Some of the most basic and most beautiful of life’s traditions are in the health professions. Practitioners of human care and treatment throughout history have tended

to view the world in ways different from those in other

sectors such as business and industry. In return, societies

have granted honor and privilege to health care practitioners. Those differences between health care and business are diminishing. We must now account for what we

do, why, what we produce and how much it costs. Analysis of the multiple factors that led to the current situation

is a study in itself beyond the scope of this paper.

The purpose of this paper is to explore some perspectives

on outcomes research and the alternatives for integrating

the nursing component into the larger picture. The main

points are:

1. Health care has been removed from the realm of the

sacred and has entered the era of accountability, most

clearly signaled by the emphasis on effectiveness and

outcomes research.

2. Each of us sees the world through our own conceptual

lenses that usually are undefined and unrecognized by

ourselves and others.

3. Nursing, like other health professions, defines the

world, including outcomes, through the lens of its own

discipline.

4. Assessment of health care outcomes requires not just

multi-disciplinary, but meta-paradigmatic research.

A constant focus in this paper in this paper is the varied

and multiple world views and the alternative approaches

to outcomes research that are possible and likely with

different conceptual lenses. Several building blocks provide the foundation for this discussion, including the traditions of the professional world, alternative conceptual

lenses, nursing research and health care outcomes, and

the necessity of multiple perspectives in the assessment

of outcomes and effectiveness of health care.

The Professional World View

Like many other trades, the health care professions build

on the history of the guilds of craftsmen. In a less complex era, guilds were the backbone of productive societies. Each guild was entrusted by society to set the standards for the trade, train its new practitioners, monitor

quality of work in meeting the standards, provide social

identification, and promote a sense of community among

its practitioners. Then as now, a fundamental tenet of the

work group was service to the client - a person-to-person

relationship. Focusing on the necessity and quality of

their own work did not preclude an appreciation of the

Outcomes Research:

Integrating Nursing Practice Into The World View

Sue T. Hegyvary, PhD, FAAN

...our basic assumptions about the nature of truth and reality and the origins of knowledge shape the way

we see the world and ourselves as participants in it. They affect our definitions of ourselves, the way we

interact with others, our public and private personae, our sense of control over life events, our views of

teaching and learning and our conceptions of morality. (Belenky et. al., 1969, p. 3)
overall societal complexity, through managing the larger

picture was not the task of the individual craftsman.

In addition to the societal trust accorded to guilds, the

health professions have enjoyed further protection by

society. The religious origins of the health professions,

especially nursing, the intimate nature of our work, and

the fact that we watch over life and death have both promoted and permitted health care to be viewed in the realm

of the sacred. Our social contract has been based on a

trust and freedom from public scrutiny not accorded the

world of business and commerce.

The social contract has been rewritten. Relman (1988)

called the current stage “the era of assessment and accountability.” Valhalla has fallen. Health care practitioners now work, not in cloisters, but in the open world of

science and business. Accounting for outcomes and the

structures and processes that produce them is a necessary

and appropriate result.

Still, the traditions of the past give meaning and purpose

to the work of current professionals, and allow each practitioner to construct a world view in the context of the

discipline. The health care professional’s sights necessarily remain at a personal level, the recipient of services

and the service itself. Thus, the typical view of health

outcomes is the specific effect on an action or treatment

by a specific practitioner, e.g., actions toward alleviating

symptoms and curing disease.

Facing the complexity of health care services and the

demand for integrative activity, a new mentality is necessary. Instead of defining the world in the context of

our disciplines, how do we define our disciplines in the

context of a modern complex world? How do we retain

the elements of one-to-one care and service - the micro

level of analysis - and at the same time understand the

power and influence of the organizational and societal

context? How we approach those questions is a product

of the lenses through which we see the world.

Alternative Conceptual Lenses

Just as there is not a single World View, no objective

reality that is universally agreed upon, neither is there a

singular definition of the approaches to define views of

the world. Several perspectives are described in the literature. These alternative conceptual lenses give insight

into nursing’s definitions, approaches and dilemmas in

outcomes research.

