Nursing theory

15

CHAPTER 2 Understanding Middle Range Theory by Moving

Up and Down the Ladder of Abstraction

Mary Jane Smith and Patricia R. Liehr

Every discipline has a process of reasoning that is rooted in the philosophy, theories, and empirical generalizations that defi ne it. The reasoning process is logical when all levels come together and make sense in an orderly and coherent manner. The ladder of abstraction is a logical system for locating and relating three different and distinct levels of discourse: the philosophical, theo- retical, and empirical. The purpose of this chapter is to describe the ladder of abstraction as central to understanding and using middle range theory in research and practice. The ladder of abstraction is a structure that maps the connection between levels of discourse (see Figure 2.1). If one pictures a ladder with three rungs, the highest is the philosophical, the middle the theoretical, and lowest is the empirical. These rungs represent levels of discourse, or differ- ing ways of describing ideas.

■ PHILOSOPHICAL LEVEL

The philosophical is the highest level, representing beliefs and assumptions that are accepted as true and fundamental to any theory. It represents belief systems essential to understanding the reasoning found in the theoretical and empirical expression of middle range theories. The philosophical level includes assumptions, beliefs, paradigmatic perspectives, and points of view. Reasoning through a nursing situation for practice and for research is based on assumptions and beliefs accepted as true about what constitutes reality.

A paradigm is a worldview including disciplinary values and perspectives that are at the philosophical level. Multiple paradigmatic schemas have been developed in nursing, and several of these are discussed in Chapter 1. The schema used to guide discussion of the theories in this book is the one devel- oped by Newman, Sime, and Corcoran-Perry (1991), who identifi ed caring in the human health experience as the focus of the discipline of nursing. They also identifi ed three paradigms that structure the disciplinary perspective: the particulate–deterministic, interactive–integrative, and unitary–transformative.

Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0002

16 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

Each paradigm incorporates unique values about the person, change, and the knowledge base of the paradigm. In the particulate–deterministic para- digm, the person is viewed as an isolated entity, change is primarily linear and causal, and the knowledge base is grounded in biophysical sciences. The inter- active–integrative paradigm describes persons as reciprocal interacting enti- ties, change is probabilistic and related to multiple factors, and the knowledge base is that of the social sciences. In the unitary–transformative paradigm, the person is viewed as unitary evolving in a mutual and simultaneous process, change is creative and unpredictable, and the knowledge base is grounded in the human sciences.

One can clearly see that the three paradigms are at differing levels of philo- sophical abstraction. All three hold assumptions, values, and a point of view at differing levels of abstraction. The most abstract is the unitary–transforma- tive, next is the interactive–integrative, and lowest in level of abstraction is the particulate–deterministic. This is an example of levels of abstraction within the philosophical rung of the ladder. Although theorists may not explicate their assumptions or paradigmatic perspective, a careful reading of the the- ory will lead to understanding where each stands in relation to what are the philosophical underpinnings of the proposed theory. The ladder of abstraction (Figure 2.1) depicts the highest level of abstraction as the philosophical level, including the particulate–deterministic, interactive–integrative, and unitary– transformative paradigms.

The middle range theories presented in this book have been placed by the editors in one of these paradigms on the philosophical rung of the ladder. This was a judgment refl ecting the view of two people that was made through scholarly discourse. It is important for the reader to understand that different

FIGURE 2.1 Ladder of abstraction.

Philosophical level

Theoretical level

Empirical level

M or

e co

nc re

te

M or

e ab

st ra

ct

Particulate– deterministic

Interactive– integrative

Unitary– transformative

Grand theory

Middle range theory

Microrange theory

Physiological indicators

Questionnaire

Observation

Interview

Narrative

2 . UNDERSTAND ING M IDDLE RANGE THEORY  17

judgments may be made by different people who have a different understand- ing of the theory and the paradigms. There isn’t a “right” way to link a theory with a paradigm, but there are always reasons for the linking decisions that are based on logical coherence. The editors made the decision about the the- ory–paradigm link based on an understanding of the knowledge roots of the middle range theories.

