Development of the theory of wisdom in action for clinical nursing

As nurses, we seek to gain nursing wisdom and apply it in our daily practice, yet the process of practicing with wisdom has not been well explained for nursing. The purpose of this dissertation was to develop a theory of wisdom in action (WIA) for clinical nursing, beginning with a formal concept analysis. In Phase 1 (Aim 1), a preliminary theory was developed deductively using derivation and synthesis, based on theories and models from psychology, education, and nursing. Pertinent concepts were identified and nursing-specific definitions created. The theory included four dimensions: person-related factors, environment-related factors, knowledge, and wisdom. Separately, a constructivist grounded theory approach inductively captured the experience of wisdom in nursing practice (Aim 2), based on wisdom narratives from 30 emergency department nurses. The resulting grounded theory focused on two processes, technical and affective, juxtaposed on a foundation of expertise. New findings were the importance of affective characteristics such as emotional intelligence and confidence. Finally, the theories were synthesized into the Theory of Wisdom in Action for Clinical Nursing. The theory describes two antecedent dimensions, person-related and setting-related factors, and two types of wisdom processes. General wisdom processes apply to patient care and describe the actions nurses take during a stressful or uncertain event. Personal wisdom develops afterwards, as a feedback loop with reflection, discovery of meaning, and learning, followed by increased knowledge and confidence. Wisdom is critical for all areas of nursing practice. The Theory of Wisdom in Action for Clinical Nursing provides a working framework for translating wisdom in clinical nursing practice into theoretical and practical terms, depicting both the science and the art of nursing. This novel theory displays how nurses practice with wisdom, and reveals that wisdom in action requires clinical skills, experience, knowledge, and affective proficiency.

DEVELOPMENT OF THE THEORY OF WISDOM IN ACTION FOR CLINICAL NURSING by Susan A. Matney A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing The University of Utah August 2015 Copyright  Susan A. Matney 2015 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Susan A. Matney has been approved by the following supervisory committee members: Nancy Staggers , Co-Chair April 17, 2015 Date Approved Lauren Clark , Co-Chair April 17, 2015 Date Approved Kristin Cloyes , Member Date Approved Kay Avant , Member April 17, 2015 Date Approved Monisha Pasupathi , Member Date Approved and by Patricia Morton , Dean of the College of Nursing and by David B. Kieda, Dean of The Graduate School. ABSTRACT As nurses, we seek to gain nursing wisdom and apply it in our daily practice, yet the process of practicing with wisdom has not been well explained for nursing. The purpose of this dissertation was to develop a theory of wisdom in action (WIA) for clinical nursing, beginning with a formal concept analysis. In Phase 1 (Aim 1), a preliminary theory was developed deductively using derivation and synthesis, based on theories and models from psychology, education, and nursing. Pertinent concepts were identified and nursing-specific definitions created. The theory included four dimensions: person-related factors, environment-related factors, knowledge, and wisdom. Separately, a constructivist grounded theory approach inductively captured the experience of wisdom in nursing practice (Aim 2), based on wisdom narratives from 30 emergency department nurses. The resulting grounded theory focused on two processes, technical and affective, juxtaposed on a foundation of expertise. New findings were the importance of affective characteristics such as emotional intelligence and confidence. Finally, the theories were synthesized into the Theory of Wisdom in Action for Clinical Nursing. The theory describes two antecedent dimensions, person-related and setting-related factors, and two types of wisdom processes. General wisdom processes apply to patient care and describe the actions nurses take during a stressful or uncertain iv event. Personal wisdom develops afterwards, as a feedback loop with reflection, discovery of meaning, and learning, followed by increased knowledge and confidence. Wisdom is critical for all areas of nursing practice. The Theory of Wisdom in Action for Clinical Nursing provides a working framework for translating wisdom in clinical nursing practice into theoretical and practical terms, depicting both the science and the art of nursing. This novel theory displays how nurses practice with wisdom, and reveals that wisdom in action requires clinical skills, experience, knowledge, and affective proficiency. TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF TABLES ............................................................................................................. ix LIST OF FIGURES .............................................................................................................x ACKNOWLEDGEMENTS ............................................................................................... xi Chapters 1 INTRODUCTION ............................................................................................................1 Background ................................................................................................................... 1 Statement of the Problem .............................................................................................. 2 Proposed Solution ......................................................................................................... 4 Study Purpose and Aims ............................................................................................... 4 Significance................................................................................................................... 5 Theoretical Framework ................................................................................................. 7 References ..................................................................................................................... 8 1 REVIEW OF THE LITERATURE ................................................................................10 Nursing Informatics and the DIKW Framework ........................................................ 10 Data ....................................................................................................................... 11 Information ........................................................................................................... 12 Knowledge ............................................................................................................ 12 Wisdom ................................................................................................................. 13 Literature and Theories Pertinent to the Theory of Wisdom in Action ...................... 15 Philosophy............................................................................................................. 15 Psychology ............................................................................................................ 16 The Balance Theory of Wisdom ........................................................................... 18 The Berlin Wisdom Paradigm .............................................................................. 20 The MORE Wisdom Model .................................................................................. 23 The Model of Wisdom .......................................................................................... 26 Wisdom Nursing Theories and Literature................................................................... 33 Nursing Models of Wisdom .................................................................................. 33 vi Wisdom Attributes in Nursing .............................................................................. 34 Nursing Theory Purpose and Development ................................................................ 37 Theory-Development Strategies ........................................................................... 38 Metatheory ............................................................................................................ 39 Grand Theory. ....................................................................................................... 40 Midrange Theory .................................................................................................. 41 Microrange Theory ............................................................................................... 42 Current Nursing Culture ....................................................................................... 42 Summary ..................................................................................................................... 46 References ................................................................................................................... 47 3 STUDY OVERVIEW .....................................................................................................55 Methods-Aim 1 ........................................................................................................ 56 Theory Derivation ................................................................................................. 56 Theory Synthesis ................................................................................................... 57 Methods-Aim 2 ........................................................................................................ 58 Constructivist Grounded Theory........................................................................... 59 Sampling and Participants..................................................................................... 64 Data Collection Methods ...................................................................................... 66 Data Analysis ........................................................................................................ 68 Trustworthiness ..................................................................................................... 74 Conclusion .................................................................................................................. 76 References ................................................................................................................... 78 4 PHILOSOPHICAL APPROACHES TO THE NURSING INFORMATICS DATA-INFORMATION-KNOWLEDGE-WISDOM FRAMEWORK .....................81 DIKW Framework in Nursing .................................................................................... 83 Data ............................................................................................................................. 83 Information ................................................................................................................. 84 Knowledge .................................................................................................................. 84 Wisdom ....................................................................................................................... 84 Philosophical Approaches ........................................................................................... 85 Definitions................................................................................................................... 85 Postpositivism ............................................................................................................. 86 Gadamerian Hermeneutics .......................................................................................... 88 Discussion ................................................................................................................... 91 Conclusion .................................................................................................................. 92 References ................................................................................................................... 93 5 TOWARD AN UNDERSTANDING OF WISDOM IN NURSING .............................95 Abstract ....................................................................................................................... 95 Introduction ................................................................................................................. 96 vii Nursing Theory ........................................................................................................... 97 Review of the Wisdom Literature ............................................................................... 98 Philosophy............................................................................................................. 98 Psychology ............................................................................................................ 99 Nursing ................................................................................................................ 101 Identification of Wisdom Characteristics ................................................................. 103 The Data, Information, Knowledge, Wisdom Framework ................................. 104 The Berlin Wisdom Paradigm ............................................................................ 104 The MORE Wisdom Model ................................................................................ 106 The Model of Wisdom ........................................................................................ 109 Derived Nursing Wisdom Antecedents and Characteristics ..................................... 111 Discussion and Summary .......................................................................................... 113 Conclusion ................................................................................................................ 114 References ................................................................................................................. 116 6 DEVELOPMENT OF THE THEORY OF WISDOM IN ACTION FOR CLINICAL NURSING ..............................................................................................120 Abstract ..................................................................................................................... 120 Introduction ............................................................................................................... 121 Theory Development ................................................................................................ 122 The Theory of Wisdom in Action for Clinical Nursing ............................................ 125 Person-Related Factors ....................................................................................... 125 Environment-Related Factors ............................................................................. 129 Information System Factors ................................................................................ 130 Knowledge Dimension........................................................................................ 131 Wisdom in Action ..................................................................................................... 133 Reflection Feedback Loop .................................................................................. 135 Discussion ................................................................................................................. 137 Conclusion ................................................................................................................ 139 References ................................................................................................................. 