In his study of intellectual and ethical development in the

college years, Perry (1970) defined four stages of development. The first is basic dualism in which the person

views the world in polarities of right and wrong, black

and white, we or they, good or bad. The second level is

multiplicity. At this level the person realizes that authorities do not have all the answers and learns that multiple

views may stem from fact, opinion, or individual preference. The third stage is relativism subordinate in which

a person takes an analytical evaluative approach to knowledge, at least in regard to one’s own sphere of work in a

discipline. That stage is subordinate to the fourth level

called relativism. At this level of greater maturity and

personal freedom, the individual sees the truth as relative

and understands that events have meaning only in the

context in which they occur, and according to one’s framework for perceiving those events. This highest stage of

analysis and insight allows the individual to see that

“knowledge is constructed, not given; contextual, not

absolute; mutable, not fixed” (Belenky, 1969, p. 10).

Belenky and associates (1969) defined ways of knowing

that in part reflect individual world views. Received

knowledge comes from listening to the voices of others;
subjective knowledge is the inner voice and quest for self;

procedural knowledge is based on the voice of reason

with both separate and connected knowing; and finally

constructed knowledge requires integrating the voices.

Perry (1970) summarized these types as maturation of

the intellect, i.e., development from the simplistic and

passive to the complex and interactive. Belenky and associates (1969) regarded the ways of knowing as separate types, though one also might interpret them as developmental stages.

In contrast, Gioia and Pitre (1990) outlined four alternative paradigms for research and generation of knowledge:

the functionalist and interpretive, the radical humanist and

the radical structuralist. The functionalist and interpretive paradigms are similar to, but not synonymous with,

the traditionally defined quantitative and qualitative approaches, or deductive and inductive methods. The goal

of the functionalist paradigm is to search for regularities

and to test in order to predict and control. The approach

to building theory is refinement through causal analysis.

In contrast, the goal of the interpretive paradigm is to

describe and explain in order to diagnose and understand.

The radical humanist and radical structuralist approaches

aim to describe and critique in order to change, and to

identify sources of domination to guide revolutionary

practices. The theoretical concerns and assumptions of

distortion, domination, alienation, emancipation, liberation and so on, (Gioia and Pitre, 1990, p. 591) may be

real, but likely cast these two approaches into marginality in the scientific world.

Gioia and Pitre discussed the differences but also the compatibilities of the functionalist and interpretive paradigms,

including the questions they raise, the choice of methods, and what constitutes explanation. Their view is that

“there is more to learn than any single view can account

for” (p. 590).

Allison’s (1971) analysis of the dynamics of the Cuban

missile crisis is a dramatic portrayal of how different world

views pervade decisions and perceptions of outcomes.

He portrayed three models to explain what actually happened during those critical ten days that could have ended

in a nuclear holocaust. The rational actor or classical

model is based on the perspective that important events

have important causes, and that action is a matter of strategic choice. By analyzing the strategic problem, the

analyst argued toward one goal - that of rectifying the

nuclear balance. In allison’s definition, this approach

proceeds as if it were simply describing an exercise of

logical reasoning, choice and action in a “disembodied”

fashion.

The organizational process model regards action as organizational output - asses what outputs of which organizations led to the outcome, i.e., the blockade. Organizational processes produced the awareness of the problem,

defined the alternatives and implemented the action. This

approach has explained an event when it has identified

the relevant organizations and patterns of organizational

behavior in which the action emerged. Thus, predictions

have identified trends that reflect established organizational programs and fixed procedures. Thinking of this

approach in relation to outcomes research, we see immediately that it may illuminate, but also may simply perpetuate existing organizational mechanisms/

Allison’s third approach, the government politics model,

focuses on the varied perceptions, motivations, positions,

power and maneuvers of the players. This analyst regards action as political outcome - who did what to whom

that yielded the action in question. Predictions are generated by identifying the game in which an issue will arise,

the relevant players and their levels of power and skill.
Like others describing multiple views, Allison (1971) does

not imply that any of these approaches is right or wrong.

He concluded: “As we observe the models at work, what

is striking are the differences in the ways the analysts

conceive of the problem, shape the puzzle, unpack the

summary questions, and pick up pieces of the world in

search of the answer” (p. 249). Allison noted that these

three perspectives were not mutually exclusive if analytical frameworks and conceptual lenses are defined.

