Sally Nan Morgan, PhD, RN and Jane M.

Georges, PhD, RN
Abstract: Using a critical, post-modern perspective, the need for a mid-range theory is proposed regard-
ing the risk and potential oppression caused by the socially-constructed phenomenon of perfection and its
distorting influence on development of a nursing lens. The term, nursing lens, is analyzed from a histori-
cal perspective, defined as a concept, and differentiated from a nursing gaze. The relationship between
a nursing lens and nursing gaze is explored suggesting a process for developing nursing perceptions about
practice and self. The position of perfection in the industry of healthcare and nursing is examined with
the Perfectibility Model as an exemplar. Perfectibility is proposed as a distortion to a nursing lens lead-
ing to unsafe practice and an unrealistic view of self. Implications are explored for fully developing the
mid-range theory of Refocusing a Nursing Lens Distorted by Perfection, and testing the theory for use in
education and practice. The incipient theory has potential to radically transform nursing.

Key words: nursing gaze, nursing lens, Perfectibility Model, perfection, critical, post-modern

Refocusing a Nursing Lens Distorted by

Perfection: The Call for a Mid-range Theory

“Y
ou should fail your student and any student who
makes a med error!” retorted one nursing faculty to
a fellow clinical instructor. The student in question
did make a medication error, by misreading a poorly written
order, and gave ten times the amount of insulin. However,
realizing the mistake, the student notified the staff nurse, called
the physician and implemented a plan to counteract the increased
insulin, notified the clinical instructor, and completed an adverse
event form. These activities constitute the appropriate response
of an experienced nurse when a medication error occurs. The
clinical instructor, however, perceived the event differently
than the nursing faculty, and instead of failing the student,
commended the actions taken to insure the safety of the patient.
The perspectives of the nursing faculty and clinical instructor
were widely divergent. Inherent to the student-faculty power
relation, each perspective had the influence to effect an adaptive
or ineffective outcome.
This scenario resonated from a collage of the authors’ lived
experiences as nursing students, staff nurses, nursing faculty,
and nurse executives. In our lived experience, once an error
occurred, a course of events took a specific direction depending
on the perspectives of those with decisive power in the situation.
Examining the genesis of unique perspectives and the ways in
which they inform practice and errors in practice became a focus
of our scholarship. Ultimately, we undertook a body of work
in which the term “nursing lens” and its resulting theoretical
implications are central foci (Morgan, Mayo, Georges, & Garon,
2012)
The term nursing lens is a frequently used but somewhat
ambiguous concept in nursing literature. In its most general
sense, the term is used to capture how nurses currently and
historically view themselves and their patients, practice, and
environment (Beckstead & Stamp, 2007; Kelly & Hammond,
1964; Mallison, 1990; Thompson et al., 2007). Using a critical
social theory and post-modern perspective, this article explores
the concept of a nursing lens as a basis for needing a mid-range
theory regarding potential distortion of a nursing lens by the
socially-constructed phenomenon of perfectibility. The purposes
of this article are to (a) introduce the concept of a nursing
lens, (b) describe the relationship between a nursing lens and
a nursing gaze, (c) examine related constructs, (d) propose the
call for a mid-range theory regarding the potentially oppressive
consequences of distorting a nursing lens, and (d) explore
implications for nursing education, practice, and research.
Nursing Lens Concept
Looking through the lens of a profession is not unique to
nursing. Related cases within other professions described viewing
a phenomenon through a given perspective. Examples include
a business or entrepreneurial lens used to theorize and observe
ethics (Solymossy & Masters, 2002), and childhood education
viewed through the lens of psychology (Zimiles, 1997).
The nursing profession has employed other theories as lenses
to view nursing phenomena. These include the application of
critical social theory, middle-range theory, parenting typology,
and cultural social determinants lenses (Ekstrom & Sigurdsson,
2002; Liehr, 2005; Luther, 2007; Wuest, 2006).
Mallison (1990) used the term nursing’s lens to describe 90
years of seminal achievements and challenges faced by nursing.
In doing so, the utility of a nursing lens was described. The
defining attributes included (a) the dominant presence of a
nursing context, (b) the ability to zoom out for a wide-angle
perspective, (c) the ability to zoom in for a narrowed, multifocal
view of details and patterns and, (d) the ability to focus and
refocus between the attributes.
Applying Mallison’s (1990) metaphor to individuals expands
the nursing lens concept to be understood as how nurses view
themselves and their practice, and what factors influence lens
development. The nursing lens is comprised of both content and
such attributes as zoom and focus. Proposing that the nursing lens
is by its nature contextual, arising out of the sociopolitical context
in which it develops, it can be shaped in ways both subtly and
overtly violent, reflecting the power relations inherent in a given
context. The lens, therefore, can become clear and useful with

