Middle Range Nursing Theory

Nursing theories help in describing the various aspects of the nursing profession, and this article discusses the middle-range nursing theory, which has a limited scope but provides the best knowledge for the specific profession. As an individual’s concepts are cleared or justified, interest in the middle range of nursing theory grows. The practice paper covers a variety of topics that can be useful to others, including a concise description of the middle-range nursing theory, followed by an overview of the nursing theorist to explain what the background is.

The perspectives on health, the environment, patients, and nursing are as follows. The significance of middle-range nursing theories for new students and the improvement achieved while using this theory clearly states that students can improve their nursing practice while using this theory. Finally, the paper concludes with the main key points discussed in the paper (Mary Jane Smith, 2008).

There are various types of theories, such as Grand Nursing Theory (which has the broadest scope and provides general concepts but does not allow for empirical testing and thus limits the ability to provide explanation or prediction of situations), Middle Range Nursing Theory (which has a narrow scope and connects the two other theories, provides suggestions on a lower level, and provides the certainty of research-based work and nursing practice), and Nursing Practice Theories (has the most limited scope and can be used only for a small range of situations, provides a framework, predictions, and impact of nursing practice).

Theory of Middle-Range Nursing

Middle-range nursing theory provides a concrete foundation for dealing with complex situations. In comparison to the Grand Nursing theory, it is a more narrowly defined phenomenon. It offers less abstract and more empirical testing, as well as more specific phenomena. This nursing theory proposes descriptions, predictions, and explanations to answer questions not covered by other nursing practice theories.

This theory provides perspectives that train students to handle complex and emergency situations, as well as aids in nursing interventions. This theory is more applicable in nursing practice when explanations and implementations are required.

Middle-range nursing theories are a sub-discipline of nursing that focuses on potential knowledge of the discipline by broadening the phenomenon related to patient health care. The middle-range nursing theory is precisely defined using the ladder of abstraction, which states that as we move down the ladder, the abstraction level decreases while the conciseness increases (empirical level), and the exact opposite happens as we move towards the philosophical level. The empirical level is subdivided into the middle-range nursing theory (Sandra J. Peterson, 2009).

A Nursing Theorist’s Overview

The background for the pregnancy issues is provided by Kristen Swanson’s nursing theory. Kristen Swanson earned her bachelor’s degree in nursing from the University of Rhode Island in 1975 and her master’s degree in 1978. The Swanson nursing theory takes the necessary steps to deal with miscarriages during pregnancy.

The Swanson Theory of Caring revolves around counseling for parents and their families following miscarriages. The theory entails a combination of techniques for dealing with the sociocultural effects that arise after the loss of a baby. This theory provides an overview of aspects that go beyond the patient’s physical condition. These factors are taken into account by health care professionals in order to improve the emotional recovery of both the mother and father following a miscarriage or abortion.

The theory is based on Dr. Kristen Swanson’s study and research, which focused on the issues faced by parents and families during a woman’s pregnancy. The theory provides a foundation for the potential healing of the parents. The theorist’s studies have incorporated educational models and practices from other physicians across the country (Ahmed, 2006).

Meta-paradigm in Nursing

The nursing meta-paradigm is a large set of models that depict the clear relationship between current theoretical nursing practices. Many nursing practices are currently being considered for acquiring the relationship between the four main components of the meta-paradigm. (Parker, 2006).

The following are the four major meta-paradigms in the nursing profession:

• Person: who receives nursing care; this paradigm can be the ill individual who is treated as a subject in the treatment process. Between the individual and his environment, a constant changing process occurs. Nursing patients can be sick individuals, entire families, or entire communities.
• Health is defined as an individual’s level of wellness. It is a dynamic process that an individual describes throughout his or her life. The primary emphasis on the subject’s health is on the nature of physical, aesthetic, social, and ethical territories. Illness or sickness is defined as an individual’s experience with dysfunctions caused by health care.

A person’s health status is an expression of the common interacting processes that occur between the individual and their environment.

