Rodger concept
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James P. Robson, Jr., BSN, RN, and Meredith Troutman-Jordan, PhD, PMHCNS-BC
A Concept Analysis of Cognitive Reframing
Abstract: Cognitive reframing is a concept that has gained increasing popularity in nursing literature in recent years, but it has rarely been defined. Moreover, definitions vary among sources. This systematic evaluation of cognitive reframing is ana- lyzed using Walker and Avant’s classic framework for concept analysis. Diverse disciplines are reviewed including psychology, pastoral care, art and architecture, and nursing. The analysis provides an operational definition of the concept based on inter- disciplinary literature and establishes four defining attributes of cognitive reframing: (1) sense of personal control; (2) altering or self-altering perceptions of negative, distorted, or self-defeating beliefs; (3) converting a negative, self-destructive idea into a positive, supportive idea; and (4) the goal for cognitive reframing is to change behavior and/or to improve well-being. This analysis provides the reader with a clear understanding of cognitive reframing within a nursing context.
Keywords: Behavioral change, cognitive reframing, cognitive restructuring, concept analysis
In the most recent edition of Nursing: Scope and Standards of Practice (2010), the American Nurses Association identifies five standards of practice for the registered nurse: assessment, diagnosis, outcomes identification, planning, and implementa- tion of care. One barrier to change that nurses often encoun- ter in the planning and implementation phases is the client’s unwillingness to change because of perception or beliefs. Nurses can affect client outcomes by altering the client’s viewpoint, or perspective, on an issue. While cognitive reframing is described in psychosocial nursing literature, it is ill defined and demands further investigation.
Framework for Concept Analysis Simply defined, a concept analysis is a systematic explora- tion of a concept that determines what a concept is and what a concept is not (Walker & Avant, 2005). One of the most popu- lar models used for concept analysis today, Walker and Avant’s model streamlines Wilson’s (1963) concept analysis procedure into eight steps. These eight steps include: concept selection, de- termining the aims or purposes of the analysis, gathering all uses and definitions available in interdisciplinary literature, identify- ing case studies to describe the concept, identifying antecedents and consequences, and defining empirical referents. Walker and Avant’s eight step model will be used as the framework for this concept analysis of cognitive reframing.
Theoretical Context and Selection of Concept This concept analysis was inspired by Nola Pender’s Health Promotion Model ([HPM], revised) which seeks to describe the variables that influence health promotion behaviors (Pender, Murdaugh, & Parsons, 2011). One theme found throughout the revised HPM is patient perception. In a recent concept analy- sis by McDonald (2012), perception was defined as “a personal manifestation of how one views the world that is colored by
many sociocultural elements” (p. 5). This perception, according to the revised HPM, is hypothesized to influence variables leading to health promoting behaviors (Pender et al., 2011). However if positive perception affects behavioral outcomes, it is reasonable to conclude that negative perception might result in unchanged health behaviors. An alteration in perception using cognitive reframing might cause a change in the health behavior outcomes – yielding positive health promotion versus stagnation or negative health behaviors. Without defining cognitive reframing, however, one cannot logically make this conclusion or test the derivative hypothesis.
Aims of the Concept Analysis The purpose of this concept analysis was to systematically explore cognitive reframing in the context of nursing practice to provide an operational definition. The analysis adds to the body of knowledge unique to the nursing profession, which can later be used in research instrument and theory development (Walker & Avant, 2005).
Uses of the Concept Literature Search Methods A preliminary expanded search without limiters found that a formal concept analysis on cognitive reframing had never been published, thus providing additional support for the need of formal concept analysis. To better define the concept of cogni- tive reframing, a specific comprehensive literature search of academic journals and dissertations/theses published in English was conducted using several nursing and non-nursing databases. Of the 175 articles that met search criteria with duplicate articles removed, seven came from the nursing literature; most came from the disciplines of pastoral care and psychology. Of the seven nursing articles, five articles were excluded because they did not define cognitive reframing.