The Journal of Theory Construction & Testing - 26 - Volume 19, Number 1

 Figure 1. Perfectability Model

The Journal of Theory Construction & Testing - 27 - Volume 19, Number 1

efficient attributes, or distorted and limited in function.
Initial antecedents to the development of a nursing lens include
what the entering student brings to nursing school, as well as the
transformative learning that occurs during the course of study.
Pre-licensure nursing education, both theoretical and clinical, is
pivotal in assisting the student to develop their nursing lens. On-
going antecedents, once licensure is achieved, include advanced
and continuing education, practice, research, and personal
experience.
Nursing Lens and Nursing Gaze Relationship
The related term nursing gaze has been used in similar
contexts as nursing lens (Ellefsen, Kim, & Han, 2007). However
distinguishing the two terms and establishing their relationship
provides conceptual clarity. At the most basic level, gazing is
what nurses do, and the lens is what they look through. Gazing
through the lens is how nurses view themselves and their practice
and influences how they see. An application of the distinction
between a gaze and a lens was captured by Bucknall (2007) when
proposing nursing would use “A gaze through the lens of decision
theory toward knowledge translation science” (p. 60).
The differentiation between lens and gaze becomes salient
when considering such related concepts as Foucault’s (1973)
“medical gaze” as a hegemonizing device. To Foucault, the body is
the ultimate site of control in Western culture, and the “objective”
gaze that the medical professional uses is an important element in
the armamentarium of control. Contrarily, Georges and Benedict
(2008) defined “nursing gaze” as “nurses gazing with, rather
than merely at, patients in a reflective fashion in the context of
connection, caring, and empowerment” (p. 141).
Adopting the “gaze through a lens” metaphor affords
the opportunity to explore and perhaps capture what nurses
perceive through their nursing lens, and factors influencing lens
development in their lived experience as a nursing student and
a registered nurse. A focus for theory development resides in
the nursing lens and the content and influences shaping lens
development.
Related Constructs
The emerging theory of Refocusing a Nursing Lens Distorted
by Perfection is influenced by three constructs: two theoretical
models, and an educational movement. Exploring the distinction
from and influences of the Lens Model, the Perfectibility Model,
and the movement to transform nursing education will elucidate
the need for a fully developed mid-range theory.
The Lens Model
The Lens Model developed by Brunswik (1943) has
been widely used in the social sciences. Succinctly, the model
purports that cognition is determined by a lens that focuses on
environmental uncertainty. The lens uses multiple informational
cues to develop the person’s perception. Therefore, perception
can vary between persons and moves beyond what the cues are by
themselves. Hammond, Hursch, and Todd (1964) applied the
Lens Model to judgment analysis for clinical decision making in
such diverse fields as medicine, psychology, and nursing.
A sample application of the Lens Model in the investigation
of nursing judgment demonstrated the Model’s limitations for
a praxis-based discipline. Thompson et al., (2007) conducted
a quantitative research study to evaluate nurses’ assessments
of critical event risk. Using written simulated scenarios, nurse
participants were asked to rate the patient risk level and evaluate
if further intervention was needed. The results included a wide
The Journal of Theory Construction & Testing - 28 - Volume 19, Number 1
variation in nurses’ risk assessments and decisions to intervene.
From these findings, the authors concluded that non-linear
thinking and intuitive reasoning influenced the results, in the
sense of contaminating the participant’s nursing lens. Thompson
questioned the wisdom of the public’s trust in nursing.
The application of a mechanistic, rational-technical
worldview reflected in Brunswik’s model demonstrated an
inability to capture the complexity and richness of nursing’s ways
of knowing (Carper, 1978) or the dynamic nature of a praxis-
based discipline (Hawkins & Morse, 2014). If nursing is an art
and a science, then using an acontextual model in the analysis of
nursing judgment is as inappropriate as evaluating visual artwork
by simply analyzing artists’ written descriptions of color, subject,
medium, and brushstroke technique.
Theories about a nursing lens must be sufficiently robust to
include the context in which nursing occurs, including the power
relations that shape it. Thus, a critical social theory paradigm is an
appropriate approach for attempting theoretical development in
this area. Therefore, we undertook proposing theory development
based upon a concept of nursing lens that reflects a critical social
theory paradigm as an alternative to the previous acontextual
formulation of the Lens Model by Brunswik (1943).
The Perfectibility Model
The Perfectibility Model is a theoretical construct used to
explain the risky and dangerous behavior following medication
errors (Crigger, 2005, Leape, 1994, and Wolf, 2007). Figure 1
depicts the constructs of a simple causal relationship identifying
the results of professionals being taught and expected to be
perfect. The Model proposes if a professional is sufficiently
trained and properly motivated, they will not make a mistake. But
mistakes, such as medication errors, happen because professionals
are human.
When a mistake occurs, the one who is responsible for
the error has failed at her duty and is at fault. Supervisors and
peers react by blaming and holding the person culpable. A
combination of the perception of failure and the reaction to
blame gives rise to secrecy, limited disclosure, discounting, and
feelings of anger, fear, and sadness by the one who is deemed
responsible for the error. This dynamic decreases the option to