Ultimately each approach had some explanatory power.

In the heat of the crisis, however, the President had to

estimate which view was more accurate and therefore

what action to take.

These and other views of our conceptual lenses use different words to convey a common thread. Each of us as

individuals and groups brings our own world view to any

given situation. In regard to outcomes research, nurses

and others enact varied, often undefined, assumptions and

perspectives. Assessing our current and desires positions

will enhance both communication about and conduct of

outcomes research.

Issues in Nursing and Outcomes Research

Professions have developed their practice over time

through focus on the standards, activities and results of

the discipline. Those efforts provide an essential base

for outcomes research. To proceed with the conduct of

outcomes research, however, nurses and other health professionals now must assess the assumptions and perspectives implicit in outcomes research. At issue are: the views

of the nature of the problem, views on how to solve problems, and differing levels of analysis.

The nature of the problem in outcomes research can be

stated simply as: determine what conditions and actions

produce what outcomes. But how do health care professionals define outcomes, actions and conditions? We may

wish to assume that the desired outcome of health car

services is health of the population. Yet “health” requires

an operational definition, a measure. Within and between

health care disciplines, researchers vary in those definitions and measures. I submit that we will never understand and document health of populations if we continue

to regard outcomes as what we do to people. Is the outcome the number of surgical procedures, or number of

admissions?

Lohr (1988) observed that the definition of “medical outcomes” has shifted in recent years. The classic definition

included “the five D’s”: death, disease, disability, discomfort and dissatisfaction. The shift has been toward

more positive aspects of health including survival rates,

states of physiological, physical and emotional health and

satisfaction with health care services.

A wide scope of outcomes has been addressed in nursing

research over several decades. A major emphasis has

been the construction of valid and reliable measures, such

as the work of Horn and Swain (1978). Other nursing

research addressed differing levels of analysis to relate

organizational variables to clinical processes and patient

care outcomes (Hegyvary and Haussmann, 1976a, 1976b,

and to apply a contingency model to assess relationships

among structure, technology and quality of nursing care

(Overton, 1977; Alexander and Randolph, 1985;

Alexander and Mark, 1990).

These and other studies vary in the definition of outcomes.

The dependent variable may be short-term change in the

patient’s condition, long-term general health status of a

sample of patients, such as persons with a particular disease of disorder, or overall indicators of health status of a

population. In some studies, however, outcomes are defined as organizational outputs: for example, levels of
staff performance, staff satisfaction, and costs per patient

diagnostic group.

How researchers define outcomes is in part a matter of

practicality. Even if the researcher recognizes the overall complexity of analyzing outcomes, it is very difficult

to address a full scope of outcomes in a single study.

Perhaps an even more basic issue in the move toward

integrated outcomes research is the contrasting views of

how to solve problems.

The alternative conceptual lenses previously described

portray a variety of perspectives and approaches to defining and solving problems. The dominant paradigm in

the sciences has been the rational actor or functionalist,

deductive approach. A causes B. Therapeutic actions or

initiatives cause designated effects. The interest in intervention studies signals a belief in this perspective. Guba

and Lincoln (1989) wrote: “In the past, the methodology

employed in evaluations has been almost exclusively scientific, grounded ontolologically in the positionist assumption that there exists an objective reality driven by

immutable natural laws, and epistemlogically in the counterpart assumption of a duality between observer and

observed that makes it possible for the observer to stand

outside the arena of the observed, neither influencing it

nor being influenced by it” (p. 12).

This approach is limited when it looks at variables out of

the context in which they occur. Like Allison’s analysis

of the Cuban missile crisis, it assumes a linear chain that

is disassociated from its complex environment, including organizational, social, and political forces. Even in

controlled clinical trials, particularly with limited samples,

there may be many variables other than the experimental

treatment that explain significant amounts of variance in

results.

Yet a logico-deductive approach, testing hypotheses under defined conditions, cannot be ignored. If practice is

based on science, the technologies of practice must be

subjected to the test of effectiveness. Recognizing the

limitations of this approach and keeping the test in context are the true challenges.

