The Nursing Knowledge Pyramid

Advances in Nursing Science Vol. 41, No. 3, pp. 293–302 Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

The Nursing Knowledge Pyramid A Theory of the Structure of Nursing Knowledge

Veronica B. Decker, DNP, PMHCNS-BC, MBA; Roger M. Hamilton, PhD

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A theory of the structure of nursing knowledge is proposed. Using retroductive reasoning to build upon an existing theory, the goal of the Nursing Knowledge Pyramid is to integrate disparate forms of nursing knowledge into a comprehensive, coherent, and useful structure to enhance the learning, development, automation, and accessibility of nursing knowledge. Education uses are discussed. Key words: machine knowledge, nursing knowledge, tacit knowledge, theory

N URSES must have the required knowl-edge, skills, and attitudes necessary to take actions that will achieve optimal patient outcomes. When it comes to the knowledge part of a nurse’s job, an important question is how the nursing knowledge base should be structured so that it is most useful to nurses in practice. Knowledge structures are impor- tant for nursing practice because they shape nursing behavior.1

However, nursing knowledge, like knowl- edge in other disciplines, is not a single depos- itory of well-ordered knowledge,2 and long ago Donaldson and Crowley3 encouraged nurse authors to seek a means of explicating the nursing discipline’s body of knowledge. More than 30 years later, the problem was still challenging, as Kim1 concluded that having a unifying framework for epistemo-

Author Affiliations: University of Central Florida College of Nursing, Orlando (Dr Decker); and Consultant, Mt Dora, Florida (Dr Hamilton).

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publi- cation of this editorial.

Correspondence: Veronica B. Decker, DNP, PMHCNS- BC, MBA, University of Central Florida College of Nurs- ing, 12201 Research Pkwy, Ste 300, Orlando, FL 32826 (

DOI: 10.1097/ANS.0000000000000204

logical discussions about nursing knowledge was critical. Addressing this need, in this article, we present an overview of a unifying theory of the structure of nursing knowledge, the Nursing Knowledge Pyramid (NKP) (Figure 1).

Science uses 3 kinds of reasoning: de- duction, induction, and retroduction.4 Sim- ply stated, deduction is top-down, general-to- specific reasoning; induction is bottom-up, specific-to-general reasoning; and retroduc- tion is the improvement of existing theories.1

In the NKP, moving from bottom to top is de- ductive whereas moving from top to bottom is inductive. Retroductive reasoning improves existing theory wherever it is appropriate and is best illustrated in Figure 2.

As shown in Figure 2 (left), the current highest-level organizing structure of nursing knowledge may be the Structural Holarchy of Contemporary Nursing Knowledge (hereafter “holarchy”).5(p4) Fawcett called the holarchy a theory of the structure of nursing knowledge. It consists of a metaparadigm, philosophies, conceptual models, theories, and empirical in- dicators in a holarchy organized by decreasing levels of abstraction. Using retroductive rea- soning, we build upon this theory to create an alternative theory—the NKP (Figure 2, right). We do so because we hypothesize that the NKP structure better supports the learning, development, automation, and accessibility

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.


Statements of Significance

What is known to be true or assumed to be true about this topic:

• Nursing knowledge structures shape nursing practice.

• The highest-level organizing structure for nursing knowledge may be the Structural Holarchy of Contemporary Nursing Knowledge, a theory consisting of a metaparadigm, philosophies, conceptual models, theories, and empirical indicators arranged in a holarchy organized by decreasing levels of abstraction

What this article adds: • Using retroductive reasoning, the

proposed NKP builds upon the Structural Holarchy of Contemporary Nursing Knowledge to provide an alternative theory of the structure of nursing knowledge

• The NKP theory may better support the learning, development, automation, and accessibility of nursing knowledge and therefore may better support nursing practice.

