THEORIES discussion

Overview of Se ected Middle Range Nursing Theories Melanie McEwen

Elaine Chavez is employed as a nurse at a public health clinic in on urban area. She is also in her second semester of a graduate nursing program preparing to became a mentol health nurse practitioner. In her practice, Elaine hos worked with a m:imber of women who have been abused by their partners, and she hos observed a potterin of comorbidities in these women, including depression, alcoholism, substance abuse, and suicide attempts. Over the last few months, Elaine hos reviewed the nursing litemtm,e and identified several intervention strategies that have been effective in work'ing with women who hove been victims of domestic violence. Using this information, she would like to implement a program to promote early identification of abuse and multiple-level in1erven- tions. This is a project that will work well with one of her master's portf,olio assignments.

From her literature review, Elaine identified several theories related to her study. She was particularly interested in examining the set of circumstonces that would cause the women to seek help. For this, she performed a more detailed literature review and identified Kolcaba's (2003, 2017) Theory of Comfort, which !helped her conceptualize many of the issues faced by abused women. Indeed, the theory de- scribed individual characteristics thot contributed to health-seeking behavior. Tihese were stimulus situations, which can cause negative tension . By providing comfort measures, the nurse con help decrease negative tensions and promote posiitive ten- sion. Elaine wanted to continue ta identify comfort measures that would encourage the women to seek core for their problems.

For the next phase of her project, Elaine collected all of the information she could find on Kolcabo's theory. This included studies that hod used the model 'O'S a conceptual framework and studies that had tested the model. From thot ,i111formotion and the articles she hod gathered previously about issues related to domestic vio- lence, she was able to draft a set of interventions that she hoped ,ta implement ,a,t the clinic following approval by her supervisor.

223

224 Unit II Nursing Theories

Pn.·,·ious duptn, lun: de~..:ribed the growing emplu~i~ on the dc\'dopment .md test- ing of middle range theories in nur\ing. A~ a r.:sult, during th.: pl~t two dcc1<.ks, .1 signiticJnt number of the~.: theorie~ hJ,·c been prc~entcd in the mir~ing literature. The purpose ofthi!i ..:haptcr is to introduce some of the commonly used middle range nursing theories as well as some of the recent!~- published ones to familiarize readers with these works .u1d direct them to resourcn for more information. An attempt was nude to include works from .1 ,·Jriery of an:as .md from man~- scholars but by no mcam i~ the li~t pre~entcd hen: C\hausti\'e. :--:or doc~ indm.ion ur c:xdusion rdat.: to the quality or signiti..:ance of the theory or it!i usc:fulrn:ss in research or practice.

To assist with organization of the chapter, the thL·orie~ arc Lfa·idcd into sections based on wlu:thcr they appL·,u to be "high," ·' miJdk," or "low" middle range theo- ries. A, cxpbincd in C h.1ptcr 10, the high/middle/Im,· distin..:tion relate~ to the kwl of Jbstra..:tion as posed hy Liehr .rnd Smith p 999 J, with the "high" middle range tlu:oric, being the mu~t .1bstract and nc.ire~t to the grand theoric~. The "low" mid- dle r.mgt' tl1L'orit:~, on the other hand, arL· till· le:ist ahstr.Kt, and they .uc ~imil.ir to pr.1eti.:e or sinution-spc:cific theories. It is noted th.1t these design,1tions are .1rguably .1rbitrary .rnd that one theory that is listed hl·re J S "high middle" may he considered by others to he ~1 grand theory. Likewise, .mother theory listed here .1s '' middle middle" might be L"omidcred. by other~ to be .1 high middk r.rng.e theory, and ~o forth.

Elt'mcnt~ of theory de~cription .md theory analysis ,ls explained in Chapter :i sen.: .1~ till' l1.1sis for the: more detailed di~L"us~ions of selected tllL·orics. Each will induLk a bril"f owrvicw, an outline of the purpo~e .rnd major concepts of the theory, and context for llSl' and nursing implications. Fin.illy, e,·iJence of cmpiri..:,11 tl·~ting .md .1pplic.1tio11 in pr,Kti..:.: arc dc,cribcd (Box 11-1 ).

High Middle Range Theories The high middle r.mgl' theories prt'sented here .1re 'iOnlL' of the most well-known .111d widdy used tht'ories in nursing. Indlllkd .11-c- the works of Benner, Leininger, Pender, .rnd Mclei'i. The~e theories ma~· be consid1.:red grand thcrnics or ..:oncrptull framc\\·ork~ b~· other m1rsing s..:holar~ and po~sibl~- by the ;1uthor of till' thL·ory. These rhcoric~, hom,:,·rr, do l1t)t totall~· fit with the critcri.1 for grand theoril·s .1s outlined in this text and therefore .1rc not covered in the chapters dealing with that contL·nt. In .1ddition, the Synergy Model, a nursing model th.11 is wide!~· used in rt'scar..:h .md praL"tiL"e, particularly in ..:ritical c.ue, will he discussed. T.1blc 11 -1 li~t~ other hig.h mid- dle r.rng;L· theories or ..:on..:cptual models, their puq1me~, .md major ..:onccpts.

Benner's Model of Skill Acquisition in Nursing Patrici.1 Brnner'~ thcoretic.11 model was tir'it puhlislKd in 1984. The modd, which .ipplie, the Drcyfm model of skill a.:quisition to nursing, outlines five st.1g:e1, of skill

Box l 1-1 American Association of Colleges of Nursing Essentials

Middle range theory is vital for the ongoing development of the nursing profession. Indeed, according to the doctorate of nursing practice "essentials," "Nursing science frames the development of middle range theories and concepts to guide nursing practice" (American Association of Colleges of Nur~ing, 2006, p. 91.

Chapter 11 Overview of Selected Middle Ronge Nursing Theories 225

Tobie 11- l High Middle Range Nursing Theories Theory/ Model

Tidal model (psychiatric o nd mental health nursing) !Barker, 200 lo, 20016]

Spiritual Core in Nursing Practice Theory (Burkhart & Hogon, 2008)

Porish nursing (Bergquist & King, 19941

Porish nursing (L. W Miller, 1997)

Neal Theory of Home Health Nursing (Neal, 1999a, l 9996] Occupational health nursing (Rogers, 1994)

Omaha System (Martin, 2005)

Schuler Nurse Practitioner Practice Model (Shuler & Davis, 1993)

Public health nursing practice (K. Smith & Bazini-Borokot, 2003)

Rural nursing !Weinert & long, 1991)

Purpose

Describes psychiatric nursing practice focusing on three care processes; emphasizes the fluid nature of human experience characterized by change and unpredictability

Describes the process in which posi- tive nurse-patient spiritual encoun- ters con lead to positive spiritually growth.filled memories that will increase nurses' spiritual well-being

Describes the integration of physical, emotional, and spiritual components in provision of holistic health core in o faith community

Integrates the concepts of evangel- ical Christianity with application of parish nursing interventions

Describes the practice of home health nurses as they use process of adaptation to attain autonomy

Shows how the occupotionol health nurse works to improve. protect, maintain, and restore the health of the worker /work- force and depicts how practice is affected by both external and internal work setting influences

Comprehensive classification system that promotes documen- tation of client core, generally in community and home health nursing practice

Integrates essential nursing ond medical orientations to provide a framework for holistic practice for nurse practitioners (NP]

Guides public health nurses to improve the health of communities and target populations

Guides rural nursing practice, research, and education by understanding and addressing the unique health care needs and preferences of rural persons

Major Concepts

Personhood (dimensions-world, self, others), discrete holistic !exploratory] assessment; focused !risk) assessment, empowerment, narrative as the medium of self

Patient cue, decision to engage/not engage, spir- itual intervention, immediate emotional response jpositive or negative], search for meaning, forma- tion of a spiritual memory, spiritual well-being

Client (spiritual, physical. emotional components). parish nurse (spiritual maturity, pastoral team mem- ber, autonomy, coring, effective communication), health (physical, emotional, and spiritual wellness and wholeness). environment (faith community)

Person/parishioner, health, nurse/parish nurse, community/parish, the triune God

Autonomy, three stages {dependence, moderate de- pendence, and autonomy), logistics, client's home, cli- ent's resources, client's needs, and learning capacity

Work setting influences !corporate culture/mission, resources, work hazards, workforce characteristics), external factors (economics, population/health trends, legislation/politics, technology), occupational health nursing practice (health promotion, workplace hazard detection, case management/primary core, counseling, management, research, legal/ ethical monitoring, community orientation)

Depicts the nursing process os circular rather than linear; steps are collect and assess data, stole prob- lems, identify admission problem roting, pion and intervene, identify interim/dismissal problem rating, ond evaluate problem outcomes.

Patient ond NP inputs (noted as episodic and com- prehensive with and without health problem]; data gathering/role modeling; patient and NP throughputs include identification of problems and diagnosing, contracting, and planning and implementing of the plan of core. Outputs involve comprehensive evalua- tion of patient and NP outcomes.

Interdisciplinary public health team, standards of public health nursing practice, essential public health services. health indicators, population-based practice (systems, community, individual, and fam- ily locus), healthy people in health communities Health (health as ability to work), environment (distance and isolation}, person (self-reliance and independence}, nursing [lock of anonymity, out- sider/insider. ond old-timer/ newcomer!

226 Unit II Nursing Theories

acquisition: novice, ad,·anced beginm:r, competent, proficient, .1.nd expert. :\!though Iknner\ \\·ork is much mon.: encompassing in regard to nursing dom~1im .111d spccitic function~ .111d inrcrvcntiom, it is the ti,-i: ,rages of skill .1cquisition th,u l1.1s recei\'Cd the most attention \\'ith reg.1rd co .1.pplic.1.tion in .1dministr.1tion, cduc.ttion, practice, .1nd rese;1rch.

Purpose and Major Concepts Benner', model delineJtes the imporrance of retaining Jnd rewarding nunc dini- ci.rn~ for their dinic.11 expertis1.: in pr.Kticc scttings bcc.rnsc it dcscribes thc cnilution of "excellent caring pr.1cticcs." Shc notes that resc,m.:h ,krnonstmle~ tha t practice grow~ "through experiential k.1.rning .111d through tr Jmmitting tlut lea ming in prac- tic.11 settings" ( Bl·nncr, 2001. p. l'i \. Expertise de\'Clups when the dinician tests .md reline~ propositiom, hypothesc~, .111d principle-b;1~ed expect.1.tiom in .icru,11 pr.1cticc: situatiom. Finally, the model seeks ro describe clinii:al expatise including six .m:a~ of practical kno\\'lcdge ( graded qu.1lit.1tin: distinctions; common me.rnings; .1ssump· tions, expcdations, .rnd sets; par.1digm c.1ses Jnd personal knowledge; 111.nims; and unp!Jnned practices) ( Benner. T.11111<:r, & Chesl.1, 2009}.

Thl· centr.11 concepts of Benm:r·~ model .1re those of compctt'nce, ~kdl .1cquisi- tion, cxpcriencc, dinic.11 k.no\\'lcdgc:, .rnd pr.tctic.1.l knO\dedge. She .1.lso idemitit:~ the following ,l·,cn dumaim of nursing practice:

Helping role Te,Khing; or co.tching; fu1Ktio11 Di.1gnostic dil·nt-inonitoring ti.mction Effrcti\'c m.1.n.1gcme11t of r.1pidh· changing ,itu.uion~ .-\dministering .ind monitoring ther;1peutic inten·entions and rq;imens Monitoring .md ensuring qu.tlity of health c,m.: pr,Ktices Org.111iz.1ti011.1l and \\'ork-rolc compi.:tern:ies l Benner, 200 I)

Context for Use and Nursing Implications T he Bi.:nner model lus becn used extensh·d y J.s ration.1lc for can.:i.:r deH:lopment .md continuing education in nursing. Are.1~ ~pecitic.1lly cited for uriliz.trion indude nurs· ing m.rnagemem, career enhancc1m:nr, clinical specialization, staff dc,·elupmcnt pro· grams, stJfhng, e,·J..lu.ttion, dinical internships, and pn:cepting \tudents .rnd novici.: nLirSl' ( Benner. 200 I; Benna ct al., 2009 1.

Evidence of Empirical Testing and Application in Practice O ver the pre,·ious dec.1de, dozens ofarticks have: been ,,•1;ttcn based on Benner's model, .md a number of thc~c wen: resc.1rch-based srudics. for ex.m1plc, \Vilson, HJ.r\\'ood, .rnd Oucbhoorn { 20 l 5) eumini.:d rhe "perpen1al nu,·ice phenomenon," and Cates ;111d colk.1gues ( 2015 J t'mployed J. Delphi method to dt'.,·clop a ~imul.niun·bascd compe· tenc,· .bse~smenr instrument for neonatal nurse pr.tctitioners, both basi.:d on lknner·s model. In other re~c.:Jrch, 1\krt'roj.1 .rnd Koponcn \ 2012) u~ed Benner\ model to com- pare nurses• opti111.1I .rnd a,nml compercncie~ in clinic.11 ~ettings, .rnd Abra Imm ( 2011) reporred on a study ro e,·,1lu.1ti: .1 pwgr.1111 b.1sl·d on lknner's model, which \\'.lS de· signed to de,·elop leadership skills .111d profrssionalism. Last!~-, Hum.ird 120 I 3 I reported on .1 corrcl.1.tional srudy \\'hicb u~i:d Renner'~ no,·ice-to·cxpcrt theory to comp.ue exir examination score~ .md K.1tional Council Licensurc Ex.1111ination ti.,r Registered Nur~es (NCLEX-R.i"\1) pJ~s r.uc~ among sn1dcnt~ in a prclicensure nursing progr.1m tc:1llowi11g implementation of .1 program using stand.1rdizcd testing. Non- rese.1.rch-ba~ed .1nide~ included a report by Woody and D.wis ( 2013 ) \\'hich described ho\\' ro use Benne r's

Chapter 11 Overview of Selected Middle Range Nursing Theories 227

model to den:lop ,rnd implement .m edu.:ationaJ module de:-.igned to impron: nurse .:ompetern:e in peripher.11 inrr.in-nom ther.1py.

A fairly ..:0111111011 theme \\'as noted a~ ~en:r.11 writers discussed lknner's .ippli..:.1- bility in dcn:lopmcnt of proo:dures and protocols for orientation of new gr.iduatcs or nurses into new speci.ilty .ucas. For ex.implc, using Bennn's model, Kolurchik, Caputi, Robb, ,md Culleiton ( 2015) presented ,1 process \\'hi..:h ..:.111 be used by clini.:.11 fa.:ulty ,111d preecptor, to den:lop clinic.ii rt:.isoning in nursing students; Coyk ( 20 I l) disrns~ed an internship progr.1111 in home he.11th for ne\Y gr.1duares; .1nd Du111d1in ( 20 l O) de~cribed a mcrhud for using onli1ll' k.1rni11g cxperienCl'S to de,·dop perioper.itin: mir,c~. Finally, Benner·~ work w.1s med in sen:r.11 article~ (e.g., Bit.rnga & Austria, 2013; H.1.1g-Heitman, 2012; O\\'cm & Ck.1ves, 2012) to di~..:ms the development or updating of c,1recr enhancement or clini.:al ladder programs.

Leininger's Cultural Care Diversity and Universality Theory i\l.1ddeinc Leininger w,1s instrument.ii in dcmon~tr.uing to nur-,n the imporr.11Kc of considering the imp.Kt of .:ulturc on he.11th and hc,1ling ( Leininger, 2002 ). Prior to her death in 2012, Lciningn wa~ .1 proliti.: nursing researcher .rnd schol.1r, .md she is credited \\·ith starting rhc specialty of tran~rnltur.11 nursing. 1 n addition, she was ,1

lcading proponent of the ide.1 tlut nursing is synonymous with .:.iring. Leininger reported th.It she conceptualized tr.111s.:ultur,1l nursing .1~ .1 di~tin.:t

are.1 of nursing pra.:ticc in the late ] 9;i0~ during her dtKtor.11 \\·ork in anthropology; she .:ontinued to study and de\'dop a tr.lllscultur.il nursing ..:on..:eprual fr.1111c\nirk throughout the l 960~. In the mid-1970~. she pn:semed a "tran cultur.11 health model" tlut w.1s expanded in 1978 .rnd 1980. The Leininger Sunrise 1\lodel \\'JS tirst de~.:ribcd as ~uch in 198-l .rnd depicts the tr,rns.:ultural dimcnsiom of rnl- turologic inter\'iews, assessments, .rnd therapies ( ~kF.1rl.1nd, 2014; 1\kF.1rl.111d & \Vchbe-Alamah, 2015 ).

Purpose and Major Concepts T he purpose of Leininger' ~ thcorT is to gener:itc knowledge rcl,1tcd to the nursing can: of people \\'ho ,·alue their cultural herit:ige ,rnd litt:ways. 1\bjor .:nnceprs of thl.· model .1rc ..:ulture, culture care, ,111d culture ..:arc diff,.:ren..:cs (diwrsities) ,llld ~imi!Jr- irie, (uniYersals) pcrt.1ining ro tr,111s.:ultur.11 human .:are. Other major ..:otKepts .1re .:arc and c,1ring, emi.: \·iew (l.1nguage exprcssiom, perceptions, beliefs, and pra.:tice of indi,·iduals or groups of .1 p.1rticul.1r .:ulture in reg.1rd to certain phenomena), etic Yiew { univer~al l.tnguage expression beliefs .md practices in rt·gard to .:err.tin phenomcn,1 that pertain to sn·cr.11 cultures or groups), lay system of he.11th cJrc, professional svstem of health care, .md culturally congruent nursing .:arc t Leininger, 2007; ~kfarland, 2014 ).

Context for Use and Nursing Implications Till· goal for application of Lcininger's theory is to pn)\'idc rnlrurally ..:ongrucnt nursing .:arc to persons of din:rse cultures. :\ central tcner of the thcory is rh.1t it b importJnt for the nur1.e to underst,md the individual's YiC\\' of illnesl. . .-\lso, the fo.:u~ i~ on recognizing ,rnd under-~tanding cultur,11 simil.1ritics .rnd ditkrcn..:c~ and using this information to positi,·ely infllll'llCe nursing .:,1rc and health (i\kF.1.rl.md & \Vehbc-.'\lamah, 2015 ). The theory has been widel~• med for resc.1rd1, .1.nd finding~ are .1ppropri.1te for nurses in Jn~· setting \\·ho work \\'ith indi,·idu.1ls, familie~, ;rnd group~ from ,1 .:ultur.11 b,1ckground ditfrrent from th,: nur~e \ .

