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S tra teg ic m an agem en t in nursing: A con cep t analysis
Galante, Christine M arie, Ph.D.
George Mason University, 1991
UMI
300 N. ZcebRd.
Ann Arbor, M I 48106
Strategic Management in Nursing: A Concept Analysis
A dissertation submitted in partial fulfillment of the

requirements of the degree of Doctor of Philosophy at
George Mason University.
By
Christine M. Galante, LTC, AN

BSN Niagara University 1972
MA Pepperdine University 1974
MSN Catholic University 1982
Director: Dr. Mary C. Silva, RN, Ph.D.

Doctoral Program Coordinator
School of Nursing
Fall Semester 1990

George Mason University
Fairfax, Virginia
Acknowledgements
The author acknowledges the assistance and support of

the following persons:
Dr. Mary Silva, my chairman, and Drs. Jacqueline Dienemann

and Evelyn Jacob, my committee members, for their
consistent commitment to scholarship throughout
this dissertation.
Dr. Daniel Rothbart, Professor, School of Philosophy,

George Mason University, for his guidance in the
development of the discussion of the philosophical basis
of the study's theoretical framework.
Mr. Hugh Howard, Research Librarian, The Pentagon, for his

his assistance in the search and retrieval of database
citation information.
My husband, Sam, and my mother, Mrs. Helen Dinnis, for

their unfailing support, caring and encouragement
throughout this degree process.
Table of Contents
Page
Title Page................................................... i
Acknowl edgements Page ii
Table of Contents......................................... iii
List of Tables............................................ vii
Abstract.................................................... ix
CHAPTER 1 .................................................... 2
INTRODUCTION.................................................2
Context and Significance of the Study...................2
Statement of the Problem............................... 10
Research Obj ectives..................................... 12
Definition of Terms..................................... 14
Summary.................................................. 16
CHAPTER I I .................................................. 18
CONCEPTS: A REVIEW OF THE LITERATURE..................... 18
Philosophical Approaches............................... 18
Philosophy of Science............................... 18
Philosophical Approaches............................... 30
Nursing Science...................................... 3 0
Discussion: Philosophical Basis of This Study........ 39
Methodological Approaches.............................. 41
Wilson's Technique of Concept Analysis................ 41
Walker and Avant's Technique of Concept Analysis...... 44
The Hybrid Model of Concept Development............... 45
Rodgers' Technique of Concept Analysis................ 49
Comparison of Rodgers, Wilson, Walker and Avant, and
Schwartz-Barcott and Kim....... 52
Summary..................................................54
CHAPTER III.................................................57
METHODOLOGY.................................................57
Overview (Rodgers' Technique of Concept Analysis) ... ...57
Literature Search Procedures .......................... 59
Computer Searches....................................... 59
Dialog.................................................59
Health Planning and Administration...................60
Books in Print Plus...................................61
Manual Searches......................................... 61
Discussion............................................ 62
Literature Sampling Procedures......................... 62
Overview.............................................. 62
Management Literature................................ 66
Journal Citations: Sampling Criteria........... 66
Book Citations: Sampling Criteria............... 68
Health Care Literature............................... 69
Nursing Management Literature....................... 70
Data Analysis............................................70
Overview.............................................. 70
Data Coding...........................................77
Concept Analysis Element Specification............. 79
Validity and Reliability................................ 82
Validity.............................................. 82
Reliability................................. .........83
Intrarater........................................ 83
Interrater........................................ 84
Summary.................................................. 85
CHAPTER I V .................................................. 87
RESULTS..................................................... 87
Introduction............................................. 87
Assumptions.............................................. 87
Results Related to Validity and Reliability........... 88
Validity.............................................. 88
Master Citation List Review Outcomes & Analysis.88
Management Discipline.............................89
Master Citation List Responses................... 89
Reliability...........................................90
Intrarater........................................ 90
Interrater........................................ 91
Results Related to Search & Sampling Outcomes.......... 91
Summary of Literatures............................... 91
Management Literature.............................93
Health Care Management Literature................94
Nursing Management Literature.................... 94
Sampling and Retrieval Outcomes.................. 95
Results Related to Research Objectives................. 97
Overview.............................................. 97
Management Literature............................... 100
Overview..........................................100
Relevant U s e ..................................... 101
Surrogate Terms.................................. 107
V
Antecedents...................................... 110
Consequences..................................... 112
Related Concepts................................. 114
References........................................115
Attributes........................................120
Health Care Management Literature................... 129

Overview.......................................... 129
Relevant U s e ..................................... 131
Surrogate Terms.................................. 136
Antecedents.......................................138
Consequences..................................... 141
References........................................ 145
Attributes........................................148
Nursing Management Literature...................... 152

Overview.......................................... 152
Relevant U s e ..................................... 157
Surrogate Terms.................................. 162
Antecedents.......................................164
Consequences..................................... 166
References........................................169
Attributes........................................171
Model Case ........................................176
Interpretation and Discussion..........................182