• Environment: it refers to the internal and external factors that influence an individual’s level or degree of health. It refers to the effect that geography and landscape have on an individual. The impact of physiological, psychological, economic and social, cultural, historical, and developmental factors prevalent in the society where the individual lives is one of the dimensions that may cause harm to the individual.
• Nursing: this is the profession that provides health care services in hospitals. Nursing interventions provide care to the sick patient.

These four nursing meta-paradigm concepts comprise a complete directional understanding of the profession. These four concepts incorporate fundamental nursing theory, philosophy, education, research, and nursing experience.

Middle Range Theory’s Importance

Nursing theories provide the principles that support new students’ nursing practices and aid in the generation of nursing knowledge (Colley, 2003). The middle-range nursing theory is important for nursing students because it provides a middle reality view as well as generalized practice areas for nurses. It also gives the nurses concrete ideas, which are limited but extremely useful. The characteristics of the propositions are clearly stated in middle-range nursing theory, allowing a better decision to be made for the patient’s health care.

The level of testability provided by the middle-range nursing theory may generate a test hypothesis. Because the middle-range nursing theory evolved from the Grand nursing theory and the nursing practice theory, the theory includes all of the literature reviews, clinical practices, and guidelines that nurses should follow.

What Difference Will This Theory Make in Nursing Practice?

The middle range theory for nursing is very important for nurses, and it can be used to improve nursing practice. This theory’s foci develop a concrete and conceptual framework of ideas in nurses, allowing them to practice their profession effectively. The scope of the middle-range nursing theory is, however, limited, but the ideas and literature that it contains are concrete, which aids in the improvement of nursing practice.

Grand Theories of Nursing

• Imogene King’s General Systems Theory • Erickson, Tomlin, and Swain’s Modeling and Role Modeling Theory • Madeleine Leininger’s Transcultural Nursing (formerly Culture-Care)
• Myra Estrine Levine’s Conservation Model • Margaret Newman’s Health as Expanding Consciousness
• Ida’s Nursing Process Theory Orlando, Jean
• Rosemarie Rizzo Parse Theory of Human Becoming
• Humanistic Nursing – Loretta Zderad and Josephine Paterson

Hildegard E Peplau’s Interpersonal Relations Model • Martha E Rogers’ Science of Unitary Human Beings

Sister Callista Roy’s Roy Adaptation Model • Jean Watson’s Philosophy and Theory of Transpersonal Caring

• Wittman-Price Emancipated Decision Making in Health Care
• Dorothea Orem’s Self-Care Theory

Acute Pain Management Theory

Marion Good, PhD, RN, has focused her research on complementary medicine for pain and stress, acute pain, and stress immunity in her study “A Middle-Range Theory of Acute Pain Management: Use in Research.”

The goal of this theory is to put pain management guidelines into practice. Good (1998) emphasized the importance of striking a balance between medication use and pain medication side effects. The theory also encouraged the development of plans for acceptable levels of pain management and patient education regarding pain management following surgery. Deductive reasoning was used to develop this theory.

Deductive reasoning is defined by Chinn and Kramer (2008) as moving from a broad concept to a more specific concept. According to Good (1998), there was a balance between analgesia and side effects, with two outcomes:

(1) a decrease in pain

(2) a decrease in side effects. These outcomes can be studied further or deduced to yield more detailed concepts.

Important Ideas

The hypothesis’s major concepts are divided into three categories:

• multimodal intervention
• attentive care,
• patient participation. Potent pain medication, pharmacological adjuvants, and non-pharmacological adjuvants are all concepts in multimodal intervention. Attentive care is concerned with the assessment of pain and side effects, as well as intervention and reassessment.

Goal setting and patient education are examples of patient participation. The balance between analgesia and side effects is the result of these three categories working together.

Using Levine’s nursing conservation model, we evaluated nurse staffing patterns and neonatal intensive care unit outcomes.