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Definitions In order to explore cognitive reframing, one must first estab- lish what each of these words mean individually. Cognitive. Cognitive is an adjective that means of or related to cognition. Cognition, according to Merriam-Webster (n.d.), refers to “a mental process…intellectual act…or process of know- ing.” Frame. According to Merriam-Webster (n.d.), the word frame has several meanings. It can be used to as a verb to describe a process by which one constructs a structure (either physical or conceptual). It can also be used as a noun to describe a physical structure that encloses something, such a photograph; an object that holds corrective lenses for eyeglasses; or a physical skeleton of an animal or human being. For the purposes of this concept analysis, framing, or rather re-framing, will utilize the first defini- tion (a process of constructing a conceptual structure). Cognitive reframing. Reframing has been defined as chang- ing the conceptual viewpoint in relation to which a situation is experienced. Placing the situation in a different frame that fits the concrete “facts” equally well changes its entire meaning (“Refram- ing,” 2009). Revisiting and reconstructing one’s view of an experi- ence imbues it with a different usually more positive meaning in the individual’s mind (Jonas, 2005). Specifically, cognitive refram- ing involves changing the way people see things and trying to find alternative ways of perceiving ideas, events, or situations (Throop, 2012). Psychology. The concept of cognitive reframing can be traced back to the introduction of cognitive behavioral therapy (CBT) in psychology. In a classically recognized article, Beck (1970) described cognitive therapy as “a set of operations focused on a patient’s cognitions (verbal or pictorial) and on the prem- ises, assumptions, and attitudes underlying these cognitions” (p. 187). Since that time, both the name and goal of the concept have evolved; instead of the goal being invalidation of the client’s cognitions, the goal of cognitive reframing today is to change, or reframe, the client’s perspective from a negative into a posi- tive. Vernooij-Dassen, Draskovic, McCleery, and Downs (2011) describe cognitive reframing as a method of CBT that is defined as “changing self-defeating or distressing cognitions into those cognitions that support adaptive behaviour and reduce anxiety, depression and stress” (p. 3). Ivings and Khardaji (2007) take a unique stance separate from all other definitions found in the lit- erature, contending that the approach “involves eliciting, explor- ing, and, if appropriate, directly challenging such positive beliefs” (p. 118). This definition suggests that cognitive reframing is used to determine why clients assign a positive value to their beliefs rather than accepting them at face value. Nursing. As previously mentioned, only two sources within recent nursing literature define cognitive reframing. Ko and Degner (2008) describe it as “probabilistic thinking to reframe uncertainty by encouraging patients to view the situation from a positive perspective” (p. 752). Similarly, Lachman (2010) sub- scribes to Attwood’s (2007) definition, describing it as “a method by which a person learns to stop his or her negative thought processes and substitute the negative thoughts with more positive self-talk” (para. 24). Both definitions involve the client changing his or her perspective; however, the former involves an outside entity [nurse] encouraging the client to reframe whereas the latter implies that the motivation for reframing comes from within. Indeed, this slight distinction is made throughout the literature of other disciplines also. Pastoral care. Pastoral care differs from both nursing and psychology in its more holistic definition. One source suggests that cognitive reframing is a therapeutic technique to help the client “create new meaning from distressing situations where irrational, distorted, or imbalanced thinking has affected his/her behavior, mood or both” (Wicks & Buck, 2011, p. 11). Wicks and Buck further explain that the goal of cognitive reframing
“is not to eradicate the defenses/growing edges, but to recognize them for what they are while simultaneously applauding the gifts in all parts of ourselves or the persons being guided” (p. 12). A qualitative study from the field of pastoral care describes cogni- tive reframing as a coping mechanism employed by clients with chronic illnesses (without encouragement from an outside party) that is frequently used in combination with spirituality (Gros- soehme et al., 2012). Arts and architecture. The arts and architecture fields ad- dress reframing, but differ from those of nursing, psychology, and pastoral care, as they deal with both intellectual and material practices, often occurring in a studio setting (University of North Carolina at Charlotte College of Arts and Architecture, 2014). Similar to the aforementioned definitions, for these disciplines, reframing can suggest facilitating another’s new perspective on a project design or artistic plan. Indeed, “the ability to frame a problematic situation in new and interesting ways is widely seen as one of the key characteristics of design thinking” (Paton and Dorst, 2011, p. 573). In another sense, reframing can have a more material meaning. For example, a museum curator might reframe a canvas when the frame is damaged or when it does not fit the piece or the period in which the canvas was painted. An architect might have contractors reframe a residential or com- mercial building if it fails to meet new safety standards or codes for construction. These meanings from aesthetic disciplines add substance and understanding to the specific context of cognitive reframing because, in each case, a difference in perspectives ex- ists, which challenges the status quo or prevailing notion of what constitutes an accurate belief or correct course of action.