• As one exemplar, nurse educators and nursing students should consider using the NKP as a powerful cognitive tool for organizing the teaching and learning of nursing knowledge.

of nursing knowledge and therefore will be more useful to nurses.

For example, we propose that all nurs- ing knowledge can be categorized using the NKP. That is, every component of nursing knowledge should be locatable in the NKP, regardless of the knowledge source. Whether a piece of knowledge is an entry into a database table, a blood pressure reading, a theory, or a nurse’s intuition, if the NKP

is truly exhaustive, the knowledge should map to some component(s) of the pyramid. Once the piece of knowledge is located on the pyramid, whether it is a new idea or an old one, the nurse then seeks to fill out each block of the pyramid to create a deep, ratio- nal, coherent, well-developed idea. This pro- cess leads to the learning of existing knowl- edge, the development of new knowledge, and the automation of all but intuitive knowl- edge. The details are provided later, however, think of the NKP as the building blocks of knowledge, from the most abstract to the most concrete.

To determine how to organize our discus- sion, we first need to decide which available theory template, which we call a meta-theory in this article, is appropriate. To leverage the integrity of the holarchy as much as possi- ble, we adapted the Fawcett and DeSanto- Madeya analysis and evaluation nursing theory organizing framework as our meta-theory, as shown in the Table.5 Therefore, the NKP the- ory analysis overview (part 3) is analyzed ac- cording to its definition, scope, content, and context. External critics can then evaluate the theory according to the evaluation structure of the Table meta-theory (part 4).


Definition of a theory

A theory is “the creative and rigorous structuring of ideas that projects a tenta- tive, purposeful, and systematic view of phenomenon.”6(p255) Since Fawcett described her holarchy, upon which we build the NKP, as a theory of the structure of nursing knowl- edge, so shall we. It is a grand theory in scope and a descriptive theory in purpose. Overall, our purpose is to build a more useful structure of nursing knowledge.

Theory scope

Kim1 identified 4 levels of theory in decreasing levels of scope: grand, meso, middle-range, and micro. Grand theories further develop a particular aspect of a

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Nursing Knowledge Pyramid 295

Figure 1. The Nursing Knowledge Pyramid.

conceptual model.5 A specific kind of con- ceptual model with a specific purpose is a discipline boundary metaparadigm (without the “-”), which places a boundary on the phenomenon of interest.5 Our selected nurs- ing discipline boundary conceptual model, the Metaparadigm of Nursing, consists of the 4 concepts (the “nouns” bounding a disci- pline) of nursing, human beings, health, and environment.5 Because the NKP addresses the structure of knowledge required to en- act optimal nursing actions, the NKP devel- ops the concept of nursing. The NKP theory can, therefore, be classified as a grand theory.

Theory context

The phenomenon of interest is the struc- ture of nursing knowledge at its most inclu- sive, most comprehensive level. It has rele- vance to what the profession knows and what a nurse knows. Epistemology is the branch of

philosophy related to the nature and extent of human knowledge, that is, a system of jus- tified true beliefs.7 The guiding philosophy of the NKP is epistemological coherentism, which is a foundational theory that is based on justifications and implies that for a belief to be justified, the range of beliefs it is based on must cohere with one another.”7 The se- lections for the abstraction levels of the NKP will visibly support each other if they are log- ically coherent.

Theory content

Our purpose is to propose a nursing knowl- edge framework that facilitates the learn- ing, development, automation, and accessi- bility of nursing knowledge by retroductively enhancing the holarchy theory it is based on. As shown in Figure 2 (right), the NKP the- ory enhanced the holarchy theory through 6 innovations: (1) added the tacit knowledge

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Figure 2. The Structural Holarchy of Contemporary Nursing Knowledge (left)5(p4) and the Nursing Knowledge Pyramid (right). The shaded areas represent common components. From Fawcett and DeSanto-Madeya.5 Used with permission.