Aims To investigate the effects of nursing care intensity and consistency on health and economic outcomes using Levine’s Conservation Model of Nursing as the guiding theoretical framework.

Background Professional nursing practice models are becoming more popular, despite limited research on their effectiveness.

Method A structural equation modeling approach was used to examine the impact of nursing care intensity (direct care by professional nurses and patient-nurse ratio) and nursing caregiver consistency on morbidity and resource utilization in a neonatal intensive care unit (NICU) setting using primary nursing.

Results Nursing caregiver consistency was found to be a powerful mediator of the length of stay and duration of mechanical ventilation, supplemental oxygen therapy, and parenteral nutrition. An examination of nursing intensity indicators revealed that a combination of professional nurses and assistive personnel was most effective.

Conclusions Consistent nursing caregiver availability may improve both health and economic outcomes. New evidence has been discovered to support the effectiveness of the primary nursing model in the NICU.

Implications for nursing administration Designing nursing care delivery systems in acute inpatient settings with an emphasis on the consistency of nursing caregivers could improve health outcomes, organizational effectiveness, and patient and family satisfaction.

The foundation of middle-range theory has been described and analyzed over the last decade. A CINAHL search turned up 22 middle-range theories that met certain criteria. This foundation provides a solid foundation for new millennium theory.

Future theorizing recommendations include:

• clear articulation of theory names and approaches for generating theories;
• clarification of concept linkages with diagrammed models;
• deliberate attention to research-practice connections of theories;
• creation of theories in concert with the disciplinary perspective
• movement of middle-range theories to the front lines of nursing research and practice for further analysis, critique, and development.

NURSING THEORY IN THE TWENTIETH CENTURY

The foundation of middle-range theory has been described and analyzed over the last decade. A CINAHL search turned up 22 middle-range theories that met certain criteria. This foundation provides a solid foundation for the new millennium theory.

Future theorizing recommendations include a clear articulation of theory names and approaches for generating theories; clarification of concept linkages with diagrammed models; deliberate attention to research-practice connections of theories; creation of theories in concert with the disciplinary perspective; and movement of middle-range theories to the front lines of nursing research and practice for further analysis, critique, and development.

A SPINNER prepares wool by combing it to remove debris and align the strands of a matted mass, much like content is sifted to separate central ideas from extraneous ones. The nurse theorist spins central ideas into a synthesized thread for research and practice, much like a spinner twirls strands to compose a single thread. Twisting single threads together strengthens the product, as does the creation of research-practice links in the development of strong middle-range theory.

The beauty of any woven article is determined by the warp and weft; similarly, the esthetics of the discipline are determined by its theories. Spinning, like theorizing, is arduous work aimed at producing aesthetically pleasing and functional products. This article describes and analyzes a decade’s worth of middle-range theory products that lay the groundwork for the new millennium. This foundation highlights the current structure of middle-range theory and provides guidance for spinning in the twenty-first century.

MIDDLE RANGE THEORY’S HISTORICAL CONTEXT

Modernism, postmodernism, and neomodernism are historical descriptors that represent shifts in a developing discipline’s thinking and scholarship. Modernism believes in a one-dimensional and stable human existence, whereas postmodernism believes in a multidimensional, ever-changing, and complex human unfolding existence.

