Introduction to Middle Range Nursing Theories
Annette Cohen is a second-year graduate nursing student interested in starting her major research/scholarship project. For this project, she would like to develop some of her experiences in hospice nursing into a preliminary middle range theory of spiritual health. Annette has studied spiritual needs and spiritual care for many years but believes that the construct of spiritual health is not well understood. She views spiritual health as the result of the interaction of multiple intrinsic values and external variables within a client’s experiences, and she believes that it is a significant contributing factor to overall health and well-being.
After reviewing theoretical writings dealing with spiritual nursing care, Annette found a starting point for her work in Jean Watson’s Theory of Human Caring (Watson, 2005) because of its emphasis on spirituality and faith. From Watson’s work, she was particularly interested in applying the concepts of “actual caring occasion” and “transpersonal” care. To develop the theory, Annette obtained a copy of Watson’s most recent work and performed a comprehensive review of the literature covering theory development and the Theory of Human Caring. She then did an analysis of the concept of spiritual health. Combining the concept analysis and the literature review of Watson’s work led to the development of assumptions and formal definitions of related concepts and empirical indicators. After conversing with her instructor, she concluded that her next steps were to construct relational statements and then draw a model depicting the relationships among the concepts that comprise spiritual health.
As discussed in Chapter 2, middle range nursing theories lie between the most abstract theories (grand nursing theories, models, or conceptual frameworks) and more circumscribed, concrete theories (practice theories, situation-specific theories, or microtheories). Compared to grand theories, middle range theories are more specific, have fewer concepts, and encompass a more limited aspect of the real world. Concepts are relatively concrete and can be operationally defined. Propositions are also relatively concrete and may be empirically tested.
The discipline of nursing recognizes middle range theory as one of the contemporary trends in knowledge development, and there is broad acceptance of the need to develop middle range theories to support nursing practice (Alligood, 2010; Fitzpatrick, 2003; Kim, 2010; Peterson, 2013). According to Morris (1996) and Suppe (1996), this call to develop middle range theory is consistent with the third stage of legitimizing the discipline of nursing. The first stage focuses on differentiation of the perspective of the emerging discipline, which is characterized by separation from antecedent disciplines (i.e., medicine) and the establishment of university-based education, which in nursing occurred during the 1950s and 1960s. The second stage is marked by the quest to secure institutional legitimacy and academic autonomy. This stage characterized nursing during the 1970s and through the 1980s, when pursuit of nursing’s unique perspective on and clarification of the phenomena of interest to the discipline were stressed. The third stage began in the 1990s and is distinguished by increased attention to substantive knowledge development, which includes development and testing of middle range theories. This stage is expanding and evolving further to include evidence-based practice and situation-specific theories (see Chapter 12).
Middle range theories are increasingly being used in nursing research studies. Many researchers prefer to work with middle range theories rather than grand theories or conceptual frameworks because they provide a better basis for generating testable hypotheses and addressing particular client populations. A review of nursing research journals and dissertation abstracts indicates that nursing research is currently being used in the development and testing of a number of middle range theories, and middle range theories are frequently being used as frameworks for investigation. Furthermore, middle range theories are presently being refined on the basis of research results.
Despite the promotion of middle range theories in recent years, there is a lack of clarity regarding what constitutes middle range theory in nursing. According to Cody (1999), “It appears that almost any theoretical entity that is more concrete than the broadest of grand theories is considered middle range by someone” (p. 10). It has been noted that nursing theory textbooks (e.g., Alligood, 2010; Chinn & Kramer, 2011; Fawcett & DeSanto-Madeya, 2013; Parker & Smith, 2010) disagree to some degree on which theories should be labeled as middle range. Indeed, some authors list a few of the readily accepted grand theories (e.g., Parse, Newman, Peplau, and Orlando) as middle range. Others consider somewhat more circumscribed theories (e.g., Leininger, Pender, Benner and Erickson, Tomlin, and Swain) to be middle range, although the theory’s authors may not agree. In essence, there has been a paucity of discussion on the subject and therefore there is little consensus. This issue is discussed in more detail later in the chapter.