Grand Nursing Theories Based on Interactive Process

Grand Nursing Theories Based on Interactive Process

Evelyn M. Wills

Jean Willowby is a student in an RN to master of science in nursing program. She is working to become a pediatric nurse practitioner. For one of her practicum assignments, she must incorporate a nursing theory into her clinical work, using the theory as a guide. During an earlier course on theory, Jean read several nursing theories that focused on interactions between the client and the nurse and between the client and the health care system. She remembered that in the interaction models and theories, human beings are viewed as interacting wholes and client problems are seen as multifactorial.

The theories that stress human interactions best fit Jean’s personal philosophy of nursing because they take into account the multitude of factors she believes to be part of clinical nursing practice. Like the perspective taken by interaction model theorists, Jean understands that, at times, the results of interventions are unpredictable and that many elements in the client’s background and environment have an effect on the outcomes of interventions. She also acknowledges that there are many interactions between clients and their environments, both internal and external, some of which cannot be measured.

To better prepare for the assignment, Jean studied several of the human interaction models and theories, focusing most of her attention on the works of Roy and King. But after discussing her thoughts with her professor, she was referred to the Artinian Intersystem Model (AIM), a relatively new model by Barbara Artinian. After reviewing some of the precepts of the model, she thought that it appeared to best fit her pediatrics practice and determined that she would learn more about it.

As discussed in Chapter 6, interactive process nursing theories occupy a place between the needs-based theories of the 1950s and 1960s, most of which were philosophically grounded in the positivist school of thought, and the unitary process models, which are grounded in humanist philosophy, which expresses the belief that humans are unitary beings and energy fields in constant interaction with the universal energy field. The interactive theories are grounded in the postpositive schools of philosophy.

The theorists presented in this chapter believe that humans are holistic beings who interact with and adapt to situations in which they find themselves. These theorists ascribe to systems theory and agree that there is constant interaction between humans and their environments. In general, human interaction theorists believe that health is a value and that a continuum of health ranges from high-level wellness to illness. They acknowledge, however, that people with chronic illnesses may have healthy lives and live well despite their illnesses.

Nursing models that can be described as interactive process theories include Levine’s Conservation Model; Artinian’s Intersystem Model; Erickson, Tomlin, and Swain’s Modeling and Role-Modeling; King’s Systems Framework and Theory of Goal Attainment; Roy’s Adaptation Model; and Watson’s Philosophy and Science of Caring. Each is discussed in this chapter. The models treated in this chapter are not arranged historically; some date back to the 1960s, whereas some are relatively new. Levine’s model is placed early in the chapter because it is one of the classic models.

An attempt was made to ensure that a balanced approach was used in presenting the works of these theorists. However, some of the theories are quite complex (e.g., those of Erickson, Tomlin, and Swain; King; and Roy), whereas others are quite parsimonious (e.g., those of Levine and Watson). Additionally, some of the models have been revised repeatedly (e.g., Artinian, King, Roy, and Watson). As a result, the sections dealing with some models are longer or more involved than others, but this does not imply that the works of any of the theorists discussed are more or less important to the discipline than others.

Myra Estrin Levine: The Conservation Model

The ideal of conservation pervades the background of some nurses’ ideas (Mefford, 2004). Myra Levine (1973) stated that “nursing is a human interaction” (p. 237). Her model deals with the interactions of nurse and client. It considers multiple factorial interactions, which may produce predictable effects using probability as the reality.

Background of the Theorist

Myra Levine earned a diploma in nursing from Cook County School of Nursing in Chicago, Illinois, in 1944; a bachelor’s degree in science at the University of Chicago in 1949; and a master of science in nursing from Wayne State University in Detroit, Michigan, in 1962. She held numerous clinical and education positions during her long career (Schaefer, 2010). She published An Introduction to Clinical Nursing in 1969; this work was revised in 1973 and again in 1989 (Levine, 1989). Levine enjoyed a long and productive career, which included a distinguished publication record. She died in 1996, at age 75, leaving a legacy to nursing of education, administration, and scholarship (Schaefer, 2002).

