THEOR E TIC AL FOUNDAT ION

IN NUR SING

IN TR ODUC TION TO
MIDDLE RANGE
NURSING THEORIES
SU B U NIT 10
BASBA S, ROBI LYN
BANTAYAN, MELODY T.
CALIG- ONAN, JER AVELLE T.
CAM POREDONDO, JESSA D.
 INTRODUCTION TO
MIDDLE RANGE NURSING
THEORIES
BANTAYAN, MELODY T.
An n ett e Co h en is a se co n d-ye ar grad uat e n ursin g st ude nt
int erest ed in st arti n g h e r major re se arch /sch o lar sh ip
project .

Sh e wo uld like t o develop so me of h er ex pe rien ces in

h o spice nu rsin g int o a pre li min ary m iddle- ran ge t h eo ry
of spir it ual h ealt h .

An n ett e h as st udie d spi rit ual n ee ds an d spir it ual care for

many year s but be lieves t h at t h e con st ruct of spirit ual
h e alt h is n ot well un der st o od.
Aft er reviewin g t h e oreti cal w riti n gs dealin g wit h spirit ual n ur sin g care ,
An n ett e fo un d a st arti n g po int fo r h e r work in Je an Wat son’s Th e ory of
Hum an Carin g ( Wat so n , 2012) because of it s emp hasis on spirit ualit y an d
fait h . Fro m Wat son’s (2012) wor k, sh e was p ar ti cularly int erest ed in
ap ply in g t h e co n ce pt s of “act ual car in g occasion” an d “t ran spe rson al” care.
To deve lop t h e t h e or y, An n ett e o bt ain e d a copy of Wat son’s m ost re ce nt
work an d pe rform ed a compreh e n sive review of t h e lit e rat ure cove rin g
t h eo ry developme nt an d t h e Th eo ry of Hum an C ar in g.

Combin i n g t h e con cept an alysi s an d t h e lit erat ure review of Wat so n’s wor k
led t o t h e develo pment of assumpti on s an d formal defi n iti on s of relat ed
con cept s an d emp irical in dicat ors.
Com pare d t o gran d t h eo rie s, middle ran ge t h eor ies are mo re specifi c,
h ave fewe r co n ce pt s, and en compass a more limit ed aspe ct of t h e real
world. Co n cept s are relati ve ly con cret e an d may be e mpirically t e st e d.

Th e disciplin e of n ursin g recogn izes midd le ran ge t h e ory as on e of t h e

cont e mporary t ren ds in kn owledge develop ment , an d t h e re is broad
accept an ce of t h e n ee d t o develop middle ran ge t h eor ies t o suppo rt
n ursin g practi ce an d nur sin g re se arch ( Alligoo d, 2014; Fit zpat r ick, 2014;
Kim, 2010; Pet er so n ,2017) .
Acco rdin g t o Suppe (19 96), t his call t o deve lop middle range t h e ory i s
co n sist ent w it h t h e t h ird st age of leg iti mizin g t h e discip lin e of n ursin g.
Th e fi r st st age focusses on diff e renti ati on of t h e per spe cti ve of t h e
e mergin g disciplin e, wh ich is ch aract erized by separati o n from ant ecede nt
disciplin es.
Th e seco n d st age is m arked by t h e quest t o se cure in sti t uti o n al
le gi ti m acy an d acade mic aut on o my. Th is st age ch aract e rize d n ursin g durin g
1970s an d t h ro ugh t h e 1980s, wh e n pursuit of n ur sin g’s un ique
per specti ve o n an d clar ifi cati on of t h e ph e n ome n a of int e rest t o t h e
disciplin e we re st ressed.
Th e t h ird st age began in t h e 1990s an d i s disti n guish e d by in creased
att enti o n t o subst anti ve kn ow le dge deve lo pm ent , w h ich in clude s
deve lopme nt an d t e sti n g of m iddle ran ge t h eo ries.
A review of n ursin g re se arch j ourn als and disser t ati o n abst ract s in di cat es t h at
n ursin g research is curre nt l y bein g used in t he develo pment and t e sti n g of a
n umbe r of m iddle ran ge t h e or ies, an d m idd le ran ge t h e or ies are f reque nt ly
bein g used as framewo rk s for i nve sti gati on .