The middle range theories of Uncertainty, Bureaucratic Caring, Unpleasant Symptoms, Self-Effi cacy, Symptom Management, Cultural Marginality, Transitions, Moral Reckoning, and Self-Care of Chronic Illness, are rooted pri- marily in the social sciences and relate to a multidimensional and contextual reality. These nine theories have links to the interactive–integrative paradigm. The middle range theories of Story, Meaning, Self-Transcendence, and Self- Reliance are primarily rooted in the human sciences encompassing a process of mutual and creative unfolding. These four theories describe values consistent with the unitary–transformative paradigm. There is usefulness in understand- ing the paradigmatic perspective of a theory because it helps to lay out a start- ing point by establishing the philosophical foundation.

■ THEORETICAL LEVEL

Ideas are languaged to explain and describe their essence. Ideas at the theo- retical level are concepts specifi c to a theory. Concepts are the essential ideas that build a theory; concepts characterize properties that describe and explain the theory at a middle range level of discourse. Levels of discourse are differ- ing ways of expressing, defi ning, and specifying an idea. If one idea is more abstract than another, then it is more encompassing, enveloping a broader scope. On the other hand, if an idea is less abstract it is more concrete. This notion of the relationship between levels of abstraction is key to understanding and making sense of the theoretical. Levels of abstraction apply to each rung of the ladder in relation to the other rungs. That is to say, the philosophical is at a higher level than the theoretical rung of the ladder. When one is grappling with understanding the theoretical or middle level on the ladder, the process is to move the idea up to evaluate the philosophical premise and move down to empirical indicators, where the theory connects to the world of practice and research. To have a complete understanding one moves the theoretical idea back and forth, along the rungs of the ladder and within the rungs of the lad- der. For example, if trying to understand a theory, a start at the middle rung of the ladder would lead to the question: How is the theory defi ned concep- tually? What are the concepts, and what do the concepts mean? Then given the answers to the fi rst set of questions, move to a lower ladder rung and ask: What does this mean to me and how does it connect with what I already know, namely my experience? Then one might look at how personal experience fi ts with the description of the theory. One might also question what values and

18 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

beliefs are included in the assumptions of the theory, thus moving the theory up the ladder of abstraction. The point is that in coming to know the realm of the theoretical, one thinks through the theory by moving up and down the rungs of the ladder. The theory becomes understandable through personal refl ection and discourse with others; processes that include reading, thinking, and dialogue. Coming to understand a theory requires both tacit and explicit knowing. This means that a person can begin to describe in words the meaning of an abstract idea and at the same time hold tacitly more knowledge about the idea than can be made explicit. Each time the idea is described through talking, writing, and discussion, a greater grasp of the theoretical is achieved.

The theoretical is in the realm of the abstract, consisting of symbols, ideas, and concepts. Many of the theories in this book are known by a central abstrac- tion. For instance, uncertainty, meaning, and self-transcendence are some of the theoretically abstract ideas that will be discussed in this book. Implicit in abstraction is an outer shadow of vagueness that enables the ongoing devel- opment of the idea. This bit of vagueness can throw a person off guard and engender confusion about the meaning of an idea. However, the abstract nature of theory is not intended to be confusing or abstruse. In deciphering the abstract and differentiating ideas according to the philosophical, theoretical, and empirical, one fi gures out meaning and comes to know what is explicit about an abstract idea.

The theoretical rung on the ladder of abstraction includes concepts, frame- works, and theories. A theoretical concept is different from an everyday con- cept because it is a mental image of an aspect of reality that is put into words to describe and explain the meaning of a phenomenon signifi cant to the dis- cipline of nursing. A theoretical framework is a structure of interrelating con- cepts that describe and explain the meaning of a phenomenon. What then is a theory? Theory is described in the literature at all levels of abstraction. The accepted defi nition of a theory rests in the eye of the beholder. Chinn and Kramer (1999, p. 258) defi ne theory as “a creative and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenom- ena.” Im and Meleis (1999, p. 11) defi ne theory as “an organized, coherent and systematic articulation of a set of statements related to signifi cant ques- tions in a discipline that are communicated in a meaningful whole to describe or explain a phenomenon or set of phenomena.” McKay (1969), on the other hand, describes theory as a logically interrelated set of confi rmed hypotheses. Chinn and Kramer’s defi nition of theory is at the highest level of abstraction, next is Im and Meleis, and at the lowest level is McKay. Given this array of theory defi nitions it is easy to understand why one could argue several ways about whether a particular theory is indeed a theory: it all depends on the way theory is defi ned.

