THEORIES discussion

Introduction to Midd .e 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 o preliminary middle range theory of spiritual health. Annette has studied spiritual needs and spiritual care for mony yeairs but believes that the construct of spiritual health is not well understood. She views spiritual heolth as the result of the interaction of multiple intrinsic values and external variables within o client's experiences, and she believes thot it is a significant con- tributing factor to overall health ond 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, 2012) because of its emphasis on spirituality and faith . From Watson's (2012) work, she was particularly interested in applying the concepts of "actual caring occasion" and "tronspersonal" 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 corncept analysis ond the literature review of Watson's work led to the development of assumptions and formal definitions of related concepts and empirical indicaitors. After conversing with her instructor, she concluded that her next steps were to construct relational statements ond then draw a model depicting the relationships among the concepts that comprise spiritual health.

As discussed in Chapter 2, middk range nursing theories lie bct\\"Cen the most ab- stract theories (grand nursing theories, models, or concq,tual frameworks ) ,md mon: circumscribed, concrete theories (practict· theories, situation-specific theories, or mi· crotheories ). Compared co grand theories, middle range theories arc more specific, ha,·e fc:wcr concepts, and encompass a mo re limited aspect of the real world . Concept~ .11-c rclatiwly concrete and can be operationally defined. Propositions an: also rcla· tivcly concrete and mav be empirically tested.

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208 Unit II Nursing Theories

The discipline of nursing middle r.mge theor~· .1~ oil\.' of the crnuem- porary trc:mh in knowledge dn·dopmem, and there i~ broad .1ccept.ll1Ct" of the: need to de\'elop middle r,mge theories to support nursing practice .md nursing rcst·arch (Alligood, 20 I 4; Fitzpatrick, 20 I+; Kim, 20 IO; Pt·terson, 20 I 7 ). ;\crnrding to Suppe ( l 996 ), thi~ call to de,·elop middle r.mge theory i!> consistent with the third stage of legitimizing the di~(ipline of nursing. The lin,t ~rage frKuses on ditkn:miation of the pnspc:cti\'e of the emerging discipline, which is duracterized by sq1aration from .mtecedt·nt di~(iplines (i.e., medicine) .md the c,t.1bli~hment of uni\'ersity-based edu- cation, which in nursing occurred during the 19:i0s .md l 960s. The o;ec(md ,rage: is marked by the: quest to se(ure institution.11 kgitim.1cy .rnd .Kademic .1utonomy. This stage d1a1-.1cteri1ed nursing during the l 9 7(h .md through the I 9XOs, when pursuit of nursing's unique pcrspt·ctiw on .md cl.1rilic.1tion of the phenomena of interest to the dis.:iplinc wen: ,;tressed. The third st.1ge beg.111 in the I 990~ .md i~ distinguished by in- (n:ased ,lttention tu substanti,·e knmdedge dewlopmenr, whkh includes den·lopment and testing of middle r.mge theories. Thi~ stage i\ expanding and <:\'CJh-ing ti.1rther to indude e,·idcnce-lused pra(tice .111d situ.uion-spe(ilic rhenries (sec Chapter 12 ).

i\liddk range th1:ori1:s .ire in..:re.1singl~· being med in nursing n:\eJrch studies. J\,bny researchers prefrr to \\'Ork with middle r.rnge theories r.lther than grand theories or com:eptual frameworks bec,wse they pro,·ide .1 better basis for generating te::.table hypotheses .md .1ddressing; particubr dicnt popul.itions. A n.:,·ie\\' of nursing research journ.ils and dissertation .1bstracts indicate, that nursing research is currently being used in the de,·elopment and testing ofa number of middle r.111g:c theories, .rnd middle range thernies arl.' frequently being used ,ls fr.uneworks for in\'l:stigation. Furthermore, middle r.111ge tl1l.·ories .11-c pn:sentl~· being relined on rhe basis of research resL1lts.

Despite the recent promotion of middle range theories, there is .1 l.1ck of t'lar- ity reg.1rding "hat constitutes middk· range d11:ory in mtr~ing. ,-\ccording to Cody ( 1999 ). "It ,1ppears thJt almost any theoretic.11 entity that is more co ncrete than the bro.1dest of grand theories is considered middle r.rngc by someone" (p. l O ). Sen.:r,11 nursing theory textbooks (e.g., ,-\lligood. 2014; Chinn & lvamcr, 2015; Fawcett & DeSanto-Madey.1, 2013; M. C. Smith & Parker, 2015) disagree to some ntent on \\'hich theories should be labeled ,l\ middle range. Indeed, some .mthors list a ti:w of the rcadih· aC(Cpted grand theories (e.g., Pari,e, Newman, Peplau, ;111d

Orlando) ,ls middle r,mge. Other~ (on~ider somewhat more circumscribed thcorie~ (e.g., Leininger, Pender, Benner and Erickson, Tomlin, ,rnd S\\'.tin) to be middle: range, ,1ltl10ugh the theory's authors 111.1~· 1101 .1gree. 111 e~sence, there h.1s been a paucity of discussion 011 the subject, and therdim:, there is little (onsensus. This issue is disrnssed in more ~ktail later in the chapt<:r.

Purposes of Middle Range Theory Middle r.111g1: theori~·s were lirst suggested in the discipline of sociology in thl.· 1960s .md were introdt1L·ed tll nmsing in 1974. Scholars CJ.me to believe that middle r.rngc theories were usdi1I for emerging. disciplines bec.1use they .1re more readily operation- .1lized and .1ddressed through researd1 than arc grand theories. 1\.lorc th.m I :i ~·1.::1r~ elapsed, hm,·e,·er, befrlre there was a concerted (.111 for middle r,mgc theory de\'Clop- ment in nursing (Blegen & Tripp-Reimer, 1997; Meki~, 2012).

Dcvdopment of middle range theories is supported by the frequent critique of the abstr,1cr natllre of grand theories and the ditliculr~· of thcir .1pplic.1tiun to practice .md research. The ti.mction of middle range theories is to describe, c.xplain, or predict phenomen.1, and, unlike grand theory, they muM bl.· explicit and testable. Thus, they

Chapter 10 Introduction to Middle Range Nursing Theories 209

:trc easier to apply in prac.:tic.:c ~iruations and to use a:, frameworks for research :,tudies. In .1ddition, middle range theories h,we the potential to guide nursing inccr\'cntiorn. and change conditions of a situation to cnhancc nursing care. Fin.1II\', a major role of middle r.tngc thcory is ru ddine or rdinl' the substanti,·e component of nursing science .rnd practice { Higgim & i\loorc, 1000 ). Indeed, Lenz ( l 996) noted that prac- ticing nur:,c:, arc J.c.:tually ming: middle r.rnge tl1eoric:, but arc not c.:onsc.:iously a\\'arc that they .1rc doing so.

Each middk r.mgc.: theory addresses rclatin:ly c.:on~·rete ,rnd specific.: phenomena by stating what rhc phcnome11.1 arc, why they occur, and how they occur. In addition, mid- dk rnnge the()rics can pro\'idc structure for the intc111rcration of bcl1a,·ior, situ.1tiuns, .md c,·cnts. They supp()rt understanding of the .:onnc.:tions between diagnosis .1nd out- comes and bctwcen intern:ntions and out.:omc.:~ ( Fawcett & DcSanro-J\ladc.:ya, 2013 ).

Enh.111c.:ing the focus un middlt: r.tngc.: th.:oric.:~ in nursing is supported by sc.:wral fa.:tor:,. Thcsl· indude thc ob:,erntions ch.tr middle r.111gc theories:

Arc more usdi.1I in n::,c.:.1r.:h than grand theories bcc.:ause of their low Jcycl of .,bstrac.:tion .rnd c.,~c of operation.1l iz.1tion Tend to !>Upport prediction better than gmnd thcori1::s due.: to .:irc.:ums.:ribcd r.rnge and spc.:.:ihc.:iry of the .:on.:cpts .-\re mnn: likdy to bc adopted in pr.1ctice because their rc.:l.1ti\'c simplicity .:ases the proccs~ of developing intcn·cmiom tiir idcntihed health problems ( Cody, 1999; Peterson, 2017 l

I.ikc theory in gener.11, middle r,rng;e theory has tlm:c fun.:tiom in nursing knowl- edge de\'clopment. first, middle range.: thcorics arc used as theoretic,11 fr,1mc\\·nrks for rcsc.:.1rc.:h studies. Sc:cond, middle range.: theories arc open to use in practice .rnd should be tested by research. Finally, middk range theories can bc the scicntific.: end produ.:t th,tr cxpre~~c~ nursing knlm·lcdgc ( Suppc.:, 1996 ).