140 7 NURSES' WISDOM IN ACTION IN THE EMERGENCY DEPARTMENT ...........143 Abstract ..................................................................................................................... 143 Introduction ............................................................................................................... 143 Methods..................................................................................................................... 146 Design and Approach .......................................................................................... 146 Sample and Setting ............................................................................................. 147 Data Collection Methods .................................................................................... 147 Findings..................................................................................................................... 152 Expertise ............................................................................................................. 153 Technical Process Wisdom Categories ............................................................... 154 Affective Process Categories (The Celtic Knot of Nursing Care) ...................... 158 Discussion ................................................................................................................. 162 viii Conclusion ................................................................................................................ 164 References ................................................................................................................. 165 8 DISCUSSION AND CONCLUSIONS ........................................................................169 Summary ................................................................................................................... 169 The Use of Derivation and Synthesis .................................................................. 170 Emergency Room Nurses' Wisdom Processes ................................................... 171 The Synthesized Theory of Wisdom in Action for Clinical Nursing ....................... 173 Wisdom Antecedents .......................................................................................... 173 Setting-Related Factors ....................................................................................... 176 The Theory of Wisdom in Action for Clinical Nursing ............................................ 176 General Wisdom in Action ................................................................................. 177 Personal Wisdom in Action ................................................................................ 178 Interpretation of Findings ......................................................................................... 178 Comparison to Other Nursing Theories .................................................................... 179 Novice to Expert ................................................................................................. 179 Types of Knowing............................................................................................... 180 The DIKW Framework ....................................................................................... 181 Significance and Implications ................................................................................... 182 Strengths and Limitations ......................................................................................... 183 Theory Strengths and Limitations ....................................................................... 183 Study Strengths and Limitations ......................................................................... 185 Future Research ........................................................................................................ 186 Conclusion .......................................................................................................... 188 References ........................................................................................................... 190 Appendices A RECRUITMENT FLYER..................................................................................... 192 B NURSE DEMOGRAPHICS FORM ..................................................................... 194 C INTERVIEW GUIDE ........................................................................................... 196 D CONSENT AND AUTHORIZATION DOCUMENT ......................................... 198 E TYPIST'S CONFIDENTIALITY PLEDGE ......................................................... 203 LIST OF TABLES Tables 5.1 Derived Antecedents and Characteristics ..................................................................112 6.1 Antecedent and Characteristic Definitions ................................................................124 7.1 A Grounded Theory of Wisdom in Emergency Nursing ...........................................154 8.1 Wisdom Antecedent Definitions ................................................................................175 8.2 Wisdom Attribute Definitions....................................................................................177LIST OF FIGURES Figures 2.1 The Berlin Wisdom Paradigm .....................................................................................21 2.2 The MORE Model of Wisdom ....................................................................................26 2.3 The Model of Wisdom .................................................................................................27 3.1 Representation of Constructivist Grounded Theory Analysis Process ........................69 3.2 Emotional Intelligence Network Diagram ...................................................................71 3.3 Clustering Diagram ......................................................................................................73 4.1 DIKW Framework .......................................................................................................83 5.1 Revised Nelson Data Information Knowledge Wisdom (DIKW) Model ..................105 5.2 Berlin Wisdom Paradigm ...........................................................................................107 5.3 The MORE Model of Wisdom ..................................................................................108 5.4 Model of Wisdom Development ................................................................................110 6.1 The Theory of Wisdom in Action for Clinical Nursing .............................................126 7.1 Representation of Constructivist Grounded Theory Analysis Process ......................149 7.2 The Process Practicing with Wisdom ........................................................................151 8.1 The Synthesized Theory of Wisdom in Action for Clinical Nursing ........................174 ACKNOWLEDGEMENTS I express my deepest appreciation to my committee chairs, Dr. Nancy Staggers and Dr. Lauren Clark; both mentored and inspired me on this educational quest. I am truly transformed after this experience, and have gained a deeper love and respect for the nursing profession. Dr. Staggers challenged me to do something new and guided me as I worked to achieve it. Dr. Clark's expertise in qualitative research was essential to my research; her excitement when teaching was contagious, and she made me-and every other student-feel important. Without the guidance of and consistent help from these two experts, this dissertation would not have been possible. I thank my committee members, Dr. Monisha Pasupathi, Dr. Kay Avant, and Dr. Kristen Cloyes, whose work demonstrated that providing service and support to students is imperative to education. I particularly thank Dr. Avant for her one-on-one mentorship and guidance regarding theory development. Her love of nursing theory is obvious and catching. Most importantly, I acknowledge the love and sacrifice of my family. My husband and sweetheart, Fred, allowed me to cry on his shoulder, loved me, and supported me every step of the way. Thanks to my children David, Stephen, and Sarah, and their families, for their support. Finally, thanks to my dear mother, Merna Ray, for giving me the desire for education. This dream has been achieved because of you. CHAPTER 1 INTRODUCTION Background Informatics has been identified as one of the core competencies for nurses in all specialties and at all levels of practice, not just for informatics nurse specialists (American Nurses Association [ANA], 2008; Staggers & Thompson, 2002). Early definitions of nursing informatics (NI) coalesced around Graves and Corcoran's (1989) seminal article outlining data, information, and knowledge as foundational concepts for the specialty (ANA, 2008). In 2008 the ANA revised the Scope and Standards of Practice for nursing informatics to include an additional concept-wisdom-in the definition of nursing informatics (ANA, 2008; Nelson, 2002). Building upon early work in the fields of information science and informatics, this resulted in the Data, Information, Knowledge, Wisdom (DIKW) framework (ANA, 2008). The DIKW framework is one of the core conceptual frameworks for the study of nursing informatics; however, the wisdom concept within the framework has not been clearly explained or defined. In order for the framework to be effective, nurses must understand what the concepts, including wisdom, represent in the context of clinical nursing practice, and how they are formulated and applied. The fundamental precept of nursing informatics is that NI supports nursing in all 2 settings and roles, and that informatics knowledge and skills are integral for all nursing practice. Thus, it logically follows that the concept of wisdom applies to nursing practice as a whole and is not limited to nursing informatics specialty practice. It also does not appear that the ANA intended the concept of wisdom to be limited to its use within the DIKW framework, because the concept was included within the ANA's core definition of informatics practice (ANA, 2008). Statement of the Problem The addition of wisdom to the nursing informatics scope and standards raises a number of questions and challenges. Nurses are challenged to develop ways to classify and measure wisdom. Means to discover the meaning and experience of wisdom in practice by identifying wisdom attributes (inherency and cause) and the relationships between them are essential to support expert practice as well as the decision making of more novice nurses (ANA, 2008). The concept and experience of wisdom within clinical nursing practice have not been clearly explained, however, and the applicability of applied wisdom (or wisdom in action) to clinical nursing practice has not been researched. Therefore, the extent to which wisdom is uniquely experienced among nurses in clinical situations is unknown. Including wisdom as one of the concepts within the DIKW framework suggests that the concepts influence each other and that wisdom is in some way the result of combining or synthesizing the other three concepts. On the other hand, data, information, and knowledge have specific implications in terms of information structures (Blum, 1986; Graves & Corcoran, 1989), while wisdom seems to be an intrinsically human attribute (Matney, Brewster, Sward, Cloyes, & Staggers, 2011). 3 Wisdom is a cultural construct (Baltes & Staudinger, 2000). A cultural construct is an anthropological term that suggests our shared understanding of some aspects of the world, such as illness, gender roles, or the experience of death, are culturally defined. It reflects the shared views of a group of people who see the world a certain way, and how these shared views shape behavior. The social construction of reality is an unending process, reproduced by people acting on their interpretations and their knowledge of it. Wisdom can be thought of as a cultural construct that is uniquely defined by a group of people; the descriptors of wisdom vary in different cultures (Staudinger & Glück, 2011; Takahashi & Bordia, 2000). Wisdom has been modeled and explained in other disciplines, such as psychology and education, but the extent to which those models are useful in nursing is unclear. Similar concepts, such as expertise and various forms of knowledge and ways of knowing, have been articulated in the nursing literature, but those concepts seem not to be quite the same as wisdom (Benner, 1984, 2000; Carper, 1978; Smith, 2009). We do not know precisely what the attributes of wisdom are, nor the relationship between those attributes. Hence, we do not have a formal definition of wisdom within the context of clinical nursing practice. We do not know the extent to which wisdom may have unique meanings and relationships in nursing; it is therefore difficult to determine how nursing knowledge influences nursing wisdom, how experience is reflected in nursing wisdom, or how wisdom relates to concepts such as clinical judgment, expertise, forms of nursing knowledge, empathy, and intuition. 4 Proposed Solution Wisdom has not been explained specifically for nursing practice. Benner (1991) defined nursing practice as skilled action and expertise. Nurses practice in many roles and settings, but most nurses practice in the clinical setting, doing bedside care at some point in their career. Therefore, we need to understand how we should think about wisdom as applied within the context of clinical nursing in specific situations before we can progress to address other challenges. The specific practice examined was emergency room nursing, because emergency room nurses have the autonomy to make decisions and perform interventions. There are three assumptions regarding wisdom in action (WIA). The first assumption is that nurses provide care for patients using wisdom. Second, data, information, and knowledge precede wisdom. Third, wisdom is a situational process. Finally, during the act of providing care, data, information, and knowledge are used to assist in decision making and care. Study Purpose and Aims The purpose of this dissertation was to develop a theory of wisdom in action for clinical nursing. Theory draws key concepts together by positing relationships between them, and as a result of the concepts being related in particular ways, processes or phenomena are defined. The theory then produces an explanatory framework that reinforces its own orientation while also shaping subsequent observations. Nursing theory provides the principles that underpin practice and helps us decide what we know and what we need to know (Colley, 2003). Therefore, defining a theory of wisdom in action can stimulate an interest in the area and provide an understanding of the nurse's purpose 5 and role in the healthcare setting. The process of theorizing WIA was developed in three steps: first, a theory was developed using derivation and synthesis. Next, a second theory was developed using constructivist grounded theory (CGT). Finally, the two were compared and synthesized to produce the final Theory of Wisdom in Action for Clinical Nursing. Specific aims were: • Aim 1: To develop a descriptive construct and graphical representation (model) of wisdom in action within the context of clinical nursing practice. The research questions were: (a) What are the attributes of wisdom in clinical nursing? (b) What concepts are related to, but distinct from, wisdom in clinical nursing? and (c) What are the relationships between the attributes of wisdom, and between wisdom and related concepts, in the context of clinical nursing? • Aim 2: To understand how emergency room nurses construct the meaning of wisdom in the emergency room setting within the culture of clinical nursing practice. The research questions were: (a) What does wisdom mean to emergency room nurses? (b) What central