Furthermore, there are levels of theory within the theoretical rung of the lad- der. At the most abstract level, there are the grand theories. These are theories that have a very broad scope. The conceptual focus of some of these grand

2 . UNDERSTAND ING M IDDLE RANGE THEORY  19

theories includes goal attainment (King, 1996), self-care (Orem, 1971), adapta- tion (Roy & Andrews, 1991), becoming (Parse, 1992), and unitary human fi eld process (Rogers, 1994). Each of these grand theories shares the common ground of offering a structure that enables description and explanation of essential conceptualizations of nursing. However, even on the common ground of grand theory, some are more abstract than others. For instance, becoming is more abstract than goal attainment.

Middle range theories, the subject of this book, are described by Merton (1968, p. 9) as those “that lie between the minor but necessary working hypoth- eses that evolve in abundance during day-to-day research and the all-inclusive systematic efforts to develop unifi ed theory.” He goes on to say that the prin- cipal ideas of middle range theories are relatively simple. Simple, here, means rudimentary straightforward ideas that stem from the focus of the discipline. Thus, middle range theory is a basic, usable structure of ideas, less abstract than grand theory and more abstract than empirical generalizations or micror- ange theory.

Microrange theories, described as situation-specifi c by Im and Meleis (1999, p. 13), are theories that focus on “specifi c nursing phenomena that refl ect clin- ical practice and that are limited to specifi c populations or to particular fi elds of practice.” These theories “offer a blue print that is more readily operational and/or has more accessible utility in clinical situations” (p. 19). Microrange theory is lower on the ladder of abstraction than middle range theory. While Im’s Theory of Transitions (see Chapter  11) is at the middle range level of abstraction, the population-specifi c theories that emerge from it are at a lower level of abstraction and identifi ed as situation-specifi c theories. Examples of situation-specifi c theories are menopausal transition of Korean immigrant women, learned response to chronic illness of patients with rheumatoid arthritis, and women’s responses when dealing with their multiple roles (Im & Meleis, 1999). In this case, a middle range theory has spawned situation- specifi c theories that have direct application to particular nursing practice situations.

The ladder of abstraction depicts microrange theory, middle range theory, and grand theory on ascending levels of discourse (Figure 2.1). The ladders for each theory presented in this book show a description of the philosophical, conceptual, and empirical connections. Each chapter’s author has specifi cally identifi ed theory concepts, so the inclusion of concepts on the ladder was a straightforward process. This may not always be true; sometimes the authors of published articles on middle range theory do not clearly identify concepts. In that instance, the reader is left to decipher what the concepts of the theory are and how they are defi ned. For some middle range theories it may be neces- sary to differentiate concepts by a very careful reading of the manuscript and examination of the model. When this interpretative process is needed, there is always a risk that the concepts identifi ed by the reader are not exactly what the author of the theory intended.

20 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

■ EMPIRICAL LEVEL

The empirical level represents discourse that brings a theory to research and practice. Empirics include physiologic indicators, questionnaires, observation, interview, and narrative (Figure 2.1). Like other rungs on the ladder, the empir- ical level of discourse moves from the most concrete (physiologic indicators) to the most abstract (narrative). Even at this lowest level of discourse there is a range of abstraction. The empirical is the lowest rung on the ladder, at a concrete level of discourse. The empirical represents what can be observed through the senses and moves beyond to include perceptions, symbolic mean- ings, self-reports, observable behavior, biological indicators, and personal sto- ries (Ford-Gilboe, Campbell, & Berman, 1995; Reed, 1995).

Whether practicing or doing research, the nurse connects with the empirical level. The advanced practice nurse may use physiologic indicators, interview, and observation while applying theory to caring in the human health experi- ence. The nurse researcher may use observation and narrative in a single study while applying theory to examine caring in the human health experience. Decisions about empirics are guided by philosophy and theory. It is important that the nurse choose empirics that fi t with philosophical and theoretical per- spectives, thus providing a match between all levels of abstraction.