Characteristics of Middle Range Theory Sc.:,-cral c.:har;1ctc.:ristics idc.:nti~- nursing theories J.~ middle range. First, the princip;tl iJc.:,ts of middlc range theories .1rc rcbti\'ely simple.:, str,1ighrforn·.1rd, .111d general. Second, middle r;mgc thcorie!> .:onsidc.:r .1 limited number of , ·ariables or concepts; they h.1vc ;t parti.:ul.,r subst.mti,·e fo.:m .1nd c.:onsider a limited ,1spect of reality. In addition, the~· arc re.:eprin: to empiri.:al testing and can be .:onsolid.1tcd into 111Cll"L' widc-r;rnging theories. Third, middle range theoric.:~ fonts primJrily on dient prob- kms .111d likely outcomes .1s \\"ell .1s the.: dfrcts of nursing inrern:ntiom on dic.:nt out- comes. Finally, middle r.1ngc thL'oril's .in: spccifi.: to nursing. .rnJ ma~- spcci~- an arca of pr:i.:cice, .1ge r,mgc of the diem. nursing ,Ktions or int.:n·cntions, and proposed outcomes ( J\1elcis, 20 l 2; P<:terson, 20 I 7).

Thc more fn:quc.:ntly used middle range theories t-.:nd to bc those.: th.tr .m: dearly statl.'d, l.'.tsy to understand, internally ...-onsistent, .md ...-oherent. They deal with current nursing perspectives and adJr.;sb :,o.:ially relc,·:int topics thJ.t ~olve mt:aning.ti.tl .md pcrsistl.'nt problems. In summary, middle range theories for nursing combine posru- 1.lted rclJ.tionships between specifi.:, wcll-Jcfincd c.:onccpb with the ability to mc.\~urc or obje.:ti,·ely code .:on..:cpts. Thub, middk range theories contain concepts and stJ.tC· menrs from "'hi..:h hypothcsc.:s may be logically dc.:ri\"t'd .md c.:mpiricall\' tt:stt:d, .md they ..:an be eJ.sil~· ,tdoptrd to guide nursing pra.:til·c.:. Table l 0 - l ..:ompan.:b chara.:ter- i~ric:, of grand theory, middle: range theory, and prac.:tict:/siru.1tion-specihc theory, .md ..:har:ict..:risti.:s of middle range theory .1re shown in Ro'I. 10-1.

210 Unit II Nursing Theories

Tobie 10-1 Characteristics of Grand, Middle Range, and Practice/ Situation-Specific Theories

Characteristic Grand Theories Middle Range Theories Practice/Situation-Specific Theories

Complexity/ Comprehensive, global Less comprehensive than Focused on o narrow abstractness, viewpoint (all aspects of grand theories, middle view view of reality, simple and scope human experience) of reality straightforward

Generalizability/ Nonspecific, general Some generalizability across Linked to special populations specificity application to the discipline settings and specialties, but or on identified field of

irrespective of setting or more specific than grand practice specialty area theories

Characteristics of Concepts abstract and not Limited number of concepts Single, concrete concept that concepts operationally defined that ore fairly concrete and

may be operationally defined is operationalized

Characteristics of Propositions not always Propositions clearly stated Propositions defined propositions explicit

Testability Not generally testable Moy generate testable Gaols or outcomes defined hypotheses and testable

Source of Developed through thoughtful Evolve from grand rheories, Derived from practice or development appraisal and careful consid- clinical practice, literature re- deduced from middle range

erotion over many years view, ond practice guidelines or grand theory

Concepts and Relationships for Middle Range Theory 1\liddlc range theories comist of t\\'O or more (OJKepts .md ,1 specified relationship between the .:oncepb. 1\lliddlc range theories .1ddress phenomena (concept~ ) that arc toward the middle of .1 continuum of scope \,·irh the mct,1paradigm .:oncepts ( nurs- ing, person, health, cn\'ironment) ,lt Olll' end .md ~pccilic concrete actions or events (medic.uion administr;ition, preoperati\'e te.Khing, dectrul~'te m.1nagemcnt, fall pre- \·ention) at the othn. The cnnn:pt~ should be di~L·retc, obsen·ablc, and sufficiently .1bstr,1ct to hi: .1pplied ,lLTOS~ multiple setting~ .rnd used ,,·ith clients with diff\!ring problem~ (Blegen & Tripp-Reimer, 1997). Ex;implcs from the nursing literature in- clude theories Je~cribing; health promotion, comfort, ..:oping;, rc~ilicncc, uncertainty, pain, grid~ fatigue , selfcare, ,1daptation, selt: tr.1nsccndcncc, and transition~ ( Mdeis, 2012; Peterson, 2017; M. J. Smith & Liehr, 2014 ).

Box 10-1 Characteristics of Middle Range Nursing Theory

Not comprehensive but not narrowly focused Some generalizations across settings ond speciolties Limited number of concepts Propositions that ore clearly stated Moy generote testable hypotheses

Chapter 10 Introduction to Middle Range Nursing Theories 211

;,,.Jiddk r.ing,: th..:ori'-·~ link di~aete .ind ob~c:n·.1bk ph'-·nomc:11.1 or ..:011,:,:pt~ in rc:- 1.uionships ~t.1ti:ml'nt!.. In middk r.rng,: theory, rcl.uionships .1rc c:xpli..:itlr st.1ti:d, and, prekrably, th,:y .m: unidire..:tion.1I. Rdationships ..:.111 be of ~c:vi:ral ~'P'-'s. Th.: most common ari: ..:.1us.1I n:l.1tionships that sr.u.: th .it .1 ,:hang'-' in the \'.1lue of on,: vari.1bk or ..:on..:.:pt i~ .1s~o..:iared with J dung,: in the ,·.1luc of ,mother n1ri.1blc or ..:onc..:pt (Peterson, 2017).

Categorizing Middle Range Theory The question .1~ to whi..:h nursing thi:oric~ .1re middle range is nor ckar-..:ur. ;,,.liddle rang,: theory is more sp'-·..:iti..: tlun grand theory but .1b~rra..:t ,:nough to support both gener,1liz.1rion .111d oper.1tio11.1lization a..:ro,, .1 r.mg'-· of popL1lations; thi, ~.:rs it .1part from pra..:tkc or ~ituati011-~r'-·citi..: theory.

In .1 wcll-rcscan:hc:d dfort to dc~.:ribc the pla..:l:' of miJJk range theory in nur~- ing, Liehr .md Smith ( 1999) an.1lyzeJ 22 middk r.1ng;,: theoric~ publi~hed during the pr.:,·ious dt:cadc Thcsc tht:ori,:~ wen: ,:.1ti:goriz\.'J .,~ "high-middk." "middk," .ind "low-middle" ba~t:d on their k\·d of .1b~tr.1..:tion or degree of speciti,:i~-- In tlw re\·iew, high-middle: rhc-orics indudt:d ,:on..:cpr~ sud1 .1~ cJring, growth .1nd de,·clopmrnt, ~dftr.1n~Cl'nd1:nce, resilic1KC, .ind psyi:hologk.11 adaptation. 1\iiddlc tht:oril'., induJed concepts ~u,:h .1s unc.:rt.1inty in illncs,, unpkas.mr symptoms, ..:hronii:: sorrow, pc;Kt:- ful '-·nd of litl"., i:ulrur.11 brokering, .ind nursi:-cxprc:s~.:J t:n1p.1thy. Low-middle thco- rie~, tho,l:' rh.1t .ire doslT to praakl:' or sit1.1.1tion-spl'citfr theories, indudcd h.u.udom ,ccrets, womc:n's ,rng:cr, nurse midwit;;:ry ,:arc, a..:ur,: p.1in m.m.1g:cmcnt, hdpks~ncss, .rnd imnn:-nrion for posr~urgir.:.11 pain.

As mt:ntioncd, rh.:rc i~ wme dcb.1tt: on which theories should he- ,:onsidncd mid- dle r.rnge_ Jndt:cd, ~omt: rhcoric, 11,11 rcrmcd middlt: range morc .1ppropriatdv tit tht: ..:riteria of middle- r.mgc theory th.m .1 gr.1nd tht:ory, .1nd ~ume thi:orics thJt Jrc Lihdcd middle range bcrter tit tht: critl·ria of situation-specific or practio: theor~·- Ch.1pter 11 presents J number of middle r.mge nursing rhcoric~ de~..:ribcJ in the literature, org.1- nizi:d .,~ high, middle •• mJ low tht:oric~. It ~hould bt· not..:d tlut the 1.ksign.1tions ,Ht: .1rguabl~· arbirr.iry .md that onl' theory thar is li~tc-d hat: JS "high-111iJJ.k" m.1y be ..:on- ~idc.:rcd by othc-r~ to be J grand theory. Likcwisl', .motha theory li~tc-d here .1s "middk'' might be considcrt:d by otht:r~ ro be .. hig:h-middll'" .1nd so forth. Siru.1tion-1-pt'..:itic tht'orie, and their rclatiomhip to e,·idenci:-b.1sed pr.1..:ti..:c .ire 1.hs1:ussed in mort: dc.:t.1il in Chapter 12.