processes are used to practice wisely and gain knowledge through practice? (c) What key concepts are involved in the processes? and (d) How are the processes related to each other? Significance The initial construct work and the results of the qualitative study resulted in a new nursing theory, the Theory of Wisdom in Action for Clinical Nursing. Theory provides a framework for what is currently known and links nursing research, nursing practice, and 6 nursing knowledge. Therefore, this new theory can provide a working framework for explaining wisdom, in the context of clinical nursing practice, in theoretical and practical terms. The eventual goal was to provide the ability to classify, measure, and document wisdom. This will allow the development of information systems, research methods, and educational programs that support nursing practice, clinical decision making, critical thinking, and the development of wisdom. Nurses in all areas, including research, education, and practice, will be able to use the theory as a theoretical framework for their practice. Nursing researchers will be able to research different aspects of the theory. Each of the concepts and relationships within the model provides research opportunities. The theory needs to be tested using examples from multiple specialties, settings, and institutions. This research and theory can be significant for nursing education by serving as a roadmap that illustrates how knowledge leads to wisdom. The levels of knowledge within the theory can prescribe the types of knowledge required for clinical nursing by level of expertise or by specialty. The theory can inform instructors about how information can be presented to assist with knowledge development. The theory also emphasizes the importance of reflection; thus, a future implication for education may be establishing how to teach reflection. Reflection may be used to discover meaning and increase knowledge, thus enhancing future practice. The theory can have the most impact in clinical nursing practice, with the ultimate result of improving patient care; it explains how knowledge can be applied as wisdom as well as how information can become knowledge. Knowing what knowledge is needed to 7 care for a patient in a stressful situation and applying it successfully is wisdom. Theoretical Framework This dissertation is theory building; therefore, the framework was a theory construction approach outlined by Walker and Avant (2011). The construct, development (Aim 1), construct validation, and final theory development is specifically outlined within their approach. Aim 2, the qualitative research portion of this study, was approached using constructivist grounded theory (CGT). CGT allows the researcher to develop formal theory that explains human behavior, interactions, and cognitive and social processes (Charmaz, 2006; Jeon, 2004; Morse et al., 2009). The interpretation and analysis from the study will provide insights into ideas, beliefs, and knowledge of the process of wisdom in practice within the culture of the emergency room setting. 8 References American Nurses Association. (2008). Nursing informatics: Scope and standards of practice. Silver Spring, MD: Author. Baltes, P. B., & Staudinger, U. M. (2000). Wisdom. A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist, 55(1), 122-136. doi:10.1037//0003-066X.55.1.122 Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P. (1991). The role of experience, narrative, and community in skilled ethical comportment. Advances in Nursing Science, 14(2), 1-21. doi:10.1097/00012272-199112000-00003 Benner, P. (2000). The wisdom of our practice. American Journal of Nursing, 100(10), 99-105. doi:10.2307/3522335 Blum, B. (1986). Clinical information systems. New York: Springer-Verlag. doi:10.1007/978-1-4613-8593-6 Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage. Colley, S. (2003). Nursing theory: Its importance to practice. [Review]. Nursing Standard, 17(46), 33-37. Graves, J. R., & Corcoran, S. (1989). The study of nursing informatics. Image: Journal of Nursing Scholarship, 21(4), 227-231. doi:10.1097/00004650-199610000-00005 Jeon, Y. H. (2004). The application of grounded theory and symbolic interactionism. Scandinavian Journal of Caring Sciences, 18(3), 249-256. doi:10.1111/j.1471-6712.2004.00287.x Matney, S. A., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6-18. doi:10.1097/ANS.0b013e3182071813 Morse, J. M., Stern, P. N., Corbin, J. M., Bowers, B., Clarke, A. E., & Charmaz, K. (2009). Developing grounded theory: The second generation. Walnut Creek, CA: Left Coast Press. 9 Nelson, R. (2002). Major theories supporting health care informatics. In S. Englebardt & R. Nelson (Eds.), Health care informatics: An interdisciplinary approach (pp. 3-27). St. Louis, MO: Mosby. Smith, M. C. (2009). Holistic knowing. In R. C. Locsin & M. J. Purnell (Eds.), A contemporary nursing process: The (un)bearable weight of knowing in nursing (pp. 135-152). New York: Springer. Staggers, N., & Thompson, C. B. (2002). The evolution of definitions for nursing informatics: A critical analysis and revised definition. Journal of the American Medical Informatics Association, 9(3), 255-261. doi:10.1197/jamia.M0946 Staudinger, U. M., & Glück, J. (2011). Psychological wisdom research: Commonalities and differences in a growing field. Annual Review of Psychology, 62, 215-241. doi:10.1111/j.1471-6712.2004.00287.x Takahashi, M., & Bordia, P. (2000). The concept of wisdom: A cross-cultural comparison. International Journal of Psychology, 35(1), 1-9. doi:10.1080/002075900399475 Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall.CHAPTER 2 REVIEW OF THE LITERATURE This chapter reviews literature relevant to this dissertation and is divided into five sections. The first section provides context for the dissertation and contains a brief overview of the DIKW framework and the role this framework has played in NI definitions. (Note that Chapter 4 is a review of philosophical underpinnings of the DIKW framework [Matney, Brewster, Sward, Cloyes, & Staggers, 2011]). The second section is a literature review of wisdom in nursing and other disciplines. Wisdom definitions and theories in both psychology and education literature were examined. Nursing literature was reviewed for concepts similar to wisdom, such as phronesis, knowledge, and expertise. The third section contains an examination of nursing theory development and validation. This section describes nursing theory and the method for the construction and validation of an initial construct of wisdom in action for clinical nursing. The fourth section is an examination and review of constructivist grounded theory (CGT). The final section concludes with a description of the current culture of nursing. Nursing Informatics and the DIKW Framework The DIKW framework is an integral part of nursing informatics. It is described at length in Chapter 1; therefore, only a brief synopsis of the DIKW framework 11 development and structure is presented here. The American Nurses Association (ANA) definition of nursing informatics includes special emphasis on the continuum of data, information, knowledge, and wisdom (Schleyer & Beaudry, 2009). Graves and Corcoran (1989) published a foundational article outlining data, information, and knowledge for nursing informatics. Early definitions of NI relied heavily on the Graves and Corcoran perspective, and the first version of the ANA Scope and Standards of Practice for NI contained the DIK portion of the framework (ANA, 2001). It was not until the 2008 edition of the ANA Scope and Standards of Practice that wisdom was added to the formal definition of nursing informatics (ANA, 2008). The DIKW framework was first mentioned in the computer science literature (Cleveland, 1982). Within computer systems, data are transformed into information, information is transformed into knowledge, and knowledge can lead to wisdom. This framework has become the foundational model for nursing informatics. Data Data are symbols that represent properties of objects, events, and their environments; they are products of observation (Ackoff, 1989). Data are discrete facts described objectively without interpretation (Graves & Corcoran, 1989). Data have no inherent structure or relationships between them (Ahsan & Shah, 2009), and thus a single piece of data has little intrinsic meaning (Hebda & Czar, 2012). Data are foundational components and are built on to provide a basis for reasoning, discussion, or calculation (Ahsan & Shah, 2009). 12 Information Information is data plus meaning. Information is derived from aggregated data, the total of all the facts known (Cleveland, 1982). When facts are put into a context and combined within a structure, information emerges (Tuomi, 1999). Information is derived computationally by manipulating the symbols, or data, using procedures in an organized or structured way (Graves & Corcoran, 1989). Information can be quantifiable, objective, transferable, transparent, and measurable. It has shape and can be processed, accessed, generated and created, transmitted, stored, sent, distributed, searched for, used, compressed, and duplicated (Hey, 2004). Information answers questions that begin with "who," "what," "where," "when," and "how many." It may be organized in ways that serve the interest of the discipline (Turley, 1996). When context changes, even though the data remain the same, new relationships are formed that can generate new information (Kaipa, 2000). Knowledge Knowledge is information that has been synthesized so that relationships, or associations, are identified and formalized (Graves & Corcoran, 1989). Just as data can be transformed into meaningful information, so information can be transformed into knowledge (Shedroff, 1994). Knowledge answers the questions that begin with "why." Knowledge is defined as being either tacit or explicit. Tacit knowledge is personal and context-specific, and therefore is difficult to formalize, summarize, and communicate to others (McGonigle & Mastrian, 2008; Tuomi, 1999). Explicit knowledge, in contrast, can be formalized, and can be encoded and transmitted in a language. Explicit knowledge is the type of knowledge informaticists try to capture, codify, store, transfer, and share. 13 Wisdom Wisdom has been defined by the ANA and others. The ANA (2015) defined wisdom as the appropriate use of knowledge to manage and solve human problems. Other nursing literature notes that wisdom implies an ethical duty to understand the rationale behind clinical actions (Zeleny, 2006). Wisdom involves recognizing what is most important by making distinctions among alternatives. It comprises the application of experience, intelligence, creativity, and knowledge, as mediated by ethics and values, toward the achievement of a common good (Nelson, 2002). Nursing wisdom is based on clinical judgment and a thinking-in-action approach that encompasses intuition, emotions, and senses (Benner, 2000). These definitions show that wisdom is inconsistently defined. According to the ANA, wisdom is only the use of knowledge, although other authors include cognitive and emotion concepts in their descriptions. It is also difficult to decipher from these definitions whether wisdom is framed as an object to be defined or as a process. This indicates that even though definitions of wisdom are found in the literature, the process of practicing with wisdom needs to be explained and formally defined, including the antecedents, defining characteristics, and relationships between the concepts that describe wisdom in nursing practice. There is very little research regarding the concept of wisdom in the nursing or medical literature. There have been two recent qualitative research publications regarding wisdom. First, Matney, Maddox, and Staggers (2013) performed a qualitative content analysis study to determine if knowledge and wisdom were exchanged during patient care handoffs. They defined knowledge as information that is synthesized so that relationships are identified and formalized. The concept of knowledge was encoded when critical 14 thinking or nursing judgment was articulated. Wisdom was defined as "the ability to add experience and intuition to a situation and apply knowledge with empathy and compassion" (Matney et al., 2013, p. 179). Results indicated knowledge was present in every handoff, making change-of-shift reports more than just an information exchange. Subtypes of knowledge related to the care delivery process, including concepts such as assessment and physiology, activity, intake and output, and pain. Wisdom was not found or encoded in any transcripts. This was surprising to the authors, and indicates that possibly the definition of wisdom developed and practiced in nursing needs to be expounded upon. Plews-Ogan, Owens, and May (2013) conducted a grounded theory study evaluating how physicians coped positively after making a serious mistake. Five categories were identified: acceptance, stepping in, integration, new narrative, and wisdom. Each category had subthemes, and the subthemes for wisdom included sense of strength, humility, compassion, learning from mistakes, tolerating ambiguity, and seeing the deeper meaning. The authors discussed the importance of openness to learning, especially after a mistake. The researchers in these two studies approached wisdom definitions differently. The first study defined wisdom deductively a priori, and in the second study the categories were inductively derived from physician interviews. These two different approaches frame wisdom quite differently. The first describes wisdom cognitively, using knowledge to compassionately care for a patient, and the second describes wisdom more affectively, illustrating wisdom in the form of humility and compassion stemming from medical errors. 