak. When I heard her speak, I realized that she meant much more by self-care. It is to care for the self. I think because she came from a German background, and the self has a much deeper meaning than maybe what we would always understand it within our ordinary English. Lastly, I think of humans in interaction with their physical and social environment, which is drawing from Martha Rogers’ (1970) science of unitary human beings and Rosemarie Rizzo Parse’s (2021) humanbecoming paradigm, especially the nurse’s living true presence with individuals that are transformative. Those theoretical frames in nursing make possible changing the arc of people’s lives. There is this possibility of nursing, particularly because of the circumstances in which nurses interact with others. We can change or enhance the arc of peoples’ lives, and that would be one of the most wonderful things for nursing to achieve.
Your explanation resonates with me about the future and prosperity of nursing. I hope the scholarly dialogue with you will help the reader contemplate concept analysis, nursing science, and the future of nursing. Do you have anything to add?
No, I just want to thank you for this opportunity.