228 Unit II Nursing Theories

Evidence of Empirical Testing and Application in Practice Lciningt:r ( 2007) explained th.u her theory was dcrin:d .md re lined through .1 num- her of yean, nf stud\'. OYcr the pa~t two dc.:adcs, rc,ean:h on ,·a1iou1, group, \\'J.,

conducted, and ~hc listed cultur.1I \\1lues .rnd culture care meanings .md .1ctio11 modcs for 23 cultur.11 groups in her hook. 1'l.111y graduah: stutknrs .111d m1r~ing scholar.-. hJ,·e med Leininger\ tl1t·ory .1s a b.1si~ for research, .rnd .1s .1 result, hundred~ of examples of ,lrtidc~ can be lo.:atcd in the litaaturc. i\l.u1y of these med Leininger'~ work .1~ .1 conceptual framcwork to stud~· cultur.11 implil'.atiom of J ,·Jriety of heaM1 prob- ktm. for ex;1111ple, J. M. Long and colkagucs 12012 ) examinni he.11!t11 bdid~ .unong four ditfrn:nt Lirino rnbgroup~ ~pt·cific.1llv rd.1tt·d to type 2 di,1betes; (.;ilium ,md colleague, ( 2011 ) resc.m.:hcd c.1rdi0Yas.:ul.1r dise.1se in the Amish; Mixer, fornchcd, Varnc~· •. md Lindky (2014) ex.unined cnd -oHifr care for people in rural App.1bchia; .md L<'1pc1-Entr.unb.11,,1guJs, c.;r,111ero-1'lolina, .md hrn.111dez-Sol.1 120131 ~tu died the incidence nfHl\'/AIDS .1111011~ .1 group of sex mirkcr~ in Boli\"i.1.

Leininger\ rnmkl lus .i.bo been uscd hy many author, to identi~· \',ui.1bles or .:h.1r- ,Kteristic~ uf cultural groups or ,ubculrures that might influence l1t·.lith. for cx.1111pk, h1rren ( 20 I :i) performed a comprchensi\'e liter.uure re,·iew of re\e.1rch th.u e:-..1111- ined rnltur.11 ditfrrenc.:-s in cancer ~un·i,·ors' pen:eptiom and experiences to promote p,1ticnt-ccntered, culrur.1Uy congruent c.1re tiJr .1dult .:.mccr patient~, .md L,:,: ( 2012) uscd Leininger-inspired "ctbnonursing re~earch mcthmh" to disco,-cr cu-e m.:;ining\ .tnd expre~~ion among Appabchi;m Ill< ,rhcrs li,·ing with their children in a homdcs~ :;hel- ter. Other 1:x,11npb of rcsc.1rch ~tudic-, ming Lciningcr's nmdd .11-c listed in Bm 11 ·2.

Box 11 -2 Research Studies Using Leininger's Theory of Cultural Care Diversity and Universality

Bhat, A. M., Wehbe-Alamah, H., McFarland, M., Filter, M., & Keiser, M. (2015]. Advancing cultural assessments in palliative care using web-based education. Journal of Hospice and Palliative Nursing, 17(4), 348-354.

Doornbos, M. M., Zandee, G. L., & DeGroot, J. (20141. Attending to communication and patterns of interaction: Culturolly sensitive mental health core far groups of urban, ethnically diverse, impoverished ond underserved women. Journal of the American Psychiatric Nurses Association, 29[4). 2 3 9-2 4 9.

McCullagh, M. C., Sanon, M. A, & Faley, J. G . (2015). Culturol health practices of migrant seosonal farmworkers. Journal of Cultural Diversity, 22[21, 64-67_

Millender, E. (2012). Acculturotion stress among Mayo in the United States. Journal of Culturol Diversity, 19(2]. 58-64.

Missol, B. (20131. Gull Arob women's transition to motherhood. Journal of Cultural Diversity, 20(4]. l 70-17 6.

Morris, E. J. (2012). Respect, protection, faith , and love: Ma jar care constructs iden- tified within the subculture of selected urban African American ado'lescent gang members. Journal of Transculturol Nursing, 23[3), 262-269.

Street, D. J., & Lewollen, L. P. [2013). The influence of culture on breast-feeding deci- sions by African American and white women. The Journal of Perinatal & Neonatal Nursing, 27(1), 43-51.

Tas<;i-Duron, E., & Sevil, U. (2013]. A comparison of the prenatal health behaviors af women from four cultural groups in Turkey: An ethnonursing study. Nursing Science Quarterly, 26(3) , 257-266.

Turk, M . T., Fapohunda, A., & Zoucha, R. (2015] . Using photovoice to explore Nigerian immigrants' eating and physical activity in the United States. Journal of Nursing Scholarship, 47[ 1). 16-24.

Chapter 11 Overview of Selected Middle Range Nursing Theories 229

,-\ number of nonrl·,e.m.:h Jrtid,:~ do:saibing aspccr, of tr.uv,cultural nur!>ing .rnJ fo..:u1-ing on Leininger\ \\'orkl, hJ\'l' al~o bel·n publi~heJ in recent ye.1rs. The3e induJe a re,·ie\\ of J \\'ork!,hop to enh.111ce ..:ulrur.11 .1w.m:n..:,\ for nu1~c pr;1..:tirioners ( Elrninowski, 20 l 1; .1 r..:port on how to pro,·id,: culmr.111~- competent, pati..:nt·Cl"lltl.'.rl·d nur~ing ,:,uT

I D,m1..:II & Hickson, 20 l I; .111d .rn artide dc\cribing th..: impad of inrcrn,1tion,1l ~l·n·io.:l' k~1rning on nur:-.ing ~mdcm's ..:ultur.11 comp,:h:n..:c (T. Long, 2016 ).

Pender's Health Promotion Model :--:ol.l l\:nder bqtJn studying h..:alth-prumuring bch.1,·ior in the mid-197(>-. ,llld fir.t publi~heJ the Health Promotion i\icJJ,:I / HP~l i in 1982. She reportcJ rh,lt the model w.1~ ..:onstru.:teJ from ..:xpc..:t.111cy-\".1luc theory .mJ ... oci,11 cogniti,·e theory ui.ing a nursing pcr~pe..:ti\'e. Thl' mmkl ,,·a~ moditkd ,1igl1tly in the I.Ht' 1980s .mJ .1g,1in in l996 (Pender, r.h1rd.1ugh, & Par-.on~. 2015).

Purpose and Major Concepts The H Pl\.1 \\'as proposed as .1 frarne\\·ork for intl'gr,uing mirsing .rnd bd1,1, ior.11 s..:ien.:l° perspl·l.·ti,·e, on fa..:torl> rlut influtnL·l° IK·alrh bch.wiors. The moJd i~ to bl' u~ed .1~ a guide to explore the biop!>~·chosoci.il prn..:l·'-'cs chat moti,·.ite indi,·idu.11), to .:ng..1gc in bch.wior~ Jin:..:teJ tow.ud health enh.11icc111cnt ( Pender .:t al., 2015 ). Thl· rnoJd hjs bcl°n used cxtcnsi\'dy .1:-. ,1 fra1111:work. for rc,e.m:h ,limed .:it predicting hl'alth promoting liti:),~·ks ,l!, \\'di .1s specilk beh:n-ior~.

1\bjor .:011..:..:ph of the 1-1 P ,\ 1 .1rc indi, iduJI d1.1r.1cte1i~tks .md experience~ 1 prior rd.m:d bL·h.1,·ior .md p..:r~o11.1I t:Ktors ), beha\'ior-~pecitk L·ognitiom .rnd .1tkct ( p<-'r..:ci,·t'd bendit~ of action, pcrc,:i\"l.'d b.irricr-. to adion, pcr..:ei\'..:d sdf.dfi..:.10.:y, a..:ti,·i~·-rcbted ,1tfrct, intcrper~onal influence),, .rnd ),itu.nion.11 inflm·n(l'~ ), .md beh,n·ior,11 om.:omc~ ( commitment to ,l pl.m of .Ktion, immi:di.ne ..:ompc:ting. dem.md~ .111d prl°krenccs, .md hi:alth-promoring beh,n-ior). figure 11-1 ,how!> the: HP~L

Context for Use and Nursing Implications Heal th promotio n inri:n-entions arc l·ssenrial for impro\'ing rhe he.11th ofpopul.1tion~ e,·erywhl·rc. It is noted that ptoplc of .1II .1gn .:.111 bendir from hL·Jlth promotion c.ire, whid1 ~hould be Jdi\"cred ,1t sites whnc ptopk ~pend mud1 of their time (e.g., ~..:hoob .md workplaco ). >,!ur,e, ..:.m den~lop .ind e:-.,xmc he.11th-promoting imer- ,·..:ntion:- ti,r individuals, group~ .• rnd familil.·~ in schools, nursing ccnccr~. <KCL!pa· tio1ul he.11th settings, .rnd rhc communi~· Jt hug;t. Per the Hl'i\1, mir,e, ,hould \\'ork tow,trd cmpo\\·trmtnt for ~df-c.1rc .ind c11h.1nd11g; the dicnt ', l·,1p,Kity for ~df-c.ue through cdu.:.nion j!ld per\oJul dc,·dopmcnt.

Evidence of Empirical Testing and Application in Practice Pendcr .111d colleagues ( 2015) \\TOtl' th~, t the modd ha~ bccn med b,· J very signif. icanr number of nursing scholar~ .rnd rt~l·,uchn~ .111d has been useful in explaining .rnd predicting spcciti.: health bch.1,·ior,. Indeed, in rhe I.1st del·Jde, more than 2 ~() Engli~h l.111gu.1gc .1rtick\ that reporr..:J using or Jpplying Pcn~kr\ H P,\I hJ\'C been publi\h<:d .

,\lost rl°\rar.:h ,tudie~ usc,:d Pcnda\ \\"ork .1~ one .:ompon<:nt of a conceptual ti-Jml°work for ~tuJy. f or example. P.irk, Choi-Kwon, .rnd Han (2015) used the HP1\I to study hc.1lrh bd1a,·iors of Kore.111 nursing ~tudcnr, rdated to obesity .ind l>sreoporosis, .md Ja..:kMm .md ..:ollcagm:s (2016) med thl· modd to l.'xplain thl' rd.ilinnship bern·cen ,cn·ral factor~ induding physi.:JI functioning, personal fac- tor,, .md behavioral influcn.:e~ on physil-al acrh·ir,· hetween pr..:hypl'rti:nsi\"e .ind

230 Unit II Nursing Theories

Individual Characteristics

and Experiences

Prior related

behavior

Personal factors:

biologic, psychological, sociocultural

Figure 11-1

- r+

-

-

y I-->

- _..

I

Behavior-Specific Cognitions and Affect

Perceived benefits of action

Perceived barriers to action

t Perceived

self-efficacy

t Activity-related

aHect

Interpersonal influences

(family, peers, providers): norms,

support, models

Situational influences:

options,

,-

,--

,--

,-

r---

demand characteristics. aesthetics

Health Promotion Model.

Behavioral Outcome

Immediate competing demands

(low control) and preferences

(high control)

,., ,., ' Commitment Health-

to a I+ promoting plan of action !behavior

, •

!Adopted from Pender. N J . Murdough C. l . & Parsons, M A. Health Promotion in Nursing Practice. 7th ed .. © 2015. Reprinted by permission of Pearson Education. Inc, New York. New York I

hypertensive Afric.m .-\mericttn ,,·omen. Also tixusing 011 pll\·sic.11 acti\·ity, HJtztdd, Nelson, Waters, and Jennings (20 16 ) used the HP.\l to eumine factor~ influencing health beh,l\'iors ,11nong actin: dmy air frm:e persunnd.

Other studies use h1::alth promotion as .m outcome or to predict beh.n·iors. Burm, Murrock, .rnd Gr;:10r ( 2012 ), for exJmpk, used the model to idcntih· the rd.1- tionship between bodv mass and injury se\'erity Jmong adolescents, concluding tlut m-crn·eight/obese ,ldole~cents nuy be at incre.,scd ri~k for ~erious injury .. -\dditinr1.1l examples of reeent research studies ming Pender\ HPl\l are listed in Box 11 -3.

Transitions Theory

Mdeis (2010 ) wrorc that the Transitions Theory evulYcd ovn the coLrrst· of.1bout four decades. She explained that it began in practice with her obser\'ations of the experiences rhat humans face as they deal with changes rebting to he.11th, \\'ell-being, and their

Chapter 11 Overview of Selected Middle Range Nursing Theories 231

Box 11 -3 Research Studies Using Pender's Health Promotion Model

Anderson, K. J., & Pullen, C. H. (2013). Physical oclivity with spirituol strategies inter- vention: A cluster randomized trial with older African American women. Reseorch in Gerontologicol Nursing, 6( 1 ], 11-21.

Bhandari, P., & Kim, M. Y. (2016). Predictors of the health-promoting behoviors of Nepalese migrant workers. TheJournol of Nursing Research, 24(3), 232-239.

Bryer, J., Cherkis, F., & Romon, J. (2013). Health-promotion behaviors of undergraduate nursing students: A survey analysis. Nursing Educotion Perspectives, 34(6), 410-415.

Kim, H.J., Choi-Kwon, S., Kim, H., Pork, Y. H., & Koh, C. K. (2015). Health-promoting lifestyle behoviors and psychological status among Arabs and Koreans in the United Arab Emirates. Reseorch in Nursing & Health, 38(1), 133-141.

lubinska-Welch, I., Pearson, T., Comer, L., & Metcolfe, S. E. (2016). Nurses as instruments of heoling: Self.core practices of nursing in a rural hospitol setting. )ournol of Holistic Nursing, 34(3), 223-228.

McClune, A. J., & Conway, A. (2016). Form sofety: A tole of translational research ond collaboration. Pediotric Nursing, 42(1], 31-35.

Volek, R. M., Greenwald, B. J., & lewis, C. C. (2015). Psychological factors ossocioted with weight loss mointenonce: Theory-driven proctice for nurse proctitioners. Nursing Science Quarterly, 28[2). 129-135.

ability to c;m: for tht:msdn:~. 1\kkis'l. \\'ork mm·t:d tl1rough multipk ~t1.:ps, induding co1Kt::pt a11.1lysi~ .rnd scvcr.11 comprd1en~in: lita;lture rc\'iC\\'~. Tht: result w.i~ .1 condu- ~ion th,n "tmnsitions" is ., c1.:11tr,1l wnc.:pt in nursing ( Schumad1a & l\kki~, 199-h l\lon: frxmed attention t11rnugh ohs1.:n·.1tion .rnd rese;m:h Ii.is (ontributni to tc,nnJI Lkwlopmt:nt, testing, .rnd .ipplication of the th.:orv ( J\kl1.:is, 20 IO).

Purpose and Major Concepts Transitions Th1.:ory .1ttcmpts to d.::<,crib1.: Jnd att.:nd to the intcrai:tions b.:tw1.:en nur~es .md p,uicms, ~uggcsting th.u nursn .ire concerned with th<:· expcricni:es of peopk .i~ they undergo transition~ whcnen:r health .md ,,·di-being ar.: thc dc~ircd outcome. The goal of"nursing thcrap.:utics," then, is to i:oncepmalizc .md addr.:s~ th.: potcmi.11 problems that indi,·idu.1ls encounter during transition.,! 1.:xpericni:cs .md dcn:lop pr1.:- \'.:ntati\'1.: .1nd therap1.:utic interwntiom to support tht: patient during these occ.isiom (George & Hickman, 201 l; Im, 2(ll-!; .Mdeis, 2010).

Mekis ( 20 IO) dd111cd transitions .1~ "a pas,agc from 0111.: fairly stJbk st.m: to .111- otha fairly ,t,ibk state, .,nd it is .1 pnic1.:s~ t1igger.:d by a change" (p. l l ). Furthamorc, tramitions .ire ch.1raacriz..:d by diffi.:n:nr :-r.igcs, milcsro111.:s, .md turning point~. Thc.:sc ch.mges, or tr.msitions, can b.: .i,si:,tcd or managed by nurs..:~ ,ls they i:.1re for p.nients.

~umerous years of rc:,can:h .rnd an.ilysis into tr.rnsitiom kd i\klcis and lwr col- 1.:ague~ to the idl'ntific.1tion "of four 111Jjor catt:gories of transitiom that nur,es t1.:11d to bL· inYnln:d in" ( i\kkis, 2010, p. 3 ). These transitiom .rnd rl'pn::~cnratin: exJmpl.:s .m::

1)1.:,·clopmcnt.1.l transitions- birth, adolescence, 111cnop.rns1.:, Jging, d1.:ath Siru,1tional transitions--ch.rngc"> in cduc.uional .rnd professional roles, d1.111gcs in family ~itu.1tion.., ( c .g., di,·orcc, widmd10od ), or dungc~ in li,·in~ .:,rrang..:mt:nt.s ( e.g., mon· to .1 nursing; home, homelessness J

Health-illness transitions-rccon:ry prn(t:S~, hmpit.11 di~durge, di.ignmis of ..:hronic illnc..,~ Org.miz.itional transition-changing en\'ironm1.:m.il conditions th.it afte..:t th1.: li,·cs of di.:nts; m.1y be ~ocial, political, or economic ( Im, 20 H)

23 2.

...

Unit II Nursing Theories

Other kc,· concepts indudc "p.1ttcrm," .rnd "properties" of the transitiom. P.1tt,c:rns dcnote whether tlw transition!'> .1re single:, multiple, !>cqui:nti;u, simult.meous, rcbtcd, or unrdatnl. Propatie!> of tlw tr.m~ition c-.;pcriencc an: ofrcn intc:rrdatcd in .1 compln \\·ay and rder ro .1warencss, cngagcmcnt, changc/ Jitkrencc, rimc sp~rn, and critical points .1nd cwnts ( Im, 2014 ).

In Tr.1nsitions Theory, thc nmsc mu~r consider thc "facilitator\" .rnd "inhibitor.'>" of the tr,rnsirion conditions. These include persrnul meanings, .:ulrur.11 belief., and .utitudcs, socioeconomic status, pn:par,uion, and knowledge. Community conditions .md socict.1I conditions may also facilitate or inhibit transition~ ( Im, 2014 ).