The Concept, Strategic Management: Consensus
and Disagreement Among theLiteratures............ 182
Overview.......................................... 182
Relevant U s e ..................................... 184
Surrogate Terms......... ....................... 185
Antecedents.......................................185
Consequences..................................... 186
References........................................188
Attributes........................................193
Overview.......................................193
Management and Health Care Management........ 193
Management and Nursing Management............ 196
Nursing Management and Hlth Care Management.200
Rodgers' Technique of Concept Analysis............ 203
Summary................ 207
CHAPTER V .................................................. 209
SUMMARY AND CONCLUSIONS................................... 209
Background.............................................. 209
Rationale for the Study................................ 209
Method of Analysis..................................... 210
Limitations............................................. 210
Findings................................................ 213
Philosophical Implications.............. 220
Nursing Management Implications....................... 222
Directions for Future Research........................ 222
REFERENCES................................................. 224
APPENDICES................................................. 233
A. Morgan's Metaphor Scheme........................... 233
B. Systems View Model..................................236
C. Wilson's (1963) Technique of Concept Analysis.... 237
D. Walker & Avant's Technique of Concept Analysis...238
E. Schwartz-Barcott and Kim's Hybrid Model.......... 239
F. Attributes of Health Policy and Related Themes...240
G. Overview of the DIALOG Information System.........241
H. Dialindex Categories ......................... 242
I. File-Specific DIALINDEX Search Outcomes........... 243
J. Year/Journal Matrix: Management Literature........247
K. Year/Journal Matrix: Health Care Management
Literature.......... 249
L. Year/Journal Matrix: Nursing Management
Literature.......... 250
M. Letter of Invitation: Reviewers.................. 251
N. Master Citation List Reviewers.................... 257
0. Master Citation List Form.......................... 259
P. Coding Instructions.................................260
Q. Concept Analysis Coding Form....................... 268
R. External Reader Interrater Reliability Record.... 269
VITA ........................................................270
vii
List of Tables
Table Page
1. Examples of Nurse Theorists' Views of Concepts 33
2. Concept Analysis Element Generation Process 81
3. Results Related to Search and Sampling Outcomes 92
4. Discipline-Specific Sampling and Retrieval Outcomes 96
5. Relevant Use: Management Literature 104
6. Surrogate Terms: Management Literature 109
7. Antecedents: Management Literature 111
8. Consequences: Management Literature 113
9. Related Concepts: Management Literature 114
10. References: Management Literature 119
11. Attributes: Management Literature 121
12. Relevant Use: Health Care Management Literature 133
13. Relevant Use: Health Care Management Literature 135
14. Surrogate Terms: Health Care Management Literature 137
15. Antecedents: Health Care Management Literature 140
16. Consequences: Health Care Management Literature 142
17. Related Concepts: Health Care Management Literaturel44
18. References: Health Care Management Literature 146
19. Attributes: Health Care Management Literature 149
20. Relevant Use: Nursing Management Literature 159
21. Relevant Use: Nursing Management Literature 161
viii
List of Tables: continued
22. Surrogate Terms: Nursing Management Literature 163
23. Antecedents: Nursing Management Literature 165
24. Consequences: Nursing Management Literature 167
25. Related Concepts: Nursing Management Literature 168
26. References: Nursing Management Literature 170
27. Attributes: Nursing Management Literature 172
28. Suggested Revision: Rodgers' Technique 205
Abstract
STRATEGIC MANAGEMENT IN NURSING: A CONCEPT ANALYSIS
Christine M. Galante, M.S.N.
George Mason University, 1990
Dissertation Director: Dr. Mary C. Silva
This study examined the concept, strategic management,
u s ing the literatures of management, health care
management, and nursing management and Rodgers' (1989)
technique of concept analysis. Differences in the use and
application of the concept across disciplines demonstrated
a lack of conceptual clarity regarding the concept,
neces s i t a t i n g the analysis. Using Rodgers' (1989)
technique, seven aspects of the concept were identified:
1) relevant use; 2) surrogate terms; 3) antecedents; 4)
consequences; 5) related concepts; 6) references; and 7)
attributes. Differences in the use and application of the
concept were found in all seven of the aspects, with
findings regarding attributes and references considered to
be two of the most important. The six attributes
identified in the management and health care management
literatures were Strategy, Structure, Behavior,
Perspective, Influentials and Systems. In the nursing
management literature, five of these six attributes were
identified. Attribute life cycle, dimensions, and the
scope of dimensions and/or themes varied across discipline
literatures.
References, the range of events, situations or
phenomena over which the application of a concept is
considered to be appropriate, was a concept analysis
element unique to Rodgers' (1989) technique which reflected
Rodgers' belief that the purpose of concept analysis is the
exploration and explanation of differences in the use and
application of concepts across contexts. Differences in
the number and types of references were found across
discipline literatures. References in management were the
most restrictive, totaling four and consisted of the
organization (in two forms, public and private), intra-
organizational units, and phenomena. Five references of
strategic management were identified in both health care
management and nursing management. In health care
management, these were the organization (one form, no
distinction between public and private), intra-
organizational units, phenomena, systems and people.
Nursi n g man a g e m e n t ' s five references were 1) the
organization; 2) intra-organizational units; 3) phenomena;
4) people; and 5) resources. Collectively, findings
xi
indicated that the concept, strategic management, has
enjoyed widespread use among these three disciplines, that
among and within them, its analysis elements have changed
over time, and that its scope of application continues to
change and widen. Rodgers' (1989) technique appeared both
philosophically and methodologically sound, and more
philosophically appropriate than others in the nursing
literature. Conceptual clarity of the concept, strategic
management, resulted from this study, culminating in the
proposal of a findings-based conceptual definition of
strategic management specific to nursing management.
CHAPTER I
INTRODUCTION
Context and Significance of the Study
Access, quality and cost are now and will continue to
be three of the most important issues in health care. A
host of internal and external environmental changes have
transformed health care into an industry. Rising costs and
shrinking human and fiscal resources are contributing to
unprecedented levels of competition among providers, while
turbulence and complexity are constant forces impacting on
survival and success.
Faced with these conditions, health care increasingly
has turned its attention to its planning and management
systems. Management practices and leadership styles have
been and continue to be the personal and organizational
characteristics that most directly influence survival and
success. However, the trusted methods and solutions of the
past have proved to be inadequate. New initiatives such as
strategic planning have achieved limited success. This is
due to a number of factors, including excessive emphasis on
3
the performance of protocols and the inadequate integration
of strategy formulation and implementation. From this
turmoil has come the concept, strategic management, offered
as an innovative approach to integrate planning and
management. For health care organizations, strategic
management may offer a planning and management system
needed to achieve and maintain success in dealing with
current and future care delivery challenges.
Differing views as to the use, application and
definition of the concept, strategic management, exist in
the management, health care management, and nursing
management literatures. These differences demonstrate a
lack of conceptual clarity regarding this concept. As a
result, the growth and refinement of its theoretical and
empirical knowledge base is impaired and its adoption in
the work place is impeded. Concept analysis, a technique
originating in analytic philosophy, is the method of choice
for resolving this problem.
There are both practical and theoreti_al reasons why
nursing should be knowledgeable about and interested in the
concept of strategic management. As a practical matter,
today's nurse executives are increasingly being expected to
directly contribute to ensuring organizational survival
and success. These contributions require the nurse
executive's active participation in organizational plans
4
and decisions. This participation can demonstrate
nursing's support for the organization, and gain the
organization's support for nursing. To achieve such
support, nursing leadership must demonstrate that it can
manage strengths, weaknesses, threats and opportunities
successfully, and can conduct its operations efficiently
and effectively. To accomplish these tasks, increasing
numbers of nurse executives are embracing department-level
strategic planning (see Nash & Opperwall, 1988; Lukacs,
1984) . Like organizational strategic planning, it focuses
on manag i n g based on mission, goals, resources and
cons i d eration of internal and external environmental
variables.
Historically, nursing administrative planning and
management behaviors have been reactive and crisis-oriented
in nature. Adoption of a strategic orientation to planning
and management would reflect a significant change of time
orientation for administrative nursing practice. By doing
so, nurse executives may resolve numerous longstanding
management problems, may find they can respond effectively
to the spiral of change, and may be successful in creating
a preferred future.
As a theoretical matter, the adoption and adaptation of
concepts from other disciplines by nursing should result
in a genuine contribution to nursing's knowledge base. A
5
clear understanding of the meaning of the concept, and a
reasonable expectation that its use in nursing is
appropriate are necessary pre-conditions for such adoption
and adaptation.
Meleis and Jennings (1989) caution that valuing and
using concepts and theories developed in other disciplines
without question is an inappropriate practice. Knowledge
development in nursing practice, research and
administration may be constrained by a strong dependence on
theories external to nursing. Stevens (1979) suggests
instead that nurse managers and administrators synthesize
the disciplines of nursing and management, blending,
transforming and balancing the two sources of knowledge in
order to keep nursing care as their focus. This process is
hampered when a concept is used differently by disciplines,
and the rationale for different uses is not known.
The need for clarity is discussed by Henry (1989), who
suggests an epistemological framework for performing
integration of nursing and management knowledge. She
believes that integration is appropriate in nursing
administrative practice as a means to enhance the interface
between nurse and non-nurse managers. Such integration can
result in educational programs that prepare nurses to
effectively manage health care and the environments of care
(e.g., organizations). Drawing on the work of Petrie
6
(1976), Henry (1989) suggests that the first step in this
integration should be that participants learn the
observational categories and key terms in each discipline.
Examining a discipline's metaphors is one way to learn
observational categories and key terms. Henry (1989)
defines metaphors as visual pictures, theories or models
created by a discipline. She (1989) believes that by
comparing nursing and management metaphorically, the world
views of each discipline becomes clearer and can, as Petrie
(1976) suggests, bridge the gaps of differing categories
and concepts among disciplines.
Morgan (1986), in discussing metaphors, believes that
effective managers are skilled in the art of "reading"
situations around them. This skill involves the ability to
formulate images and explanations. Metaphors imply ways of
thinking and of seeing that reflect one's view of the
world. Morgan (1986) lists eight metaphors which
frequently are used to classify and describe organizations.
Morgan's (1986) metaphor scheme, and the basic concepts and
major theorists associated with it, are depicted in
Appendix A. Three are often mentioned in the management
discipline's strategic management literature. They are:
l) organizations as open systems; 2) organizations as
brains; and 3) organizations as cultures.
In an effort to d emonstrate the potential for
7
blending nursing and management knowledge, Henry (1989)
adapted Morgan's (1986) metaphor categories to nursing,
changing the focus from organizations to individuals and
groups. Not unexpectedly, the best "fit" occurred with
the metaphor of individuals and groups as organisms.
Variations in the use of language and metaphor may
suggest an explanation for the lack of conceptual clarity,
and subsequent variety in meaning, use and application of
the concept, strategic management, in management, in health
care management, and in nursing management.
Complementary to the use of metaphor and building
further on the discussion of the integration of nursing and
management knowledge is the work of Scalzi and Anderson
(1989), who have proposed a multi-stage Systems View Model
(Appendix B presents Stage 3 of this model). The
organizing framework for this model is the concept of
domain. Domain is defined as an explicit sphere of
influence or activity associated with specific goals. In
Stage l, the nursing domain is the fundamental element.
Nursing administration is described as the application of
administrative knowledge to nursing to provide quality
nursing care. In Stage 2, the organizational domain, with
its goal of organizational effectiveness, enters and
becomes an element of concern and influence for the nursing
administrator. Also in Stage 2, a new component called the
8
interface comes into being and is broadly defined as the
area in which the multiple and diverse concerns of all
parties interact. In this stage of the model, the two
domains of nursing and organization exist as separate
entities with their own distinct set of goals. The nurse
administrator is bombarded with conflicting concerns from
both domains, and strives to balance actions that may
conflict with the two sets of domain-specific goals.
In Stage 3, a systems view emerges. Here, the nursing
and organizational domains are interdependent, and jointly
form a "system" of domains with a single set of goals that
seek to maximize the vitality of the system. A key
assumption underlying this stage of the modelis that
quality nursing care is delivered by viable organizations,
and that the effectiveness of such organizations is, in
turn, dependent in part on the quality of nursing. Such a
valuing of nursing is typified in the view of nursing as
the hospital's competitive edge (Shaffer & Preziosi, 1988).
Achie v e m e n t of a systems view, characterized by
interdependence and jointly-held goals, is comparable to
the attainment of conceptual clarity resulting from the
successful performance of a concept analysis. In the
former, the resolution of domain-specific differences
permits the achievement of system success (i.e., quality
nursing care and i. viable organization) . In the latter,
9
attainment of conceptual clarity and the explanation of
inter-disciplinary differences in use and application
result in the ability to develop theory and conduct
research based on clear, sound conceptual grounds.
The value of Scalzi and Anderson's (1989) view to this
study is significant. For theory development, the system
view model exposes the dilemma present in the development
of nursing administration theory: that theories can be
extracted from either the nursing or organizational domain
and applied to nursing administrative practice. However,
as domain-level theories, they are inadequate to address
the system perspective. Instead, such theories must be
extended to the system level of complexity so that the
system view is reflected.
In so far as concepts are the building blocks of
theory, a study such as this, which examines and seeks to
clarify a particular concept across multiple disciplines
(i.e., domains), is a timely and cogent research endeavor.
It may pave the way for the extension and/or expansion of
current domain-specific theories, and ultimately, may
contribute toward resolving the "theoretical deficit"
inherent in the practice of nursing administration (Dimond
& Slothower, 1978).
The findings of this study will have significant value
for management, health care management, and nursing
10
management in the areas of practice, theory development
and research. New opportunities for development of
strategic management theory may emerge, and the door of
interdisciplinary research may be opened, expanding the
knowledge base of all three disciplines.
Statement of the Problem
The recurring presence of the concept, strategic
management, within the literatures of management, health
care management, and nursing management, attests to its
being a significant concept valued by those disciplines.
However, the use, application and definition of it differs
within and among them.
Management writers have focused on describing its
practical use and application in organizations and as an
approach for dealing with a variety of phenomena (e.g.,
technology, human resources, crises, etc.), while
generally ignoring its conceptual dimensions. Definitions,
when present, vary widely.
H ea l t h care m a n a gement writers have focused on
explaining and advocating its use and application in
health care organizations and in some functional elements
(e.g., the blood bank) as the "answer" to the pressures of
change and other stressors in health care management.
Definitions, when present, are taken from the management
literature and, as such, exhibit management's diversity of
11
views. Differentiation between the terms strategic
management and strategic planning is not consistently
clear.
Nursing management writers have focused on describing
the use and application of the terms strategic planning
and strategic management. Nursing elements ranging from
the operating room to the corporate level nursing team
consistently have described strategic planning and/or
strategic management according to the steps or phases of
assess-plan-implement, and occasionally have included
evaluation. W r iters who use the term, strategic
management, demonstrate wide variety in the scope of its
application and exhibit no definitional consensus.
These differences in use, application and definition
demonstrate a significant lack of conceptual clarity
regarding this concept. This study will use concept
analysis, a technique of analytic philosophy, to attain
conceptual clarity. Support for this methodology includes
that offered by Walker and Avant (1988) who state that when
there are competing or inconsistent points of view about a
concept, analysis can clarify its use, nature and
properties.
Analysis is a methodology defined as a process of
identifying parts and components of concepts or theories
and examining them against a set of criteria (Chick &
12
Meleis, 1986) . In analytic philosophy, the techniques of
analysis are used to improve an understanding of important
human actions by the clarification of language. Nagel
(1960), in explaining the task of analysis said that
"Analysis not only seeks to clarify concepts for the sake
of clarification, but also to criticize cognitive claims in
order to suggest alternative ways for organizing patterns
of knowledge" (p. 75).
Chick and Meleis (1986) conclude that a nursing
perspective of analysis can result in development of
theoretical and empirical linkages with the domain concepts
of nursing, health, person and environment, and propose
that this offers a significant and original approach to
nursing knowledge development. Thus, attaining clarity of
the concept, strategic management, for nursing, offers the
opportunity to link a conceptualization of nursing
management directly with these domain concepts.
Research Objectives
Based on the preceding conceptualization, the research
objectives are as follows:
1. to identify the relevant use of the concept,
strategic management, in the management, health care
management, and nursing management literatures.
2. to identify surrogate terms for the concept,
13
3. to identify antecedents of the concept, strategic
management, in the management, health care management, and
nursing management literatures.
4. to identify consequences of the concept, strategic
5. to identify concepts related to the concept,
strategic mai-agement, in the management, health care
6. to identify references of the concept, strategic
7. to identify attributes of the concept, strategic
8. to identify a model case of the concept, strategic
management, for nursing management.
9. to compare and contrast the attributes in
a. the management and health care management
literatures.
b. the management and nursing management
literatures.
c. the health care management and nursing
management 1iteratures.
14
Definition of Terms
Research often involves the use of new terms, or the
application of familiar terms in accordance with the
purpose of the study. The following are conceptual
definitions for the key terms used in this study.
Concept Analysis: a research methodology originating in
analytic phi l o s o p h y wh e r e b y the c o n n ection between
concepts and the development of knowledge is demonstrated
through the outcomes obtained from the performance of a
specified analysis procedure.
Content Analysis: a qualitative research data
analysis technique that focuses on identifying the content
characteristics of text and describing findings using
either or both quantitative and qualitative formats.
Definition: a statement which attempts to assign
meaning to a phenomenon.
Themes: manifestations of the use and/or application
of the concept that occur repeatedly in a literature.
Relevant Use: employment of a concept in ways that
are pertinent, germane, material or apropos to the focus or
objectives of the research activity.
Surrogate Terms: substitute or alternative word
labels used to refer to a concept.
Antecedents: events or phenomena that are generally
found to precede a concept.
15
Consequences; events or phenomena that are generally
found to follow or result from the occurrence of a concept.
Related Concepts; concepts that are similar to the
concept of interest but which represent an incomplete
grouping of its attributes.
References; the range of events, situations or
phenomena over which the application of the concept is
considered to be appropriate.
At t r i b u t e s : the describing or defining
characteristics of a concept.
Model Case: an everyday example of the concept which
includes all its attributes.
Management: the art and science of planning,
organizing, staffing, directing and controlling fiscal,
material and/or human resources to result in the
performance of work by oneself or others in order to attain
individual or group goals.
Health Care Management: the art and science of
applying management processes to the offering, providing,
and monitoring of health care products and services
directly or indirectly to clients and/or their advocates
seeking supportive or preventative care, diagnosis, and/or
treatment of injury or illness.
Nursing Management: the art and science of applying
management processes to the assessment, planning,
16
implementation and evaluation of the delivery of nursing
products and services. Management processes are consistent
with and supportive of overall organizational mission,
goals and objectives, and with the nursing organization's
philosophies, goals and objectives regarding the concepts
of nursing, health, person, and environment.
Summary
This chapter presented an introduction to the concept,
strategic management, within the context of the significant
changes occurring in health care. Causes, outcomes and
responses to these changes were discussed.
Nursing management involvement in organizational
survival and success at both the department and
organizational levels was discussed. Indications of a
change from a reactive, crisis orientation to a strategic
orientation to planning and management were noted and
benefits from such a change suggested.
The issue of knowledge development in nursing was
discussed and a balanced approach, consisting of an
integration of knowledge from both within and outside
nursing, recommended. Learning the observational
categories and key terms of a discipline through
examination of its metaphors was suggested as a way to
begin such knowledge integration. Scalzi and Anderson's
(1989) Stage 3 of their Systems View Model was presented
17
and discussed to illustrate an approach in support of
knowledge integration focused on theory development.
Attainment of conceptual clarity of the concept,
strategic m a n a gement in nursing, needed because of
differences in its use, application and definition as
present in the management, health care management and
nursing management literatures was presented as the
research purpose of this study. Analytic philosophy's
approach to analysis was discussed, along with the
potential for achieving linkages between the concept,
strategic management, and the domain concepts of nursing,
health, person and environment. The research objectives
specified the methodology of concept analysis to be used in
this study, and conceptual definitions of key terms were
provided.
The following chapter discusses the findings from a
review of the literature on concepts as regards
philosophical and methodological approaches to them.
CHAPTER II
CONCEPTS: A REVIEW OF THE LITERATURE
Philosophical Approaches
Philosophy of Science
Since the 1940's, two major schools of philosophical
thought have influenced philosophy of science: logical
positivism and historicism. Logical positivism (also known
as logical empiricism) views science as a product, composed
of concepts, theoretical assumptions and empirical
generalizations, whose goal is the logical explanation of
the nature of scientific knowledge. In contrast,
historicism views science as a process composed of
concepts, scientific theories and research traditions,
whose goal is the historical explanation of the nature of
scientific knowledge (Silva & Rothbart, 1984).
Logical positivism's roots date to the seventeenth
century, when Francis Bacon argued that knowledge is gained
by unbiased observation. Traditional logical positivists
believe that observation is the ultimate source of all
knowledge. Reese (1980) traced the progress of the
empiricists into the twentieth century, where some became
18
19
known as logical positivists based on the development of a
language of science that relied heavily on formal logic.
This core group became known as the Vienna Circle, and the
view they espoused as the Received View (RV).
The RV dominated the philosophy of science from the
1930's until the early 1960's, when a wave of criticism
began. Attempting to increase rigor, the RV became
increasingly more detached from the reality of science. As
a result, a paradigm shift began to occur and historicism,
a view of science more consistent with its practice, came
to the fore. The differences between these two schools of
thought are typified in their approach to concepts.
The term, concept, is one of the oldest in the
philosophical vocabulary and one of the most equivocal.
Though frequently a source of confusion and controversy,
it remains useful, in part, because it provides a means to
examine and interpret theories as diverse as those of
meaning, thinking and being. Logic, epistemology and
metaphysics have all used it, with the differences present
best understood by considering what is implied in
expressions such as "having a concept" or "acquiring the
concept of...," etc. Heath (1967) posits that to "have" a
concept implies
1. knowing the meaning of the word, "x"
20
2. being able to pick out or recognize a presented "x"
or being able to think of (i.e., have images or ideas of)
"x" when it is not present
3. knowing the nature of "x"; to have comprehended the
properties which characterize "x" and make it what it is.
These descriptions are neither exhaustive or exclusive.
However, philosophers have differed long on the question of
what kind of detailed account is to be given to explain
what it means to "have" a concept. Thus, the meaning of
the term, concept, fluctuates. According to Heath (1967),
the answer to the question of the kind of detailed account
explaining "having" a concept determines whether the chosen
model of conceptual use demonstrates a a) cognitive
relation between a subject or an object or b) the exercise
of a function. Based on a choice of a) or b) , the concept
involved would come to be regarded as either an entity or a
disposition. Entity theories of concepts describe them as
"things" such as word meanings or ideas, while
dispositional theories consider concepts to be
capacities for behavior, such as the use of words or the
performance of certain mental or physical actions.
Many philosophers have offered philosophies of
language, suggested theories of meaning and discussed
entity and dispositional theories of concepts. Ludwig
21
Wittgenstein, however, is the one among these who is
credited with exerting the most profound influence. (D.
Rothbart, personal communication, July 20, 1988) .
Hartnack (1962) notes that Wittgenstein occupies a
singular place in the history of philosophy, having first,
at an early age, written a work which exercised a decisive
influence on the philosophical thought of his time, and
then, in his mature years, rejecting his early theory and
producing a second one which, by sheer originality, stature
and influence, has become even more important than the
first.
Wittgenstein's early works were especially influential
on the logical positivism popular in the years between
World War I and II. In them, he presented what has become
known as the "picture theory". He argued that language is
a depiction of the logical structure of facts, i.e., a
"picture" of reality. Wittgenstein based this view on the
Augustinian conception of language, which proposed that the
individual words of a language were names of objects, and
sentences were combination of names.
The Augustinian conception of language said that in
order to master a language, one must learn the individual
names of words which represent phenomena. Mastery is
complete when one has learned all the names by ostensible
definition - by pointing to a thing and simultaneously
22
saying its name.
In his later writing, Philosophical Investigations, a
1953 posthumous publication, Wittgenstein repudiated his
"picture theory" and the Augustinian conception of
language, and instead, initiated a totally new view of
language. In it, he asserted that the meaning of a word is
learned by discerning its u s e . Wittgenstein's best known
remark on meaning is in section 43 of Philosophical
Investigations. Here he (1953) says the following: "For a
large class of cases - though not for all - in which we
employ the word 'meaning' it can be defined thus: the
meaning of a word is in its use in the language" (p. 20) .
The difficulty in understanding this passage is the result
of what Rodgers (1987) and others (e.g., Canfield, 1986)
call errors of omission in Wittgenstein's later writings.
These errors occur with regard to three elements of
Wittgenstein's philosophy, namely (a) meaning and use,
(b) language games, and (c) context.
The key error of omission in the element of meaning
and use is that Wittgenstein does not clearly define and
explain his employment of the terms "meaning" and "use."
As Hunter (1986) notes, saying that "meaning is in use"
does not tell us (a) how to determine the meaning of a
word, (b) how to explain the meaning of a word, or (c)
what form the statement of meaning should take.
23
As a result, writers who attempt to explain and critique
Wittgenstein's later writings do so based on their
interpretation of these terms. Ebersole (1986), in his
analysis, concludes that explaining the meaning of words
can be done in two ways. The first is to identify and
describe the characteristics or features of the phenomenon
to which the word applies. This method is consistent with
the identification and discussion of attributes, and may be
described as an internal assessment of the word. The
second way is to identify and describe the context of use-
what variables determine when, where and how a word is
used, who uses it and under what circumstances or
conditions it is used. This second method is consistent
with the identification and discussion of a constellation
of variables, all contributing to a holistic knowledge and
understanding of meaning. Surrogate terms, antecedents,
consequences, references and related concepts are products
of analysis that can result from theidentification and
description of the context of use. As such, this method
may be described as an external assessment of the word.
Concept analysis uses both methods to achieve clarification
of meaning and use.
In the evolution of Wittgenstein's philosophy of
language, the idea of drawing an analogy between a
language and a game provided a way for him to make a
24
transition away from the view of a single language with a
single logical, syntactical system of formational and
transformational rules. Language-games, the term created
from this analogy, reflected Wittgenstein's new view of
language as a group or "family" of languages, each with its
own set of rules. Wittgenstein posited the following
regarding language-games: (a) There is no definite limit to
the possibility of constructing language-games; (b) Only
certain language-games consist solely of names; and (c) It
is incorrect to think that languages, even those consisting
primarily of names, can be learned by ostensible
definition, as these apply only to thosewho already have
some knowledge of language.
Language-games is the second area where errors of
omission occur in Wittgenstein's writings. Gadamer (1976)
identifies three deficits in the development and
presentation of Wittgenstein's views of language-games.
The first is that Wittgenstein identifies no mediation
between them. While acknowledging that there are "family
resemblances" between language-games, Wittgenstein sees no
common structure that philosophical analysis can use as a
basis for mediating between them. He holds this position
because to him, any mediation that breaks down the autonomy
of the grammar of an individual language-game signals a
return to the rules of universal language. This view
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
25
causes him to overlook the "assimilative power of language"
(Gadamer, 1976, pp. xxxvi).
The second deficit in Wittgenstein's discussion of
language-games is that he never clarifies the position of
the person who analyzes language-games and uncovers the
rules. Gadamer's (1976) critique of this area is grounded
in his view of understanding. Gadamer asserts that the
achievement of understanding has an essentially mediating
or integrating quality to it, and that one who analyzes
language-games is engaged in the integration or fusing of
them. Wittgenstein's lack of clarity on this issue leaves
the subject open to the interpretations of those who
attempt to understand and explain his language-game tenet.
The third deficit in Wittgenstein's discussion of
ianguage-games is that he does not address the issue of how
one learns new language games. Gadamer (1976) takes the
view that while we learn a language by actual use, learning
one's first language and then subsequent ones is not the
same thing. This is because the latter presupposes the
former. In learning a first language, one acquires the
basis for altering it and fusing it with others. Thus,
with the learning of a first language, we have learned how,
in general, to learn languages.
Context is the third area in Wittgenstein's writings
where his discussion lacks clarity and completeness. While
26
acknowledging that context is a phenomenon within which use
of words occurs and thus, one in which meaning results, he
offers no guidance on what constitutes context or on how,
when, or why it impacts on use and meaning.
Gadamer (1976) discusses context from the perspective
of language learning. He suggests that one never learns in
a vacuum, but instead, participates in a constant mediation
and integration of languages within a dynamic socialization
process. Gadamer's views of language and context reflect a
Hegelian influence. It was Hegel who viewed knowledge as a
dialectical process and who, in the Phenomonoloav of Spirit
(1977), proposed that every new achievement of knowledge is
the mediation or refocusing of the past within a new and
expanded context.
While helpful, Gadamer's (1976) views of context are
still incomplete. Another writer, Stephen Toulmin, must
be examined in order to develop a clear understanding of
this phenomenon.
Despite the difficulties encountered, the views
ex pre s s e d in Wittgenstein's later writings represent
significant and important contributions to the discussion
of language, meaning and concepts. Despite their obvious
break with the dominant entity views of the times, these
views should not be construed strictly as dispositional.
S uch a label too narrowly defines Wittgenstein's
27
phil osophical perspective and dim i n i s h e s the value
attributable to his work. Rather, it is more accurate to
say that the W i t t g e nsteinian approach provides an
opportunity to expand the horizons of the discussion of
concepts and to legitimize the inclusion of contemporary
views on the philosophy of language, such as espoused by
the historicist, Stephen Toulmin.
Toulmin's prime area of interest and concern is human
understanding, a phenomenon characterized by two tenets:
1) man knows; and 2) man knows that he knows. Thus, human
understanding is grounded in knowledge. Toulmin discusses
concepts because they are the central element in human
understanding (Toulmin, 1972, p. 11).
In Human Understanding. Toulmin (1972) offers two views
of particular significance in the current discussion of the
theore t i c a l and philosophical bases of language and
concepts. First, he posits that language and conceptual
thought (and thus concepts) are developed via an
interactive social process called enculturation, a view
that appears to be compatible with Gadamer's (1976) and
Wittgenstein's (1953) notion of context. Second, he
observes that concepts exhibit diversity and variation over
time and concludes that this is a result of concepts
c hang i n g over time. This latter position directly
challenges the view of concepts as universals, unaffected
28
by change and motion in the world. Toulmin rejected this
view, arguing that it denied the existence of historical
and social influences on concepts.
Toulmin (1972) argues that we acquire our grasp of
language and conceptual thought in the course of education
and development. The particular set of concepts we adopt
reflects forms of life and thought, understanding and
expression current in the society.
Toulmin's ideas on conceptual change and the context of
concept development and use add significantly to the
philosophical discussion of concepts. However, criticism
appears warranted in two areas. First, like Wittgenstein,
Toulmin never directly defines a concept. Instead, he asks
a question which implies description of a concept. What,
Toulmin (1972) asks, "are the skills, traditions,
procedures or instruments of man's intellectual life and
imagination - the concepts - through which human
understanding is achieved and expressed?" (p. 11).
A second criticism is that Toulmin does not address the
importance of public acceptance and use of concepts.
These are factors which contribute to concept development,
and, as such, their discussion might have enhanced his
ideas of conceptual change and context. Despite these
areas, Toulmin's introduction of new thought on concept
development and change adds significantly to an
29
understanding of concepts.
To summarize then, the view of language and concepts
expressed in Wittgenstein's later writings is that for him,
meaning is use. The focus of inquiry regarding concepts
should be directed toward identifying and explaining
differences in meaning found in use contexts, and how the
concept of interest is related to other concepts. This
Wittgensteinian approach rejects the key tenet of the
logical positivist view of concepts that concepts are
characterized by rigid sets of necessary and sufficient
criteria - and instead proposes that concepts can be
bounded by criteria, so long as these criteria are
sensitive to the context in which the concept is being
used. This is consistent with a historicist approach.
Toulmin (1972) builds on the later Wittgensteinian view
of context, using the term, enculturation to explain the
social process through which language and conceptual
thought are developed. Moreover, he extends the discussion
by proposing that concepts respond to historical and social
influences by changing over time and thus concepts reflect
the forms of life, thought, understanding and expression at
a particular time in a particular context. The views of
Wittgenstein and Toulmin provide a strong base of support
for the view of concepts as including sensitivity to
context and time to attain clarity.
30
The technique of concept analysis used in this study is
consistent with the views of the later Wittgenstein (1953)
and Toulmin (1972) in five areas: 1) its goal is to attain
conceptual clarity of the concept; 2) it acknowledges
multiple use contexts; 3) it focuses on identifying and
expl aining differ e n c e s in meaning present in those
contexts; 4) it supports examination of these differences
identified in relation to historical or social influences
on the concept; 5) it examines how the concept under
analysis is related to other concepts.
Philosophical Approaches
Nursing Science
The writings of nurse theorists regarding concepts
reflect the influence of philosophy on nursing, especially
in the areas of epistemology and the philosophies of
science and language.
The logical positivist tradition in philosophy of
science has permeated modern nursing theory from its
beginnings in the 1960's to the present. Dickoff and
James (1968), the early Jacox writings (1974), Hardy
(1974), and Walker and Avant (1988) are representative
examples of this influence. As a result, most nursing
theorists discuss concepts in accordance with the logical
positivist view. However, since the early 1980's, a
recogn i t i o n of the p h i l osophy of science paradigm
31
shift away from logical positivism and towards historicism
is evident in a decline in commitment to logical positivism
and an upsurge in interest in historicism by some nurse
theorists. Watson (1981), Duldt and Giffin (1985) and
Rodgers (1987, 1989) are representative examples of this
trend. Here, the nursing view of concepts reflects the
influence of Wittgenstein (1953) and Toulmin (1972). In
short, the competing influences of logical positivism and
historicism on nursing theory have contributed to a lack of
consensus in nursing regarding concepts.
Systematic theory development in nursing arose from a
need to capture or clarify the nature of nursing. Interest
in theory development arose because nurse leaders saw it as
a means to establish nursing as a profession, and believed
in the intrinsic value of theory to nursing (Walker &
Avant, 1988).
Nurses who studied theories and theory development in
other disciplines determined that there existed concepts
unique to nursing that merited study. Meleis and Jennings
(1989) , among others, have voiced support for theory
development in nursing, noting that the service orientation
and centrality of human beings to health care are
overriding reasons that preclude the wholesale
transplanting of concepts, conceptual models and theories
from other disciplines to nursing.
32
The concepts of person, environment, health, and
nursing (or variations of these), a constellation which
Fawcett, Botter, Burritt, Crossley & Frink (1989) refer to
as the metaparadigm of nursing, appear in nearly every
conceptual model of nursing. Fawcett et al (1989) posit
that conceptual models present global views of certain
phenomena. Concepts here are not always clearly defined
and propositions generally are not empirically testable.
In contrast, theories are more circumscribed, with each
theory dealing with one phenomenon. The concepts and
propositions making up a theory are more specific and
concrete than those of a conceptual model. Concepts of a
theory are usually clearly defined and propositions are
empirically testable. To the extent that concept analysis
contributes to attainment of conceptual clarity, it
nurtures the development of sound nursing theory.
When discussing concepts, nurse theorists frequently
focus on concept identification, concept classification and
concept definition. Table 1 summarizes the views of some
significant nurse theorist authors selected as
representative examples of the scope of nursing views
regarding concepts:
33
Table 1
Representative Examples of Nurse Theorist Views of Concepts
Author(s) Concept Concept Concept
Identification Classification Definition
Fawcett & variable/ observability words/phrases
Downs (1986) nonvariable measurability that describe
mental images
or abstract
ideas.
Meleis (1985) primitive/ Same Same
derived
Walker & primitive/ Same a mental
Avant (1988) concrete/ image or
abstract phenomenon;
Duldt & categories levels a term or
Giffin (1985) of phenomena of abstraction word used
to describe,
classify or
designate a
phenomenon
Diers (1979) abstract/ levels words with
physiologic of abstraction meaning via
common usage
34
Fawcett & Downs (1986) identify concepts as being
either variable or nonvariable in nature. A single
dimensional concept, e.g., one that merely labels a
phenomenon, is a nonvariable concept. In contrast, a
variable concept is multi-dimensional. The basis for this
distinction is found in the issue of measure/measurability
of concepts. They classify concepts according to their
observability or their measurement characteristics, and
suggest that Kaplan's (1964) classification by
observability scheme and Dubin's (1978) classification by
measurement characteristics scheme, taken together, provide
a comprehensive method of concept classification.
Fawcett & Downs (1986) state that both theoretical and
operational definitions are necessary to make concepts
empirically testable. A theoretical definition states what
the concept means, while an operational definition defines
a concept in terms of observable data, such as the
activities necessary to measure or manipulate it.
Meleis (1985) parallels Fawcett & Downs' (1986) views,
adding that concepts are tinted with the theorist's
perceptions, experience and philosophical perspective, and
that they bring order to observations and perceptions.
Meleis (1985) identifies concepts as being either primitive
(i.e., originating in a particular theory) or derived
(i.e., concepts taken from outside the theory that have
35
taken on a different meaning within the new theory).
Meleis (1985) states that concepts evolve out of a
complex constellation of impressions, perceptions, and
experiences. Conception, in her view, is organized
perception. She expresses this view by saying that
"phenomena are perceived, and only when they are organized
and labeled do they become concepts" (p. 127) .
Although clearly entity-based in her view of concepts,
Meleis (1985) acknowledges that the process of concept
analysis can include a variety of techniques, and consider
context. She notes that "the process of concept analysis
may include corroboration, semantic analysis, analysis of
logical derivations, and analysis of the context of the
concept or the context where the concept may be absent"
(Meleis, 1985, p. 128).
Walker and Avant's (1983, 1988) views on concepts are
some of the best known and most influential in nursing.
They discuss concepts within the overall framework of
theory construction, agreeing with Hardy (1974) that they
are the building blocks of theory. Like Wilson (1963),
Walker and Avant (1983, 1988) acknowledge that concepts are
expressed by means of language, and that the language
labels (or words) used are a way of communicating our view
of the concept to others. Like Meleis (1985) , they view
concepts as an assist to classifying experience.
36
Walker & Avant (1983, 1988) identify concepts as
primitive, concrete and abstract. Primitive concepts have
a common shared meaning among all individuals in a culture.
Both concrete and abstract concepts can be defined by
primitive concepts; however, concrete concepts are limited
by space and time and are observable in reality, whereas
abstract concepts are independent of reality. They
acknowledge Kaplan's (1964) empirical-theoretical continuum
as a valid and useful means to classify concepts and define
a concept as a mental image - an idea or construct in the
mind about a thing or action.
Duldt and Giffin (1985) identify concepts as categories
of phenomena and classify them along a continuum according
to level of abstraction. They concur with their nurse
colleagues' definition of a concept as a term or word used
to classify or designate a set of phenomena or conceptions,
and as a timeless abstract idea.
Fawcett and Downs' (1986), Meleis' (1985) and Walker
and Avant's (1988) views on concepts reflect a strong
logical positivist orientation to theory construction in
general. Their work has not acknowledged the rise to
prominence of historicism within philosophy of science.
Thus, their views may be criticized as not in keeping with
the paradigm shift in the philosophy community.
37
Collectively, these theorists' views of concepts
are consistent with the traditional entity theory view of
concepts which describes them as "things” such as word
meanings, ideas or mental images. In contrast, the views
of Diers (1979) and Duldt and Giffin (1985) are generally
more consistent with the dispositional theory of concepts,
and reflect the historicist approach to science and theory.
They describe concepts as terms or words used to describe
or classify a phenomenon whose meaning is based on usage.
As such, they are supportive of the views of the later
Wittgenstein (1953) and Toulmin (1972).
Diers (1979), for example, views concepts as words to
which meaning has been attached through formal definition
or common usage. Employment of the term "usage” links
with Wittgenstein's tenet of "use" and "common usage"
suggests consideration of a social component to concept
development. Duldt and Giffin (1985), though entity-based
in their definition of concepts, identify an associative
link between concepts and language and acknowledge a social
component to concepts.
Duldt and Gif fin (1985) believe that at the core of
theoretical and scientific endeavor is the human ability to
symbolize. Symbolizing and conceptualizing permits us to
describe, understand, predict and even control the social
and physical environment. For them, an essential element
38
of theory development is the assignment of meaning to
concepts. While they agree with their nurse theorist
colleagues that definitions are a primary way to assign
meaning, they differ in their approach to definitions.
They suggest a number of different ways to define a
concept. These i n clude dictionaries, etymology,
operationalization, identifying the scope, role or
functions of a concept, and by use of metaphor.
Duldt and Giffin (1985) see the role and function of a
concept as that of labeling phenomena. Meanings are
assigned to concepts and based on them, judgments are made
and actions taken. Of significance is their comment that
meanings vary with the context, a view consistent with the
later Wittgenstein (1953) and Toulmin (1972).
While Diers' (1979) definition of concepts and the
majority of Duldt and Giffin's (1985) comments about them
reflect alignment with the views expressed in the later
Wittgenstein (1953) and Toulmin (1972), and, as such,
support a contemporary view of concepts, the linkage is not
obvious or robust. A direct acknowledgement of support for
the contemporary view of concepts would strengthen their
philosophical base. Allen (1986), in his discussion of the
use of philosophical and historical methodologies to
understand concepts, is an example of one who does
acknowledge support for the contemporary view of concepts.
39
Discussion: Philosophical Basis of This Study
The contemporary dominant view of concepts in the
philosophies of science and language, and as expressed by a
minority in nursing, is selected as the philosophical basis
of this study. The following summarizes its views
regarding concepts and the method of concept analysis:
1. Concepts are terms whose meanings are grounded in
use.
2. Through a process of socialization and repeated
public use, concepts become associated with particular
themes which, when clustered, result in the identification
of an attribute of the concept.
3. An everyday example of a concept which includes all
its attributes is called a model case.
4. The clustering of attributes ultimately results in
a definition of a concept*
5. Definition of a concept promotes its effectiveness
as a contributor to the development of knowledge.
6. Concepts are publicly manifested primarily through
linguistic behaviors.
7. Linguistic applications are primarily indicators of
a concept's use.
8. Written discourse is an acceptable form of
linguistic behavior and therefore is an appropriate data
source for use in analysis.
40
9. Analysis of a concept is a description of its use,
that is, its attributes, characteristics, differences in
meaning it receives in different contexts, and how it is
related to other concepts.
10. Through an analysis of use, a concept may be
defined and clarified.
11. Analysis of use includes identification of
surrogate terms, antecedents, consequences, references, and
related concepts.
12. Concepts change over time as a result of the impact
of historical and social influences.
A close relationship exists between conceptual
analysis and the formulation of definitions, in that one
can analyze a concept by studying the meanings of its
related terms, and a definition is a formulation of
meaning. Thus, concept analysis may be viewed as a
complicated and extended definition whose process requires
a lengthy and intricate exploration. As the objective of
philosophical analysis is to arrive at something like a
definition, it cannot begin with one (Green, 1971). Thus a
concept analysis of strategic management seeks to refine it
by analyzing its use and the variables impacting on that
use in order to arrive at a better definition (i.e., to
attain conceptual clarity).
41
Methodological Approaches
Differences in views of concepts in philosophy of
science and nursing science are reflected in the multiple
techniques present in the literature. The following are
representative examples of these techniques.
Wilson's Techniques of Concept Analysis
Wilson (1963), Walker and Avant (1983, 1988), Schwartz-
Barcott and Kim (1986) and Rodgers (1987, 1989) all propose
techniques of concept analysis. Wilson's (1963) technique
(Appendix C ) , the oldest, consists of eleven steps and has
served as the basis for the latter three.
Wilson's (1963) technique is generally consistent with
the logical positivist view of concepts. In Wilson's
(1963) technique, steps 1 and 2 involve isolating questions
of concept and identifying right answers. Identifying and
naming the concept, identifying its uses, and identifying
its attributes are the major tasks associated with these
steps.
Steps 3 through 7 reflect a view of concepts as
grounded by definitive sets of necessary and sufficient
criteria, properties or conditions, and a view of concept
analysis as the means to distinguish between the defining
and irrelevant attributes of a concept. Here, a model case
is picked, along with contrary, related, borderline and
invented cases. When compared to the model case, these
42
latter ones are examples of incomplete or erroneous
attribute sets. Their identification assists in the
identification of irrelevant attributes.
Steps 8 through 11 require that the concept be examined
according to four criteria: 1) social context; 2)
underlying anxiety; 3) practical results; and 4) results in
language. These demonstrate a departure from the logical
positivist approach and a move towards the historicist
perspective.
In dis c u s s i n g "social context", Wilson (1963)
acknowledges that language "is not used in a vacuum" (p.
33) and that knowing the nature of the circumstances
surrounding use is very important for understanding a
concept. Wilson (1963) explains that the reason why this
knowledge is necessary is because questions of concept are
concerned with meaning - but not the meaning (i.e., a
particular definition) but rather with meaning as it is
reflected in the different ways the concept is used.
Wilson contends that concepts, in and of themselves, do not
have meaning, but rather have diff e r e n t uses and
applications. Thus, for Wilson (1963), the task of concept
analysis is to map out these uses and applications, and
describe the r esulting different meanings found in
different contexts. This notion of concepts is highly
consistent with the views expressed in Wittgenstein's
43
later writings (Wittgenstein, 1953) and with Toulmin's
(1972) views on concept development.
"Underlying anxiety" refers to the identification of
the mood or feelings of the speaker (or writer) when
discussing a concept. Identification and understanding of
underlying anxiety requires identification of the features
behind a concept which are sources of concern, uncertainty
or insecurity. Such identification is most likely to be
possible when analysis involves the discursive (spoken)
medium of communication. However, when considered in the
analysis of nondiscursive text, underlying anxiety may be
characterized as a demonstration of the dynamic tension
inherent in the process of conceptual change.
Wilson (1963) notes that some concepts and conceptual
questions are often misleading in that they lack definitive
right or wrong explanations and answers. Such a situation
results in the guessing of meaning. Wilson (1963) suggests
that subjecting the concept or conceptual question to the
conditions of everyday life may improve the quality of the
proposed meaning, and may help decide what, if any,
practical value the concept has.
Finally, step 11, "results in language" acknowledges
the potential for ambiguity in concept use and proposes
that when no central meaning can be identified, "it is more
sensible or useful to adopt some meanings rather than
44
others” (Wilson, 1963, p. 36). Looking at the "results"
(of use) in language assists in the selection of these
meanings. Within this process is the step of picking the
"most useful criteria for the concept" (Wilson, 1963, p.
37) , a step interpreted by othersas determination of
defining attributes (Rodgers, 1987, 1989; Walker & Avant,
1983, 1988). Performance of this step assists in the
identification of the scope and variety of concept use, as
portrayed in language, and results in being "able to use a
word to its fullest advantage" (Wilson, 1963, p. 37).
The Wilson (1963) technique has served as the basis for
three philosophically and fundamentally different
approaches to concept analysis, represented in the work of
Walker and Avant (1983, 1988), Schwartz-Barcott and Kim
(1986) and Rodgers (1987, 1989).
Walker and Avant’s Technique of Concept Analysis
Walker and Avant first introduced a technique of
concept analysis in a 1983 textbook. In its second
edition, they credit Wilson (1969) with this technique
(Appendix D) . Personal communication with these writers
revealed that the 1969 date listed was a typographical
error. They acknowledged that their technique (Appendix D)
is, in fact, a modification of Wilson (1963) (K. Avant,
personal communication, May 3, 1990). The Walker and Avant
adaptation of Wilson (1963) has become the dominant
45
technique of concept analysis in the nursing literature
(see Goosen, 1989; Reed & Leonard, 1989; Rew, 1986).
The W a lker and Avant technique (1983, 1988) is
consistent with the logical positivist view of concepts and
concept analysis. However, in their discussion of the
Wilson (1963) technique, they appear to interpret one of
his steps according to the historicist view of concepts.
Specifically, they relate their step of identification of
antecedents and consequences to Wilson's (1963) step of
examining the social context of the concept saying that
identifying antecedents and consequences "may shed light on
the social contexts in which the concept is generally used"
(Walker & Avant, 1988, p. 42). This mention of "social
context" is the only point where their technique appears
to acknowledge and apply a historicist perspective to
concepts.
The Hybrid Model of Concept Development
Schwartz-Barcott and Kim (1986) have proposed a three
phase hybrid model of concept development which they posit
approaches concept analysis by interfacing theoretical
analysis with empirical observation (Appendix E) . The
mo d e l 1s stated purpose is to combine the rigors of both
approaches, resulting in concepts having both analytical
and empirical foundations at the initial stage of their
theoretical development. The authors credit the works of
46
Reynolds (1971), Wilson (1969) and Schatzman and Strauss
(1973) with providing the bases for the model's steps.
Madden's (1990) examination of the concept, therapeutic
alliance, is a current example of the application of the
model in nursing.
Schwartz-Barcott and Kim's (1986) model is
characterized by a cyclic process involving analysis,
testing, evaluation and refinement. While the idea of a
process approach such as this has merit, this model errs in
that the focus is not the concept itself, but rather the
concept as conceptually defined. The majority of the
model's effort is spent on testing, evaluating and refining
the conceptual definition - a definition that is chosen,
rather than inductively derived, from the literature
(i.e., the definition is not based on identification of
elements such as attributes, antecedents, consequences,
related concepts, etc.). These elements are ignored or
assumed dealt with by the selected definition. Thus, the
