Select one of the middle range theories derived from a grand nursing theory and one derived from a non-nursing theory. Analyze both for ease of application to research and practice.
CHAPTER 10: Introduction to Middle Range Nursing Theories
Melanie McEwen
Annette Cohen is a second-year graduate nursing student interested in starting her major research/scholarship project. For this project, she would like to develop some of her experiences in hospice nursing into a preliminary middle range theory of spiritual health. Annette has studied spiritual needs and spiritual care for many years but believes that the construct of spiritual health is not well understood. She views spiritual health as the result of the interaction of multiple intrinsic values and external variables within a client’s experiences, and she believes that it is a significant contributing factor to overall health and well-being.
After reviewing theoretical writings dealing with spiritual nursing care, Annette found a starting point for her work in Jean Watson’s Theory of Human Caring (Watson, 2005) because of its emphasis on spirituality and faith. From Watson’s work, she was particularly interested in applying the concepts of “actual caring occasion” and “transpersonal” care. To develop the theory, Annette obtained a copy of Watson’s most recent work and performed a comprehensive review of the literature covering theory development and the Theory of Human Caring. She then did an analysis of the concept of spiritual health. Combining the concept analysis and the literature review of Watson’s work led to the development of assumptions and formal definitions of related concepts and empirical indicators. After conversing with her instructor, she concluded that her next steps were to construct relational statements and then draw a model depicting the relationships among the concepts that comprise spiritual health.
As discussed in Chapter 2 , middle range nursing theories lie between the most abstract theories (grand nursing theories, models, or conceptual frameworks) and more circumscribed, concrete theories (practice theories, situation-specific theories, or microtheories). Compared to grand theories, middle range theories are more specific, have fewer concepts, and encompass a more limited aspect of the real world. Concepts are relatively concrete and can be operationally defined. Propositions are also relatively concrete and may be empirically tested.
The discipline of nursing recognizes middle range theory as one of the contemporary trends in knowledge development, and there is broad acceptance of the need to develop middle range theories to support nursing practice (Alligood, 2010; Fitzpatrick, 2003; Kim, 2010; Peterson, 2013). According to Morris (1996) and Suppe (1996), this call to develop middle range theory is consistent with the third stage of legitimizing the discipline of nursing. The first stage focuses on differentiation of the perspective of the emerging discipline, which is characterized by separation from antecedent disciplines (i.e., medicine) and the establishment of university-based education, which in nursing occurred during the 1950s and 1960s. The second stage is marked by the quest to secure institutional legitimacy and academic autonomy. This stage characterized nursing during the 1970s and through the 1980s, when pursuit of nursing’s unique perspective on and clarification of the phenomena of interest to the discipline were stressed. The third stage began in the 1990s and is distinguished by increased attention to substantive knowledge development, which includes development and testing of middle range theories. This stage is expanding and evolving further to include evidence-based practice and situation-specific theories (see Chapter 12 ).
Middle range theories are increasingly being used in nursing research studies. Many researchers prefer to work with middle range theories rather than grand theories or conceptual frameworks because they provide a better basis for generating testable hypotheses and addressing particular client populations. A review of nursing research journals and dissertation abstracts indicates that nursing research is currently being used in the development and testing of a number of middle range theories, and middle range theories are frequently being used as frameworks for investigation. Furthermore, middle range theories are presently being refined on the basis of research results.
Despite the promotion of middle range theories in recent years, there is a lack of clarity regarding what constitutes middle range theory in nursing. According to Cody (1999), “It appears that almost any theoretical entity that is more concrete than the broadest of grand theories is considered middle range by someone” (p. 10). It has been noted that nursing theory textbooks (e.g., Alligood, 2010; Chinn & Kramer, 2011; Fawcett & DeSanto-Madeya, 2013; Parker & Smith, 2010) disagree to some degree on which theories should be labeled as middle range. Indeed, some authors list a few of the readily accepted grand theories (e.g., Parse, Newman, Peplau, and Orlando) as middle range. Others consider somewhat more circumscribed theories (e.g., Leininger, Pender, Benner and Erickson, Tomlin, and Swain) to be middle range, although the theory’s authors may not agree. In essence, there has been a paucity of discussion on the subject and therefore there is little consensus. This issue is discussed in more detail later in the chapter.
Purposes of Middle Range Theory
Middle range theories were first suggested in the discipline of sociology in the 1960s and were introduced to nursing in 1974. At that time, it was observed that middle range theories were useful for emerging disciplines because they are more readily operationalized and addressed through research than are grand theories. More than 15 years elapsed, however, before there was a concerted call for middle range theory development in nursing (Blegen & Tripp-Reimer, 1997; Meleis, 2012).
Development of middle range theories is supported by the frequent critique of the abstract nature of grand theories and the difficulty of their application to practice and research. The function of middle range theories is to describe, explain, or predict phenomena, and, unlike grand theory, they must be explicit and testable. Thus, they are easier to apply in practice situations and to use as frameworks for research studies. In addition, middle range theories have the potential to guide nursing interventions and change conditions of a situation to enhance nursing care. Finally, a major role of middle range theory is to define or refine the substantive component of nursing science and practice (Higgins & Moore, 2000). Indeed, Lenz (1996) noted that practicing nurses are actually using middle range theories but are not consciously aware that they are doing so.