"Nur~ing therapcuti..:s" Jrc those .1..:ti,·ities .rnd a..:tions that nurses may rake during times of tr.111sitions (Schumacher & ~kkis, 1994 ). Thcsc include ·.1ssessnwm of n:ad- incss ( .1sscssmcm of e,Kh of thc tr.rnsition \ conditiom J, preparation for transition (typically inn,h·e!> cducation to enhJnce optim.11 conditions to prepare for transition), .md role supplementation (use nf education and practice ro fa..:ilit.m: the tr.msir,ional procc:.s ) I George & Hi..:k.nun, 20 I 1 ). The outcrnne:, of transitions, .,nd potential for nursing thl'rapcLtti..:s, include 1he "patt..:rns of response" of thc patient. These ;1re dcsignared ,ls pro..:ess indi..:arors ( frding conncctl·d, imcr,Kting, loc,1ting .rnd bcing situated, dewloping confiden..:c, .rnd coping) .md <Jut..:ome indic.1tor:, /mastery and "fluid inrcgrati,·c identitics") ( Im, 2014 }. fig.urc 11 -2 show:, the inter.i..:tion nf th,;: nujor con~tru..:t:. of the theory.

Context for Use ond Nursing Implications A..:..:ording to .''viclcis (2010), most nursing can: o..:..:urs during ,l transition tha1 th<: patient is expl·riencing, .md the g.0~11 of nur:.ing. ..:arc i:. to promok ur encour.,ge

Nature of Transitions Transition Conditions: Facilitators and Inhibitors Panerns of Response

mes fmona.! Developmental Meanings Feeling Connected Situational 1.- Cultural beliefs and attitudes Interacting Health/Illness Soc1oeconom1c status Location and Being Situated Organizational Preparation and knowledge Developing Confidence and

Coping eanems I \ Single t Multiple Outcome Indicators Sequential , .. Simultaneous

I l+-+1 I Mastery

Related Commuaily SocJe.ty Fluid Integrative ldentilles Unrelated

Prooenles Awareness t ! Engagement Change and

I I Difference I+ Nursing Therapeutics Transition nme

Span ' Critical Points and Events

Figure 11 -2 Transitions Theory.

!From Meleis, A I.. Sawyer. L M ., Im. E.-0. Messios D. K H. & Schumacher K. [2000] Experiencing transitions· An emerging middle range lheory. ANS. Advorices in Nursing Science. 23[ l OJ, 12-28. Used w11h perm1ss1on.l

Chapter 11 Overview of Selected Middle Range Nursing Theories 233

ht:.:ilth outcomes during thesl:' <KCJ!>iom. !11LkeJ, ,\kkis :1nd Tr:1ng;t:nstein ( 199-t) denned nursing .1!> the .1rt and !>Cience of faciliution of rht: tr.msitions of he.11th and well-being :1nd noted th.u nurses ll"t: concerned "with the processes and experiences of human beings undergoing transitiom \\·hc.:re health and percei,·ed \\'di -being i!> the outcome" (p. 257 ).

Tr.msitions Theory i!> widdy .1pplic.1blt: and pro\'ide!> a comprchrnsin: guide that considers ntlturnl .:ind social diversity. It wa!> den:lopeJ from multipk n:search studies .1111ong \'Cry l.fo·er!>e groups of peopk, during many typo:~ of transitions. Additionally, it lus b(:en !>hown repcm:dl~· rob..: able to Jirt:cr nursing; practice, research, .111d education.

Evidence of Empirical Testing and Application in Practice Transit io ns T heory has bt:en based in both rc!>t.'arch and generated re~eJrch ( Geo rge & Hickm.111, 201 l; Mdei!>, 2010). 1\frkis {2010 ) .:ompiled and publisht:d a history of the de,·dopm..:nt of the theor~· .:ilong with multiple exampks of rese.:in:h and appli- cation in pr.1ctice. Additional ex.1mpk!> art: becoming incr.:.1singly e\'ident in the litt:r- .nure. So m,: of these focus t>ll resl:arch ex.unining patient trnnsirions encountered lw nurses in \'arious special~· areas. For example, Joly ( 2016 l .1ddre%cd supporti\·e care fo r young people with 111edic,11ly complex nenh as they tr,m!>ition into adulthood; Rew, Tyler, Fredland, .rnd H.rnruh ( 2012 l examined .,dolesCt'.nt!-.' concerns as they tr.rnsitiun through high school; Ekim and Oc.1kci ( 2016 ) looked ,lt tht: tramitions in- ,-olwd i11 discharge planning for children \\'ith asthm.1; and H:iggstr{im, Asplund, .rnd Kristiamen ( 2012) rt:!-.l:arched p,Hicnts' tr.msition from the intensiw c.ut: unit (ICU ).

Sl·vcral research studi,:s using Transitions Theory focus..:d on thl: .:xperience of caregiYers. One ( Beaudet & Ducharme, 2013 J ~uch study identified tramitions en- countered by patients with Parkim,on dise;1se .md their caregin::rs. Tlw intent \\',1!> to devdop mo re focused inren·entiom to assist tlw careg;i,·ers. In ano ther example, Dossa, Bokhour, .md Hoenig (2012) performed a groundt:d theory stud~· that ex- amined the transitiom from hospit.11 to homt: for patients with mobili~· imp.:iirments and thl·ir family c.1rt:giwrs; the\' concluded that hl:alth care prm·idcrs need to impro\'e systems to address p.uient concerns .1ti:1.:r disch.uge, focusing; on irnproYing; communi • cation .md coordirution to facilit.ltl' recon:ry and prevent complic.uiom.

Finally, Ge.uy and Schunucher (2012) prt'.sented ,m inten:sting; look .1t tht' ince- gr.1tion of Tr,msitiom Theory \,·ith con.:epn, from complcxi~· scienc.:. They Jrg;ued that the complexi~· of m.1ny of th,: transition situations encountert:d by nur~es md.1y is bt:ttt:r dt:scrib.:d when the tl11.:orie;:s ,ll"l.' integrated, concluding rhar the inrcgr.1tion 1.:ncour.1ges recognition th.1t rr.msitinns aftcct many, including the parknts, their care- giYers, he.11th c.:.1re pro,·ider,, .rnd the h.:alth cart: system. Integration of th.:: theorie~ should enh.111C.:(: dialogue and promote betrt:r understanding of the situ.uions through ch.111ging outcome~ for the bt.·ttt:r.

The Synergy Model The SyncrsTY Model for Patient Care \\'~1s dewloped in thl:' mid- l 990s by a panel of nurses of the American Associ.uion of Critic.11-Care Nur~c (AACN) Certific.1tion Corpor.1tion as J frJmework for certified practice. The initial model w.1s rcvised snme- \\'hJt, and the rc\'ised version was th..:n used ,l s tht'. b,1sis fr,r the AACN 's ci:rtification examination ( Curle~,, 2007; H.udin, 2017 ).

Purpose and Major Concepts The purpose of the Synergy Model is tn ,1rticulate nur!-.e~' contributions, JctiYities, and outcomes ,1·ith regard to CJring for critic,1Ily ill p.uienr~. The model idcntifit:s eight

234 Unit II Nursing Theories

Box 11 -4 The Synergy Model: Patient Characteristics and Nurse Competencies

Patient Characteristics Resiliency Vulnerability Stability Complexity Resource ovailobility Porticipotion in care Participation in decision making Predictability

Source· AACN {2016).

Nurse Competencies Clinical judgment Clinical inquiry Facilitation of learning Collaboration Systems thinking Advocacy ond moral agency Caring practices Response to diversity

patient need~ or dur.Kteristics .ind l"ight competencies of m1r~es in critical cJn: situ- ,niom ( AACN, 2016; Pate, 2017 1. Of the nuny unique cluracteri~tic/, nun,e~ ,1sses~. the eight mo~t consistent!~· obsern:d .m: li~ted in Bm: 11-4. The nursing comp..:tcn- cies dcnore how knmdedgc, skill/,, .md experience .1re integrated within m1r~ing. o.:.1rc.

The Synerg,· i\lodel .1lso de~.:ribe~ thn:..: k,·el, ofoutcom..:s-rhos..: rd.1ting to the p.tti..:nt. the nur~e, ,llld th.: system. Patil·nt outcome, indud..: fun.:tion.11 .md b.:h.1,·- ior.11 o.:h.mge, trust, satisfaction, comfort, .md quality oflitc. Nurst: outcome:. include physiologi.: d1ange/,, pr.:sen.:e or .1h,..:nc..: of .:omplic.1tiom, .111J. ei..renr to whid1 .:,ire objccri, cs were ,maim:d. S\'stcm 011h.:01m:~ include rl.'..:idh·i1,m, costs, Jnd rr,ou1n· utilization I Curky, l 998, 2007 ). ror mon: infornution, sec :\:\CN ( 2017).

Context for Use and Nursing Implications As mentioned, the Synergy Model \\'as orig.inall~· t.k\'eloped to stn1..:rurc the .-\:\CN'~ cercitic.1tion 1.:x.m1in.uion by identil\'ing nursing compt.:tencit.:~ th,u .ire essential fr,r those pro\'iding .::arc to the critic,1lly ill. In 2002, .,~surnptions of the model wac ..:x- panded to establi"h it ,1$ ,1 con.::eptu.1( fra1rn:work for designing practkt.: and deYclop- ing .::ompctencies rt:quired co .::ar .. · ti_,r critic.tlly ill patiems. Use of the Synergy Model in practi.::c is designed tu optimiLc patient uut.:c,Jlle\. \\'hen patient o.:har,ictl.'ri~tio and nur~e .:ompctencie~ m.it.::h .1nd ~~·ncrg;ize, out.::omc\ for the p.nicnt arc optimal (Curley, 2007; Hardin, 2017). In .1ddition, rhe modd c.rn lx med for .. kwloping nursing curri..:ul.1 .1nd for conducting. resc.1rch ( Curl.:y, 2007; Hardin, 2017).

Evidence of Empirical Testing and Application in Practice Although thl· Svner~· 1\lmkl i~ rdatiYdy nc.\\ , ;:i significant number of articles h.\\·e been published describing it~ me in pranicc. ldemiti.:d \\WC two .1nide~ tlut tested .1pplic.uion of th,: model in ..:ritic.11 .:Jre situations. For example, Swickard, Swi.:kard, Reimer, Lindell, ,md Winkelman (2014) dcscrib..:d thl· pro.:cs.s ofdl•,·elopment of.1 tool to determine the .ippropriatc kwl of care nc,:ded for intcrfa.:ility p.1ticnt tram- porr, using the Synngy ~1odd .1~ .1 guidl·. ln anoth..:r work, Stacy t201 l) usl·d thl· Synergy ~lndd .1s .1 fr.un,:work when reporting on "progressi,·l.' c.1re units," which .ire i1Kn' .1singl~· being m..:d to bridge the g.tp b.:rnecn ICUs .md medical-surgi .. -al unit\. A ti:\\· \\'or~ 1H.1rdin, 2012; Hart, Hardin, Townsend, R.1111scy, & i\bhrk-Hcnson, 2013; T l.'jcro, 20 12) dc~..:ribcd r .. ·,car.:h ~tuJie~ using the Synergy i\ !odd ·" a fr.1me- work. Box 11-5 shmn \Cn:r.11 ex.implcs of .1rridcs dcsaibing chi: model'!. u,c in kadcrship/.idministration, pra.:tke, .rnd cdu.:.1tion.

Chapter 11 Overview of Selected Middle Range Nursing Theories

Box 11 -5 The Synergy Model in Practice and Education

Garon, S. F. (2011 ). A new view: Tele-intensive care unit competencies. Critical Core Nurse, 31(5), 17-29.

235

Graltan, K. S., & Brett, S. A. {2012). Integrating the synergy model for patient care at Children'$ Hospital of Wisconsin. Journal of Pediatric Nursing, 27( 1), 7 4-81.

Hardin, S. R. (2012). Engaging families fa participate in core of older critical care patients. Critical Core Nurse, 32(3), 35-40.

Hardin, S. R. (2015). Vulnerability of alder patients in critical care. Critical Core Nurse, 35(3), 55-61.

Helman, S., Lisanti, A. J., Adams, A., Field, C., & Davis, K. F. (2016). Just-in-time train- ing for high-risk law-volume therapies: An approach ta ensure patient safety. Journal of Nursing Core Quality, 31 (l ). 33-39.

Jeffery, A. D., Christen, M., & Moore, L. 12015). Beyond a piece of paper: Learning to hire with synergy. Nursing Management, 46(1), 52-54.

Kohr, L. M ., Hickey, P. A., & Curley, M. A. Q. {2012). Building o nursing productivity measure based an the synergy model: First steps. American Journal of Critical Core, 21 (6), 420-430.

Schleifer, S. J., Carroll, K., & Moseley, M. J. [2014). Developing criterion-based com- petencie$ for tele-intensive core unit. Dimensions of Critical Core Nursing, 33(3), 116-120.

Middle Middle Range Theories l\ number of nursing thi:ories mJy be c.ttegorized ,\~ "middle midJk r.rngc.~ four tht'o- tii:s th.u h.wc: been cited in .1 con~idn.1bk number of nursing studies ,m: discm~ed in th.: following sections. Thcy ,tri: 1i,hL"l', ( 198-1-) LTncert.1inty in Illness Theory, Kok,1ba \ ( 1994 l Theory of Comfort, Lent. and collc.1guc~' Theory of LT11plc,1s.1nr Symptutm (Lenz, Pugh, Millig,m, Gilt, & Supp.:, 1997; Lenz, Suppc, <.;ift, Pugh, & i\lillig.m, l99~J •• md Recd'!> ( 199lbl Sdt:Transc..:ndence Theory. T.1bk 11-2 li~t~ other middk middk r.1nge th.:oric~ that h.1n: becn lbed in nursing practicL" .ind n:!>c.1rch.

Mishel's Uncertainty in Illness Theory ~krk ,\lishcl begJn studying th.: w11Ccpt of um:cnainty in illnc,~ in the c.1rly 1980, when ~h..: de~ired to explain the ~tre" th.lt re~ult:, from hospitalization ( 1\lishcl, 1981. 198-! ). In thl" l.ue 1980s. ~he fonmlly de\'clopni the theory, which sh.: then revi~ed in the early 1990s I ~fohd, 20 I-!). The ;\lishel Llnccrt.1inry in Illness Sc.iii: w,1Hrcated to better n.1111inc the concept, .rnd ~in.::e th,ll time, her model .md imtruments h.1,·e liecn u~.:d in rntmcrou:. nursing :.rudi..:, ( B.1ilcy & Stc\\'J.rt, 201-1-; tishd, 20 H ).

Purpose and Major Concepts According to Mi~hcl ( 1999, 201-! ), the Unccrt.iinty in lllm:!>~ Theory cxp!Jins how client, cogniti,·el~· procn!> illne,~·rdated qimuli .md l°on,tru.::t llll',ming in tl1c,c e,·..:nt~. Uncertainty i1, ~1.·cn as "the in.1bility to strucrnre me.ming of illnc~~-rel.1tcd ewnt, indmi,-c of inability to ,m,ign Jclinitc \"J.lue and/or to ,KntrJ.tcl~· predict om- coml·~" 1i\lishcl, 201-l-, p. 56).

The <.:Jrly itcr.1tion of the modd ( 1\foht·I, l 988 l de~crib.:d the concepts of "stim- uli fr.unc" 1 symptom p.1rt.:rn, l·,·em familiarity, t.:\l'nt congruenc~· ), "cogniti,·c capJc· irie~," ,md --~rru..:turt• pro\'iders" (..:redibk :\Utlmrity, ~ociJI support, cdu.::i.tion) rh.1r

236 Unit 11 Nursing Theories

Table l l · 2 Middle Middle Range Nursing Theories

Theory/ Model

Self-help (Broden, 1990)

Chronic Illness Trajectory Framework (Corbin & Strouss, 1991, l 9921

Motivation in health behavior (heolth behavior, self-determinism) [Cox, 1985) Theory of Care-Seeking Behavior (Louver, 19921

Self-efficacy {Lenz & Shortridge-Baggett. 2002)

Model for socio! support (Norbeck, 1981 I

Theory of Resilience (Polk, l 997)

Theory of Coring (Swanson, 1991 I

Theory of Successful Aging (Troutman-Jordon, 2015)

Theory of Self-Core of Chronic Illness (Riegel, Joorsmo, & Stromberg, 2012)

Purpose

Describes o process of factors ihot decrease self ond life quality and factors that increase learning a self-help re- sponse ond thus a greater quality of life

Describes o view of chronic illness with eight phoses, from pretrajectory lo dying, with each possessing the possibilities of reversals, plateous, and upword or downward movement; allows for conceptuolizotion of the course of illness lo comprehensively direct core ond conduct reseo rch

Describes intrinsic motivation in heolth behavior

Explains the probability of engaging in heolth behavior os o function of psychosocial voriobles and focilitoting conditions regarding the behavior

Applies Bonduro's work in nursing to assist people ta be m independent os possible in monoging their health

Outlines the elements and relationships that must be studied to incorporote sociol support into nursing practice; emphasis placed on developing the environment

Proposes interrelatedness of dispo- sitionol, relotionol, situotionol, ond philosophical patterns to describe con- cept of resilience to guide generation of nursing interventions to ossess and strengthen resilience

Proposes o definition of coring and the five essential categories or processes that characterize coring

Describes the process in which indi- viduals use vorious coping mechonism to progress toward desirable adoption to physiologic and functional chonges over their lifetime

Describes the process of maintaining health with heolth-promoting practices within the context of the monogement required of a chronic illness

Major Concepts

Diseose characteristics. background induce- ments, monitoring [level of information about illness!, severity of illness, dependency, un- cerlointy, enabling skill, self-help, life quolity

Trajectory, tro;ectory phases (pretrojec• tory, trajectory onset, crisis, ocute, stable, unstable, downward, and dy,ng) projection, trajectory scheme (shope illness course, control symptoms, ond hondle disability)

Individual's self-0etermined heolth judg- ments, self-0etermined heolth behavior, perceived competency in health molters, internal-external cue responsiveness

Cl1n1col and sociodemographic voriobles, affect !feelings ossociored with core-seeking behavior) utility (expectations ond values about outcomes). normative influences, hobits, core-seeking behavior

Person (perception, self-referent), behavior (initiation, effort, persistence), efficacy- expectation (magnitude, strength, generality), information sources !performance, vicarious experiences, verbal persuasion. phy,10109,c information), and outcome expectations

Properties of lhe person (oge, demographic chorocteristics, needs), properties of the situa- tion (role demands, resources, slressors), need for social support, avoiloble sociol support

Dispositional pottern (pattern of physical ond ego-related psychosociol attributes thot contribute lo monifestotion of resilience), relotionol pottern (roles and relationships thot influence resilience), situational pattern (chor- octerislic opprooch to situations or stressors), philosophicol pattern (personal beliefs)

Knowing, being with, doing for, enabling, ond maintaining belief

Successful aging (meoning, purpose in life), functional performance mechanisms (health promotion activities, physical heolth, physi- cal activities). geotronscendence (decreased death anxiety, purpose in life), intrapsychic factors (creativity, personal control), spiritu- olity (spiritual perspectives, religiosity)

Self.core maintenance, self.core monitoring, and self-core monogement, influencing foe- tors (experience, skill, motivotion, culture, confidence, hobits, function, cognition, support, access to core)

Chapter 11 Overview of Selected Middle Range Nursing Theories

DANGER

COPING. MOBILIZING

STRATEGIES, AFFECT·

CONTROL STRATEGIES

237

STIMULI FRAME Symptom pattern Evenl familiarity Event congruency

UNCERTAINTY INFERENCE

ILLUSION I ADAPTATION I OPPORTUNITY

( + t

COGNITIVE CAPACITIES

STRUCTURE PROVIDERS

Credible authority Social support Education

Figure 11 -3 Model of perceived uncertainty in illness.