15 Literature and Theories Pertinent to the Theory of Wisdom in Action Wisdom is not a new concept that has emerged from the advanced information age of today; rather, the search for wisdom is almost as old as humankind (Staudinger & Glück, 2011). Hence, there is a plethora of literature regarding wisdom. The literature reviewed here applies to clinical or practice wisdom; literature is also reviewed from the domains of philosophy, psychology, education, and nursing. Philosophy Philosophical underpinnings of wisdom are described in Chapter 4. A brief synopsis of wisdom in the philosophy literature is presented here. Early definitions of wisdom were found in the writings of Greek philosophers. Socrates described wisdom using three forms; Sophia, phronesis, and poiesis (Guthrie, 1981). Sophia is a love of knowledge, which was a virtue for the Greeks. Phronesis is a Greek word for a type of intelligence corresponding with human understanding, and is analogous to practical wisdom (Barnes, 1984). Poiesis is creative knowledge. Other philosophical conceptions of wisdom have followed, with varying emphasis on the application of wisdom, or wisdom in action. We see in Gadamerian hermeneutics the re-emergence and importance of practical wisdom (Kuhn, 1962). Hermeneutics has been considered the art of interpretation, and has been described as a method for understanding texts. Multiple approaches to hermeneutics exist. Gadamer's approach is based on the centrality of language and dialogue to understanding, and the premise that language is bound to our history (Crotty, 1998; Schwandt, 2001). Gadamer replaced the theoretical concept of 16 knowing with that of human understanding in practice (Dowling, 2004). He reclaimed the meaning of Aristotle's concept of phronesis. Psychology The literature in the psychology discipline defined two major types of wisdom: general and personal. General wisdom is concerned with other individuals from a third-person perspective. It includes giving advice and assisting others. A person with general wisdom is wise regarding life and problems of other people. Personal wisdom is insight into life based on personal experience. This is wisdom about one's own life and problems seen from a first-person perspective (Staudinger, 1996). Wisdom research in psychology has been conducted from two different approaches: descriptor-rating research and experience-based research. In the descriptor-rating approach, researchers ask a group of participants to list characteristics they associate with wisdom. These characteristics are rated by another sample. The ratings are statistically analyzed, using factor analysis, to determine the underlying components of wisdom (Clayton & Birren, 1980; Holliday & Chandler, 1986; Smith, Dixon, & Baltes, 1989). In the experience-based approach, individuals are asked to describe their experiences with wise people or with wisdom in their own life to identify the characteristics of wise individuals, wise thoughts, or behavior. Attributes of Wisdom in Psychology Research Different researchers arrive at a different number of components or label them differently, but all agree that wisdom has a strong cognitive basis. Bluck and Glück (2004) studied people's views of wisdom in themselves or others by analyzing individual 17 autobiographical narratives describing a time these individuals thought they did something wise. Results indicated five essential components: the first is the cognitive component. The second component is insight, or a type of intelligence that goes beyond cognition. Third is a reflective attitude, thinking critically and deeply about themselves and others. Fourth is a genuine concern for others that goes beyond general interest. Finally, the fifth component is real-world problem-solving skills used to apply wisdom effectively. In their second qualitative study, Glück and Baltes (2006) asked subjects to describe wise people and explain why they considered them wise. Themes that emerged from this research included morality, integrity, overcoming risk or adversity, searching for insight, and striving toward improvement. Findings indicated that wisdom is often manifested in social situations when there is a need for advice-giving or education. Seven elements of wisdom were characterized; people with wisdom (a) are unexpected, (b) are moral, (c) are selfless, (d) overcome internal and external orders, (e) strive toward balance, (f) take risks, and (g) strive toward improvement for mankind. Psychology Wisdom Literature Sternberg (2007) hypothesized that effective leadership is the combination of wisdom, creativity, and intelligence. He and his team proposed a measurement approach to general wisdom by presenting complex problems to participants and asking them to think aloud about the solution. The solutions were scored by formal thinkers with a high degree of interrater reliability. Sternberg's findings showed that people with general wisdom are wise when it comes to other people; these people may or may not make good use of that same personal wisdom for themselves (Staudinger & Glück, 2011). 18 Researchers at the Max Planck Institute in Berlin, Germany have engaged in research on wisdom-related performance since the late 1980s. Explicit theories of wisdom were developed through empirically investigating expressions of wisdom. This was done by measuring wisdom in terms of personality characteristics, characteristics of adult thought, and performance on life tasks. They defined wisdom as "expertise in the fundamental pragmatics of life" (Baltes & Staudinger, 2000, p. 124). Think-aloud methodologies were used to explore different aspects of wisdom, such as aging, different professional experiences, moral reasoning, and personality characteristics (Baltes, Smith, & Staudinger, 1991; Baltes, Staudinger, Maercker, & Smith, 1995; Staudinger, 1996; Staudinger, Baltes, & Smith, 1994; Staudinger, Maciel, Smith, & Baltes, 1998; Staudinger, Smith, & Baltes, 1992). In each of the studies, a hypothetical life situation was given to a sample of participants. Baltes and Staudinger (2000) identified six properties of wisdom: (a) a high level of knowledge and judgment, including expertise in listening, evaluating, and advising; (b) the ability to address significant and difficult questions and form strategies about the conduct and meaning of life; (c) knowledge about the limits of knowledge and uncertainties of the world; (d) knowledge with uncommon scope, depth, measure, and balance; (e) a synergy of mind and character; and (f) knowledge used for the well-being of oneself and of others. The Balance Theory of Wisdom Sternberg's (1998) Balance Theory of Wisdom is based on the fundamental premise of balance in life. The first "balance" is the well-being of an individual and that of the community, environment, or situational context. Responses reveal an interaction between the person making the judgment and the environmental context. Second is the 19 balance of cognitive, conative, and affective processes. People may balance interests in different ways. This balancing is influenced by the person's goals for the common good. The base of the model is tacit knowledge underlying practical intelligence. This is portrayed in the model as a rectangle forming a foundational base. Tacit knowledge is usually acquired without the direct help of others, thus allowing individuals to aspire to achieve goals they value. Intelligence is defined as the ability to practically solve problems and express oneself verbally. Intelligence assists with goal orientation and fluid thought. Tacit knowledge and practical intelligence are applied to interpersonal and extrapersonal interests. This involves understanding people's mental processing, motivations, and affects, and is used to shape and select environments. Again, the goal is the common good. All of the balancing and definition of the "common good" is value driven. Ethics mediate how one balances interests and responses for the common good. People's moral values mediate their use of tacit knowledge in "the balancing of interests and responses" (Sternberg, 1998, p. 350). The concepts are well defined in the model. No antecedent concepts are defined. Linear relationships come out from the base "tacit knowledge," through balance of interests and balance of responses, to environmental context, ending at the common good. The theory is very simple and easy to understand. It makes sense that there is a life balance between interests for the goal of the common good. This aligns with the nursing goal and outcome components of the nursing process (ANA, 2012). The model is limited because it is too abstract, and it lacks antecedents and many common attributes of wisdom. Because the model does not capture the complexity of the practice environment 20 of wisdom it has limited use for the model of wisdom in action for clinical nursing. The Berlin Wisdom Paradigm Researchers at the Max Planck Institute developed a framework of wisdom called the Berlin Wisdom Paradigm (BWP; see Figure 2.1). The BWP describes antecedent factors and processes required for the development and acquisition of wisdom. It was developed using a compilation of multiple theoretical perspectives, including research from the Max Planck Institute, and Erikson's (1959) Theory of Wisdom. Their purpose in creating the framework was to define wisdom in the conduct and meaning of life. The theory is highly abstract and covers antecedent factors, processes for the acquisition of wisdom, and wisdom in action. The BWP is composed of three different sections. The first section, "person-related factors," contains three categories considered antecedents relevant to wisdom development. The first category is "general person factors, which holds concepts such as cognition, mental health, and ego. The second person factor category is "expertise-specific factors." The concepts found in this category deal with experience, receiving mentorship, and motivational disposition. The final category is "facilitative experiential context," which includes concepts such as age, education, being a mentor, and the professional work context. The second section of the BWP framework was titled "Life Context," and was derived from Erikson's (1959) theory. This is the area dedicated to the application of wisdom to actual life. They called this "wisdom in action." Wisdom in action involves good judgment, insight, emotional regulation, and empathy in all areas of life, including family interactions, writing, and personal relations. The categories in this section are "life Person Related Factors Life Context Problem Solving Figure 2.1 The Berlin Wisdom Paradigm. From "Wisdom. A Metaheuristic (Pragmatic) to Orchestrate Mind and Virtue Toward Excellence," by P. B. Baltes & U. M. Staudinger, 2000, American Psychologist, 55(1), p. 121. Copyright 2000 by American Psychological Association. Reprinted with permission. 21 22 planning," "life management," and "life review." The categories were not defined in the description of the model. The third section of the BWP framework portrays theoretical frameworks or paradigms, and qualitative criteria used when solving problems. The problem-solving criteria section contains five expertise-specific categories. This section contains two basic categories and three meta-criteria categories. Expertise development progresses sequentially through the categories. The first basic category is rich factual knowledge, which is extensive knowledge of life matters; this is considered the foundation of wisdom. The second basic category is rich procedural knowledge used for decision making and action planning. The three meta-criteria include life-span contextualism; value, relativism, and tolerance; and recognition and management of uncertainty. Life-span contextualism is understanding social and individual differences across all ages and cultures. Value, relativism, and tolerance refer to knowledge about different values, priorities, and goals. The final criteria, recognition and management of uncertainty, are connected to the fact that one cannot know everything and can recognize when he or she lacks the knowledge to deal with a situation. The BWP framework is potentially useful in thinking about wisdom in action in clinical nursing. The definitions of the concepts are theoretical, meaning they are high-level and abstract, with lower-order concepts describing them (Hinami, Farnan, Meltzer, & Arora, 2009). One example of an abstract concept is "person-related factors," with lower-order description concepts such as mental health, cognitive style, and creativity. No operational rules have been defined for measuring the concepts. 23 Causal relationships link the person-related factors and expertise-development factors to life context. The linear ascending relationships in the expertise-development concepts indicate sequential development building upon each concept. Two critiques of the model were identified. First, the "wisdom in action" section should be moved to the far right, or final section of the model because it is the application of the person-related factors and the qualitative criteria of everyday life. Second, the graphic should display the qualitative criteria from the basic criteria up to the meta-criteria, because the criteria build upon each other for the development of wisdom. Benefits are that the theory clearly describes antecedents and attributes of general wisdom, is generalizable, and is applicable to clinical nursing because real nursing-use cases can be walked through the model. To be a wise nurse, one needs to have experience, expertise (knowledge mastery), and good cognitive abilities. The sequential course of expertise development aligns with Benner's (1984) Novice to Expert Theory. A nurse needs to have basic knowledge regarding life and procedures before understanding lifespan and contextual differences. It takes an expert nurse to handle uncertainty with ease. Finally, a nurse must apply all of these attributes in action to be a wise nurse. The MORE Wisdom Model The most current model of wisdom developed in the psychology discipline is the MORE Wisdom Model (Glück & Bluck, 2013). Research resulting in this model was focused on the development and manifestation of wisdom. The researchers ascertained that wisdom development occurs through dealing with and thinking about life challenges. They used qualitative research and asked the participants to describe life stories. The narrative stories were solicited with the following questions: (a) What life challenges 24 have you encountered in your life? (b) How did you deal with the life challenges? and (c) How have you integrated the challenges into your life story? Their research findings demonstrate that individuals display high levels of four interrelated characteristics they consider relevant for the development of wisdom across the lifespan: Mastery, Openness to experience, a Reflective attitude, and Emotional regulation skills. They feel that individuals are not born with these characteristics but that they can be developed throughout life. They published them in this order to create a nice acronym (MORE), but they are defined below in a more logical sequence. In order for a person to develop knowledge and use it wisely, he or she must be open to experience. This implies that he or she has an interest in new experiences and ideas. People who are less judgmental and unprejudiced can accept that others share their own goals and values; they are not afraid of change. Glück and Bluck considered openness as "a necessary precursor to wisdom" (2013, p. 85); thus, high levels of openness may help individuals seek out wisdom-fostering situations. Emotional regulation skills involve two things: first, the control of one's own emotions, and second, the ability to be sensitive to others' emotions and understanding what they feel. Wise individuals are calm and self-controlled. The MORE model proposes that wise individuals can perceive their emotions accurately and manage appropriately in both positive and negative situations. Wisdom concerns not only the ability to regulate one's emotions in stressful situations, but is also the capability to reach out to others with understanding and compassion. Sense of mastery is an individual's belief that he or she can deal with any of life's challenges, but also the awareness that everything cannot be controlled. Challenges are 25 dealt with head-on or adapted to. He or she does not feel victimized when events are beyond his or her control. Individuals who do not feel victimized and learn from challenging situations develop a sense of mastery after crisis. Wise individuals have a reflective attitude. This is not just the ability to reflect but a high motivation to think deeply. They can step back and examine the situation to understand the context. They seriously examine their own past behavior to gain meaning and set direction. The description of the model is supported by the developers' qualitative research; the text includes narratives from the research participants' stories to illustrate each concept (Bluck & Glück, 2005; Glück & Bluck, 2011). They also used findings from the same research to validate the model. No tools have been developed to measure the concepts because they are determined by qualitative research. The articles reviewed did not include a picture of the model, but there is a one in a presentation given by Glück on YouTube (Glück, 2010; see Figure 2.2). The relationships in the model illustrate that life challenges lead to learning through a reciprocal relationship to the four characteristics. This is an iterative process causing learning and resulting in wisdom. The model visually includes multiple colors, for example the life challenge boxes are blue, and there is no explanation regarding the reasons for the colors. The model does not show any relationship between the four characteristics except that they are bound together. It also illustrates them as equally weighted. This does not feel correct and is not described or supported in the research (Bluck & Glück, 2005; Glück & Bluck, 2011). Finally, the model portrays life challenges, learning, and the four 26 Figure 2.2 The MORE Model of Wisdom. Copyright 2010 by Judith Glück. Used with permission. characteristics as antecedents to wisdom. This model aligns with the wisdom stories elicited from nurses. They discussed challenging situations and what they learned from them. Personal experience has shown that reflecting on information leads to knowledge and learning. Once knowledge is gained from experience and reflection, it can be applied in future situations. The Model of Wisdom Within the field of education, Brown (2004) researched how wisdom develops in college students. He used grounded theory (GT) to develop a conceptual and theoretical model of wisdom called the Model of Wisdom (MW), as well as a validated Wisdom Development Scale (WDS). His research defined wisdom development by examining how it develops and identifying what conditions assist its development. The goal was to describe what conditions facilitate wisdom development. The model creation involved studying different aspects of a student's life in a campus environment, which facilitated 27 "the process of integration leading to the development of wisdom" (Brown, 2004, p. 135). The MW describes how wisdom is developed (see Figure 2.3). The central or core component of the model is learning from life. This component contains the concepts of reflection, integration, and application. This means that we must take information in, ponder, analyze, process, and integrate it into our conscious and unconscious actions. Once that is achieved, the information can be used and applied. If application does not occur, the knowledge obtained does not result in growth or change. Linked to the core component are three conditions: (a) orientation to learning, (b) experiences, and (c) interactions with others. These are considered circumstances that impact the development of wisdom. Orientation to learning is how a person approaches Figure 2.3 Model of Wisdom. Copyright 1999 by Scott C. Brown. All rights reserved. Reprinted with permission. 