Each middle range theory addresses relatively concrete and specific phenomena by stating what the phenomena are, why they occur, and how they occur. In addition, middle range theories can provide structure for the interpretation of behavior, situations, and events. They support understanding of the connections between diagnosis and outcomes, and between interventions and outcomes (Fawcett & DeSanto-Madeya, 2013).
Enhancing the focus on middle range theories in nursing is supported by several factors. These include the observations that middle range theories
· are more useful in research than grand theories because of their low level of abstraction and ease of operationalization
· tend to support prediction better than grand theories due to circumscribed range and specificity of the concepts
· are more likely to be adopted in practice because their relative simplicity eases the process of developing interventions for identified health problems (Cody, 1999; Peterson, 2013)
Like theory in general, middle range theory has three functions in nursing knowledge development. First, middle range theories are used as theoretical frameworks for research studies. Second, middle range theories are open to use in practice and should be tested by research. Finally, middle range theories can be the scientific end product that expresses nursing knowledge (Suppe, 1996).
Characteristics of Middle Range Theory
Several characteristics identify nursing theories as middle range. First, the principal ideas of middle range theories are relatively simple, straightforward, and general. Second, middle range theories consider a limited number of variables or concepts; they have a particular substantive focus and consider a limited aspect of reality. In addition, they are receptive to empirical testing and can be consolidated into more wide-ranging theories. Third, middle range theories focus primarily on client problems and likely outcomes, as well as the effects of nursing interventions on client outcomes. Finally, middle range theories are specific to nursing and may specify an area of practice, age range of the client, nursing actions or interventions, and proposed outcomes (Meleis, 2012; Peterson, 2013).
The more frequently used middle range theories tend to be those that are clearly stated, easy to understand, internally consistent, and coherent. They deal with current nursing perspectives and address socially relevant topics that solve meaningful and persistent problems. In summary, middle range theories for nursing combine postulated relationships between specific, well-defined concepts with the ability to measure or objectively code concepts. Thus, middle range theories contain concepts and statements from which hypotheses may be logically derived and empirically tested, and they can be easily adopted to guide nursing practice. Table 10-1 compares characteristics of grand theory, middle range theory, and practice/situation-specific theory, and characteristics of middle range theory are shown in Box 10-1 .
Middle Range Theory Derived From a Grand Theory
As explained previously, many nursing theorists and scholars agree that grand theories are difficult to apply in research and practice and suggest development of middle range theories derived from them. During the last two decades, several theories developed from grand theories have been published in the nursing literature. One example is a middle range theory of nurse-expressed empathy (Olson & Hanchett, 1997), which was derived from three relational statements taken from Orlando’s model. These statements were developed into theoretical propositions focusing on nurse-expressed empathy. Two examples used Orem’s theory. In one, Riegel, Jaarsma, and Stromberg (2012) developed the theory of self-care of chronic illness, patterning their notion of self-care from Orem’s theory. Similarly, Rew (2003) developed a theory of self-care from experiences of homeless youth based on Orem’s theory.
In other examples, Hastings-Tolsma (2006) developed the Theory of Diversity of Human Field Pattern from Martha Rogers’ Science of Unitary Human Beings. Cazzell (2008) employed the Neuman Systems Model as a basis for the middle range theory of adolescent vulnerability to risk behaviors, and in another work, Polk (1997) cited the work of both Margaret Newman and Martha Rogers as sources contributing to her middle range theory of resilience.
Several middle range theories were found which were developed from the Roy Adaptation Model (RAM). In one example, Dobratz (2011) derived the theory of psychological adaptation in death and dying from a series of studies linked to the RAM, and in another example, Hamilton and Bowers (2007) developed the Theory of Genetic Vulnerability from Roy’s work. Similarly, Smith and colleagues (2002) developed a theory describing caregiving effectiveness based on the structure and concepts from the RAM, and Whittemore and Roy (2002) used concept syntheses to integrate concepts and assumptions from the RAM to theoretically describe “adapting to diabetes mellitus.” Finally, Roy’s model was also used in the development of a middle range theory of caregiver stress (Tsai, 2003).
NURSING EXEMPLAR 2: MIDDLE RANGE THEORY DERIVED FROM A GRAND THEORY
Mefford (2004) used Levine’s Conservation Model of Nursing to develop a Theory of Health Promotion for Preterm Infants. In this case, Levine’s theory was used as a framework for nursing practice for the NICU to ensure that needs of both the infant and family are addressed.
Theory Development Process: To develop the Theory of Health Promotion for Preterm Infants, the theorist first described elements of Levine’s Conservation Model internal and external environments, wholeness and conservation principles (conservation of energy, structural integrity, personal integrity, and social integrity) and applied these concepts in the NICU. She determined a “goal of restoring a state of wholeness, or health” (p. 260) ( Figure 10-1 ).
FIGURE 10-1: Conceptual diagram of Levine’s conservation model of nursing.
(From Mefford, L. C. (2004). A theory of health promotion for preterm infants based on Levine’s Conservation Model of Nursing. Nursing Science Quarterly, 17(3), 261. Used with permission of SAGE Publications, Inc.)
Following initial development of the theory, its validity was tested in a retrospective study of 235 preterm infants. This study was designed to examine the influence of “consistency nursing care” on the health outcomes of the infants at discharge. Structural equation modeling demonstrated “strong support for the utility of this theory of health promotion … as a guide for nursing practice in the NICU” (p. 266). It was noted that the derived middle range theory validated Levine’s work