De spit e t h e re cent pro moti on of middle ran ge t h e orie s, t h ere is a lack of clarit y
re gardin g wh at con sti t ut es middle ran ge t h eo ry in n ursing . Accordin g t o Codd y
(1999) , “ It appear s t h at almost any t h e oreti cal enti t y t hat is m ore con cret e t h an
t h e bro adest of gran d t h eo ries is con side red m iddle ran ge by so meo n e”.
Seve ral n ursin g t h eor y t ex t bo ok (e .g., Alligood, 2014;Ch i n n & Kram er, 20 15;
Fawcett & DeSant o- Madeya, 2013; M . C . Smit h & Parker, 2015) d isagre e t o
some ex t ent o n wh ich t h eo rie s sh ould be labele d as middle ran ge . In de ed,
some aut h or s list a few of t h e readily accept e d gran d t h eo ries (e.g., Parse,
Newman , Pe plau, an d Orland o) as middle ran ge. Ot h er s co n sider somewh at
mo re circumscribe d t h eor ies (e.g., Lein in ge r, Pen de r, Ben n er an d Erickso n,
To mlin , an d Swain) t o be middle ran ge , alt h o ugh t h e t h e ory ’s aut h ors may n ot
agre e.
 Purposes of Middle Range
Theory
Middle ran ge t h e or ies were fi rst sugge st e d in t h e d isciplin e of socio lo gy in
t h e 1960 s an d were int roduced t o n ur sin g in 1974.

Develop ment of m iddle ran ge t h e orie s is suppor t ed by t h e f re quent

criti que of t h e abst ract n at ure of gran d t he or ies an d diffi cult y of t h eir
applicati o n t o practi ce an d research . Th e f un cti o n of m iddle range t h e or ies
is t o describe, ex plain , or p red ict p h en o men a, an d, like gran d t h e or y, t h ey
must be ex plicit an d t e st able. Th us, t h ey are e asie r t o apply in p racti ce
sit uati on s an d t o use as f ramewo rks for re search st ud ies.
Fin ally, a majo r role of middle ran ge t h eor ies but are n ot con sciously aware t h at
t h ey are doin g so.

Each middle ran ge t h e orie s in n ur sin g is suppo rt e d by several f act o rs.

 Are mo re usef ul in research t h an gran d t h e orie s because of t h e ir low level

of abst racti o n an d e ase of ope rati o n ali zati on .
 Te n d t o suppo rt pre dicti on bett e r t h an g ran d t h e orie s due t o circum scribe d
range an d specifi cit y of t h e con cept s
 Are mo re like ly t o be adopt e d i n p racti ce b ecause t h e ir re lati ve simplicit y
eases t h e p rocess of deve lopin g int er venti on s for identi fi ed h ealt h
pro ble ms (Cod y, 1999; Pet e rso n , 201 7).
Middle Range Theory has three functi ons in nursing knowledge
development:

First, middle range theories are used as theoreti cal frameworks for
research studies.
Second, middle range theories are open to use in practi ce and
should be tested by research.
Finally, middle range theories can be the scienti fi c end product that
expresses nursing knowledge (Suppe, 1996).
 Characteristic of Middle Range
Theory
Several ch aract e risti cs identi f y nu rsin g t h e orie s as
middle ran ge.
First , t h e prin cipal ide as of m iddle ran ge t he or ies are
re lati ve ly simple, st raightf o rward, an d ge n eral.
Secon d, middle ran ge t h eo ries co n sider a lim it ed
n umbe r of variables or con cept s; t h ey h ave a parti cular
su bst anti ve focus an d con side r a limit e d aspe ct of re alit y.
Th ird, middle ran ge t h eo rie s focus o n prim arily on
client proble ms an d likely o ut co mes as well as t h e eff e ct s
of n ursin g int erventi on s on client out come s.
 Fin ally, middle ran ge t h e or ies are specifi c t o n ur si ng an d may specif y an area
of practi ce, age ran ge of t h e clie nt , n ursin g acti o n s or int er venti on s, an d
prop osed out come s ( Me leis, 2012; Pet erson , 2017).