■ CARING IN THE HUMAN HEALTH EXPERIENCE

All theories in the book comply with the focus of nursing as presented by Newman et al. (1991), who say that nursing “is the study of caring in the human health experience” (p. 3). They go on to say “A body of knowledge that does not include caring and human health experience is not nursing knowledge” (p. 3). Caring is described as a moral imperative having a service identity. All 13 middle range theories described in this work have a focus of caring in the human health experience. Application of any one of these theo- ries in practice or in research aims at facilitating change in the human health experience.

The human health experience is explicit in each of the theories as experienc- ing: uncertainty, suffering, spiritual–ethical caring, vulnerability, symptoms, decisions to make behavioral change, a health challenge that complicates everyday living, life transitions, being responsible, disciplined and confi dent, living at the margin of cultures, caring for self, and situational binds that demand moral reckoning. It is noteworthy that two of the middle range theo- ries, Unpleasant Symptoms and Symptom Management, share the common human experience of symptoms. There is also common ground for the theories of meaning and self-transcendence through their respective focus on suffer- ing and vulnerability, which are intricately connected human health experi- ences. Furthermore, the theories of Cultural Marginality and Self-Reliance are

2 . UNDERSTAND ING M IDDLE RANGE THEORY  21

rooted in unique cultural perspectives. It should also be noted that Self-Care of Chronic Illness and Bureaucratic Caring hold caring as a central focus.

Caring in the human health experience requires consideration of how the nurse lives relationships with people regarding health. Based on these theories, some of the ways that caring transpires in the context of nursing are through: promoting structure and order in uncertain circumstances; intentionally engag- ing in dialogue to address what matters most; supporting inner resources to move beyond vulnerability; exploring symptom experience; and discussing situational binds with practicing nurses.

The middle range theories in this book add to the body of knowledge about nursing regardless of their discipline of origin. All of the theories have been applied in nursing practice and research to enhance caring in the human health experience. Theories belong to many disciplines. What is important to nursing science is that the research and practice based on a theory can be grounded in the focus and paradigmatic perspective of the discipline of nursing.

■ MIDDLE RANGE THEORIES ON THE LADDER OF ABSTRACTION

There are 13 middle range theories in the book, presented in chronological order according to when the chapter author introduced the idea in a refereed publication. This approach to ordering the chapters places explicit emphasis on the continued work necessary to grow ideas over time. Nursing scholars must be willing to persist with the sometimes tedious work of theory building that often occurs with spurts and stalls over decades.

The fi rst middle range theory is Uncertainty in Illness and conceptualized for both acute and chronic illness. Mishel and Clayton coauthored the chapter on uncertainty in the fi rst and second editions of this book. The chapter in this fourth edition was coauthored by Clayton and Dean. Clayton was a student of Mishel and Dean has published on uncertainty. The original uncertainty theory pertains to acute illness while the reconceptualized theory pertains to the continual uncer- tainty experienced in chronic illness. On the ladder, the reconceptualization is represented in bold print at the philosophical and theoretical level. The theories are consistent with beliefs associated with the interactive–integrative paradigm.

Persons experience uncertainty during diagnosis and treatment and when illness has a downward trajectory, and persons experience continual uncer- tainty in ongoing chronic illness and also with the possibility of recurrence of an illness. Concepts at the theoretical level in both theories are antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty. Concepts added in the reconceptualized theory include self-organization and probabilis- tic thinking. Moving to the empirical level with practice is offering information and explanation, providing structure and order, and focusing on choices and alternatives. An instrument has been developed that is directly related to the theory, the uncertainty in illness scale (see Figure 2.2).

22 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

The second middle range theory is the Theory of Meaning, based on the work of Viktor Frankl. The theory was authored by Patricia Starck in all three of the previous editions of this book. When Dr. Starck was invited to revise the chapter for this edition, she graciously requested that authors be found who were interested in the theory. Teresa Ritchie and Suzy Walter, the coauthors of the theory in this fourth edition, have been teaching and applying the theory to their advanced practice. This theory is grounded in the unitary–transforma- tive paradigm. It is assumed that through a transformative process, persons fi nd meaning. When confronted with a hopeless situation, meaning can be freely and responsibly realized in every moment. Concepts at the theoretical level are life purpose, freedom to choose, and suffering. Practice approaches at the empirical level include derefl ection, paradoxical intention, and Socratic dialogue. Empirical indicators for research are questionnaires, interviews, and other narrative approaches (see Figure 2.3).