COPING. BUFFERING STRATEGIES

(From Mishel, M. H. [ 1990]. Reconceptuolizoliori ol the uncertoinly ,n illne~ theory. lmoge- TheJoumoJ of Nurs,ng Scholorsh,p 244]. 256-262 Used wilh permission ol Wiley I

m.iy lt:.1d to un..:crtJintv. Other ..:oncept~ indudc apprai~al, interence, illusion, and (lpportunity ,ls \\'di .ls coping mechanisms; thcsl.' may kad to J.dapr.nion. In 1990, thl.· prrn:css of theory derivation \\'as used to upd.1tt: ;111d re,·isc the theory to .1ddress isHtcs rcl.1ted tc, chronic uncertainty. Interestingly, dum theory was ll!,ed in this process ( i\1ishcl, 1990). Fig;me 11-3 ~hows the Uncertainty in Illness Theory.

Context for Use and Nursing Implications The U1Kcrtaimy in lllncss Thcory expl.iins ho\\' indi,·idu:ils cog;niti,·cly proce.ss illnc~~- rdatl·d i.timuli and how they ~tructure mcJJung, for thme C\'Cnts. In the theory, .1d.1p- tatiun is the desirabk cnd-<,tatl.' :1d1ic,·cd afrcr coping \\'ith thc uncertainty. Nurses 111.1y de\'clop nursing. intetTentions that attempt to influence the person', cognitiw proccs:, to address the unccrt.1inty. This, in rum, ~hould producc positiYc coping .111d .,daptation (Mishd, 1999, 20141.

Evidence of Empiricol Testing and Application in Practice During thl· prol"l.':.s of tlwory dcn:lopmen t .md refincm.:nt, i\lii.hd de,·cl(lped and rcsted se,'Cral research instruments . These arc thc Adult Uncertainty in llhwss Scak .md rhc Adult Uncertainty in IlhK·s~ Sc.,k-Community form, the Parents' Percep- tion of U1H:crt.1inty in Ill1ws:, Sc.,lc, tlK· Parents' Perception uf Uncertainty in Illness Scale-family i\kmbcr r 1\lishd, 2014 J, ,rnd thc LTncertainty Scale fr>r Kids ( Stewart, Lynn, & i\1ishd, 2010).

The Unccrt,1inty in Illness Theory il, becoming int:rl·,1sing;I~· rccognizcd in nursing litaatun.· as a n:~uurcc for rcsean:h J.nd practice. A significant number of rc~l·arch stud- ic~ "c1-c identified using i\ lishel's tl1eory or instrumcntl, or both in addressing; hl·,1lth issues amnng .1 wide variety of groups and covering many different hl·alth problem~.

238 Unit II Nursing Theories

For example, in .1 lungirndin.il ~tudy, B.iiky, K.izc:r, Pot.,~cik, Jnd Rl•bar~on t 2014) Lht:d Mishcl\ thc:ory J.!, p.ut of the conccptu.11 fi-.1me\\'ork that l"X,1mim:d uncertainty experi- enced by men who mu,t han: their prostatt:-!>pccific ,llltigcn lc,·cls moniton:d following pro~r.itc ..:anccr !,urgay. Other rcscan.:h cmplo~'ing Mi,hcl\ imtrumcnrs indudcd works b,· Kurita, Garon, Stanton, .md ~kvcrowitz ( 201 J ), who studied uncerr.iinty .unon~ p:uicnts with lung c.m.:a .md thei; psychologic.il .1djusnm:nt, ~Uld C~•prc~s·~ (2016) namin.uion of the uncert.1inty experienced hy patient~ in the l CO. lnten:stingly, m.1m· ,rudie!, using ,\1i,hcl\ theory \\'ere dire..:ted .lt paricnts and rheir families or can:givers. For examplt:, White. Barrientos, .md Dunn ( 2014) cx.unincd uncat-ainty experienced bv stroke ~ur\'inm, and familv caregi, ers; LTmon, flnm, <.;Jcndon. H..1.nrn:s, .md S,lllcho ( 2015) ,tudicd the ~m:~s .u;d u11e~crt.1inry of the c:uegi,·cr!, of pc:r~m~s with dementia; .rnd <.,crmino .md n>lk.1gues (2013 l looked .n uncertaim~· of brcJst cam:cr su1Ti\'ors .rnd their familic.:~.

,\lishc.:I\ work h.1~ achic.:, cd m irld\\'idc.: renignition, .md her insmtmem, h.1,·c l~en tr-.1mlarcd into ~e\·eral langu.1gl's including ltJliJn ( <.1iammanco, <.iitto, B.1rberis, & S.rntoro, 2015/, l\:r...ian (Saijadi. ll1ssouli, Abb.1~z.1dch, .-\l.11·i i\lajd, & Zemkhdcl, 2014 ), .rnd hc.:nd1 (C. ,-\. i\lillc.:r, 1015 ). hn.111~·. ( "hristcn!,ell ( 2015) described den:lop- menr of the Hc,1lth Ch.mge Tr.1jector~· ~lodd-J llC\\' middle rJng.e theory-intcgr..1.ting. concept~ .md rcl,1tiomhip!, from i\li~l,cl\ L1ncc:rrainty in Illnt·!,~ Th.:ory and th.: Corbin .md Str.u1s~ Chronic lllnes~ Trajccror~· hamc\\'ork I Corbin, 1998 ).

Kolcoba's Theory of Comfort K.nhnim· KokJb.1 ( 20 I 7) \\Totl' th.lt the first ~rep in de\'cloping. the Theory of Com- fort w.1~ .1 ..:oncept .rn.1lysi~ conduaed in 1988 \\'hik ,he 11·.1s .1 graduJtc.: ~tudcnr. following. a number of step~ 01·er ,c,·cral years, the Theor~· of Comfort \\'.l~ initially publbhed in 1994 .md later modified ( Kolcaba, 1994, 200 I).

Purpose ond Major Concepts 1:-:okaba ( 1994 ) defined comfort within nursing pr.1cticc.: .,~ "the ~atist~Ktion ( Jctivcly, p.1s- si\'ch·, or co-oper .uin:ly) of the b.1~ic human nc.:cd~ for relief, e.1se, or tramccndence ..1.ris- ing from hc.ilth c.1rc ~itu.niom that .1rc strl·ssfol'' (p. 1178). She explained that ,1..:lient\ need!> .uise trom a ~timulu~ ,in1.1rion that ran c1usc ncgati\'c tc.:nsion. hicrca!,ing comfort mc,1!,urc~ can result in having ncgati\'c tc.:nsions rn.luccd and ro~itiw tcmion~ eng.1gc.:d. Comfort is ,·ic.:wed .1~ .111 uutt:Ollll' of c.ire th.1r c.111 promote or fucilit:itc.: he~1lth-sccking bcl1a,·ior~. It is posited that increasing comfort c.rn cnharnx health-seeking heh.wiors. One proposition nmc!, that "if cnhan..:ed ..:umfort is achie,·cd, p.1tie11ts, fumily members .ind/or nurse!, arc srrengrhened to cng..1.gc in HSBs [ health-seeking bcha\'iors I, which ti.1rrhc.:r cnh.u,c.:c comfort" (Kokaba, 2017, p. 200).

,l\t.1jor concept~ de~c.:ribcd in the Theory of Comfort include comfort, comfort c:ire, comfort measure,, cumt<lrt needs, health-seeking bcha,·ior.., institution.,! integ- rity, .md intcrYenin~ \',1ri.1bks. There arc .1lsu eight ddinc.:d propositions th.it link the detinc.:d conccrr~ t Box J 1-6) 1 Kokaba, 200 l, 20 l 7 J. figure l L-4 present, the Theory of Com forr.

Context for Use and Nursing Implications Comfort T heory nb~c.:r\'C, that patients cxpl·ricnce needs fur comfort in ,tre~~- ful he.11th ..:.1re simations. Some of these need!> .uc identified by the nurse, \\'ho th1:n impkmc.:nrs intcn·enrions to meet the.: need~ I Kok.1b..1., 1995 ). K, ,kab,1 { 2017) StJtcd rh.1t "Comtl>rt Theory can bt' .1dapted to any health can· setting or ,1gc group ... "(p.2001. L'ndcrstanding of ..:omfort c.m promotc nursing ..:.:ire.: th.it i~

Chapter 11 Overview of Selected Middle Range Nursing Theories 239

Box 11 -6 Propositions of Comfort Theory

I . Nurses and members of the health care team identify comfort needs af patients and family members.

2. Nurses design and coordinate interventions to address comfort needs. 3. Intervening variables ore considered when designing interventions. 4. When interventions are delivered in o caring manner and ore effective, the outcome

of enhanced comfort is ottoined. 5. Potienls, nurses, and other health core team members agree on desiroble and reolistic

heolth-seeking behaviors. 6. If enhanced comfort is achieved. patients, family members, ond/or nurses ore more

likely to engage in health-seeking behaviors; these further enhance comfort. 7. When patients and family members ore given comfort core ond engage in

health-seeking behaviors, they a re more satisfied with health core and hove better health-related outcomes.

8. When patients, families, and nurses ore satisfied with health core in on institution, public ocknowledgment about thot institution's contributions to health core will help the institution remain viable and flourish. Evidence-based practice or policy improvements may be guided by these propositions and the theoretical fromework.

Sources: Kolcobo 12001 , 2017}.

hofo,tic .md indmi,·c of physic.1.I, psyi.:hospiritual, soci.il, .1.nd c:1wironmcnr.1I intcr- \'l"ntions. Ir i~ mm:d th.lt ,my Jl°tually unluppy, unhc:,1lthy, or unwell patients ..:.rn be: nl.ldl· more cornfort.1.ble ( Kok.1.b.1, 199-l ). tin:1lly, outi.:ornc~ of comfort c,u, bl· mcJsur.1hk, holi~tic, positin:, .rnd nur~c ~c:nsiti\'c.

Evidence of Empirical Testing and Application in Practice The General Comfort Questionnaire (GCQ) is a 48 -ircm Likcrr-typc sc.ik rh.u \\,\, dc\'dopcd to mca~urc concept~ .md propositions dcsffibc:d in the theory. The: G('Q l1.1~ bc:cn modificd tu he used for ditli:rcnt popubrions in a number of ~tud.ic~, and .1

~hortcncd c.;cQ (28 item~) i~ abo in me (Kokaba, 201 7).

Figure 11 -4 The conceptual framework for the Theory of Comfort.

!© Kolcobo (2007] Used with permission. http:/ /thecomfortline.com I

240 Unit II Nursing Theories

Kok,1b.1 12017) dt"~.:rib,·d dcn:lopmcnt of other tool~ to assist in rcscan:h and pral·tice Jpplic.ttion for the Theory of Comfort. Thc,;c include tht.: Verb.ii R..ning; S.:Jk Questionnaire, the Ibdiation ThcrJpy Comfort Quc:~tionn.1irc, the Hospi.:c Comfort Qucstionnair.:, thl· Urin.uy ln(ontini:ncc and Fre14ucn.:y Cumfr>rt Questionnaire.:, .md the Hc.1ling Tou.:h Comfort Qm·stiomuire. In .1ddition, thC" Comfilrt Reha,·· ior~ Ch,:,:kliM w.1~ de\'elopc:d to mea~un: comfort in patient who c.m 't u~c tr.1dition.1l questiomuire, or other instrumem-..

A number of research srndie1- h.1,·e been condu,t,·d lw J..:.ok.1b,1 Jnd lwr colleagues u,;ing th,· imtrumrnt:. listed earlier. rm eumpk, Amkrsen, Jylli, .md .-\mbud ( 201-1-) used Koh.:,1b.1 ', Comfort Beha\'ior,; ( "h,·.:klist to ev.1lu.1te the comfort ,;,re prm·idr:d hy J group of he.11th prm·iders .md Seycdfatemi, Ilitii. R.ezaei, .rnd Kokab.1 ( 20 l-1-J med her imtruments to study comfort .md hope .1mong preoperatin· p.1tiem~. \\'hitehead. Anderson, lkdic.111, ,md Str.ltton I 2010) reported using Kok.,b.1\ insrrumcnts to study the dti:ct~ of .111 end-1,f.liti: nur~ing cduc.1ti1>11 prngr.11111>11 llllrscs • Jc.1th anxiety, knowkdg,· of the dying. process, .md rel.ired con..:erns. :\lso cx.unining m1rsing care .it the end of lite, Mum1y ( 20 IO) used Kokaba ·, instrument~ to .,s~es~ ~piriru.11 he lief~ and practiccs of nurscs c.1ring for patient!'> at thc L"IKi of lite, Jlong with ~imilarities .1.nd diffcren.:es in ~piritual beliefs and pra.:ticcs .:omp.irini:t hospice nurses .md nur,c!'> \\'orking on onrology ,md othcr ~pe1.·ial (J.rr: units.

In pra...:ti.:c-spc.:itk cx.1.mpks, Mardrnk ( 2016) deS1:ribcJ how Comforr Thcor~· c.in be .1pplicd in c:nd-ofliti.: .:an; in the m:on.1t.1l inrensi\'e .:.ire unit ( NICLT ), and Krin~ky, l'-lurillo, .u1d John:-,on I 2014-J cxplJ.incJ ho\\· .:om fort 1111.'.tsurc~ ..:.111 be w.cd to impro\'e mming .:arc for c.udi.1c p.1ticnts. Fin.111~·, BouJiJb and J,.:.okab.1 (2015) presentcd .1 comprehcnsi\'e look ,\t th,: .1pplic1tio11 of Comfort Theory in directing. holistic, quality c.1re for ,·cter.rns .md their families.

Lenz and Colleagues' Theory of Unpleasant Symptoms The Theoq· of Unpli:.1s.1.nt Symptoms was de,·cloped by .1 group of nurses int1.'H'stcd in a \'Jricty of nursing issues, induding symptom managcmenr, theor~r Jc\'elop- 1m:11t, .md nursing :-,cience ( Lenz, Pugh, Millig.111, & l.iitt, 2017 ). The thcor~· wa:-, initi.111~· published in the nursing lite: rnture in thc mid- I l)I)()\ ( Lenz Ct ;tl., 1995) .llld chm updJtcd .1 tc,, year~ later ( Lenz er al., 1997 l. The cheor~· ,va~ ba!>ed. on the pn·misc rh.u thi:rc .1rc .:ommonJlitics in cxpcricn.:ing ditkrcnt s,·mptoms .1111ong. Jiffercnt groups Jnd in diffcrcnt :,itu.1tions. Thc theory wa:. developed to integr.1te existing knowkdgc .thout .1 ,·ariety of ~ymptom., to hener prep.tr'-' nur,c1, in symp- tom m.111.1gc111cnr.

Purpose and Major Concepts Tlw purpose of rhc Theory of l'npk.1s.1nt Symptoms i!> ~co impro\'e und1.·rst.mdin1,t of the wmptom expcriencc in v.1rious c.:ontc.xts ;md to pro\'ide inform.Hion u,eful for dcsignini:t et1i:ctivc m1.·.1.11~ to prevcnt, ;1mcliorJtc, or m.mai;c unplcas.un ~ympt<1111~ .111d thcir ncgatin: ctkcr!',., ( Lenz & Pugh, 201-1-. p. 166 ). Lell7 .111d collea1u1es ( 1997 l reported thJ.t rhc theory h.1s tlirce major components: ( l) thl· ,~·mprom!> th.it thl' indi- ,·idual is cxpaicncing. ( 2) the inlluencing factors that produce or .1ffr.:t the !>ymptom experience, .ind (3) thi: c.:omcqucnces of thc symptom r:xp1.-rience.

\\'ithin the thcor~·, !>ymptoms .1rc Jc:,c.:ribcd in tcrm:, of duration, intensity, dis- tres:., .rnd qu;1lity. lnfluen.:ing factor~ c.111 bc ph\"siologic factors, p!>\Thologic.1I factors, .md/or :o.ituational factor1,. Pcrform.mcc i:o. described in term~ offimctionJ.I ~r.nu,. cog · niti, c fimcrioning, or physi.:.11 performance ( Lenz ct JI., 2017). Figure 11-5 depicts thi: Theory of Unplc;,sJ.nt S~·mpto1m,.

Chapter 11 Overview of Selected Middle Range Nursing Theories '241

. . . . . . . .. . .. .. . . .. .. . . . . . . - - ---"'--- .... • • • • • • • • ( Performance ) .. . . -• • ·. ,,.

Key: ---+ Influences

Interacts with

.. Feedback (reciprocal influence on factor or svmotom orouosl

Figure 11 -5 Updated version of the middle range Theory ,of Unpleasant Symptoms,

(From Lenz. E. R., Pugh, l. C., M,lligon, R. A., Gif1, A, & Suppe, F. [1997]. The middle range theory of un· pleosanr symptoms. An update, ANS Advances in Nursing Science, 19[ 3]. 14-27. Used w<th permission.)

Context for Use and Nursing Implications The Theory of Unpleasant Symptom~ hdps nurses re.::ognize the need to .\ssess multi- ple aspect~ of symptom~, including characteristic~ of tht' symptom( s ) itsdf; the undcr- h-ing diso:ase or otho:r c:mse; a~ well as the frequo:ncy, intc:nsity, duration, quality, J.nd distress tl'.lt by the patient due tn the symptom( s) ( Lenz ct al., 2017 ). The de\·c:lupcrs of the Theory of U npleasant S\'mptoms note th.1t it is dinicallv applicable to multi- ple client ~ituations because it ~hould stinrnl,\te nurses to consider factor; rh.n might inflm:nce more th:1 11 one symptom and th.: way~ in \,·hid1 ~ymptoms interJct with e.1ch oth.:r ( L.:nz ct al., 1997 ). The theory's devclop..:rs noted that it ha~ be.:n us~:d in .m emergency dcpJrtment (EDI to d.:,·dop a symptom assessment scale for cardi,1c pati.:ms Jnd has 1-lccn useful in predicting thl' need for hospitalization among patienb \\'ith chronic ob~tructive pulmonary disea~e ( COPD ).