Development of Middle Range Theory S'-·wr.11 mi:thod~ for de\'dopmt:nt of middle r.1ng.c- thi:oril'~ h:1,·e bl'cn idcntitii:d in the nursing lircr.uurc. ~lid.die r.mg.t: theori\.'s eml'rg:c from '--ombining rc~t:ar..:h Jnd pra..:ti..:c .1nd building on the work of othl:.'rs. Sour,:~·~ w,cd to gl'ncr.1rc middle: r.1ngl' theory include: litt:r,lture rcYiew!>, lluJ.lit.1tin: rest:arch, field studies, .::onceptu.11 moJ- ds, taxonomii:~ of nursing di.1gnoses and intcrwntions, clinical pra..:tir.:c guiddincs, thcori.::-. from other di!,dplinl:'s, and ,t.ltisrical analysis of t'mpirir.:.11 dat.1 ( F:iwcett & DcS.1ntu-M.1deya, 2013; Pcrc.:r~on, 2017 ). Fiv,: .1pproachc~ for mi<ldk rJ.ngc theory generation were i<lcntiti~·d by Liehr and Smith 11999) ( Box 10-2 ). The following Sl'..:riom prc~cnt cx.1111pks dl',aibing: the sour..:e .md de\·clopment pro..:css of middle r.tng.e rhcori\.'S from 1-',Kh of the: tivt: ,lppro.1..:hes listed in Box I 0-2.

212 Unit II Nursing Theories

Box 10-2 Approaches for Middle Range Theory Generation

1 . Induction through reseorch and practice 2. Deduction from research and practice or opplicotian of grand theories 3. Combination of existing nursing ond non-nursing middle range theories 4. Derivation from theories of other disciplines that relate to nursing 5. Derivation from practice guidelines ond stondords rooted in research

Middle Range Theories Derived From Research and/ or Practice The most cn111111011 ~ourcc:, for dcn:lopmcnt of middle: r.1ngc nursing theories and models .in: rrnr~ing re1-c.uch ,llld nursing practice. l;roundcd theory rcse,1n:h .111d other qu.1litJti,·c rrn:th(lds in particular .ire frequently noted ,ls soun.:es for middle r.rngc.: theory dc,·clopmcnt. Ex,unpk~ of middll' range theories derived from qualit.Hin: n.:~cJrch include the Thc.:on· of fJmily \'igilancl' ( Carr, 201-1- / (SC{' Nursing Exemplar 1 ), the Theor~· of Spiritu.11 Circ in Nursing Pr.icticc ( Burklurt & Hogan, 2017 ), .1 thcory d\'.M:ribing sust.1ining he.11th in faith com- munity nursing prJcticc ( Dyess & ChJse, 2012 ), ,1 theory describing "de.1th imrninl'nct' a\\'arcnes:," of familv membn of patients in .:ritic.11 care ( Baumhnver, 2015 ), ,llld J theory of c.u~·cr persistem:e in acute care.: nurses ( Hodgl's, Troyan, & Keeley, 20 IO).

\'ari,ltions of the idea of Je\'clopmcnt of middle r.rngc theory from rl'search .1rc fairly commc,n . Thcorists report l'.ombining qu,1lit,ltiff n:seJrch with litn.1- tun: n:vil'w, l'.oncqlt ,lllJlysis, concept synthesi~, theory synthesis, .111d other tech- niq ucs in the procc~.~ of Jc,·eloping middlc range theory. For cx.rn1ple, i\lurrock and Higgin~ ( 2009 I cxpl.1ineJ that they u~ed st,ltemcnt .md thcorv svnthesis, Jlong with liter.1ture rl'\'iew, to de\'clop "thl' thl'ory of mu~ic, mood and 1110\'l'· mcnt to impro\'l' IH:alth 0L1tco111cs." In other works, Da\'idson ( 20 l O) dc,·clopl'd "facilitated Sl'nscmaking" to support familic:, of i ntl'nsi\'C \'.arc unit (IC L1 J p.1- til'nts following sy~.tl'matic litcr,1ture review .111d s~·mhesi~, and Eake~, Burke, and H.1insworth developed the middle range Thcor~· of Chronic Sorrow from ,111 ex• tc:nsi,·e rl'\'iew of the litcr.1ture and d.tta g.1thc.:rcd through JO qualitati,·e rl'se.irch studil.'s ( Eakes, 20 I 7).

ldenrification of middle rangc thcmic:, .rnd mod1.:ls deri,·l'd primarily from prac- tice i~ morl.' difncult. Onl' cx,unpk is the Theory of l1npkas.mt S~·mptoms ( Lenz, Pugh, Milligan, & Gift, 20 I 7), which w,H> rcportl.'dly tk\'Clopl'd by intcg;r.lting or melding l'Xisting pr.Kticc and research inform.1tion about .1 ,·ariery of symptoms. ;\ Sl'Cond l.'XJmple i~ the Client Experience Mmkl I Holl.rnd, Gra~·, & Pierce, 20 I I), which was reportedly den:lopl'd through clinical ob~cn·,uions in .Kutc c.1rc.: Sl'ttings using .1 pracricc-to-thcon· method.

Some models that 1.ksi:ribc areas of spci:i,1lty nursing pr.Kticc rq10rt being dc- ,eloped from comhin.1tio11 of practice and .1110ther soun.:e, rypit:ail~' n:11c.1rch or ~ran- dards. Onl' cx.1mplc nf this tcchniqul' is Benoit .rnd !I I ion ' .s ( 2012) mo1.kl for pre~sure ulcer etiology in criticall~· ill p.uienr~, \\'hich ,,·.1~ .:on~tructl'd from combining a litcra· turl' rl',·ic\\' Jnd practicl' standard~. The Om.iha System, which i~ J model for commu- nin· .md home health nursing practiCl', i~ a ~ecnnd exampk. i\fartin ( 2005 / cxpl.1ined th.it the coni:eptu:tl frame\\'ork ti.Jr thc Omaha System wa, a combination of practice, research, Jnd litnaturc reYicw.

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NURSING EXEMPLAR 1: MIDDLE RANGE THEORY DERIVED FROM RESEARCH/ PRACTICE The process used to develop o middle range Theory of Family Vigilance was described by Corr (2014). Her purpose was to provide on explanation of "the meanings, patterns and day-to-day experience of family members staying with hospitalized relatives" (p. 25 l ).

Theory Development Process: The Theory of Family Vigilance was derived from three ethnographic studies carried out among family members of patients in various units of a large, acute care hospital. The first study among family members of patients in a neurology unit, yielded five "categories of meaning" -commitment to core. resilience, emotional upheaval. dynamic nexus. and transition. Corr 12014) noted that each of these categories of meaning were supported by the findings of the subsequent studies.

Corr (2014) then described how she employed the strategies of concept synthe- sis and statement synthesis to define and then illustrate the relationships between and among the different defining characteristics of the categories that comprise family vig· ilonce. Finally. through the process of theory synthesis. she constructed the information into a formalized theory.

Middle Range Theory Derived From a Grand Theory As cxpl,1incd prc\'iously, many mirsing theorists and sd10bn, Jgree tll',lt grand then· rie~ .m: difficult to .1pply in re,carcl1 .rnd practice ,111d suggest de\'clopmcnt of mid· dk rang~· theories dcri,·ed from them. During the I.1st two dec-.1dcs, sc,·cr.11 theoric, dc\'dopcd from grand rheorie~ h.1,·e b~·en published in dk· nursing literature. One i:xample is a middk range theory of health promotion fr_ir pretcrm infants ( Mefford, 2004 ), "·hid, w.1s deriwd from .1pplication of L~·,·ine 'i, Cnmerv,nion Model ( see Nursing ExemplJr 2). Two cx.unplc:, us~·d Orem's theory. In one, Riegd, J.ursnu, and Striimbt·rg (2012) de\'clopeJ the Theory of Self-Can· of Chronic Illnes~, pat- terning their notion of sdfc.1r~· from Orem's theory. SimilJrly, Pickett, Peters, and J.uosz ( 20 l 4) dew loped J middle range Theory of Weight ~bnagement bJseJ on Orem'~ theory.

In other cx.1mplcs, Hasting~•Tobma (2006) de\'eloped the Theory of Di,·ersity of Hum.rn Field Pam:rn from fi.Lirrha Rogns's Science of Llnit~uy Hum.111 Being~. C.1zzdl ( 2008 ) employed the 1':eum.m Systems Modd a~ a ba~i~ for the middle r.mge theory of .1dolc:scent n1lncrability to risk bcl1a\'iors, and in another work, l'l>lk ( 1997 1 cited the work of both i\fargaret :--:ewman .md l'vlarrha Roger\ as soun:cs contributing to her middle range theory of resilience.