Defining Attributes Recurrent themes across the literature help one to best categorize concepts into defining attributes, or characteristics that are necessary to meet the proposed definition of the concept. In the context of nursing, defining attributes for cognitive refram- ing include: (1) sense of personal control (Chou, Chan, Phillips, Ditchman, & Kaseroff, 2013; Grossoehme et al., 2012; Lach- man, 2010; Parveen, Morrison, & Robinson, 2014; Sun, 2014); (2) altering or self-altering perceptions of negative, distorted, or self-defeating beliefs (Grossoehme et al., 2012; Ko & Degner, 2008; Vernooij-Dassen, Draskovic, McCleery, & Downs, 2011; Wicks & Buck, 2011); (3) converting a negative, self-destructive idea into a positive, supportive idea (Grossoehme et al., 2012; Lachman, 2010); (4) the goal for cognitive reframing is to change behavior and improve well-being (Ivings & Khardaji, 2007; Lach- man, 2010; Vernooij-Dassen, Draskovic, McCleery, & Downs, 2011; Wicks & Buck, 2011).
Model Case Walker and Avant (2005) include development of a model case in their framework of concept analysis. The purpose of a model case is to provide a clear example including all attributes of the target concept. Based on the aforementioned four defining attributes, the following model case illustrates cognitive refram- ing.
Janice is a 59 year-old African American woman who has recently been diagnosed with end-stage renal disease. As a result, Janice is told that she will require four hours of hemodialysis treatment three times per week for the rest of her life. In the weeks that follow, she becomes resent- ful and directs her anger towards the staff. The dialysis social worker, Judy, discovers that Janice’s anger comes from feelings of powerlessness. Judy validates Janice’s feelings but encourages her to recognize aspects of her treatment over which she maintains control: staying on the machine for her prescribed treatment time, faithfully attending dialysis treatments, keeping her dialysis access site clean, and selecting a fistula (native access) over a dialysis catheter to mitigate her risk for infection. Judy encourages Janice not
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to feel like her kidney disease is in control of her life but rather that she controls the progression and treatment of her kidney disease. Consequently, Janice complied with the dialysis schedule and took an active role in care of dialysis access site.
The above scenario meets all four criteria for cognitive re- framing. Judy reframed Janice’s negative and self-defeating belief that she has no control, fostered sense of personal control, and acknowledged that some things in her life have changed, thereby altering Janice’s perceptions of negative beliefs. By doing so, Janice experienced a shift in her frame of reference which resulted in a regained sense of control, improved relationships with the dialysis staff, and new behaviors geared toward improving her well-being.
Borderline Case A borderline case is one where some, but not all attributes of the concept are present. Borderline cases clarify the target concept because one or two defining criteria are missing.
Mac, a 54 year-old truck driver, is trying to make lifestyle changes to improve his obesity and sedentary habits by planning meals in advance and walking on his breaks. He posts reminder notes in his truck to eat healthily and af- firms “I can do this,” which alter negative perceptions and self-defeating beliefs. Mac has begun to feel a little better about himself; he no longer is hypercritical when he fails to walk on busy days; he used to think “what a loser I am!” if he did not walk or ate an unhealthy meal. Instead, he thinks “tomorrow is another day” converting negative ideas into positive, supportive ones. Mac commits to his goals of cutting out all beef and losing 30 pounds by the end of the year, a goal to change behavior and improve well-being. However, Mac frequently “falls off the wagon” and resets his goals every few weeks, making no progress with losing weight or reducing his cholesterol.
This case includes several defining attributes of cognitive reframing. Although Mac has some success with reframing, he fails to adequately exhibit personal control. Mac commits to a behavior change, but actual change is insufficient to reach desired goals. This borderline case represents good intention, but failure to follow through due to lack of personal control. Related Case A related case, according to Walker and Avant (2005), il- lustrates a similar concept but one which differs from the target concept when scrutinized. The purpose of a related case is to discriminate similar concepts from the concept being described. Below is an example of a related case.