abstraction level; (2) surfaced the database abstraction-level idea from the narrative to the diagram; (3) reversed the level-of-abstraction direction; (4) added knowledge meta-types; (5) wrapped the abstraction levels in a pyra- mid metaphor; and (6) added knowledge groups. As Wallis reminds us: “The creation of each theory requires a tradeoff between simplicity, generality, and accuracy.”2(p82) Al- though the NKP diagram is more complex than the holarchy diagram, our goal in the NKP diagram is to hit a cognitive “sweet spot” by increasing its self-explanatory con- tent without making it overly complex, which discourages comprehension.6 Readers will need to refer to Figure 2 (right), as the follow- ing sections briefly describe the major con- cepts of the NKP and the rationales for these changes to the holarchy.

Abstraction levels

Tacit knowledge

The discipline of nursing is concerned with what the nurse knows but has not been made explicit. Tacit knowledge is the naturally oc- curring intuitive or prescient knowledge that

is accessible to nurses but cannot be articu- lated. Intuition refers to the ability to quickly appraise the situation and act without con- scious reasoning and has been proposed as an important explanatory concept that influ- ences nursing practice.1 Prescient knowledge knows what is going to happen before it hap- pens. For example, a nurse’s “gut feeling” may inform an intervention decision, but the nurse

Table. Example of a Meta-Theoretical Structure Outline

1. Name (source): Framework for Analysis and Evaluation of Nursing Theories5(p311)

2. Definition of meta-theory 3. Analysis

Step 1: Theory scope Step 2: Theory context Step 3: Theory content

4. Evaluation Step 1: Significance Step 2: Internal consistency Step 3: Parsimony Step 4: Testability Step 5: Empirical adequacy Step 6: Pragmatic adequacy

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Nursing Knowledge Pyramid 297

may not be able to articulate the source of that feeling. Tacit knowledge is inherently disor- ganized. If it became consciously organized, it could be articulated and become explicit knowledge.

We believe tacit knowledge is important to any exhaustive typology of nursing knowl- edge. It is placed at the bottom of the pyra- mid because all knowledge is rooted in tacit knowledge.8


Philosophies are the epistemological, onto- logical, aesthetic, logical, metaphysical, and ethical claims of a discipline. In other words, they are the broad perspective for practice, re- search, and scholarship9 and the foundation for any theory development.10

Paradigms/conceptual models

The next level of the NKP reflects a philosophical stance11 and addresses the paradigms and conceptual models that pro- vide alternative ways to view the subject mat- ter of a discipline and the central concepts of a discipline. Fawcett and DeSanto-Madeya defined conceptual models as:

A set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe those concepts, and the propositions that state rel- atively abstract and general relations between two or more of the concepts.5(p13)


There are 4 kinds of types or purposes of theories: descriptive, explanatory, predic- tive, and prescriptive.1 Descriptive theories are the most basic of theories and describe the essence of the phenomenon under study: its concepts, properties, and dimensions.12

Here, the phenomenon is the structure of nursing knowledge and the theory was cre- ated through a critical evaluation of the holarchy—specifically examining its empir- ical and pragmatic adequacy—and finding opportunities for improvement. Addressing these inadequacies led to the NKP descriptive theory.

Empirical indicators

Empirical indicators are the second from the highest tier in the NKP and bring forth the lower abstraction levels into the real world. Empirical indicators measure concepts and are the basis for evidence-based practice. More specifically:

An empirical indicator is defined as a very concrete and specific real-world proxy for a middle-range theory concept—an actual instrument, experimen- tal condition, or procedure that is used to observe or measure a middle-range theory concept. The in- formation obtained from empirical indicators typi- cally is called data.5(p17)


The data in nursing knowledge can be found in databases—organized collections of data. This level recognizes the reality that the nursing knowledge base is distributed be- tween humans and machines. In the NKP, the term “databases” are used as a general term to denote explicit or original nursing knowledge that resides on machines.