28 specific knowledge-gaining experiences; this involves motivation and a desire to learn. Experiences refer to any circumstances or activities a person is involved in that result in knowledge acquisition. The core component and the condition are embedded in the environment. This is the context and setting where learning occurs. The influencers of learning, such as teachers and mentors, depend on the person's specific learning style. The model is clearly described and includes reciprocal relationships between the conditions. Each condition results in learning from life, with the final development of wisdom. Each shape in the model contains dotted lines indicating the "permeable nature of each element" (Brown, 2004, p. 141). The model is compared to and aligned with other wisdom theories. This wisdom development model is applicable to nursing because nurses require experiences, interaction with others, and an openness and willingness to learn to gain the knowledge and wisdom needed to care for patients. This also necessitates the ability to reflect, integrate, and apply the learning into their practice. Brown (2004) found that the construct of wisdom consists of six interrelated dimensions: self-knowledge, understanding of others, judgment, life knowledge, life skills, and willingness to learn. Self-knowledge is a person's self-awareness of his or her own talents, interests, morals, and beliefs. The person has an awareness of his or her personal genuineness and has personal confidence. Self-knowledge pertains to multiple areas of a person's life, such as spiritual, professional, and political. "Self-knowledge embodies the adage, ‘to thine own self be true'" (p. 137). Understanding of others refers to a genuine caring and compassion for others no matter the race, gender, culture, or educational level. It involves a willingness to give of oneself to influence the common 29 good. Judgment is the ability to assess, assimilate information, synthesize, and make a sound decision. Life skills are characterized by "personal competence in life matters" (p. 138) and expertise in balancing daily life. How one handles emergencies and utilizes available systems is a life skill. The final dimension is willingness to learn-being open and ready to learn. Willingness to learn requires admitting that one does not know everything (humility), the understanding of one's current level of knowledge, and the desire to know more. The model is well described in Brown and Greene's articles (Brown, 2004; Brown & Greene, 2006), but its visual depiction is somewhat confusing. The reciprocal arrows between "Experience" and "Orientation to Learning" and "Interactions with Others" each feel incorrect. There should be a single arrow from the "Experience" to the condition. It seems that "Learning from Life" should have bidirectional instead of unidirectional arrows to each concept on the left of the diagram because life learnings impact experiences, interaction with others, and orientation to learning. Other than self-knowledge, no other types of knowledge are depicted in the model, which is puzzling, because the model was developed for education. The final confusing aspect is that the "Environment" label at the top has no linkages to any concepts in the model. Brown and Greene (2006) developed a wisdom measurement questionnaire for education, the Wisdom Development Scale (WDS). The purpose of the questionnaire was to create a theoretically and psychometrically valid instrument that aligned with the model of wisdom and could measure wisdom development. The questionnaire was initially divided into six factors (sections): self-knowledge, interpersonal understanding, judgment, life knowledge, life skills, and willingness to learn. The six factors were 30 hypothesized to intercorrelate given that the model predicts that all six attributes contribute to the development of wisdom (Brown & Greene, 2006). The WDS was developed in phases. First, the researchers drew survey items from the MW study and aligned them with each dimension of the wisdom construct. The initial questionnaire had 141 questions. Second, the 141 questions were given to three focus groups that varied in educational major and ethnicity. In addition to the questionnaire, they were asked to describe someone wise and to complete several questions regarding the clarity and comprehensiveness of the questions. Revisions were made to the questionnaire based on the feedback from the focus groups, but the articles did not describe the type of revisions made (Brown & Greene, 2006; Greene & Brown, 2009). Third, the questionnaire was administered via a Web survey to 1,188 undergraduate students. A series of exploratory factor analyses using latent factor technique was used to determine the final questions in the questionnaire. Finally, there was a second research study of the WDS in which the sample included both professors and undergraduate students (N > 3,000). This study specifically evaluated construct, discriminant, and criterion validity (Greene & Brown, 2009). In the first study (Brown & Greene, 2006), both exploratory and confirmatory factor analyses were performed on the model as a means of cross validating the latent factor structure of the model. Prior to the factor analysis, the researchers used the Kaiser-Meyer-Olkin (KMO) method to determine if factor analysis was necessary. The KMO was .944, which indicated a high level of correlation between each pair of items. A split-halves method was used by dividing the sample in two through random assignment. Exploratory factor analysis (EFA) was calculated using the first half. Results of the EFA 31 revealed strong support for self-knowledge, judgment, and life-knowledge factors. The original "understanding of others" construct was divided into two factors, which were called altruism and inspirational engagement. Similarly, the hypothesized construct of life skills was also split between two factors, entitled emotional management and life skills. Reliability analyses on the final scale scores exposed Cronbach alpha values above .8 for each of the seven factors. The results of the EFA were used to generate the final scales used for confirmatory analyses of the model. Confirmatory factor analysis is another form of validation regarding the scale scores' reliability and factor structure (DeVellis, 2003). The proposed factor and item structures were analyzed for fit using multivariate structural equation modeling. This was used to compare how the data fit the model. Correlation of the EFA was done using the results of the Social Desirability Scale (SDS) that had been administered at the same time (Brown & Greene, 2006). Using the scores derived from the EFA, those questions that had significant correlation with SDS were kept in the questionnaire. The altruism scale had 7 of 14 items, the inspirational engagement scale had 8 of 11 items, the judgment scale had 4 of 11 items, the life skills scale had 3 of 9 items, and the emotional management scale had 9 of 11 items. The WDS was given to focus groups and administered for two different reliability and validation research projects (Brown & Greene, 2006; Greene & Brown, 2009); the consistent findings demonstrated internal consistency. The different types of validity described in the articles were construct validity, criterion validity, content validity, and discriminant validity. Several steps were taken to determine construct validity. First, the initial set of questions was drawn from the development of the theory. Second, 32 confirmatory factor analysis was used to determine the relationships between the concepts themselves. In the first study (Brown & Greene, 2006), construct validity was established for six of the seven factors (but not willingness to learn), and in the second study (Greene & Brown, 2009) all factors were validated. Internal consistency was statistically assessed by computing the WDS mean scores and performing Pearson correlations against the Social Desirability Scale (Reynolds, 1982) for the first study and Iowa Student Development Inventories (Hood, 1986) for the second study. The results of the analysis showed a Cronbach's alpha between .83 and .89, which demonstrated evidence for criterion validity (Greene & Brown, 2009). Construct validity was evaluated to determine the degree to which the items sufficiently capture the construct. In the first study, items in the WDS were correlated with the Social Desirability Scale utilizing factor analysis. All items except willingness to learn were validated. In the second study, all constructs were validated. Early evaluation of the WDS has shown preliminary utility within the context of education because the research has demonstrated a good fit with the theory and the scale itself. Discriminate validity was assessed in the second study (Greene & Brown, 2009). The authors hypothesized that the latent mean scores for the professionals would be higher than the scores for the younger students; this was determined by examining the chi-square differences of the two scores. They found that those with higher education did indeed have higher latent mean scores. The major weakness of the WDS is that there is no evidence that the scale measures a level of wisdom within a specific individual. Therefore, it can be concluded that the instrument neither differentiates nor captures levels of wisdom. 33 The previous sections have described literature and wisdom models from disciplines other than nursing. Concepts and relationships have been used to derive the first draft of the construct of wisdom in action for clinical nursing, which is described at the end of this chapter. Nursing literature and wisdom models are used for synthesis of the construct and are described in the next section. Wisdom Nursing Theories and Literature Nursing Models of Wisdom Two clinical models of practice wisdom were found in the literature. First, Edmonson and Pearce (2007) described a model of clinical wisdom, which was illustrated using cases from psychiatry. They defined a "trifoliate model of wisdom" that incorporates capacities of self, the other, and the problem itself. They used the metaphor of three leaves adjacent to, overlapping, and intertwining with each other. The capacities of self include the attributes of practice reasoning, professional knowledge, and moral characteristics. The authors stated that the problem may include technical and medical issues, but may "also possess some social, emotional and moral characteristics" (p. 238). This model appears insufficient to serve as a general representation of nursing clinical wisdom. "The other" is not well defined, but Edmonson and Pearce stated that it needs to be treated with tolerance within the context of the situation. There were implied relationships between the three entities (self, the other, and the problem), but the attributes of wisdom were not defined. In a second model, Haggerty and Grace (2008) described a model for clinical wisdom consisting of the three key elements: (a) balancing and providing for the good of another and the common good, (b) the use of intellect and affect in problem solving, and 34 (c) the demonstration of experience-based tacit knowing in problematic situations. The authors postulated that clinical wisdom is a more specific type of general wisdom that can be linked to wisdom for nursing practice. No illustrations were provided, and no definitions of the concepts or relationships were described; thus, there is insufficient detail about the model to determine the alignment with nursing practice. Wisdom Attributes in Nursing The ANA (2008) defined wisdom as the appropriate use of knowledge to manage and solve human problems. Wisdom involves recognizing what is most important by making distinctions among alternatives. It comprises the application of experience, intelligence, creativity, and knowledge, as mediated by values, toward the achievement of a common good (Nelson, 2002). Beyond that, wisdom as described in the nursing literature, including nursing theories, shares many of the attributes described in the other disciplines. These attributes include phronesis, ethics, good judgment, values, understanding of others, and life skills, and are discussed below. Much has been written about phronesis in nursing (Connor, 2004; Flaming, 2001; James, Andershed, Gustavsson, & Ternestedt, 2010; Leathard & Cook, 2009). Phronesis has been defined in the nursing literature as practical wisdom. It has been likened to the moral foundation of nursing, meaning that nurses must being ready to assess the situation, determine the most appropriate response, think before acting, and intervene for the good of the situation (Chen, 2011; Connor, 2004; Davis, 1997; Flaming, 2001). Flaming (2001) posited that if we used the word "phronesis" instead of "research-based practice," we could utilize the other sciences in our practice. Wisdom and ethics share similar attributes such that they may be closely related 35 or even borderline cases of each other. The main attribute is the goal of caring for the patient for the common good by exercising values, judgment, caring, and responsibility. Wisdom is intertwined with the principles of morally doing the right thing (Carper, 1978). Wisdom implies an ethical duty to understand the rationale behind clinical actions (Zeleny, 2006). Proficient nurses show clinical wisdom with ethical discernment by demonstrating the ability to think critically