The third middle range theory of Bureaucratic Caring developed by Ray is a new theory in the fourth edition and is supported by assumptions of the inter- active–integrative paradigm. Caring is humanistic, spiritual, and ethical; and bureaucratic systems are political, economic, technological, legal, and sociocul- tural. The merger of caring and bureaucratic values distinguishes this theory. Concepts include the social–cultural, legal, technological, economic, political, educational, and physical dimensions of spiritual–ethical caring. It allows for both quantitative and qualitative approaches to research. The theory has been used in Magnet® hospital designation processes. Most recently, it has been adopted by the U.S. Air Force to serve as a foundation for an interdisciplinary practice model (see Figure 2.4).

FIGURE 2.2 Ladder of abstraction: Uncertainty in Illness.

Interactive–integrative paradigm

Concepts of the middle range theory

ResearchPractice

Persons experience uncertainty during diagnosis and treatment and continual uncertainty in ongoing chronic illness Persons experience uncertainty when illness has a determined downward trajectory and continual uncertainty with the possibility of recurrence of an illness

Uncertainty, cognitive schema, and self-organization, probabilistic thinking

Uncertainty in illness scaleOffering information and explanation Providing structure and order Focusing on choices and alternatives

Assumptions of the theory

2 . UNDERSTAND ING M IDDLE RANGE THEORY  23

FIGURE 2.3 Ladder of abstraction: Meaning.

Unitary–transformative paradigm

Life purpose Freedom to choose Suffering

Practice Research

Dereflection Paradoxical intention Socratic dialogue

Questionnaire (e.g., PIL, SONG, MIST Life Purpose); interview; narrative

Persons find meaning even when confronted with a hopeless situation that cannot be changed. Persons are free and responsible for the realization of meaning. A person’s life offers meaning in every moment and situation.

Assumptions of the theory

Concepts of the middle range theory

FIGURE 2.4 Ladder of abstraction: Bureaucratic Caring.

Assumptions of the theory

Humanistic

Social-cultural Legal Technological

Political

Foundation for Magnet(R) recognition status

Qualitative (phenomenology; ethnography; grounded theory), Quantitative and mixed methods

Educational Physical

Economic

Spiritual Ethical

Interactive-integrative paradigm

Concepts of the middle range theory

Spiritiual-ethical caring

Practice Research

Economic Political

Technological Legal Social-cultural

Bureaucratic systems are:Caring is:

The fourth middle range theory, Self-Transcendence developed by Reed, is grounded in assumptions of the unitary–transformative paradigm. Self- transcendence is a unitary process. The theory assumes that persons are inte- gral and coextensive with their environment and capable of an awareness that extends beyond physical and temporal dimensions. Concepts at the theoretical

24 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

level of discourse include vulnerability, self-transcendence, and well-being. Taking the theory to the empirical level with practice includes integrative spiri- tual care, support of inner resources, and expansion of intrapersonal, interper- sonal, temporal, and transpersonal boundaries. Like the Theory of Uncertainty, a research instrument has been developed that is directly related to the theory, the self-transcendence scale (see Figure 2.5).

The fi fth theory presented in the book is Symptom Management Theory by Bender, Janson, Franck, and Lee. These four authors, like the author group in the third edition, are members of the University of California, San Francisco Symptom Management Faculty Group. The theory is grounded in assump- tions of the interactive–integrative paradigm, in which persons manage their symptoms in interaction with the environment. The specifi c assumptions of the theory are that: health and illness affect symptom management, improve- ment in symptoms extends beyond personal health, and symptoms are subjec- tive and experienced in clusters. There are three concepts at the middle range level of discourse. The concepts are symptom experience, symptom manage- ment strategies, and symptom status outcomes. At the empirical level, prac- tice application occurs with patient–provider communication marked by an understanding of the symptom experience and implementation of effective strategies. Research application includes measurement of symptom-specifi c outcomes and contextual factors related to the symptom under study (see Figure 2.6).