Fawcett and DeSanto-Madeya5 mention “patient databases” and “computer informa- tion systems” as part of the holarchy empiri- cal indicators abstraction-level narrative. This approach may be problematic because they group nonempirical indicator knowledge un- der the empirical indicator label. For exam- ple, while typical real-world empirical indica- tors (eg, a patient’s blood pressure readings over a week) can be stored in a database, other kinds of databases exist that do not con- tain empirical indicators. Would collections of nursing theories, nursing interventions, or nursing decision-making strategies be empiri- cal indicators? We think not. And what would you call the data generated by an empirical study that is stored in a database table but has not yet been analyzed and interpreted? It is nursing knowledge, but it is not tacit hu- man knowledge and is not yet explicit human knowledge. These are examples of a different kind of knowledge, which we call machine knowledge, discussed later.

Also, collections of data have their own emergent knowledge, distinct from individual

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pieces of knowledge. For example, knowl- edge discovery techniques such as data min- ing and text mining can uncover hidden knowledge by looking for patterns and rela- tionships within the data and text, thereby generating new knowledge. This knowledge- producing function of machine knowledge may be hidden behind the empirical indica- tors label in the holarchy, but it is not explicit.

Note that although not all explicit knowl- edge needs to be databased to be useful, do- ing so makes knowledge useable by pow- erful automated analytical tools and widely accessible to nursing stakeholders. For ex- ample, the scholarly nursing journal Nurse Education Today and many other journals encourage authors to enable readers to link to the actual data sets referenced in their articles.13

This level of the NKP is placed at the apex because the contents of the databases depend on the knowledge in the lower levels of ab- straction, and is more specific than the lower levels. This type of knowledge will become more important as the field of nursing infor- matics grows and more nursing knowledge is databased and made more accessible.

Knowledge meta-types

Why does the NKP have a line down the middle? The substance at each level of abstrac- tion is important and so is its form. Except for the inherently disorganized tacit knowledge level, the vertical line in the NKP diagram di- vides each abstraction level into 2 parts: (1) an overarching structure (the “meta-” on the left side, of which there can be more than 1 to select from [hence the “1 . . . n” subscript]); and (2) the substance in that structure (the examples on the right side, of which there can also be more than 1 to select from). The Table shows an outline of a “meta-” (left side) at the theories level, which is adapted from Fawcett and DeSanto-Madeya.5

To avoid confusion, note that at the level of paradigm/conceptual models, a “meta- paradigm” is not the same as a “meta- paradigm.” We use the “meta-” prefix to in-

dicate a structure and “meta” (without the “-”) to refer to a higher abstraction level within an example, such as the Metaparadigm of Nursing. Kim1 noted the importance of both metatheorizing and substantive theoriz- ing to more richly develop nursing knowl- edge. Meta-types provide an ideal structure for discussing the examples, acting as a qual- ity control, so they are located next to, and immediately accessible to, the examples in the NKP. They also provide the ability to compare, contrast, and evaluate examples sys- tematically (eg, comparing 2 theories). Al- though Fawcett and DeSanto-Madeya5 exten- sively discuss model and theory frameworks in their book, they are only tangentially asso- ciated with the holarchy theory, which does not include frameworks. Because we believe these frameworks are valuable components of the nursing knowledge base, we have in- cluded them as an integral part of the NKP theory and brought them forward in the NKP diagram.

Knowledge groups

The NKP theory groups the vertical abstrac- tion knowledge levels into tacit knowledge, explicit knowledge, and machine knowledge (Figure 3). As discussed previously, tacit knowledge is the naturally occurring, but inar- ticulable, intuitive, and prescient knowledge that is accessible to each nurse individually. Explicit knowledge is the declarative, proce- dural, conditional, and structural knowledge deliberately accessible to nurses that can be articulated. Machine knowledge is explicit or original knowledge that resides on machines such as computers.