Philosophical Underpinnings of the Theory

Levine (1973) based the Conservation Model on Nightingale’s idea that “the nurse created an environment in which healing could occur” (p. 239). She drew from the works of Tillich on the unity principle of life, Bernard on internal environment, Cannon on the theory of homeostasis, and Waddington on the concept of homeorrhesis. The works of other scientists were also used. Four conservation principles form the basis of the model; these were synthesized from her scientific study and practice (Levine, 1990).

Major Assumptions, Concepts, and Relationships

The following four conservation principles are the major principles around which the model is constructed:

·        The principle of the conservation of energy

·        The principle of the conservation of structural integrity

·        The principle of the conservation of personal integrity

·        The principle of the conservation of social integrity (Levine, 1990, p. 331)

According to Levine’s model, nursing interventions are based on conservation of the client’s integrity in each of the conservation domains. The nurse is seen as a part of the environment and shares the repertoire of skill, knowledge, and compassion, assisting each client to confront environmental challenges in resolving the problems encountered in the client’s own unique way. The effectiveness of the interventions is measured by the maintenance of client integrity (Levine, 1973, 1990).

Assumptions About Individuals

·       Each individual “is an active participant in interactions with the environment constantly seeking information from it” (Levine, 1969, p. 6).

·       The individual “is a sentient being and the ability to interact with the environment seems ineluctably tied to his sensory organs” (Levine, 1973, p. 450).

·       “Change is the essence of life and it is unceasing as long as life goes on. Change is characteristic of life” (Levine, 1973, p. 10).

Assumptions About Nursing

·       “Ultimately the decisions for nursing intervention must be based on the unique behavior of the individual patient” (Levine, 1973, p. 6).

·       “Patient-centered nursing care means individualized nursing care. It is predicated on the reality of common experience: every man is a unique individual, and as such he requires a unique constellation of skills, techniques and ideas designed specifically for him” (Levine, 1973, p. 23).

Concepts

Many concepts are discussed in the model. Major concepts are listed in Table 8-1.

Table 8-1: Major Concepts of the Conservation Model

Concept	Definition
Environment	Includes both the internal and external environment.
Person	The unique individual in unity and integrity, feeling, believing, thinking, and whole.
Health	Patterns of adaptive change of the whole being.
Nursing	The human interaction relying on communication, rooted in the organic dependency of the individual human being in his [sic] relationships with other human beings.
Adaptation	The process of change and integration of the organism in which the individual retains integrity or wholeness. It is possible to have degrees of adaptation.
Conceptual environment	The part of the person’s environment that includes ideas, symbolic exchange, belief, tradition, and judgment.
Conservation	Includes joining together and is the product of adaptation including nursing intervention and patient participation to maintain a safe balance.
Energy conservation	Nursing interventions based on the conservation of the patient’s energy.
Holism	The singular, yet integrated response of the individual to forces in the environment.
Homeostasis	Stable state normal alterations in physiologic parameters in response to environmental changes; an energy-sparing state, a state of conservation.
Modes of communication	The many ways in which information, needs, and feelings are transmitted among the patient, family, nurses, and other health care workers.
Personal integrity	A person’s sense of identity and self-definition. Nursing intervention is based on the conservation of the individual’s personal integrity.
Social integrity	Life’s meaning gained through interactions with others. Nurses intervene to maintain relationships.
Structural integrity	Healing is a process of restoring structural integrity through nursing interventions that promote healing and maintain structural integrity.
Therapeutic interventions	Interventions that influence adaptation in a favorable way, enhancing the adaptive responses available to the person.
Source: Adapted from Levine (1973).

Relationships

Relationships are not specifically stated but can be extracted from the descriptions given by Levine (1973). The relationships serve as the basis for nursing interventions and include:

·        1. Conservation of energy is based on nursing interventions to conserve energy through a deliberate decision as to the balance between activity and the person’s available energy.