and to practice responsibly by applying abstract thinking and knowing to specific acts of care. Wisdom is about comprehensibility, understandability, and ethics of doing (Zeleny, 2006). Nurses with wisdom are engaged and pay attention to the ethical challenges they face. They believe that the principles of morality and acceptable conduct are important for all people (Schmidt Bunkers, 2009). Nurses cannot be wise and unethical. Benner (2000) based the understanding of wisdom in nursing on clinical judgment and a thinking-in-action approach that encompasses intuition, emotions, and the senses: "Clinical judgment requires moral agency, insight, skilled know-how, and narrative reasoning about patient transitions" (p. 103). Judgment implies that there is an internal connection between what matters and what is learned, known, and concluded within the mind (Uhrenfeldt & Hall, 2007). Clinical judgment requires the ability to effect and influence situations, perception, skilled know-how, and reasoning about particular clinical situations (Benner, 2000). Wisdom in action in nursing requires the element of caring; indeed, caring is the central component of nursing practice (Benner, 2000). Nursing has always been an exemplar for genuine caring and compassion. Benner (1991) defined care as "the alleviation of vulnerability, the promotion of growth and health, the facilitation of 36 comfort, dignity, or a good and peaceful death; mutual realization" (p. 2). The scope of practice for nursing mandates the understanding of others across the lifespan, including social and cultural differences. Benner (2000) illustrated this in her article, "The Wisdom of Our Practice," with many stories describing how nurses gave of themselves and cared for others. Carper's (1978) Ethical Pattern of Knowing deals with issues for which there are no black-and-white solutions. This knowing deals with items such as society, norms, moral issues, and legal issues. Life skills in nursing encompass nursing competencies and align with Carper's (1978) Empirical Pattern of Knowing and Personal Pattern of Knowing. Carper's Empirical Pattern of Knowing is scientific knowledge, and personal knowledge is what one knows from lived experiences. These attributes also align with Benner's (1984) definition of proficient and expert nurses. Benner (1984) considered this practical knowledge, or "know-how." She stated that this requires the development of knowledge in applied disciplines and is characterized by an understanding of the know-how of clinical experience. How we handle emergencies and utilize available systems is a learned skill that demonstrates proficiency or expertise. Benner (1984) described proficient nurses as those who can learn from experiences and adapt and modify plans as needed. The expert nurse has an intuitive grasp of clinical situations with highly proficient performance. This section described attributes of nursing practice relevant to wisdom. In the following section, the use of formal theory in nursing is reviewed. There are also lay underpinnings and culturally specific, socially constructed theories of how things work. Many nurses are taught nursing theory in school but never hear about it again in actual 37 practice; instead, they have culturally based theories. The attributes of wisdom reviewed so far may or may not be related to nursing culture. After reviewing the models and literature pertaining to wisdom, it makes one wonder if wisdom can truly be defined, or if wisdom is an occasional destination in specific situations and the process of getting there should be defined. The ANA stated that nursing should support the development of wisdom (ANA, 2008). Development is a process toward some sort of growth or evolution. A definition of wisdom that might be derived from the models and the literature is "openness to learning, the ability to gain a sense of knowledge mastery, the practice of applying knowledge with empathy and emotion regulation, and the ability to reflect on nursing practice from multiple perspectives and to integrate knowledge gained from reflection back into the nurse's knowledge bank for future use." This definition is the beginning of the construct of wisdom in action and theory construction. The following sections discuss nursing theory as the foundation of nursing practice. Nursing Theory Purpose and Development Nursing theory provides the principles that support practice and help to create nursing knowledge. Theory shapes practice and provides a methodology for expressing key ideas regarding the essence of nursing practice (Walker & Avant, 2011). Nursing theory draws key concepts together by positing relationships between them. As a result, the internally consistent groupings present a systematic view of a phenomena, or process, for the purposes of describing, explaining, predicting, and/or prescribing. The groupings are an explanatory framework, or theory. Theory is used in all aspects of care across the care continuum. It assists the practicing nurse to organize patient data, understand patient 38 data, analyze patient data, make decisions about nursing interventions, and plan patient care. Theory shapes practice at the bedside, in education, and in research (Chinn & Kramer, 2011; Reed & Shearer, 2007; Risjord, 2009; Walker & Avant, 2011). Theory-based clinical nursing practice occurs when nurses intentionally structure their practice around a particular theory to guide them in their care of the patient. Theory provides a systematic way of thinking about nursing care that is consistent and guides the decision-making process. In nursing education, at the undergraduate level, theory is used to teach the care process. Theory is introduced at the master's level to introduce practice-based evidence from research and experience. Finally, theory is used at the doctoral level as the framework for research. Great strides have been made in theory-based research. Nursing research is necessary to test and refine theory, hence refining the knowledge base of nursing. Once a theory has been validated, it can be used as a framework for research. Research findings enable nurses to improve the quality of care and to understand that evidence-based nursing influences patient outcomes. Theory-Development Strategies Theory can be developed two ways: inductively or deductively (Reed & Shearer, 2007). This research used both methods, deductive for Aim 1 and inductive for Aim 2. In deductive theory development, ideas that are established in one field and are considered for ways in which they can be applied to another field. Deductive nursing theory can be developed when someone has an idea and wonders if it pertains to practice. 39 Walker and Avant (2011) described this as theory developed by derivation and synthesis. Inductive theory arises out of practice. It does not depend on already established theories, but rather involves exploring practice and generating ideas. GT is an example of inductive theory development and is commonly used in nursing research to develop midrange theories (Engward, 2013; Jeon, 2004; Marcellus, 2005; McCallin, 2003; Morse et al., 2009). Chinn and Kramer (2011) described a four-step process of creating empiric theory. The first step is creating conceptual meaning; this involves defining the concepts after they are identified. The second step is structuring and contextualizing the theory; this involves defining the relationships for the theory. The third and fourth steps are testing and applying the theory. Walker and Avant (2011) further defined how qualities of concepts from derived theories are identified and developed by synthesizing the nursing literature. They also specified the types of relationships used within nursing theory, such as a causal relationship (one concept is said to be the cause of the other). Four different levels of nursing theory are described in the literature: metatheory, grand theory, midrange theory, and microrange theory. Each type is described below, and examples are provided. Metatheory Metatheories focus on theory about theory. These theories were created by asking philosophical and methodological questions that formed the nursing foundation. Florence Nightingale's work closely related to her philosophical orientation of the patient-environment interaction and the principles on which nursing practice was founded 40 (Nightingale, 1898). Nightingale believed that health was a reparative process, and that the patient's surroundings, including fresh air, warmth, noise reduction, good diet, and light would contribute to that process. She also believed that every person desired good health and would cooperate with the nurse and nature to allow the healing process to take place. Grand Theory The next level of nursing theory is grand theories. Grand theories give a broad perspective to the purpose and structure of nursing practice (Peterson & Bredow, 2008; Walker & Avant, 2011). Many of these theories were developed between the 1960s and the 1980s. One of the greatest contributions grand theories provide for nursing is the differentiation between nursing practice and the practice of medicine. Grand range theorists are numerous, and include Wiedenbach, Orem, Peplau, and King. Wiedenbach (1964) concentrated on the art of nursing and focused on the needs of the patient. She described four elements that guide the nurse's action: philosophy, purpose, practice, and art. She outlined four assumptions related to human nature. First, each human being has a unique potential to develop self-resources from within that enable him or her to maintain and sustain him-/herself. Second, each human being strives toward and desires independence, and will make best use of his or her capabilities to achieve this. Third, self-awareness and self-acceptance are essential to an individual's sense of self-worth. Finally, whatever the individual does represents his or her best judgment at the moment of doing. Orem began publishing about nursing care in the 1950s. Her theory of self-care emphasized the person's need to care for himself (Orem, Taylor, & Renpenning, 1991). 41 Her work identifies three types of nursing systems: wholly compensatory, in which the nurse does everything for the patient; partly compensatory, in which the nurse helps the patient care for himself or herself; and supportive educative, in which the nurse helps the patient learn to do for him- or herself. Peplau's (1952) contribution to nursing and the specialty of psychiatric nursing has been colossal. She identified four phases of the nurse-patient relationship: orientation, identification, exploitation, and resolution. Peplau proposed and described six nursing roles: stranger, resource person, teacher, leader, surrogate, and counselor. The final grand range theorist described in this literature review is Imogene King (1981). King began publishing in the mid-1960s. Her conceptual framework specifies the following interacting systems: personal, interpersonal, and social. The concepts of the personal system are perception, self, body image, growth and development, and time and space. The concepts of the interpersonal system are role, interaction, communication, transaction, and stress. Grand theories lay the foundation for nursing and offer general perspectives for nursing practice; however, because they are so abstract and are not concrete enough to test, they have gone out of vogue for nursing. Middle-range theory has emerged as the theory that guides nursing practice today (Smith & Liehr, 2008; Walker & Avant, 2011). Midrange Theory Midrange nursing theories contain a related set of ideas and variables, are narrower in scope than grand theories, and are testable (Smith & Liehr, 2008; Walker & Avant, 2011). They offer the specificity needed for usefulness in research and practice. Midrange theories usually focus on one specific topic or area of care and are often begun 42 with a concept analysis and the development of a conceptual model or construct. Smith and Liehr (2008) described a "ladder of abstraction" (p. 13) for the three levels (or rungs) of discourse needed in a midrange nursing theory development. The first rung of the ladder is the philosophical level that represents beliefs and assumptions about the theory. The second rung is the theoretical level, consisting of symbols and concepts linked with relationships. The third and final level is the empirical level, which is the most concrete portion of the model and includes items such as practice stories, physiological indicators, and questionnaires used to test the theory. All three levels must be included to be a midrange theory. Microrange Theory Microrange theory is more focused than midrange theory and is comprised of very few concepts. Microtheory is often defined as a set of working hypotheses. The above section defined four different levels of nursing theory. The Theory of Wisdom in Action for Clinical Nursing was developed both deductively and inductively as a midrange theory. The philosophical assumption was that all nurses want to apply knowledge in practice using wisdom. Some of the concepts of the theory of wisdom in action are described above and were refined during the first aim of this research. The empirical level is also addressed. All levels of the theory were evaluated by conducting a focused ethnographic study and using the results to refine the theory defined in Aim 1. Current Nursing Culture Culture is important when considering researching nursing practice. Culture has been defined by many, and these definitions include concepts such as values and belief 43 systems, acquired knowledge, behaviors, and understandings shared by certain groups of people (Morse & Richards, 2002). One definition given by Merriam-Webster aligns specifically with this dissertation: "The integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations" (Culture, 2015). According to Van Maanen (1988), A culture is expressed (or constituted) only by the actions and words of its members and must be interpreted by, not given to, a fieldworker. To portray culture requires the fieldworker to hear, to see, and most important for our purposes, to write of what was presumably witnessed and understood during a stay in the field. Culture is not itself visible, but is made visible only through its representation. (p. 3) One key point regarding culture is that knowledge and beliefs are shared. Shared ideation makes it possible to include a finite number of individuals as cultural informants because each of them is accessing shared cultural knowledge (and probably some personal idiosyncratic knowledge as well). The goal for Aim 2 of this study was to discover the general, shared nursing knowledge and how the social processes of applying wisdom in clinical environments are a cultural or social event. Nursing culture is influenced by cultural models as well as nursing theory. Cultural models are taken-for-granted models of the world that are widely shared by the members of a society, in this case nursing (Kleinman, 1978). They play an enormous role in nurses' understanding of the world and influence ways that nurses think about practical problems. An example of a past cultural model in healthcare was the relationship between the provider and the patient. In the past the provider was the primary decision maker in the patient's care, but that is currently evolving to a model in which the patient plays a larger role in his or her care. The culture of nursing is changing. Nurses have always been expected to 44 transform data into information, formulate that information into knowledge, and wisely apply that knowledge for the good of the patient. Florence Nightingale (1898) wrote that nurses need to know how and what to observe in the patient, and understand what symptoms indicate improvement. This was the first documentation