Several middle rJngc theories were found which were de,·elopl·J from the Roy Adapt,ltion Model (RAM). In one nampk, Dobratz (.2011) derived the Theory of Psycl1ologic.1l Adapt:1tion in death and dying frnm a ~cries l>f studic~ linked to the R.-\tv\, .md in .1 similar example, she synthesized the middle rang~· Theory ofAdapti,·e Spirituality based on 21 published studies in which the RAM ex.,mincd .,~peas ofspir· iruality ( Dobratz, 2016 ). In other examples, HJmilron and Bowers ( 2007) developed

214 Unit II Nursing Theories

NURSING EXEMPLAR 2: MIDDLE RANGE THEORY DERIVED FROM A GRAND THEORY Mefford (2004) used Levine's Conservation Model of Nursing to develop o Theory of Health Promotion for Preterm Infants In this case, Levine's theory was used as o frame- work for nursing practice for the neonatal intensive core unit (NICU) to ensure that needs of both the infant and family ore addressed.

Theory Development Process: To develop the Theory of Health Promotion for Preterrn Infants, the theorist first described elements of Levine's Conservation Model internal and exter- nal 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 l 0-1 j

Following initial development of the theory, its validity was tested in a retrospec- tive 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). II was noted that the derived middle range theory validated Levine's work.

Conception

\ Preterm B l rth

1/

Term Bi rth

Figure 10-1

Physiologic Structural Physiologic Minimal Immaturity fmmaturrty Nursing Extraulerme

Stability Structural ln1ury

Environment Preterm Infant 1-i in the NICU Adaptat

\ Health

Intrauterine Competencies Stable

Neurolog,c Disruption

Immaturity in Family System

Conceptual diagram of Levine's conservation model of nursing.

{From Mefford. l. C. [2004]. A theory of heolth promotion for preterm 1nfonts based on levines conservation model of nurs;ng. Nursing Sc,ence Quarterly 17[3]. 261 Used w ,th permission of Sage Publications, Inc.I

the Theory of Genetic Vulnerability from Roy's work, anJ Troutman-Jordan ( 2015) applied the results of ,l concept analysis within the RA~1 to devdop thl" Theory of Succl."ssful Aging. finally, Roy (2014 l JescribeJ svnthesis of a middle rangl" Theory of Coping using concl."pts and prrn:csscs from the R.-\M.

Middle Range Theory Combining Existing Nursing and Non-Nursing Theories Combining concl."pts or demcnrs of nrnltiplc thcorie~ is common in middk r.111g1: thl"on· de,·clopment. In many cases found in recent nursing litaarure, the authors of a middle r,mge theory reported tlut tht·y lud deri,·ed their theory from both nursing

I Chapter 10 Introduction to Middle Range Nursing Theories 215

NURSING EXEMPLAR 3: MIDDLE RANGE THEORY COMBINING EXISTING NURSING AND NON-NURSING THEORIES Dunn 12004) provided an excellenl example of combining existing nursing and non- nursing theories in development of a middle range Theory of Adaptation to Chronic Pain. Her intention was to describe coping and pain control in older adults with the purpose of maintaining their quality of life ond functional ability.

Theory Development Process: Dunn wrote that the first step in developing her theory was to review and synthesize the theoretica l knowledge related to pain in older adults, coping with pain, religious coping, and spirituality. She reported identification of three theoretical models that addressed concepts related to pain control and coping in older adults. These were Melzock and Wall's 11992) Gate Control Theory of Pain, Lazarus and Folkman's [ 1984) Stress and Coping Theory, and Wallace, Benson, and Wilson's ( 1971) Relaxation Response. To ensure !hat the final model was applicable to nursing, she selected the RANI to guide the theory development process.

The second step reported by Dunn was to define assumptions for the theory; these were reportedly bosed on the assumptions from the four models from which the theory was drown. Using the process al theoretical substroction, she then took concepts, rela- tional statements, ond propositions from the existing theories and arranged them into a diagram to represent the theorelicol and operational systems. Finally, the concepts from the Adaptation to Chronic Pain Model were linked lo empirical indicators to provide o logical ond consistent connection.

and non-nursing theories. For example, Sousa and Zausznic:,,·ski ( 200;;) usc:d Orem 's Selt:Cm: Thc:ory and Bandura 's Self- Etlicacy Theory to c.kvc:lop .1 theory of diahetcs selt:c.m· managc:mcnt. Simil.1rly. Ulbrich t l 999) den:loped rhc Theory of Exercise ,1.s Sclf-C.u-c through "triangulation of Orem 's l>df-carc deficit theory of nursing, the tr.msthenrctical model of exercise bdu\'ior, and charactc1istics of a popularion at ri~k for c,m.iim·,\~cuhlr disease" (p. 65 ). In .111nthcr example, RL"cd (2014) used the phil- osophic ,·iews of Rogers•~ Science of Unitary Human Beings to relate the nursing perspective to ~elf-transcendence. F11r this theory, Rog.:r~ 's work \\·as used as a frame- work, and it \\'as reportedly combined with concepts .md processes from de\·elopmen- tal psYchologists, including Pi.1gct and F.1gan. finally, Dunn (200-! ) combined scwr.11 non-nursing theories wirh rhc RAM to den~lop her middle rJngc Theory of Adaption to Chronic Pain (sec Nursing Exc.:mpl.u 3 ).

Middle Range Theory Derived From Non-Nursing Disciplines A signific.mr numbl.'r of middle range nursing theories arc developed from one or more non-nursing theories. Indeed, non-nursing theories, including those from the bcha\'ior.1I sciences, sociology, physiology, .rnd anthropology, .1ppcar to be the most common source for rheory dl·\·dopmcnt, and many examples arc C\'idcnt. Kokaba 's Them·~· of Comfort, for cxamp!t.·, \\'JS reportedly dcri\·cd from a rc,·il"\\' of litera- ture.:- from medicine, ps~·chiatry, ergonomics, and psychology .is \\'di .1s from nurs- ing lit.:ramrc .rnd history ( Do\\'d, 2014 ). Role Theory was foundational for both

216 Unit II Nursing Theories

Mcleis's Tr,msitiom Theory ( Mc leis , 2015 ) and ~krcer's Theory of M.1h:nu:I Ro le Attainment ( Meighan, 201-1 ). In other ex.impks, Benner explained that tlH: Dreyfus Model of Skill Acquisition, developed by a mathematician and a. philosopher, \\'as tht: primary so urer for her work ( Rrykczynski, 2014) and Mishcl's U nccrcainry in rnrn:$s Theory incorporated clements of C haos Theory ( Mishel, 2014 ).

In ::i wo rk of theory synthesis, Pickering and Phillips (20 14 } described how their model for cider mistreatment w.1~ dcri,·ed from s~·vcral sources including Car0cgiver Burden Theory, theories describing "non-normal carcgin:rs," Transgcnerational

Covell (2008) proposed the middle range Theory of Nursing Intellectual Capital to explain the influence of nurses' knowledge, skills, and experience on patient and orga· nizotional outcomes.

Theory Development Process: Covell 12008) described using strategies of concept and theory derivation followed by research synthesis to develop and support the theory's propositions. Specifically, she noted haw "Intellectual Capital Theory" (ICT) consisted of concepts from economics, accounting, and organizational learning theory. Key con- cepts or elements from ICT applied to her work were human capitol, structural capital, relational capital. social capitol, and business performance outcomes.

In applying ICT to nursing, Covell 12008) explained that she followed the steps in Walker and Avanl's process of theory deriva!ion lo identify and define the theory's major concepts: nursing human capital and nursing structural capital. She also identified two factors within the work environment that influences nursing human capilol-specificolly nurse staffing and emplayer support for continuing professional developing. Following this, she proposed relationships among the concepts and illustrated how they influence both patient and organizational ou!comes [Figure l 0.2).

Nurse staffing

Employer support for nurse

continuing professional development

Nursing structural

capital

Patient ou,tcomes

Organizational ou1comes

Figure 10-2 Middle range nursing intellectual capita'I theory. (From Covell C L [2008]. The m,ddle-ronge theory of nursing 1ntellectuol capitol. Journal of Advanced Nursing, 63[ I]. 94-103 Reprinted with permission of John Wiley ond Sons.)

