Middle Range Theory
Middle range theories were first suggested in the discipline of sociology in the 1960s and were introduced to nursing in 1974. At that time, it was observed that middle range theories were useful for emerging disciplines because they are more readily operationalized and addressed through research than are grand theories. More than 15 years elapsed, however, before there was a concerted call for middle range theory development in nursing (Blegen & Tripp-Reimer, 1997; Meleis, 2012).
Development of middle range theories is supported by the frequent critique of the abstract nature of grand theories and the difficulty of their application to practice and research. The function of middle range theories is to describe, explain, or predict phenomena, and, unlike grand theory, they must be explicit and testable. Thus, they are easier to apply in practice situations and to use as frameworks for research studies. In addition, middle range theories have the potential to guide nursing interventions and change conditions of a situation to enhance nursing care. Finally, a major role of middle range theory is to define or refine the substantive component of nursing science and practice (Higgins & Moore, 2000). Indeed, Lenz (1996) noted that practicing nurses are actually using middle range theories but are not consciously aware that they are doing so.
Each middle range theory addresses relatively concrete and specific phenomena by stating what the phenomena are, why they occur, and how they occur. In addition, middle range theories can provide structure for the interpretation of behavior, situations, and events. They support understanding of the connections between diagnosis and outcomes, and between interventions and outcomes (Fawcett & DeSanto-Madeya, 2013).
Enhancing the focus on middle range theories in nursing is supported by several factors. These include the observations that middle range theories
· are more useful in research than grand theories because of their low level of abstraction and ease of operationalization
· tend to support prediction better than grand theories due to circumscribed range and specificity of the concepts
· are more likely to be adopted in practice because their relative simplicity eases the process of developing interventions for identified health problems (Cody, 1999; Peterson, 2013)
Like theory in general, middle range theory has three functions in nursing knowledge development. First, middle range theories are used as theoretical frameworks for research studies. Second, middle range theories are open to use in practice and should be tested by research. Finally, middle range theories can be the scientific end product that expresses nursing knowledge (Suppe, 1996).
Characteristics of Middle Range Theory
Several characteristics identify nursing theories as middle range. First, the principal ideas of middle range theories are relatively simple, straightforward, and general. Second, middle range theories consider a limited number of variables or concepts; they have a particular substantive focus and consider a limited aspect of reality. In addition, they are receptive to empirical testing and can be consolidated into more wide-ranging theories. Third, middle range theories focus primarily on client problems and likely outcomes, as well as the effects of nursing interventions on client outcomes. Finally, middle range theories are specific to nursing and may specify an area of practice, age range of the client, nursing actions or interventions, and proposed outcomes (Meleis, 2012; Peterson, 2013).
The more frequently used middle range theories tend to be those that are clearly stated, easy to understand, internally consistent, and coherent. They deal with current nursing perspectives and address socially relevant topics that solve meaningful and persistent problems. In summary, middle range theories for nursing combine postulated relationships between specific, well-defined concepts with the ability to measure or objectively code concepts. Thus, middle range theories contain concepts and statements from which hypotheses may be logically derived and empirically tested, and they can be easily adopted to guide nursing practice. Table 10-1 compares characteristics of grand theory, middle range theory, and practice/situation-specific theory, and characteristics of middle range theory are shown in Box 10-1.
Table 10-1: Characteristics of Grand, Middle Range, and Practice/Situation-Specific Theories
|Characteristic||Grand Theories||Middle Range Theories||Practice/Situation-Specific Theories|
|Complexity/abstractness, scope||Comprehensive, global viewpoint (all aspects of human experience)||Less comprehensive than grand theories, middle view of reality||Focused on a narrow view of reality, simple and straightforward|
|Generalizability/specificity||Nonspecific, general application to the discipline irrespective of setting or specialty area||Some generalizability across settings and specialties, but more specific than grand theories||Linked to special populations or an identified field of practice|
|Characteristics of concepts||Concepts abstract and not operationally defined||Limited number of concepts that are fairly concrete and may be operationally defined||Single, concrete concept that is operationalized|
|Characteristics of propositions||Propositions not always explicit||Propositions clearly stated||Propositions defined|
|Testability||Not generally testable||May generate testable hypotheses||Goals or outcomes defined and testable|
|Source of development||Developed through thoughtful appraisal and careful consideration over many years||Evolve from grand theories, clinical practice, literature review, and practice guidelines||Derived from practice or deduced from middle range or grand theory|
Box 10-1: Characteristics of Middle Range Nursing Theory
· Not comprehensive, but not narrowly focused
· Some generalizations across settings and specialties
· Limited number of concepts
· Propositions that are clearly stated
Elaine Chavez is employed as a nurse at a public health clinic in an urban area. She is also in her second semester of a graduate nursing program preparing to become a mental health nurse practitioner. In her practice, Elaine has worked with a number of women who have been abused by their partners, and she has observed a pattern of comorbidities in these women, including depression, alcoholism, substance abuse, and suicide attempts. Over the last few months, Elaine has reviewed the nursing literature and identified several intervention strategies that have been effective in working with women who have been victims of domestic violence. Using this information, she would like to implement a program to promote early identification of abuse and multiple-level interventions. This is a project that will work well with one of her master’s portfolio assignments.
From her literature review, Elaine identified several theories related to her study. She was particularly interested in examining the set of circumstances that would cause the women to seek help. For this, she performed a more detailed literature review and identified Kolcaba’s (1994, 2003, 2013) Theory of Comfort, which helped her conceptualize many of the issues that the women faced. Indeed, the theory described individual characteristics that contributed to health-seeking behavior. These were stimulus situations, which can cause negative tension. By providing comfort measures, the nurse can help decrease negative tensions and promote positive tension. Elaine wanted to continue to identify comfort measures that would encourage the women to seek care for their problems.
For the next phase of her project, Elaine collected all of the information she could find on Kolcaba’s theory. This included studies that had used the model as a conceptual framework and studies that had tested the model. From that information and the articles she had gathered previously about issues related to domestic violence, she was able to draft a set of interventions that she hoped to implement at the clinic following approval by her supervisor.
Previous chapters have described the growing emphasis on the development and testing of middle range theories in nursing. As a result, during the past two decades, a significant number of these theories have been presented in the nursing literature. The purpose of this chapter is to introduce some of the commonly used middle range nursing theories as well as some of the recently published ones to familiarize readers with these works and direct them to resources for more information. An attempt was made to include works from a variety of areas and from many scholars, but by no means is the list presented here exhaustive. Nor does inclusion or exclusion relate to the quality or significance of the theory or its usefulness in research or practice.
To assist with organization of the chapter, the theories are divided into sections based on whether they appear to be “high,” “middle,” or “low” middle range theories. As explained in Chapter 10, the high/middle/low distinction relates to the level of abstraction as posed by Liehr and Smith (1999), with the “high” middle range theories being the most abstract and nearest to the grand theories. The “low” middle range theories, on the other hand, are the least abstract, and they are similar to practice or situation-specific theories. It is noted that these designations are arguably arbitrary and that one theory that is listed here as “high middle” may be considered by others to be a grand theory. Likewise, another theory listed here as “middle middle” might be considered by others to be a high middle range theory, and so forth.
Elements of theory description and theory analysis as explained in Chapter 5 serve as the basis for the more detailed discussions of selected theories. Each will include a brief overview, an outline of the purpose and major concepts of the theory, and context for use and nursing implications. Finally, evidence of empirical testing and application in practice are described.