Melissa is a 17 year old Caucasian woman who presents to her nurse practitioner (NP) because she has gone four months without menstruating. She measures 5’10” and weighs 96 pounds, yielding a body mass index of 13.8 (severely underweight). When confronted, Melissa denies that she is underweight, stating that she still feels “fat” but admits to only eating twice a week because “it’s the only thing I can control.” The NP tells her that her BMI indicates that she is severely underweight and recommends that she see a specialist about her disorder. Melissa reluc- tantly admits that her perceptions differ from those of her practitioner and family, acknowledging the symptoms the NP has identified, but states that she does not “think I need to make any changes now. I will be fine.”
While the NP attempted to alter Melissa’s cognitive distor- tions by citing her BMI with the intent of changing her eating
habits and improving her well-being, she did not reframe her distortions. Thus, Melissa failed to alter her negative, distorted, self-defeating beliefs because she did not perceive these to be unrealistic or in need of change. Had the NP converted Melissa’s perceived loss of control by focusing on the things in her life over which Melissa did have control, this scenario would have met the criteria for cognitive reframing. This case scenario lacks conver- sion of the negative ideas and consequent behavior change to improve well-being. Although the NP is sincere and tries to help, this concept is more accurately described as symptom recognition and referral, which Melissa resists.
Contrary Case Describing what a concept is not can also be helpful when explaining the nuances unique to concepts. A contrary case is one in which the example presents the concept’s opposite. One can easily recognize this concept as an antithesis of the target concept (Walker & Avant, 2005).
Joe, a 72 year old man, has recently lost his wife of 50 years, Mary, to cancer. They had three children together, two of whom live in town. Mary was Joe’s confidante and best friend; he confided everything in her. Since her death, he has had no one with whom he feels comfortable sharing his feelings of grief and loss. His loss of support system has caused him to turn to alcohol to try to take the pain away, and he feels “hopeless and powerless” since his wife’s death with a low sense of personal control. Joe presents to his primary care physician (PCP) for an unrelated issue and is diagnosed with an infection. Because of his multiple drug allergies, his PCP determines that the only drug that would treat his infection is metronidazole, an antibiotic that, when taken with alcohol, produces a violent reaction. He is cautioned by his PCP that he cannot drink alcohol with this medication and Joe confesses that he drinks at least a pint of liquor each day due to loneliness and depression. Joe’s PCP has six other patients waiting to be seen and in- stead of investigating and perhaps suggesting that Joe speak with his children who understood the dynamic of Joe and Mary’s relationship, or referring him for further assessment by an addictions specialist, the PCP states, “you’ll just have to stop drinking while you take this medication.” Thinking that at his age, Joe will resist any change, and probably will not comply with the prescribed antibiotic, the PCP turns and walks away.
Cognitive reframing was not utilized in this situation. In- stead of reframing negative feelings and loss of support system or suggesting a change in perspective (i.e., that the children could serve as a sounding board, and an addictions specialist could help this geriatric onset drinker), the PCP’s solution to Joe’s alcoholism was to tell him to stop drinking. The intent behind the PCP’s solution was neither to change Joe’s behavior nor to improve his well-being but to expeditiously move on to the next patient. There was no recognition of the need for or possibility of altering Joe’s negative, distorted beliefs, and consequently no conversion of negative ideas into positive, supportive ones. Moreover, Joe experienced no behavioral or cognitive changes to improve his well-being.
Antecedents and Consequences In order to truly understand a concept, Walker and Avant (2005) contend that one define antecedents that must be present prior to the concept’s occurrence. In order for cognitive refram- ing to occur, the following five antecedents must occur. First, the client’s perspective on a belief must differ from that of the nurse, and the nurse must believe the client’s perspective is inaccurate or negative. If the client’s use of cognitive reframing is unaided by the nurse, the client must recognize that his or her belief is
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negative, distorted, or self-defeating. Second, there must be a different, more positive belief that the client can choose to accept or reject. Third, the client must be open to a new belief. Fourth, the client must be ready to alter his or her point of view. Fifth, the client has to view the proposed idea as more rational and valid than the idea he/she currently holds. Walker and Avant (2005) also posit that one must define what outcomes or consequences must happen as a result of the concept’s occurrence. An absolute necessity for cognitive refram- ing to have taken place is an altered, more positive perception. If cognitive reframing is unsuccessful and the client does not change his or her perspective on the matter at hand, the client has not “reframed” a belief and, thus, cognitive reframing has not occurred. For this reason, altered, more positive perception, rather than attempted altered perception, is the only consequence of cog- nitive reframing. Before the nurse is able to reframe a thought or viewpoint, he/she must first recognize that the client holds a different per- spective. Once this disparity is determined, the nurse must then decide if the client’s perspective is inaccurate or negative.