Evidence of Empirical Testing and Application in Practice A growing number of rescan:h ~tudi.:s using the Theory of UnplcJsant Symptom~ a~ a conceptual or organizing frame\\'Ork ha\·,: been conducted. Onc study by Kim, Oh, Lee, Kim, and Kim (2015 ) used the theory in their inn:stigatinn of predictors of symptoms and symptom .:xpericncc among cancer patients undergoing d1t' ·

rnother.i.py. Also studying cancer patients, HM1 and Tu ( 2014) used th.: Theory of Unpleasant Symptoms to t,·.1lu.1tc the cffrcts of cancer tn·a.rmc1ns on ti.111c- tio1ul st.Hus, depn.:ssiv.: symptom~, fatigue, and <..Juality of life. Otha work.\ applied the TIH'.ory of l npla.-,ant Symptoms in caring for p.tticnt~ und.:rgoing b.ui.nric surgery (Tyln & Pugh, 2009), pJ.tirnt~ with coronary hcJrt disea~.: I Ecklu.rdt, Devon, Piano, Ryan, & Zcr\\'ic, 2014 ), and patient~ with infhmm.ltor~· bowd di~- .:ase ( brre ll & Savage, 20 IO) .

242 Unit II Nursing Theories

Reed's Self-Transcendence Theory Pamda Recd tirsr wrote about tlw concept ofselt:trarn.ccmknce in 1983 and fornully outlined her theory in 199 I ( Rl'l'd, 199 lb). Sht· reported thar slw usni "dedrn.:ti\'l' n:formulation" of thl.·ories of lik sp:rn de\'c:lopment in constructing the tlwory. Thcsl' she intcgr.1tcd wirh Rogas\ concl'ptual ~ystem, dinic.11 expctiencc, .111d empirical work ( Reed, 1991 b ). Sdf-trJnM.:enden..:e i~ developed by inrrospecti\'c activities .md concerns .1bout the welfarl.' of othl."rs and by integrating perceptions of one•~ past and future to l'nluncc the preSl'nt ( Recd., 199 Ll ).

Purpose and Major Concepts Sdt:transccndcncc is considered to b1: a ''dur,Kteristic of developmental m.m1rity whereby there is .rn expansion of sdfboundarics .md orientation toward broadened liti: pcrspccti\'es .rnd purposes" ( Recd, 1991 b, p. 6-t ). Sdftramccndence 111<)\'l.'S the individu.11 benmd the immediate or constricted "iew of self and thl.· \\'Orld I Reed, 1996 ). \•Vi thin self-tr.rnscendencc, thcrl.' i~ ''.m cxp.msion of personal bound.uie~ out- wardly ( to\\'Jrd othl."rS and the etwironmenr ), irn,·ardly ( roward greater .nvan:111:ss of bdiets, values, and dn:ams), and temporally (rcm·ard integration of p.1st .111d futurl' in the present)" ( Recd, 1996, p. 3 ). Othl."r central concepts of the theory indudi: well-being ( a sense of \\'holcness and health) and ,·ttlncr.1bility I ,l\varenes~ of personal mormlity) (Coward,201-t; Reed, 201-tl.

Context for Use ond Nursing Implications R.ci.:d ( 1991 b) reported that a tlwory of sdf-tr,1mccndl.'nce may be used by nur~cs to .urend to spirim.11 .md psychmoci.11 expressiom of M,lf-tramcl.'ndenl.'i: in diL'nrS who .1rc confrontl'd "·irb end-ot:Jit~ issues. To prrnnotl.' sclfrran~cendencc, nurse~ may use interTcntions such as meditation, sclf-reflc.:tion, ,·isualiz.ltion, religious expression, .:ounsding, and journ.iling to exp:md rhi: individual's houndarics.

Evidence of Empirical Testing and Application in Practice A number of nursing researd1 studies have used the thl.'ury of seJt:rransccndcncc. In an earl~· work, Recd ( 199 l ,1) found support for the theorr in an examin.1tion of the ment,11 he.11th of okkr .1dults. In the study, shl.' idcntifil:d a rel.irionship be- tween self-transcendence and llll."tH.11 health and an im·erse relationship between selt:rr.msccndence and depression. Mure recently, sttrdii:~ h.n·c bt:en undertaken ro cx.1minc sdf-tramcendence and its ctkct on \\'di-being or other , ·:uiablcs. These studies .1rc conducted .mwng those with health issue~ sud1 as spitul mus..:ul,1r .nrophy (Ho, Tseng, Hsin, Chou, & Lin, 2016), Alzheimer disease (Walsh er a.I., 2011), h~l1ertension ( Thoma~ & Dunn, 201-t ), and ar the end of lite ( Shnckcy-Stcpht'nsun & Berry, 2015).

Several projects h.1\·c looked ,lt selftransccndcn..:e ,1mong nurst.:h and/or nur~- ing students. For ex.unplc, Hunnibdl and colleague~ ( 2008) studied ditkrcnn: in sdftranscendencc bt:rn·een hospice Jnd on..:ology nur~e~, analyzing how it in- flut:nccd burnout in those groups. In simibr works, Palmer, Quinn Griftin, Recd, .md Fitzp:itrick ( 20 IO) studied self-transcendence and cngJgemcm in .1cute c.1re rcgi~tcrcd nursl.·s ( RNs l, and Haugan (2014) examined \\'hether ,tu dent nurses' self-tr.inscendcncc ..:ould positively influence their .lttirudcs tow.ud caring for older adult:;. Finally, st:veral "·orks were idenritied that sought to enhanct: self transcenden(e or to .1ssociare it "·ith ~ucccssful :igeing. These included J study by t.kCarth), Ling, and C.1rini r 2013 J and a second study by McC:irrhy, Ling, Bo\\'bnd, H.111, and Connelly ( 2015 ).

Chapter 11 Overview of Selected Middle Ronge Nursing Theories 243

Low Middle Range Theories The number oflow 111iddle r.rnge theories Jppear!> tu be growing .1~ nursing: resean:h- ers .rnd nursing sd1ol.1r~ desaibe phenomen.i directly related to pra.:ricc. Three theo- ries .m.: exa111im:d in rht: following se.:tions. They arc E.1kes, Burke, .i.nd H,1insworrh 's ( 1998) Theory of Chroni.: Sorrow; Beck's I 1993) Posrp.1rtum Depre~sion Theory; .rnd Men:er's ( 1981 l Concc;:ptualiz.uion of i\Lltenul Role ArrJ.inmem/lkcoming a i\lorher. Tabk 11-3 list~ other low middle r.mge theorie~.

Eakes, Burke, and Hainsworth's Theory of Chronic Sorrow The conccpr of chronic ,orrm, w.1s inrroducni in th.: early l 96(h to describe grief obSlT,·ed in rhc p.1remi. of children ,, ith mental ddicirni:ie\. Suhsl'quent research in- dic.1ted ~imilar patrcrm of chronic \otTo,,· in p.1rents of 111ent,11ly or phy~ically disabled childn:n. The Nur.;ing. Corn,ortium for Rese.m:h on Chronic Sorrow expJnded rhe concept to include indi,·idu.1ls who experience a \'J.riery oflms situations .111d to their family caregin:-rs ( fakes, 2017; F.ake~ er al., 1998).

The middle r.rng.e Theory of Chronic Sorrow was forn1Jlizcd in 1998 . Thl· theory was induc:ri,·cly derived .rnd ,·alid.1tcd through a series of studies ,rnd .1 airical re,·ie\\' of the l'Xisting re~c.uch. Chroni..: sorro\\ is defined .1s the "periodi.: recurren.:c of per- 111.ment, pervasi\'e ~adne~s or other grief related fedings as~ociated with a ~ignincant los~" ( Eakes et al., ] 998, p. 179 ), whil:h \Ya~ described as ,1 norm.ii rc~pome to ongo- ing disparity ,hS<>ciarcd with loss.

Purpose and Major Concepts T he Theory l)fChronic Sorrow ,,·a!> den·lopcd ro help analyze individual rcspome!, of people cxpt:riencing ongoing disparity due to chroni..: illnes~, .:aregiYing; responsibil- ities, ]o!,:, of the .. pcrtccr" child, or bereJ\'l'lllenr. Chronic ,orrm,· ,,·.1, dur.Kterized .1~ pcn·.Jsi,·e, permanent, periodic, and potentially progressin: in n.uure. The person 11.1~ ,1 pa.:cption of ~adnes:, or ~orrm, m·er time in a ~im.nion with no predictable end. The ~adness or sorrow is cyclic or recurrenr .rnd bring!> ro 111ind .1 per!>on\ losses, disappointments, or te.1rs ( Eakes, 2017).

The prim,uy anrccedcm to chronic sorrow is in\'olvemcm in .tn experience of sig- nificanr loss. The loS!, i~ Olten ongoing with no pn:dictablc rnd. DispJ.riry is .1 second ,111tecedent .rnd is cre.m:d by Ins!> experience!> whcn rhe indi,·idual'~ .:urrent reality difti:rs from the idealized. Trigger e,·etm, (c.g., miksmm."!,, circumstances. situations, .md conditiom that .:rcate n.:gari,·e disparity resulting from the !OS!, expericn..:e) focm or ex,1cerbat('. thc experkncc o f disp.1rity. The .. lack. of dosure Js~ociatcd \\'Ith ongoing disparity ~crs the st.igc ti-ir chroni..: -;orro\\', wirh rhc: los~ expe1ienci:d in birs and pieces o,·er time" 1E.1ke3, 2017, p. 95 ).

Context for Use and Nursing Implications Chronic sorrow is ..:ommonly experienced by indi,·idua.ls ,Kro.% the lite span who hJ,·e encountered signitic.mt los3 or experience ongoing; loss. The theory's de\'dopers suggest that nurses need ro \'iew chronic sornm as a normal response to loss and providl· supporr by fostering; posiri,·c coping srr.uegic\ Jnd en..:our.1ging acti,·itics that in..:rca~e comfort.

Intern:nriom rhat dcmonsrr.1ce an empathic presence .md J caring proti:ssio11.1I are hdpful. These include raking time ro listen, offering support and reas~urance. recognizing JtH.i focusing on teelings, and .1ppreciating the uniqueness of each indi- ,·idu.1I. Other inren·entions include proYiding infornurion in a m.mncr that ..:an be under\tood and nftcring practic.1I tips for dealing with thc challenges of c.1rcgi\'it1g.

244 Unit II Nursing Theories

Table 11-3 Low Middle Range Nursing Theories

Theory/ Model

Theory of Adaptation to Chronic Pain (Dunn, 2004)

Acute pain management (Good, 1998; Good & Moore, 1996)

Theory of SuHering (Morse, 2001)

Theory of the Peaceful End of Life !Ruland & Moore, 1998]

Coregiving EHectiveness Model (C. E. Smith et ol., 2002)

Theory of Caregiver Stress (Tsai, 2003)

Theoretical model for the development of skin ulcers of nonsystemic origin and dependence-reloted lesions !Gorcio-Fernondez, Agreda, Verdu, & Poncorbo-Hidalgo, 2013)

Theory of Family Vigilance [Corr, 2014)

Purpose

Describes the process and outcome of adaptation to chronic pain through use of religious and nonreligious coping to create human and environmental integration that promotes survival, growth, and integrity

Proposes prescriptions for nursing activities to reduce pain alter surgery or trauma to ensure that clients hove less intense pain with minimal side effects al medications

Describes phases of suffering and relationship between states of enduring suffering and caregiver response

Directs core necessary for termi- nally ill clients; enhances nursing core by combining the dimensions that ore important to dying in a unifying whole

Explains ond predicts outcomes of technology-based home coregiving provided by fomily members

Predicts caregiver stress and its outcomes from demogrophic char- acteristics, burden in core giving, stressful life events, social support, and social roles

Explains the production mecha- nism of seven dependence-related lesions considered to lead to pressure ulcers

Describes the meanings, patterns, ond doy-to-doy experience of family members staying with hospitalized relatives

Major Concepts

Stimuli !background contextual variables, total pain intensity), compensatory life process (religious and nonreligious coping), adaptive modes [functional ability, psychological, and spiritual well-being)

Potent pain medication, phormocologic adju- vant, nonphormocologic odjuvant, assessment of pain and side effects, goal setting, and balance between analgesia and side effects

Enduring !emotional suppression) and emotional suHering, outcomes (recognition, acknowledgments, acceptance)

Not being in pain, experience of comfort, experience of dignity and respect, being at peace, closeness ta significant others and people who core

Coregiving context lcoregiving characteristics, coregiving/ core-receiving inleroctions, patient education), adoptive context (family economic stability, caregiver health status, family adap- tation, reactions to coregiving), caregiving eHectiveness outcomes (patient quality of life, caregiver quality of life, patient condition, technologic side eHects)

Caregiver odoptotion, input !objective burden, stressful life events, social support, social roles, demographic information), control process (per- ceived caregiver stress and depression). output !physical function, sell-esteem, role enjoyment. marital satisfaction)

Moisture lesions (incontinence exposure) , fric- tion lesions (friction/grazing). pressure ulcers !pressure [decreased capacity for reposition- ing, decreased sensory perception]. sheorJ

Commitment to care (advocacy, love, respon- sibility, solicitude, involvement!, resilience !cor- ing for self, perseverance, hope), emotional upheaval (anxiety, uncertainty, life and death decisions), dynamic nexus (relationships with family/friends, relationsh ip with health care providers) , transition (li festyle, doily rhythm, comfort, space)

Chapter 11 Overview of Selected Middle Range Nursing Theories 245

Evidence of Empirical Testing ond Application in Proctice Eakes and colleagues ( 1998) rcpurrcd that a number of research studies were used co develop Jnd support the theory. SeH:rJI recent re:,earch studic!, were identified using the Theory of Chroni, Sorrow ;\S .1 ,onceptual fr,uncwork. Thes4..• include \'itak .111d Falco's (201-+) examination of parental chronic sorrow exp..:riem:cd with the prema- ture birth of their infants; Nik.farid, RJssouli, Borimnej.1d, and AIJ,·imajd 's ( 2015) sn,dy of dtronic M1rrow in mother:, of d1ildrcn with ca1Ker; and Ruwes, Lowes, Warner, :md Gn:gory's \ 2009 i study of d1ronk !,orrm,· in p.m:nts of ~-hildren with type I diabete:,.

Other work.~ focmed on how to c.1rc !t.>r those experiencing chronic sorro\\. Among them, Glenn (2015) described the use of on line health communication tech- nology to hdp mothers of children with r,1n: di:,casc:, m.rnag;e chronic \orrm,·. Also, Joseph ( 2012) dncribed the importance of ED nur~e~ recognizing chronic sorro\\' .1mong family member of parirnts seen in the ED.

Beck's Postpartum Depression Theory Building on a bJi:kground of research on postpJrtum depression ( Beck, Re~'lll>lds, & Rurcm·ski, 1992 ), Cheryl Beck { 1993) den:loped .1 theory regarding postpartum deprcssion. A grounded theory appro.Kh w.1s used to formulato: the theory, which shc descrih<'d as a four-stage process of "tcetering on the cdgc" into postp.1rwm depression.

Purpose and Major Concepts The purprn,e of the theory w.1s to pro\'idc insight into the experienn: of postp.,r- mm depression. The concepts or stages in Reck\ ( 1993) theory wtn: do:fined ,1:, encountering terror ( horri~•ing anxiety att.1ck.s, obscssi\'e thinking, .111d enn·lop· ing. foggi111:ss ), dying. of self ( Jlarming. "unn:alness, isolation of selt~ and contcm- p!J.tion of self-destruction), struggling to ~ur\'iYe ( b.ntling the system, praying. ti.,r rdief, .rnd seeking solace), and rcg:iining control ( making transitions, mounting lmt time, md attaining a guarded r.:cm·ery). A met,1-synrhesis of postp.1nu111 de- pression by Beck ( 2002a) produ.:-td ;1 list of predictors or risk. factors, induding prcnarnl depression, child c.ire ,trcs~, lifr stress, soci.il support, prenatal anxiety, marital satisfaction, history of depression, infant t,mpo:rament, maternity blue~, sclf.estec-m, so..:ioc~·onomic statm,, marit;1I status, and whether the pregnancy wa~ planned. Distillation of predictors rnd risk factors of postpartum deprt·ssion .1Jded rhe~e stressors/potential conseqm:nce~: sleeping and eating disturban..:t:s, anxiety and inse..:uriry, emotional l.1bility, m.:ntal ..:onfusion, loss of sett: guilt Jnd shame, and ~uicidal thoughts ( Maeve, 20 H ).

Context for Use and Nursing Implications The model proposed nursing inter\'l.'ntions to alert mirses to the incidence and impact of postpartum dt>pr,!>sion. lkck stressed the importance of identifying ne,,· mothers who might be suffering from postpartum depression and ~ugg;estcJ inten·entiom such ,1s referral to po~tpanum depression support groups ( Reck ct al., 1992 ).

Evidence of Empirical Testing and Application in Practice Beck's theory has been used in a significant number of nursing studies and in practice situations ( Marsh, 2013 l. To further cxamin~· the concept of posrparrum depression, Reck ( I 995, 1998) performed J meta-analysis to document irs cft~cts. R.1sc:d on the

246 Unit II Nursing Theories

information from a mcta-.uulysis, Rcck .111d Gable ( 2000 J dew loped the Postpartum Depression Screening Sc1k ( PDSS) to impro,·e detection uf the tfoordcr. The tool was re\'isnl in 2002 ( Beck, 2002b ), translated into Spanish ( Beck & Ga hie, 2003 l, and re,·i~ed further in 2006 ( Reck, Records, & Rice, 2006). The:,c tools ban: been ,·alid.1tni { Reck ct al., 2006; Clemmens, Driscoll, & Beck, 2004) ;1nd used by mme:, in .\ gro\\'ing list of research studies in 111.rn~· countries .md in .1dditio1ul bngu,\g.es (1\ben:, 2014).