Phase I (the theoretical phase) procedure is not reflective
of a rigorous, theoretic approach to concept analysis.
Phase II (the fieldwork phase) proports to reflect a
rigorous empirical approach. However, it is not well
linked to the outcome of Phase I, and does not specify
clearly the process for data collection and analysis.
Phase III (the final analytical phase) seeks justification
47
for the selection of the concept as its first task (i.e.,
the findings validate the concept's importance to nursing),
and then proceeds to its second task of reconsidering the
findings (from Phase II) in light of the concept's
"definition and measurability" (Schwartz-Barcott & Kim,
1986, p. 100). While no clarification is provided, the
definition mentioned is assumed to be the one chosen in
Phase I, and measurability is suggested as relating to the
empirical findings from Phase II.
The p rimary problem with this model of concept
development is that it proceeds in a fashion contrary to
both of the approaches to concept analysis that it proports
to integrate. Instead of analyzing a selected concept by
identifying explanatory components (e.g., antecedents,
attributes, etc.), it searches literatures for definitions,
selects one, proceeds to collect empirical data, and then
attempts to determine if the data matches the definition
which, at some point, was subjected to a dissection into
definitional components. Cases which match all the
components are labeled as model cases, those which match
some as borderline, and those where no match occurs as
contrary.
A second problem with this model is that it could not
be used effectively with concepts where significant
definitional variation exists or is suspected. To do so,
48
one would be choosing among different and competing
definitions as a first step, collect data, compare the data
with the chosen definition and ultimately, render findings
regarding cases of the concept. In such a situation, the
generalizability of findings would, of necessity, be
limited to that group which agreed with the originally
chosen definition. Finally, validity and reliability of
the data/definition match would be hampered by the
existence of competing (and not chosen) definitions.
A modification of this model which would improve its
alignment with both approaches to concept analysis would be
to conduct Phase I in accordance with Rodgers' (1989)
technique, to conduct Phase II by 1) identifying a clear
conceptual definition of the concept (based on Phase I
findings); 2) operationally defining the concept's
attributes; 3) specifying the criteria for case selection;
3) specifying the process for data collection and
analysis. Depending on how concept measurement was
operationalized, both quantitative and qualitative findings
would be possible. Finally, in Phase III, the Phase I
concept analysis outcomes could be evaluated against the
Phase II empirical data, resulting in further clarification
of the concept, and together, Phase I and II data could
result in specific findings relating to the study's
research questions.
49
Rodgers' Techniques of Concept Analysis
Rodgers (1987) developed and applied her own version of
a technique of concept analysis, based on an examination
and interpretation of the historicist view of concepts in
the philosophies of science and language as expressed by
the writings of the later Wittgenstein (1953), Toulmin
(1972), and others. She later modified this original
technique (Rodgers, 1989), making two changes: 1) she
introduced the task of identification of surrogate terms
and 2) she limited the scope of use to relevant use. In
all other respects, the two techniques (i.e., Rodgers,
1987 and Rodgers, 1989) are identical.
Rodgers' (1989) technique of concept analysis, her most
current, was selected for use in this study. Rodgers
(1989) technique demonstrates consideration of Wilson's
(1963) steps 8 through 11 and is consistent with his
previously-discussed views of concepts, meaning and use,
and with the historicist view presently dominant in the
philosophies of science and language, as presented in the
writings of the later Wittgenstein (1953) and Toulmin
(1972). Her consistency with these views is evident in
the following tenets which represent her beliefs regarding
concepts and analysis:
1. Concepts possess descriptive and/or explanatory
power and thus are vital to the development of knowledge.
50
2. Concepts are basic elements of theory development.
3. Concepts develop within an interactive social
process.
4. This interactive social process acknowledges and
permits the existence of multiple use contexts.
5. Multiple use contexts result in differences in
meaning.
6. Analysis of concepts should focus on a)
identification and explanation of these differences in
meaning and b) identification and explanation of the
relationship between the concept of interest and other
concepts.
The steps of her 1989 technique focus on identifying
relevant uses, surrogate terms, attributes, antecedents,
consequences, related concepts and references, and are
detailed in Chapter III, pages 56-57.
Rodgers initially developed and applied her technique
of c oncept analysis to the concept, health policy.
Examining the health and policy literatures, she employed
multiple readings and proceeded in an inductive manner to
identify themes and the common use of the concept within
those literatures. Use was further analyzed to identify
definitions, surrogate terms, references, antecedents,
consequences, and related concepts. Findings were then
viewed in their entirety to identify the attributes of the
51
concept. Based on these attributes, she searched the
literatures for an example of a model case of the concept.
Clustering of related themes resulted in the
identification and labeling of four attributes which
characterized the concept, health policy. These were 1)
attitude 2) direction 3) practice and 4) domain. These
attributes and their related themes are depicted in
Appendix F.
From this research, Rodgers (1987) successfully
demonstrated that the concept, health policy, arose from
the superordinate concepts of public policy and social
policy and was characterized by four major attributes.
Other findings included the significant consistency in the
use of the concept across disciplines and the frequent use
of concrete terms (e.g.,law, program,etc.) to discuss this
otherwise abstract concept. Such a pragmatic approach to
concept discussion is consistent with her proposed cycle of
concept development, which views concepts as developing in
a social context for purposes of contributing to the
attainment of human goals. Additionally, the findings
regarding pragmatic use and application indicate that
abstract concepts may be analyzed effectively without
examining the actual process of human cognition.
52
Comparison of Rodgers to Wilson. Walker and Avant. and
Schwartz-Barcott and Kim
Rodgers1 (1989) technique differs from that of Wilson
(1963) in the absence of the requirement to identify
contrary, borderline and invented cases. This is
consistent with her rejection of the logical positivist
view of concepts as characterized by sets of necessary and
sufficient conditions, properties and criteria. She
rejects this view because 1) she believes that it values
reductionism in an attempt to isolate the essence of a
given concept, rather than to focus on the multiple
interrelationships with it that may exist in the world and
2) because it subscribes to a static view of the world
which posits that concepts do not change across time and
are consistent across contexts. It is these tenets and the
logical p o s i tivist view in general that have been
supplanted by the historicist view of concepts.
Rodgers' (1989) technique differs from Walker and
Avant's technique in three ways:
1. the absence of borderline, contrary, invented and
illegitimate cases.
2. substitution of identification of references for
definition of referents.
3. identification rather than construction of a
model case.
53
References, the range of events, situations, or phenomena
over which the application of a concept is considered to be
appropriate, is a concept analysis element unique to
Rodgers' (1987, 1989) technique of concept analysis. It
replaced the element, empirical referents, an analysis
category which Rodgers excluded based on her belief that
measurement (and thus the identification of empirical
referents) was not a purpose inherent in concept analysis.
Considered in this light, References represents a
significant point of difference between Rodgers' (1987,
1989) techniques and other techniques of concept analysis
(e.g., Schwartz-Barcott & Kim, 1986; Walker & Avant, 1983,
1988; and Wilson, 1963). Perhaps more importantly,
however, the step of identifying the References of a
concept directly addresses concept application. When the
use and application of a concept varies among disciplines,
identification of References of the concept in each
discipline can assist in understanding and explaining these
differences.
Finally, identification rather than construction of a
model case is consistent with her position that the
development and use of concepts occurs within everyday
social contexts. Thus one or more model cases are likely
to exist in the literature and should be identified.
Rodgers' (1989) technique differs most substantially
54
from that of Schwartz-Barcott and Kim (1986) . While
Rodgers' technique focuses on clarifying conceptual meaning
and use, Schwartz-Barcott and Kim's technique includes a
cursory conceptual examination of the selected concept (the
theoretical phase) and instead, focuses on the testing
(fieldwork phase) and evaluation of findings (final
analytic phase) regarding a concept. With the exception of
their first two steps of 1) selecting a concept and 2)
searching the literature, there is virtually no similarity
between these two techniques. This is the result of the
stark contrast evident in t h eir philosophical and
theoretical views of the technique of concept analysis.
Summary
This c h apter began with a discussion of the
philosophical approaches to concepts in philosophy of
science and nursing. In philosophy of science, an overview
of logical positivism and historicism, and of the history
of the term, concept, along with definitions of entity and
dispositional theories of concepts were presented.
The works of Ludwig Wittgenstein and Stephen Toulmin
were presented and discussed as representative examples of
the contemporary view of concepts. Wittgenstein's views on
language, meaning and concepts were discussed and critiqued
on areas lacking clear explanation. Toul m i n ' s
contributions to these topics, in the areas of conceptual
55
change and context, were presented, along with criticism of
two areas characterized by incomplete explanation.
In nursing science, the influence of the logical
positivist and historicist schools of thought on nursing
theory development was discussed through presentation of
views of concepts by prominent nurse theorists.
The entity theory of concepts was identified as the
dominant view e x pressed by nurse theorists. Four
representative examples were discussed and critiqued, along
with two examples of nurse theorists more aligned with the
historicist perspective.
The discussion of methodological approaches to concepts
discussed the techniques of concept analysis proposed by
Wilson (1963), Walker and Avant (1983, 1988) Schwartz-
Barcot & Kim (1986), and Rodgers (1987, 1989).
Wilson's (1963) technique demonstrated the influence of
both the logical positivist and the historicist views of
concepts. Overall, however, his textual discussion of
concepts and e x planation of his t echnique's steps
demonstrate a solid and consistent alignment with the
historicist view, and with the views expressed in the
writings of the later Wittgenstein (1953) and Toulmin
(1972).
Walker and Avant's (1983, 1988) technique was discussed
as a modification of Wilson's (1963) technique. Their
56
adaptation reflects the logical positivist perspective and
has become the dominant technique in nursing.
Schwartz-Barcott and Kim's (1986) hybrid model of
concept development was presented as a recent alternative
to the established techniques of concept analysis. While
the process approach of the model appears to have merit,
methodological flaws significantly impair its use and
application. Modifications to correct these flaws and
strengthen the model's design were suggested.
Rodgers' (1987, 1989) techniques were discussed as
another example of a modification of Wilson (1963). Her
most current work has strong consistency with the
historicist view components in Wilson (1963) and the views
of concepts presently dominant in the philosophies of
science and language.
Chapter III discusses the methodology of this study.
CHAPTER III
METHODOLOGY
Overview
Concept analysis is defined in this study as a
technique of analytic philosophy whose goal is to achieve
clarity regarding the use of a particular concept. This
clarity is attained by applying a prescribed analysis
procedure to identify and describe the use, nature and
properties of the concept under study. In this study,
Rodgers' (1989) technique of concept analysis was used to
examine the concept, strategic management. The steps of
her technique are as follows:
1. Identify and name the concept of interest.
2. Identify surrogate terms and relevant uses of the
concept.
3. Identify and select an appropriate realm (sample)
for data collection.
4. Identify the attributes of the concept.
5. Identify references, antecedents, and consequences
if possible.
6. Identify concepts related to the concept of
interest.
57
58
7. Identify a model case of the concept.
S ele c t i n g a medium of expression precedes the
performance of a concept analysis and sets the direction
for data collection. The written word and the spoken word
are considered the two most common forms of medium of
expression.
In this study, the written word was chosen as the
medium of expression, and was operationalized as the
professional literature, in the form of books and journal
articles, identified and selected based on pre-established
search and sampling criteria, from the disciplines of
management, health care management, and nursing management.
These disciplines provided the boundaries from which the
sample was identified and selected. Search periods were
selected based on 1) known history of the concept's
existence within each discipline's literature (i.e., 1974-
1989 for management; 1980 - 1989 for health care
management; 1983 - 1989 for nursing management) and 2)
online data retrieval constraints. Each discipline was
operationally defined as follows:
Management: the body of management literature identified
and selected from computerized searches of the DIALOG
database categories of Books, Business Economics,
Management, and Market Research, on the search term,
strategic management, according to the time period covered
59
for each file in these categories.
Health Care Management: the body of health care management
literature identified and selected from computerized
searches of the DIALOG database category of Medicine (with
the exception of file #218 (see below) the Cumulative
Index to Nursing and Allied Health Literature), the Health
Planning and Administration database, and the Books in
Print Plus database, on the search term, strategic
management, according to the time period covered for each
file or database.
Nurs ina Management; the body of nursing management
literature identified and selected from computerized
searches of the DIALOG database category of Medicine, file
# 218 (the Cumulative Index to Nursing and Allied Health
Literature) , the Health Planning and Administration
database, the Books in Print Plus database, and from manual
searches of five specified nursing management journals, on
the search term, strategic management, according to the
time period covered for each file or database.
Literature Search Procedures
Computer Searches
Dialog. Using the search term, strategic management,
and the DIALINDEX feature of DIALOG, a general overview
search of multiple database categories was performed.
Appendix G presents an overview of the DIALOG database
60
system (Dialog, 1988), Appendix H lists the specific
database categories searched in this study, and Appendix I
presents information about the specific databases searched
in each category. A total of 27 databases for management,
8 for health care management, 1 for nursing management and
21 for other were searched. The time periods covered for
each database varied, reflecting constraints such as the
file's duration of existence, frequency of updating, and
online data storage and retrieval ability. Collectively,
the files reflected periods starting in the 1960's (N =
13/22%), the 1970' s (N = 26/41%) and the 1980's (N =
23/37%).
The DIALINDEX feature permitted the widest possible
overview of published materials and yielded specific
information on the database locations of citations
containing the search term. Based on these results,
customized searches of categories and databases were
performed, resulting in printing of individual citations
(with abstracts as available). The population of citations
obtained was reviewed and sorted according to literature
type and discipline.
Health Planning and Administration. Using the search
term, strategic management, the Health Planning and
Administration database was searched to locate citations
specific to health care management and nursing management.
61
The search covered the period of 1/1975 through 8/1989.
Books in Print Plus. Two searches of the Books in
Print Plus were performed, both for the period 1/1983
through 8/1989. The first used the search term, strategic
management, to locate citations in health care management.
A second search, using the search terms "nurse/nursing" and
"management/administration" was done to identify nursing
management citations. Additional manual searches were
performed as described below.
Manual Searches
A manual search of five management-focused nursing
journals was performed in an attempt to locate citations
not captured in the computerized searches. This was
necessary because many health care-focused databases do not
require authors to submit abstracts. As a result,
computerized searches can only identify a citation if the
search term is in the title or is listed as an identifier
or descriptor term in the citation. This manual search
covered the period 1/1983 through 12/1989, the literature
review period of the nursing management literature. The
following journals were selected as representative
examples of those with a nursing management focus: Nursing
Management; Journal of Nursing Administration: Nursing
Economics; Nursing Administration Quarterly; and Nursing
and Health Care.
62
The nursing management books identified in the Books in
Print F3ns search were manually examined for the presence
of the term, strategic management in the index.
Discussion
The broad spectrum search approach used in this study
is recommended, but it has limitations. One of these is
the fact that journals can and are indexed by more than one
file, resulting in repetition of citations among files.
The decision to search files similar in focus was
based on the knowledge that the configuration of citations
results from sets of software decision rules which differ
among files. While the inclusion of citations in files is
primarily directed by source, the ability to locate and
extract a citation is determined by two criteria: 1) the
format of the search request and 2) the number and type of
d es c r i p t o r and/or identifier terms included in the
citation. However, even with the duplication created, the
broad spectrum search approach is recommended as the most
sound and economic means to maximize the potential for
each existing citation's identification.
Literature Sampling Procedures
Overview
Researchers performing concept analysis studies use
both probability and nonprobability sampling techniques.
Probability sampling is based on the premise that each
63
element of a population having an equal chance for
inclusion maximizes the representativeness of the sample
and, by doing so, strengthens the validity of the study
findings. As such, probability sampling is the model
espoused for scientific inquiry (Kerlinger, 1986, p. 110).
Nonprobability sampling is regarded by many as the
method of choice only if probability sampling cannot be
done. This position, however, demonstrates a constrained
view of representativeness by ignoring the need to include
consideration of the purpose of the research and the
research objectives when selecting a sample.
The equal chance for inclusion provided in probability
sampling assumes an equality of value among all elements of
the population of interest. In some studies, however,
nonprobability sampling may result in a genuinely more
"representative" sample by making a deliberate effort to
select sample elements on the basis of criteria which
directly support the research purpose and its objectives
(Treece & Treece, 1977, p. 104).
Morse (1986) provides a thorough and insightful
discussion of the differences in assumptions, purposes and
limitations in probability and nonprobability sampling.
Key points from her discussion are as follows:
Probability Sampling:
1. It is based on the laws of chance and theory of
64
probability.
2. The most common uses of probability samples are to
determine the distribution of a variable in a population
and to test relationships between variables.
3. Limitations include:
a. cannot be used to obtain information about the
meaning of a construct.
b. requires the researcher to know a great deal
about the population in order to identify the sampling
frame and draw the sample.
c. confusion between concepts and demographic
characteristics can occur.
Nonprobability Sampling:
1. The underlying assumption is that all population
elements are not equal.
2. It is a method that assists a researcher who is
interested in meaning, seeks to understand a concept or
make sense of a setting.
3. Data collection and analysis occur simultaneously.
4. Most common types are volunteer, snowball and
purposive, with purposive the preferred method. It allows
the researcher, after becoming familiar with the setting
and the participants, to select into the sample according
to theoretical needs and the direction of the research.
5. Nonprobability sampling seeks to facilitate
65
understanding, description, and to elicit meaning, allowing
the researcher to develop rather than test theory.
6. A limitation of the use of nonprobability samples
is in generalizability. This is because the distribution
of the phenomenon in the population usually is not known.
Morse (1986) suggests that appropriateness and adequacy
be used as the criteria to evaluate samples. She defines
appropriateness as the degree to which the method of
sampling fits the purpose of the study (as determined by
the research question), and adequacy as sufficiency and
quality of the data. Using Morse's (1986) reasoning, a
nonprobability sample's appropriateness and adequacy should
be evaluated by the quality, completeness and amount of
information contributed by the sample elements. Morse
(1986) cautions that researchers must accept the
restrictions and limitations of the real world and attain a
balance between the ideal and the feasible in sampling.
Based on this review, a nonprobability sampling
approach and the technique of purposive sampling was
determined to be best suited to support the purpose of the
research and the research objectives for this study.
Purposive sampling was o perationalized through the
development and application of sampling criteria which
resulted in the following outcomes:
1. the selection of literature across time and
66
across disciplines
2. the selection of literature by major writers
3. the selection of literature which focused on
strategic management as a concept.
Management Literature
Purposive sampling was applied to the management
literature as follows:
Seven purposive sampling criteria based on the method
of analysis were developed and used to select the journal
citations. All journal citations which met criteria #1,
plus one or more of the remaining criteria, were selected.
As a result of requesting the long format, journal citation
p r in t o u t s included abstracts. These permitted the
screening and selection of citations which met the seven
purposive sampling criteria identified below.
Journal Citations: Sampling Criteria.
1. The article employed the concept in a manner
germane or apropos to the purpose of the study and the
research objectives (relevant u s e ) .
2. The article used substitute terms to refer to the
concept (surrogate terms).
3. The article described or discussed descriptors or
defining characteristics of the concept (attributes).
4. The article described or discussed events or
67
phenomena preceding the occurrence or existence of the
concept (antecedents).
5. The article described or discussed events or
phenomena following or resulting from the occurrence or
existence of the concept (consequences).
6. The article described or discussed concepts
similar to the concept (related concepts).
7. The article described or discussed a range of
events, situations or phenomena over which the application
of the concept was considered appropriate (references).
Citations selected covered the period of 1973 through
1989 and represented 74 different journals. Appendix J
presents a year/journal matrix summary of this sample.
The use of these criteria resulted in the exclusion of
the following types of citations:
a. case studies (whether by firm, strategic group,
region or industry).
b. discussions of particular strategy content or
process components (e.g., market share determination,
environmental scanning), strategy applications (e.g.,
downsizing, joint ventures, acquisitions, etc.), or
management tasks/behaviors (e.g., portfolio analysis).
c. citations demonstrating "broken" term use (e.g.,
strategic communications management).
d. citations focusing on particular role
68
performance (e.g., CEO behaviors, top management team
attributes, job characteristics of human resource
professionals, economists, marketers, etc.).
e. educationally-focused citations (e.g.,
curriculum programs, educator behaviors, learning needs of
managers, etc.).
Book Citations: Sampling Criteria.
Book citations covered the period of 1976 through
1989. Because no form of book citation printout contained
abstract-like information, the previously developed journal
citation purposive sampling criteria could not be applied
to books. Instead, two purposive sampling criteria
specific to books were developed and used to select the
book citations. Each book selected met one or the other
of these criteria. The criteria developed were as follows:
1. The book was written or edited by an author or
author group with two or more book publication credits in
strategic management.
2. The book presented a unique approach to or an
unusual focus on strategic management
Author frequency of publication and book focus served
as the bases for these criteria. To determine author
frequency of publication, citations were arrayed in an
author/year matrix, and the author(s) with two or more
publications identified. From this group, one book written
69
or edited by each author/author group represented was
randomly selected for inclusion in the sample (n = 22).
Book focus sought to identify those books which used
and applied the concept, strategic management, in ways
other than the traditional, industrial/commercial case
study approach. To determine book focus, the titles of the
entire population of book citations were reviewed and those
which suggested a unique or unusual approach to strategic
management selected for inclusion in the sample (n = 4).
Health Care Management Literature
Purposive sampling was applied to the health care
management literature as follows:
Journal Citations: Sampling Criteria. The same seven
purposive sampling criteria used to select management
journal citations were used to select the health care
journal citations. The use of these criteria resulted in
the exclusion of the same types of citations noted as
excluded from the management journal literature. Journal
citations selected covered the period of 1974 through 1989
and represented 40 different journals. Appendix K presents
a year/journal matrix of this sample.
Book Citations: Sampling Criteria. The health care
mana g e m e n t book citations selected represented the
population identified from the search. Due to the small
number (n = 3) , the entire population was used as the
70
sample.
Nursing Management Literature
Pur p o s i v e sampling was applied to the nursing
management literature as follows:
Journal Citations: Sampling Criteria. The nursing
management journal citations covered the period of 1983
through 1989 and represented the population identified from
the computerized database and manual searches. Due to the
small number (n = 17) , the entire population was used as
the sample. Appendix L presents a Year/Journal matrix of
this group.
Book Citations:____ Sampling Criteria. The nursing
management book citations represent the sample resulting
from an examination of the nursing management and
administration book population identified from the Books in
Print Plus searches. The criterion for selection was the
presence of the term, strategic management, in the index.
Due to the small number, (n = 3) the entire population
containing the term in the index were included in the
study.
Data Analysis
Overview
In research, data analysis can be performed using a
number of different approaches. This is especially true
for qualitative research (see Leininger, 1985, pp. 57-67).
71
Upon review of Leininger's typology of methodologies for
qualitative research, the methodology of content analysis
was selected as the one most appropriate for use in this
study. Leininger (1985) indicates that two views of
content analysis exist. The first view, which is
quantitative in focus, describes content analysis as a
research technique for the objective, systematic, and
quantitative description of the manifest content of
communications (Holsti, 1968). Holsti (1968) and
Krippendorff (1980) are present day examples of proponents
of this view. The quantitative approach to content
analysis has dominated its performance for nearly thirty
years.
In the early 1980's, another view came forward to
challenge the quantitative approach to content analysis.
Qualitative in focus, it described content analysis as a
research technique primarily concerned with identifying
and understanding the structural features and meanings in
communications. The quality and characteristics of these
features and meanings are the important outcomes of
analysis for those who ascribe to this view. Lindkvist
(1981) and Rosengren (1981) are present day examples of
proponents of this view.
Upon consideration of these views, both were
determined to have merit and utility for this study.
72
Consequently, an integrated approach to content analysis,
one with steps consistent with both views, was used. This
integrated approach was characterized by the selective use
of numerical indicators (such as frequency counts) and by
the use of narrative discussion and textual examples of
findings.
Wilson (1989, pp. 469) describes content analysis as a
procedure for analyzing unstructured qualitative data which
consists of three basic steps:
1. Deciding on the unit of analysis.
2. Borrowing or developing a set of categories.
3. Developing the rationale and illustrations to
guide the coding of data into categories.
The concept analysis element (CAE) specification process
follows the completion of these steps.
In STEP ONE, text segments (e.g., words, phrases, or
sentences) were selected as the unit of analysis. In STEP
TWO, categories were developed based on the steps of
Rodgers' (1989) technique of concept analysis and the
additional category of definitions. The specific
categories used in this study were: 1) relevant use; 2)
definitions; 3) surrogate terms; 4) antecedents; 5)
consequences; 6) related concepts; 7) references; and 8)
attributes. The category, definitions, was included to
assist in isolating examples of relevant use. Definitions
73
were selected for this because they are the most common
places where writers indicate how they are using a
concept. As a result, findings in the category,
Definitions, will be discussed in Chapter IV (Results) in
relationship to relevant use, and not as a separate
concept analysis element category.
Category definitions initially were presented in
Chapter I. The following category definitions represent a
more detailed operationalization of these initial category
definitions. These guided the coding of data into
categories.
1. Relevant Us e . Use is the most general level of
discussion of a concept. It is the common manner in which
the concept is employed. In order to clarity and focus
efforts directed at examining and describing use of a
concept, discussion centers on relevant use. Relevant
refers to that which is pertinent, germane, material or
apropos to the discussion at hand (Merriam-Webster
Dictionary, 1974, pp.589). This approach is in contrast
to use as inclusive of all the ways a concept is employed.
In research, limiting a concept's discussion to its
relevant uses does not imply any negative connotations to
those uses not included. Instead, it provides a means to
focus discussion of the concept in terms of the purpose of
the study and the research objectives.
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As an example, in the management literature, a frequent
relevant use of the concept, strategic management is to
describe a process.
2. Definitions. A definition is a statement which
attempts to assign meaning to a phenomenon. Definitional
statements often begin as "strategic management is...".
For this study, definitions included those statements
identified in the literature samples which do one or more
of the following:
a. operationalize the concept, i.e., describe
the conditions or means necessary to produce
it or which result in it.
b. describe the scope of the concept.
c. describe the limitations of the concept.
d. describe the concept's role and/or function.
e. use a metaphor to demonstrate the concept.
f. use a model to identify elements of the
concept.
In the management literature, a frequent definition of
stra t e g i c management is as a process by which the
organization establishes and maintains alignment with its
environments.
3. Surrogate Terms. Individual concepts are not
necessarily employed in association with only one term.
Rather, there may be several terms that serve as
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manifestations of the concept. Such substitute or
alternative terms used to refer to a concept are known as
surrogate texms. The term "business policy" is an example
from the management literature of a term frequently used
interchangeably (i.e., as a surrogate term) with strategic
management.
4. Antecedents. Antecedents are events or phenomena
that are generally found to precede the occurrence of a
concept. In the management literature, phenomena such as
drastic change, environmental turbulence, complexity and a
sense of threat frequently are mentioned as conditions
which preceded (and contributed to) a decision to practice
strategic management. Another group of antecedents are
those p h enomena w h ich frequently are mentioned as
approaches to management which preceded or evolved into
strategic management. These most often include various
types of planning and budgeting behaviors, such as long
ra nge planning, strategic planning, and p o rtfolio
management.
5. Consequences. Consequences are events or
phenomena that are generally found to follow or result from
the occurrence of the concept. Consequences reflect the
outcomes of the use and application of the concept. These
outcomes are most often discussed as positive (e.g.,
survival, success, attainment of competitive advantage,
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etc.)/ but negative outcomes also sometimes are discussed
(e.g., power shifts, organizational upheaval, chaos, etc.).
6. Related Concepts. Concepts related to the concept
of interest are similar to it, but different in that they
lack one or more of the attributes of the concept of
interest. Related concepts provide a way of recognizing
the actual and potential interrelatedness of concepts in
general, and the likelihood of their change over time. In
the management literature, classical program management and
organizational development are two examples of concepts
which share some, but not all, of the defining attributes
of strategic management.
7. References. References are the range of events,
situations or phenomena over which the application of the
concept is considered to be appropriate. Appropriateness
is a function of the common and accepted use and
application of the concept. In the management literature,
the organization is a frequently cited reference of
8. Attributes. Attributes are the descriptors or
defining characteristics of a concept. Attributes explain
or describe aspects or components of a concept. These
aspects/characteristics/components, taken collectively,
build a "picture" or definition of the concept. In the
management literature, strategy, structure, and systems
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are consistent examples of attributes of the concept,
Data Coding
The THIRD STEP in performing a content analysis
involves developing the rationale and illustrations to
guide the coding of data into categories. Wilson (1989,
p. 470) notes that this task requires the coder to make a
decision as to the most correct category for each unit of
analysis. Clearly defining the categories and using
examples from the data to illustrate their properties are
vital tasks to ensure coding accuracy and consistency.
In this study, coding was performed according to the
following steps and using the following example:
1. Segments of text were identified and selected for
coding using the research objectives, the concept analysis
element (CAE) categories to which they referred, and the
category element definitions as guides.
EXAMPLE: "A rapidly changing environment has forced
major changes in health care delivery today."
2. Each text segment selected was labeled with a
theme, using key words in the text segment which
demonstrated that theme.
EXAMPLE: theme = rapidly changing environment.
3. Through a second reading of the selected text
segments, the researcher examined and reflected upon the
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chosen themes in an effort to determine their accuracy in
describing the particular segment.
EXAMPLE; is "rapidly changing environment" the best
description of this text segment's theme?
4. Each text segment selected was assigned to a
concept analysis element (CAE) category based on the
relationship between the content of the text segment and
category element definitions.
EXAMPLE: the theme, "rapidly changing environment,"
assigned to the antecedent category.
5. Lists of themes in each concept analysis element
(CAE) category were initiated and maintained.
EXAMPLE: antecedent themes: rapidly changing
environment, changing technology, turbulent marketplace,
increased competition, economic decline, etc.
6. In each concept analysis element category, themes
were examined and reflected upon to identify similarities
and differences among them.
EXAMPLE: antecedent themes in #5.
7. Similar themes were clustered together in groups.
EXAMPLE: antecedent themes: one group, labeled
"CHANGE", might consist of the following: rapidly changing
environment, changing technology, social change,
deregulation, and changing consumer behavior.
8. Through a review of the groups(s), the researcher
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reflected upon the appropriateness of each theme's
assignment to that cluster. Cluster group composition
revisions were based on this review.
EXAMPLE; should each of the themes clustered
together in the group in #7 remain there?
9. Each group was named by means of a label. Each
label described the most significant shared feature
present among the group themes.
EXAMPLE: for the group in #7, the label, CHANGE.
10. Through a review of the group labels, the
researcher reflected upon them to determine the extent to
which they accurately described the most significant shared
characteristic of the cluster. Labels were revised as
necessary to improve their descriptive power.
EXAMPLE; does the label, CHANGE, for the antecedent
group in #7 reflect the most signif i c a n t shared
characteristic among these antecedent themes?
Concept Analysis Element Specification
With the completion of data coding process, specifying
each category's concept analysis elements began. In this
study, concept analysis element specification was performed
according to the following steps and using the following
example.
1. In each concept analysis element category, the
groups identified were analyzed for common foci and then
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arranged into sets of groups.
EXAMPLE: In the category, Antecedents, a group of
themes labeled "environmental complexity" was clustered
with a group of themes labeled "formation of complex
organizations".
2. A label was applied to each analysis element group
set. This label was operationally defined as that element
(e.g., an antecedent).
EXAMPLE: The two groups of themes clustered together
in #1 above were labeled, Complexity.
3. All of the labels in each analysis element were
considered, resulting in label wording refinement.
EXAMPLE: In the category, Antecedents, the concept
analysis element label, Complexity, was considered and
determined to be the best label wording for the two groups
of themes it represented.
4. Dimensions within concept analysis elements were
specified where such dimensions were evident.
EXAMPLE: In the category, Antecedents, no dimensions
within its elements were evident.
Collectively, the steps of data coding and concept
analysis element specification represent the Concept
Analysis Element (CAE) Generation process. This process is
depicted in Table 2.
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Table 2
Concept Analysis Element (CAE) Generation Process
DATA CODING STEPS
1. Identification of text segments
2. Labeling of text segments with themes
3. Reflection: Accuracy of theme as a descriptor
4. Assignment of themes to CAE categories
5. Initiation and maintenance of lists of themes
6. Reflection: Similarities and differences among
themes
7. In each CAE cateory, clustering of similar themes
into groups
8. Reflection: Appropriateness of theme assignment
9. Labeling of groups according to most significant
shared feature
10. Reflection: Appropriateness of group labels
CONCEPT ANALYSIS ELEMENT SPECIFICATION STEPS
1. In each CAE category, clustering of similar groups
into sets
2. Labeling of group sets = RESULTS IN A CONCEPT
ANALYSIS ELEMENT (e.g., an attribute)
3. Refinement of concept analysis element wording
4. Specification of dimension(s) within concept
analysis elements.
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Validity and Reliability
Validity
Measures to enhance methodological rigor first sought
to support the content validity of the literature sample by
confirming that it contained the key, critical literature
relating to the topic from each discipline. This was
accomplished by creating master citation lists, organized
by discipline, of the books and periodical literature
identified as a result of the purposive sampling technique
previously discussed. Initially, five strategic management
experts in each discipline were identified and queried by
letter to solicit their participation as reviewers of these
lists (Appendix M) . The initial reviewers were identified
based on the following factors:
1. duration and frequency of publications on the
topic.
2. frequency of their citation by others.
3. being currently active in roles such as writer,
researcher, educator and/or practitioner of
Replies from these included recommendations for four other
individuals to serve as reviewers. As a result, a total of
nineteen experts in strategic management from each of the
disciplines represented (i.e., 7 in management, 6 in health
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care management, and 6 in nursing management) were queried
by letter to solicit their participation as reviewers.
After an initial and a repeat mailing two weeks later a
total of 7 experts (3 from management, 1 from health care
management and 3 from nursing management) agreed to serve
as master citation list reviewers. The list of
participants, with comments on their credentials, appears
in Appendix N.
Those agreeing to participate received a copy of the
master citation list for their discipline. The Master
Citation List form (Appendix 0) consisted of two parts:
1. a set of forced choice response categories
requiring respondents to indicate their assessment of the
importance of including each listed citation in the sample.
2. a comments section where respondents were could
write in additional citations which they considered
crucial for inclusion in the sample.
Reliability
Intrarater
Reliability was addressed from two perspectives. The
first focused on researcher intrarater reliability on theme
identification and assignment to concept analysis element
(CAE) categories. Fifty percent of the total number of
citations and their originally selected text segments were
re-read, the coding repeated and findings
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compared with that done initially. An intrarater
reliability score resulted from each citation review and
comparison, and the total group of scores summed and
averaged.
Interrater
Two external readers were used to evaluate interrater
reliability. Two nursing doctoral student colleagues who,
along with the researcher, had taken an introductory
course in qualitative research, served as external readers.
This course established a baseline of knowledge regarding
this research technique. Additionally, in preparation for
their participation in this study, the researcher provided
individualized training and practice in the coding process
developed for use in this study, along with a set of
written coding instructions (Appendix P) . The external
readers received Concept Analysis Coding Forms (Appendix Q)
and text materials which included selections from the
samples of each of the three disciplines reviewed in the
study. The readers coded the identified text segment,
specifying their themes and assigned them to the concept
analysis element (CAE) categories. Ten percent of the
total retrieved literature sample was reviewed in this
manner. This percentage was determined to be appropriate
based on the use of two readers and the requirement that
each literature element attain an interrater reliability
score of 80% as a minimum. The readers' completed coding
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forms were compared with those of the researcher, and an
interrater reliability score calculated for each form. A
minimum score of 80% was considered acceptable. The
interrater reliability score was computed based on a
comparison (between the coder and the researcher) of the
total number of matching notations identified for all eight
categories listed on the coding form. Coding forms were
completed and returned to the researcher in accordance with
the time frames specified in the directions. Findings were
documented on the External Reader Inter-Rater Reliability
Record (Appendix R ) .
Summary
This chapter presented a discussion of the methodology
used in this study. Rodgers' (1989) technique of concept
analysis was discussed as the one chosen to examine the
concept, strategic management.
The wr i t t e n word was chosen as the medium of
expression for this analysis, and was operationalized as
the professional literature from the disciplines of
Operational definitions of these disciplines were provided
which specified the literature boundaries.
Literature search and sampling procedures were
discussed in depth. Search procedures included
computerized searches of multiple databases, as well as
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manual searches. Purposive sampling, a nonprobability
sampling technique, was selected for use.
The searches of the health care management books and
nursing management journal citations and books revealed
populations so small that sampling was deemed
inappropriate. Instead, all located citations in these
groups were included in the study.
A second, broader search of the nursing management
book literature was performed to identify texts which might
contain references to the term, strategic management. All
located books were manually examined and those in which the
term appeared in the index were included in the study.
The data analysis procedure used in this study was
presented, and coding ca t e g o r i e s were defined and
discussed.
The chapter concluded with a discussion of validity
and reliability measures used in the study.
The following chapter presents the results of the
application of Rodgers' (1989) technique in an analysis of
the concept, strategic management.
CHAPTER IV
RESULTS
Introduction
The performance of a concept analysis of the concept,
strategic management, permitted the identification and
analysis of the use and application of this concept across
the disciplines of management, health care management, and
nursing management. The discussion of findings which
follows begins with a presentation of the assumptions
underlying the study. Findings then are organized into
three sections, namely 1) results related to validity and
reliability; 2) results related to search and sampling
outcomes; and 3) results related to research objectives.
Assumptions
As with any research effort, certain assumptions
guided the conduct of the study. In this study, the first
and primary assumption was that the researcher assumed the
validity of Rodgers' (1989) technique of concept analysis.
This assumption is supported by the findings discussed in
Chapter III regarding Wittgenstein's (1953) and Toulmin's
(1972) philosophical approaches to concepts, and Wilson's
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88
(1963) methodological approach to analysis.
A second assumption concerned the relationship between
the concept, strategic management, in the literatures of
management, health care management, and nursing management
and its use among managers in practice. It is assumed that
the fact that strategic management is comprehensively
discussed in the professional literatures of these
disciplines indicates its use by managers in their
practice.
A third assumption concerned the process for locating
the concept in the literatures. Computer technology was
assumed by the researcher to be an efficient and reliable
approach to literature searching.
Lastly, it was assumed that the performance of a
concept analysis on the concept, strategic management,
would result in new knowledge about the concept which would
facilitate its use and application in nursing and promote
interdisciplinary theory development and research.
Results Related to Validity and Reliability
Validity
Master Citation List Review Outcomes and Analysis
A total of seven experts (3 from management, 1 from
health care and 3 from nursing) agreed to serve as master
citation list reviewers. Initially, a criterion of three
reviewers for each discipline was established as the
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minimum number upon which to base response analysis.
Despite mailings to a total of six health care experts,
only one ultimately agreed to participate. As a result, no
health care management reviewer responses were analyzed.
Discipline-specific master citation lists and other
explanatory materials were sent to each of the three
management and three nursing management experts who agreed
to participate. Unfortunately however, despite a time
extension and two follow-up mailings, only the three
management experts returned their reviews in time for
inclusion in the study. As a result, only the management
master citation list reviewer responses were analyzed.
A discussion and analysis of these responses follows.
Management Discipline:
Master Citation List Responses
The management master citation list contained a total
of 206 citations. Analysis of the responses of the
management reviewers revealed the following:
1. A total of 86 (42%) of the listed citations were
rated by one or more of the reviewers as critical or
important for inclusion in the sample.
2. A total of 69 (33%) of the listed citations were
rated by two or more of the reviewers as a "no” (i.e., not
recommended for inclusion in the sample.
3. No consensus among the reviewers was found
regarding rating of citations as "no opinion."
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4. A total of two additional books and no additional
journal citations were recommended by the reviewers.
As a result of these outcomes, the following decisions
were made regarding the management literature sample:
1. The retrieval effort would focus on the critical or
important-rated citations as a first priority.
2. The 69 citations listed as "no" by a majority of
the reviewers would be dropped from the sample.
3. The retrieval effort on those citations rated as
"no opinion" by reviewers (an outcome which occurred in no
consistent pattern among reviewers) would be as a second
prio r i t y (i.e., as many as could be located after
completing retrieval of the citations rated as critical or
important by the reviewers).
As a result of these decisions, the total number of
ma n a g e m e n t l i t e rature citations was reduced to 139
citations (206 - 69 + 2) . This number was ultimately
reduced to 133 citations as a result of the deletion of two
repeat book and three repeat journal citations and the
presence of a skipped number in the citation list.
Reliability
Intrarater
As indicated in Chapter III, fifty percent of the
total number of citations and their originally selected
text segments were re-read, the coding and repeated, and
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findings compared with that done initially. A cumulative,
average intrarater reliability score of 97% was obtained.
Interrater
Two nursing doctoral student colleagues served as
external readers. Each read and coded five percent of the
total retrieved literature sample, using Concept Analysis
Coding Forms (Appendix Q) to document findings. A
comparison of external reader coding with that done on the
same citations by the researcher found that for each
citation, a minimum acceptable score of 80% interrater
agreement was achieved, along with a composite average of
91%. A summary of individual scores for each citation
coded by the external reader is presented in Appendix R.
Results Related to Search and Sampling Outcomes;
Summary of the Management. Health Care Management,
and Nursing Management Literatures
Table 3 d etails the final totals for each
discipline's literature sample, based on search and
sampling outcomes and the analysis of the management master
citation list reviewer responses:
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Table 3
Results Related to Search and Sampling Outcomes
Management Health Care Nursing
Management Management
JOURNAL CITATIONS
Population identified 3385 504 17
Sample selected 118 75 17
Rationale for inclusion (a) (a) All
BOOK CITATIONS
Population identified 180 3 65
Sample selected 15 3 3
Rationale for inclusion (b), (c) All (d)
TOTAL SAMPLE 133 78 20
a = Rationale for inclusion was concept analysis criteria
met and expert review.
b = Rationale for inclusion was purposive sampling
publication criterion met.
c = Rationale for inclusion was purposive sampling unique
focus criterion met.
d = Rationale for inclusion was presence of search term.
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The population of 3385 journal citations identified in
the DIALOG search was reduced to a sample of 118 citations
as a result of duplicates, transfers to the health care
management an d nursing management citat i o n sets,
elimination of non-English citations, the application of
the purposive sampling criteria (see pp. 65-66 of Chapter
III), and the deletions recommended by the majority of
management master citation list reviewers.
The population of 391 management book citations was
reduced to 180, based on the following exclusions:
1. Citations pending publication in 1990 6
2. Citations listed as out of print 7
3. Repeat citations among files 197
4. Non-book citations (journals) 1
211
Application of the purposive sampling criteria (see pp. 67
of Chapter III) to the corrected population of 180 books
and the deletions recommended by the management master
citation list reviewers resulted in a sample of 15
citations. Of these, 11 were selected based on the
publication sampling criterion and four based on the unique
focus sampling criterion. Therefore, the total number of
citations selected in the management literature sample was
118 journals and 15 books.
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Health Care Literature
A total of 504 journal citations were identified, of
which 2 36 were found in DIALOG and 268 in the Health
Planning and Administration database. This population was
reduced by elimination of duplicates and the application of
the same purp o s i v e sampling criteria developed for
management journal literature (see pp. 65-66 of Chapter
III) to a sample of 75 citations.
A total of three book health care management book
citations were identified from the Books in Print Plus
search. Due to the small number, all were entered into the
health care management literature sample. As a result, the
total number of citations selected in the health care
management literature sample was 75 journals and three
books.
A total of 17 journal citations were identified in the
nursing literature on the topic of strategic management.
Of these, 8 were found in DIALOG, 8 in Health Planning and
Administration, and one from a manual search of selected
nursing management journals. Due to the small number, all
were entered into the nursing management literature sample.
A total of four nursing management book citations
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were identified as containing the term, strategic
management. These were located by means of two Books in
Print searches. The first search used the term, strategic
management, as a title and located one citation. However,
no other mention of strategic management was found in the
text, and so the citation was dropped from the sample. A
second search focused on identifying nursing management and
nursing administration books in general. A total of 65
books were identified. Of these, 92% were retrieved and
examined for the presence of the term, strategic
management. Three contained it. Due to the small number,
all were included in the nursing management literature
sample. As a result, the total number of citations in the
nursing management literature was 17 journals and three
books.
Sampling and Retrieval Outcomes
Table 4 lists the subtotals for each discipline's
literature sample, retrieval outcomes for each sample, and
the grand total of the sample for this study.
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Table 4
Discipline-Specific Sampling and Retrieval Outcomes
DISCIPLINE SAMPLING OUTCOMES RETRIEVAL OUTCOMES
MANAGEMENT: 118 journal citations 87 citations (74%)
15 book citations 13 citations (87%)
Subtotal: 133 citations 100 citations (75%)
HEALTH CARE
NURSING
TOTALS:
Journals: 210 journal citations 179 citations (85%)
Books: 21 book citations 19 citations (90%)
TOTAL: 231 citations 198 citations (86%)
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Results Related to Research Objectives
Overview
In this study, a concept analysis of the concept,
strategic management, was performed using Rodgers' (1989)
technique of analysis. This technique was selected because
of its strong consistency with both the philosophical and
methodological approaches to concepts acknowledged as the
most influential in shaping present day views of concepts.
Specifically, Rodgers' technique is consistent with the
philosophy of science view of concepts offered by Ludwig
Wittgenstein (1953) and with the philosophy of language
view espoused by Stephen Toulmin (1972). These two
philosophers consistently have been identified as major
contributors to knowledge in their respective disciplines,
and acknowledged as primary influentials on the present day
view of concepts.
Rodgers' (1989) technique also is consistent with the
focus and major steps of Wilson's (1963) seminal work on
the technique of concept analysis. Rodgers' (1989)
technique reflects an interpretation of Wilson (1963)
co n s i s t e n t with the philosophical and theoretical
frameworks of Wittgenstein (1953) and Toulmin (1972). As
such, her technique represents an opportunity for knowledge
development in nursing to proceed in accord with present
day philosophical and methodological views.
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As noted in Chapter I, the research objectives of this
study are as follows:
1. to identify the relevant use of the concept,
2. to identify surrogate terms for the concept,
management, and nursing management literatures
3. to identify antecedents of the concept, strategic
4. to identify consequences of the concept, strategic
5. to identify concepts related to the concept,
6. to identify references of the concept, strategic
7. to identify attributes of the concept, strategic
8. to identify a model case of the concept, strategic
management, for nursing management.
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9. to compare and contrast attributes in
a. the management and health care management
literatures.
b. the man a g e m e n t and n ursing management
literatures.
c. the health care management and nursing
management literatures.
Results related to these objectives will be presented
separately for each discipline's literature and in the
order of the listed objectives. For each discipline's
literature, the discussion of objective #1, relevant use,
will include example definitions, as these are the most
common places where writers indicate how they are using a
concept. Additionally, Chaffee's (1986) examination of the
conceptual evolution of the concept, strategy, and the
three models of it she identified in the business
literature, also will be presented in the discussion of
relevant use for the following reasons: 1) as an example
of research on conceptual evolution which demonstrates
strong consistency with and support of the philosophical
basis of this study (i.e., Wittgenstein's (1953) and
Toulmin's (1972) views of concepts as previously discussed
in Chapter II) ; and 2) as an assist to understanding
findings regarding the use, application, and definition of
the concept, strategic management, in this study.
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Interpretation and discussion of findings will include
issues of consensus and disagreement regarding the concept
across disciplines. The chapter will close with comments
