1. Chapter 11 Overview of Selected Middle Range Nursing Theories

2. Levels of Middle Range Theory
May be categorized as “high,” “middle,” and “low” middle range theories
High middle range theories include broad, fairly abstract concepts.
Caring, transcendence, adaptation, culture
Middle middle range theories generally consist of theoretically defined, fairly specific constructs.
Uncertainty in illness, unpleasant symptoms, chronic sorrow
Low middle range theories are more defined and specific.
Women’s anger, acute pain management, intervention for postsurgical pain

3. High Middle Range Theories
Nearest to grand theories
Some may be considered grand theories or conceptual frameworks.
Include some of the best known and most frequently used of the nursing theories
Pender—Health Promotion
Leininger—Culture
Transitions
Synergy Model

4. Pender’s Health Promotion Model
Developed by Nola Pender to study health promotion behaviors; initially published in 1982
Explores biopsychosocial processes that motivate individuals to engage in behaviors that promote health

5. Health promotion model. (Adapted from Pender, N. J. , Murdaugh, C. L
Health promotion model. (Adapted from Pender, N. J., Murdaugh, C. L., & Parsons, M. A. [2011]. Health promotion in nursing practice [6th ed.]. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)

6. Pender’s Health Promotion Model—(cont.)
Major Concepts
Individual characteristics and experiences
Prior related behavior and personal factors
Behavior-specific cognitions and affect
Perceived benefits of action
Perceived barriers to action
Perceived self-efficacy
Activity-related affect
Interpersonal influences
Situation influences
Behavior outcomes

7. Pender’s Health Promotion Model—(cont.)
Used by nurses to develop and execute health-promoting interventions
Used to develop research studies focusing on one aspect of health promotion
Used frequently as a framework for research studies

8. Pender’s Health Promotion Model—(cont.)
CINAHL search produced 148 articles describing use of the HPM in practice or research.

9. Question
Tell whether the following statement is true or false: Nola Pender is the theorist credited with the development of The Omaha System.

10. Answer
False Rationale: Nola Pender is credited with the development of Pender’s Health Promotion Model. The Omaha System was developed by the nurses of the Visiting Nurses Association.

11. Leininger’s Culture Care Theory
Madeleine Leininger first presented the “transcultural health model” in the mid-1970s; it has been modified and updated several times.
Purpose of the theory is to generate knowledge related to caring for persons considering their cultural heritage and values.
Goal is to provide “culturally congruent” nursing care to persons of diverse cultures.

12. Leininger’s Culture Care Theory—(cont.)
Leininger was an anthropologist as well as a nurse by education.
Major concepts of the model are culture, culture care, cultural differences (diversities), and cultural similarities (universals).

13. Leininger’s Culture Care Theory—(cont.)
During the past two decades, research on 23 different cultural groups has been conducted using her theory.
Many graduate students and nursing scholars have used her theory as a basis for research.

14. Leininger’s Culture Care Theory—(cont.)
Central tenet of the theory is that it is important for the nurse to understand the individual’s view of illness.
Understanding cultural similarities and differences will allow the nurse to positively influence health.
More info:

15. Leininger’s Culture Care Theory—(cont.)
One of the most frequently cited theories in nursing literature—197 citations of Leininger’s theory in CINAHL during the past 10 years.
Dr. Leininger died in 2012 (87 years old).

16. Transitions Theory
Afaf Meleis developed Transitions Theory over about four decades.
Began with observations of experiences faced as people deal with changes related to health, well-being, and ability to care for themselves
“Transitions” is a central concept in nursing.

17. Transitions Theory.
(From Meleis, A. I., Sawyer, L. M., Im, E. O., Messias, D. K. H., & Schumacher, K. [2000]. Experiencing transitions: An emerging middle range theory. Advances in Nursing Science, 23[10], 12–28. Used with permission.)

18. Transitions Theory—(cont.)
Purposes
Attempts to describe the interaction between nurses and patients
Nurses are concerned with people as they undergo transitions.

19. Transitions Theory—(cont.)
Purposes—(cont.)
Goal of nursing therapeutics is to recognize and address potential problems encountered during transitional experiences.
Develop preventive and therapeutic interventions to support patients during these occasions

20. Transitions Theory—(cont.)
Transitions are viewed as a passage from one fairly stable state to another fairly stable state; process is triggered by a change.
Transitions are characterized by different stages, milestones, and turning points.
Transitions can be assisted or managed by nurses.
Categories of transitions
Developmental
Situational
Health–illness
Organizational

21. Transitions Theory—(cont.)
Nurses should consider “facilitators” and “inhibitors” of transitions.
“Nursing therapeutics” are activities and actions.
Readiness
Preparation for transition
Role supplementation
Relatively new theory but becoming increasingly recognized in the literature
Widely applicable and used in both practice and research