In one ex.implc, Le, Perry, .md Sheng ( 2009 l used the PDSS to examine the feasibility of using the Internet to screen for pm,tpartum depn:ssi\'c symptoms, conduding th.n it is viabk .rnd kasibk tool to \Creen for pmtpartum depres- sion. In another \\·ork, Logsdon, Tomasulo, Eckert, lkck, and Dennis (2012) presented g,uiddines for hospit.11-b.m:d postpartum depression screening using the PDSS . .-\ tcam lead by Thom.1son (_Tho111Json ct al., 2014) used the PDSS tu cx.1111inc p,1renting strcss and ~kprcssi,·e symptoms, .rnd Lucero, Beckstrand, Callister, and Sanchez Birkhead ( 20 I 2) used the Spanish \"crsion of tlw PDSS to examine the pre,·akn.:e of po~tp.irtum depre~sion ,1mong Hisp.ll1k immigr.mt~ in the l lnited Statl's.

Mercer's Conceptualization of Maternal Role Attainment/Becoming a Mother Ramona i\krccr first described a thcorctical framl'\Vork for the maternal role in the early I 980s; ,he cxpandcd on tht: proct:ss in .\ subsequent publi.:arinn in 1985. Shc reported tlut the thcon· w.1, based on role thcory, knowledge of thc infant's traits, .md a n:,·iew of the literature to identifr , ·:.1ri,1blc~ that influence or arc influenced by m,lten1.1I roles. She ddined maternal rok .1n.1inment .1~ ,\ process "in \\fod1 the mother a...-hi~·,·cs cnmpetetKe in the role and integrates the mothering. beha\·iors into her c~tablishnl role set so that she is comfortable: ,,·ith hcr identity as .1 mother" ( Mercer, 1985, p. I 98 J.

Following ,\ rn·icw and synthesis of rcs~·.1rch rcl.1tcd to the concept of ''111,,rcr- nal rok att,1inmcnt," lcrccr ( 2004) proposed dunging the n.\mc of her theory to "Becoming a Mothcr." This change was latcr ~·xpandcd un ( 1\krcer, 2006 ), and a number of related nursing inten·cntiom \VI.Tc identified supporting the clungc ( Mercer & Walker, 2006 1.

Purpose and Major Concepts Mercer attempted to idcnti~1 the "form ,rnd strcngth of the rel.1tionships bet\,·crn key macern,\I .md infant ,·ari.,ble~ ,ltld matertlJI rnk ,1tt.1in111cnt" as well a~ "othn factors that .1ppe.1r to influence matcrnal role attainment" (1\lerccr, 1981, p. 73). She propmcd that the v,1riabks of .\ge, pen:eption of the birth cxpcrience, early tnJtcrnJl- infanr separation, social ~tress, ~upport system, self-concept and per\011.11- ity trait\, 111atcrn.1I illness, childrearing attitudes, infant temperament, infant illncss, culturc, .rnd sociocconomic IC\·el .\ttcct thc mJtertl.\l rnlc.

In the more reccnt itL'ration of her theory, ,\lcn:cr I 2004 l explains that the process of estJblishing maternal identity in becoming ,l mother is (I) commitment, .1tt,1ehmcnt, Jnd prepar atiun ( during prcgn;mc,· ); ( 2) .1equaintJ11~·e, lc.uning, .md physical restoration ( in the first 2 to 6 weeb follo\\·ing birth); ( 3) lll<lYing to\\'Jrd a new norm,11 ( 2 weeks to -+ months); and ( 4) achie\'emcnt of thL' mJtcrnal idcntity ( around 4 months). She noted rhar these stages may oYerlap ,md may he high!~· ,·ariable Jue to 111,Hernal and infant , ·ariables .1s wcll ,1s the social/ c1wironmcntJI con- text. Additional kcy concepts and ideas identified in Mercer's works include infont

Chapter 11 Overview of Selected Middle Ronge Nursing Theories '247

temper.m1ent, infant he.11th status, infunt d1Jr,Kteristics, and infant cues ~1s well .1~ family, family functioning, father or intimate partner, mothc.:r-father rdJtionship, rnd social support (1\,kighan, 201-:1:).

Context for Use and Nursing Implications Nurses in postpartum situatio ns should recognize that compctenc,· in the materrul role toward "becoming; a mother" increa~e~ with .1ge and experience. Also, the de- m.mds on first-time mothers challenge the nurse to be acti\"C in .mticip~1tory social- izacion and guidJ1Ke tu prepare for the rc.1lities of the matcnul rok. Imcn·cmions suggested in Mercer\ work~ include promoting parenting groups to highlight mater- nal nee&, during the first nwnths ( ~oseff, 2014 ).

Evidence of Empirical Testing and Application in Practice Tn early works, i\1ercer ( 1985 ) re-ported th.lt mothering OYer the first YL',u pre~cnt~ similar challenge~ for all groups, .md J study by rowle~ ( 1994) med i\1ercer\ theory a~ part of her concq1tual frame,n.>rk to examine the re!J.tionship between maternJI attachment, postp.irtum depression, .111d m.nenul role attainment. !\lore recently, a comprehensiYe study of m.1ternal role attainment with medically fr.1gile infants \\·,1s undertaken to e:\.amine the quality of parenting ( Holditch-Dm·is, J\1ilcs, Burchin.11, & Goldman, 2011) .rnd characteristics that influenced maternal role ,1ttad1mcnt longitu- din,llly ( Miles, Holditch-Da,·is, Burchinal, & Brunssen, 20 LI). In other worb, Kinsey, Bapti~tt.:-Roberts, Zhu, and Kjerul ff ( 201-l) ~tudied the effect of mis..:arri.1ge history on m.itcrnal-infant bonding, and Sriyasak, Aknlind, Jnd AkhaYan ( 2013 / naminni childn:.uing among Thai tecn.1ge mothers using 1Vlcrcer'~ theory ,\.S .1 framn,·ork. Lastly, Fouquicr ( 2013) performed ,l ..:omprchcnsin: liter.irnre review to e,·Jluatc the applicabilin· of M..:rccr's theory to .-\frican AmeriG111 womL·n. She determined th.1t the homogeneity of the samples tc)r most uf the research on Men:er'.s theory is nut necessarily generalizable to African American women .rnd concluded r]ut more re- search is needed to idcnti~· attributc~ th,u influcnct· m.uernal role ,lttJiinment to that population.

Summary This ch.1ptcr prescntcd a wide ,-.11-iety of middle range nursing theorie,\. BccJu~c of space limit.1tions, the descriptions arc \"Cry brief and .1re intended to merely introduce the theories. The rc,1dcrs .1re directed to original .md supporting ~ources for more informJtion.

Elaine ChJ.vez, the graduate s tudent from thc opening c.1se study, sa,,· how one of the numerous middle r.111ge nLJrsing thcories that h.we been published in rcccnt vears could be used to develop inren·cntions in her prJ.cticc. All nurses should likewise continue to rcvie\\' current nursing; litcr.1ture for nc,,· theories .rnd ideas rh.1,t arc being prcsented to remain current and knmdedgeable .1bout nursing practice. To ilh1srrate, Link to Practice 11 -1 proYides some thought~ on how nurscs c.m apply middle range theories in their daily pr.1etice.

It must be mentioned ag.1in thJt the high, middle, and lo\\" r.rnge theories de- scribed here an· b~- no me.ms an c:-.hausti\·e display of the growing number tha l ha\'e been presented in the nursing litcratun:. Indeed, it was remarbblc to observe the growth in middle range theory dc,·elopment ewer the last decade, .111d it is anticipatcd that this 1:mph.1sis will continue \n:11 into the future.

248 Unit II Nursing Theories

Link to Practice l l - l Applying Multiple Middle Range Theories in Practice How might nurses apply multiple middle range theories in their practice? Consider these situations:

1. A nurse is providing care for o women with ovarian cancer (Theory of Unpleasant Symptoms) who recently immigrated to the United States from Somalia (Leininger's Culture Core Diversity and Universality Theory) in an ICU (Synergy Model).

2. A nurse manager is charged with developing an orientation packet (Benner's Model of Skill Acquisition) for nurses new too hospice practice (Kolcaba's Theory of Comfort) focusing on their oworeness of beliefs, values, and well-being (Reed's Self-Transcendence Theory).

3. A family nurse practitioner is working with o new mother (Mercer's Theory of Becoming a Mother) who has just given birth to a child with a severe genetic disor- der (Theory of Chronic Sorrow) .

4. A public health nurse is charged with teaching o group of American Indian women (Leininger's Culture Care Diversity and Universality Theory) how to develop a healthy lifestyle (Pender's Heolth Promotion Model).

Key Points A growing number of widely used middle r.rngc theories have been proposed, .1pplicd, .rnd rested .rnd lu\'e been presented in the nursing. liter.uure. Among thl· " high" middle range nursing rheorie~ ( theorie~ that an: rclJtiwly .1bstr.Kt .md .1pply to .1 n:ry broad aspect o f nur~ing ) frequently us..:d by nu.rs..:s for research .rnd practice .1re the \\'orb of Benner, Pender, Leininger, .md [\ lcleis and the Synergy i\ lode I. " Middle" middle range nursing theories (theories th.lt applv in .1 many aspects :md situations ) frequently used by nurses for research and pract,ice include the Llncerrainry in Illness T heory, the Theory of Comfort, the Theory of Llnple.1s.mt Symptom~, .md R,:ed·~ Sclf-Transcende1Ke Theory. "Lo\\'" middle range nursing rheorics ( theorie~ th.It .u-e fairly ..:oncretc and .1pply to .1 narro\\' range of patients and situ,ltiom) frequently used by nurse~ in re- search .rnd practice include the Theory of Chronic Sorro\\', Beck's Postpartum Depression Theory, and Mercer's Theory of tvl:m: rnal Role Attainment. M,ul\' other middle range theo ries have been described in the nursing litnarure, and nt\\' o ne~ .1re being de\'l.:lopcd by researchers ,md ~chol.us to imprm·e nursing c.1re .md patient outco mes.

Learnin Activities 1. Select one of the middle range theories discussed in this chapter. O b'ta,in a copy

of the o rig inal work(s) a nd perform on analysis/ evaluation using the criteria presented in C hapter 5 .

2. Select one of the high middle range theories covered in this chapter a nd obtain a copy of the original work. Review three or four of the research studies citied for

Chapter 11 Overview of Selected Middle Range Nursing Theories 249

that theory thot either study relationships of the theory or use it as a conceptual framework. While reviewing these works, consider the following questions: Do the studies oppear to use the theory appropriately? Are the works consistent in their use of the theory? Do the studies contribute to the knowledge base of the theory? How? Write a paper describing your findings.

3. Seorch current nursing journals for examples of the development, analysis, or use of middle range theories in the discipline of nursing. Debote trends with classmates or develop your analysis into a paper.

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Bed •. (. · . T. 1 l 995 •· Tht.· ctl;,.-,t~ uf po,tp.J.rtum Jcprc~,1on on mJtc.·r· n.tl-infanc um•rJ,uon: . .i.. n1~t1 ,n,h•s1, . .\'11J·J111ir /{mnrc/J. +Ii 51, .?98- .304 . ..

Reck, C. T. ( 1998 ). The ctli:ct, of postpartum Jeprc,,ion on .:hild d"1,.•clopmcnt: A mct.1-.m.1lp•i~. Arr/Jn•o ,f fS)•duan·ir ~11rsi11_1f, 121 I 1, 12- 20.

Hc1.:k. C. T 12002;1 J. 1\lothcnng multiple~: A mct.i ~vnthesis ol\.juJl it,lthc n:,c.iri:h .l/C.'I 17u Amn·icnu Jm1r1111/ 11{.\lnur1111I Child "°"""'-"· 21-l ,. 21+-221

Bc ... ·k. C . r. 1.2002h 1. RL'\ i,1on uf the Po,rp.trt um Dcprt:i.'-ion Pre.> dJCtnr!> l1ncnton· /1111rual 11/'(Jfotarit-, c;,,,,rrnlo11ic. 1rnd X(lmnmf .\"urSlll/1, 3/t4J. ,;9~--Hl2 . .

Rc..:k. C . T . , & G.1hk. R. K 1200lH. Po-;rpartum Dcpn.:~,ion ~,rccnin~ Si.:Jlc: Dc,·dupmcm J.nd p,y..:hrnm:tri...-: tc,ung., ~b1n·11tn /lnmrch. N , 'i t. 171-1112

B<.:,:k, < . r .. & liJblc. R. I.:. i 2003 ,. l'ostp.trtt1rn l'>t..·prc.:~!)1011 'Krccn in~ ,i:,th.:: Spanid1 vcr\1011. X11n11JJJ Rot1HYh. -i] ( :i t, 296- 306

Bc..:k. C. -1 .• Record,, K .. & Rkt:, ~t c.200(')1. Further dc\1,.•h,pm«:nr nf the 1>osrr:1rtum lkprc~1011 Prc...ikton; lm.:nton Rr\1~d. f,mr11nl 11( ()/1JUtrfr. (;wucol,wic, ,111tl Xt,mntnl .\"111·Jw11. 3S{ 61, 73~-74:i . - .

B~ck, C T .. Rcmold<. M. A., & Rutow,ki, I'. t l 9921. MJternit,· blucc;. ,lnti p<-•:,.tp.trtum depression. Jrmr,rn/ tfOb.rtt:n-i.-. L~v11ec~- l1tnfr. nutf Xr·m,.1111/ .1,;nni1Jp. 21141. 187-193.

lknocr. I' 119841. Fr,m, 11m11rt to txptrr: Ewdlo1Ct" 1111d p,rn•fr 111

d1111rn/ 11t1Y1m_q prnrrfrt . . \knlo rJrk. C:\ AJ,h-..>n-1\'c,lc\·. lknncr~ l', 1 200 l L F,·om 1uwut lO t'Xpt,·r.· 1-. wdlt'ntt ,uui pou10· t11

di11iml 111mi"·" prnaiu I Commcnwr,m,c edi1inn, F.n!,!lcw,_._._1 Clift,. SJ. Prentice H.111.

lk1mcr, P. Tanner, C . & Chesla. C. c 2009 ,. £1·11,·rtis.- iJJ ,,,,,.,;,,_q pralllff: < artn .. 1t. drnu,tl J11rf.!,mt'1Jt. ,11,d Niuo 1 2nd ed. 1. ~l''-'

Ynrk.. ~Y: ~pnn~er Puhlt~hmg:. lkrg,1ui,t. "·· & King. f _ f J i , PJn,h 11u~i11~-j ..:-on~cptu.,I

fr,lllll'\\ nrk J,m r1111! 1~f Ho/1.ct,r .\"unw,!r, I Ji 1 ,. l ='5-170 . B1t.mg., .. \l. 1-..• & A\1,tn.1. i\1 t 201..~ ). Chmb1ng. d1i: ...:hmL'..11 IJddcr-

uni; nmg Jr .1 t1111i:. N11rm1 ... n \/11111y1c"mfnt. +K5 ), 23---4. 17. H1,udi.1b. L [') . & Kok.1h,1. K i 201 i t , .mti\rt thcnr\'· l'nr.1\dim!

1ht..: \.ompk,itic.., nf H·t<.·rJn·, hi:.1lth c..irc ncnh . . -t \"\. A1fra11r;.t in .\'unin~r, \.rtotrc. 3l\'4 ), 270-178.

l\o\H.·~. \ .• Lowes. L.~ \\".1r11c.·r, J .. & lin:g( 1rY. I. \\'. 1 200'11. ( 'hroni'-- \nrro\\ in p.ircnt of i:hilt.iren "ith t\ pt.· J diJhctc-~. /011r11n/ ,if .1rl1·14,r((r/ .\"111'.<!JJ~. 0.'( ,. 9'>2-1 (1()0

llr.1dcn. C J. IY901 .-I, l<',1 of the ,,:Jr-help m, .. tcl: LcJrnnl re- ..,pon" .. · tu \'.hr,1n1..: 11Jni:..,, c"•,;:pcricni:c-. Xunm .. 11 RtstardJ, 3'-11 l I. H-li

l\urkh.m. L.. & Hogan, N. S. t 2008 t. .\n "pcncntiil them•,· of .,p1ritu.1I ("Jn: in nur-ing pr.1ai1.·c.:. Qu11litnti1•t Htalth Rcs,nrrh. ISO 1, 928-9.~8

!\urns, K . . \\urrnd,, L J.. & Graor, C. H 12012 1. llo,.h- mass mJn ~rnd mjun :,c:n:rin· in ,ltiolc-...:-cnt mJ.lc?t. Jo11r1rnl · of Pfdifl rri,· .,·,,,.,;,,_~, j-, 5 '· 5011-513.

C,1rr. J. M. (2014 1 A 1111ddk r.1ng.c theory of fami!r ,·igil.in.:c .lltdsur._11 S11nJ1JJ1, 13141 • .25 t-1;5_

t".ncs. L.A., Bi!lhop. \., Armentrout. D .• \Crkb.n, T .• -~nukJ, J.. & Duuglm. C". 12015). Initial ,k,•clopment ofC :\.T.E.S.- A ,im ul,1m,n-h.1~d i.::<m1pt..·tcn1...~ ,\v.,1..'li.\mcnt 1n,1rumcm t<1r 11ctm..11.1J m1~· pr.ll.'.tinonc.:r,. ,\'t1111t1t11/ Stnl'm·I.•, 3-Jlhl •. ~29-33fi.

Chri~r<..'nscn~ n. f 201 :l L Th<..' hL".1hh dung.c: rr.11cccor~· mo<lcl: .-\n int~S,TJtcd nwJd of hc.llth (h.mgc ... -1_\',\ Ad:·1111cc'J t11 X11rJ111 .. lf Stimrr, 31/1, I 1, il5-{i7

Ckmmem, D., Dn,rnll, I. W .• & Beck, C:. T. I 20W l. Pmtputum dcpre,wm ~, prolilc,l throu,th the dcrrc~~inn ~rccmng ...:Jlc .\!CS. 17,,· .-l111<1·1rn11 /1111mn/ 11f.\fntrr·JJnl C/11/d .-..:m·smp. 2~ .1 ,, IRO-lll5

Ct1rhin. J. ~1. 1194.JR l. lltc C(>rh1n JnJ StrJ.u~, chromt: illnt'\\ tr:i1c,- ton- mot.lei An upd.nt..· . . \t'h,,/11,·~\' hurwr_v fOr .\'11rri11_1f Prn.-tia. 12111. 33--41.