correct for or minimize the risk of error in future practice with a
negative effect on patient safety.
The marginalizing and oppressing actions and discourse
culminating from a mistake, according to the Perfectibility
Model, give rise to an examination from a critical social theory
and postmodern perspective. Foucault (1973) found power
relations in institutions characteristically diffuse and obscured.
Power relations are embodied in the work of health professionals
who create particular organizational, individual, and cultural
practices. As a result, the insidious drive for perfection, and the
elements of perfectibility, may be housed in professional behavior
beyond medication error scenarios. Distorting the nursing lens
may account for risky and dangerous behavior sometimes taken
by nurses who are, in contrast, devoted to their patients’ well-
being. Yet perfectibility is not a course of study or a topic for
continuing education. Where perfection exists cannot be easily
pinpointed; however, in its presence the nursing lens is distorted.
Movement to Transform Nursing Education
Professional nurses share the foundational experience
of a formal educational process to become a nurse. From a
postmodernist stance, the professional socialization of nurses
Figure 2. Adaptive Lens Development
constitutes the foundational narrative for where a nursing lens
is first formed. Benner, Sutphen, Leonard and Day (2010)
provided a stunning critique of contemporary nursing educational
practices. These authors documented and articulated what
many in nursing education have long thought – that a radical
transformation is desperately needed in the most basic premises
of nursing education. No longer can a disconnected, behaviorally-
driven model of observable skills form the basis for nursing
education. Instead, Benner et al. called for nurse educators to
design educational experiences based on a sense of salience,
and clinical and moral imagination. Sherwood and Horton-
Deutsch (2012) responded to the call for radical transformation
in education by purporting a nurse educator needs to teach from
and instill in their students reflective and mindful practice as the
means to quality and safety.
To build upon the momentum of change in the very
understanding of what nursing education can and should be,
development of the nursing lens in students may be crucial
to radical transformation. Congruent with Benner, et al.’s
(2010) vision, nursing education is challenged to provide a
learning environment where students can develop a clear and
useful nursing lens through which their gaze is connected and
empowering. A full treatment of such lens development is
beyond the scope of this article. As a starting place, however, we
call for a mid-range theory regarding the nursing lens and a key
factor in its distortion, the socially-constructed phenomenon of
perfectibility.
Refocusing a Nursing Lens Distorted by Perfection
The consequences of gazing through a clear, dynamic,
nursing lens with functioning zoom and focus attributes may
infer better decision making and safer clinical outcomes for
patients as illustrated in Figure 2. Intuitively, a realistic view
of one’s self and confidence in one’s perception could lay the
groundwork for an effective self-dialog during reflection and
decision-making. Whereas, gazing through a distorted, cloudy
lens with damaged focus and zoom attributes may influence poor
clinical judgment and risk to patients (see Figure 3). In addition,
The Journal of Theory Construction & Testing - 29 - Volume 19, Number 1
a lens distorted by perfectibility may be the genesis of an
unrealistic, misrepresented view of oneself owing to the need to be
perfect. The compensatory actions of secrecy, limited disclosure,
discounting, and the associated negative feelings described in
the Perfectibility Model could give rise to a misrepresentation of
oneself. Differentiating the influences for adaptive and ineffective
lens development may provide insight into the distinction
between a clear and useful lens and a distorted one
If the unrealistic prospect of perfection was replaced with a
more rational expectation, such as excellence, a nurse or nursing
student may have the opportunity to gaze through a nursing lens
that is clear, with attributes that easily zoom out to focus on the
larger context of health care, and zoom in to assure care quality
and safety for each patient. Therefore, a mid-range theory of
Refocusing a Nursing Lens Distorted by Perfection is needed as a
starting place for transformative nursing education, practice, and
research.
Nursing Education and Practice
To search for the origins and maintenance of perfection’s
influence on nursing lens distortion, the dominant discourse
of the processes and values of science in the Enlightenment
sense needs consideration. According to Georges and McGuire
(2004), this dominance creates hegemony in nursing and
marginalizes postmodernist discourse. As an example, nursing
education and practice have continued to insert additional
“rights” to medication administration in hopes of perfecting the
medication administration process (Elliott & Liu, 2010; Potter,
Perry, Stockert, & Hall, 2013). Furthermore, institutions are
encouraged to focus on systems analysis for zero tolerance of
errors (Spath, 2011), yet medication errors and underreporting
routinely happen (Agyemang & While, 2010; Aspden, Wolcott,
Bootman & Cronenwett, 2007; Mayo & Duncan, 2004;
Ulanimo, O’Leary-Kelley, & Connolly, 2007). As long as nursing
education and practice continue to stealthily support perfection
as a dominant influence in reducing mistakes, the overt and
covert power relationships inherent in perfectibility will continue
to fuel the nursing lens distortion. Giving voice to the nurses
and nursing students experiencing their practice and the errors
inherent in being human may provide the insight needed to
illuminate a high level of accuracy, instead of perfection.
Figure 3. Ineffective Nursing Lens Development