on Rodgers' (1989) technique of concept analysis.
Overview
Since its entry into the management literature in the
1960's, the concept, strategic management, has evolved in
accordance with the reality of management practice. A
large volume of descriptive, advocative, and empirical
writings exist. Descriptive and advocative citations
frequently employ a macro approach to discussion, while
the majority of empirical work is conducted and reported at
the individual organization level, most often in the form
of a case study. When a macro approach is used in
management's empirical literature, it frequently is
characterized by studies of industry practices, issues
impacting on performance (in economic terms) and
organizational structure-strategy relationships. Globally,
a limitation of the literatures is the lack of
investigation of fundamental research areas, such as a
detailed examination and discussion of concepts used as
variables in these studies. Keats' (1986) examination of
the construct, business economic performance, is one
example of research that is contrary to this trend.
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While strategic management has been and continues to be
linked with a number of other concepts (e.g., strategic
planning and transformational leadership), its strongest
link is with the concept of strategy. Chaffee's (1986)
work on the evolution of the concept of strategy offers
substantive insight into the evolution of the concept,
strategic management. Perhaps most important is that her
findings regarding the concept, strategy, support Toulmin's
(1972) contention that concepts exhibit diversity and
variation over time. In doing so, her research strengthens
the basis for rejection of the view of concepts as
universals, unaffected by change and motion in the world,
and strengthens the basis for acceptance of the reality of
conceptual change.
Relevant Use
Relevant use is the employment of a concept in ways
that are pertinent, germane, material, or apropos to the
discussion at hand (Merriam-Webster Dictionary, 1974,
pp.589). As noted earlier, limiting discussion of a
concept to its relevant use provides a means to focus that
discussion in terms of the purpose of the study and the
research objectives.
In the management literature, relevant use of the
concept, strategic mangement, began and continues to be
primarily to describe a process. Chaffee (1986) credits
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Ansoff and Hayes (1976) with introducing the concept.
However, in this study, journal citations were identified
which precede their text.
Ansoff and Hayes (1976) wrote of the need to move away
from the concept, strategic planning, and to one (strategic
management) which addressed more variables and issues
consistent with the reality of management practice. In
essence, they advocated that the task of strategic planning
be replaced by the process of strategic management. In the
literature sample used in this study, terms such as model,
framework, means, and system frequently were used
interchangeably with the term, process.
Relevant use of the concept, strategic management, to
describe a process has remained remarkably consistent in
the literature across time. However, change has occurred
in two areas, namely: 1) in the number and types of
purposes for use of strategic management as a process and
2) in the scope of applicability and degree of complexity
of the process itself.Definitions of strategic management
will be used to assist in illustrating these changes.
As noted earlier, definitions assist in isolating
examples of relevant use, and are the most common places
where writers indicate how they are using a concept. As a
result, all findings in the category, Definitions, will be
discussed in relationship to relevant use, and not as a
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separate concept analysis element category.
Definitions of strategic management across time were
found to contain recurring references to a number of
concepts. The most prominent concept mentioned in these
definitions was that of strategy.
Strategy presents as a consistent and recurring theme
relating to strategic management. Chaffee (1986) examined
what she called "the business literature" (p. 138) (which,
in this study, is called the management literature), for
the period 1962 through 1983, in order to perform an
indepth analysis of the evolution of the concept of
strategy. She organized her findings by identifying three
models of strategy present in the literature. These models
demonstrated change in the use, application and definition
of the concept of strategy over time. Table 5 presents
i llu s t r a t i v e examples of d efinitions of strategic
management organized according to Chaffee's (1986) three
models of strategy.
104
Table 5
Relevant Use of the Concept. Strategic Management:
Definitions and Strategy Models; Management Literature
DEFINITIONS STRATEGY MODEL
1. A management system for formulating, Linear
and implementing strategy.
2. A process consisting of strategic Linear
planning and strategy implementation.
1. A process to ensure long-term growth Adaptive
via continuous adaptation to changes
in the environment.
2. The management of competitive advantage. Adaptive
1. The process of creating and maintaining Interpretive
systems of shared meaning that facilitate
organizational action.
2. A cultural process aimed at altering Interpretive
managers' interpretations about the
fundamental nature of the organization
and their roles in it.
105
The first of these, the linear model of strategy,
dominated from the early 1960's through the late 1970's.
The initial description of strategic management as a
process is predicated upon this model. Here, strategy is
viewed as a series of decisions designed to achieve
organizational goals. Planning is the essence of strategy
in this model. Terms such as strategic planning, strategy
formulation and strategy implementation are consistently
associated with it.
The existence of the linear model of strategy and its
use as a foundation for the early literature in strategic
management helps explain the finding that management
writers of the late 1970's (specifically those whose works
were included in this study) frequently used strategic
planning as a surrogate term for strategic management.
Movement away from the linear model of strategy
occurred in the late 1970's. Environmental complexity-
technical, economic, informational, and psychological
complexity (among others) - increased at an unparalleled
pace and forced the management discipline to seek new and
better ways to cope. From this situation came the adaptive
model of strategy.
In the adaptive model, strategic management's relevant
use is still as a process, however, its purpose changed
106
from that of organizational goal achievement through
planned strategies to the purpose of achieving a viable
match between the organization and its environments.
The adaptive model of strategy introduced the
opportunity for growth in the scope and depth of the
strategic management process by its inclusion of more
variables in the process and by its view of the strategic
management process as a way for the organization to deal
with the environment. Despite its apparent advantages over
the linear model, however, the adaptive model still did not
account for all of the variables in modern day management
practice or all cf the complexity present. To address
these needs, a third model, the interpretive model of
strategy, emerged.
As in its predecessors, strategic management's relevant
use again is to describe a process, however, the nature of
process has changed. The interpretive model of strategy is
based on a social contract view of the organization. Thus,
corporate culture, symbolic interaction, and perceptual
congruence are vital model variables. Van Cauwenberg and
Cool (1982) have suggested that this model of strategy
differs from the other two in three significant ways:
1. Organizational reality is considered to be
107
incoherent rather than coherent.
2. Strategy is an organization-wide activity.
3. Motivation is the critical factor in achieving
adequate strategic behavior.
In summary, the relevant use of the concept, strategic
management, in the management literature has been to
describe a process. This use has been consistent over
time, with changes occurring in the number and types of
purposes for using it as a process and in the scope of
applicability and degree of complexity of the process
itself. Definitions were suggested as an appropriate
starting point for identifying uses of a concept.
Definitions of strategic management identify the concept of
strategy as the most prominent component in the strategic
management process. Chaffee (1986) identified three models
of strategy from her review of the literature. Definitions
of strategic management consistently matched the
descriptions of Chaffee's (1986) models of strategy,
indicating that the evolution of the use of the concept
strategic management is linked to the evolution of the
concept of strategy.
Surrogate Terms
Surrogate terms are substitute or alternative word
labels used to refer to a concept. A total of eleven
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surrogate terms for the concept, strategic management, were
identified in the management literature. Of these,
business policy was by far the most frequent, followed by
strategic planning and strategic decision-making. Table 6
lists these terms.
Use of the term strategic planning as a surrogate term
occurred throughout the 198 0's. This finding is
interesting in that Chaffee's (1986) work would have
predicted it to occur in the late 1970's, when the linear
model of strategy was dominant. The continued use of
strategic planning as a surrogate term for strategic
management in the middle to late 3.980's (the time period
after Chaffee's 1986 work) appears to indicate that 1) the
linear model of strategy continues to influence the
strategic management literature and 2) diversity in the use
of the terms strategic planning and strategic management
among management writers continues to the present.
109
Table 6
Surrogate Terms of the Concept. Strategic Management:
TERM EXAMPLES FREQUENCY CITATION Y E A R (S )
Business policy 8 1976, 1980, 1980,
1981, 1981, 1982
1986, 1989
— business strategy 2 1980, 1981
— business planning 1 1980
Strategic Planning 6 1980, 1984, 1985,
1986, 1987, 1988
Strategic Decision-
Making 1975, 1976, 1981
Organizational
Adaptation 1978
General Management 1981
Strategic Behavior 1984
Long Range Planning 1985
Innovation Management 1986
The Strategic Model 1986
Corporate Strategy 1988
Strategic Thinking 1988
110
Antecedents
Antecedents are events or phenomena that generally are
found to precede a concept. A total of nine antecedents
were identified in the management literature. Change,
turbulence, and c o mp lexity were mentioned the most
frequently. In general, antecedents existed in the
external environment and acted as stressors whose presence
chal l e n g e d organizational survival or success. One
exception to this trend was found in a 1982 citation where
the decision to adopt strategic management was preceded by
a broad-based effort by an organization's members to
achieve successful cooperation among themselves. Table 7
presents the identified antecedents of strategic management
and examples of their associated themes.
Ill
Table 7
Antecedents and Associated Antecedent Themes of the
Concept. Strategic Management: Management Literature
CHANGES TURBULENCE COMPLEXITY
environmental discontinuity market conditions
organizational chaotic environment industry growth
demographic globalization organizational
growth
regulatory turbulent market
technologic dynamic settings
UNCERTAINTY INTEGRATED COMPETITION
EFFORT
lack of direction success diversification
unknown future new entrants
information gaps global competition
ECONOMIC STRATEGIC PLANNING STAKEHOLDER
DECLINE INEFFECTIVENESS ACTIONS
obsolescence incomplete implementation coalitions
short PLC* inconsistent market performance demands
*PLC = Product Life Cycle
112
Consequences
Consequences are events or phenomena that generally
are found to follow or result from a concept. The variety
in the number and type of purposes for strategic management
mentioned in the discussion of relevant use have resulted
in a similarly wide array of consequences attributed to
strategic management. Eleven consequences of strategic
management were identified from the management literature.
Positive consequences are most often reported, although
empirical validation is lacking in many cases. Table 8
details th e identified consequences of strategic
management and examples of their associated themes.
113
Table 8
Consequences and Associated Consequence Themes of the
Concept. Strategic Management: Management Literature
BUSINESS SURVIVAL BUSINESS SUCCESS COMMON PERSPECTIVE
sustained balance profitability member commitment
effectiveness efficiency cohes iveness
operational growth shared values
performer competitive advantage goal agreement
COMMON CULTURE PLAN/ACTION LINKS CREATION OF FUTURE
teamwork consistent implementation vision
7S element fit coherent strategy corporate
guidance
managed conflict plan/operation sync world view
CHANGE MANAGEMENT EMPLOYEE ENHANCEMENT RESISTANCE
adaptation increased motivation less to change
risk-taking success increased satisfaction
ENHANCED STRATEGIC CREDIBILITY IMPLEMENTATION PROBLEMS
consistent market performer insufficient planning
established reputation inaccurate action plan
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Related Concepts
Related concepts are ones which are similar to the
concept of interest but differ in that they lack one or
more of its attributes. A total of ten related concepts to
the concept, strategic management, were identified from the
management literature. Four of these, strategic planning,
marketing, administrative behavior and industrial
organization, were cited more often than others. Table 9
lists the ten concepts identified as related to the concept
Table 9
Concepts Related to the Concept. Strategic Management:
Rational problem solving Industrial organization
Decision analysis Strategic planning
Long range planning Creative management
Administrative behavior Organizational development
Marketing Classic program management
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References
References are examples of the range of events,
situations or phenomena over which the application of a
concept is considered to be appropriate. In the management
literature, the organization is the single most frequently
cited reference of the concept, strategic management, with
terms such as firm, company and corporation used
interchangeably in discussions of it. Overall, the message
of the management literature is that strategic management
is a process p r acticed by and for organizations,
specifically private sector, for-profit organizations.
However, since the mid 1980's, there is evidence in the
literature that the scope of application of the concept,
strategic management has widened. Growth in firm size and
complexity, fueled by conglomerate-building takeover
actions and an upsurge in firm diversification activity has
resulted in very large organizations with highly complex
structures. While corporate-level strategic management
c ontinues to be a significant activity in these
organizations, diversity within and outside the
organization and the complexity inherent in that diversity,
has resulted in fundamental changes in the nature of the
relationship between the organization as a corporate entity
and its business units and functional components.
116
Diversity is manifested in three major phenomena. They are
1) increasing rates of turnover in the content and
structure of the business portfolio (fueled by the need to
respond to changing market conditions); 2) major changes in
the demographic profile of the work force; 3) recognition
of the importance of a constellation of factors (e.g., as
portrayed in the McKinsey 7S Framework) as influencing the
attainment and maintenance of competitive advantage. The
result of these factors has been the extension of the
application of the concept, strategic management, to levels
and components within the organization.
While their strategic plans must be in harmony with the
mission, philosophy and plan articulated at the corporate
level, these elements are characterized as having
significant autonomy in the assessment, planning, and
implementation of their strategy, and their strategic
management process is generally very similar to that of
their parent organization. Most often, these elements are
referred to as strategic business units.
Recently, a small body of management literature has
come forward which includes intra-organizational elements
such as multifunctional units and departments as references
of strategic management. Here again, the extension of the
application of this concept appears to be linked to changes
117
and stressors which have forced a rethinking of existing
management tenets and resulted in an increase in the scope
of application of the concept, strategic management, by
organizations.
In addition to intra-organizational elements, two other
references of strategic management were found in the
literature. First among these is the public or not-for-
profit sector, characterized by government bodies, the
military, and social, cultural and educational associations
and organizations, among others. This finding indicates
that the concept, strategic management, is being embraced
across a wide range of organizational types. Its use in
these new settings is characterized by modification of its
competitive advantage seeking and profit-maximizing private
sector purposes in favor of the setting, mission and
purpose needs in the public and not-for-profit sectors.
Among management writers, there are those who question the
appropriateness of the extension of the concept, strategic
management, to these new settings. This represents a major
research area for this concept.
The other new reference for the concept, strategic
management, is phenomena. Five of the most frequently
cited phenomena over which the application of strategic
m anagement is considered appropriate are innovation,
118
res o u r c e allocation, h u man resources, crises, and
technology. In applying strategic management in this
manner, most writers begin by conceptualizing the concept
as a process, and then proceed to apply it to a variety of
settings and circumstances. Focusing on a single attribute
subdivision area of a concept (in this case, the process
subdivision of the Strategy attribute) as the basis for its
use may prove to be detrimental, in the long run, to the
maintenance of conceptual clarity. Further research on the
linkages among the analysis components in general, and
betw e e n attributes and references in particular, is
necessary to address this issue. The expansion of
references of the concept, strategic management is, in
itself, a major area in need of further research. Table
10 summarizes the references and their associated themes.
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Table 10
References and Associated Themes of the Concept.
Strategic Management: Management Literature
THE ORGANIZATION (PRIVATE) INTRA-ORGANIZATION UNITS
the firm strategic business units
the company multifunctional units
the corporation departments/divisions
PHENOMENA THE ORGANIZATION (PUBLIC)
innovation not for profit businesses
human resources government bodies
resource allocation military
crisis agencies
technology associations
120
Attributes
Attributes are the describing or defining
characteristics of a concept. Attributes of the concept
strategic management identified from the management
literature reflect the evolution of its use and application
in management practice.
Attribute identification began with documentation of
attribute themes found in the literature sample. Over one
hundred twenty-five themes were identified. These
clustered into twenty-seven groups which were analyzed for
the presence of common foci and then arranged into sets of
groups. Six sets of groups resulted from this arranging
process. As occurred with group sets in each of the other
concept analysis category elements, the label applied to
each attribute group set was operationally defined as an
attribute. These attributes were then considered against
the findings in the other concept analysis element
categories, resulting in attribute label refinement and the
identification of two dimensions within five of the six
attributes. Table 11 illustrates the resulting attributes,
their dimensions, and examples of associated themes
identified from the literature.
121
Table 11
Attributes. Attribute Dimensions, and Associated Themes
of the Concept. Strategic Management: Management Literature
STRATEGY STRUCTURE
Process | Content Organization | Environment
Preparation Decisions Type Type
Formulation Priorities Design Design
Implementation Action Plans Fit Fit
Outcomes Type Power Strategic groups
BEHAVIOR PERSPECTIVE
Organization | Environment
Strategic type Turbulence Performance goals
Risk posture Complexity Social role
Leadership Markets Strategic thinking
INFLUENTIALS SYSTEMS
Person I Context Interface | Integration
CEO Resources Information Congruence
Stakeholders Culture Task forces Balance
Managers Competition Corporate/units Excellence
122
Strategy. The attribute, Strategy, accounted for the
largest number and widest range of attribute themes.
These themes spanned the entire time frame of the
literature reviewed (1974-1989) and primarily addressed
either the process of strategy (e.g., pre-strategy
planning, formulation, decision-making, implementation,
evaluation, etc.) or the content of strategy (e.g.,
priorities, decisions, choices, action plans, timetables
and models of strategy). As noted earlier, strategic
management frequently has been described and discussed in
terms of the process aspect of strategy. Numerous writers
have described it as a series of steps or phases applied by
and to individual, private, for profit organizations, and
more recently, to other organizational forms (e.g., public
organizations) and intra-organizational elements (i.e.,
strategic business units, departments, etc.). Most
recently, strategic management as a process aspect of
strategy has been applied to the management of phenomena.
Phenomena examples include innovation, human resources and
technology.
Strategy content themes identified in the management
literature focused on decisions. Priorities, the number
and types of strategy choices present, and the type of
strategy model followed represented themes associated with
123
the content of decisions.
Structure. The attribute, Structure, included themes
relating to its dimensions of organization and environment.
Organizational structure has long been discussed in the
mana g e m e n t literature. Its link with strategy was
solidified by Chandler (1962), whose landmark text was one
of the first to propose the notion that successful strategy
formulation and implementation required an appropriate and
supporting organizational structure. The type of
organizational structure (e.g., flat v. pyramid), the
design of the structure (e.g., matrix v. hierarchical), and
the quality of fit between the organization's structure and
its strategy were the frequent themes associated with the
orga n i z a t i o n a l aspect of the Structure attribute.
Recently, however, the theme of power and the
organizational structure has emerged as another
significant structure-related theme.
While the organizational (or internal) aspect of the
Structure attribute continues to be important in the
management literature, the environmental (or external)
aspect of Structure has increased in significance. A
volume of literature exists dedicated to discussing,
describing and examining the many aspects of environmental
124
structure. Themes found here included environmental type
(e.g., stable v. turbulent), design (e.g., many mature
industries v. emerging ones), fit (i.e., between the
environment and the organization), and the number and
composition of strategic groups in the environment.
Behavior. Behavior, another attribute of strategic
management identified in the management literature, also
demonstrates themes relating to its dimensions of
organization and environment. Themes dealing with
behavior of the organization most frequently involved the
triad of strategic types (usually discussed according to
Miles and Snow's typology), risk posture, and leadership.
Miles and Snow (1978) found that organizations behaved in
one of four ways, based on the focus of the organization's
strategy, the level of risk accepted, and the quality of
leadership present. As a result, behavior of the
organization has become synonymous with strategic type.
However, other themes relating to the organizational aspect
of Behavior were also found in the literature. These
included the relationship between an organization's
developmental stage and its behavior, the systems which
characterize or support its behavior, and competitive
position as an outcome of organizational activity. Most
recently, the behavior of individual organizational
125
elements (e.g., functional units such as the marketing or
human resources divisions) and the behavior of individuals
and groups within the organization is being addressed in
the literature. These discussions are consistent with the
expansion in references of strategic management to intra-
organizational elements and with a new awareness of the
importance of individual organization members as vital
components in attaining and maintaining success.
The area of environmental Behavior began to achieve
prominence in the management literature in the 1980's.
Change, and the turbulence and complexity resulting from
it, were the themes most frequently mentioned in
discussions of environmental Behavior. While present
throughout the time frame of the literature reviewed, the
nature of environmental change has shifted focus across
time. In the mid 1970's, environmental change primarily
was discussed in terms of markets and competition. With
the 1980's, however, environmental change themes began to
shift toward concern about turbulence and complexity.
Change began to be characterized by type (e.g., social,
political, economic, technological, etc.) and began to
reflect a more global view of the environment. This latter
trend continues today in the management literature's focus
126
on issues such as the strategic management of multi
national corporations
Perspective. The attribute, Perspective, differed from
the other attributes identified in that no dimensions
emerged. Instead, clustering of themes occurred in three
areas: 1) performance goals; 2) social role; and 3)
strategic thinking.
Perspective themes related to performance goals were
evident throughout the time frame of the literature
reviewed and frequently linked the "how, what, when and
where" aspects of the organization with its "why". These
linkages translated into qualitative performance goals
which reflected the views of organizational leaders.
Having and communicating a vision of the firm as a market
leader was the most frequently cited performance goal
Perspective theme. More often, however, Perspective themes
relating to performance goals focused on quantitative
outcome achievement.
Perspective themes relating to social role began to
appear in the literature in large numbers in the 1980's as
firms began to reassess their missions and purposes in
light of the changing world around them. The organization
as a partner in society as the most frequently present
127
social role Perspective theme. Acknowledgement of
political interests and the need to manage conflict and
achieve consensus also were frequently mentioned themes.
Finally, were Perspective themes related to strategic
thinking. Strategic thinking has emerged as the construct
which attempts to capture the essence of the cognitive and
psychosocial aspects of strategic management. Vision and a
proactive orientation to the future were the dominant
Perspective themes here. Other themes included opportunity
seeking, innovation, and entrepreneurialism, balanced with
recognition of the social and political realities of the
marketplace. Overall, strategic thinking Perspective
themes dominate this attribute and appear likely to
continue to do so.
Influentials. The attribute, Influentials, included
themes relating to its dimensions of person and context.
While examples of such themes were present throughout the
time frame of the literature reviewed, changes were evident
in the number and types of Influentials and in the relative
power of their influence. For example, the Chief Executive
Officer (CEO) and the top management team (TMT)
consistently have been identified as m a jor person
influentials in an organization's strategic management
efforts, while competition has been the most consistent
128
context influential. However, since the mid 1980's, new
influential themes began to appear. Among the new person
influentials were managers, workers and groups known as
stakeholders. This finding is consistent with firms
choosing to leave the linear model of strategy and follow
the adaptive or interpretive models. Similarly, among
context influentials, culture and values were recognized as
having significant ability to assist or impede strategic
management efforts. It appears likely that as the
references of strategic management expand, themes of this
attribute will likewise continue to grow in number,
reflecting the diversity of settings and applications of
Systems. The final attribute of strategic management
identified from the management literature was that of
Systems. It included themes relating to its dimensions of
interface and integration. Its prominence stems from the
fact that it represents themes which provided explanations
for the primary purposes of strategic management.
Themes in the interface dimension focused on process
and included themes about the types of systems and their
interactive roles (e.g., information systems, communication
systems, logistical management systems, etc.) and types of
interpersonal systems (e.g., task forces, authority and
129
responsibility relationships, etc.)* In contrast, themes
in the integration dimension focused on outcomes, and
included themes ranging from attainment of balance and
stability through to the achievement and maintenance of
excellence. These findings reflect a view in the
m a n ag e m e n t literature of strategic management as a
comprehensive, multi-dimensional phenomenon designed to
address the reality of management practice in its totality.
In summary, six attributes of strategic management
were identified from the management literature. These
were Strategy, Structure, Behavior, Perspective,
Influentials, and Systems. In five of these, themes were
found to exist along two dimensions, namely Strategy:
Process/Content; Structure: Organization/Environment;
Behavior: Organization/Environment; Influentials:
Person/Context; and Systems: Interface/Integration.
While all the attributes were found to be present across
the entire time frame of the literature reviewed,
dimensions entered and themes within them changed over
time, resulting in new interpretations of attribute
meaning.
Overview
The term, strategic management, first appeared in the
130
health care literature in an article by Brown (1978) which
asked what should be the responses of Protestant hospitals
to the changes in their environments. Brown noted that the
strategic management response of many has been to develop
integrated hospital management systems. While offering no
definition or discussion of the concept, the article is
significant, both in the timeliness of its appearance and
in its linking of the concept, strategic management, with
the concepts cf change, decisions and vision.
The next citation located appeared in an article by
Smith and Bishop in 1981. This article examined the
relationship between organizational development and what it
called strategic management planning. From this point
forward, the health care literature began to demonstrate a
significant volume of articles on the topics of strategic
planning and strategic management. Unfortunately, the
i nco n s i s t e n c i e s present in the management literature
regarding these two concepts carried over into health care,
evidenced in areas such as the diversity of views as to
which steps or phases constituted strategic planning versus
Overall, the majority of literature on strategic
management in health care is descriptive or advocative in
nature. Four empirical studies on strategic management in
131
health care were located. These examined two areas:
1. the application of Miles and Snow's (1978)
strategic management style topology among health care
organizations.
2. marketing's role in and relationship to the
strategic decision-making process.
No studies were located which examined the outcomes
attributable to strategic management's use in health care.
This finding indicates that research to date has focused on
its process and content aspects.
Relevant Use
In the health care management literature, relevant use
of the concept, strategic management, began and continues
to be primarily as a process. However, the dominance of
this use is not as strong as that found in the management
literature. Instead, three other major relevant use themes
were evident, along with numerous minor (i.e., single
application) use themes. The four major relevant use
themes identified were (a) as a process, (b) as a means to
deal with change, (c) as an approach to management, and (d)
as a remedy for the failure of strategic planning.
Collectively, these four major relevant use themes
accounted for 81% of the total number of use themes
identified in the literature. Table 12 summarizes these
132
four major relevant use themes according to their years and
frequency of appearance.
133
Table 12
Maior Themes: Health Care Management Literature
MAJOR THEMES FREQUENCY YEARS
OF CITATION CITED
1. As a process/system 22 1980 through 1989
— of decision-making 5 1984, 1985,
1987, 1988, 1989
2. As a means to deal 1982, 1984, 1985,
with/facilitate change 1986, 1987, 1989
3. As an approach to 1986, 1987, 1988
management
— as an advanced system 1985, 1987 (2)
of health care planning
4• As a remedy for the 2 1987, 1989
failure of strategic planning
— as a concept which corrects 3 1985, 1988, 1989
deficiencies of strategic planning
134
D e finitions of strategic management across time
demonstrated no specific pattern of reference of other
concepts as was found in the management literature with the
concept, strategy. However, there was evidence that
definitions of strategic management in the health care
management literature matched Chaffee's (1986) three
models of strategy and demonstrated a pattern of movement
through them. Specifically, definitions reflecting the
linear model of strategy dominated the health care
management literature from 1980 - 1982 and appeared
o cca s i o n a l l y after that. From 1983 through 1988,
literature definitions found were firmly grounded in the
adaptive model of strategy. In late 1988, the first
definitions of strategic management consistent with the
interpretive model of strategy began to appear. However,
overall, the majority of the literature from 1983 through
1989 reflects adherence to the adaptive model of strategy.
These findings are parallel to those found in the
management literature and reflects its influence on the
health care management literature's use and application of
the concept. Table 13 lists examples of definitions of
strategic management and the model of strategy to which
each is linked.
135
Table 13
Definitions and Strategy Models;
1. a means by which organizations Linear
identify, specify, formulate, organize,
and evaluate goals.
2. the application of business Linear
planning techniques.
1. the ability of the organization Adaptive
to turn strengths and market planning
into identifiable, quantifiable results.
2. the process of adaptation that Adaptive
characterizes the relationship between
the organization and its environment.
1. a system of corporate values and Interpretive
planning capabilities that couples strategic
thinking with operational decision-making.
2. an approach to management that Interpretive
encourages key administrators to think
innovatively and act strategically.
136
Surrogate Terms
A total of nine surrogate terms for the concept,
strategic management, were identified in the health care
management literature. Of these, strategic planning was
the most frequently cited, followed by strategic decision
making, strategy-driven management and strategic change
management. Table 14 lists all the surrogate terms
identified.
As in the management literature, use of the term,
strategic planning, as a surrogate term for strategic
management occurred throughout the 1980's. This finding,
and the number of surrogate terms identified, attests to
the influence of the management literature on health care
management writers.
137
Table 14
Surrogate Terms of the Concept. Strategic Management:
TERM EXAMPLES FREQUENCY CITATION Y E A R (S )
1. Strategic Planning (SP) 5 1982, 1985, 1986
1988, 1989
— 4th Stage of SP 1 1987
— Strategic Business Planning 1 1983
2. Long Range Planning 2 1987 (2)
— nursing resource planning 1 1987
— corporate planning 1 1984
3. Strategic Decision-Making 3 1985, 1989 (2)
4. Strategic Change Mgt 2 1982, 1986
— change management 1 1989
5. Strategic Adaptation 2 1987 (2)
— organizational adaptation 1 1987
6. Strategy-Driven Mgt 1 1987
— strategic aspects of mgt 1 1988
7. Mgt by strategic analysis 1 1986
8. Strategic competition 1 1985
9. Strategic alignment 1 1982
138
Antecedents
A total of ten antecedents were identified in the
health care management literature. Eight of these were the
same as those found in the management literature, one of
which, strategic planning, was found in two forms, (i.e.,
strategic planning ineffectiveness and strategic planning
as a predecessor to strategic management). One new
antecedent titled "support/need for a new approach" also
was identified.
In the health care management literature, competition
and change were the most frequently cited phenomena
preceding the introduction of strategic management,
followed by uncertainty, performance decline/increased
costs and turbulence. Complexity, strategic planning as
predecessor, and stakeholder actions were cited the least
of all antecedents. These findings indicate that the
introduction of competition in health care, fueled by a
variety of changes, forced health care management to
act / r e a c t to new challenges to survive. Strategic
management was adapted as a response to crisis, rather than
as an evolution of existing management practice.
Competition as the primary a n t e cedent to the
introduction of strategic management in health care is
consistent with the evolutionary history of strategic
13 9
planning in health care. Prior work by this researcher
found that strategic planning began being adapted in health
care in 1975, with the introduction by the Federal
Government of fiscal and management pressures. The finding
of competition as the primary antecedent for strategic
management in health care indicates that in the majority of
cases, health care management adapted strategic management
in responses to external environmental stressors. Table 15
lists the ten antecedents of strategic management in health
care management identified, along with examples of their
associated themes.
140
Table 15
Antecedents and Associated Themes of the Concept.
Strategic Management: Health Care Management Literature
COMPETITION CHANGE UNCERTAINTY
hostile environment environmental change ambiguity
competitive market organizational change unpredictable
PERFORMANCE DECLINE/ TURBULENCE STRATEGIC PLANNING
RISING COSTS INEFFECTIVENESS
increased turnover conflict non-implementation
cost controls disequilibrium failure
economic recession
SUPPORT/NEED FOR A COMPLEXITY STRATEGIC PLANNING
NEW APPROACH
sophisticated planning difficulties strategy plans
long range finance plans complex planning actions
STAKEHOLDER ACTIONS
increased numbers
new constituencies
idea promotion
141
Consequences
A total of nine consequences of strategic management
were identified in the health care management literature.
Eight of these were the same as those found in the
management literature. One new consequence titled
"enhanced decision-making process" was identified. Table
15 lists these consequences and examples of their
associated themes.
Among the eight consequences shared by the management
and health care management literatures, Business Success,
Business Survival, and Plan/Action Links were the most
frequently cited, while qualitatively-focused consequences
e.g., Common Culture, Common Perspective, and Creation of
Future were the least frequently cited. These findings
indicate that the health care management literature
generally describes the consequences of strategic
management in terms of the Linear model of strategy, while
including a minor acknowledgement of the Adaptive model of
strategy (as in the consequence, Change Management).
However, this literature has not yet recognized and/or
emphasized the qualitative processes and outcomes described
in the management literature since the early 1980's (see
Peters & Waterman, 1982). Table 16 details the
consequences of strategic management.
142
Table 16
Consequences and Associated Themes of the Concept.
Strategic Management: Health Care Management Literature
BUSINESS SUCCESS BUSINESS SURVIVAL PLAN/ACTION LINKS
efficiency effective integration
thriving a performer strategy execution
competitive functioning plans/action match
CHANGE MANAGEMENT CREATION OF FUTURE ENHANCED DECISION
MAKING PROCESS
innovation performance monitors revitalized
adaptable vision to reality decentralized
attains change environmental fit
EMPLOYEE ENHANCEMENT COMMON CULTURE COMMON PERSPECTIVE
increased morale organizational commitment
increased output stable work force collegiality
143
Related Concepts
A total of thirteen different concepts were identified
from the health care management literature as related to
the concept, strategic management. Three of these,
marketing, strategic planning, and strategic human
resources management, were cited twice as often as the
other ten related concepts.
Collectively, the related concepts group in this
literature exhibited significant diversity, a finding which
attests to the depth and scope of this concept. Table 17
details the thirteen concepts related to strategic
management in the health care management literature.
144
Table 17
1. Marketing 6. Decision Support
2. Strategic planning Systems
— strategic market planning 7. Strategic Development
— business planning 8. Corporate Strategy
— forecast-based planning 9. Managerial Control
— externally-oriented planning 10. Stakeholder Mgt
— portfolio applications 11. Product Line Mgt
3. Strategic Human Resources Mgt
— resource management
4. Long Range Planning 12. Conflict Management
5. Organizational Development 13. Change Management
145
References
A total of five references of the concept, strategic
management, were identified in the health care management
literature. As occurred in the management literature, the
organization was the single most frequently cited reference
of strategic management. The hospital was the primary
organizational type cited, followed by HMOs and physician
groups. No distinction was evident in the application of
the concept to ownership forms of health care
organizations. Thus, discussion of organizations as a
reference of strategic management in this literature
includes all forms (i.e., public, private, for profit, not
for profit, etc.).
As was the case in the management literature, the
health care management literature included evidence that
the scope of application of the concept, strategic
management, has widened to include multiple references.
Since 1985, four other references have been identified.
These were 1) intra-organizational units; 2) phenomena; 3)
systems and 4) people. Table 18 details all five
references.
Table 18
References of the Concept. Strategic Management:
THE ORGANIZATION INTRA-ORGANIZATION UNITS
— hospitals — radiology departments
— HMOs — clinical laboratories
— MD groups — pharmacies
— nursing departments
PHENOMENA SYSTEMS
— change — multi-national
corporations
— national systems
PEOPLE
— oneself
— organization members
— managers/other groups
— external stakeholders
147
Types of intra-organizational units identified as
references of strategic management included radiology
departments, clinical laboratories, pharmacies and nursing
departments. Among phenomena, change was cited the most
often. This may be an outcome of the finding of change as
a significant stressor as an antecedent of strategic
management. Systems of health care as a reference of
strategic management included systems created by management
activity (e.g., expansion of a health care organization
into a multinational corporation) as well as national
systems of health care delivery (e.g., as in Canada and
Great Britain). Finally, the reference, People, was found
to include the application of the concept to oneself (e.g.,
the individual health care professional's career management
style) to managers and other groups within health care
organ i zations and to stakeholders external to the
organization.
148
Attributes
Attributes of the concept, strategic management, in the
health care management literature, were consistent with
those found in the management literature. The forty-four
attribute themes identified clustered into twenty-one
groups, and ultimately, into six sets of groups. As with
each of the concept analysis category elements, the label
applied to each attribute group set was operationally
defined as the attribute. These attributes were then
considered against the findings in the concept analysis
element categories, resulting in attribute label
refinement and the identification of two dimensions in
three of the six attributes. Table 19 illustrates the
attributes, their dimensions and examples of their
associated themes as identified from the literature.
149
Table 19
Attributes. Attribute Dimensions and Examples of Associated
Themes of the Concept. Strategic Management:
STRATEGY STRUCTURE
Process | Content Organization
Preparation Decisions Power
Formulation Knowledge Design
Implementation
BEHAVIOR PERSPECTIVE
Organization
Flexible/Adaptable Vision
Capability Commitment
Strategic Type New Directions
Leadership Entrepreneurship
INFLUENTIALS SYSTEMS
Person | Context Interface | Integration
Stakeholders Values Relationships Integration
Top Mgt Team Culture
150
Strategy. As in the management literature, the
attribute, Strategy, accounted for the largest number and
widest range of attribute themes. Themes spanned the
entire time frame of the literature reviewed (1980-1989)
and primarily addressed the process dimension of Strategy,
with minor attention paid to the content dimension. This
finding wa s consistent with that of the management
literature, where d i s c ussion of strat e g y process
consistently overshadowed that of strategy content.
Decisions and the knowledge contributing to them were
the primary strategy content themes identified. Again,
findings here were consistent with that of the management
literature, though their scope was more limited.
Structure. In the health care management literature,
the attribute, Structure, focused exclusively on themes
relating to that of the organization. Organizational
structure themes included those relating to design and
type, along with that of power, noted earlier to be an
organizational structure theme new to the management
literature.
Behavior. In the health care management literature,
the attribute, Behavior, demonstrated the second largest
number of themes and focused exclusively on themes relating
to the organization. Organization behavior themes
151
identified included ones highly consistent with those found
in the management literature, such as strategic type,
leadership and adaptability.
Perspective. As in the management literature, no
dimension emerged from within the attribute, Perspective.
Instead, clustering of themes again occurred, but only in
the area, strategic thinking. Here again, vision and a
new directions orientation to the future were dominant
themes of this attribute.
Influentials. The attribute, Influentials, referred to
those persons or contextual variables which could (and
often did) influence strategic management efforts. From
1982 forward, both the person and context dimensions of
this attribute were present in the literature. Person
themes focused on the top management team and stakeholders,
while context themes addressed corporate values and
culture.
Systems. In the health care management literature, the
Systems attribute included a small number of themes in
both its interface and integration dimensions. As was
found in the management literature, interface themes
focused on process, including themes about relationships
(e.g., among people, units, systems), while integration
themes focused on the outcomes of Systems activity.
152
In summary, six attributes were identified from the
health care management literature. These were Strategy,
Structure, Behavior, Perspective, Influentials and Systems,
and were the same six attributes identified from the
management literature. In two of these (Structure and
Behavior) , the singular dimension, Organization, was
identified. In three others, two dimensions were
identified, namely, Strategy: Process/Content;
Influentials: Person/Context; and Systems:
Interface/Integration. No specific d imension was
identified for the attribute, Perspective.
Only the attributes of Strategy and Perspective were
found to have themes present across the entire time frame
of the literature reviewed. Attribute dimensions entered
and themes within them changed over time, resulting in new
interpretations of attribute meaning.
Overview
Confusion and inconsistency in the use and application
of the concept, strategic management, have characterized
the nursing management literature. The following
discussion of strategic planning, the concept which
preceded it in the nursing management literature, is
presented here with it as a necessary and appropriate
153
a djunct to understanding the evolution of strategic
management in nursing.
The earliest citation on strategic planning located in
the nursing management literature was by Fox and Fox
(198 3) . Tit l e d "Strategic Planning for Nursing," it
described strategic planning as a systematic process for
decision making. In their view, a strategic plan for
nursing was "a systematic way of giving direction to
decision making in the present for the future well-being of
the department, its patient clientele, and the institution"
(Fox & Fox, 1983, p. 11). This work used Drucker's (1974)
definition of strategic planning, one consistent with the
linear model of strategy which viewed strategic planning as
a process involving the following three areas:
1. the making of risk-taking decisions.
2. the organizing of efforts to carry out the
decisions.
3. the evaluating of results of the decisions.
In discussing the performance of strategic planning,
Fox and Fox (1983) elaborated on it as a five phase cycle
of 1) values and mission identification; 2) data
collection; 3) goals and objectives formulation; 4)
implementation of operations; and 5) evaluation. The
phases of this cycle were remarkably consistent with the
154
majority of strategic management process models which were
then and still are present in the management literature.
Parallels also are evident between Fox and Fox's (1983)
strategic planning cycle and the generally recognized steps
of the nursing process (i.e., assessment, planning,
implementation and evaluation). The congruencies
discu s s e d here may explain why their work attained
prominence in subsequent nursing management literature on
strategic planning.
The concept, strategic management, first appeared in
the nursing management literature in 1984 (Bopp & Hicks,
1984) . This article discussed strategic management in
accordance with the adaptive model of strategy, and is
noteworthy for successfully integrating the works of a
number of major management writers in its discussion of the
concept. However, though p r esent in the nursing
literature, the focus of the article was on the use and
application of strategic management in the health care
industry, and by health care organizations, with a minor
discussion of nursing present at its end. The authors'
viewed nursing's participation in strategic management as
limited to actions which directly supported the
organization. This view is consistent with the finding of
the organization as the primary reference of the concept,
155
strategic management, in both the management and health
care management literatures. Suggested supportive nursing
actions included 1) internal self-change by nursing to
enable it to better meet the new challenges in health care
and 2) initiating the identification of non-nursing areas
needing change and promoting the accomplishment of change.
Bopp and Hicks' (1984) linking of strategic management
with the concept of change also is consistent with the
finding of change as one of the most frequently cited
antecedents of the concept, strategic management, in both
the management and health care management literatures.
However, they did not link strategic management with
strategic planning. Instead, they presented strategic
management as a process and a management style needed to
cope with discontinuous change, and as an assist to
businesses to "reconceptualize their role in a changing
environment" (Bopp & Hicks, 1984, p. 93). The lack of
acknowledgement of a strategic management/strategic
planning linkage is viewed as a significant contributor to
the confusion surrounding the use and application of this
concept in the nursing management literature.
A third major citation in the nursing management
literature occurred a few months after the Bopp and Hicks
(1984) article. In it, Lukacs (1984) discusses strategic
planning in hospitals, and advances the a position in favor
156
of its use in nursing (a position previously stated by Fox
and Fox (1983)), presenting a strategic planning method for
application by nurse executives.
Citing Rothchild's (1976) work on strategic thinking,
Lukacs (1984) posited that effective strategic planning
"permitted an organization to anticipate and actively
respond to changes in its environment" (p. 11). This view
was remarkably consistent with that expressed by Bopp and
Hicks' (1984) as the purpose of strategic management.
Lukacs (1984) expanded this discussion, asserting that
strategic planning could and should be done at the
department level (as well as at the organizational level)
in order to support increases in management effectiveness
through the matching of departmental strengths with
environmental opportunities.
Interestingly, the Lukacs (1984) article contained no
reference to either Fox and Fox (1983) or Bopp and Hicks
(1984), and instead used a variety of management and
nursing references dating from 1976 through 1983.
The discussion of these three seminal articles on
strategic planning and strategic management in the nursing
management literature provides a basis for understanding
the evolution of the confusion in the use and application
of the concept, strategic management, which characterized
157
subsequent nursing management literature. For the period
1984 to 1988, the nursing management literature was
characterized by descriptive and advocative articles about
a phenomenon labeled as "strategic planning" but which, in
reality, was the phenomenon, strategic management (as
defined in the management literature of that time period).
From 1988 to the present, other changes have occurred
in the use and application of the concept, strategic
management, in the nursing management literature. The
discussion that follows examines these changes through a
report of findings from the analysis of the nursing
management literature sample.
Relevant Use
In the nursing management literature, relevant use of
the concept, strategic management reflected the impact of
the diversity of views surrounding this concept in the
manag e m e n t and health care m a n a gement literatures.
Overall, the primary use has been to describe a process.
However, as was found in the health care management
literature, the dominance of this use is not as strong as
that found in the management literature. Instead, six
other major relevant use themes were evident. The seven
relevant use themes identified in the nursing management
literature were:
158
1. as a planning method.
2. as a means to strengthen competitive position.
3. as a process to manage change.
4. as a means to maintain a healthy organizational
climate.
5. as a means to manage resources.
6. as a process for formulating and implementing
strategy.
7. as a way to examine provider/environment match.
Table 20 summarizes these major relevant use themes
according to their years and frequency of appearance.
Table 20
Relevant Use of the Concept. Strategic Management;
Major Themes; Nursing Management Literature
MAJOR THEMES FREQUENCY YEARS
OF CITATION CITED
1. A planning approach 1 1984
— comprehensive approach 1 1985
— planning method to enable
the organization to respond
successfully to environments 2 1988, 1989
2. A means to strengthen
competitive position 6 1984, 1988 (4)
1989
3. A process to manage change 2 1986, 1988
4. A means to maintain a healthy
organizational climate 1 1986
5. A means to manage resources 3 1988 (2), 1989
6. A process of formulating and
implementing strategy 2 1988, 1989
7. A framework to examine
provider/environment match 1 1989
160
Definitions of strategic management in the nursing
management literature across time (1983-1989) demonstrated
specific patterns of reference to the concepts of strategy,
environment and organizations, as well as a matching with
Chaffee's (1986) three models of strategy. However, unlike
the health care management literature, definitions
reflected the existence of all three models in the same
year (e.g., 1988). In general, definitions consistent with
the adaptive model of strategy predominated. This finding
is consistent with that found in both the management and
health care management literatures. Table 21 lists
examples of definitions identified and the model of
strategy to which each was linked.
161
Table 21
Definitions and Models of Strategy:
The Nursing Management Literature
1. The formulation and Linear
implementation of strategy.
1. The process of matching Adaptive
the organization with its
environment.
2. A framework for decision-making Adaptive
1. A term that encompasses Interpretive
strategic planning and strategic
thinking.
162
Surrogate Terms
A total of six surrogate terms for the concept,
strategic management, were identified in the nursing
management literature. Of these, strategic planning was
the most frequently cited. Table 22 list the six terms
identified.
As in the management and health care management
literatures, use of the term, strategic planning, as a
surrogate term for strategic management occurred throughout
the 1980s. However, it was only one of four surrogate
terms focusing on planning found in the nursing management
literature. This was in contrast to the smaller planning
emphasis found in the management and health care management
literatures.
163
Table 22
Surrogate Terms of the Concept. Strategic Management;
TERM EXAMPLES FREQUENCY C I T A T I O N
YEARS
Strategic planning 1984, 1986,
1988 (3)
Comprehensive planning 1985
Planning process 1989
Program planning 1989
Participative Management 1985
Nursing Case Management 1988
164
Antecedents
A total of seven antecedents of the concept, strategic
management, were found in the nursing management
literature. Of these, antecedent themes dealing with
chan g e predominated, followed by those addressing
competition. Other antecedents ment i o n e d included
turbulence, crisis/failure, and a need/desire to ensure
quality (this latter antecedent being unique to this
literature). There was no finding of antecedent themes of
stakeholder action or strategic planning ineffectiveness.
The absence of the former may be a function of the newness
of the concept to nursing, while, for the latter, the
comprehensive view of strategic planning found in the
nursing literature (i.e., one which included implementation
and evaluation) , and the general lack of criticism of it
may explain this theme's absence. Table 23 lists the seven
antecedents of strategic management identified in the
nursing management literature, along with examples of their
associated themes.
165
Table 23
Antecedents and Associated Themes of the Concept.
Strategic Management: Nursing Management Literature
CHANGE COMPETITION TURBULENCE
competitive posture new entrants turmoil
environment evolving markets discontinuity
industry
QUALITY CRISIS COMPLEXITY
ASSURANCE
quality focus decline complex
improvement need failure intricate
DECLINING
RESOURCES
workforce changes
reimbursement issues
166
Consequences
A total of seven consequences of strategic management
were identified in the nursing management literature, with
the leading one being Business Success. Unlike the
management and health care management literature, however,
Business Success in the nursing management literature was
discussed in both qualitative and quantitative terms.
Qualitative Business Success included themes such as
increased scope of practice, increased self-esteem and
increased power base, while Quantitative Business Success
themes focused on efficiency indicators such as service
delivery operations and increased market share. This
finding, unique to this literature, was consistent with
nursing's view of the scope of use and application of this
concept. Table 24 lists the consequences of strategic
management and examples of associated themes found in the
nursing management literature.
167
Table 24
Consequences and Associated Themes of the Concept.
Strategic Management: Nursing Management Literature
BUSINESS SUCCESS BUSINESS SUCCESS
(QUALITATIVE) (QUANTITATIVE)
increased scope of practice operational efficiency
increased self esteem management effectiveness
increased power base increased market share
BUSINESS SURVIVAL COMMON CULTURE
decreased environmental threat internal configuration
decreased organization stress business concept
decreased crisis management organizational elements
PLAN/ACTION LINKS
Strategic management systems
168
Related Concepts
A total of seven concepts were identified from the
nursing management literature as related to the concept,
strategic management. Strategic planning was the most
frequently cited, followed by marketing and organizational
development. Table 25 lists the seven related concepts of
strategic management found in the nursing management
literature.
Table 25
Strategic planning Facilities planning
Marketing Program planning
Organizational development Program development
Forecasting
169
References
A total of five references of the concept, strategic
management, were identified from the nursing management