Chapter 10 Introduction to Middle Range Nursing Theories .217

Tobie 10-2 Middle Range Nursing Theories Derived From Behavioral Theories

Theory Non-Nursing Theory Source(s)

Commitment to Health Theory (Kelly, 2008) Tronstheoretical Model of Behavior Change

Recovery Alliance Theory of Mental Health Nursing Humanistic Philosophy !Shanley & Jubb-Shonley, 20071

Health Promotion Model (Pender, Murdaugh, & Social Learning Theory and Expectancy-Volue Theory Parsons, 2015)

Theory of Core-Seeking Behavior (Lauver, 1992) Health Belief Model ond the Theory of Reasoned Action

Medication Adherence Model (Johnson, 2002) Health Belief Model, Social learning Theory, the Theory of Reasoned Action, ond the Self-Regulation Model

Self-Efficacy in Nursing Theory (Lenz & Shortridge- Social Learning Theory Boggelt, 20021

Theory of Prenatal Core Access !Phillippi & Lewin's Theory of Human Behavior Romon, 2013)

Cues to Participation in Prostate Screening (Nivens, Health Belief Model, Social Learning Theory Hermon, Pweinrich, & Weinrich, 200 l)

Model For Cross-Cultural Research (Poss, 2001) Health Belief Model, Theory of Reosoned Action

Tr,msmission of \"iokncr Thrnry, n:ological thrnry, thr F.imily Curgi,·ing Dyn,1111- il.:~ ,\!odd, and th..: l'hrnomrnon of Cm:gin:r Dcp,111..kncy. Lastly, Cowll ( 2008 l nplJin,d how ~h..: deri,·,d the middk-r.mge Theory of Nursing lnn:lk.:tu.1! C.1pit.1l from ,1 numhn of organizational beh,ffior th..:orii:s ( sec Nur~ing Ext:mpl.lr 4 ).

S1..·Ycral middk rang, m1r~ing theories h.1,·r hccn dcri\'i:d from theorii:s or molkls ofbi:havioral change. hcqurntly ..:iced arc the Hi:alth Belief Model ( Bi:..:kcr & M.1iman, 1975; Rosrnsro..:k, 1990 ), the Theory of Ri:.1~011..:d .\..:tion [Ajzcn & hshb..:in, 1980 ), .111d th..: Soci.11 Le.1rning/So..:ial CognitiYc Theor,· ( B.111dur.1, 1977, 1986), along with other~. T.ible 10-2 li~t~ some ufth,~, middk range the- ories and gi\'cs ~ourci:~ from whi..:h rhi: theorist claims dcrivJtion of portion~ of their\\ ork.

Middle Range Theory Derived From Practice Guidelines or Standard of Core Pra..:tice guiddincs or standard~ of ..:.m: appi:.ir to be the k;1st .:nrnmon M>ur..:1..· for middle range th1..·or~· 1.kvdopmcnt, as only J ti:w example~ ..:ould be found. ln oni: cxampl,, the Publi..: He.11th Nursing Pr.i..:tici: ;\lodd (K. Smith & Ba1.ini-B.1r.1k.tr, 2003) \\'JS dcn·lopcd by "melding of n.1tionally ri:..:ognizcd components" (p. 44) of public hi:alth nursing ( PHN) pr,Ktin: . The identified ..:omponrnts \\·i:n: the Stan- da rds of PH N pra..:ti..:c, thi: IO b~1..·nti,1l l'u bli..: He.11th ScrYi..:c~, Hmltl~,• A·oplc 20 JO\ IO Li:ading He.11th Indicators, and i\linni:wta 's Public Health lntcn·entions Model. ln o th..:r examples , Good ( 1998 l Lt~cd dini..:~11 guidelines for 111anagi:1m·nt of pmtop- cratiw p.iin to de,·dop a middk rnng;e Thi:ory of Acute Pain Managemi:nt, and Huth :ind i\loori: ( l 998 ) used pracri..:, stJndarc.b to di:vi:lop .1 Th1..·ory of Arn tr Pain Man- .1gement in infants .111d children. F inally, Ruland and ,\ loon: ( 1998 I u~..:d ~t.111d.1rds of ..:arc to dc,·elop the Thi:ory of the: Pca..:cful End of Lili: from st.md.1rJs of ..:,ur for terminally ill pati1..·nts { sn· Nursing Exempl.lr 5 ).

218

I Unit II Nursing Theories

NURSING EXEMPLAR 5: MIDDLE RANGE THEORY DERIVED FROM PRACTICE GUIDELINES OR STANDARD OF CARE Ruland and Moore [ 1998) developed the Theory of the Peaceful End of Life from ston· dords of core for terminally ill patients. In this work, the theorists observed that relational statements of the standards needed to be more specifically defined to make them Off plicoble for empirical testing. Because the standards were too specific, they were too detailed to illustrate the major themes succinctly.

Theory Development Process: The first step of the theory development process wos to define the theory's assumptions based on the standards of core. The second step was to perform a "statement synthesis, " w hereby five outcome criteria were developed that contributed to o peaceful end of life (not being in pain, experiencing comfort, experi· encing dignity and respect, being at peace, and experiencing closeness to significant others or another coring person). Far the th ird step, conceptual definitions for each of the outcome indicators were determined, and the fourth step involved defining relational statements bel\.veen the outcome indicators ond the nursing interventions. In this step, all process criteria from the standard were examined ond combined into "prescriptors" to facilitate the desired outcome. The process of theory synthesis was then used to combine the relational statements into on integrated structure or theory. The final step was to draw o diagram of the relationships os a model [Figure 10-3).

NOT BEING IN PAIN

Monllonng and administering pain

reflef

Applying phermacologlcaJ and non-pharmacolog,cal

1nterven1Jons

Figure l 0-3

EXPERIENCE OF COMFORT

Preventing, monllonng, and relieving physical

dlscomlort

Faalitattng rest, relaxation, and contentment

Preventing compllcat1ons

EXPERIENCE OF DIGNITY/RESPECT

Including patient and Signilk:ant others 1n

<IBCtS4on malung

Being anentJve to patient's ll)(pressed needs. wishes. and

preleren0eS

BEING AT PEACE

Providing ernollonat SUIJPOII

Mon,tonng a.nd meotlng pallenl's

needs for anh•aruoety medlCBltonS

Inspiring trust

Providing patoent/ slgnlllcant 01hers with gwoance tn practical

Issues

ProVtd1ng pllyslcal assls111nce of another

canng person. II desired

CLOSENESS TO SIGNIFICANT OTHERS/ PERSONS WHO CAR

Faeillta11ng porticlpation of Slglllf1cant others ,n

patient care

Attending to significant others f gnet, wornes.

and questions

Facll11aung opportunities tor lamily closeness

Theory of f?eaceful end of life: Relationships between the concepts of the theory.

!Reprmled from Ruland. C. M., & lv\oore, S. M. [ 1998] Theory construction based on standards of core: A proposed theory ol the peoceh,1 end of life. Nursing Ourlook. 46(4]_ 174. Used with permission from foevier.)

Chapter 10 Introduction to Middle Ronge Nursing Tlheories 219

Final Thoughts on Middle Range Theory Development i\liddlt· r,mge theories should be "user-friendly" in IJngu.1ge .md style. The~· m:ed to be described with practice implicatium in jourmls th.1t practicing nur~cs arc likely to read, and the theorists need to identi~· implications and specific.: ,int~·nentions sug· gcsted by the theory (Lc:nz, 1996.l. Liehr .md Smith's ( 1999) specin-: n:commcnd.1- tirms tn 1:nhanc.:e dc:n:loprrn:nt and use of middh: r.mge theory include:

Clearly ,1rticulatl· the theory name. Succinctly desaibc .1pproad1l:s used tiir generating the theory. Cl.1rit\ the cnn-:cptu.11 linkages of the theory in J diJgrammcd model. Elucid.ne the rcse.1rch-praaicc links uf the theory. Explain the association bet\\ cen the theory and the: discipline of nursing.

Analysis and Evaluation of Middle Range Theory The move to enhance middle rnngc them-~· dc,·clopment .md use in 11Ur!,ing practice and n:scarc.:h neccssit.lles corresponding .111.1lysis ,md critique. Like grand theoric\ .md c.:onccprual frameworks, middle range theories should be subject tu evaluation. In addition, rc~carch guided by middle r.1ngc theory should be congruent with the phil- osophic.:.11 underpinnings of the theory and should be critiqued \\'ith rl·gard to more th.111 just the statistical significance: of the nndings.

\Vlull ( 2016) spl·cifically .1ddres~cd an.ilysis and n ·alu.1tion of middle r.111ge theory. Her l'ritcriJ modified the guidelines she used for .inalysis and c\'Jlu.nion of grand nursing theories. The mmiincatiom rcmo,·ed explil·it re\'icw of the 111ct.1p,1rn- digm -:oncept~, which arc assumed to be: more implicit than explicit in middle range theory, ,111d ,1dded questiom regarding the congruenct and fit of the middle r~rnge tl1cor~· with the existing nursing pcrspecti,·e .md donuins. Furthc:rmorc, \Vlull ex- plained th.n middle range: theories should proYidc specific empirical rcfrrcnts for defined concepts. The ,1biliry to opcration.ilizc .ind measure aspects of the theory is cxtrcmdy important in middle range theory, and opl·rational definitions should be C\'Jlu.1ted. FinJ!ly, she suggested .rn.1lysis of middle r.rnge theoric~ to .1sse,~s their c.:ongrucncc \\'ith gr.rnd theories.