Empirical Referents The final step of Walker and Avant’s concept analysis model (2005) is identifying empirical referents, which are ways by which the defining attributes of the concept in question can be measured. Cognition, behavior, and motivation are all highly complex concepts on which cognitive reframing may have an effect. While it is possible to determine if a behavior change has occurred after cognitive reframing, it is difficult to say if the behavior change is the result of cognitive reframing, a change in perception of self-efficacy, a sudden change in motivation, or a myriad of other factors. One might hypothesize that this is the reason that no tools or instruments exist that directly measure cognitive reframing. As previously alluded to, one can indirectly measure cogni- tive reframing by utilizing tools in existence to measure its defin- ing attributes. Determining which tools are appropriate, however, will vary because of the different domains in which cognitive re- framing can be employed. For example, if a researcher wanted to assess individuals’ beliefs about their ability to lose weight, he/she might choose to search for a scale that measures self-efficacy. This is further complicated by the fact that self-efficacy is a complex domain-specific concept. While an individual might have high self-efficacy to perform physical activity, he/she might have low self-efficacy to adhere to a healthy diet. Thus, tools that indirectly measure cognitive reframing are context dependent and vary in usefulness.
Operational Definition of Cognitive Reframing Cognitive reframing is a therapeutic technique used to alter or self-alter perceptions of a negative, distorted, or self-defeating belief with a goal of changing behaviors and/or improving well- being.
Implications for Nursing Practice and Nursing Science With a well-developed operational definition, it is clear that reframing has a place in arts and architecture, psychology, pastoral care, and nursing. Nurses in all settings can use this technique to help clients and families view a situation from a different, more positive perspective, thereby changing behaviors and improving well-being. Well-being is a broad term that has been purposely chosen to allow for physical, social, emotional, spiritual, psycho- logical, mental, and financial wellness. Several practice implications are identified. Rather than nurses identifying clients as nonadherent or treatment resistant, and limiting therapeutic potential, nurses who utilize cognitive reframing as an intervention may transcend client resistance or other barriers to well-being. For example, the nurse who practices with cognitive reframing in mind will be sure to assess for the
defining attributes, and intervene accordingly. The nurse might consider a client’s sense of personal control related to a particular disease process or psychosocial situation by assessing self-efficacy specific to the diagnosis or circumstances. (See Bandura (2005) for how to construct a self-efficacy scale.) Encouraging social support might also be a means of foster- ing personal control, altering negative or distorted perceptions, and encouraging behavior change. Social support has repeatedly been associated with these positive changes (Gerstorf, Röcke, & Lachman, 2011; Jerliu et al., 2013; Uchino, 2009). To facilitate social support, nurses can refer clients to local support groups (via internet searches for meeting times and locations), recommend pastoral care (from the client’s religious institution or within the hospital setting, if applicable), or encourage meetings with family, friends, or neighbors to educate these potential support persons about the client’s perceptions and needs. Clients who resist changes in their thinking, or those who have deeper psychological distress, might benefit from referral to a therapist, such as a coun- selor, an advanced practice psychiatric nurse, or a psychiatrist, depending upon the nature and severity of their circumstances. There are also research implications from this concept analysis. For example, a clear definition of cognitive reframing can be used by nurse scientists to develop additional theoretical frameworks and to further test the effects that having an altered, more positive perspective can have within already established frameworks and models, such as Pender et al.’s (2011) revised HPM. Investigation of cognitive reframing across various age groups and health condi- tions might yield additional information that could influence design of tailored interventions.
Conclusion With a shift to a more cost effective, evidence-based health care system, it is more vital than ever to determine innovative solutions to problems with client adherence and, thus, disease progression. Application and testing of cognitive reframing as a nursing intervention to improve client outcomes would seem like a logical solution to the growing health care crisis. This concept analysis is one step towards enhanced understanding of cognitive reframing. Future research might assess the efficacy of cognitive reframing in various patient populations as one effort to develop innovative therapeutic solutions.
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James P. Robson, Jr., BSN, RN is an MSN (Family Nurse Practitioner) student at the University of North Carolina at Charlotte. Meredith Troutman-Jordan, PhD, PMHCNS-BC is an associate professor of nursing at the same institution. Mr. Robson may be contacted at [email protected].
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