Cognitiveframeworkarticle.pdf

The Journal of Theory Construction & Testing – 55 – Volume 18, Number 2

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.

The Journal of Theory Construction & Testing – 56 – Volume 18, Number 2

Definitions
In 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

The Journal of Theory Construction & Testing – 57 – Volume 18, Number 2

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.

B line Case
A b line case is one where some, but not all attributes
of the concept are present. B line 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 b line 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 dis . 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 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 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

The Journal of Theory Construction & Testing – 58 – Volume 18, Number 2

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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