There are at least 2 reasons for creating knowledge groups: (1) they provide cogni- tive scaffolding for learning the abstraction levels; and (2) they provide an entry into the pyramid for the discipline of knowledge development. To illustrate this, by adapting the SECI (socialization-externalization- combination-internalization) knowledge conversion model,14 Figure 3 shows how knowledge can be converted and developed

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Nursing Knowledge Pyramid 299

Figure 3. The Nursing Knowledge Pyramid translated for knowledge development.

from one knowledge group to another using the strategy exemplars shown. For example, tacit knowledge can be converted to explicit knowledge by using externalization strate- gies such as interviews and questionnaires. Likewise, machine knowledge can be con- verted to explicit human knowledge through knowledge discovery techniques such as data mining and text mining.

Pyramid metaphor

Why use a metaphor? We recognized an opportunity to create a metaphor as a cogni- tive tool to enhance the teaching and learn- ing of nursing knowledge. Educational re- search shows that students excel when the teacher’s teaching styles are congruent with their learning styles.15 The Kolb Learning Style Inventory classifies learners into 4 dis- tinct styles: divergers, assimilators, converg- ers, and accommodators.16 Most first-year un- dergraduate nursing students, as measured by

the Kolb Learning Style Inventory, have ei- ther a diverger or assimilator learning style.17

Divergers have a strong imagination, are aware of meanings and values, and have a good ability to generate ideas, whereas assim- ilators have a strong ability to create theo- retical ideas and like to reason inductively.17

When a learner is a diverger or assimilator, presenting a metaphor (such as the NKP) to the learner is an effective instructional strat- egy that promotes learning.18 Furthermore, when the content to be learned is either declarative knowledge (eg, remembering the NKP levels or remembering the definition of a theory) or procedural knowledge (eg, remem- bering how to substruct a study, discussed later), then the instructional strategy of presenting a metaphor is again recommended to promote learning.19 This is not surpris- ing because metaphors can convey declar- ative, procedural, and conditional kinds of knowledge, and a metaphor can have pow- erful effects on long-term recall.19 Because a

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metaphor structure helps a novice integrate new information into existing knowledge,18

it is a powerful instructional tool.19

Why use a pyramid metaphor? Chinn and Kramer write that “structural forms are powerful devices for shaping our perceptions”6(p194) and can convey “mean- ing of a whole beyond the formative elements.”6(p131) Specifically, the pyramid form can convey broad-to-specific and complex-to-simple properties.6 These are the emergent properties of the NKP. For exam- ple, one quality of a pyramid is that of having a firm foundation. Here, to follow the phi- losophy of epistemological coherentism men- tioned earlier, each level “rests upon” and is explicitly linked to the underlying levels to create a strong, unified, logical, broad-to- narrow abstraction whole. That is also why the NKP reverses the abstraction levels of the holarchy—to reinforce the idea of building a solid, coherent foundation.


Chinn and Kramer assert that “an important theory is forward looking; usable in practice, education, and research; and valuable for cre- ating a desired future.”6(pp206-207) The NKP can support nursing practice, education, and re- search in many ways. This section highlights 2 uses for nursing education.

A vehicle for integrating new knowledge

The NKP provides valuable scaffolding for learning the nursing knowledge base. In ad- dition to learning the definitions of the NKP concepts (eg, paradigm, theory), building a complete coherent pyramid for any nurs- ing knowledge is a powerful motivator and learning experience, as selecting from the available entities (eg, philosophies, theories) at each abstraction level requires familiarity with those entities in the nursing literature. Nurse educators may want to consider requir- ing new students to learn the NKP early in

their curriculum to help them integrate new nursing knowledge, clarify their thinking, and through meta-types, spur them to higher stan- dards of scholarship in all their communica- tions.