Th e m ore freque nt ly use d middle ran ge t h e orie s t en d t o be t h o se t h at are

clearly st at e d, easy t o un de rst an d, int e rn ally co n sist ent , an d co he re nt . Th ey
deal wit h cur rent n ursin g pe rspecti ve s an d addre ss so cially re levant t opics t h at
so lve me an in gf ul an d per sist ent pro blems.
.
 CONCEPTS AND
RELATIONSHIPS FOR
MIDDLE RANGE THEORY
BASBAS, ROBILY N
 Concepts and Relationships for

Middle Range Theory

Middle range theories consist of two or more concepts

and a specifi ed relati onship between the concepts.
Middle range theories address phenomena (concepts)
that are toward the middle of a conti nuum of scope
with the metaparadigm concepts (nursing, person,
health, environment) at one end and specifi c concrete
acti ons or events (medicati on administrati on,
preoperati ve teaching, electrolyte management, fall
preventi on) at the other.
 Concepts and Relationships for

Middle Range Theory

The concepts should be discrete, observable, and

suffi ciently abstract to be applied across multi ple
setti ngs and used with clients with diff ering problems
Examples from the nursing literature include theories
describing health promoti on, comfort, coping,
resilience, uncertainty, pain, grief, fati gue, self-care,
adaptati on, self-transcendence, and transiti ons (Meleis,
2012; Peterson, 2017; M. J. Smith & Liehr, 2014).
 Concepts and Relationships for

Middle Range Theory

Middle range theories link discrete and observable

phenomena or concepts in relati onships statements. In
middle range theory, relati onships are explicitly stated,
and, preferably, they are unidirecti onal. Relati onships
can be of several types. The most common are causal
relati onships that state that a change in the value of
one variable or concept is associated with a change in
the value of another variable or concept (Peterson,
2017).
Categorizing Middle Range
Theory

BASBAS, ROBILY N
 Categorizing Middle Range Theory

The questi on as to which nursing theories are middle

range is not clear-cut. Middle range theory is more
specifi c than grand theory but abstract enough to
support both generalizati on and operati onalizati on
across a range of populati ons; this sets it apart from
practi ce or situati on-specifi c theory. In a well-
researched eff ort to describe the place of middle range
theory in nursing, Liehr and Smith (1999) analyzed 22
middle range theories published during the previous
decade. These theories were categorized as “high-
middle,” “middle,” and “low-middle” based on their level
of abstracti on or degree of specifi city.
 Categorizing Middle Range Theory

In the review, high-middle theories included concepts

such as caring, growth and development, self-
transcendence, resilience, and psychological adaptati on.
Middle theories included concepts such as uncertainty
in illness, unpleasant symptoms, chronic sorrow,
peaceful end of life, cultural brokering, and nurse-
expressed empathy. Low-middle theories, those that are
closer to practi ce or situati on-specifi c theories,
included hazardous secrets, women’s anger, nurse
midwifery care, acute pain management, helplessness,
and interventi on for postsurgical pain.
Development of Middle
Range Theory