22. Transitions Theory—Resource

23. Synergy Model
The Synergy Model for Patient Care was developed in the mid-1990s by the AACN Certification Corporation.
Designed to be a framework for certified practice

24. Synergy Model—(cont.)
Purpose is to describe nurses’ contributions, activities, and outcomes related to caring for critically ill patients.
Model intended to be a conceptual framework for designing practice and competencies.
Also used for research

25. The Synergy Model delineates three levels of outcomes: Those derived from the patient, those derived from the nurse, and those derived from the health care system.
(From Curley, M. A. Q. [1998]. Patient–nurse synergy: Optimizing patients’ outcomes. American Journal of Critical Care, 7[1], 69. Used with permission of American Association of Critical-Care Nurses.)

26. Synergy Model—(cont.)
Involves three levels of outcomes—relating to the patient, nurse, and the system
Patient outcomes include functional and behavioral change, trust, satisfaction, comfort, and quality of life.
Nurse outcomes include physiological changes, complications, and attainment of objectives.
System outcomes include recidivism, costs, and resource utilization.

27. Question
Which of the following is NOT one of the levels of outcomes included in the Synergy Model?
Outcomes of the nurse
Outcomes of the patient
Outcomes of the system
Outcomes of the provider

28. Answer
D. Outcomes of the provider Rationale: The Synergy Model does not include the outcomes of the provider in the three levels of outcomes of the model.

29. Synergy Model—(cont.)
Use of the Synergy Model is designed to optimize outcomes.
When patient characteristics and nurse competencies match and “synergize,” outcomes for the patient are optimal.

30. Synergy Model—(cont.) The model has been used for about a decade.
Many articles have been published; most describe practice application, some research.
Also considerable indication that it can be used in practices other than critical care

31. Examples of Other Middle Range Theories
High middle range theories
Model of Skill Acquisition in Nursing (Benner, 2001)
Omaha System
Tidal Model (psychiatric nursing) (Baker, 2001)
Occupational Health Nursing (Rogers, 1994)

32. Middle Middle Range Theories
Most frequently identified theories as “middle range”
Not as broadly applicable as the “high” middle range theories but do relate to multiple settings and populations
Frequently used examples
Uncertainly of Illness Theory
Theory of Comfort
Theory of Unpleasant Symptoms

33. Uncertainty in Illness Theory
Develop by Merle Mishel in the early 1980s
Intent to explain stress resulting from hospitalization
Theory explains how clients cognitively process illness- related stimuli and construct meaning in these events.
Uncertainty is the inability to structure meaning and develops if the person does not form a “cognitive schema” for the illness.

34. Uncertainty in Illness Theory—(cont.)
Individuals cognitively process illness-related stimuli.
Explains how they structure meaning for the illness stimuli
Adaptation is the desirable end state.
Achieved after coping with the uncertainty
Nursing should develop interventions to influence the person’s cognitive process to address the uncertainty, thus producing positive coping and adaptation.

35. Model of perceived uncertainty in illness.
(From Mishel, M. H. [1990]. Reconceptualization of the uncertainty in illness theory. Image: Journal of Nursing Scholarship, 22[4], 256–262. Used with permission of John Wiley & Sons, Ltd.)

36. Question
Tell whether the following statement is true or false: According to Mishel in the Uncertainty in Illness Theory, the clients’ cognitive process and understanding of their illness construct the meaning of events.

37. Answer
True Rationale: In the theory by Mishel, Uncertainty in Illness, the patient’s cognitive ability and understanding has an impact on the constructed meaning of the situation.

38. Uncertainty in Illness Theory—(cont.)
Forty-six articles were identified using this theory in practice or research.
Examples—studies looked at:
Quality of life among elder breast cancer survivors
Use of social support to reduce illness uncertainty
Examination of effect of illness uncertainty on anxiety and depression in adolescents with asthma

39. Comfort Theory
Katherine Kolcaba started developing the Theory of Comfort as a concept analysis while she was a graduate student.
The Theory of Comfort was initially published in 1994 and later modified.
Comfort theory observes that patients experience need for comfort in stressful health care situations.

40. Comfort Theory—(cont.)
Comfort is the “satisfaction of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful.”
Increasing comfort can result in having negative tensions reduced and positive tensions engaged.
Comfort is an outcome of care that can promote or facilitate health-seeking behaviors.

41. Comfort Theory—(cont.)
Needs of the patient are identified by the nurse, who then implements interventions to meet them.
Outcomes of comfort can be measurable, holistic, positive, and nurse sensitive.
Several research studies by Dr. Kolcaba and her associates have been published.