Smith (2014) .1lso proposed .1 ti.mnar for C\',tluation of middk rJnge theories. She suggested cnluation based on three- categories: suhstanti,·c found.1tions, ~truc- tur.11 integriry, and ti.111ctional adcqu,tcy. When c,·aluating subst,111tive foundatiom, one \\'ould determine whether the theory was within the focus of nursing; \\'hethcr assumptions arc specified and congruent \\'ith the fixus; whether the theory prm·idcs substJnti\'e description, explanation. or interpretation of a phenomenon thJt \\'Ould be considered middle range; .md whether the theor,· is rooted in practice or research c:xpericncc. b·,1lu.1tion of structural integrity would determine \\'hcthcr c.:nnccpts .1rc dearly defined ,md at the middle range of abstraction, whether the number of (011·

c.:cpts is appropriate, and whether the concepts and relationship .1re logically n:prc- sentcd with a model. E,·aluation of h111ctio11<1l Jdc:qu,1ey cx,1mine,; \\'hcther the theory c.:;m be applied in practice or with ,·arious diem groups, if empirical indi-:aror, ha,·e been idrntified for thcorctic.11 concept~, and if there are published cumplc~ of use of r.hc thenr,· in pr.11.'.til.'.e or research.

Cluprer 5 indudes a more det:i.iled discussion of .111,1lysi~ and c,-.tluation of middk range theorie~. In addition, the synthesized method tor theory e,·.1luarion I sec Box 5-3, p. 107) l.'.an be med .is .1 guide for a11Jl~·sis .111d C\'~1luation of middle range theory.

220 Unit II Nursing Theories

Summary Thi~ chapter h.1s described the current cmplusi~ of nursing theory den·lopment, \\'hich fon1~e, 011 efforts to comtrnn, tc~t. rdim:, and cnluJ.te miJdk range the- orks. To help .id,·ance thl· discipline, nu n,e~ ~houlJ he encouraged to write and publi~h p.1per, th.it de~i:ribe middle r.rnge theoric~ .md report resc.ud1 ~;rudie~ in which .1 middle t\rngc rhcor~· h.1~ been u~ed . This process of middle r.rnge theory generation anJ retincmcnt will further Jcvdop thl· discipline 'l> substantin- kn<m l- edge base.

Annette Cohen, the gr:idu.1te ,tudent in till· opening c:i~e ~tudy who w.1.~ working tow.1rd development of a theory of ~pirimal health. rdatl'd it to the pr:icticc of hm- pke nursing. Like Annette, nur.,c, in .1II set ring~ .~hould ,triw ro lc.:.m, .1bour existing or emerging middle r.mge theorie, or ~eek to de\'clop .md de~cribc theoric~ th.lt will l'Xpl.1in phcnomen.1 they obscrw in practiCl'.

Nursing ha~ the knowkdge, skill~. m.mpm\·l•r, .rnd n:~ourl·c~ ro mo,·c be~·ond ddinc.::ition of ctmcc.:ptual model~ .md donuin conl·ept~ to c.:mplusilc dC\·dopmenr .md applic.1tion of middle.: range theory. ;\liddlc r.mge theory holds much promise for the.: ..-,·olution of the disdplinc·l, l,dencc J.nd pr,.Kti~·c. But, h Liehr ,rnd Smith ( l999) pointed out, the challenge.: i~ to de\"dop middle.: r.rnge theorie~ th.u .ire.: empiric.,lly sound, coherent, mc.:aningti.il, u,c.:ful, J.nd illumi1uting.

Key Points Middk range nursing theories were fin.t introduced into nursing in the rnid- I 970s; their numl"l<.'r .md w,c.: h.m: grmrn dr.1matic,llly in tl1l· I.1st dec.,dc. i\liddk r.rngc.: thc.:oric~ arc.: more.: l,pccitic.:, h.n·c frwcr concept~, .md cn,ompas~ .1

mon· limited .1~pect of the rL·al world comp.lrl·d with grand nur!>ing thcoriel,; they Jrc.: Jlso more rcadil\' tcst.ibk in rc.:i.can:h. i\liddlc.: rang<.' theories 111.1~· be de,·clopcd through n:l,c,1rd1, pracric.:c, or litc.:r.uurc synthcsii.; the,· m.1~· be deri, ed from grand nursing thcu1ie~ ur non-nursing theories; or they m.1y bc.: deri\'Cd from practict" guidc.:linci, and ~t.md.mk lkforc being usc.:d in a rcse:m:h study or .1pplied in pr.Kti,e, middle rangl' nursing thcoriel, ~hould be.: ,lll:ih·zed or c,·.1l u.ued.

Learn in Activities

1. Search current nursing journals for examples of the development, analysis, or use of middle range theories in the discipline of nursing. Con any trends be identified?

2. Select one of the middle range theories derived from a grand nursing theory and one derived from o non-nursing theory. Analyze both for ease of application to research and practice .

3. Annette, the nurse from the opening case study, determined that she wanted ta develop a middle ronge theory af spiritual health. Consider a concept of inter- est or one relevant to your practice. How could you develop the concept into a preliminary middle range theory following one of the processes presented in this chapter?

Chapter 10 Introduction to Middle Range Nursing Theories 221

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( cn...-11. C. L. 110081 The nuddk r.u,~c thcor~ ufnuf'ing, 111rdl..-r- tuJI 1..·.1pir.1L /1111n111/ ,,{A,frnnrof .\'m·H1J,.11. t,3r I), 94-J o.;.

n.nidson,,. E. 120101. F.11..ilitat ... ·d , ... ·n~c111.1klnµ: .-\ ~trntc..·~y ,llld JU-\\

middle range dl1..·ory lo famih..:~ nf iiuc1hi\c c,u1..· unir p.u11..·1tt!<io. Crttit,rl Cnrc }\~u,·if. 3(~ (1 ), :?~- ~9

llohr.u,. i\ t. C. 11011 ,. Toward dcn:lnpmc1u of .1 1111ddlt:-r.111g.c thc11n nt p,,·dmlu~t.::.11 .1d,lpl,1ti1111 in dc.1th .:ind dvm~. Xm·.o,~n \ttrllff QllfJl'lff~l, ].J,. --1- 1. ... 0- 376

llohrJlJ . .\t C. r2016l Hu1ldrng ., m1d .. tk r.1ngc: chcor~· uf.td.1ptiH' ,pintu.alir, ~ '11ri111_11 .\nn1ff (J._1rnrrt·t·~,. ,.?fA21, 146-15.~.

()11\\d, T. 1.'?0141 ~uh.1ri111:: Kuk.1ha rhc1JrY nf comtC.,rr. In .\l ft :\llictu,d ! I:.d 1 • • Vuniu11 tlH11,•ists ,uid tl11·ir ll'orl: t ~rh c ... L l'P· c,~"- <,-1 I St Lo11i, •. \iO. ,\lo,h,

Dunn, K. S. c:!0041 row.1rJ J 1111ddk rJ.I~~ ... - thl'lir~· 11f.td.1pt.nion In duonk p.tin .\"10·s11tn \ontff ~w,rto-/.,., / 7 1 ,. -s-tit.;.

l)~·cs.,, 'i ,\t., & Ch.he<;_ 2011 1 \u,t.1111111~ h,:.tlrh in faith com mumri nur,ins pr.Ktt(c Em~r!!"'!! pro.:c.w,·, tlut ,11rror1 the development ofJ. tnldtik r.in}!c thcon H,1hu1r ,Xm)iJt.11 /"r,utur. lcH,. 221-227.

r.,ln. (._j 12(1171. (. hrl1llk \llrf'l\\ In .... I Pt'tl.'.r\.llll & T ~- lln.:d1m 'h.l, 1, 1\/t,ftfll raupl' rhtorus: . .J.ppl:.-,uirm '" 11t1rJir1...t1 rrs,.flrd, 14th ,·d, pp.'13-1051 l'lul,1<klph1J. l'A. \\i,lter. Khmer

F.,w~crr. I .• & l)l.-.~.,nto i\ l.idL.',-.1, c 20 l 31. C.:wiumpm·m:,· 11ursll(l1 k1w1rltdqt: #-l"nlvsi.< n11rl n•nlwttiotJ ,,{nt1ru,111 uwdds am{ rh,·,,- r1t.•, .~nl ed 1. l'hil,1,klphi.1. I'.-\: F..-\. )).\\is •

Fu,p.un~k. I. [. 1201-11 Foreword. 111 .\I J. ~m,rh & J' It. l.ielir t l-.d~ , . . \11ddlr mttf1t" thl'm'\' f;,r mtrHll._11 1 Jrd ed.~ pp xi-~ii l ~C\\ Yurk, ~\': 'lrrin~i.·r Puhli,h1n~.

ti11ud •• \t r 1CJ9XJ .-\ mit.ldk·-r.1;11~'-· d1 ... ·un nf ,lcuh.· pain m.m.1~c: 111.:nr: l · .. cm rc,4.:.u1.:h. Xur, 11111 ( Jnr/,,111·. -I<>-. 31. l 20-J 24

I .f.tmilron. R J.. & Hower.,, B. J. 1}oo71. {"11,.- t hc11n· of ~L.'rh.'tl..: , ul 11cr.1hi1i1y. :\ Ro~· modd l.'.'\c-mpl.1r. Nm·si1(f1 ~r~o1r/ Qum·rcrf\', 2,u1. 2s-1--2M.