BASBAS, ROBILY N
 Development of Middle Range Theory

Several methods for development of middle range

theories have been identi fi ed in the nursing literature.
Middle range theories emerge from combining research
and practi ce and building on the work of others.
Sources used to generate middle range theory include
literature reviews, qualitati ve research, fi eld studies,
conceptual models, taxonomies of nursing diagnoses
and interventi ons, clinical practi ce guidelines, theories
from other disciplines, and stati sti cal analysis of
empirical data (Fawcett & DeSanto-Madeya, 2013;
Peterson, 2017). Five approaches for middle range
theory generati on were identi fi ed by Liehr and Smith
(1999)
 Development of Middle Range Theory

Approaches for Middle Range Theory Generati on:

1. Induction through research and practice

2. Deduction from research and practice or application of grand theories

3. Combination of existing nursing and non-nursing middle range

theories

4. Derivation from theories of other disciplines that relate to

nursing

5. Derivation from practice guidelines and standards rooted in

research
Middle Range Theories
Derived from Research
and/or Practice
BASBAS, ROBILY N
 Middle Range Theories Derived From Research

and/or Practice

1. Theory of Family Vigilance (Carr, 2014)

The most common sources for

development of middle range nursing
theories and models are nursing research
and nursing practice. Grounded theory
research and other qualitative methods in
particular are frequently noted as sources
for middle range theory development.
Examples of middle range theories derived
from qualitative research include the
 Middle Range Theories Derived From Research

and/or Practice

2. The Theory of Spiritual Care in

Nursing Practice (Burkhart &
Hogan, 2017)
 Middle Range Theories Derived From Research

and/or Practice
3. A theory describing sustaining health
in faith community nursing practice
(Dyess & Chase, 2012),
 Middle Range Theories Derived From Research

and/or Practice

4. A theory describing “death imminence awareness” of family member

of patients in critical care (Baumhover, 2015),
 Middle Range Theories Derived From Research

and/or Practice

5. And a theory of career persistence in acute

care nurses (Hodges, Troyan, & Keeley, 2010).
Middle Range Theories Derived From Research

and/or Practice

Variations of the idea of development of middle range

theory from research are fairly common. Theorists report
combining qualitative research with literature review,
concept analysis, concept synthesis, theory synthesis,
and other techniques in the process of developing
middle range theory.
 Middle Range Theories Derived From Research

and/or Practice
For example, Murrock and Higgins (2009) explained that they used statement and theory
synthesis, along with literature review, to develop “the theory of music, mood and movement
to improve health outcomes.”
 Middle Range Theories Derived From Research

and/or Practice
In other works, Davidson (2010) developed “facilitated sensemaking” to support families of
intensive care unit (ICU) patients following systematic literature review and synthesis,
 Middle Range Theories Derived From Research

and/or Practice
and Eakes, Burke, and Hainsworth developed the middle range Theory of Chronic Sorrow from an extensive
review of the literature and data gathered through 10 qualitative research studies (Eakes, 2017).
 Middle Range Theories Derived From Research

and/or Practice
Identification of middle range theories and models derived primarily from practice is more difficult. One
example is the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, & Gift, 2017), which was reportedly
developed by integrating or melding existing practice and research information about a variety of
symptoms.
 Middle Range Theories Derived From Research

and/or Practice
A second example is the Client Experience Model (Holland, Gray, & Pierce, 2011), which was reportedly
developed through clinical observations in acute care settings using a practice-to-theory method.

Some models that describe areas of specialty

nursing practice report being developed from
combination of practice and another source,
typically research or standards. One example of
this technique is Benoit and Mion’s (2012) model
for pressure ulcer etiology in critically ill patients,
which was constructed from combining a
literature review and practice standards.
 Middle Range Theories Derived From Research

and/or Practice

The Omaha System, which is a model for community and home health nursing practice, is a second
example. Martin (2005) explained that the conceptual framework for the Omaha System was a combination
of practice, research, and literature review.
MIDDLE RANGE THEORY
DERIVED FROM A GRAND
THEORY
CALIG- ONAN , JERAVELLE T.
 Middle Range Theory Derived From a Grand Theory

