Four Ways to Ask Why They Do Not Come: Philosophical Paradigms and a Doctoral Question About Pulmonary Rehabilitation in Rural COPD
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Doctor of Nursing Practice Program, Aspen University
DNP845: Theoretical and Scientific Underpinnings
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Month Day, Year
Four Ways to Ask Why They Do Not Come: Philosophical Paradigms and a Doctoral Question About Pulmonary Rehabilitation in Rural COPD
Every practice question carries assumptions about what is real, what can be known, and how knowledge should be pursued. These assumptions, organized into paradigms, shape the methods a DNP project uses and the kinds of answers it can produce. This paper examines one doctoral practice question, why rural patients with chronic obstructive pulmonary disease do not attend pulmonary rehabilitation, under four paradigms: postpositivism, interpretivism, critical theory, and pragmatism. It argues that pragmatism best fits a practice doctorate whose purpose is to improve outcomes in a particular setting.
The Practice Question
In a composite farming county, the only hospital, a 25-bed critical access facility, runs a pulmonary rehabilitation program with capacity for 24 patients per cohort. Last year, 180 patients with COPD were referred, 61 attended a first session, and 34 completed the program. Pulmonary rehabilitation improves exercise capacity and quality of life, yet a systematic review found that travel and transport were consistently identified as barriers to both starting and completing programs, that a lack of perceived benefit affected both, and that current smokers and people with depression were more likely not to complete (Keating et al., 2011). The DNP student wants to understand and improve attendance in this county.
Paradigms and Their Assumptions
Weaver and Olson (2006) describe paradigms used in nursing research as patterns of beliefs and practices that regulate inquiry by providing lenses, frames, and processes. Paradigms differ in ontology, what is taken to be real; epistemology, how knowledge is gained and the relationship between knower and known; and methodology, the approaches used. Four paradigms are relevant here.
Postpositivism
Postpositivism holds that reality exists independently of the observer but can be known only imperfectly and probabilistically. Knowledge is pursued through measurement, controlled comparison, and attempts to falsify hypotheses. Under this paradigm, the question becomes: which measurable factors predict nonattendance, and does an intervention such as transportation vouchers increase attendance compared with usual care? The strength is clear evidence about effect. The limitation is that the factors must be defined in advance, so reasons the investigator did not anticipate may be missed.
Interpretivism
Interpretivism, or constructivism, holds that reality is socially constructed and that knowledge comes from understanding the meanings people give to their experiences, with the researcher and participants creating understanding together (Weaver & Olson, 2006). The question becomes: what does pulmonary rehabilitation mean to rural patients with COPD, and how do they decide whether to attend? Interviews might reveal that some patients see breathlessness during exercise as dangerous, or that attending a hospital gym feels like admitting decline. The strength is depth; the limitation is that findings describe meaning without testing whether a change improves attendance.
Critical Theory
Critical theory holds that reality is shaped by social, political, economic, and historical forces, and that inquiry should expose power and inequity in order to change them. The question becomes: how do rural poverty, the closure of public transit, and the location of services in a single town create unequal access to rehabilitation, and who benefits from the current arrangement? The strength is attention to structural causes that individual-level studies miss. The limitation for a DNP project is that structural change may lie beyond what one project can achieve.
Pragmatism
Pragmatism does not insist on one view of reality. It judges knowledge by its consequences, what works to solve a problem in a particular context, and it accepts whatever methods are useful for the question at hand. Kaushik and Walsh (2019) describe pragmatism as a paradigm that focuses on the problem and its practical consequences, supports mixing qualitative and quantitative methods, and treats knowledge as provisional and grounded in experience. The question becomes: what combination of changes will increase attendance and completion in this county, and how will we know?
Pragmatism fits the practice doctorate because it asks the same question a DNP project asks: what will work here, for these patients, and what is the evidence that it did? It allows the student to begin with brief interviews to understand local reasons for nonattendance, design changes that respond to them, such as volunteer drivers, a home-based option, and a physician script that explains benefit, and then measure attendance and completion before and after.
What the Choice Means for the Project Design
The paradigm shapes concrete decisions. Under pragmatism, the DNP student would begin with 12 to 15 short telephone interviews with referred patients who did not attend, asking open questions about their decision, and would review referral records to see how physicians described the program. The findings would guide a small set of changes, tested in plan-do-study-act cycles over two cohorts. Attendance at the first session and completion of at least 80 percent of sessions would be tracked monthly against the prior year's baseline, and a short survey would ask participants what made attendance possible. Each component answers a practical need: the interviews prevent the student from guessing at reasons, the changes respond to what patients say, and the measures show whether the changes worked. A postpositivist design would have required a comparison group the county cannot provide, and a purely interpretive design would have ended before anything changed for patients.
Defending the Choice
Choosing pragmatism does not mean abandoning rigor. The measurement component follows postpositivist standards: clear definitions of attendance and completion, baseline data, and consistent follow-up. The interview component follows interpretive standards: open questions, careful listening, and attention to participants' words. And critical theory remains a useful lens for interpreting findings, for example if interviews reveal that the lack of public transit reflects a policy decision that the DNP student could raise with county officials. Pragmatism allows the student to draw on each paradigm's strengths in service of the practical goal.
A critic might argue that pragmatism is theoretically thin, a justification for doing whatever seems convenient. The answer is that pragmatism requires explicit reasoning about why each method fits the question and honest reporting of what worked and what did not, which is exactly the discipline a quality improvement project needs.
Conclusion
The question of why rural patients do not attend pulmonary rehabilitation looks different under each paradigm: a prediction problem, a problem of meaning, a problem of structural inequity, or a practical problem to be solved. For a DNP project whose purpose is to improve attendance in one county, pragmatism provides the best fit, allowing the student to combine understanding and measurement while keeping structural causes in view.
References
Kaushik, V., & Walsh, C. A. (2019). Pragmatism as a research paradigm and its implications for social work research. Social Sciences, 8(9), Article 255. https://doi.org/10.3390/socsci8090255
Keating, A., Lee, A., & Holland, A. E. (2011). What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chronic Respiratory Disease, 8(2), 89-99. https://doi.org/10.1177/1479972310393756
Weaver, K., & Olson, J. K. (2006). Understanding paradigms used for nursing research. Journal of Advanced Nursing, 53(4), 459-469. https://doi.org/10.1111/j.1365-2648.2006.03740.x
How this DNP 845 Module 2 example is structured
DNP845 Module 2 papers typically weigh philosophy of science stances against a doctoral practice question. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example defines paradigms by ontology, epistemology and methodology, reframes one question under four of them with strengths and limits, and defends a choice against a likely criticism.
DNP845 Module 2 questions, answered
What does DNP845 Module 2 usually ask for?
The module typically asks you to weigh philosophy of science positions, such as postpositivism, interpretivism, critical theory and pragmatism, against your own doctoral practice question. Aspen does not publish module deliverables, so your classroom's instructions govern.
Why is pragmatism often chosen for DNP projects?
Pragmatism judges knowledge by what works to solve a problem in context and supports mixing qualitative and quantitative methods, which matches the goal of a practice doctorate: improving outcomes in a specific setting and showing that the change worked.
What are ontology and epistemology?
Ontology concerns the nature of reality, what exists and can be known. Epistemology concerns how knowledge is gained and the relationship between the knower and what is known. Paradigms differ on both.
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