• Watson
• defined postmodern nursing as reconnecting with “truths of unfoldment, an expansion, and fusing of meaning horizons, an attending to the authenticity, ethos, and ethic of caring relations, context, continuity, connections, aesthetics, interpretation, and construction” (p63) She concludes that developing the art and science of nursing as a caring-healing transformative praxis paradigm is directly related to these postmodern dimensions.
•  Reed advances beyond postmodernism to neomodernism, advocating for synthesis of modernism and postmodernism. She describes the synthesis as a metanarrative that reflects the human development potential, transformation, and self-transcendent capacity for health and healing, as well as a recognition of people’s and contexts’ development histories.
• The historical context that defines the time is expected to yield theories that offer direction for the new millennium.
• The current environment encourages a focus on the human development potential of health and healing, as well as a nursing knowledge base that integrates art and science; practice, and research. Theories at the middle level of discourse are consistent with the historical context that ushers in the new millennium.
• Merton defines middle-range theories as those that exist between minor but necessary working hypotheses that emerge in abundance during day-to-day research and all-encompassing systematic efforts to develop a unified theory that will explain all observed uniformities of social behavior, social organization, and social change. 4(p39)
• He then describes the fundamental ideas of middle-range theory as “relatively simple.” In this context, simple means rudimentary, straightforward ideas derived from the discipline’s perspective. One such idea is that when people tell their stories to someone who truly listens, something changes. This concept is central to the middle range theory of embracing story attentively. 5 Middle-range theory ideas are simple yet general, and they are more than just empirical generalizations.
• In accordance with Merton’s views, 4 the nursing literature provides the following descriptions of middle-range theory: testable and intermediate in scope, 6 adequate in empirical foundations, 7 neither too broad nor too narrow, 8 circumscribed and substantively specific, 9 and more circumscribed than grand theory but not as concrete as practice theory. 10 Jacox 11 defined middle-range theories as those with a limited number of variables and a focus on a specific aspect of reality in 1974. Each of these descriptions emphasizes a scope in the center, allowing for broad definitions.
• Lenz 12 addresses the issue of definitional clarity, arguing that while definitions of middle-range theory are consistent, theories of varying scope have been labeled as middle-range, and the discipline may benefit from recognizing levels of theory within the middle range. She claims that the discipline’s challenge will be to develop a few empirically sound, coherent, meaningful, useful, and illuminating theories rather than a plethora of middle-range theories. 12 To meet Lenz’s challenge in the next century, middle-range theories must emerge from the twisting of research and practice threads by nurse scholars who are building on the work of others and shaping the discipline’s future direction.

The existing middle-range theory foundation will guide the spinning of middle-range theory in the next century.

THE EXISTING FOUNDATION OF MIDDLE-RANGE THEORY

To assess the current foundation of middle-range theory, a CINAHL search of the last 10 years of nursing literature was conducted using the search terms middle-range theory, mid-range theory, and nursing. Two institutions conducted the search independently. All papers written in English that were discovered during the combined search were considered for inclusion in the foundation list of middle-range theories (Table 1). The following criteria were used to determine inclusion:

1. the theory was identified as a middle range by its author;
2. the theory name was accessible in the paper;
3. concepts of the theory were explicitly or implicitly identified in propositions;
4. the development of the theory was the primary focus of the paper.

These criteria reflect an intention to be inclusive, offering the most comprehensive view of available middle-range nursing theory. However, some papers were excluded because they were primarily methodological in nature. 13,14 These were discovered during the literature review but did not meet the criteria. Table 1 describes the foundation of the middle-range theory that has emerged over the last decade. Along with identifying and locating information about the theory, it mentions the inclusion of a diagrammed model and the author’s approaches for theory generation.

Methods for creating middle-range theory

Lenz 12 identified six approaches for developing middle-range theory, which were used to classify the methods used by the creators of the 22 theories identified in the foundation. Because theorists frequently used more than one approach, the categories are not mutually exclusive.

Lenz’s approaches are as follows:

1. inductive theory development through research,
2. deductive theory development from grand nursing theories,
3. combining existing nursing and non-nursing theories,
4. theory development from other disciplines,
5. theory development from published research findings,
6. theory development from clinical practice guidelines.

According to a review of the foundation theories, fourteen * appeared to use inductive theory building through research. Three derived the theory from grand nursing theory, two combined nursing and non-nursing theories, thirty-seven derived theories from other disciplines, twenty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-eighty-e When categorizing the theories, Lenz’s approach of synthesizing theories from published research proved difficult to determine.