In contrast, the interpretive approach has both an intuitive and scientific appeal of going to the source for clarification of phenomena. Studies of client perceptions,

satisfaction, beliefs and practices are examples in this

category. the value of this type of research is evident, for

example, in the work of Swanson (1991) and Benner

(1984) in their use of qualitative, interpretive methods to

define variables and relationships among variables. This

naturalistic approach is very useful in the current stage of

development of outcome measures. Yet it is too limited

for a comprehensive, complex societal level of analysis.

The main issue is not an a priori selection of functionalist or interpretive approaches to the definition and investigation of outcomes. The issue is the need to clarify

assumptions inherent in each approach that cut off other

routes of inquiry. Each approach, taken in isolation, provides a narrow prescription of what constitutes definition, procedure and explanation.

Theoretical and methodological views of how to solve

problems may reflect Perry’s (1970) stages of development, proceeding from dualism to multiplicity to relativism. The literature illustrates progression from basic dualism, that is, seeing measures as right or wrong, good or

bad, to multiple views of methods and outcomes. Perry’s

third stage portrays a more analytical and evaluative approach to knowledge, yet still limits it to one’s own discipline. Outcomes research in nursing has progressed

beyond the “law of the tool”, but still tends to be restricted

to a disciplinary view. Current initiatives in the effec-
tiveness of health care services demand progression to

the fourth stage, that is, relativism, which takes into account the overall context in which events occur and the

fact that events have meaning only in the full context of

life. Belenky and associates (1969) referred to that perspective as constructed knowledge or integrating the

voices.

Contrasting views also reflect differing ways of knowing, each of which may be valid for certain types of information. Received knowledge is essential for building

on past research. Procedural knowledge if necessary as

practitioners and organizations struggle to define and

continuously improve their actions. Achieving constructed knowledge requires combining alternative perspectives. Whether the outcomes analysis pertains to

health care or to a missile crisis, several sources of information and ways of knowing may be useful.

In the past few years we have had many discussions about

“nursing outcomes” and the necessity of measuring our

own effectiveness. Studies that investigate the actions of

a single provider group, be they nurses, physicians or others, run the risk of ignoring the context. To assess health

care outcomes, I believe that each group of practitioners

must define and measure their actions and the intended

results, then integrate those disparate views. Thus both

discipline-based and interdisciplinary research are necessary. Progressing to constructed knowledge, which

would appear to be true outcomes research, requires discussion of another issue - the level of analysis.

Levels of analysis range from the individual, micro level

to the most complex, macro systems constellation. Professional socialization teaches practitioners to center on

the dyad of practitioner and client. Nurses, like other

health care practitioners, are concerned with the care of

individuals, and perhaps their families. Professionals learn

to exercise clinical judgment at an individual level, in

parallel with practitioners in other disciplines. The aim

is an appropriate assessment, diagnosis, and treatment

process to achieve the intended outcomes. But this process never is limited to the immediate interactions of two

people. It occurs in a sociocultural, economic, political

and organizational context, any part of which may affect

both the processes and the outcomes, usually in ways we

little understand.

The presence of groups of practitioners and groups of

clients in organizations adds a layer of contextual variables to the challenge of analyzing health care services

and their outcomes. Add yet another level - the community context with diverse populations, changing economics and multiple interests in health care - and the complexity is overwhelming. Analyzing the structures, processes, and outcomes requires including all relevant variables embedded in clinical therapeutics, individual and

family conditions and responses, and multiple, interacting environments.

Outcomes research, then, contains many levels of analysis. At the micro level, controlled clinical trials investigate individual responses to therapy. The meso level included investigation of questions related to the provision

of clinical services, such as staffing, job satisfaction, patient acuity, and other mid-range organizational and patient variables in relation to clinical and organizational

outcomes. The macro level pertains to institutional, inter-institutional and social variables in relation to health

of the population.

The case of infant mortality is an example of such complexity and the need for systems thinking and research.