The sixth middle range theory is Unpleasant Symptoms by Lenz and Pugh. The theory is grounded in the beliefs and assumptions associated with the interactive–integrative paradigm. Specifi c beliefs of the theory are that there

FIGURE 2.5 Ladder of abstraction: Self-Transcendence.

Concepts of the middle range theory

ResearchPractice

Human beings are integral with their environment. Human beings are coextensive with their environment and capable of an awareness that extends beyond physical and temporal dimensions.

Vulnerability Self-transcendence Well-being

Self-transcendence scaleIntegrative spiritual care Support of inner resources Expansion of intrapersonal, interpersonal, temporal, and transpersonal boundaries

Assumptions of the theory

Unitary–transformative paradigm

2 . UNDERSTAND ING M IDDLE RANGE THEORY  25

are commonalities across different symptoms experienced by persons in varied situations, and that symptoms are subjective phenomena occurring in family and community contexts. Concepts at the theoretical level include symptoms, infl uencing factors, and performance. Practice application at the empirical level includes assessment of the symptom, symptom management, and relief intervention. Empirical measurements are gathered through scales and obser- vations that capture the symptom experience (see Figure 2.7).

The seventh middle range theory is Self-Effi cacy by Resnick, grounded in the assumptions of the interactive–integrative paradigm. Persons change in a reciprocal interactive process when they exercise infl uence over what they do and decide how to behave. Concepts at the theoretical level include self-effi - cacy expectations and self-effi cacy outcomes. Examples of practice applications at the empirical level include learning about exercise, addressing unpleasant sensations, and cueing to exercise. Research based on this middle range theory uses self-effi cacy scales (see Figure 2.8).

The eighth middle range theory presented is Liehr and Smith’s Story Theory, which is grounded in the assumptions of the unitary– transformative paradigm where change is viewed as creative and unpredictable. Story is a narrative hap- pening in the unitary nurse–person process. The specifi c assumptions of the theory are that persons change in interrelationship with their world as they live in an expanded present and experience meaning. There are three concepts at the theoretical level: intentional dialogue, connecting with self-in-relation, and creating ease. At the empirical level the health story is the basis for both

Interactive–integrative paradigm

Concepts of the middle range theory

Assumptions of the theory

Symptom experience Symptom management strategies Symptom status outcomes

Person, environment, and health/illness affect symptom management. Improvement in symptoms extends beyond personal health. Symptoms are subjective in nature and experienced in clusters.

Patient–provider communication is essential to understand symptom perception, accept experience, and implement effective strategies.

Measurement of symptom-specific outcomes and relevant contextual factors related to symptom being studied (e.g., sleep, constipation).

Practice Research

FIGURE 2.6 Ladder of abstraction: Symptom Management.

26 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

practice and research. Examples of empirical approaches in practice include creation of a story path and family tree. Health story data may be analyzed using phenomenological, linguistic, case study, or story inquiry methods (see Figure 2.9).

The ninth theory found in the book is the Theory of Transitions presented by Im. This theory is in keeping with the assumptions of the interactive–integra- tive paradigm and describes circumstances related to change in health/illness,

FIGURE 2.7 Ladder of abstraction: Unpleasant Symptoms.

Interactive–integrative paradigm

Concepts of the middle range theory

Symptoms Influencing factors Performance

Practice Research

Assumptions of the theory There are commonalities across different symptoms experienced by persons in varied situations. Symptoms are individual subjective phenomena occurring in family and community contexts.

Assessment of dyspnea Symptom management Symptom relief intervention

Fatigue scale Duration, intensity, and quality of dyspnea Symptom experience

Interactive–integrative paradigm

Concepts of the middle range theory

People exercise influence over what they do. People decide how to behave.

Self-efficacy expectations Self-efficacy outcomes

Practice Research

Walk Address unpleasant sensations Learn about exercise Cueing to exercise

Self-efficacy scales

Assumptions of the theory

FIGURE 2.8 Ladder of abstraction: Self-Effi cacy.

2 . UNDERSTAND ING M IDDLE RANGE THEORY  27

Unitary–transformative paradigm

Concepts of the middle range theory

Persons live in an expanded present. Persons change as they interrelate with their world. Persons experience meaning.