HJ\ting, l'olsnu. M. 1 2llll('l I Towlrd ,1 thrnn of di,·<1'11\ ofhum,n fi1..•l:i p,1ttcrn. t·1sro11s: J1u J1111r11nl of'Ro11~·n1111 .\"unin,r s,.-;,-,,r,., l-112,. 3H7. . ..

Hi!',~""· P .. \ .. & Moore, S .\I. 120llll1 Lcn,I, ntthcorctKll rlunk in~ in mlr',nu!, . .\"ursmn o,ulnnk. -1~4-i. 179-11'.13.

Ho..!~~-- H. I·. Trm.m, r'. r. & Kc~k\', .... C. ' 21)101, C,r,,r J'l:r :0-.1,rrn\'.'1.' in h.1c(~1J.mrc.Hc prc.:p.trnJ ,Kutt.: L,UL· nu~c.·,, /1111nurJ r,f .\'r,n11tt1 .Vh<>lnrsbtp. -1:21 I 1. X.l-'l l.

Hull.m,L ll. r .. l;,~,. [ .. & 1'1erce. T. II. 120111. The diem expert L'lll"<.' Il'l:th.td: s~ 1nhc:,,i~ Jnd Jpplii:Jtuin to ,-\friL.111 .-\rn~rfr.in \\ ith n1t1lripk ,-.:kro\is. 1111· }mtt·nal oJ TJ101r_1 C 'nns11·11tll1t1J .... Tr"sri11 .. t1. /.'ii 2 '· 31>--!IJ.

Hurh, ,\I. /1·1., & /llourc. ~- ,\I. 1 199/l 1. l'rnenpmc theory of lCUtc p.tln m.111.1µ:i:m'-=nt in mtJnt:o-. .md ..:hil ... trcn. fimrunl ofrbt Society ,f I'fd1t11ru \rtff,f£.I, .l! I I . 2,:; .... 32

John!rlon. ~t. r. 120(121. The mtdK,lt11,n .11.ihc:rcll\'.l0 rnodd: :\ gui ... k for .1~st.'Mri1lll( mi:1.iic.1.tion r.iJang lfr.rrnrrh nmf 11Jtor_v _fi1r .\"11r.c- i11,r l'..nrti((, /t>,31. li9-l'12.

1'.-lh, \ \\', I 200R 1. Crnnmirmrnt to heahh rheun·. /{r,cni·r/, mu/ J7,r·on· ti,r .\'11rs111t1 Prnau,-, 22, 1. l-U<- 1 ~8.

K.1111. I! ~-- t .'.?010 1. -:/71( n,um·e "' tht111•ttu1il tl1111!·111q 111 ,111rs11u1 I ~rd i:d. /. ~C\\ York. 1'\': ~pr~n~cr P\lhhsl11ng. .. L

L.ittH'f, n. 11')92 1 :\ rhrnn of (lrr·,n·king hrha,·iur. bm1,11r-"/]1c /rinnurl ,~f 1.\·1u-n11p .\d111/a,·rlnp. 2..Ji. 4 l. :?S 1- 287

J...1.1.~1ru~. H... \ ., & 1-olknun, S. 1 )9N,j.1, ,,,.,.,~. npprrrw1l. 111111 oipin.._t1 :\~:\, York. ~Y: ~pring.cr l1ubh\htn~.

Len,.~. R , 19'16, ,\l,l\ ), ,\I,d,1/,. rrt1t111' tht1wr: Rolr m rar11,.d11111d p,·nai..-r. P.1pcr prc~ntc,t .u the ~i,th Ru~cmar~ Elli~ SdH1tir·~ lletr~lt, ( 'k"d,111d, OH.

Lenz, r. R., l'u!l-h, L C. M1ll1g:Jn, R., & (jift. ,'\. r 20171, lln- plc.t!'rl,ml wmptonh. In .\. I. Pctc:r~un & T. S. Bredow I Eds.. I, .\luf,ilt 1·11,t_qt" 1J,,-,,rif1 .·lpplirnrtm1 w 11ursi1t_n Yflt'ilfCb I 4:th c:d .• pr. r,~-71! 1 l'hil.1ddph1.1, I'.-\ \\"ol1crs Khmer.

Len,. E. R., & \hortn.li;,· B.1~gctt. L. 1 Ed,. 1. , 2002 1 .v/(,:/Jimcv 1111d Jlltr"J1'l,.Jf. :...:~,\ York., ~·y. \prm}!a l\1hh~hrn~.

( ichr. P. & Smirh, ~·1. J i 1999 J, ~l1ddh,: ranµc th1..·11n· \p111mn2,t rc- .,..._.,uch .md pr,tl.'.th:c to ncJt( kn11\\ k-d~t: tt•r the: 111.·" milknmum. A.\".\. ~-id1•m,i"a i11 N11ni11q.\dtJJU. 211-+i. ~1-Y]

~l.irtm. K. S. 1200:l L 17x Omal;a !)'Sttm: .-l kt'yw prncruc, 1f1tcu111r1Jt11nm1. 1111d i11/iin1rmio11 manani'mmr. St. I, ,ui,, ~I(): E.11e, icr S.,undcr,;

~ktlurd. i .. (.. t 2004 I . .\ thc.·on· of hc.tlth promotmn tflr prcti:nn mt.,nt, h.1..,cd •>11 J .t.'\1Jl1..•', i:,>n!<n,lli,111 m(,.._ld c1f nuf'\ir,~. Snr1i,tt1 \001c.- Q_11aru,·fr. 17 3 1. 26t)-1<>6

.\tl'.'Ji-th,tn •. \I 201-1 •. 1L1111on.1 I .\h:ri.-cr .\bii:nuJ rok ,1nJ1111111.·nt-

b1.·1..umln~ J l'nothcr. Jn .\1. R. :\lli~o<11.i i l-.J. i~ ·:,,,lr,n11tt1 rl1nwut1 ~111drhar11-o,-l· 181h..:d .pp 538- :i5-l 1 'it. l.oui,,.\I() ~1o,h,.

,\kk,,, .;\. Li 2011 t 17,nn-a,.-,r/ IJIO'Hlt._lJ: Jki•rlopmr11t n,,d Jm~11rrss 151h ed. I. l'lub,klph10. I':\: l.1ppin,·nn \\'1lli,m, & Wilkm,

,\klci!\, :\. l. I 10l:i ,. lr.m,it1on-. thcoT\'. ]n ~l C . .Smith & ,\1 E. P.1rkcr I l·d, 1 • • \'11n111_!1 t/Jrorits .. IJ1trsi11..,11 prt1afrt -+th ed.~ rr. 3()1 - 380 ). Phil.1dclphi.1. PA, F..-\ 0,\\i,

,\kl,.1.:k. R., & \\",111, I'. 0 . 1 l'N2. l'wchophv,inln~ynr'r.2m. In I) C: Turk & R. ~kl,.Kk I l::d,.1. Hnndh,mk 1fpni11111,d n11mm,·1Jt 1 pp .• l-25 ). :\f.'\\ York. 1':Y: GuHford Pre,~

~li,hcl. ,\1. H. 1201-h Thl'onc, of un,crtai1m in ilh1<·~,. fn ,\I. I. ~m1th & P.R. Lu.:hr ( (~J, 1, .\l,ddl, n1llf1t' rhmn- 1;w ,rnn111,1 1 .~rd ed .• rr. ii.~-N6 ), :-:ell York. :\Y: \pn11ga l'uhi,~hlll!(, -

.\lurro~.:k~ C. J .• & Hi'.\!.~ITl'I. P .. \ ,2009 ·11,c thcon ol musK. mooJ .111d mon.'ml'nl to .. ;mproq· hl·.,lth CllJlt:"umc, Jm,,-11,1/nfAdnwcrtf :,iunin ... 11~ i'l.il IO 1 • .2.?4-9-.!2;\7

:S:i1cn, .. -\. S .. Hcrm.111, f. l'wcumch. S. P .. & \\'cu1n.:h. ~1. C. , 2001 ). ( uc, to p.1rm:ipat1nn lf1 pro:-.t.tll" L.::.JIKl.'r r;,crcrnmg. :\ thc.·c tr\ tCn- pr.Kti.._ . .._._ < )ncr1l,t,r.1· ,\'m"tr{l1 Fon,m. 2N 9 . 1449- 1.f.56.