There was no mention of a middle-range theory based solely on published research. Even when it wasn’t stated explicitly, there were hints that each theory had been based on published research when it was developed. Two theories 32,46 do not fit into any of Lenz’s approaches. Recently, Ruland and Moore 46 proposed using standards of care to generate a middle-range theory, and Kinney 32 describes a practice example to demonstrate a middle-range model.

Seven theories, including Kinney’s, explicitly cited personal practice experiences as contributing to middle-range theory development (7,15,32,36,37,40,42,44). Only four of the seven (7,15,36,40,42) also described research threads, allowing the spinning of research with practice in the development of middle-range theory.

According to the analysis of approaches for generating middle range theory, Lenz’s listing is generally complete. The approach of noting synthesis from published research findings may be appropriate, and an expansion of “clinical practice guidelines” to “practice guidelines and standards” will cover Ruland and Moore’s recent work. 46 The practice thread is essential for 21st-century spinning.

As a result, the following five approaches for middle range theory generation in the new millennium are proposed:

1. induction through research and practice;
2. deduction from grand theory research and practice applications;
3. combination of existing nursing and non-nursing middle-range theories;
4. derivation from theories of other disciplines that relate to nursing’s disciplinary perspective;
5. deduction from research-based practice guidelines and standards.

As nursing enters the twenty-first century, none of these theory generation approaches are likely to stand alone. To effectively guide the discipline, each will need to be combined. Theories that spin research and practice to focus on the human developmental potential of health and healing are most likely to provide guidance for the new millennium.

Grand nursing theory in comparison

As middle range theory is developed for the new millennium, it is critical that it transcends the polarities that are frequently created between it and grand theories. Individuals who attempted to create a comprehensive view of nursing espoused all-encompassing grand theories. Small circles of schools of thought have formed in which an all-or-nothing adherence to the perspective is strongly advocated.

This approach has advanced the discipline by generating scholarly endeavors and provides a foundation for the middle-range theory. It is neither separate nor opposed to the development of middle-range theory.

Merton 4 identifies the following criticisms of middle-range theory leveled by those who advocate grand approaches:

(1) it has low intellectual ambitions;

(2) it completely excludes grand theory;

(3) it will fragment the discipline into unrelated special theories;

(4) it will result in a positivist conception of theory.

There is no evidence that these criticisms have been taken into account. Nursing’s current middle-range theory foundation: reflects scholarly work conceptualized at a lower level of abstraction that rises to the intellectual challenge; builds on’grand theory that continues to offer a foundation for development; and projects a historical context to begin the millennium with middle-range theories in the discipline’s perspective.

Middle range theory foundation’s disciplinary perspective

Two themes emerged during the reflective process of dwelling with the essence of the disciplinary perspective and the named middle-range theories. These were the caring-healing processes and the transforming struggle-growth themes. These themes provide a disciplinary perspective on the existing middle range theory foundation as well as an integrated paradigm for spinning middle range theory in the new millennium.

Where will the nursing theory be in the future?

In conclusion, there has been a lot of thoughtful spinning of middle-range theory over the last decade, and while knots and tangles have been created along the way, it is important to remember that spinning theory is a creative human endeavor that is best described as a work in progress. The spinner’s persistence and careful attention to creating and combining fibers are expected to sort out the knots and tangles.

Several recommendations for developing middle-range theory in the future are made based on the description and analysis of the current middle-range theory foundation. The creators of middle-range theory should:

1. take care to clearly articulate the theory name and approach used to generate the theory;
2. strive to clarify the conceptual linkages of the theory in a diagrammed model;
3. give deliberate attention to articulating the theory’s research-practice links;
4. create an association between the proposed theory and a disciplinary perspective in nursing;
5. move middle-range theory to the forefront.

These recommendations present a challenge to twenty-first-century theorists. The challenge is to advance nursing theory by spinning research and practice into middle-range theories that are congruent with the current historical context. This forward movement will give the discipline substance and direction. As nurse theorists spin and twist fibers from the past-present into the future, the middle-range theory will weave the disciplinary fabric of the new millennium.

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