of the transformation of data to knowledge in a nursing text. Now, with advancing technology, nurses are seeing, and are required to process, much more data and information into knowledge than ever before. In addition, it is mandated that they use and understand computerized documentation. In 2011 the Institute of Medicine (IOM) released The Future of Nursing, and stated that the landscape of nursing was changing so much that nursing is required to "undergo a fundamental shift" (p. 115). The technological changes, such as more advanced patient monitoring equipment and the shift from paper to electronic documentation, requires a change in workflow and decision making. This means that clinical practice habits will need to be adapted to adjust to this change (Thede, 2009). It also implies that new skills and behaviors will need to be acquired to locate data in the computer instead of on paper. In addition, data capture from electronic devices such as automatic blood pressure cuffs, cardiac monitors, and so forth, provide massive quantities of data. Those data need to be processed, either in the mind or electronically, to provide care. The present nursing culture classifies nursing and technology as separate entities. Clark (2004) argued that information technology can be an extension of the mind because the mind expands with technology. Nurses who do not embrace technology are required to do low-level cognitive processing, such as data processing, within their own mind, 45 whereas nurses who allow the computer to process data can potentially free up some of their mental space for higher-level critical thinking activities when they receive preprocessed information from the system. Changes in work environment resources will alter nursing culture and ultimately transform care at the bedside. They will also entail that nursing education systems provide the tools required to utilize the technology (Abbott & Coenen, 2008; Benner, 2012; Benner, Sutphen, & Leonard, 2009; IOM, 2011; McNeill & Porter-O'Grady, 2007). These tools can be used to leverage evidenced-based practice and interoperable quality measures (Mason & Wesorick, 2011). The IOM (2011) suggests that nursing culture (including the transmission of values and behaviors via education) should change and adapt along with healthcare organizations, and build in an ongoing process of adaptation to technology as part of the cultural values and socialization of new members. Nursing culture is changing in concert with the advancing technologic environment. Culture materialists believe that changes in technology play a role in changing society (Harris, 2001). Therefore, utilizing this technology (e.g., computerized documentation, advanced monitoring equipment, reports, alerts, and quality measurements) will require a change in how data, information, and knowledge are processed by nurses in order to provide wise care. The major change is focused on the technological advances in nursing, which necessitates re-educating the bedside nurse as well as transforming nursing education to meet the technological education needs. There are three assumptions regarding wisdom in action: (a) nurses provide care for patients using wisdom; (b) data, information, and knowledge precede wisdom; and (c) practicing with wisdom is a process. During the act of providing care, data, information, 46 and knowledge are used to assist in decision making and care. Summary The nursing informatics (NI) scope and standards imply that data, information, and knowledge can lead to the development of wisdom, yet wisdom has not been defined for nursing. The ANA (2008) definition of wisdom within the NI scope and standards focuses on the appropriate application of knowledge, implying that the intent is to focus on wisdom in action. There is an abundance of literature pertaining to wisdom that describes attributes of general wisdom, but the pertinence to and application for nursing is unclear. Nursing theory guides practice, but there is no theory for nursing that pertains to wisdom in action. No formal models are present in the nursing literature for wisdom, although the nursing literature contains related constructs such as expertise and knowledge. Wisdom is unique within the context of clinical nursing due to the cultural context of providing care. Grounded theory is an appropriate way to study actions within a culture. The next chapter contains a detailed description of the methods used for this dissertation. 47 References Abbott, P. A., & Coenen, A. (2008). Globalization and advances in information and communication technologies: The impact on nursing and health. [Review]. Nursing Outlook, 56(5), 238-246 (e232). doi:10.1016/j.outlook.2008.06.009 Ackoff, R. (1989). From data to wisdom. Journal of Applied Systems Analysis, 16, 3-9. Ahsan, S., & Shah, A. (2009). Data, information, knowledge, wisdom: A doubly linked chain? Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.89.5378&rep=rep1&type=pdf American Nurses Association. (2001). Scope and standards of nursing informatics practice. Washington, DC: Author. American Nurses Association. (2008). Nursing informatics: Scope and standards of practice. Silver Spring, MD: Author. American Nurses Association. (2012). The nursing process. Retrieved from http://nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html American Nurses Association. (2015). Nursing informatics: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author. Baltes, P. B., Smith, J., & Staudinger, U. M. (1991). Wisdom and successful aging. Nebraska Symposium on Motivation, 39, 123-167. Baltes, P. B., & Staudinger, U. M. (2000). Wisdom. A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist, 55(1), 122-136. doi:10.1037//0003-066X.55.1.122 Baltes, P. B., Staudinger, U. M., Maercker, A., & Smith, J. (1995). People nominated as wise: A comparative study of wisdom-related knowledge. Psychology and Aging, 10(2), 155-166. doi:10.1037/0882-7974.10.2.155 Barnes, J. (1984). The complete works of Aristotle: The revised Oxford translation (Vol. 1). Princeton, NJ: Princeton University Press. Benner, P. (2012). Educating nurses: A call for radical transformation-How far have we come? [Editorial]. Journal of Nursing Education, 51(4), 183-184. doi:10.3928/01484834-20120402-01 Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. 48 Benner, P. (1991). The role of experience, narrative, and community in skilled ethical comportment. Advances in Nursing Science, 14(2), 1-21. doi:10.1097/00012272-199112000-00003 Benner, P. (2000). The wisdom of our practice. American Journal of Nursing, 100(10), 99-105. doi:10.2307/3522335 Benner, P., Sutphen, M., & Leonard, V. (2009). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. doi:10.3928/01484834-20120402-01 Bluck, S., & Glück, J. (2004). Making things better and learning a lesson: Experiencing wisdom across the lifespan. Journal of Personality, 72(3), 543-572. doi:10.1111/j.0022-3506.2004.00272.x Brown, S. C. (2004). Learning across the campus: How college facilitates the development of wisdom. Journal of College Student Development, 45(2), 134-148. doi:10.1353/csd.2004.0020 Brown, S. C., & Greene, J. A. (2006). The wisdom development scale: Translating the conceptual to the concrete. Journal of College Student Development, 47(1), 1-19. doi:10.1353/csd.2006.0002 Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Xcience, 1(1), 13-23. doi:10.1097/00012272-197810000-00004 Chen, R. P. (2011). Moral imagination in simulation-based communication skills training. Nursing Ethics, 18(1), 102-111. doi:10.1177/0969733010386163 Chinn, P. L., & Kramer, M. K. (2011). Integrated theory and knowledge development in nursing (8th ed.). St. Louis, MO: Elsevier Mosby. Clark, A. (2004). Natural-born cyborgs: Minds, technologies, and the future of human intelligence. New York: Oxford University Press. Clayton, V. P., & Birren, J. E. (1980). The development of wisdom across the life span: A reexamination of an ancient topic. Life-span Development and Behavior, 3, 103-135. Cleveland, H. (1982, December). Information as a resource. Futurist, 34-39. Connor, M. J. (2004). The practical discourse in philosophy and nursing: An exploration of linkages and shifts in the evolution of praxis. Nursing Philosophy, 5(1), 54-66. doi:10.1111/j.1466-769X.2004.00152.x Crotty, M. (1998). The foundations of social research: Meaning and perspective in the 49 research process. London: Sage. Culture. (2015). Merriam-Webster online dictionary. Retrieved from www.merriam-webster.com/dictionary/culture Davis, F. D. (1997). Phronesis, clinical reasoning, and Pellegrino's philosophy of medicine. Theoretical Medicine and Bioethics, 18(1-2), 173-195. DeVellis, R. F. (2003). Scale development: Theory and applications. Thousand Oaks, CA: Sage. Dowling, M. (2004). Hermeneutics: An exploration. Nurse Researcher, 11(4), 30-39. Edmondson, R., & Pearce, J. (2007). The practice of health care: Wisdom as a model. Medicine, Healthcare and Philosophy, 10(3), 233-244. doi:10.1007/s11019-006-9033-3 Engward, H. (2013). Understanding grounded theory. Nursing Standard, 28(7), 37-41. doi:10.7748/ns2013.10.28.7.37.e7806 Erikson, E. H. (1959). ldentity and the life cycle. New York: International University Press. Flaming, D. (2001). Using phronesis instead of 'research-based practice' as the guiding light for nursing practice. Nursing Philosophy, 2(3), 251-258. doi:10.1046/j.1466-769X.2000.00066.x Gluck, J. (2010). Defining wisdom. Retrieved from http://wisdomresearch.org/Arete/GluckVideo.aspx Glück, J. (2011). "She looks back without bitterness": Wisdom as a developmental opposite of embitterment? In M. Linden & A. Maercker (Eds.), Embitterment: Societal, psychological, and clinical perspectives (pp. 70-82). New York: Springer Verlag. Glück, J., & Baltes, P. B. (2006). Using the concept of wisdom to enhance the expression of wisdom knowledge: Not the philosopher's dream but differential effects of developmental preparedness. Psychology and Aging, 21(4), 679-690. doi:10.1037/0882-7974.21.4.679 Glück, J., & Bluck, S. (2011). Laypeople's conceptions of wisdom and its development: Cognitive and integrative views. Journals of Gerontology. Series B, Psychological Sciences And Social Sciences, 66(3), 321-324. doi:10.1093/geronb/gbr011 Glück, J., & Bluck, S. (2013). The MORE Life Experience Model: A theory of the 50 development of wisdom. In N. Ferrari & N. Weststrate (Eds.), The scientific study of personal wisdom: From contemplative traditions to neuroscience (pp. 75-98). New York: Springer. doi:10.1007/978-94-007-7987-7 Graves, J. R., & Corcoran, S. (1989). The study of nursing informatics. Image: Journal of Nursing Scholarship, 21(4), 227-231. doi:10.1097/00004650-199610000-00005 Greene, J. A., & Brown, S. C. (2009). The Wisdom Development Scale: Further validity investigations. International Journal of Aging and Human Development, 68(4), 289-320. doi:10.2190/AG.68.4.b Guthrie, W. K. C. (1981). A history of Greek philosophy. Vol. VI, Aristotle: An encounter. Cambridge, MA: Cambridge University Press. Haggerty, L. A., & Grace, P. (2008). Clinical wisdom: The essential foundation of "good" nursing care. Journal of Professional Nursing, 24(4), 235-240. doi:10.1016/j.profnurs.2007.06.010 Harris, M. (2001). Cultural materialism: The struggle for a science of culture. Walnut Creek, CA: AltaMira Press. Hebda, T., & Czar, P. (2012). Handbook of nursing informatics (5th ed.). Upper Saddle River, NJ: Prentice Hall. Hey, J. (2004). The data, information, knowledge, wisdom chain: The metaphorical link. Retrieved from http://web.archive.org/web/20071202033948/http://ioc.unesco.org/Oceanteacher/OceanTeacher2/02_InfTchSciCmm/DIKWchain.pdf Hinami, K., Farnan, J. M., Meltzer, D. O., & Arora, V. M. (2009). Understanding communication during hospitalist service changes: A mixed methods study. Journal of Hospital Medicine, 4(9), 535-540. doi:10.1002/jhm.523 Holliday, S. G., & Chandler, M. J. (1986). Wisdom: Explorations in adult competence. In J. A. Meacham (Ed.), Contributions to human development (pp. 1-96). New York: Karger. Hood, A. B. (1986). The Iowa Student Development Inventories. Iowa City, IA: Hitech Press. Institute of Medicine. (2011).The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press. James, I., Andershed, B., Gustavsson, B., & Ternestedt, B. M. (2010). Knowledge constructions in nursing practice: Understanding and integrating different forms of knowledge. Qualitative Health Research, 20, 1500-1518. 51 doi:10.1177/1049732310374042 Jeon, Y. H. (2004). The application of grounded theory and symbolic interactionism. Scandinavian Journal of Caring Sciences, 18(3), 249-256. doi:10.1111/j.1471-6712.2004.00287.x Kaipa, P. (2000). Knowledge architecture for the twenty-first century. Behaviour & Information Technology, 19(3), 153-161. King, I. M. (1981). A theory for nursing: Systems, concepts, process. Albany, NY: Delmar. Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine. Part B: Medical Anthropology, 12, 85-93. doi:10.1016/0160-7987(78)90014-5 Kuhn, T. S. (1962). The structure of scientific revolutions. Chicago: University of Chicago Press. doi:10.7208/chicago/9780226458144.001.0001 Leathard, H. L., & Cook, M. J. (2009). Learning for holistic care: Addressing practical wisdom (phronesis) and the spiritual sphere. Journal of Advanced Nursing, 65(6), 1318-1327. doi:10.1111/j.1365-2648.2008.04949.x Marcellus, L. (2005). The grounded theory method and maternal-infant research and practice. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(3), 349-357. doi:10.1177/0884217505276053 Mason, J., & Wesorick, B. (2011). Successful transformation of a nursing culture. Nurse Leader, 9(2), 31-36. doi:10.1016/j.mnl.2011.01.001 Matney, S., Maddox, L., & Staggers, N. (2013). Nurses as knowledge workers: Is there evidence of knowledge in patient handoffs? Western Journal of Nursing Research, 7(5), 171-190. doi:10.1177/0193945913497111 Matney, S. A., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6-18. doi:10.1097/ANS.0b013e3182071813 McCallin, A. M. (2003). Designing a grounded theory study: Some practicalities. Nursing in Critical Care, 8(5), 203-208. doi:10.1046/j.1362-1017.2003.00033.x McGonigle, D., & Mastrian, K. (2008). Nursing informatics and the foundation of knowledge. Mississouga, ON, Canada: Jones & Bartlett. McNeill, A. L., & Porter-O'Grady, T. (2007). Engaging transformation: Constructing a 52 new model for nursing education and practice. Nurse Leader, 5(3), 30-60. doi:10.1016/j.mnl.2007.03.008 Morse, J. M., & Richards, L. (2002). Readme first for a user's guide to qualitative methods. Thousand Oaks, CA: Sage. Morse, J. M., Stern, P. N., Corbin, J. M., Bowers, B., Clarke, A. E., & Charmaz, K. (2009). Developing grounded theory: The second generation. Walnut Creek, CA: Left Coast Press. Nelson, R. (2002). Major theories supporting health care informatics. In S. Englebardt & R. Nelson (Eds.), Health care informatics: An interdisciplinary approach (pp. 3-27). St. Louis, MO: Mosby. Nightingale, F. (1898). Notes on nursing: What it is, and what it is not. New York: D. Appelton. Orem, D. E., Taylor, S. G., & Renpenning, K. M. L. (1991). Nursing: Concepts of practice. St. Louis, MO: Mosby. Peplau, H. E. (1952). Interpersonal relations in nursing. American Journal of Nursing, 52(6), 765. doi:10.1097/00000446-195206000-00062 Peterson, S. J., & Bredow, T. S. (2009). Middle range theories: Application to nursing research. Philadelphia: Lippincott Williams & Wilkins. Plews-Ogan, M., Owens, J. E., & May, N. B. (2013). Wisdom through adversity: Learning and growing in the wake of an error. Patient Educucation Counseling, 91(2), 236-242. doi:10.1016/j.pec.2012.12.006 Reed, P. G., & Shearer, N. C. (2007). Perspectives on nursing theory (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Reynolds, W. M. (1982). Development of reliable and valid short forms of the Marlowe-Crowne Social Desirability Scale. Journal of Clinical Psychology, 38(1), 119-125. doi:10.1002/1097-4679(198201)38:1%3C119::AID-JCLP2270380118%3E3.0.CO;2-I Risjord, M. W. (2009). Nursing knowledge: Science, practice, and philosophy. Oxford: Wiley-Blackwell. doi:10.1002/9781444315516 Schleyer, R., & Beaudry, S. (2009). Data to wisdom: Informatics in telephone triage nursing practice. AACN Viewpoint, 31(5), 1-13. Schmidt Bunkers, S. (2009). Questions of wisdom. Nursing Science Quarterly, 22(2), 120-124. 