Corhin. J. ~I.. & "trJll!-!lo, .-\. 1 f99 I ,. ,--\ nur.ing: mudd for ..-hronil.'. 1ll nc,, 1n.m.lgcnt1,.•nt h.1:,c1.t up1111 rh..: tr~1iccror~ fr .imc:,, nrk Srl1ul- 1Jr~\' lnq11iry_1(w Nnrsin~" T•rnaut. 513 l ~ 155- 1-,-1

Cnrhin, J. 1\l.. & '\trJUS..(,, .-\. 11991_1 .-\ nursing moJd ti>r i:hrom ... · 1llnc~b m::u1.1gc1nr:nr h.i!<cd upun the: trJJC('tory fr.Jmework.. (n Jl. \\'r••I,! I EJ.), 711r dmJ/Jif il/11m trnj.-rt<1r_1·Ji·nwrn•arlt: 1111· Cr1rbi11 ,wd ,\trnrm JJur,iJJ,n rrwdrl I Pl'· 9- 21l 1. ~e" York, !\"Y· \pringcr l'ubli,hmg.

Cow.1rd, l). D . 110 I 4 L P.undil G . ~cd: ScJt:rransccndc:ncc thcorv. Jn ~\. R .. -\llil!<Hklihl ,. -;,:,,,..,;,,qrl,rorittsn11dtlmrwort •8thcJ°., pp. ; 7+-~92\ St Lnrn,, ,\10: ~lo,l,v.

C:m, C. 1I9X51. The l·cl.·.1lth ~clt-lk1cr,111111s1n J11d.:\. Xi,1·,11i_n Rornrd,. 3~3~.17~-183.

Coyle, J. S. 1101 lJ. Dc\dctpmt..'nt of .1 rn<Kkl h1>mc hc.1.lrh nunc- intc:rn"ibip progrJm t(1r llt.:\\ ~r.1JuJ.tc:, K..:y h.•st;,,on., lc:irncJ. /011r11al '1{C:,mr11111i1ur f.'dt,car,i,n ;,, .\rurs11u1. 42( 5 ). 201 -214. - • •

250 Unit II Nursing Theories

( urk·~. ,\I .\. Q I l Y'JX I P.u1c..·m-nLir..,c..· :,.\ ncrg) . OptimiJ.in~ p.1t1c:111·, omi.:,,mc: .... 4-lmo·1i"n11 f,111,·n,i l 1!f <."nru .1/ Cm1·. 1 1 1, (tt-- 2

l urll'\, .\1 . . -\. (J. 11007 J • • ~\'no:,~,·: 11u 11111q1u· rdm1,m,411pb,·t1ra111111ntJ. aud pllflflJtJ. l,u.ii.lll~ll'")(•li,. 11'\: ~1~111.1 llu:t.1 T.m l1Ucm.m1111.ll

( ~pre:-.,. H. "'· 12016 i. l '1hkr.t.uidin~ 111t..:-crtamt)· .11m111g critkJlh ill p.uicnc~ in the intl.'.11 .. iH· (J.n.: unit, u,ing ~li'ihcr~ thc,•r~ ot un.:..:rt.11nt, ot 11lnc.:,,. /Juni-11~111w of ( ·,.,tun/ ( ·.,,.t l\'m,w11. 35411.-12-49. . ..

D.undl. 1 "-·· & Hi\.'.k,on. S. \" t 20 l;) 1. <. ultur.11 ,.:nmpc..·t.:nt pJt1c:m-,:c.:ntc:rct..i nuP,111g i.:.m.:. 11,,. S'u,·.rm .. tr Clt111c3 ,f .~·,,,.,h .·lmo·r,n. ,r~ I,. 9'1- 1011.

D,1~,J. :\ . . H,1.k..hc1ur. n .. & Hl\.Ctlll.!.. H 120)2 1. C.ltc lr,lfl ... itlllll'- trum the hu!trital to homi: t(n .. p.n1cnt:, with moh1litv 1111p.ur mc:nt, P.1ti~111 .i.nd t:lmih \'.'J.rc~hcr c.\pcricm.:c, Rdm/,i/irnrim1 _\rursi,t11, 3 -(6 ), 177'- 2S5

Dumdun, ;\1. 120)0) RcJdining th<.· i'uturt..' 111 pcnopcr.1th·t.· mar, mg. cdui.:.1tinn: .-\ i.:mKcpn1.1I fr.,ml'work . .,-J (JR,\· }r111rm1( Y2i l 1.

87- 100 Dunn.~-\. 120041 To,,,mJ .1 mid<lk r.m~c chcnr~ of.11.faputio11 tt1

..:hronh,: !Min. Nur.ri,(11 ·'-"una Q_u,rrro·~,·. 1-1 l 1. i8-K4. E.U:.cs. (j 1.20 l i 1. Chro1Ui.: sorrow. 111 .\. I. Pctcrc;.on & T S. Hrcd1 m

1 Ed~. i-• • \lu{dlr rnr1.11r thnn-i,-r .'1pJ'lttn1im1 tn 1111rsl11 .. n rcs,·nrcb 14th ed., pp. 9.•-10:ii l'hi!Jdclphi,t , I'.", Wolters Klu\\cr.

!-.air.cs,(;., llurkc, ,\I. I.., & HJin,\\tirth • . \I.:\. , J 99~ 1. ~lid.Jk-r~nl!c rhc:un of 1.'.hron11.: ,orrcm. Jmn,tri--·17Jt /0111·1111/ ,f S11nm ... 11 .\ch;,/. 1mhip. JrA 2 1, l 79- 1 K4.

f.d.ltJrdt. A. I. .. Dc\'nn, H . ,",., l'iJnn .. \I.. R\'.m, C I .. & Zcrw1,. 1 J. 1101-1- ) f.1ugrn: in lhl· rrc.:..,cth.:c uf..:uronary hc.1rr di~c.1\C .\111r•111" R o1·nrd1. t'1312 1. N~9

F.k.1111~ .-\., & O.:ak.c1~ .-\. F. t.20161. l-.Hic.u. ... ,· of .1 rr.1n'1tion chl·o n·-h.,~d d)s..:h.1rgt.: pl.111111ng rro~r.nn for (hilt.ihuod ,lstlrnl.l m.111.1~cmcnt. /111,-r1111tw11nl J111,n111/ of .\'11rsi11 .. 11 Kmm•fr1(11t. 27 21, 70-711.

Elminowski. N. S t .20151 Dt..·,·clopini:t J.nd implcmcntm~ .1 oJJrurJ.1 awareness workshop for nu,.., pra,titinncr,,. Jo11r1tal o(C11/t11rnl Di1•mir:,, 22(31, 10:i-l 13.

t.1rrdl, n .. & S.1,-.1gc, E. 120101. \ymptom hur\.kll in $nll.1mm.1 tor) l,o,,d Jl..,c:.H,:: Rctlunk.tn~ t:on\.°Cl"lH.1) .1nd tl1t.·11n.:ti,.1I w1- dcrpinnm~. hut1·11nrw11,1J /uur1Jnl ,f S11nw ... 11 P,·aaiu, Jn 5 1. i.r--Hl.

F.1rr1.·n •. \. T. 1201?, 1 Lcuun~c:r·, crl11,,111ur·,i11.g. rc..,cJn;h mctho .. inl o~~· .l1t\.l ,lultit·, of C.ltH.:cr ~Ur\'hor,: A rc,·u~,,. Jm,run/ ofTr1111s- rnlt11ml .'l/ttni11,r, 2(;41, 4111-117

fouquic..·r. h.. F l20 I .. ~/. '-it.He of lhc :-.'-·11,:n.:c: llrn.:, the..· thc:or~ of m.ucrn.11 role .ut.1innn·m .1pph tu Afm,:,m Aml"ri\'..I mntherht>o\l? Jm1r,,n/ uf.\fidn11Jf"1:'f ... Ui,11101 }· Ht,1itl1. ,.:;b, 2 1, :!DJ-210.

fo" lcs~ E. R. 1 1994 1. 77u rd11111Jmb1p ba1rft'U prow ml 11uu,-,-11nl nrtndnnrur. porrpnrtwu dcpl"fn il't symprnms. f1lld mnttrunl rolt nrrninmou. Chk,1i;.o. II.. l.ornl.1 LTnhl'r:,.iry nfChi..:.1~0.

ll.1n:1.1 fl"rn.mdl'Z. F, r .. :\grcd.1 . J. J .• \ 'l•r .. iu. r. . & r.uh:orho lhd..1lg.o . P. L 120141. .\ nc\, thcorcnc.11 1nnJd 1i,r Jen~Jor mcnr of prc:,,.!turc ukcr~ .rnd olhcr dcp..:-rn.kn,'-" ·rd.1h:J k ~ion:-.. /r>r,1·11,1/ of ?-,'11r.<11(1I \rlt,.l,1rsl1ip. ,ir,. I 1, 28-.~II.

l;cJr\', C.R., & !->du11tud1cr, K. L (20l2 1. C.trc tr,rn,iti,m,· lntc gratmg tran,1ti,,n 11H.·on .ind 1.'c m1plc\1t\ ",(ll"lll.'."-' 1. llJh .'..::pt, A :V.\. ... ·l'11•n11t o m .Vr,rs111,r .\001cr. ,')_")( .~ J. 1 .~6-248

Gcor1tc. ). II .. & Hickm,tn. I ' I 101 l ). Other thcoric, uf rite I 9R(h, In J. H. l;l'<)r!-1,..: t Ed. J • .\"11 rHf{JI rJuoru.l' ·t1Jt" bnsr jiu· pro·

j f Jm 111n/ ,,,,rs, 11._11 pn 1tr t(1' 1 tnh .;J.1 Pl'· t,(IO-C1.~4 1 • l'~'pt.:r S.1dJk

R1, er, ~I: Pc.ir,on l:du1..\t11 ~11 (;crmino, B. 8. , 1-li,hd. XI H . . ( ramkll. ) ., )'one r. L., llhler. IL

J..:ncrc:ttc:~ C., ct aJ. c 2013, ,. ( }ut,·( ,me, of .m mh.:crt.,inn 111.111 .1gcmc11t intcrvcntmn 111 youngt.·r .\tri..:.111 .--\1m:ri\',m .md C.m "-•1..,1.1n brc.ts( l'..111\."cr ,un in,r-. ( )11coh~11.,· Xursw~n Forum. -/,(~ 1 !, 111- 91.

Gi.lllllll.lll(O, ~1. 11 .. (.i1tto, L. n.irhcrl~. ~. & S.mtoro. D. 12015 i . ",,l.iption u f the ~\i,hd l ' n,crumty o f llln~" S,alc , ~ll'IS I ti,r ...-hrom\." p.ttJCnh m Jul>. Jm,n,nl ,f Cl•nlunr1<m w C:l,11unl flnir· tia, 2114,. 64-9- 655.

Gillum, D.R .. StaOikno. ll. .",. , Sdm,trt1. KS .. lnkc. L. fng.!!,. L . &. Reiling.. n 1201 l ). C".1rdio,J, i.:ul.1r JbcJ~C in lhc..· .-\Ju1!-h: . ..\n e,plor.uory ,n11..t~ of knn,\k,i~c. hi.:hc..•I, , .llhl hL·.thh 1,,.,1n: pr.1i.: t1( i.:,. H,,luru .\W'fW/1 • .!."il.b l.1XtJ-2lJ -

c.;1c:nn • • ..\. n. 1201:=i, l <in1! onlinc he.11th 1,,.·<1mnll11lll.'..ltutn t" m.rn . t~c duunii.: ,orru" : 1\1Dthc:r, of .:h1IJr1,,.•11 "ith r,1rc Ji, cJ"le, <peak. J,mn,nl 11ff',-,f,nt1·1( ,'i111·.,,ii.~ • . ?(~ I l, 17- 2-l.

Good, .\\. 1 1991-l 1, ,\ J111ddl1..· r.in~c thcon of J.~Utc pJln n,J.11.1~«: m,nt: L',c in n.:,c.m,:h . .\"111·.,111 ... tr()111/11ol·. -1«31, 120-12.-1.

liood, ~t., & .Moore.'\ ~\. 119961 Ch1m,:,1I pr.1i:t1(c guukhnc.,_ .i.., J. 11t:\\· ~ouri.:l· uf middk ra.11~c theory: fo(:u, on .1cur\.· r,1111 1\"urs· m_11011rl,10!·. +I< l 1. 7-¼--79

H.1.i.g~H1.•itmJ.n, R. L~0l2 ). '\upponin~ tr.111~iti1111, In dini(,1! pr.'K tll'.i.: 1.lt.·vc:lupmcnt. '/1,,· jm11"11nl 1!( l'frmntnl C' ~-c'fllurtnl ~·un· m,11. 2111 I ,. 5- 7.

H-1!;:l:~~tr,)m ... l\·I., A."'plund. h.., & J.:.rh,ri.m,c11. L. ,20l.2 J H ow ,.111 nur,..-~ tJdlit.itr.· p~1ti<.•11r', tr.m~irjon, Ii-om mrc.-11,i,c ~.uc:? .-\ gr• ,umkJ th.:nr~ uf nur'iinl!,. buo1.m1t C: .. Crttual CnN ~•urs· "'!1- 2/ll.41. 21-¼-.!JJ_

1-1.udm, S. R. f 20111. Hc.uin!?,. lo!t~ 111 older ,rirK,11 c.1rc p.ulenh: P.1rt1,.:1p,1ri,H1 in di.:ci,i1Hl rnakin~. ( 'ririrnl Cn1·.- Sur.rt, .-?1161, 4J-:i0.

l lardm, ~. It. 120 I :-1 -1 h<· .",.",( >: ,yncq,:, · model In \. J. l'ctcrsun & T .S l\rcd.ow I f:ds. 1 • .\ftddk rnn ... trc rh,·,wu.f.· Appl,cnrum '" 1111r>i11 .. " m.-nrch nnrl pm mer 14th ed .. pp. 193-303 1. Phil.1ddphi.1. P:\: \\'nllt."f' l(lt1\\c t.

I l.trt. A., H.1rd1n. ~. R , !'"""'"""· :\. I'., R.,m,.,·,·. -., . & ~bhrlc I kn,1111,. \ 12C)J 3 1 < ·nui.:.11 (Jrc , ·1~1t ,lt1un: ~urc;.C .111d family prd - t.:Tc..·n..:t.·. I Jm,.-11.mm.1 11( ( ·nr,m / Cnn- .\"11n111._fl. 321 6 ), 28lJ-29'1

H.>t1.fi:IJ, J. J .. :-,;c1,on, ~I. S., W.ucr., C. ~I.. & knnmi:,. l\. ~l 1101<) ). f.t(t<H'' i11Uu...-111.111g. hc-.1hh hc h.1,10~ J.muni:t ,KtlVc: Jue~ .--\ir h>r(c pcr,.(1nnd . .\"urcrn .. 11 f)uthJ11t·. ll-A5 J. -HO--l-49,

H.J.ug:.111, ti 1 201-1: J ';\:ur~"-· p.n1cnt 111n:r.h:t111111s .1 rcsour\.·l· tc,r hopl·. m ..:.min~ m lik .rnd '"·If tr.m~...-cndc:11".:t" 111 nur,in~ horm: p.ltic.:nr.. .\m111liw11•mu /illll'na l "I Cnnm1 .,.-,o,u,, 2N< l 1. 7+-RX

Ho, H ,\I., T,m!!. Y. H _- Ihm.\. ~I.. Chou. F. H. & Lin,\\' T. 120161 L1,·111~ w1ch 1llm.-~liii .1.nd c;.clf cr.111,;;.:cnJc1Kt": The lin~J ..:~perfrn\.°c of p.,~ienT!\ "ith ~pin.ti 111u~·ul.u .itrophy. Jo11r11nl nf Adi•nnffd .\"ur.dr1.n, -.21 I I ,I , 26CJ5<:~705.

l lolditd1 D.m,. D .. ,\l1Jc,. ,\I.~ .• Burdt11t.t!, ;\I. R., & l;nJdnun . II I) t201 l 1 ~IJtcrnJI role Jn•inmcm w11h n1cdk•ll, frJi,:1k 111- fants: l'.trt 2. Rd.1t1<111,l11p to the qu.litY ofp:u-entin!!. nmm·d, m .\'m·m,.q .:' Hm/1/,, 3-i< I 1. 35--48.

1[11111.,rd, (.' 1'I. 120).~ ). Jmp.11."t ( )r.l tc-..;t p.t(~.,gc nn C\lt ~·,J1nit1.1tiun ,(Ol'C.:!>,llld ;'\{ 'LE~-ll~ OUt(oll\c..."", , n,c- /a111·11nl ,f Xm:n11..11 F..d11cnt11m~ :i21 J 1. I 7~-178.

H,11. ,\I. ( .. & T11. l. H. 1201-! 1. lmprmin!\ ,1u~lit) nl~litc out \.·mnt.·, for p.H1cnt-. with ..:,101..·1.·r through mcJi.itin~ dl(.~~t~ ofdt: pn.-,"il\C ..,~mpto m, .111d fu111.:tu111.1I , t.uu,: A thrcc p.uh m~di.1t1un 1111, .. kl. /t1m·11nl 1f( .'liuunl Sursw_q. 23( 17- 18 t, .:!4() 1 2472.

H11nnibdl. LS .. Recd. I'. C .. Qumn-l,nllin, ,\1. & Ht,pJrrid .• 1.J c .2008 1 Sdf.tr.1n .... ·cndt:11P..:t.· .in .. t burm•ut in lu,,pi,:l· .md 011,,,1 - og~· nur,cs. J1111rt1i1I uf Hmpltf ,rmf J'nlhntn1t .V ur1111...11. ll~ 3 1. 17:!-l-9.

[m. E.-0. t!Uli1. :\ fat lbr,1h1m 1\1clt.·i~: rran-.1tion rht:ory. In ,\t . R. :\llil!tKKl 1 E1.1. ), ,\"unintr 1/J,-ori.fts nud tht·ir n10,.L· ( 8th t:d .• pp. 37X- J(>5 1 Sr l.oui:-. . MO .. : ~lu~hy.

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Chapter 11 Overview of Selected Middle ,Ronge Nursing Theories 251

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Lc111., E. R., l'u~h. L. ( . ,\lilh~n. IL :\. , l,ili .. \ .. & Surf'<'. I·. 1997). The mith.tll··r,mg.c thcon of unplc.1.1riJnt wmptom,· An

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.\l.m.:hnl . . .Ii.. f :!fl)(, \ EnJ-ot lilC -.'."J.r1,• Ill thl' nc,•on,.n.11 UllCOMH" ".arc unit: :\1,ph in~ .._·,,mfon chc.:ury. J11urt11111mutl Jn11r1111l of P,t/1,n • lit•t .\'tll'.lillJT, ]]t / I. 3J 7 - .~13.