During the last two decades, several theories developed

from grand theories have been published in the nursing
literature. One example is a middle range theory of health
promotion for preterm infants which was derived from
application of Levine’s Conservation Model.
 Middle Range Theory Derived From a Grand Theory

Mefford (2004) used Levine’s Conservation Model of Nursing

to develop a Theory of Health Promotion for Preterm
Infants. In this case, Levine’s theory was used as a
framework for nursing practice for the neonatal intensive
care unit (NICU) to ensure that needs of both the infant and
family are addressed.
 Middle Range Theory Derived From a Grand Theory

Conceptual diagram of Levine’s conservati on model of nursing.

 Middle Range Theory
Combining Existing Nursing
and Non-Nursing Theories

CALIG- ONAN , JERAVELLE T.

 Middle Range Theory Combining Existing Nursing and Non-

Nursing Theories

Most commonly used are the theories from behavioral

sciences, sociology, and anthropology.

Combining concepts or elements of multiple theories is common in

middle range theory development. In many cases found in recent
nursing literature, the authors of a middle range theory reported that
they had derived their theory from both nursing and non-nursing
theories. For example, used Orem’s Self-Care Theory and Bandura’s
Self-Efficacy Theory to develop a theory of diabetes self-care
management. Similarly, developed the Theory of Exercise as Self-Care
through “triangulation of Orem’s self-care deficit theory of nursing.
Middle Range Theory Combining Existing Nursing and Non-

Nursing Theories

Dunn (2004) provided an excellent example of combining

existing nursing and non-nursing theories in development of a
middle range Theory of Adaptation to Chronic Pain. Her
intention was to describe coping and pain control in older
adults with the purpose of maintaining their quality of life
and functional ability.
Middle Range Theory Combining Existing Nursing and Non-

Nursing Theories

Theory Development Process: Dunn wrote that the first step

in developing her theory was to review and synthesize the
theoretical knowledge related to pain in older adults, coping
with pain, religious coping, and spirituality. She reported
identification of three theoretical models that addressed
concepts related to pain control and coping in older adults.
 Middle Range Theory
Derived From a Non-Nursing
Discipline

CALIG- ONAN , JERAVELLE T.

Middle Range Theory Derived From a Non-Nursing Discipline

A significant number of middle range nursing theories are

developed from one or more non-nursing theories. Indeed,
non-nursing theories, including those from the behavioral
sciences, sociology, physiology, and anthropology, appear to
be the most common source for theory development, and
many examples are evident. For example, was reportedly
derived from a review of literature from medicine, psychiatry,
ergonomics, and psychology as well as from nursing literature
and history.
 Middle Range Theory Derived From a Non-Nursing Discipline

Covell (2008) proposed the middle range Theory of Nursing Intellectual

Capital to explain the influence of nurses’ knowledge, skills, and
experience on patient and organizational outcomes.

Theory Development Process: Covell (2008) described using strategies

of concept and theory derivation followed by research synthesis to
develop and support the theory’s propositions. Specifically, she noted
how “Intellectual Capital Theory” (ICT) consisted of concepts from
economics, accounting, and organizational learning theory.
Middle Range Theory Derived From a Non-Nursing Discipline

Middle range nursing intellectual capital theory

MIDDLE RANGE THEORY
DERIVED FROM
PRACTICE GUIDELINES
OR STANDARD OF CARE
CAM POREDONDO, JESSA D.
 Middle Range Theory
Middle Range Theories focus on more
specifi c phenomena than grand theories.