A vehicle for relating theory to research

Theoretical substruction uses relationship diagrams to tie nursing theory to nursing prac- tice by making the implicit assumptions of a research study explicit, such as connecting research questions to analysis.20 Substruction has been used to assess the logical consistency of theoretical structures, designs, and analy- ses; to examine research literature; to plan the research process; to facilitate grant writing; and to theoretically derive variables for study from abstract concepts.21 In the NKP (see Figure 1), conventional theoretical substruc- tion occurs at the line between the theories and empirical indicators levels. However, if substruction was utilized for transitioning between all NKP abstraction levels, this proposed deep substruction process can be a vehicle for operationalizing the previously discussed philosophy of epistemological co- herentism throughout the NKP. As we use the term in this article, deep substruction is nearly identical to Fawcett and DeSanto-Madeya’s C-T-E (concept-theory-empirical indicators) process, which is a system for translating nursing knowledge into research, educa- tion, and practice.5 Both processes attempt to explicitly show the logical transitions between the abstraction levels. However, deep substruction additionally uses the new abstraction levels, uses the new “metas,” and requires a concept map as minimal output.

For example, Figure 4 illustrates how deep substruction can be used to succinctly char- acterize and assess the coherence of the as- sumptions in a research study. In this case, a piloted study was completed where patients with cancer who self-reported distress were recommended psychosocial coping str- ategies.22 Starting at the bottom of the di- agram and following the arrows upward

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Nursing Knowledge Pyramid 301

Figure 4. An example of the Nursing Knowledge Pyramid translated for the deep substruction of a study. Used with permission from Decker and Weller-Ferris.23

through each of the abstraction levels, the situation-driven psychosocial coping strategy recommendations in the Decker Cancer Cop- ing Rulebase (top of the diagram) were gen- erated initially as tacit knowledge (bottom of the diagram) accumulated from the first au- thor’s 30 years of experience as an oncology nurse aligned with evidence-based practice.23

These rules were compiled in a book and constituted her prescriptive microtheory of cancer coping—the Decker Theory of Cancer Coping. To bridge the logical gap between the Decker Theory of Cancer Coping and her tacit knowledge, supporting philosophies and paradigms were then found in the nurs- ing literature and concept-mapped where ap- propriate. To operationalize the Decker The- ory of Cancer Coping, empirical indicators were found and used in the study as shown. To automate these prescriptions (databases level), the treatment recommendations in the book were combined with the self-report in- strument values to generate a collection of “If-Then” rules and collected in a rulebase (a type of database). Specifically, the “Ifs”

were the patient responses to the psychomet- rically sound Distress Thermometer and Prob- lem List instrument and the “Thens” were the psychosocial coping strategy recommen- dations and local referrals based upon pa- tient responses.24 This logic was then pro- grammed into an automated tablet computer application that was the centerpiece of a dis- tress management program. The tablet com- puter application received the instrument self-reported input from the patient, used ex- pert system reasoning (a type of artificial in- telligence designed to mimic the reasoning of an expert) based on the patient responses to determine the recommendations, and printed out reports to the provider and the patient. The distress management program was then piloted in a small oncology clinic.22 Data anal- ysis suggested the program was feasible, safe, and significantly effective. The NKP concept map in Figure 4 helps the reader understand the study by explaining the assumptions of the study succinctly and enables the eval- uation of their logical coherence. In addi- tion to requiring familiarity with the nursing

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knowledge base, as a learning strategy, cre- ating high levels of structural knowledge through semantic networks such as concept maps enhances comprehension of content, domain-specific problem-solving, and reten- tion of material.18


How knowledge is structured is important to any discipline, and the NKP theory pro-

vides a unifying framework for nursing knowl- edge at the highest level of abstraction. Kim reminds us that “multiple theories are not only useful but also necessary.”1(p13) Using retro- ductive reasoning, we applied 6 innovations to an existing theory to develop a new theory. Nurses and nurse educators should consider using the NKP as a powerful cognitive tool to facilitate the learning, development, automa- tion, and accessibility of nursing knowledge, thereby increasing the probability of nursing success.


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