literature. The most frequently cited of these was that of
Intra-Organizational Units, followed closely by the
Organization. Table 26 lists these five references, along
with examples of their associated themes.
In general, the nursing management literature
references identified were consistent with those found in
the other two disciplines. Unique to this literature,
however, were the finding of Intra-Organizational Units as
a more frequently cited reference than the Organization,
and the finding of Resources as a new, separate reference.
170
Table 2 6
References of the Concept. Strategic Management:
INTRA-ORGANIZATIONAL UNITS THE ORGANIZATION
nursing hospitals
the nursing department nursing organization
other departments
PEOPLE RESOURCES
nurse executives human resources
nurse administrators economic resources
social resources
political resources
PHENOMENA
change
cost/quality outcomes
171
Attributes
A total of five attributes of the concept, strategic
management, were identified from the nursing literature.
Fifty-seven attribute themes clustered into eighteen groups
and ultimately, into five sets of groups. As occurred with
all other concept analysis category elements, the label
applied to each attribute group set was operationally
defined as the attribute. These attributes were then
considered against the findings in all the concept analysis
element categories, resulting in attribute label refinement
and the identification of one dimension in one of the five
attributes and two dimensions in three of the remaining
four attributes. Table 27 illustrates the five attributes,
their dimensions, and examples of their associated themes,
as identified from the nursing management literature.
172
Table 27
Attribute. Attribute Dimensions and Examples of Associated
Themes of the Concept. Strategic Management:
STRATEGY BEHAVIOR
Process_____ |_____ Content Organization
Analysis Goals Network building
Implementation Objectives Adaptability
Evaluation Decisions Leadership
INFLUENTIALS PERSPECTIVE
Person_____ |
_____ Context
Stakeholders Organizational Culture Business Orientation
Consumers Occupational Group Entrepreneurialism
Employees Culture Visionary thinking
SYSTEMS
Interface_____ |_____ Integration
Interrelationships Organization/Environment
Linkages
7S Framework
173
Strategy. As in the management and health care
management literature, the attribute, Strategy, accounted
for the largest number and widest range of attribute
themes. Strategy themes were present throughout the time
frame of the literature reviewed, were highly concentrated
in 1988 citations, and primarily addressed its process
dimension. These findings were consistent with those in
the management and health care management literatures.
Behavior. In both the nursing management and health
care management literatures, the attribute, Behavior,
accounted for the second largest number of attribute themes
and focused e xclusively on themes relating to the
organization. Organizational behavior themes primarily
a d dre s s e d the behavior of intra-organizational units
(especially nursing). This finding was consistent with
that of intra-organizational units being the most
frequently cited reference of strategic management in the
nursing management literature. Organizational behavior
themes identified included adaptability, flexibility and
leadership, ones also found in the management and health
care management literatures.
Perspective. Perspective, the third attribute of
strategic management identified in the nursing management
literature, again contained a diverse variety of themes
174
which precluded dimension identification. As occurred in
the health care management literature, themes clustered in
the area of strategic thinking, with examples including
business orientation, openness to change and vision or
visionary thinking. The number of themes associated with
this attribute has increased steadily since 1987, resulting
in the finding that collectively, the attributes of
Strategy, Behavior and Perspective accounted for 80% of the
total number of attribute themes of strategic management
identified in the nursing management literature in this
study.
Influentials. In the nursing management literature,
the attribute, Influentials, continued to represent those
persons or contextual variables which could (and often did)
influence strategic management efforts. Though small in
number, themes in both the person and context dimensions of
this attribute were present in the nursing management
lite r a t u r e from 1984 through 1989. Person themes
identified did not include the top management team, but
rather focused on stakeholders, employees and consumers.
Context themes primarily addressed two types of culture,
namely organizational and occupational group culture.
Systems. The final attribute of the concept, strategic
management identified in the nursing management
175
literature was that of Systems. This attribute included a
small number of themes in both the interface and
integration dimensions. Themes dealing with inter
relationships (at a number of levels) characterized the
interface dimension, while organizational/environmental
linkages and themes about frameworks supporting the
integration of strategic planning and strategic thinking
(e.g., the McKinsy 7S Framework) were found.
In summary, five attributes of strategic management
were identified from the nursing management literature.
These were Strategy, Behavior, Perspective, Influentials
and Systems. These represented five of the six attributes
identified from the management and health care management
literatures. In one attribute (Behavior), the single
dimension of organization was identified. In three others,
two dimensions were identified, namely Strategy:
Process/Content; Influentials: Person/Context; and
Systems: Interface/Integration. No specific dimension was
identified for the attribute, Perspective.
Only the attribute, Strategy, was found to have themes
present across the entire time frame of the literature
reviewed. Attributes, attribute dimensions and themes
associated with them changed over time, resulting in new
interpretations of meaning. These findings are consistent
176
with Wittgenstein's (1953) views regarding concepts and
their meaning, and with Toulmin's (1972) premise that
concepts evolve in a social context and change over time.
As such, these findings demonstrate support for the
theoretical framework of this study.
Model Case. Rodgers' (1989) technique of concept
analysis requires the identification, rather than the
construction of a model case. This is in keeping with her
view that concepts exist in a real world, social context
where examples of them can and should be identified, rather
than constructed, based on the attributes associated with
them.
With the completion of all other phases of the
analysis, a model case, one representing all of the
attributes of the concept, was identified to point out a
clear example of the concept. The model case presented
here was identified from the nursing management literature
sample and concerned the formulation, implementation and
evaluation of a strategic planning process model at Sinai
Hospital, in Detroit, Michigan. The case is described in
detail in a 1988 article by Nash and Opperwall.
As was noted earlier, for the period 1984 to 1988, the
nursing management literature was characterized by
descriptive and advocative articles about the phenomenon
177
labeled as "strategic planning" but which, in reality, was
the phenomenon, strategic management. That is the case
with the article presented here as a model case. While
Nash and Opperwall (1988) label it as a discussion of the
formulation, implementation and evaluation of a strategic
planning process model, it is, in reality, a presentation
detailing the use and application of strategic management
by a department of nursing within a large, metropolitan
hospital.
The Nash and Opperwall article, presented here as a
model case of strategic management for nursing management,
indicated process to be the relevant use of the concept,
strategic management, and began by citing change and
competition, the two most frequently cited antecedents of
strategic management identified in the nursing management
literature, as the rationales for action. As Nash and
Opperwall (1988) state "as health care managers continue to
be part of an evolving, fast-paced, competitive
environment, it will be essential for them to manage
strategically" (p. 12).
The article also included identification of the two
Business Success consequences of strategic management
identified from the nursing management literature. Both
the quantitative and qualitative Business Success
178
consequences were evident in the statement that "an ongoing
stra t e g i c planning process can positively affect an
organization's growth, productivity and morale" (Nash &
Opperwall, 1988, p. 13).
Finally, the writers note that the hospital and the
Division of Nursing engaged in this strategic planning
process for a period of three years. This statement
identified both the Organization and nursing (as an Intra-
Orga n i z a t i o n a l Unit) as references of the concept,
strategic management. Again, these references were the
most frequently cited in the nursing management literature.
While the consistency evident between the literature
findings regarding relevant use, antecedents, consequences
and references is important, the main purpose of a model
case is to serve as a clear example of the concept, based
on the presence of all of the attributes of the concept.
The following discussion will focus on this aspect of the
model case.
The attributes of strategic management identified from
the nursing management literature were Strategy, Behavior,
Perspective, Influentials and Systems. All five were
present in this model case example.
The Strategy attribute, with both its dimensions of
process and content, was addressed in the discussion of the
179
formulation and implementation of the Division's strategic
plan (process) and specific examples of plan elements
(content). Similarly, the Behavior attribute was evident
in the discussion of specific tasks associated with each
step of the five step strategic planning process.
Influentials, the third attribute of strategic
management present in the nursing management literature,
and its people dimension, was addressed in the authors'
discussion of the off-site planning conference attended by
members of the medical and administrative leadership. Its
context dimension was addressed in step two of the
strategic planning process, called Identification of
Underlying Contradictions. Here, "issues, deterrents,
blocks, irritants and barriers that must be dealt with in
order for the stated vision to be accomplished" (Nash &
Opperwall, 1988, p. 13) are described.
As mentioned in the previous discussion of attributes
in the nursing management literature, themes relating to
the attribute, Perspective, have increased dramatically in
this literature and were especially strong in 1988
citations. This finding was evident in this article, where
words like vision, future perspective, innovative
strategies and proactive management typify the presence of
the attribute. In the Division of Nursing's strategic
180
planning process model, the attribute is given special
consideration in the step titled, Visionary Thinking.
Finally, there is the attribute, Systems, and its
dimensions of interface and integration. The interface
dimension of this attribute is reflected in the interface
of the organization and the nursing division in the conduct
of the strategic planning process. This dimension also is
evident in the discussion of the planning method used with
the model. The method began with the identification and
establishment of a proactive management framework. The
strategic planning process model emerged as a product of
the collaborative efforts of the consultants used and the
members of the Division of Nursing Steering Committee,
composed of managers from all nursing departments. The
importance of participation and cooperation among all
management levels in the formulation and implementation of
the process is evident in the discussion of the planning
method.
The integration dimension of the Systems attribute
received similar attention in this model case.
Organization/environment linkages were operationalized a
linkages between the nursing organization itself and its
integration within the overall organization environment.
Concern for the attainment of strong organization/
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environment linkages is evident in the articulation and
demonstration of support for the attainment of both
organizational and departmental goals. Additionally, the
integration dimension of the Systems attribute included
attention to the McKinsey 7S Framework elements within the
Division. The content of the strategic proposals developed
in the third step of the process included special attention
to the skills, staff, shared values and strategy elements
of this framework.
In summary, the five attributes of strategic management
identified from the nursing management literature were
typified in a model case which described and discussed the
formulation, implementation and evaluation of a strategic
planning process model by a Division of Nursing within a
hospital organization. The model case included multiple
examples of attribute themes for all five attributes and
their respective dimensions. Additionally, the model case
demonstrated consistency with the study's findings
regarding relevant use, antecedents, consequences, and
references of strategic management in nursing.
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Interpretation and Discussion
The Concept. Strategic Management;
Consensus and Disagreement Among the Literatures
Overview
The contemporary philosophy of science and language
views of concepts, as articulated in the later writings of
Ludwig Wittgenstein (1953) and Stephen Toulmin (1972)
provided the basis for the theoretical framework of this
study. The most important and influential views of
concepts by each of these philosophers will now be
discussed in terms of the study results.
Two of Toulmin's (1972) most important and influential
vi ews regarding concepts were that 1) language and
conceptual thought are developed through a social process
called enculturation and 2) concepts respond to historical
and social influences by changing over time. As a result,
Toulmin contended, concepts reflect thought, understanding
and expression at a particular time and in a particular
context.
Chaffee's (1986) discussion of the evolution of the
concept, strategy, was presented as a concrete example of
concept development supportive of Toulmin's (1972) views.
The results presented in this study, however, provide even
stronger support for them. The findings reported from an
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examination of the concept, strategic management, as
present in the disciplines of management, health care
management, and nursing management, clearly show that this
concept has developed within a social process and that it
has responded to social and historical influences by
changing over time.
Three of Wittgenstein's (1953) most important and
influential views regarding concepts was that 1) their
meaning is directly related to their use; 2) a focus of
inquiry regarding concepts should be directed toward how
the concept being examined is related to other concepts and
3) a focus of inquiry regarding concepts should be directed
toward identifying and explaining differences in meaning
found in use contexts. For the concept, strategic
management, the first and second of these views have been
addressed through the performance of a concept analysis
(based on Rodgers, 1989). As a result of this analysis,
relevant uses of the concept, strategic management, as well
as antecedents, consequences, related concepts, references
and attributes were identified from the literatures of
Collectively, the analysis results have suggested the
meaning of the concept, strategic management, in each of
these disciplines.
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The following section addresses the third of these
views by discussing differences in meaning across use
contexts.
Relevant Use
Across the literatures of management, health care
management, and nursing management, the primary relevant
use of the concept, strategic management, was found to be
to describe a process. In health care management and
nursing management, however, other relevant use themes also
were present.
In health care management, the relevant use theme of
remedy for the failure of strategic planning emerged as
unique to that literature. This finding may be a
reflection of the influence of the management literature's
frequently mentioned dissatisfaction with strategic
planning, which for some time (e.g., Ansoff & Hayes, 1976)
has been viewed as a process insufficient to achieve
desired outcomes.
More diversity in relevant use themes was found in the
nursing management literature. This diversity was
reflected in the 1988 literature which contained all three
of Chaffee's (1986) models of strategy. Overall, however,
definitions consistent with the adaptive model of strategy
predominated in all three literatures.
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Surrogate Terms
Across the management, health care management, and
nursing management literatures, strategic planning was the
most frequently cited surrogate term. This finding
indicates that 1) the linear model of strategy, with its
emphasis on planning, has been and continues to be a
significant influence and 2) the interchangeable use of the
terms, strategic planning and strategic management among
writers in all disciplines continues to occur.
Antecedents
Across the management, health care management, and
nursing management literatures, change was a consistently
cited antecedent of strategic management. Change themes
mentioned most often were environmental or organizational
in focus, and included themts on demographic, regulatory,
and technologic change.
In the management and nursing management literatures,
change was the most frequently cited antecedent. However,
in the health care management literature, competition
surpassed change as the most frequently cited. This
finding is consistent with the evolution of health care
into a business and attests to the significance of
competition as a stressor to health care organization
survival and success.
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Also found in the health care management literature
were antecedent themes collectively titled support/need for
a new approach. This group of antecedent themes was unique
to this literature and is consistent with health care
management's relevant use theme, remedy for the failure of
strategic planning.
Consequences
Business Success emerged as the most frequently cited
consequence of strategic management in the literatures of
all three disciplines. Themes associated with this
consequence common to all three were quantitative in
nature, and included examples such as operational
efficiency, increased market share, profitability, growth,
and competitive advantage. In the nursing management
literature, however, the consequence, Business Success
included both qualitative and qua n t i t a t i v e themes,
resulting in two Business Success consequences titled
Qualitative Business Success and Quantitative Business
Success. The Qualitative Business Success consequence
included themes such as increased scope of practice,
increased self esteem and increased power base, while the
Quantitative Business Success consequence included themes
such as operational efficiency, management effectiveness,
and increased market share. These findings indicate a more
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comprehensive view of the valued outcomes of this concept
in nursing management, and suggests a need for research in
this area.
Related Concepts
S t rategic planning, marketing and organizational
development were found in all three literatures as related
concepts to the concept, strategic management. Likewise
common along the literatures were planning-focused
concepts, with examples including long range planning
program planning and forecast-based planning. The main
characteristic of each literature's related concepts can be
summarized as follows:
1. The management literature's related concepts
focused on those concepts from management that contributed
to the conceptual underpinning of the concept, strategic
ma n a g e m e n t (e.g., administrative behavior, industrial
organization, etc.).
2. The health care management literature's related
concepts focused on planning and management areas of
application of the concept (e.g., stakeholder management,
product line management, etc.) and overall exhibited the
largest degree of div e r s i t y from among the three
literatures.
3. The nursing management literature's related
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concepts focused on planning-type concepts, and exhibited
the smallest amount of diversity from among the three
literatures.
References
Identification and analysis of the References of the
concept, strategic management, across the disciplines of
management, health care management, and nursing management
revealed a number of interesting and important facts
regarding the application of this concept by these
disciplines.
First, across all three literatures, the organization
was consistently cited as a reference of strategic
management. However, its focus and dominance varied among
them. In the management literature, use of the term,
organization, most frequently referred to a private, for
profit firm or company operating in a product-based
business. However, in the literature of the 1980s,
discussion of the application of strategic management to
public sector organizations began to appear. Public sector
firms m entioned included not-for-profit businesses,
government bodies, and associations, among others.
In the health care management and nursing literatures,
no distinction between private and public organizations was
evident. Hospitals, HMOs and physician groups were the
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most frequently cited organization themes in the health
care m a n a gement literature, while hospitals was the
dominant organization theme in the nursing management
literature.
A second finding from the analysis of references
across the three disciplines was in the number and types of
other references of strategic management. For example, in
the management literature from the mid 1980s forward,
literature began to appear which discussed the application
of strategic management to units within organizations, as
well as to phenomena both within and outside them. From
these themes of strategic management in strategic business
units (SBUs), departments, and d i visions came the
reference, Intra-Organizational Units. The inclusion of
these entities as references of strategic management
appears to be related to fundamental changes in the nature
of the relationship between the organization and its
functional elements. Overall, the literature indicates
that the inclusion of these entities as references of
strategic management is consistent with the reality of
present day management practice.
The other new reference of strategic management
identified in the management literature was that of
phenomena. Citations titled "The strategic management
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of...” characterize this literature. In this application
of the concept, the writer usually begins by
conceptualizing strategic management as a process, and then
discussing the application of that process to a particular
phenomenon. The strategic management of innovation, human
resources, crisis, and technology are examples of phenomena
references of strategic management in the management
literature.
In the health care management literature, references of
strategic management in addition to that of the
organization also were found. Intra-Organizational Units
and Phenomena again were present. Change was the most
frequently cited theme under the reference, Phenomena.
This finding is consistent with the concern about change
f req uently mentioned in the health care management
literature. Similarly, Intra-Organizational Units cited
were he a l t h care oriented and included radiology
departments, laboratories, pharmacies and nursing
departments.
Two other References of strategic management were found
in the health care management literature. These were
Systems and People. Systems reference themes included the
application of strategic management to multinational
corporations and national health care systems (e.g.,
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Canada). People reference themes included those both
within and outside the organization. The application of
strategic management to the management of people was
discussed as a necessary and logical progression in the
field of human resources management by a number of writers.
Finally, in the nursing management literature, while
the reference, Organization was present, the reference,
Intra-Organizational Units surpassed it in frequency of
citation. This finding is consistent with nursing's
increased use and application of this concept at the
department/division level.
The references People and Phenomena identified in the
health care management literature also were found in the
nurs i n g management literature, along with the new
reference, Resources. Resource themes included human,
economic, social and political resources. This finding may
reflect the emphasis in recent years on resource
management, especially given the ongoing problems of
constrained and/or declining human, material and fiscal
resources frequently discussed in the nursing management
literature.
In summary, Organization, was cited as a reference of
strategic management in all three disciplines' literatures.
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In the management literature, themes resulting in two forms
of the Organization were found (i.e., private organizations
and public organizations). No such distinction regarding
organizations was evident in the health care management or
Two other references cited in all three disciplines'
literatures were Intra-Organizational Units and Phenomena.
Intra-Organizational Unit themes included strategic
business units (SBUs), departments and divisions which, in
health care, included radiology departments and pharmacies,
among others, and in nursing, focused on the nursing
department. Phenomena themes included change, innovation,
and human resources.
In the health care management literature, in addition
to the references of Organization, Intra-Organizational
Units and Phenomena were the references Systems and People.
Systems themes included both national health care systems
(e.g., Canada) as well as international systems (e.g.,
multi-national health care corporations).
In the nursing management literature, in addition to
the references of Organization, Intra-Organizational Units
and Phenomena were the references People (as in the health
care management literature) and Resources. The finding of
this latter reference is suggested as an outgrowth of the
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influence of the ongoing problems of constrained and/or
declining human, material, and fiscal resources in health
care delivery in general, and in nursing in particular.
Attributes
Overview
In Rodgers' (1989) technique of concept analysis,
attributes are the describing or defining characteristics
of a concept. As such, they make a major contribution to
concept clarification through the identification of concept
use and application. The consistency of the attributes of
a concept across disciplines can be examined using
interdisciplinary comparison. In compliance with the final
research objective of this study, the following section
discusses the results from a comparison of the attributes
identified in each of the three disciplines of management,
health care management, and nursing management.
Management and Health Care Management
Identical attributes (i.e., the labels applied to each
attribute group set) were identified from the management
and health care management literatures (See Tables 11 and
19) . However, differences were found in four related
areas: 1) the life cycles of attributes in each discipline?
2) the dimensions associated with each attribute; 3) the
number and type of themes in each attribute dimension and
194
4) the scope of attribute dimensions and themes.
Regarding the first area of difference, that of life
cycles of attributes, only two of the six attributes
identified from the health care management literature were
found to be present across the entire time frame of the
literature reviewed, whereas, in the management literature,
all attributes were present across that literature's time
frame. This finding indicates strategic management is an
evolving concept in health care management which presently
is described and discussed primarily in terms of the
attributes of Strategy and Perspective.
The second area of difference involved attribute
dimensions. In the health care management literature, the
attributes Structure and Behavior were found to be one
dimensional, focusing only on th e m e s about the
organization. This is in contrast to the management
literature, where these attributes are two dimensional,
including the dimension of environment along with that of
organization. Three possible explanations are offered
regarding this finding:
1. The history of strategic management as a concept in
the management literature is longer than that in the health
care management literature. Thus, it may be that in
management, it is a more mature concept, whose evolution
195
has expanded to a macro view of it. This macro view has
resulted in the identification and acceptance of multiple
dimensions within the majority of its attributes.
2. Health care m a n a gement (along with other
disciplines including nursing management) "borrowed" the
concept, strategic management, from management (i.e., the
concept, strategic management, was adopted for use by other
disciplines). One outcome of this process may be that the
borrowing discipline adopts a more restricted view of the
concept. This may be due to a lack of historical
experience with the concept (and thus an incomplete
knowledge base of it) and/or due to the conscious decision
to fashion the concept to meet the purposes and needs of
the borrowing discipline.
3. Environmental change and its potential as a threat
to business economic survival and success was the primary
antecedent for adaption and use of strategic management in
the private, for profit sector of American business. As a
result, the environmental dimension in the Structure and
Behavior attributes may be the result of writers describing
and discussing the environment in the management
literature.
A third area of difference lay in the number and types
of themes in each dimension. For example, in the
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management literature, the attribute, Perspective, included
themes relating to performance goals, social role and
strategic thinking. However, only themes relating to
strategic thinking were identified in the health care
management literature. This finding may, again, reflect
the newness of the concept to the health care management
literature, demonstrated by a narrow focus to theme
development within this attribute.
The final area of difference was in the scope of
attribute dimensions and themes. For example, in the
management literature, the interface dimension of the
Systems attribute included numerous examples of two types
of themes:
1. types of systems and their interactive role.
2. types of interpersonal systems.
In contrast, in the health care management literature,
interface themes identified focused exclusively on types of
interpersonal systems.
In summary, comparison of attributes identified from
the management and health care management literatures found
the attribute sets to be identical. However, differences
in attribute life cycles and in three areas related to
attribute dimensions and themes were found.
Management and Nursing Management
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A comparison of the attributes of strategic management
in the management literatures (Table 11) and the nursing
management literature (Table 27) demonstrated a match of
the five nursing management attributes to five of the six
management attributes. The five matching attributes were
Strategy, Behavior, Perspective, Influentials and Systems.
No match occurred for the management attribute, Structure.
This occurred because no attribute themes relating to
structure were found in the nursing management literature.
This finding may be a result of the newness of the concept
to nursing management, or may reflect a fundamental
difference in the way management and nursing management
view this concept.
As occurred in the comparison of the management and
health care management literatures, differences also were
found in the four related areas of attribute life cycle,
attribute dimensions, attribute themes present, and
attribute dimension/theme scope.
In nursing management, regarding attribute life cycle,
only the attribute, Strategy, demonstrated themes present
across the entire time frame of the literature reviewed
(i.e., 1983-1989), whereas in the management literature,
all attributes were found to be present over the entire
time frame of the literature reviewed (i.e., 1974-1989).
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A difference also was found involving attribute
dimensions. In the management literature, the attribute,
Behavior, included the two dimensions of organization and
environment, whereas in the nursing management literature,
only themes relating to the organization dimension were
identified. In the nursing management literature,
environmental behavior themes were present as antecedents,
rather than as attributes of strategic management.
The number and types of themes in each attribute
d i me n s i o n occur r e d as one of the most significant
differences between the views of strategic management in
the management and nursing management literature. The
Strategy attribute was the only one where themes were
consistently similar. One explanation for this may be the
influence and interpretations of the linear and adaptive
models of strategy. In management, goal achievement (the
linear model) and organization/environment matching (the
adaptive model) are perceived and measured primarily in
quantitative, economic terms. Thus themes of strategic
m an a g e m e n t are grounded in competitive, quantitative
achievement. In contrast, in nursing management, goal
achievement and organization/environment matching are
perceived and measured primarily in qualitative, non
economic terms. Thus themes of strategic management are
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grounded in cooperation and qualitative improvement.
The final area of difference found related to attribute
dimension and/or theme scope. An example here is found in
the attribute, Systems, and the themes associated with it
in the management and nursing management literatures.
In the nursing management literature, themes relating
to Systems have only recently (i.e., 1989) begun to appear.
Thus, they are small in number and narrow in focus. In
contrast, Systems themes in the management literature have
been present throughout the entire time frame of the
literature reviewed (i.e., 1974-1989). In recent years in
the management literature, the attribute's integration
dimension has gained prominence, based on the work of
writers such as Peters and Waterman (1982). As a result,
the scope of themes in the integration dimension of the
Systems attribute is significantly higher in the management
literature than in the nursing management literature.
the management and nursing management literatures found a
match between the five nursing management attributes and
five of the six management attributes. This occurred
because no Structure attribute was identified in the
nursing management literature to match that found in the
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management literature. Additional differences were found
in the areas of attribute life cycle, and in three areas
relating to attribute dimensions and themes.
Nursing Management and Health Care Management
A comparison of the attributes of strategic management
identified from the nursing management literature (Table
26) and the health care management literature (Table 18)
demonstrated the same matching as occurred with the
management literature, i.e., the five nursing management
attributes matched five of the six health care management
attributes. As before, this occurred because of the
presence of the attribute, Structure, in the health care
management literature, and the absence of this attribute in
the nursing management literature.
In the health care m a n a gement literature, the
attribute, Structure, contained only the single dimension
of organization, rather than the two dimensions of
environment and organization found in the management
literature. Also, the themes in the organization
dimension were narrowly focused on the areas of
organizational design and power. These findings indicate
that the attribute, Structure, is less dominant in the
health care management literature than in the management
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literature. Considering this finding, the lack of match
on this attribute between the health care management and
nursing management literatures may not be as significant as
the lack of match which exists between the management
literature and the nursing management literature.
Among the five matching attributes and the themes
associated with them, differences between the nursing
management and health care management literatures involved
the attribute, Behavior, and the types of themes in the
person and context dimensions of the attribute,
Influentials.
Regarding the attribute, Behavior, in the nursing
management literature, only the dimension, organization,
was identified. This is in contrast to the health care
management literature, where this attribute included the
two dimensions of organization and environment.
Themes in the person and context dimensions of the
attribute, Influentials, represented the other area of
difference between the nursing management and health care
management literatures. Regarding the person dimension,
stakeholders, consumers and employees were the person
themes most frequently cited as influential to strategic
management efforts in the nursing management literature.
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Absent here was mention of the top management team, a group
frequently cited in the health care management literature.
This finding may reflect an assumption by nurse writers on
the inclusion of the inclusion of the top management team
(resulting in their non-specification), or it may reflect
a department level-focus contrasted with a health care
management organization level focus.
In the context dimension of the attribute,
Influentials, the nursing management literature
demonstrated themes exclusively focused on culture, while
health care management literature included mention of
corporate values. This finding in the health care
management literature is consistent with its inclusion of
the top management team as Influentials.
the nu r s i n g management and health care management
literatures demonstrated a match between the five nursing
management attributes and five of the six health care
management attributes. This occurred because no Structure
attribute was identified from the nursing management
literature to match that found in the health care
management literature. Additional differences were found
regarding the attribute, Behavior, and the person and
context dimensions of the attribute, Influentials.
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Interpretation and Discussion
Rodaers1 Technique of Concept Analysis
Rodgers' (1989) technique of concept analysis was
selected for use in this study based on two of its most
important characteristics. The first of these was its
grounding in a philosophical foundation regarding concepts
consistent with the present day view of concepts in the
philosophies of science and language. The second reason
for its selection was its rejection of reduction (i.e., the
construction of borderline, contrary, illegitimate and
invented cases of a concept) in favor of acceptance of the
possibility of multiple interrelationships and multiple
contextual uses and applications of concepts.
Rodgers believes that concept analysis should be viewed
as a process through which a clear understanding and
demonstration of the use and application of a concept is
built from an examination of that concept in the contexts
of its use and application. This belief is in contrast to
a view of concepts as characterized by rigid sets of
necessary and sufficient conditions. This latter view,
typified in the approach to concept analysis of Walker and
Avant (1983, 1988), prescribes the use of reduction to
arrive at concept clarification.
The findings from the examination of the philosophical
204
and methodological approaches to concept analysis discussed
in Chapter II of this study indicated that Rodgers' (1989)
technique of concept analysis reflected the best alignment
with the present day dominant views of concepts and the
process of analysis. Based on this finding, it was
selected for use in this study.
Having discussed the philosophical soundness of
Rodgers' (1989) technique, its strengths and weaknesses as
a methodology were considered. The following comments and
recommendations are made based on the experience of its use
in this study.
Overall, the technique as prescribed by Rodgers (1989)
was relatively easy to apply. However, two areas were
identified as needing explication and revision. These
areas were 1) explanation and discussion of the
determination of relevant use and 2) composition and
ordering of its steps.
Rodgers' (1987) work contains clear definitions,
examples, and discussion of each of her concept analysis
element categories, with the exception of relevant use. A
relationship between relevant use and definitions is
indirectly suggested in her discussion of findings. Also
in need of clarification is the relationship between
relevant uses and the other concept analysis element
205
categories. Future users of this technique would benefit
from refinement of these areas.
Second, refinement is needed in the composition and
ordering of the steps of the technique. The order of the
steps was not found to be conducive to a smooth, logical
analysis process. Based on the experience gained from its
use in this study, Table 28 is presented as a suggested
revision to the composition and ordering of the steps of
this technique.
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Table 28
Suggested Revision to Rodaers1 (1989)
Technique of Concept Analysis
1. Identify and name the concept of interest.
2. Identify and select the relevant use(s) of the
concept to be analyzed.
for data collection.
4. Identify and list the surrogate terms of the
concept.
5. Identify and list the antecedents of the concept.
6. Identify and list the consequences of the concept.
7. Identify and list the concepts related to the
concept of interest.
8. Identify and list the references of the concept.
9. Identify and list the attributes of the concept.
10. Identify and describe a model case of the concept.
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Summary
This chapter began by discussing the assumptions
guiding the study and then presented study results related
to validity and reliability, search and sampling outcomes,
and the research objectives.
Results relating to validity and reliability included a
report of the outcomes of the master citation list review
process, along with findings from intrarater and interrater
reliability actions relating to the data coding process.
Results relating to the literature search and sampling
included a summary of the literature search and sampling
outcomes for each discipline's literature and a cumulative
summary of the final sample and retrieval outcomes.
R e sults related to the research objectives were
organized and presented for each individual discipline. In
the nursing management literature, a model case of the
concept for nursing was presented.
The chapter concluded with a discussion of similarities
and differences in each of the concept analysis categories
across all three disciplines. Attributes were identified
as a singularly significant concept analysis category.
Attributes in management and health care management,
management and nursing management, and nursing management
and health care management were compared, with similarities
208
and differences discussed. A critique of Rodgers' (1989)
technique of concept analysis and a suggested revision of
it closed the chapter.
The following chapter presents a summary and
conclusions resulting from the study, along with
recommendations for future research.
CHAPTER V
SUMMARY AND CONCLUSIONS
Background of the Study
Since the mid 1970s, change, complexity and competition
have characterized the health care system. Faced with
these new challenges, health care turned to its existing
planning and management systems. However, these proved to
be insufficient to successfully address these conditions.
In response, the system began to seek out and select for
use other planning and management practices. The adoption
of the concept, strategic management, is a primary example
of this process. However, differing views as to the use,
application, and definition of this concept have appeared
in the literature. These differences indicate a lack of
conceptual clarity regarding this concept, substantiating
the need for the performance of a concept analysis, a
research technique originating in analytic philosophy,
whose function is to attain conceptual clarity.
Rationale for the Study
The recurring presence of the concept, strategic
management, in the literatures of management, health care
209
210
management, and nursing management attests to its being a
significant concept valued by these disciplines. However,
its use, application and definition were found to differ
within and among them. This study was undertaken to attain
conceptual clarity of the concept, strategic management.
Method of Analysis
Concept analysis, a technique originating in analytic
philosophy, was selected as the research method for this
study.
The literatures of three disciplines where the concept
was known to exist were sampled and analyzed, using
Rodgers' (1989) technique of concept analysis. Rodgers'
(1989) technique was found to be philosophically sound,
being highly consistent with the dominant present day view
of concepts espoused in the philosophies of science and
language. Methodologically, it was reasonably easy to use
and, with the exception of a minor recommendation regarding
the reordering of its phases, was determined to be
structurally sound as well.
Limitations
The limitations of this study were as follows:
1. The use of published materials. The population and
final content of published materials is the result of
manuscript selection and review processes, editorial
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policies and abstractor decisions. These factors impact on
the content of published materials within and among
disciplines. This study assumes that published materials
comprehensively reflect the concept being studied. This
was not validated through use of other sources.
2. Use of kev words to identify citations Key words
are the outcome of a decision process that varies among
computerized databases. Thus, it remains a possibility that
journal citations or books may have been missed, based on
the databases selected.
3. The newness of the concept to nursing. The small
volume of nursing literature identified indicates that for
nursing, strategic management is a new concept which may
not be well formed as of yet. Additionally, the
publications which do exist may not reflect the concept's
current usage, as there is a time lag between what is
spoken and what is printed. Finally, the small number
impacted on the ability to generate large quantities of
data for analysis. As a result, the findings reported must
be interpreted and applied in light of the sample size and
early stage of concept development.
4.The limited use of databases. Only databases in
DIALOG, and those of H e a l t h Care Planning and
Administration, and Books in Print Plus were included in
the samples. However, over 500 citations, representing
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government, education, humanities and the social sciences
were identified from the DIALOG database searches and not
included in the samples. Five-seven percent of these
appeared in the Social Science Citation Index, a multi
disciplinary database that includes journals in the
biomedical sciences. The non-inclusion of this index may
have resulted in the non-discovery (and hence the non
consideration) of citations that may have reflected
additional uses and/or surrogate terms.
5. The use of a new concept analysis technique.
Rodgers' (1989) technique of concept analysis has received
very limited exposure in the nursing literature and has not
been subjected to any widespread testing. Additional
research is necessary in order to speak authoritatively as
to its methodological rigor.
6. Exclusion of the economics literature. The term,
strategic management, originated in economics and was later
applied in management. Exclusion of the economics
literature may have failed to elucidate some historical
underpinnings of the concept.
7. Lack of input from experts in health care
management and nursing management. Although twelve experts
(6 in health care management and 6 in nursing management)
were queried regarding participation as master citation
213
list reviewers, only three in each discipline agreed to
participate. Of these, only one of the three health care
management and three of the nursing management experts
returned completed master citation list review forms. None
of these arrived in time for inclusion in the study. As a
result, there was no external review for validity of the
samples of these disciplines' literatures used in this
study.
8. Limited reliability testing. Both intrarater and
interrater reliability testing was used in this study.
However, their scope was limited to theme identification
and the placement of identified themes in the concept
analysis element (CAE) categories. No additional measures
were taken to address the remaining steps of data coding or
those of concept analysis element specification.
Findings
Using detailed search, sampling and data analysis
procedures, and guided by Rodgers' (1989) technique of
concept analysis, findings in seven concept analysis
element (CAE) categories for the concept, strategic
management, were identified from the management, health
care management, and nursing management literatures. The
seven categories were relevant use, surrogate terms,
antecedents, consequences, related concepts, references and
attributes. Collectively, the findings in these seven
categories resulted in the attainment of conceptual clarity
regarding the concept, strategic management. This clarity
is demonstrated in the ability to propose two conceptual
definitions of the concept (based on the findings in the
seven analysis categories); one which is consistent with
the findings common to all three disciplines and one
specific to nursing management.
A nal y s i s of the findings in each of the seven
categories demonstrated a number of patterns of consistency
in the use and application of the concept. The patterns in
each of these categories found across all three disciplines
were as follows:
1. Relevant U s e . Strategic management's most frequent
relevant use was to describe a process.
2. Surrogate Terms. Strategic planning was the most
frequently used surrogate term for the concept, strategic
management.
3. Antecedents. Change was consistently cited as an
antecedent of strategic management.
4. Consequences. Business success was the most
frequently cited consequence of strategic management.
5. Related Concepts. Strategic planning, marketing,
and organizational development were identified in all three
215
literatures as concepts related to strategic management.
6. References. The organization, intra-organizational
units, and phenomena were cited in all three disciplines as
references of strategic management.
7. Attributes. Strategy, Behavior, Perspective,
Influentials, and Systems were identified as attributes of
strategic management in the literatures of all three
disciplines.
Differences in findings among the three disciplines
were identified and examined in all the analysis
categories. However, the analysis category, Attributes,
was identified as singularly important to the definition
process. Attributes in each of the three disciplines were
compared and contrasted in order to identify and explain
differences among them.
Identical attributes of the concept were found in the
man a g e m e n t and health care m a n a gement literatures.
However, differences were found in the areas of attribute
life cycle, attribute dimensions and dimension/theme scope.
The six attributes common to the management and health care
management literatures were Strategy, Structure, Behavior,
Perspective, Influentials and Systems.
The comparison of the attributes in management and
nursing management revealed a match between the five
216
nursing management attributes with five of the six
management attributes. No match with the management
attribute, Structure, occurred. As occurred in the prior
comparison, differences also were found in the areas of
attribute life cycle, dimensions present, and
dimension/theme scope. The five attributes identified in
the nursing management literature were Strategy, Behavior,
Perspective, Influentials and Systems.
In addition to the category, Attributes, the category,
References, yielded important information about the range
of events, situations and phenomena over which the
application of the concept is considered appropriate in
each discipline. The Organization, Intra-Organizational
Units, and Phenomena were identified in all three
literatures as references. In nursing management,
additional references identified were People and Resources.
Conclusions
Conclusions resulting from this study occurred in two
areas: 1) conclusions related to the area of the concept
analysis; and 2) conclusions related to the area of nursing
management.
In the area of conclusions related to concept analysis,
the first conclusion is that concept analysis, and
specifically, Rodgers' (1989) technique of concept
217
analysis, is a philosophically and methodologically sound
research technique to identify, examine, and discuss the
use, application, and definition of a concept. This
conclusion is based on the finding that Rodgers's (1989)
technique of concept analysis was the one most congruent
with the present day philosophy of science and philosophy
of language views of concepts, as reflected in the later
writings of Ludwig Wittgenstein (1953), and Stephen Toulmin
(1972) , as well as congruent with the majority of the
views expressed in Wilson's (1963) seminal work on concept
analysis methodology.
The second conclusion in the area of concept analysis
is that a pattern of conceptual change was demonstrated by
findings of both reduction and expansion of concept
analy s i s elements in the management, health care
management, and nursing management literatures. A pattern
of reduction was evident in the use and application of the
concept from management, through to health care management,
and finally, to nursing management. Along the way, each
succeeding discipline's literature reflected the selective
adoption and use of each category's analysis elements. For
the element, Attributes, for example, the management
literature demonstrated a total of six, of which five had
two dimensions. The health care literature demonstrated
218
the same six as in management, but only three had two
dimensions. Finally, the nursing management literature
demonstrated only five of the six management and health
care management attributes, with only three having two
dimensions.
A pattern of expansion was evident in the addition and
substitution of concept analysis elements identified from
the literatures of the three disciplines. For the element,
References, for example, the management literature
identified only four, while the health care management
literature and the nursing management literature both
identified five (with differences present between them).
The relationships identified between the progression in
time among the literatures (i.e., management = 1974-
1989; health care management = 1980 - 1989; nursing
management = 1983 - 1989) and the patterns of reduction and
expansion evident in the literatures support Wittgenstein's
(1953) contention that meaning is in use and Toulmin's
(1972) contentions that use is related to context and that
concepts evolve in a social process and change over time.
A third conclusion in the area of concept analysis is
that the performance of a concept analysis can result in
the attainment of conceptual clarity of a concept. This
c onclusion is based on the ability to propose a
219
philosophically sound conceptual definition of strategic
management grounded in the analysis element findings common
to all three disciplines. This definition is as follows:
Strategic management is a process characterized by the
elements of Strategy, Behavior, Perspective,
Influentials, and Systems. Strategic planning is its
most frequent surrogate term, one or more conditions of
change frequently precede its adoption, and business
success (measured in quantitative terms), is
its most frequent result. It is similar but not
identical to the concepts of strategic planning,
marketing, and organizational development. Strategic
management can be applied to the management of
organizations, intra-organizational units, and
phenomena.
In the area of nursing management, the first conclusion
is that widespread use and application of the concept,
strategic management, in nursing management, has been
impaired by the confusion surrounding the use,
application, and definition of the terms, strategic
planning and strategic management. Recently however, some
writers have begun to differentiate between these two terms
(see Stull & Pinkerton, 1988; Young & Hayne, 1988) and
i ncr easingly are discussing the concept, strategic
220
management, from a nursing perspective (see Friss, 1989?
Garner, Smith & Piland, 1990).
The second conclusion for nursing management is that,
based on the findings of this analysis, a philosophically
sound conceptual definition of strategic management for
nursing management can be proposed. That definition is as
follows:
Strategic management is a process characterized by the
elements of Strategy, Behavior, Perspective,
Influentials and Systems. Strategic planning is its
most frequent surrogate term, one or more conditions
of change frequently precede its adoption and business
success (measured in both qualitative and quantitative
terms) is its most frequent result. It is similar, but
not identical to the concepts of strategic planning,
marketing and organizational development. Strategic
management can be applied to the management of
organizations, intra-organizational units (such as the
nursing department), people, resources and phenomena
(such as change).
Philosophical Implications
The philosophical implications of this study were
directed to the areas of analytic philosophy, philosophy of
science and philosophy of language.
221
For analytic philosophy, the study indicated that
concept analysis is a viable approach to attaining
conceptual clarity. Analysis provides a means to identify
and examine the constituent elements of a concept,
resulting in the ability to clearly describe and discuss
use and application.
For the philosophy of science, the implications of this
study were that it supported the major premises advocated
in the later writings of Wittgenstein (1953) regarding
concepts. Examination of use as an avenue towards meaning
was found to be appropriate to the goal of attaining
conceptual clarity, while inclusion of multiple use
contexts over time supported historicism, the present day
dominant school of thought in philosophy.
For the philosophy of language, the implications of
this study were that its findings supported Toulmin's
(1972) contentions regarding the processes of concept
formulation and evolution, and demonstrated that the
written language of a discipline can be an appropriate data
source upon which to perform an analysis.
Overall, the study findings supported the philosophical
premises of the study. These were 1) that the meaning of a
particular concept is evidenced by its use; 2) that use is
a function of context; and 3) that concepts evolve in a
222
social process and change over time.
Nursing Management Implications
For nursing management, the implications of this study
are that strategic management has been found to be a
concept worthy of consideration for use and application by
nurse executives and administrators. With the attainment
of conceptual clarity of this concept, nursing management
now has a concept which it can use to meet the present and
future challenges in nursing and health care delivery in a
responsible, comprehensive and proactive manner. These
chal l e n g e s include reducing slack in productivity,
supporting the expansion of services (e.g., to the
community) in the face of limited resources, and
participating actively in organizational change efforts
(e.g., mergers, acquisitions, etc.)
Directions for Future Research
Numerous nursing-focused and interdisciplinary research
programs regarding the concept, strategic management, and
Rodgers' (1989) t e chnique of concept analysis are
indicated. The following recommendations are suggested:
1. An examination and clarification of the concept
analysis element, relevant use, including its relationship
to definitions and to other concept analysis categories.
223
2. An examination of the application of the concept,
strategic management, in health care organizations in the
public sector.
3. An examination of the application of the concept,
strategic management, to references other than the
organization.
4. Consideration of the development and use of
operational definitions of the management, health care
management, and nursing management attributes of strategic
management identified in this study to guide the empirical
measurement of the concept in selected settings.
5. Analysis of the performance of strategic management
as a process by intra-organizational units (especially
nursing).
224
References
225
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Appendicies
PLEASE NOTE
Copyrighted materials in this document have