Pender.,. r.,,\lurd.,u!(h,( ,& Pl1'<11\S,,\\.:l.. 12015 1 H({J/tbpro- 11/1/hmJ 111 ,umin.rr prnmu , 7th cu. I. l"ppa \JJ,lk 11.lwr, :--J. l'rrntii:c-H,11

rctcr.cm. S. J. 12017 1. l11tr11tiu..-rion to the n.1mrc of nur~i11~ k.J1,n11.'l- <d!\e, l11 ',, J. l'<tcr..1111 & T. S. llrl'dm, I his.,, ,\fiddl, m>t«r r/Jnn·u1: 41fphi.·n t w11 h1 '""',"t" rotarr/J 1 -hh C'd .• pp 1-~~S > l'hib,ldph1.1. I':\: \\'niter; Kluwa

Phillippi. I. C .. & Ron1.111. ~I \\' 12013 1. ThL'. mo11,.1tion faL:il1- l,ll1tJ!l theory of pri:n.ttJ,( ,.m.· Jcc..:: .... ,. /t,ur11nl of .\[idw1Jfn· ..::,- llilmm, Hwltb, 51,j1>1, 509~5l5

l'i.:k«in!\, C F.. Z., & l'hillip,. L R. 120141 De,clopmcnt ot", ('JU'-1) model for cl<.kr mi-.tri.-Jtm~nt. l'uM1t Hu,lr/J ~-111.,i,,11. 3/(4), 3<,.~-~-2 ,

222 Unit II Nursing Theories

Pickett,\., l'c1c,,-, R. ~I.. & J.u-,,,.,,, I':\. 1201-h ·1,m.r,l.1 nud,Uc-rall!c(C thcnr) ,,f wcil%,)n fUjJ\.\gcmcnt ... V11rri1y1 S.-Jr11ct' <JJ,arur~~·. 21.~ ,. 242-24;"

Pon .. L \". il997l To\\Jrd J 1111ddlc.·-r.1ni.:-t.· the-on· ot rc:-.ilicn\.'c. .-i .\'~ . . ~dl'lt11rrs ii, S11rrir,n Sm·11u, IV. .i l, 1-13 ·

Po~. J. E. 120011. nc,clopi1;g .1 nc\\ rno,kl tiir ~ro~~-(:ultur.11 rc- ,c.1r1.:h· Svnthc~i,lng the hc .. 1.hh lx·lu:f mt1-1.kl .mt.I the thcor~ of rc.1.~mcd i,·wm .-i.X.'( .~d1•tuut.c w X11r~mtr \.·1,·uc,-. 23{4 ). 1- 1 ;l

llccd. I'. G. I 201-1 I.Thcon c,I ,clf-tr.rnscrndcrKc. In M. ). ~mah & I'. R I ichr l E,h. 1 • • ifufd/,· rn11_n.- t/1,·on J i>r 1111m1i.n 1 3rd ed., pp. 109-1-IOL :-Jc\\ York. :,.:y- \prin!,[cr l'uhli, lung.

R1cgcl, H .• J,ar;m.,. T.. & ~cm111bcr1,1 •• -\. '2011 /. :\ middk-rJll!,lC thcon of ~dt i'.'arc of ~hromc illoc!I-,. A..\'.\. Adi•murJ rn Sur111111 s,;,,,;, .. 3,<;i oh l 'l+-20-1. .

Ro...:n"o.:k.I.1199UJ. The hcJlth bdicf111uc.lcl: Explainin!_!. hc.1lll1 bdu""' thmush npc<lan.:ic,. In i.:. Gl.mz. F. Lc\\i,. & B. Rimer I Ee.ls.,, H,·nltb b<bnl'iur n111{ btn/rll(d,rcawm ( pp. 39- <>1 ,. 'i.m Fr.md~(o. CA: Jos~·\ B..b~.

Ruy, C. {20141 Coi~nrhc:,i" of ol middle rJngl." theory nf copin~. In C. Ro~· l l-.d. l, Gt11tr11r,,,_11 mid,f/,. rnllJ.1f r/J,ur.v: Frm11 t1 1ido1ir" rn prnaicc \PP- 211-232 1 ;,.;cw York, :-;y ,pringcr Publi,h111g

ll.ul.111J. C, M .• & Moore, S. ~1 1 1998 1 Thcurl' ,umtru,11<111 bJ>cd on ~tJm.brd:,. of \'..lft: 4..\ pruposc1..l thcur, of the.: pca1;cfut end of liti: . • \J11rsi11n 011tl1!<1k. -11'114 1, I c,9-175

\h,tnln. E .. & Jubb Shanlc,·, M. I 1007 I. The rc~rn-av .1Ui,11cc thc- t>r~· (>f mcnr~ hcilth n~rsmg. Jou nut I ,f l',ycl11nrr;r nntf .lJ,utnl Hmltb N111~i11n. l-1< II l. 734-743.

::.mith, K., & IIMini-R.1uk.11, :,.;' ,'.?003 , :\ puhli.: health m1"111~ pr.1-.:tic1..· moJd: Melt.ting puhh..: he.11th prmdpk, with thc nur. m~ proccs~ Public Ht:nlr/J .\1w·s111 ... FJ, 2(~ 1 1. 42---l-K,

\nuth, M. C. 12014-1 t-.\·.1lu.uu111 ,11 rutddk r.rngc ;hcoric~ for the: discipline 11! nur,111!' In ,\I _ f_ :O.muh & I'. R. Liehr I fak I,.\/,,/· dk rnn.11,· rJ,,.on Ji" n11r.HIJ...fl t 3rd ed ... pp. ~5-50 t. New Yurk, ~\' '\pr111µ.c.·1· Pu hli,hin~

\nuth .. \I. l . & l'.,rkcr, .\I. J., .,, 101 I, N11rsi,1,_f/ rluorfrs <::· 111mi11.,r p,·na,a 1 -4th ed. 1_ Ph1l.1ddphi.1~ P:\ F.A Ila.vis.

',mith. ~L l.. & Liehr. P.R. 1 Eds 1. 120l'11 .\fuidli- nutn,· Ihtor_Y fiw 11ur1i11 .... " I 3rd ~o I. :-,.,:i_•\\ York. :,.;y. 'ipri n~cr rublishin~.

\011,.J, \'. n .. & Z.1u,z111c\\sk1, I ,-\. 120051 Tuw:ird .J thcor\' of JtJ.httc, ,dt·(Jt\.~ mJn.1gcnu.:nt. j,mn11rl t.1f 11u,ir_v Co,utnuti,m 1111,I Trsti11n. ~2 ,,bl-67.

'\uppc. f . 1 J99h. ~hy 1. Jfidtflr 1·11111u· tbc01:\·: !"l1u-1J11 ... 11 ilum·,,- ,1wi l·11111rkd_11<' ,l,Td11p111,-11t 1',1pcr prc,rntcd ,11 the Siuh Rmrn,.,n· Elli, ',.:h11l.1r', llctrc.11. < lc,cl.rnd. OH

l'routJllJ.I'I Jonfan, ~' l. (JOI :t ,. I rou1m.1n-Jorc.fan \ thcur~ of \\.le.• ,c-"ti,J .1gcmg. I 11 ,\1. L ~nmh & 1,.1 E. Porker I Ed,.1. Xm·111r_n tbt11rio (;' 11111"Ji11,.11 pr1ur1a 1-l-ch cd"' pp. 4S34Y-l- 1. PhH.iddphiJ, I'.-\. I':\. D.,rn.

l'lbri..:h, S. 1.. 1 ll)t.)91 :--:ur,mg f'TJ\."tl(4." thcury or c.::xcr-.:J!-.1.' .1,

,elf-care. lmn_,rc-"11JC /11111·11,r/ of S11r.cm_,r Scb11/nnl111', 3/r I l, h:i- 70.

W,ll.1cc, It, llcn,on. H .. & \Vii,011, .\. Ft 197 l 1 .-\ \\akcful hypomct .1h11li1; phy,11,Jo~k ,t.itc. ]11( Amcrirnu f,mr11nl of l'lry'Jit1ltt_l1). 121, 3 \, 795- 791)

\\".tt!-.on. r. 120111. fl11111a11 rn rhu1 Jcfrncc: ~1 tbt m·,· o( n11r111111 , 2n,1 cd l Sudbur). ,\L-\: Jon,; & lt1rclc1t l.,,rnini •

\\'l1J.Jl, A. I .. 1201C>L Philt>sc,ph\' t>f,.:itn,c.~ prn,itit>tl~ .md their im pnn.11h.:.: m a1> ...... n.1w.m.1I nur,ing. ln ). J. fn1pJtrid .. & .\. L. \\'h.,11 I Eu,.'· C01urpt11al ,,,,,dd.< ~r ,,,,,.,,,,_n. (,wbnl pcrsp.-ctll'(.< 1 :ith ed., pp. 5-20). L'ppn S.lll,tlc Ril'cr. :,;J; l'rcmicc H~IL