The Journal of Theory Construction & Testing - 30 - Volume 19, Number 1

 Implications for Research
Ellefsen, et al. (2007) stated, “We know about activities,
but we do not know what goes on in the nurses’ head, what
nurses think about the patients and their problems, and how
they end up doing what they do for patients” (p. 98). Without
an analysis of the development and context of a nursing lens as
well as research methodology that compliments the dynamic
defining attributes of the lens, empirical research will continue
to pound nursing’s square peg into an round hole useful to other
professions (Beckstead & Stamp , 2007; Thompson, et al. 2007).
To begin an analysis of the development and context of a
nursing lens the participants should reflect the freshest nursing
perspective. A qualitative study using interviews of students
just prior to graduation could capture that perspective. The
methodology would include asking questions and taking
narratives related to what they have learned and what they
value. Similar research could be conducted with varying levels
of experienced registered nurses. Once the context is reasonably
captured, appropriate methodology would be used to ascertain
actual thinking processes during patient care, or at minimum,
simulated cases using human patient simulators and their
environments. Using such findings, nursing research could
embark on an unchartered course researching non-nursing topics
such as education, ethics, business, and sociopolitical contexts as
viewed through an authentic nursing lens.
Conclusion
Analyzing the frequently used but relatively undefined
concept of a nursing lens revealed a gap in nursing theory that
may contribute to the misunderstanding of the complex and
unique method of how nurses learn, perceive, and participate
in their practice. Developing a mid-range theory of Refocusing
a Nursing Lens Distorted by Perfection may begin the process of
filling the gap by studying the lens through which nurses gaze. In
so doing, nursing education, professional nursing experience, and
above all, patient safety may be given a renewed priority.
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Sally Nan Morgan, PhD, RN is an Associate Professor at

the College of Graduate Nursing, Western University of Health
Sciences in Pomona, CA. Jane M. Georges, PhD, RN is an
Associate Professor at the Hahn School of Nursing, University
of San Diego. Dr. Morgan may be contacted at smorgan@
westernu.edu.

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