not been filmed at the request of the author.
They are available for consultation, however,
in the author’s university library.
233-235
University Microfilms International
236
Appendix B
Systems View Model
Stage 3
action Nursing
ORGANIZATIONAL Domain
EFFECTIVENES
A
INTERFACE QUALITY
NURSING
PRODUCT
concern'
!
Organizational action
Domain
— 1--------------------^SYSTEM VITALITY^----------------
Note. From Scalzi, C. C., & Anderson, R. A. (1989).
Conceptual model for theory development in nursing
administration (pp. 137-141). In B. Henry, C. Arndt,
M. DiVincenti, & A. Marriner-Tomey (Eds.). Dimensions
of nursing administration. Boston: Blackwell.
(used without permission).
237
Appendix C
Wilson's (1963) Technique of Concept Analysis
1. Isolate questions of concept
2. Identify right answers
3. Pick a model case
4. Pick contrary cases
5. Pick related cases
6. Pick borderline cases
7. Invent a case
8. Examine the social context of the concept
9. Examine underlying anxiety
10. Seek practical results
11. Examine results in language
238
Appendix D
Walker and Avant's Technique of Concept Analysis*
1. Select a concept
2. Determine the aim or purpose of the analysis
3. Identify all the uses of the concept you can
discover
4. Determine the defining attributes
5. Construct a model case
6. Construct borderline, related, contrary,
invented, and illegitimate cases
7. Identify antecedents and consequences
8. Define empirical referent
Not e . From: Strategies for theory construction in nursing
(p. 28) by L. 0. Walker & K. C. Avant, 1983, Norwalk, CT:
Appleton-Century-Crofts.
From: Strategies for theory construction in nursing
(2nd ed.) (p. 35) by L. 0. Walker and K.C. Avant, 1988,
Norwalk, CT: Appleton-Century-Crofts.
♦credited to Wilson, J. W. (1963) . Thinking
with concepts. New York: Cambridge University Press.
239
Appendix E
The Hybrid Model of Concept Analysis
THEORETICAL PHASE
1. Selecting a concept
2. Searching the literature
3. Dealing with meaning and measurement
4. Choosing a working definition
FIELDWORK PHASE
1. Setting the stage
2. Negotiating entry
3. Selecting cases
4. Collecting & analyzing
data
FINAL ANALYTIC PHASE
1. Weighing and working the findings
for clarification and refinement
240
Appendix F
Attributes of Health Policy and Related Themes
Attitude Direction Practice Domain
Position Focus Action Addresses
Foundation Goals/Aims Inaction specific
Plank Objectives Interventions domain of
Values Influence Initiatives concerns:
Impetus Regime Health care
expenditures
Incentives Plan Health care
services
Guide Progress Health care
personnel
Support Legislation
Non-support
241
Appendix G
Overview of the DIALOG Information System
1. DIALOG is the world's largest online information
retrieval system. It contains over 300 databases,
representing either a given discipline or subject area or a
specific type of document.
2. DIALINDEX is a subject directory to DIALOG databases.
It assists in choosing the best database for a given search
by allowing previewing of search results across a group of
files. You define the group of databases you want to scan
and then run a search in them. Results can be viewed
online or printed offline. DIALINDEX allows you to search
either by file number or by DIALINDEX category.
3. A DATABASE is a collection of records or items of
information, usually representing either a given discipline
or subject area. An individual database is also called a
FILE, and is assigned a unique FILE NUMBER.
4. The items of information contained in the DATABASES are
called RECORDS. A RECORD may be 1) a bibliographic
reference (with or without abstract); 2) a directory entry;
3) a table of statistical information; 4) the complete text
of an article. RECORDS are divided into segments called
FIELDS. Typical FIELDS are: title, author, publication
date, and the abstract.
5. SEARCH TERMS are the words or phrases used online to
define the topic of the search.
242
Appendix H
Dialindex Categories
Books
Reviews
Business Economics
Management
Market Research
Government
Medicine
Humanities
Social Science
Not e . From DIALOG database catalogue (p. 65-75) by Dialog
Information Services, 1988, Palo Alto: DIALOG.
243
Appendix I
File-Specific DIALINDEX Search Outcomes
DIALINDEX FILE NAME/# NUMBER OF PERIOD
CATEGORY (DATABASE) CITATIONS COVERED
DISCIPLINE FOCUS: MANAGEMENT
Books LC Marc/426 151 1968-Wk 28,
1989
British/430 113 Current
Bks in Print/470 140 In Print
Book Reviews Magazine Ind/47 20 1970-August,
1989
Bk Review Ind/137 28 1969-April,
1989
Newspaper Abs/603 6 1984-1988
Academic Ind/88 9 1975-July,1989
Nat't News Ind/111 1 1979-July,1989
Courier Plus 9 1988-July,1989
Busecon Foreign Trade/90 55 1974-July,1989
Econ Lit Ind/139 17 1969-Sept,1988
Trade Ind/148 123 1981-August,
1989
244
Appendix I : continued
World Bus/583 7 1984-July, 1989
Manage ABI/Inform/15 2585 1971-Sept, 1989
PAIS/49 29 1976-June, 1989
Mgt Ctnts/75 322 1974-Sept, 1989
Har Bus Rev/122 23 1971-June, 1989
Mktres PTS PROMPT/16 84 1972-Juiy, 1989
Indus Data/189 1 1979-July, 1989
A.D. Little/192 11 1977-June, 1989
Findex/196 2 1982-Jan, 1989
Investex/545 52 1982-July, 1989
PTS MARS/570 5 1984-July, 1989
PTS New Prod/621 13 1985-July, 1989
Bus Dateline/635 35 1985-July, 1989
ICC/IBR/563 12 Thru July, 1989
PTS News/636 20 1987-July, 1989
DISCIPLINE FOCUS: HEALTH CARE
Medicine Biosis Pre/5 7 1969-July, 1989
Scisearch/34/87/94 38 1974-Wk 26 1989
Sport/48 4 1977-July, 1989
Embase/72/172/173 30 1974-Wk 27 1989
2 4 5
Pharm.Abs/74 3 1970-July, 1989
Medline/155 13 1966-Aug, 1989
Pascal/144 9 1986-May, 1989
Fed Res/Cancer/265 5 1963-July, 1989
DISCIPLINE FOCUS: NURSING
CINAHL 8 1983-Dec, 1989
DISCIPLINE FOCUS: OTHER
Govt GPO monthly/66 2 1976-Aug,1989
CIS/101 2 1971-May, 1989
ASI/102 1 1979-1989
Legal Res Ind/150 5 1980-July, 1989
Tax Notes/650 3 1986-July, 1989
Wash.Post/140 7 1983-July, 1989
Insur Period./169 5 1979-1984
Education ERIC/1 51 1966-1989
Psychinfo/11 33 1967-1989
Psychalert 1 Thru July, 1989
Humanities SocScisearch/7 207 1972-Wk 26 1989
America Hx/Lit/38 3 1963-1988
246
DissAbst/35 141 1861-July, 1989
Phil Ind/57 3 1940-July, 1989
ArchitecDB/179 1 1989
SocScience NCJRS/21 15 1972-July, 1989
SocAbs/37 16 1963-July, 1989
Pop.Bib/91 1 1965-Dec, 1984
USPolSci/93 11 1975-1989
CrimJus/171 1 1975-June, 1989
Family Res/291 1 1970-June, 1989
247
Appendix J
Year/Journal Matrix: Management Literature
JOURNAL TTHJE 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89T0Q
Decision Sciences 1 1
Calif Mgt Review 1 1 1 1 1 1 2 8
Bankers Magazine 1 1
Managerial Planning 1 1 2 2 6
Management Solutions 1 1
Business Horizons 1 1 1 3
Management Decisions 2 2 4
Journal of Business 1 1
Business Quarterly 1 1
J. Enterprise Mgt 1 1
Economist 1 1
Intemat11 J. Mgt 1 1
J. Sm Business Mgt 1 1
J. Business Strategy 1 1 2 3 2 1 1 11
J. Business Ethics 1 1
Planning Review 1 1 1 3
Tech.xore&Soc.Chg 1 1
Strategic Mgt J. 21 1 2 2 1 2 1 1 13
Intemat11 J.Manpower 1 1
J.App.Behav.Science 1 1 2
Long Range Planningl 2 1 4 1 3 3 15
Acad of Mgt Review 1 2 5 3 3 3 2 19
Acad of Mgt Proceed. 1 1
Business 1 1 1 3
Management World 1 1
Survey of Business 1 1
TREE T r a n s a c tio n s 1 1
J. of General Mgt 1 2 3
Public Admin Review 1 1 2
Public Prod Review 1 1
I’ erfaces 1 2 3
Credit Union Exec 1 1
Human Relations Mgt 1 1 2
J.Amer Plan Assoc 1 1
Industry Week 3 3
Baylor Business Rev 1 1
Acad of Mgt Journal 1 1 2
Admin in Social Work 1 1
Business Forum 1 1
Mgt Intemat'1 Rev 1 1
Quality Progress 1 2 3
Mgt Accounting 1 1
R & D Management 1 1 2
SUBTOTAL 2 3 2 1 1 2 0 6 11 12 4 26 12 11 20 2 131
248
Appendix J: continued
Year/Journal Matrix: Management Literature
JOURNAL TITLE 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89T0T
Financial Exec 1
Euro J.of O.R. 1
Intemat'1 J. Q&R 1
T m g & Devel J. 1
Intemat'1 Stu M&O 1 2
Project Mgt J. 1 1
Sloan Mgt Review 1 2
Management Review 1 1 3
Organizational Dy 1 2
Chief Executive 2
Exec Excellence 2 2
J. of Management 1 5
Exec Speeches 1
IIE Transactions
Vital Speeches
Mgt Science
J. Euro Indus T m g
CA Magazine
Futures 1
J. of Mgt Studies 2
Futurist 1
Eng.Costs.Prod.Eoon 1
Indus & Cammer.Tmg 1
Colum.J. World Bus 1
J. of Marketing 1
Practising Mgr 1
Optimum
Harvard Bus Rev 1
Perspective 1
J.of O.R.Society
Bank Sys & Equip 1
SUBTOTALS 0 0 0 0 0 0 0 2 0 0 0 4 2 6 15 16 4 49
SUBTOTALS 2 3 2 1 1 2 0 6 11 12 4 26 16 12 11 20 2 131
(Prior Page)
TOTALS 2 3 2 1 1 2 0 8 11 12 4 30 18 18 26 36 6 180
249
Appendix K
Year/Journal Matrix: Health Care Literature
JOURNAL TITLE 74 78 79 80 81 82 83 84 85 86 87 88 89 TOT
Hosp & Hit Svc Admin 2 3 1 2 8