2. Conservation of structural integrity is the basis for nursing interventions to limit the amount of tissue involvement.
CHAPTER 9: Grand Nursing Theories Based on Unitary Process

Evelyn M. Wills

Kristin Kowalski is a hospice nurse who wishes to expand the scope of her therapeutic practice. She desires to delve more deeply into holistic health care, having recently completed courses of study in herbal medicine, touch therapy, and holistic nursing. Kristin is aware that to practice independently, she needs professional credentials that will be widely accepted; therefore, she applied to the graduate program of a nationally ranked nursing school at a large state university.

Because Kristin believes strongly in holistic nursing practice, for her master’s degree she decided to focus her study of nursing theories on those that look at the whole person and have a broad, nontraditional view of health. She is particularly interested in Rosemarie Parse’s Humanbecoming Paradigm because this viewpoint stresses the individual’s way of being and becoming healthy and the nurse as an intersubjective presence.

Kristin is attracted to Parse’s idea of true presence and wishes to further explore this concept as well as the rest of the perspective. She hopes to eventually apply it to her practice and use it as the research framework for her thesis. For her thesis, Kristin wants to examine the experiences of nurses who practice therapeutic touch. She desires to learn their perceptions of how therapeutic touch interventions help their clients. She also wants to learn more about Parse’s research method and hopes to use it for her study.

The term simultaneity paradigm was first coined by nursing theorist Rosemarie Parse (1987) to describe a group of theories that adhered to a unitary process perception of human beings. This group of theorists believed that humans are unitary beings: energy systems embedded in the universal energy system. Within this group of theories, human beings are seen as unitary, “whole, open and free to choose ways of becoming” (Parse, 1998, p. 6), and health is described as continuous human environmental interchanges (Newman, 1994).

The unitary process nursing model and two corollary theories are described in this chapter: Science of Unitary Human Beings (Rogers, 1994), Health as Expanding Consciousness (Newman, 1999), and Humanbecoming School of Thought (Parse, 1998, 2010). The three are grouped together because they are significantly different in their concepts, assumptions, and propositions when compared to the theories described in Chapters 7 and 8. They are universal in scope and relatively abstract.

Martha Rogers: The Science of Unitary and Irreducible Human Beings

Martha E. Rogers first described her Theory of Unitary Man in 1961, and almost from the first, there has been widespread controversy and debate among nursing theorists and scholars regarding her work (Phillips, 1994). Prior to Rogers, it was rare that anyone in nursing viewed human beings as anything other than the receivers of care by nurses and physicians. Furthermore, the health care system was organized by specialization, in which nurses and other health providers focused on discrete areas or functions (e.g., a dressing change, medication administration, or health teaching) rather than on the whole person. As a result, it took many professionals working in isolation, none of whom knew the whole person, to care for patients. Rogers’ (1970) insistence that the person was a “unitary energy system” in “continuous mutual interaction with the universal energy system” (p. 90) dramatically influenced nursing by encouraging nurses to consider each person as a whole (a unity) when planning and delivering care.

Background of the Theorist

Martha Rogers was born on May 12, 1914 (the anniversary of Florence Nightingale’s birth) (Dossey, 2000) in Dallas, Texas. She earned a diploma in nursing from Knoxville General Hospital in 1936 and a bachelor’s degree from George Peabody College in Nashville, Tennessee in 1937. She later received a master’s degree in public health nursing from Teachers College, Columbia University in New York, and a master’s degree in public health and a doctor of science from The Johns Hopkins University in Baltimore, Maryland (Gunther, 2010).

Rogers became the head of the Division of Nursing of New York University (NYU) in 1954, where she focused on teaching and formulating and elaborating her theory (Hektor, 1989). She was teacher and mentor to an impressive list of nursing scholars and theorists, including Newman and Parse, whose works are described later in the chapter. Rogers continued her work and writing until her death in March, 1994.

Philosophical Underpinnings of the Theory

The Science of Unitary and Irreducible Human Beings started as an abstract theory that was synthesized from theories of numerous sciences; therefore, it was deductively derived. Of particular importance was von Bertalanffy’s theory on general systems, which contributed the concepts of entropy and negentropy and posited that open systems are characterized by constant interaction with the environment. The work of Rapoport provided a background on open systems, and the work of Herrick contributed to the premise of evolution of human nature (Rogers, 1994).