Assumptions of the theory

Intentional dialogue Connecting with self-in-relation Creating ease

Practice Research

Health Story

Story path Family tree Photovoice

Health Story

Qualitative: e.g., story inquiry Quantitative: e.g., linguistic analysis

FIGURE 2.9 Ladder of abstraction: Story.

life situations, and developmental stages. Assumptions include the centrality of transitions to nursing practice, reciprocity of the nurse/client relationship, and the complexity of patterns and processes of transitions. Nursing therapeutics incorporate the phases of assessment of readiness, preparation for transition, and role supplementation. Research studies have produced situation-specifi c theories on the pain experience of Caucasian and Asian American cancer patients and the menopausal experience of Asian women (see Figure 2.10).

The tenth theory is the Theory of Self-Reliance developed by Lowe. This theory is in keeping with the unitary–transformative paradigm and is rooted in the author’s Native American Cherokee values. Assumptions specifi c to the theory are the value of being true to oneself and being connected with others. Concepts of the theory are being responsible, disciplined, and confi dent. This theory articulates a process for promoting well-being with attention to appre- ciation of one’s culture. The Talking Circle offers an approach to nursing prac- tice through honoring the process of life and growth. A 24-item self-reliance instrument has been developed and used in research, including intervention studies (see Figure 2.11).

The eleventh theory presented in this book is the Theory of Cultural Marginality developed by Choi. This theory is embedded in the interac- tive–integrative paradigm and describes the experience of people who are caught between two cultures. Concepts specifi c to the theory include mar- ginal living, across-cultural confl ict recognition, and easing cultural tension. Examples of practice applications include promoting parent–child engagement through across-cultural understanding and being sensitive to the struggle of

28 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

Interactive-integrative paradigm

Concepts of the middle range theory

Practice Research

Assumption of the theory Developmental, situational, health and illness, and organizational transitions are central to nursing practice. Transitions are characterized by dynamic patterns and complex processes. Meanings attached to health and illness situations are influenced by and in turn, influence transition conditions. The reciprocal relationship between nurse and client shapes transitions.

Type and patterns Properties Conditions (facilitators and inhibitors)

Spawned situation-specific theories (Caucasian and Asian American cancer patients, pain experience; Asian immigrant women’s menopausal experience) substantiated by mixed methods research.

Nursing therapeutics through use of the following phases: assessment of readiness; preparation of transition; and role supplementation.

Process indicators Outcomes indicators Nursing therapeutics

FIGURE 2.10 Ladder of abstraction: Transitions.

FIGURE 2.11 Ladder of abstraction: Self-Reliance.

Talking circle Self-reliance instrument

Unitary–transformative paradigm

Concepts of the middle range theory

Being true to oneself Being connected

Being responsible Being disciplined Being confident

Practice Research

Assumptions of the theory

immigration. Research activities are aimed at developing an instrument to measure cultural marginality and studying mental health outcomes of persons living through across-culture confl ict (see Figure 2.12).

The twelfth theory is Nathaniel’s Theory of Moral Reckoning, grounded in the interactive–integrative paradigm. According to this theory persons engage in a social process of deliberating when faced with a moral dilemma.

2 . UNDERSTAND ING M IDDLE RANGE THEORY  29

Assumptions supporting the theory include facing a moral dilemma where no one choice is right or wrong and experiencing situational binds that are inher- ent to being human. Concepts in the theory are ease, situational bind, resolu- tion, and refl ection. Practice based on the theory includes providing structured discussion with nurses about situational binds and introduction of moral reck- oning in nursing education courses. Research guided by the theory includes study of moral reckoning with other professionals. Because moral reckoning is a human experience that is increasingly common in this day and age, it war- rants consideration for guiding nursing practice and structuring study for peo- ple who are in a moral bind (see Figure 2.13).

The thirteenth theory is Self-Care of Chronic Illness by Riegel, Jaarsma, and Stromberg. The theory is aligned with the interactive–integrative paradigm. Assumptions are in keeping with a holistic view, and the unique perspective required for multiple chronic conditions with an understanding that similar self-care behaviors occur across varying chronic illnesses. Concepts are self- care monitoring, maintenance, and management. Practice includes applying self-care approaches with persons experiencing multiple chronic conditions. Research studies center on self-care (see Figure 2.14).