At an individual level, infant mortality can be reduced

through prenatal care. Yet numerous other factors, including female literacy, income, level of education, and
ethnic minority status, also correlate with infant mortality. The relative importance of each variable and their

interactive effects can be determined only in a comprehensive analysis that constructs and uses very large data

sets (Hegyvary, 1991; World Bank, 1989).

Shortell and associates (1990) noted the complexity of

such research and the need to integrate multiple perspectives: Quantitative approaches involving time series analysis, pooling of cross-sectional data, and multivariate modeling of outcomes must be integrated with qualitative

approaches emphasizing single case studies and longitudinal comparative case studies...” (p. 298).

These issues and the components of outcomes research

point to the necessity of large sets drawn from multiple

perspectives. An issue for constant attention is clarity on

which perspectives drive the data set and conversely how

the data set supports or refutes each of the perspectives.

The complexity of outcomes research, with large data sets

of individual, organizational, social and economic variables, requires the technologies of modern information

systems. Yet information systems per se will not resolve

the dilemmas in outcomes research.

To illustrate that point, I refer to a recent experience with

consultants in information systems. You may know that

the University of Washington School of Nursing last year

contracted to design and manage health care services at a

retirement community in North Seattle. It includes 215

rental apartments, 30 assisted living units and a 74 bed

nursing home (or a we prefer to call it, the nursing care

center). Many of us with more background in acute care

and community health frankly were surprised and appalled

by the regulations and traditions in long-term care, many

of them resulting in rampant deforestation! After only a

few days in the facility, a resident;s record would already

be at least an inch thick!

For many reasons, we begin a focus on information systems — design the records to fit in community context,

cut the redundancies, and build a relevant, concise, useable

data base.

Several of us spent several hours with consultants — and

thought we were being clear in stating our objectives.

Finally, a consultant’s face lit up with the joy of discovery and ours with anticipation. We hoped he had “the

answer.” Instead, he said: “Oh, now I see: you don’t

want us to just automate the chart!

No, automating existing records add concrete to our shoes.

The reflect fragmentation, narrow, provider-oriented

thinking, procedural knowledge, and little about outcomes

or effectiveness. Proceeding to the next stage of multidisciplinary, meta-paradigmatic research requires the design and use of very large data sets to integrate the multiple voices in outcomes research. However, another cautionary note is in order regarding very large data sets.

Urging their development must assume the inclusion of

only the “relevant” data. As George Elist wrote: “If we

had a keen vision and feeling of all ordinary human life,

it would be like hearing the grass grow and the squirrel’s

heart beat, and we should die of the roar which lies on the

other side of silence.”

Integrating the Voices

Previous sections have portrayed the challenges and difficulties the nursing profession faces in outcomes research.

Those challenges are not unique to nursing and are shared

by all disciplines involved. In fact is it not part of the

human condition to apply our own conceptual lenses, be

they professional, cultural, religious or whatever, to all

parts of our lives? Aldous Huxley (1954) said in Doors

of Perception: “We must preserve and if necessary intensify our ability to look at the world directly and not
through the half opaque medium of concepts which distort every given fact into the all too familiar likeness of

some generic label or explanatory extraction” (p. 74).

Given that we all wear some kind of blinders, how is it

possible in a field as complex as outcomes research to

see life in the round? We regard the methods of science

as necessarily impartial, yet it is clear that our own concepts, assumptions and world views pervade scientific

processes. The literature about outcomes research has in

recent years begun to show at least multiplicity and perhaps relativism in attending to multiple views of decisions about health care and potential outcomes. Wennberg

(1990) discussed the high expectations of outcomes research promoted by the Agency for Health Care Policy

and Research. These priorities focus on six conditions:

angina pectoris, benign prostatic hypertrophy, gallstones

arthritis of the hip, conditions of the uterus, and low back

pain. Those conditions account for more than half of all

in-patient surgeries.

The traditional approach in outcomes assessment has been

a micro level analysis of intervention and effect. Do X

procedures to yield Y changes in pathological state. Referring to outcomes research in general and to what has

been learned to date from the efforts sponsored by

AHCPR, Wennberg (1990) said: “This line of research

will reveal, I predict, that for most conditions, rational

choices among treatments require that individual patients

understand the predicaments they face. The predicaments

arise because there is seldom a single correct answer to a

medical problem. Most conditions or illnesses entail a

number of morbidities, symptoms and disabilities. Outcomes research will clarify the probabilities of the various outcomes for the various treatments, showing many

to be effective in some respects that are important to patients” (p. 1203).