Admin Radiology 1 1 2
Hit Care Mgt Review 1 2 3 2 2 10
Hit Care Strategic Mgt 2 1 3
Hit Care Forum 2 1 3
J. of Bus Strategy 1 1 2
Modem Hit Care 2 2
Hit Care Finan Mgt 1 1 2
Behavioral Sci 1 1
Topics Hit Care Plan 1 1
Compu.Environ & Ur Sys 1 1
J.Hlt Care Marketing 1 1 2
Philosophy of Sci 1 1
Hit Care Mkt Qtrly 1 1 2
Lg Sc Sys Th & Appl 1 1
long Range Planning 1 1 1 5
Computer J. 1 1
Acad of Mgt J. 1 1
AL J.of Med Sci 1 1
Harvard Bus Rev 1 1 2
TAPPI J. 1 1
J.of O.R. Society 2 1 3
Leisure Info Qtrly 1 1 2
Anver J. Hosp Riarm 1 1
Laboratory Medicine 1 1
Trans.Research 1 1
Strategic Mgt J. 1 1
Health Progress 1 1 1 3
J.Hlt Admin Educ 1 1
Intemat11 J. HP & M 1 1 2
MID Med Lab 1 1
J. of Med Systems 1 1 2
Hosp Hit Svc Rev 1 1
Psychiatric Hosp 1 1
Personnel 1 1
Organizational Dy 1 1
Issues in Hit Care 1 1
BulletinrAm.Prot.Hosp 1 1
TOTAL 2 1 0 0 4 6 4 3 14 8 14 13 6 75
Appendix L
Year / Journal Matrix: Nursing Management Literature
JOURNAL TTTIE 83 84 85 86 87 88 89 TOTAL
J. Pediatric Health Care 1 1
J. NUrsing Administration 1 1 2 2 1 7
Nursing Clinics 1 1
Nursing Management 1 1 2
Nursing Economics 1 1
SGA Journal 1 1
Nursing Research 1 1
OR Manager 1 1
Nursing Admin Quarterly 2 2
TOTAIS 0 2 2 3 0 7 3 17
251
Appendix M
Letter of Invitation: Reviewers
7500 Harrison Lane