Practice Guidelines or
Standard of Care
Standard of care focus explicitly on
linkages between process and outcome.
 Theory of Peaceful End
Of Life: A Mid-Range Theory

Theory of the Peaceful End of Life was developed by Ruland

and Moore derived from standards of care for terminally ill
patients. In this work, the theorists observed that relational
statements of the standards needed to be more specifically
defined to make them applicable for empirical testing.
 Theory Development Process

First Step Second Step

The first step of the theory
development process was
to define the theory’s
assumptions based on the
standards of care.
The second step was to
perform a “statement
synthesis,” whereby five
outcome criteria were
developed that contributed
to a peaceful end of life.
 Theory Development Process

Third Step Fourth Step

The third step, conceptual
definitions for each of the
outcome indicators were
determined.
The fourth step involved
defining relational
statements between the
outcome indicators and the
nursing interventions.
 Theory of
Peaceful End of
Life: Relationships
between the
concepts of the
theory.
Concepts of the Theory of Peaceful End
of Life
NOT BEING IN PAIN

• Monitoring and administering pain relief.

• Applying pharmacological and
non-pharmacological interventi ons.
Concepts of the Theory of Peaceful End
of Life
EXPERIENCE OF COMFORT

• Preventi ng, monitoring, and relieving

physical discomfort.
• Facilitati ng rest, relaxati on, and
contentment.
• Preventi ng complicati ons.
Concepts of the Theory of Peaceful End
of Life
EXPERIENCE OF DIGNITY/RESPECT

• Including the pati ent and signifi cant

others in decision making.
• Treati ng pati ent with dignity, empathy
and respect.
• Being att enti ve to the pati ent’s expressed
needs, wishes, and preferences.
Concepts of the Theory of Peaceful End
of Life
BEING AT PEACE
• Providing emoti onal support.
• Monitoring and meeti ng the pati ent’s
expressed needs for anti anxiety medicati ons.
• Inspiring trust.
• Providing the pati ent and signifi cant others
with guidance in practi cal issues.
• Providing physical presence of another caring
person if desired contribute to the pati ent’s
experience of being at peace.
Concepts of the Theory of Peaceful End
of Life
CLOSENESS TO SIGNIFICANT OTHERS/PERSONS WHO
CARE
• Facilitati ng parti cipati on of signifi cant
others in pati ent care;
• Att ending to signifi cant others’ grief,
worries, and questi ons;
• Facilitati ng opportuniti es for family
closeness.
Concepts of the Theory of Peaceful End of Life
 Final Thoughts on Middle
Range Theory Development
Specific recommendations to enhance development
and use of middle range theory include:
• Clearly articulate the theory name.
• Succinctly describe approaches used for generating
the theory.
• Clarify the conceptual linkages of the theory in a
diagrammed model.
• Elucidate the research–practice links of the theory.
• Explain the association between the theory and the
discipline of nursing.
Analysis and Evaluation of Middle Range
Theory

• Middle range theories should be

subject to evaluation.
• Middle range theory should be
congruent with the philosophical
underpinnings of the theory and should
be critiqued with regard to more than
just the statistical significance of the
findings.
Analysis and Evaluation of Middle Range
Theory

Whall (2016)
• Middle range theories should provide
specifi c empirical referents for defi ned
concepts.
• Middle range theory should have the
ability to operati onalize and measure
aspects of the theory.
• Middle range theories must assess their
congruence with grand theories.
Analysis and Evaluation of Middle Range
Theory
Smith (2014)
She suggested evaluation based on three
categories:
• substantive foundations,
• structural integrity, and
• functional adequacy.
 SUMMARY
Middle Range Theory
• Middle range nursing theories were first introduced into
nursing in the mid-1970s;
• Middle range theories are more specific, have fewer
concepts, and encompass a more limited aspect of the real
world compared with grand nursing theories;
• Middle range theories may be developed through research,
practice, or literature synthesis;
• Middle range nursing theories should be analyzed or
evaluated.
 T HEORET IC AL FOU NDAT ION IN NU R SING

THANK YOU!
SU B U NIT 10

BASBAS, ROB ILYN

BANTAYAN, M ELODY T.
CALIG -ONAN , JERAVELLE T.
CAMPOR EDONDO, JESSA D.