Nursing research also is attending to multiple variables

that reflect different perspectives of outcomes. Examples

include Valentine’s (1991) assessment of caring in relation to outcome indicators of patient satisfaction, length

of stay and postoperative clinical condition. Both provider-defined and client defined variables were measured

in that study. Waltz and Strickland (1988) presented a

volume of research findings about measuring client outcomes. Research reported in that volume includes assessment of the stress of discharge, outcomes after myocardial infarction, compliance, goal attainment, pain, risk,

activities of daily living, fears, responses to chronic illness, coping behavior social support, functional assessment of the elderly, health beliefs, family well-being and

outcomes of home care — certainly multiple outcomes

and multiple views of how to study outcomes.

A recent nursing study illustrated the importance of combining approaches, i.e., both theoretical and methodological triangulation. In her continuing studies of organizational effects on outcomes of critical care, Mitchell (1991)

used two approaches to study clinical and organizational

outcomes. The system-structural view emphasizes the

value of formal structure in stabilizing organizations during change. In contrast, the strategic choice perspective

emphasizes the social creation of meaning surrounding

organizational events. In her study of collaborative practice and clinical outcomes, she applied both views. The

data supported both perspectives. Variations in clinical

and organizational outcomes were partially explained by

each of the different perspectives. As a result, Mitchell

recommended triangulation, including multiple environmental contexts, in the study of outcomes.

Gioia and Pitre (1990) urged movement to an even broader

view of the world in the conduct of research and construction of theory. They pointed out that: “A multiple

perspectives view is not a demand for integration of theo-
ries or resolution of disagreements or paradoxes that inevitably emerge from theoretical comparison. Rather is

an attempt to account for many representations related to

an area of study by linking theories through their common transition zones” (p. 596).

Their prescription for growing beyond our limited conceptual lenses is the development of meta-paradigmatic

views. Researchers already use triangulation in research.

Gioia and Pitre (1990) urge multiple triangulations - a set

of lenses above a set of lenses. Both theoretical and methodological triangulation are necessary to be adequately

inclusive of the relevant perspectives and variables in any

type of research. In their words: The notion of a

metaparadigm view is roughly analogous to the notion of

triangulation to achieve confidence in observations in

more traditional approaches to theory building. The multiple perspectives view applies a kind of meta-triangulation, not across methods within a single theory or paradigm, as is currently in vogue, but across theories and

paradigms” (p. 596).

Achieving this level of research requires health care practitioners, providers and researchers to broaden our conceptual horizons, approaching problems not simply from

the point of view of our own discipline in parallel with

others, but in an integrated way within and across disciplines, organizations and communities. Guba and Lincoln (1989) portrayed that possibility in what they refer

to as the constructivist paradigm — a type of interpretive

approach. They wrote: “...evaluations can be shaped to

enfranchise or disenfranchise stakeholding groups in a

variety of ways. Clearly there can be selective involvement of these stakeholders in the design and implementation of the evaluation... ...If there is to be a course of

action which most stakeholders can agree, it can only be

arrived at through negotiation that honors the separate

sets of values and makes it possible for individuals to

find a reason to support it, work at it, and feel good about

it...”

Conclusion

This paper has discussed views of outcomes research and

further integration of nursing into a larger world view.

Now in the era of accountability, health care professionals are accepting the challenge to document outcomes of

care. Yet the assessment of outcomes is one of the greatest challenges in health care research. Their definitions

are elusive, difficult to validate and based on varying

perspectives and world views. Nursing research has progressed dramatically to account for nursing practices and

potential effects, and now moves toward integration with

other components of the health care system.

Our challenge now is integrating the voices and world

views through recognition of our individual, disciplinary, and societal perspectives. Some of our views are

productive; others may not be valid — we may have to

look in other directions that we have thought or preferred.

Intensive collaboration among all involved in outcomes

research will enable us to achieve that goal.

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