There is one fi nal ladder of abstraction in this book in the evaluation chapter (see Chapter 3) by Smith. In this chapter, Smith offers a process for understanding and evaluating middle range theories based on postmod- ern beliefs (see Figure 2.15). Overall, the ladders of abstraction provide a structure to guide the student in deciphering theory so that it can be used productively in advanced nursing practice and research. So, we urge you to

Interactive–integrative paradigm

Concepts of the middle range theory

Assumptions of the theory

Across-culture conflict recognition Marginal living Easing cultural tension

Practice Research

Marginality is not an active choice. The clashing of two cultures is a reciprocal process, each culture affecting the other.

Develop a cultural marginality instrument and examine the relationship between cultural marginality and mental health outcomes.

Be connected, a program to promote parent–child engagement, cross-cultural understanding, and sensitivity to the struggle of immigration.

FIGURE 2.12 Ladder of abstraction: Cultural Marginality.

30 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

FIGURE 2.13 Ladder of abstraction: Moral Reckoning.

Interactive–integrative paradigm

Concepts of the middle range theory

Assumptions of the theory

Ease Situational bind Resolution Reflection

Practice Research

When faced with a moral dilemma, no one choice is right or wrong. Situational binds are recognizable experiences inherent to being human.

Structured discussion with nurses about situational binds they are experiencing; introduction of moral reckoning in nursing education courses.

Consider application to other populations and other service providers.

FIGURE 2.14 Ladder of abstraction: Self-Care of Chronic Illness.

Interactive–integrative paradigm

Assumptions of the theory

Concepts of the middle range theory

Self-care

Practice Research

Self-care monitoring Self-care maintenance

Self-care management

Self-care in Definition of self-care and its

components frame thinking for study Rationale or interpretation of findings

clinical practice— cardiac disease

Holistic view of patients—those with varied or multiple chronic conditions Multiple chronic conditions require a unique perspective Self-care behaviors similar across different chronic illnesses

begin climbing the ladders . . . stay long enough on each rung to get com- fortable, and spend enough time on all three rungs to get the whole picture of any theory. Also, expect to be uncomfortable when a rung is new to you. Discomfort is a space for growing and connecting what you know with what you are learning.

2 . UNDERSTAND ING M IDDLE RANGE THEORY  31

It should be pointed out that failure to move around all the rungs of the ladder deters understanding and limits ability to use the theory in practice or research. Sometimes scholars may choose to stay on the rung that is most comfortable. For example, theorists may stay on the theoretical rung, and researchers may stay on the empirical rung, while meta-theorists may be more comfortable on the philosophical rung. It is a premise of this work on middle range theory that in order to move nursing science to the front lines of practice and research, nurses must be skilled in moving up and down and back and forth on the ladder of abstraction when studying, practicing, and researching the science of nursing.

When all levels of an idea can be mapped on the ladder of abstraction and the levels cohere with each other, theory is guided by a logical process that provides clarity and facilitates understanding and use of the theory in research and practice. To understand a theory at all levels of abstraction requires a pro- cess of reasoning. By moving from the lower rung of the ladder to the middle and then the upper rung, one is making sense of phenomena through induc- tive reasoning. And conversely, movement from the upper philosophical rung to the theoretical and then to the empirical requires deductive reasoning. The substantive knowledge of the discipline structured by logic guides thinking through nursing research and advanced nursing practice. This point fl ies in the face of the notion that theory is bewildering logic, abstruse, and rather incom- prehensible. There is logic to the abstract that can be reasoned through with the ladder of abstraction.

Postmodern paradigm

Empirics of evaluation

Evaluation reflects subjectivity, contextuality, diversity of opinions, and the tentative nature of any outcome.

Assumption

Evaluation norms

Correspondence—substantive foundation Coherence—structural integrity Pragmatics—functional adequacy

• Nursing paradigmatic perspective • Stated assumptions • Description of substantive phenomenon at middle range • Roots in practice and research • Clearly defined essential concepts at the middle range • Concepts represented as a model • Published practice use for a range of persons and settings • Empirical indicators and published research • Evidence of evolution

FIGURE 2.15 Ladder of abstraction: Evaluation.

32 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

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