Temple Hills, MD 20748
19 January 1990
(inside address)
Dear (name),
I am currently a doctoral candidate pursuing a Doctor

of Philosophy in Nursing at George Mason University under
the direction of Dr. Mary Silva. My dissertation research
seeks to attain conceptual clarity of the concept,
strategic management, across the disciplines of management,
heal t h care, and nursing, through application of a
technique from analytic philosophy called concept analysis.
Rodgers' (1987) method of concept analysis (attachment 1)
is the structural framework for this research.
While a number of media may be used to perform concept

analysis, the written media (i.e., books and journal
articles) are the most common. The literatures of the
disciplines which use the concept, strategic management,
are the sources for this written media. Using a purposive
sampling technique (outlined in attachment 2) , I have
created citation lists for the literatures of management,
health care, and nursing.
Having identified you as a knowledgeable strategic

management author and/or educator, I am writing to request
that you serve as an external reviewer in support of my
dissertation. This role will consist of 1) reviewing one
or more discipline-specific Master Citation Lists and
indicating vour assessment of the importance of including
each listed citation in the literature sample and 2)
i ndi cating other citations which you believe merit
inclusion in the sample, along with a rationale for such
recommendation(s).
Please indicate your decision regarding participation

in this research by completing and returning the enclosed
response form (attachment 3) via the stamped, addressed
envelope provided not later than March 1. 1990.
252
Appendix H: continued
Upon receipt of your intention to participate, you

will receive one or more Master Citation Lists, along with
postage-paid return envelopes. All materials must be
completed and returned to me not later than April 15. 1990
in order to ensure inclusion in the study. As I plan to
graduate in August, this timetable provides approximately
sufficient time to complete the writing and final committee
review of this study in preparation for its oral defense
and final approval. Your assistance in maintaining this
timetable is greatly appreciated.
Thanking your for your assistance and support in this

research effort, and looking forward to your response, I am
Sincerely,
Christine M. Galante, MSN

LTC, Army Nurse Corps
Doctoral Candidate
School of Nursing
Fairfax, Virginia
end
1 - Rodgers Technique of Concept Analysis
2 - Purposive Sampling Technique
3 - Response form
253
Appendix M: Continued
Attachment 1
Rodgers' Technique of Concept Analysis
1. Identify and name the concept of interest
2. Identify surrogate terms and relevant uses of the
concept
for data collection
4. Identify the attributes of the concept
5. Identify references, antecedents and consequences,

of the concept, if possible
6. Identify concepts that are related to the concept
of interest
7. Identify a model case of the concept
Note. From "Concepts, analysis and the development of
nursing knowledge: The evolutionary cycle" by B. L.
Rodgers, 1989. Journal of Advanced Nursing. 14, p. 330-
335.
254
Appendix M: continued
Attachment 2
Purposive Sampling Technique
Researchers performing concept analysis studies use

both probability and non-probability sampling techniques.
Probability sampling (e.g., random, stratified random,
etc.) assumes that each element of the population having an
equal chance for inclusion maximizes the quality of
representativeness and thus strengthens the validity of the
study findings. In contrast, non-probability sampling
(e.g., purposive sampling) acknowledges the potential for
an inequality of value/relevance among the elements of a
population (e.g., a "classic" textbook, a frequently cited
article, etc.). In such contexts, it is the preferred
technique because it can result in a genuinely more
representative sample by making a deliberate effort to
select sample elements on the basis of criteria which
directly support the purpose of the research.
This study's purpose and the nature of the research
problem are best supported by use of purposive sampling, a
technique which recognizes the inherent inequities among
literature elements (e.g., a major text versus a minor
article) and provides a means to tailor the sample
according to predetermined criteria.
The focus of sampling in this study centered on
identifying and including the major discussive. descriptive
and conceptually-focused citations in the management,
health care and nursing literatures. Examination of
multiple disciplines' literature allowed for identification
of variations and similarities in the use of the concept
over a broad field of concern. Additionally, a broad time
frame (1971-1989 = management; 1980-1989 = health care;
1983-1989 = nursing) p ermitted examination of the
historical development/evolution of the concept, and
documented the continuing emergence of knowledge about it.
As a result, the following types of citations were excluded
from the samples;
1. Case studies (whether by firm, strategic group,

region or industry)
2. Company/corporate/industry reports
255
Attachment 2: continued
3. Discussions of particular strategy content or

process c o m p o n e n t s (e.g., value-added strategy,
environmental scanning), applications (e.g., downsizing,
joint ventures, acquisitions) or management tasks/behaviors
(e.g., portfolio analysis).
4. Literature demonstrating "Broken" term use

(e.g., strategic communications management)
5. Literature focusing on particular role

performance (e.g., CEO behavior, top management team
attributes, performance by human resource professionals,
economists, marketers, etc.)
6. Educationally-focused literature (e.g., learning

needs of middle managers, curriculum, roles of educators,
etc.)
256
Attachment 3
Master Citation List Reviewer
Response Form
(N.B. PLEASE REPLY BY MARCH 1, 1990)
NAME ____________________________________________ DATE
1. I agree/do not agree to participate as an external

reviewer in support of the dissertation titled "Strategic
Management in Nursing: A Concept Analysis" by Christine M.
Galante. I understand that participation consists of the
following actions:
A. Review of one or more discipline-specific Master

Citation Lists and indication of my assessment of the
importance of including each listed citation in the
literature sample.
B. Indication of other citations which I believe

merit inclusion in the sample, along with a rationale for
any such recommendations.
C. Completion and return of all materials to the

researcher not later than April 15. 1990.
2. I do/do not wish to receive an abstract of the

completed study.
3. I acknowledge the following individual(s)/colleague(s)

as a knowledgeable strategic management author and/or
educator and recommend that he/they be contacted and asked
to serve as an external reviewer:
NAME MAILING ADDRESS
Signature
257
Appendix N
Master Citation List Reviewers
Management Rationale
Shaker A. Zahra, Ph.D. Well known author &
Department of Management scholar in strategic
School of Business Administration p 1ann ing/management
Fairfax, Virginia 22030
Paul Shrivastava, Ph.D. Well known author &
Professor of Management scholar; frequent
Bucknell University editor; Advances in
Lewisburg, PA 17837 Strategic Management
Anne M. McCarthy Recommended by Dr.
Krannert Graduate School of Mgt Carolyn Woo, an
Purdue University initial selectee.
West Lafayette, IN 47906
Health Care
Brian Golden Recommended by Dr.
Graduate School of Mgt Stephen Shortell, an
University of Texas initial selectee.
Austin, TX 78712
258
Appendix N: continued
Nursing
Laura C. Young, RN, MSN Co-author, Nursing
Vice President Administration: From
Harris Hospital, HEB Concepts to Practice.
1600 Hospital Parkway, Box 669 Chap. 8 = Strategic
Bedford, TX 76021 Management
Lois Friss, RN, Dr PH Author, Strategic
Associate Professor Management of
School of Public Administration Nurses
University of Southern California AUPHA Press, 1989
16952 Blanche Place
Grenada Hills, CA 91344
Leann Strasen, RN, MBA, DPA Well known nursing
Vice President administration
Henry Mayo Newhall Memorial Hospital author
23845 McBean Parkway
Valencia, CA 91355
259
Appendix O
Master Citation List Form
PART I
DIRECTIONS: The following citations have been selected
using a purposive sampling technique focused on selecting
the major writers and writings in each discipline on the
concept, strategic management. In the columns below,
indicate your assessment of the importance of including
each listed citation in the literature sample. Thank you
DISCIPLINE:
Management/Health Care/Nursing
Assessment Decision
CITATION TYPE: Yes Yes No No
Books/Journals Critical Important Opinion
PART II
DIRECTIONS: In the space provided, please list other books
or journal articles which you believe merit inclusion in
this sample. Please state your rationale with each entry.
Thank you.
260
Appendix P
Coding Instructions
Introduction
The following are instructions to guide the reading
and interpretation of text in the performance of a
concept analysis of the concept, strategic management,
across the disciplines of management, health care
management, and nursing management.
Rodgers' (1989) technique of concept analysis provides
the categories into which to code the texts, along with the
additional category of definitions. The following
directions for this task are in two parts: 1) general
guidance and 2) specific instructions.
Part I : General Guidance
Concept analysis is a technique from analytic
philosophy. It requires the ability to perform the higher
level cognitive skills of discrimination, reflection,
analysis and synthesis.
In reading the text samples provided, ignore any
current knowledge or pre-conceived ideas about this
concept, and instead, let the information flow from the
literature.
The task requires concentration. The following will
improve the accuracy and objectivity of your work:
261
Appendix P: continued
1. If possible, set aside a consistent time of day and
day of week to do coding. Choose a time of day when full
attention can be devoted to the task.
2. Choose a place without distractions or
interruptions.
3. Read each text segment once casually to get the
"flavor" of it. Then read it a second time, making an
effort to identify the appropriate category for coding.
4. Underline, highlight and/or make side notes on the
copies of the text materials as necessary/appropriate to
organize thoughts and target the analysis.
5. Don't "force" text into categories. Text samples
will vary as to the number and type of category elements
present.
6. Do not attempt to link/reinforce a theme or idea
identified in one source by searching for it in others.
Read and analyze each text sample as an individual. If
there are consistencies, they will be addressed by the
researcher in the discussion of data results.
Part II: Specific Directions
Text coding involves reading and categorizing text
content. There are eight (8) categories into which text
can be coded.
262
A total of ten percent (10%) of the cumulative sample
retrieved was selected for external reader coding or a
total of eleven citations. These were distributed among
the three disciplines as follows:
Management Citations: 10 (50%)
Health Care Management Citations 8 (30%)
Nursing Management Citations: 4 (20%)
TOTALS 22 100%
The following procedure is used in the performance of
coding of each text sample:
1. Do an initial casual reading of each highlighted
text segment to obtain an overview of it.
2. Do a careful second reading and use side notes,
underlining, e t c . , to focus in on the text designated for
coding.
3. Match each text segment with a category (review
category definitions as often as necessary) and write the
name of the category selected next to each text segment.
4. Decide on the main theme expressed in each text
segment based on the key word/words that capture the
meaning of the text segment. The main theme will often be
one or more of these words.
5. Write each text segment's number and identified
263
theme in its category space on the Concept Analysis Coding
Form provided for each citation.
6. Return all coding forms to me in the envelope
provided (retain the text segment materials until I have
notified you that I have received your coding forms and
discuss our inter-rater results. After that discussion,
you may discard these materials). Please complete your
coding as soon as possible, returning all coding forms to
me NOT LATER THAN FRIDAY, JULY 6, 1990. Call me
immediately if you are unable to complete your work by this
date so that we may negotiate a new completion/return date.
The following are definitions and discussion of each of
the coding categories to guide the work:
RELEVANT U S E : Use is the most general discussion of a
concept. It is the common manner in which the concept is
employed. Attention should be focused on identifying
relevant uses of the concept, rather than all its uses.
Relevant refers to that which is pertinent, germane,
material or apropos to the discussion at hand. Definitions
are the most common places where writers indicate how they
are using a concept. In the Management literature, for
example, the concept, strategic management is frequently
used to refer to a process for executive decision-making.
264
SURROGATE TERMS; Surrogate terms are substitute terms
used to refer to the concept of interest. In the
management literature, the terms, "business policy" and
"organizational strategy" ar e frequently used
interchangably (i.e., as surrogate terms for) with
DEFINITIONS: A definition is a statement which
attempts to assign meaning to a phenomenon. Definitional
statements will often begin as "strategic management is
..." For this study, definitions include those statements
identified in the literature samples which do one or more
of the following:
1. operationalize the concept, i.e., describe the
conditions or means necessary to produce it or which result
in it.
2. describe the scope or limitations of the concept
3. describe the role and/or function of the concept
4. use a metaphor to demonstrate the concept
5. use a model to identify elements of the concept
In the management literature, an example of a
frequently seen definition of strategic management is as a
process by which the organization establishes and
maintains alignment with its environments
265
ATTRIBUTES: Attributes are the descriptors or
defining characteristics of a concept. Attributes explain
or describe aspects or components of a concept. These
aspects/character i s t i c s / c o m p o n e n t s taken collectively,
build a "picture" or definition of the concept. In the
management literature, frequently mentioned attributes
include strategy, strategy for m u l a t i o n , strategy
implementation, mission, values, culture and integration.
ANTECEDENTS; Antecedents are events or phenomena that
are generally found to precede a concept. In the
management literature,phenomena such as drastic change,
environmental turbulence, complexity, and a sense of threat
are frequently mentioned as conditions present which
preceded (and contributed to) a decision to practice
strategic management. Another group of antecedents are
those phenomena which frequently are mentioned as
approaches to management which preceded or evolved into
strategic management. These most often include various
types of planning and budgeting behaviors, such as long-
range planning, portfolio management, and strategic
planning.
266
CONSEQUENCES; Consequences are events or phenomena
that are generally found to follow or result from the
occurrence of the concept. Consequences reflect the
outcomes of the use and application of the concept. These
outcomes are most frequently discussed as positives (e.g.,
survival, success, attainment of competitive advantage,
successful strategy implementation, etc.), but negative
outcomes sometimes are also discussed (e.g., power shifts,
organizational upheaval, chaos, etc.).
RELATED CONCEPTS: Concepts related to the concept of
interest are one similar to it but different in that they
lack one or more of the concept of interest's defining
attributes. In the management literature, classical
program management (social work) and organizational
development (management) are two examples of concepts
which share some, but not all, the defining attributes of
REFERENCES; References are the range of events,
situations or phenomena over which the application of the
concept is considered to be appropriate. Appropriateness
is a function of the common and accepted use and
application of the concept. In the management literature,
the organization is the most frequently cited reference of
the concept, strategic management (i.e., the organization
267
is the phenomenon most frequently mentioned as the one over
which the application of the concept, strategic management,
is considered appropriate). Other references of this
concept in the management (and other) literatures include
distinct organizational divisions/operating elements (e.g.,
SBUs, the nursing, blood bank and radiology departments),
and more broad or conceptual phenomena, such as crisis,
technology, and human resources. Frequently, the concept
strategic management is operationalized by a writer as a
process, and then, as a process, is applied to the
management of the phenomenon identified as a reference.
268
Appendix Q
Concept Analysis Coding Form
CITATION: __________________________________
USE:
SURROGATE TERMS:
DEFINITIONS i
ATTRIBUTES:
ANTECEDENTS:
CONSEQUENCES.
RELATED CONCEPTS:
REFERENCES:
269
Appendix R
External Reader InterRater Reliability Record
DATE OUT:__26 June 1990_
TO: B.C. / P.A.
DATE RETURNED: 19 July 1990/15 August 1990
INTERRATER RELIABILITY SCORES:
DISCIPLINE-SPECIFIC CITATIONS FOR CODING
MANAGEMENT HEALTH CARE MANAGEMENT NURSING MANAGEMENT
#47: 85% #10:100% #11:100%

#51: 90% #12:100% #15: 92%
#80: 100% #15: 85% #19: 88%
#150:100% #34: 84% #20: 85%
#151: 92% #58: 38%
#156: 80% #79: 90%
#181: 90% #80: 84%
#182: 85% #81: 92%
#183: 95%
#185: 88%
COMMENTS:
__________ Composite score: 91%
Vita
Christine M. Galante was born August 16, 1950, in

Washington, DC, and is an American citizen. She graduated
from the Academy of Notre Dame girls Catholic high school
in Washington in 1968. She received a Bachelor of Science
in Nursing from Niagara University, Niagara Falls, New
York, in 1972. Following graduation, she began active duty
in the United States Army Nurse Corps at the rank of First
Lieutenant. She has maintained continuous active Federal
service since entry and currently holds the rank of
Lieutenant Colonel. Prior graduate degrees include a
Master of Arts in Education from Pepperdine University,
Malibu, California and a Master of Science in Nursing from
the Catholic University of America, Washington, DC.
Lieutenant Colonel Galante has published in both the book
and periodical literatures in nursing. Topics have
included nursing quality assurance research, as well as
book chapters on nursing diagnosis and marketing for nurse
managers.

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■ U n iv e rs ity M ic ro film s In te rn a tio n a l

S tra teg ic m an agem en t in nursing: A con cep t analysis

Galante, Christine M arie, Ph.D.

George Mason University, 1991

A dissertation submitted in partial fulfillment of the

Christine M. Galante, LTC, AN

Director: Dr. Mary C. Silva, RN, Ph.D.

Fall Semester 1990

The author acknowledges the assistance and support of

Dr. Mary Silva, my chairman, and Drs. Jacqueline Dienemann

Dr. Daniel Rothbart, Professor, School of Philosophy,

Mr. Hugh Howard, Research Librarian, The Pentagon, for his

My husband, Sam, and my mother, Mrs. Helen Dinnis, for

Health Care Management Literature................... 129

Nursing Management Literature...................... 152

Interpretation and Discussion..........................182

1. Examples of Nurse Theorists' Views of Concepts 33

2. Concept Analysis Element Generation Process 81

3. Results Related to Search and Sampling Outcomes 92

4. Discipline-Specific Sampling and Retrieval Outcomes 96

5. Relevant Use: Management Literature 104

6. Surrogate Terms: Management Literature 109

7. Antecedents: Management Literature 111

8. Consequences: Management Literature 113

9. Related Concepts: Management Literature 114

10. References: Management Literature 119

11. Attributes: Management Literature 121

12. Relevant Use: Health Care Management Literature 133

13. Relevant Use: Health Care Management Literature 135

14. Surrogate Terms: Health Care Management Literature 137

15. Antecedents: Health Care Management Literature 140

16. Consequences: Health Care Management Literature 142

17. Related Concepts: Health Care Management Literaturel44

18. References: Health Care Management Literature 146

19. Attributes: Health Care Management Literature 149

20. Relevant Use: Nursing Management Literature 159

21. Relevant Use: Nursing Management Literature 161

List of Tables: continued

22. Surrogate Terms: Nursing Management Literature 163

23. Antecedents: Nursing Management Literature 165

24. Consequences: Nursing Management Literature 167

25. Related Concepts: Nursing Management Literature 168

26. References: Nursing Management Literature 170

27. Attributes: Nursing Management Literature 172

28. Suggested Revision: Rodgers' Technique 205

STRATEGIC MANAGEMENT IN NURSING: A CONCEPT ANALYSIS

Christine M. Galante, M.S.N.

George Mason University, 1990

Dissertation Director: Dr. Mary C. Silva

This study examined the concept, strategic management,

u s ing the literatures of management, health care

management, and nursing management and Rodgers' (1989)

technique of concept analysis. Differences in the use and

application of the concept across disciplines demonstrated

a lack of conceptual clarity regarding the concept,

neces s i t a t i n g the analysis. Using Rodgers' (1989)

technique, seven aspects of the concept were identified:

1) relevant use; 2) surrogate terms; 3) antecedents; 4)

consequences; 5) related concepts; 6) references; and 7)