Rogers’ synthesis of the works of these scientists formed the basis of her proposition that human systems are open systems, embedded in larger, open environmental systems. She also brought in other concepts, including the idea that time is unidirectional, that living systems have pattern and organization, and that man is a sentient, thinking being capable of awareness, feeling, and choosing. From all these theories, and from her personal study of nature, Rogers (1970) developed her original Theory of Unitary Man. She continuously refined and elaborated her theory, which she retitled Science of Unitary Humans (Rogers, 1986) and finally, shortly before her death, the Science of Unitary and Irreducible Human Beings (Rogers, 1994).

Major Assumptions, Concepts, and Relationships

Assumptions

Rogers presented several assumptions about man. These are as follows:

·       Man is a unified whole possessing integrity and manifesting characteristics that are more than and different from the sum of his parts (Rogers, 1970, p. 47).

·       Man and environment are continuously exchanging matter and energy with one another (Rogers, 1970, p. 54).

·       The life process evolves irreversibly and unidirectionally along the space–time continuum (Rogers, 1970, p. 59).

·       Pattern and organization identify man and reflect his innovative wholeness (Rogers, 1970, p. 65).

·       Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and emotion (Rogers, 1970, p. 73).

Rogers (1990) later revised the term man to human being to coincide with the request for gender-neutral language in the social sciences and nursing science.

Concepts

In Rogers’ work, the unitary human being and the environment are the focus of nursing practice. Other central components are energy fields, openness, pandimensionality, and pattern; these she identified as the “building blocks” (Rogers, 1970, p. 226) of her system. Rogers also derived three other components for the model, which served as a basis of her work. These were based on principles of homeo dynamics and were termed resonancy, helicy, and integrality(Rogers, 1990) (Box 9-1). Definitions of the nursing metaparadigm concepts and other important concepts in Rogers’ work are listed in Table 9-1.

Box 9-1: Principles of Homeodynamics Applied in Rogers’ Theory

·       1. Resonancy is continuous change from lower to higher frequency wave patterns in human and environmental fields.

·       2. Helicy is continuous innovative, unpredictable, increasing diversity of human and environmental field patterns.

·       3. Integrality is continuous mutual human and environmental field processes.

Source: Rogers (1990, p. 8).

Table 9-1: Central Concepts of Rogers’ Science of Unitary Human Beings

Concept	Definition
Human–unitary human beings	“Irreducible, indivisible, multidimensional energy fields identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from the knowledge of the parts” (p. 7).
Health	“Unitary human health signifies an irreducible human field manifestation. It cannot be measured by the parameters of biology or physics or of the social sciences” (p. 10).
Nursing	“The study of unitary, irreducible, indivisible human and environmental fields: people and their world” (p. 6). Nursing is a learned profession that is both a science and an art.
Environmental field	“An irreducible, indivisible, pandimensional energy field identified by pattern and integral with the human field” (p. 7).
Energy field	“The fundamental unit of the living and the non-living. Field is a unifying concept. Energy signifies the dynamic nature of the field; a field is in continuous motion and is infinite” (p. 7).
Openness	Refers to qualities exhibited by open systems; human beings and their environment are open systems.
Pandimensional	“A nonlinear domain without spatial or temporal attributes” (p. 28).
Pattern	“The distinguishing characteristic of an energy field perceived as a single wave” (p. 7).
Source: Rogers (1990).

Relationships

The Science of Unitary and Irreducible Human Beings is fundamentally abstract; therefore, specifically defined relationships differ from those in more linear theories. The major components of Rogers’ model revolve around the building blocks (energy

CHAPTER 10: Introduction to Middle Range Nursing Theories

Melanie McEwen

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.

Purposes of 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

May generate testable hypotheses
CHAPTER 11: Overview of Selected Middle Range Nursing Theories

Melanie McEwen

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.