42. The conceptual framework for the theory of comfort.
(© Kolcaba, Used with permission.)

43. Comfort Theory—Resource

44. Theory of Unpleasant Symptoms
The Theory of Unpleasant Symptoms was developed in the mid-1990s by a group of nurses interested in symptom management.
It is based on the premise that there are commonalities in experiencing different symptoms in and among different groups and in different situations.
Developed to integrate existing knowledge about a variety of symptoms to improve symptom management

45. Theory of Unpleasant Symptoms—(cont.)
The Theory of Unpleasant Symptoms helps nurses recognize the need to assess multiple aspects of symptoms including characteristics of the symptom(s), the underlying disease, or other cause.
The frequency, intensity, duration, quality, and distress felt by the patient
Several articles addressing both research and practice have been published.

46. Updated version of the middle range theory of unpleasant symptoms.
(From Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. [1997]. The middle range Theory of Unpleasant Symptoms: An update. Advances in Nursing Science, 19[3], 14–27. Used with permission.)

47. Theory of Unpleasant Symptoms—(cont.)
Three major components
Symptoms that the individual is experiencing
Influencing factors that produce or affect the symptom experience
Consequence of the symptom experience
Symptoms are described in terms of duration, intensity, distress, and quality.
Influencing factors can be physiologic, psychological, and/or situational.

48. Theory of Unpleasant Symptoms—(cont.)
Growing number of research articles in the nursing literature

49. Examples of Other Middle Range Theories
Middle middle range theories
Chronic illness trajectory framework (Corbin & Strauss, 1991)
Client interaction model of health behavior (Cox, 1982)
Motivation in health behavior (Cox, 1985)
Theory of care-seeking behavior (Lauver, 1992)

50. Examples of Other Middle Range Theories—(cont.)
Middle middle range theories—(cont.)
Self-efficacy (Lenz and Shortridge-Bagget)
Social support (Norbeck, 1981)
Self-transcendence (Reed)

51. Low Middle Range Theories
The number of low middle range theories in nursing is growing.
These theories are much more focused; deal with one specialty practice, age range, or situation.
Examples
Theory of Chronic Sorrow
Postpartum Depression

52. Theory of Chronic Sorrow
Concept of chronic sorrow was first coined in the early 1960s in psychology to describe the grief of parents of children with mental deficiencies.
Later research indicated similar patterns in parents of mentally or physically disabled children.
The Nursing Consortium for Research on Chronic Sorrow expanded the concept to include individuals who experience a variety of loss situations and their caregivers.

53. Theory of Chronic Sorrow—(cont.)
The Theory of Chronic Sorrow was first published in
Derived and validated through a series of research studies and review of existing research
Chronic sorrow is the “periodic recurrence of permanent, pervasive sadness or other grief related feelings associated with a significant loss.”

54. Theory of Chronic Sorrow—(cont.)
The theory was developed to help analyze individual responses of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or bereavement.
The sorrow is cyclic or recurrent and brings to mind a person’s losses, disappointments, or fears.

55. Theory of Chronic Sorrow—(cont.)
Antecedent to chronic sorrow is experiences of a significant loss.
The loss is ongoing with no predictable end.
Disparity is created when the reality is different from the idealized.
Trigger events (e.g., milestones, situations, and conditions that create negative disparity) exacerbate the experience of disparity.

56. Theory of Chronic Sorrow—(cont.)
Nurses need to view chronic sorrow as a normal response to loss.
They should foster positive coping strategies and encourage activities that increase comfort.
Interventions include listening, offering support and reassurance, providing information, and appreciating the uniqueness of each individual.

57. Theory of Chronic Sorrow—(cont.)
Individuals and groups from the Nursing Consortium for Research on Chronic Sorrow have published several research studies using the theory.

58. Beck’s Theory of Postpartum Depression
Cheryl Beck developed a theory regarding postpartum depression using a grounded theory approach.
The purpose of the theory was to provide insight into the experience of postpartum depression.

59. Beck’s Theory of Postpartum Depression—(cont.)
Concepts or stages
Encountering terror (anxiety attacks, obsessive thinking)
Dying of self (“unrealness,” isolation, contemplating self-destruction)
Struggling to survive (prying for relief, seeking solace)
Regaining control (making transitions, attaining recovery)

60. Beck’s Theory of Postpartum Depression—(cont.)
Nursing intervention should alert nurses to incidence and impact of postpartum depression.
Stresses the importance of identifying mothers who might be suffering from postpartum depression
Although the theory is relatively new, it has been used in several studies.

61. Examples of Other Middle Range Theories
Low middle range theories
Theory of adaptation to chronic pain (Dunn, 2004)
Maternal role attainment/becoming a mother (Mercer, 1980s)
Theory of the peaceful end of life (Ruland & Moore, 1998)
Theory of caregiver stress (Tsai, 2003)