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,\l•rtin, K \. 12005 ). 17Jr Om~IJ" .\vm·m· A L-i:1· to pmct,u. d11cu111m· tnlWII, ""'' mjt,rNllftiot, llft11Ul..'101U11f t 1nd ed. ,. Phil.1.ddrhu. I'.-\: 1:.lwdcr ~June.kn..

,\kC.mh\", , ._ L.. Lin~. J., HowlJJ1<l, S .• Hall , L. .-\., & Connclli. J i 2015 1 Promotintt !-Clf tr.iri~cndcn('c JnJ ,._·~11-bctnt!, 111

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.\kC:Jrth\. \'. L. 1.ing, I. & t Jrml, R. :,1 I 201.~ I The rok ui' "clf-trJ.n~cndcn..:~: A ml.,.~in~ \.lnJ.blc m the puf'mt of \U«;t;('""-~-

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.\lni,h.rn. M. 20 I-¼ 1. R.imo11.1 T. ,\kr«r: ,\l.11ern.1l rok .m.un- mcnt-hcwminjl. l mother. In M. K . . -\ll1i:11ml I bl 1 • .\"r11·,i11." tb,·11mr, n11d 1l1trr 11•ork, l!th c<l., l'l'- ;.,N-~5-lo. St Lolll,. '.\10· El,c,kr

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.\kki-.. A. I , & Tr.in~cn,tcui., i1 .-\ 11994- J. f,,i:iJitJtm~ tran-.1tinn!t: Rnkhmt1nn 11f the nuNni;, m1,,,un . . \ 111r1Ht1J <J11tl ue1k. -llt6•. 1.~5 2~9.

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Mercer, It T.. & W,111:.cr. L. 0. 1 200(11 .-\ re, icw nf nur,inl( in- lcncntsnm It• l<i<tcr hc:.:omin~ • mu1hcr. J~11mol of U/Jrr;rric. c;.'1'1Jr'iolttnic. rr,sd .\'r111urrnJ .\'um,, .. r,. 3.~ 1. 568-5112.

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~m,th & I'. ll l.achr 11-.J,. ,, .\lid,ilo- rn11_nc- thtm·, t,>r ,wrm1t1 , .~rd c,I.. pp ~3-86,. l',:c,. York. :,;\· ~pringcr rut>li,hini:

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25,2 Unit II Nursing Theories

ScJI, I.. J., 19991,J, Th,· :-e.11 thrnrv: lmphcJt1011, for prJ.;rkc .ind Jdmm1,trrnon. How.- H,·11/tbrnr,· !\"1mc, 1-131, 181-1117.

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So-..:ll'. r 1 101-4 ,. Theory u,.,gl;' .md ,lf'rlit:'1tmn paper: i\tm.:rn.,I (olc .tttJ1nmcnt b,rtnl(Jfumni fottnml ,fC/Jildl,irt/J f:.il1,cnrio11, 21.1.~1. 51!-{)[.

()wens,.->.. L., & ClcJ,·cs, J. 12012 1. Then .111d now: L't>dJt111i,: di111- \.'.J) nu~c J,.k.m,cml·nr pn1g.ra111:,. Xuni11/r, -11, 101. 1;-11.

r.,lmcr. B., Quinn l;riflin .. \I "I. ll,:cd, I'. & l'itzp.mick. J. J tl0J0). '-IL·ll -tr,lll\l.'.clldcn..:c Jlld ,,ork cng.1~crm.·nt in J.1.'.Ute t..:.iri.' fttJft rqt1:,,tc:rc~i ttur .. 1.· .. c:nr11nl(.'41rr .\l11ni11J1 Quarurfv. 33!1!, 13~-l-¼i.

1'.,rk. D. I.. C :hoi Kwon, \., & H.m. K , 201 S ,. He.1lrh hehJ1 ion of Kon.:,111 fl·n1.1k m1r~in~ ,tt1c.k11t~ in rl'1Jtio11 to ohc~it\ ,llh.i o,tcororo'I, . . \'11/*JII{'' ( ,,;thta{', ()31 -l 1~ :;0,4...-s I l

l'J«, M. I·. D 120171. lmrodu,unn In S_ R_ H,>l'dm & R. t-:.1rlu\\ I fah.1 . . \mew for di,iic11I -.,-.-rllma: T/J.- -~-~CS m1r~m- 11wdd Jiir p11tiou .-11rr (2nJ cJ., pp. 3-101 Rurlin~ton, .\I.->.: Jone, & Bartktt.

l'cnJcr, KI .. ,\lur,bu!Ul, C. 1.., & Parsons, ,\I.:\ 111l1S1 Ht11/i/1 prnmn11,m 11111•u1w,.1r prncna 1 7ch cti. L l"ppcr SJdJk Rh-er, SJ. Prcmicc H.111.

Polk., l.. \' I lt}IJ'i'l. Tu\.\Jn.1 J. mitidk fJlll,!,c tht<lr\' of re,ilii.'n~c A,\'S. Ad1•n1ut1111 ,\Jt1r"f1r,._,q,V1ou,·~ / 1.A:~ii. 1-1~~.·

Ri·l·d. J~ li l J991JI X·lt trJJl\Lt·nJcn,.:c .md memJJ hc.·Jtth in oldl"\l old J<lult, .. ,·,,,.,,,,_,, /{arnn·h. -l<~ I ,. ;",-1 J.

JlccJ, I~ ti. I (Ql)lhl Tow.m.t J nur..in~ theory of~~•iruJm,(CllLkni:c· DcJu,tl\'l' rd,1rnwI.tt1on u~ing dc\'dopmcm.1I thct,rie,. ANS. Ad,,murs 111 ,\"11rnu11 .\CJtllU, 1.~-l J, b4-i7.

Recd, r. <..i. r 19961. l';Jll!!L:clldcncc: formulating nursing pcr.-pcc· tivc~ . . V11nw,_n S,·uuu Q11n,-1af,· ... l 1. 2-'-.

Rcct.i~ I'. t;. (20141 Theory of~df-tr,tn,~cmh:n~c ln i\1 (. "imith & I'. ll. Liehr I Ed,. I . . Utddl.- rn,i_r,r 1h.-111·_1·Jin· 111m111,r, i 3rJ ~d-, pp. 109-13•) 1. :>:cw \'nrlc., :>:\'· Sprn1i,tcr i'ublish1111;.

llew. L.. Tyler, 11 .. frc.U.111d. S .. & HJnnah. I) , !Oil 1. :\dole, i:ent:-. · i:un(1..·rn~ .,, the\' tr.111,ition through hi~h '"·hool. A.\'.\. Adl'ntJrff 111 Sum11r, s,,,.,,,, .. 3.'ii 31, 20~.::22 I. ·

Rlcl',d, R .. J.wrsou. T.: & Sm,mbc~ • . -\. 12012 I. .->. midJk-r.mg,· theory of :,df•..:Jrc of chronic dine~~- A ·ss .. -{,franas rn .\'11rsi1J,!r ~,-im,·r. 35-, .~ l. I ll+-20-1

Rogers. I\ 1 l 'l'I-¼ ,. Ocmpntiom,I !Jfnlt/1 mirsitJJr: CotJctprr n111{ prnc· tut. l'lul.llklphi•, PA: SJundcl"'.

Rul.u1d. C. i\L. & i\lo,·,ri.:. S i\l I l YY8 J Thc.11n· on1srru..:tiun ba ... cd on :.r.,ndJrd~ of ('Jrc: :\ prop11:1ocd thcorv 1.11' the pc.)~dUJ t:mt nf lite .\'m:(ilJ(J ()urlm,l•. -1,('ti,-l ', 169-1 -;-;l

SJijadi, ,\1.. l~"ouli. ~I.. .->.bl>Jv.1ekh. A .• . ->.IJ\'1 :\l.1J,I, H .• & Zcndchdd, K.. 1 10 I -l 1. l'\~·d1omcrrk propcrm:-. of the Per· ~Lrn n·r,1011 ut th1.· ~li!.hi:l'!ro l'nLcrtaintY in lllnc:i.to: ~cJlc in

p.n,c.:111, \\1th ,:.uh:cr. E11ropt"11U /01tr11(1f ,f011mlit1J.l' ,\~ursi"~'I• /S\ 1 1, 52- 5i.

~,hum.Khn. Ii:. I.., & ,\Ide"· A. I. 1 I 99-lcl. TrJns,uons: A ,en tr JI t."011\.'.Cpt Ill nu~inlt. lmn,.r,r- 771t Jo11n111J nf .-~_,;,,,""Ji11 ... rr Sdmlru:rb,p. 2ri\1J. 119- 125.

Sevc.l!Jtcmi. 1' .. lt1.tii. I' .• Rc,.,ei, :\I., & KokJb.1, K.. :20141. Com- tllrr ,llld h11r~· Ill the.· prc.111c..·,th~,1J ,t.l~c.- Ill pJth.'.11t llJh.krg;rnng c.urgcn. }11,0·,w/ cit Pa,.i,llsz/JaM .Nt,t'HtJJr. 2~ 30 t~ 213- 1.20

Shm:kc,·-Stcphcn, nn. I' .. & lkrr~. D ,\I 120151. Ik,nihing ,piri ru.1lit\ ~\t th..: t·rnl of lifr \V,su,.,, Jm,nuil (f xu,-,;,,._,, RoMrrh, .l r 'II. 1229-12-¼7

Shuler. r .. ->. .• & lh,·"· J. 1-.. 1199.~1. The Shuler nur...- prJcnt1oncr model: A rlu:orctil.'..J.I frJnu:work le.ff m .. tr!ic prJctnioncr dim\.'.:1.1m,. cJw .. ·.uon, .md fC!i.Clr,hcr /m1n111I ,f lht .-tmrrim11 Ac11do,,.,. tf ,\',iru J>r~c111:mur1. 5( I 1. I I- IX.

~mith. C. E" P-1~,. K .. 1'.o,,-hinJ_., C .• Klcmbc..:k. ~- \' .. r...t .• .Kochler, J •• & Porkc"iv\0J.\\'tcr. ~. I 20011. l .u..-gt\111£., cnc ..... n,·cnt:"s~ mnJ.d

c, oh1tion ro .1 miJrJ..n~c.· theory of home.· ~J.rc· :\ pro(c~, for L"ri- th.zuc.: .u1"t rcpli..:.1tiun ....t x,. Adi•1111ccs rn Xurs,11..,_11 .\cunu. 23( I 1, :i0-11-¼.

~mirh, 1-:.., & BJlu11-B.1r.1k.1t. ~. 1.21l03 J. ~.\ puhh1..· hc.tlrh nuriiimg pra~ri,c mo, .. k+ ,\klding publii.: ht:,llth pnn,.:1pk, with rl1( nun,· 111g prt..:c-... l'tJbli, Hmltl, .\'111-r111f1. 1<~ I 1. i2-4!1 .

~nr~~ak. A., Ak.c:rl111d. I.~ & .-\khJ,,rn. ,. 12(tl:-t 1 < htldrc,tnn~ .1mon~ l'h.11 fir.,r rnnl.' r~c;1.11.t.: mother,. /111· /111w11,1I ti{ l'r·,·urnrnl l-.tf11r;,rum. 221 .i i . .:?O 1-1 l l... ·

",1.1..:,. K. ~l. 12lll I > Prngn·,~1,·\." ..:'.lrl" unlt,: Diffi:rfm hm the ,Jmi.". ( 'ntirnl ( 'an- .V11rs1\ .? /1 .~ ), 77-H3.

\cc"Jrl, J_ L. Lynn, .\I. R .• & i\li,hd. ,\I. 1--1. 12010 1. J>,yd1um.:t- ric ,:r.1h1Jriun of ,1 Til:'\\ 111~rrumc:m lo llll'j"iLffC: unc..:crt.lmt\ m 1...hildrc.:n .md ,11..itlk,\.'.cnb \\ 1th 1..'Jt11.'.'1..·r. ,\"m-siw, l{t'unrd1. 5IJI 2 i. l 1'1- 12<>. •

._,,,.m~on. 1-:.. :,..t, c tt.>lll 1. .tmpin(JI Jt\'dormcnt of., middk t.m~e rlu:on ol cmm~. Sunmn lfrst.:arch. -l-(J:.,1, ltl)-166

..,,,1(k.u·li, \ .. ~,,h.:k.lrd. \V.. R..:11111:r .. ..\ .• Unddl. D .. &. \Vmk.dm.m, C. ,201-l 1. :\li.tpt,1tlon of the ,·\:\C~ ,yncr~ model li•r p.mcm (.Irl' 10 (lith.:.,I (',trL' trJ.:1,pt1rL ( 'nt,m/ Cnrr- .\'111-r,·. 3../C I I. lh-2ti.

·rcicro, I ... \1 .. ',. 1101.2 , The mcdralin~ rol~ oJ cht..• nursc:-p.1uc:nt J\'.1d hundin~ in hnng.111~ Jhout pJtu:nt ,.1ti~t.1..:tiun. /ounml 1,f .-4dmi,ud ~·1mi1111. (>~ S 1. 99+-1002

ThL>mJ,, S. I' .. & Ou;,n, K. S. t201-¼ I. ~dt tr.,m,rndcncc Jnd med h.:.nmn .1Jhcr-c..'n(1..· m ,~Ider ~dult". wtth hypcrtcn.'i-mn. /1.111nml ,{ Hol'-'11t S11ni11_11. 31{-41. 311'>-326.

ThnmJS<m, f .• \"ullin~. l\. L .• Flynn, H A .. Md)nnnu~h. S. C, M.,r"·u~, .\I., Lupi.:z, J. F, ct JJ. t101-l L PJrcnun~ ,tn.:" .111d Jcprc'i,1,·c wmptt,m.., in pt~tp.wtum moth~r.... B1din.·i:t1,111JI 1,r u11h..i1rc\.'.t1011Jl ctlc.:ct~? !J1Jiwt Jk/J1t1•rnr \!:."" Dr:ulup11u11t, .i.l 3 11

-¼0<>--41 :i Tr,1utm.m· l<•r,l.in. 1',1 ( 201 ), Troutm.m·loro1..fan\ thl·urv of ,ui:L.'1..""'·

fol Jgmg. ln M. <' \mith f, M, E. P.1rker1Ed,. 1. /lii,;-,u,.111/Jrnrw ""ti 1111m11,r, prnctta 1-¼th ed., pp. -¼~3-5UM I l'rulJddph1J, 1'1\: f.A. Jl.m,.

1-...ii, I~ F ( 2003 t . .\ mi1.tJk~r.u1g"· thcor~· of ..;Jrt:gi\c:r MTC!i.~ . . \luni1111 ~omr.-Qrrnrto-~v. /(1(11, 1.~7-14~.

l\kr. R .. & l'ugh, I.. C. 12009 I. :\pph-,c,nn uf the theory uf un- plc.,~ant :r,.rmrrom~ m b.1n.1tnc :,urF,cn·. Hnrrntnr X1H"r11, .. rr ,u,d .~unyicnl l'nriou ( ·nl'I', ..J(--1-1 , .2i 0-2 7o.

l'n, .. n.'l· .. Hrnn. I), likndon. ,\I :\., H.nme,. I· .. & S,rndm, D. i 2015 1. t1cmcntJJ .md (',ucg:ln.:r ,trc,;,~ .-\.n .:iprli~.ltu ,n of 1hc rcconet::ptu.1Ji1.cJ u111:c:::rt.Jincy rn illrn:s., thcor\'. /JJlft"J rn .\frutnl Hm/rl, :-.·11mu11. 3<'il 61. i39--H6.

\ "itJlc, S. A .. & f;lw. C. 1 20 I .J 1. Children born prcmJturclr: R.i,k t)f p.tn:ntJ.I \'.'hrtmk ~,rn>w. /mJnrn/ ofl'aitntrl( .'l11rsi1v1 .. 2~.~ 1. !4N-2?.l

\\'ahh. S. M .. l..1mct. :\. R .. Lindl'rrn. C. L., R.ill,tc•ne. I'., Little. D J., Stdkv, C. ~L • ..:t JI. 11011, . .\rt in .-\l1hcimn', ,.ire: Pru- mouu~ \\dl-b~:in~ m pl.'oph: wnh latc-,t.tgc ...\l;,hdmcr'., dl'-C,hc /fr/J,1b1/,rn1Hm ;\·urswn. 1():21, ()6-72.

Weinert, C., & l.on1;:. K. \ I I 'NI , l"hc thcor\" .1nd rc,e.irch hJ,c for rurJI nur .. ing pr.h:tKt: ln :\. Bu~h \ F..d.). Rurnl ""rsilt/1 I pp. l 1- 38 I. :--e" bur\" !'ark, CA: ~-•sc

White, C. I... llJrnclllm, R .. & Dunn, K 1201-1 1. Dunrn<i<>n, uf llll\.'.Crt.Unty Jftcr ~trokc: l\:rsrt:~ri,·es of the -.tn,kt.· •n1ni,·(1r Jm.i f.unily ...:.1rq~hcr. l11i" /onnwl of .\'c11ro,r1t"11rc Xurshtrr. 4t-.-l f. 233-1-¼0.

Whi1chcld, I'. B ... ->.n,kr.nn, E. S .• H.cdk.111, K. J .. & StrJllon , R. 120 t O 1. SrnJym~ rhl· d}l.,i..:rs of d1e end of life nur:--111}! cduca· tion ,onM,rtiucn Jt the in~thutirntJI k,el. Jm11·11"/ 11.f Ho1pici" and 1'1tlli,11i1·,· ,\'1mi1111. /!1-'1, IR+-19,;,

\\'il,.nn" B .• H-'.f\\'c~oJ. L., & OuJ.;.hoorn~ . .\. i 20 l:; 1. l 'nJcr,tJlh.l Ulg ,~IJ J.t.'qu1,1tion .un11ng: rcg;1~tcrcJ nurM.:s: rhc ... pcrpccuJJ nuvkc"" phenomenon. /uurnnl ,{Clmrrnl X11rs111J1~ 2--1( 23-2-l 1,

356-¼-35i5 \VooJv. (3 .. & (),.n·i,, R .\., 20131 1111.:r~.1,ing. m1r,"· ...:nmrcrcn~l·

111· 1,cnphL•r,11 mrr.1,enou"\ rhcr.1p~ /(Junu1/ f~( l1~f i1mm .'!\'11nm .. tr, 3(1(61,-¼13-419.