High Middle Range Theories

The high middle range theories presented here are some of the more well known and most widely used theories in nursing. Included are the works of Benner, Leininger, Pender, and Meleis. These theories may be considered grand theories or conceptual frameworks by other nursing scholars and possibly by the author of the theory. These theories, however, do not totally fit with the criteria for grand theories as outlined in this text and therefore are not covered in the chapters dealing with that content. In addition, the Synergy Model, a nursing model that is widely used in research and practice, particularly in critical care, will be discussed. Table 11-1 lists other high middle range theories or conceptual models, their purposes, and major concepts.

Table 11-1: High Middle Range Nursing Theories

Theory/Model	Purpose	Major Concepts
Tidal model (psychiatric and mental health nursing) (Barker, 2001a, 2001b)	Describes psychiatric nursing practice focusing on three care processes; emphasizes the fluid nature of human experience characterized by change and unpredictability	Personhood (dimensions—world, self, others), discrete holistic (exploratory) assessment; focused (risk) assessment, empowerment, narrative as the medium of self
Parish nursing (Bergquist & King, 1994)	Describes the integration of physical, emotional, and spiritual components in provision of holistic health care in a faith community	Client (spiritual, physical, emotional components), parish nurse (spiritual maturity, pastoral team member, autonomy, caring, effective communication), health (physical, emotional, and spiritual wellness and wholeness), environment (faith community)
Parish nursing (Miller, 1997)	Integrates the concepts of evangelical Christianity with application of parish nursing interventions	Person/parishioner, health, nurse/parish nurse, community/parish, the triune God
Neal theory of home health nursing (Neal, 1999a, 1999b)	Describes the practice of home health nurses as they use process of adaptation to attain autonomy	Autonomy, three stages (dependence, moderate dependence, and autonomy), logistics, client’s home, client’s resources, client’s needs, and learning capacity
Occupational health nursing (Rogers, 1994)	Shows how the occupational health nurse works to improve, protect, maintain, and restore the health of the worker/workforce and depicts how practice is affected by both external and internal work setting influences	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 care, counseling, management, research, legal/ethical monitoring, community orientation)
Omaha System (Martin, 2005)	Comprehensive classification system that promotes documentation of client care, generally in community and home health nursing practice	Depicts the nursing process as circular rather than linear; steps are: collect and assess data, state problems, identify admission problem rating, plan and intervene, identify interim/dismissal problem rating, and evaluate problem outcomes.
Schuler Nurse Practitioner Practice Model (Schuler & Davis, 1993).	Integrates essential nursing and medical orientations to provide a framework for holistic practice for nurse practitioners (NP)	Patient and NP inputs (noted as episodic and comprehensive 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 care. Outputs involve comprehensive evaluation of patient and NP outcomes.
Public health nursing practice (Smith & Bazini-Barakat, 2003)	Guides public health nurses to improve the health of communities and target populations	Interdisciplinary public health team, standards of public health nursing practice, essential public health services, health indicators, population-based practice (systems, community, individual, and family focus), healthy people in health communities
Rural nursing (Weinert & Long, 1991)	Guides rural nursing practice, research, and education by understanding and addressing the unique health care needs and preferences of rural persons	Health (health as ability to work), environment (distance and isolation), person (self-reliance and independence), nursing (lack of anonymity, outsider/insider, and old-timer/newcomer)

Benner’s Model of Skill Acquisition in Nursing

Patricia Benner’s theoretical model was first published in 1984. The model, which applies the Dreyfus model of skill acquisition to nursing, outlines five stages of skill acquisition: novice, advanced beginner, competent, proficient, and expert. Although her work is much more encompassing in regard to nursing domains and specific functions and interventions, it is the five stages of skill acquisition that has received the most attention with regard to application in administration, education, practice, and research.

Purpose and Major Concepts

Benner’s model delineates the importance of retaining and rewarding nurse clinicians for their clinical expertise in practice settings because it describes the evolution of “excellent caring practices.” She notes that research demonstrates that practice

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