53 Schwandt, T. (2001). Dictionary of qualitative inquiry (2nd ed.). Thousand Oaks, CA: Sage. Shedroff, N. (1994). Information design. Retrieved from www.nathan.com/thoughts/unified/3.html Smith, J., Dixon, R. A., & Baltes, P. B. (1989). Expertise in life planning: A new research approach to investigating aspects of wisdom. In M. L. Commons, J. D. Sinnott, F. A. Richards, & C. Armon (Eds.), Adult development, Vol. 1: Comparisons and applications of developmental models (pp. 307-331). New York: Praeger. Smith, M. J., & Liehr, P. R. (2008). Middle range theory for nursing. New York: Springer. Staudinger, U. M. (1996). Interactive minds: A facilitative setting for wisdom-related performance? Journal of Personality and Social Psychology, 71(4), 746-762. doi:10.1037/0022-3514.71.4.746 Staudinger, U. M., Baltes, P. B., & Smith, J. (1994). Manual for the assessment of wisdom-related knowledge. Berlin: Max Planck Institue for Human Development and Education. Staudinger, U. M., & Glück, J. (2011). Psychological wisdom research: Commonalities and differences in a growing field. Annual Review of Psychology, 62, 215-241. Staudinger, U. M., Maciel, A. G., Smith, J., & Baltes, P. B. (1998). What predicts wisdom related performance? A first look at personality, intelligence, and facilitative experiential contexts. European Journal of Personality, 12(1), 1-17. doi:10.1002/(SICI)1099-0984(199801/02)12:1%3C1::AID-PER285%3E3.0.CO;2-9 Staudinger, U. M., Smith, J., & Baltes, P. B. (1992). Wisdom-related knowledge in a life review task: Age differences and the role of professional specialization. Psychology and Aging, 7(2), 271-281. doi:10.1037/0882-7974.7.2.271 Sternberg, R. J. (1998). A balance theory of wisdom. Review of General Psychology, 2(4), 347-365. doi:10.1037/1089-2680.2.4.347 Sternberg, R. J. (2007). A systems model of leadership: WICS. American Psychologist, 62(1), 34-42, discussion 43-37. doi:10.1037/0003-066X.62.1.34 Thede, L. (2009). Informatics: Electronic records and organizational culture. OJIN: The Online Journal of Issues in Nursing, 14(3). Retreived from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/Electronic-Records-Organizational-Culture.html 54 Tuomi, I. (1999). Data is more than knowledge: Implications of the reversed knowledge hierarchy for knowledge management and organizational memory. Journal of Management Information Systems, 16(3), 103-117. doi:10.1109/HICSS.1999.772795 Turley, J. (1996). Toward a model for nursing informatics. Image: Journal of Nursing Scholarship, 28(4), 309-313. Uhrenfeldt, L., & Hall, E. O. (2007). Clinical wisdom among proficient nurses. Nursing Ethics, 14(3), 387-398. doi:10.1177/0969733007075886 Van Maanen, J. (1988). Tales of the field: On writing ethnography. Chicago. University of Chicago Press. Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall. Wiedenbach, E. (1964). Clinical nursing: A helping art. New York: Springer. Zeleny, M. (2006). From knowledge to wisdom: On being informed and knowledgeable, becoming wise and ethical. International Journal of Information Technology & Decision Making, 5(4), 751-762. doi:10.1142/S0219622006002222 CHAPTER 3 STUDY OVERVIEW The purpose of this dissertation was to develop a theory of wisdom in action for clinical nursing and conduct an initial validation of a model of wisdom in action for clinical nursing. The study design type was sequential, in three steps: First a preliminary theory was developed deductively using derivation and synthesis, based on theories and models from psychology, education, and nursing. Second, a constructivist grounded theory approach inductively captured the experience of wisdom in nursing practice based on wisdom narratives from emergency department nurses. Finally, the theories were synthesized into a theory of wisdom in action for clinical nursing. Specific aims of the study were: • Aim 1: To define a descriptive construct and graphical representation (model) of wisdom in action within the context of clinical nursing practice. The research questions were: (a) What are the attributes of wisdom in clinical nursing? (b) What concepts are related to but distinct from wisdom in clinical nursing? and (c) What are the relationships between the attributes of wisdom, and between wisdom and related concepts, in the context of clinical nursing? • Aim 2: To understand how emergency room nurses construct the meaning of 56 wisdom in the emergency room setting within the culture of clinical nursing practice. The research questions were: (a) What does wisdom mean to emergency room nurses? (b) What central processes are used to practice wisely and gain knowledge through practice? (c) What key concepts are involved in the processes? and (d) How are the processes related to each other? Methods-Aim 1 The method of theory derivation and synthesis as defined by Walker and Avant (2011) was used to construct of the Theory of Wisdom in Action for Clinical Nursing and to develop a graphical model for the theory. This method was chosen because derivation and synthesis, concept development, and relationship types were clearly defined. The combined use of these two strategies are described sequentially but were done conjointly. Theory Derivation Theory derivation entailed the development of a new theory using a theory or theories from other fields. Walker and Avant (2011) described a process for theory derivation using five steps. The first step was to be aware of other theories. Three theoretical models of wisdom from other disciplines and one from the nursing literature were evaluated. The second step was to gain an increased understanding of wisdom by widely reading wisdom literature pertinent to the theory. Reading materials that were sought and studied included theoretical models, literature, and poems. These readings helped to determine the concepts and relationships that were pertinent to and contributed to the new 57 theory. The third step was to select a parent theory or theories from which the new theory could be developed. The four theories chosen for derivation of the wisdom-in-action theory were the Berlin Wisdom Paradigm (Baltes & Staudinger, 2000), the Model of Wisdom Development (Brown & Greene, 2006), the Model of Wisdom (Glück & Bluck, 2013), and the DIKW framework (American Nurses Association [ANA], 2008). The fourth step was to identify which parts of the parent theories could be used to construct the new theory. The four theories were evaluated to understand the concepts, their definitions, and the relationships between them. The parts that were identified and selected from these four theories were consequently inserted into a diagram of the emerging theory. The final step of deriving the new theory was to determine if any of the concepts included in the parent theories needed to be redefined within the nursing context. This was required to develop the actual model. In addition, definitions for similar or synonymous concepts were compared. Theory Synthesis Theory development by synthesis was described by Walker and Avant (2011) as the "process of transforming practice-related research about a phenomena of interest into an integrated whole" (p. 140). The three steps outlined for this method were: 1. Identify the concepts of interest. Initially, the focal concepts came from the parent models from other disciplines which were used for the literature review. These concepts focused on both knowledge and wisdom. Further concepts of interest arose from the review of the nursing literature and nursing 58 theories. 2. Identify the related factors, and define the relationships between the concepts, including the direction and type of relationship. For example, the relationship between knowledge and wisdom depicted in the DIKW figure published in the American Nurses Association (2008) scope and standards is unidirectional, with knowledge as a necessary factor enabling wisdom development. Because wisdom influences knowledge, this should be bidirectional, with the converse happening as well. 3. Develop an integrated representation or model. This is a diagram of the concepts illustrating the relationships between them. The concepts were grouped, or put into blocks, according to their similarity. Derivation and synthesis were performed synchronously, and it was evident that the findings from one strategy influenced the other. The concepts found in the pre-existing models from other disciplines were used as the search terms for the synthesis literature review. Conversely, definitions found in the literature during synthesis were compared to the models from other disciplines and assisted in writing the definitions within a nursing context. Methods-Aim 2 Wisdom is intrinsically a social, cultural, shared construct-something perceived and difficult to define. Therefore, stories of the actions, perceptions, decision making, and human interactions of clinical emergency room nurses were examined using a constructivist grounded theory (CGT) approach. Emergency room nurses were chosen because they have a lot of autonomy in their practice to make patient care decisions. In 59 building the grounded theory, the specified processes used to practice wisely within the culture of the emergency room were examined. The theory developed from this aim was separate from the theory produced in Aim 1. The grounded theory was compared to the derived theory and the two models were harmonized to create the final Theory of Wisdom in Action for Clinical Nursing (see Chapter 8). Constructivist Grounded Theory A particular theoretical or philosophical perspective is the foundation of social research (Crotty, 1998). Wisdom is considered a cultural construct, so it is appropriate to examine wisdom as a dynamic, in how it is both socially developed as well as an exercise of wisdom in action in a particular patient scenario. The wisdom-in-action theory was developed using a grounded theory (GT) approach, more specifically constructivist grounded theory (CGT), for Aim 2 of this study. CGT is a logically consistent inductive research approach used for generating midrange theory of human behavior in a social context (Charmaz, 1996; Munhall, 2011). The goal of using CGT was to generate a theory that illustrates processes of human behavior-in this case wisdom in action-directly from the data. GT is a systematic approach of inquiry used for the purpose of theory construction. The researcher generates an explanation (theory) of a process, action, or interaction which is shaped by views of the participants: "The theory is inductively derived from the study of the phenomena it represents" (Corbin & Strauss, 2008, p. 23). This means that the data produce the theory. GT provides the tools to answer "why" questions from an interpretive stance by considering the dependent relationships between the "whats" and "hows" of social life (Gubrium & Holstein, 1997). It allows the 60 researcher to develop abstract theoretical understandings from the analyzed material. GT strategies enable researchers to control and expedite the research process because they foster momentum (Charmaz, 2014). Barney G. Glaser and Anselm L. Strauss (1965) developed GT during their research on dying in the hospital. Glaser and Straus observed how an awareness that they were dying influenced the patients' interactions with family and hospital staff. As this research progressed, they developed systematic methodological strategies that scientists could adopt for qualitatively studying other topics. These strategies were first articulated in their book, The Discovery of Grounded Theory (1967). They advocated for developing theories from research grounded in the data rather than deducing testable hypotheses from existing theories. The method includes four key strategies for data collection and analysis (Charmaz, 2006, 2012, 2014; Strauss & Corbin, 1994). First, analysis is both inductive and abductive. Inductive is a type of reasoning that is used to infer patterns from the data rather than a description or application of current theory (Charmaz, 2014). Abduction is moving deliberatively from qualitative inductive conjectures that are systematically tested deductively and using those conjectures in subsequent interviews to test within and between participants for validity (Morse & Niehaus, 2009; Schwandt, 2001). Second, the analysis is comparative. Comparison is made throughout the process and can include data with data; data with codes; codes with codes; codes with data; codes with categories; and categories with categories (Charmaz, 2014). Third, GT is interactive and requires the researcher to be continually involved with and interacting with both the collected data and the emerging analysis. Fourth, the approach is iterative in both data collection and 61 analysis. The researcher begins with the initial generative questions that guide the research. The researcher must remain open to developing the tentative interpretations into theoretical propositions about these data through codes and emerging categories, and return to the field to gather more data to check and refine major categories. In addition, the data can be recoded if needed. Theoretical sensitivity is a defining concept of grounded theory (Charmaz, 2014; Morse et al., 2009; Strauss & Corbin, 1994). Theoretical sensitivity refers to personal qualities within the researcher. These qualities include foreknowledge of the phenomenon of inquiry through previous experience, insight into the research area (which may change as the study progresses), the ability to give meaning to data, and the capability to separate the pertinent from that which is not pertinent. All this is done in conceptual abstract terms rather than concrete terms. Theoretical sensitivity is influenced by the literature, professional experience, and personal experience (Charmaz, 2014; Corbin & Strauss, 2008). GT theory differs from other methods of qualitative research. The inductive analytic process prompts process discovery then the theorization of that process; therefore, data collection and analysis proceed simultaneously in order to refine, elaborate, and exhaust conceptual categories. The systematic application of GT analytic methods progressively leads to more abstract analytic levels (Charmaz, 2014). GT is shaped by the aim to discover social and psychological processes, whereas the other methods code for topics and themes (Charmaz, 2014; Corbin & Strauss, 2008; Morse et al., 2009). Coding emphasizes actions by embedding them in the codes using nouns formed as verbs by adding "ing" (gerunds). 62 Three major types of GT are used for research: Glaserian, Straussian, and CGT. As mentioned previously, the first GT method published, now called Glaserian GT, was developed by Glaser and Straus (1967). The two researchers had different career paths, so Strauss moved on and developed collaboration with Juliet Corbin. Together, they developed Straussian GT (Morse et al., 2009). Kathy Charmaz studied under Strauss. She stated that one of the ways Strauss differed from Glaser was that he was a "theorist of actions and not of individuals" (Charmaz, 2014, p. 9). She went on to develop CGT. In GT, processes are studied, but it is also a method in process because it is young, still being developed and refined (Charmaz, 2012). The method can be adopted by researchers who embrace different