Chapter 10

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 10Chapter 10
Introduction to Middle RangeIntroduction to Middle Range
Nursing TheoriesNursing Theories

Middle Range Theory
• Middle range theories
– Lie between grand theories and practice theories
– Have fewer concepts and encompass a more limited
aspect of reality
• Concepts are relatively concrete and often operationally
defined.
• Propositions are relatively concrete and can be empirically
tested.

Middle Range Theory—(cont.)
• Middle range theories are used by “emerging
disciplines” because they are readily operationalized.
– Easier to apply in practice
– Easier to apply as frameworks for research studies

• Nursing has recognized middle range theory development
as the latest step in knowledge development.
– There is broad acceptance of the need to develop
middle range theories to support nursing practice.
– This is consistent with the desire to legitimatize
nursing as a profession.

Question
Tell whether the following statement is true or false:
Compared with grand nursing theories, middle range
theories are easy to apply in practice and can readily be
used for research.

Answer
True
Rationale: Middle range theories are increasingly being
used by nurses because they are readily operationalized
and easy to apply in clinical settings.

• Many researchers prefer to work with middle range
theories.
– They provide a better basis for generating testable
hypotheses.
– They address particular client populations and
situations.
• Nursing research is currently being conducted to develop
and test many middle range theories.
• Middle range theories were first introduced into nursing
in the early 1974 but are now being used increasingly as
frameworks for investigation.

Characteristics of Middle Range Theories
• Ideas are relatively simple and general.
• Consider a limited number of variables or concepts
• Have a substantive focus
• Consider a limited aspect of reality
• Can be tested empirically
• Focus on client problems and outcomes
• May specify an area of practice, client age range, nursing
actions or interventions, and outcomes

Frequently Used Middle Range Theories
• Are clearly stated and easy to understand
• Consistent and coherent
• Deal with current nursing perspectives
• Address relevant topics that solve persistent problems
• Can easily be adopted to guide nursing practice

Concepts and Relationship Statements
• Middle range theories consist of two or more concepts
and specified relationship(s) between the concepts.
• Concepts should be discrete, observable, and sufficiently
abstract to be applied across multiple settings.
• Examples of middle range concepts
 Health promotion
 Comfort
 Coping
 Resilience
 Pain
 Self-transcendence

Comparison of Grand, Middle Range, and
Practice Theories
GrandGrand Middle RangeMiddle Range PracticePractice
Complexity/Complexity/
abstractnessabstractness
Comprehensive,Comprehensive,
globalglobal
Middle view ofMiddle view of
realityreality
Narrow view;Narrow view;
simplesimple
Generalizability/Generalizability/
specificityspecificity
Nonspecific toNonspecific to
setting orsetting or
specialtyspecialty
May beMay be
generalized togeneralized to
multiple settingsmultiple settings
Linked to specialLinked to special
groups or type ofgroups or type of
practicepractice
ConceptsConcepts Abstract, notAbstract, not
operationalizedoperationalized
Limited numberLimited number
of concreteof concrete
Single, concreteSingle, concrete
conceptconcept
TestabilityTestability Not testableNot testable May generateMay generate
testabletestable
hypotheseshypotheses
Goals andGoals and
outcomesoutcomes
testabletestable
Source ofSource of
developmentdevelopment
ThoughtfulThoughtful
appraisal; manyappraisal; many
yearsyears
Evolve fromEvolve from
grand theories,grand theories,
practice, andpractice, and
literatureliterature
Derived fromDerived from
practice orpractice or
middle rangemiddle range
theoriestheories

Development of Middle Range Theory
• Research
• Practice
• Literature review
• Conceptual models or grand theories
• Taxonomies (interventions, diagnosis)
• Guidelines or standards
• Other disciplines

Middle Range Theories Developed From
Practice or Research
• Includes those developed from grounded theory
research and other qualitative methods
 Theory of chronic sorrow (Eakes et al.)
 Theory of transitions (Meleis et al.)
 Theory of caring (Swanson)
• Theories from practice are less common.

Question
Tell whether the following statement is true or false:
Middle range nursing theories are often developed from
quantitative research studies but rarely from qualitative or
grounded theory research studies.

Answer
False
Qualitative research studies—particularly grounded theory
studies—often contribute to the development of middle
range nursing theories.

Middle Range Theories Developed From
Grand Nursing Theories
• Many scholars suggest development of middle range
theories from grand theories because of their abstract
nature.
• Some examples
– Nurse-expressed empathy (Olson & Hanchett)—
Orlando’s Model
– Theory of self-care (Rew)—Orem’s self-care
– Prevention as intervention (August-Brady)—Neuman
Systems Model

Middle Range Theories Derived From Non-
Nursing Theories
• A very significant number of middle range theories are
developed from non-nursing theories.
• Most commonly used are theories from behavioral
sciences, sociology, and anthropology.
 Health Belief Model (behavioral sociology)
 Theory of Reasoned Action (behavioral psychology)
 Social Learning/Social Cognitive Theory

Middle Range Theories Derived From Non-
Nursing Theories—(cont.)
• Examples of nursing theories
– Theory of comfort (Kolcaba,1994)—medicine,
psychiatry, ergonomics, and psychology
– Theory of skill acquisition (Benner, 2001)—Dreyfus
model of skill acquisition (mathematician and
philosopher)
– Uncertainty in illness theory (Mishel & Clayton, 2003)
—chaos theory

Middle Range Theories That Combine
Nursing and Non-Nursing Theories
• Combining concepts or elements of multiple theories is
very common in middle range theory development.
• Examples
– Theory of exercise as self-care (Ulbrich, 1999)—
Orem’s + transtheoretical model + concept of risk
– Self-transcendence (Reed, 1991)—Rogers’ Unitary
Human Beings + developmental psychology
– Theory of adaptation to chronic pain (Dunn, 2004)—
Roy adaptation model + gate control theory, stress
and coping (Lazarus) + relaxation theory

Middle Range Theories Derived From
Practice Guidelines and Standards
• Appear to be the least common source for middle range
theory development in nursing
• Examples
– Public Health Nursing Practice Model (Smith & Bazini-
Barakat, 2003)—several sources including Healthy
People 2010, Standards of PHN Practice, and 10
Essential Services of Public health
– Theory of Peaceful End of Life (Ruland & Moore,
1998)—standards of care for terminally ill

Development of Middle Range Theory—
Guidelines
• Articulate the theory name (identify it as a middle range
theory).
• Describe approach used to develop the theory.
• Clarify the conceptual linkages in a diagram or model.
• Describe the research–practice links of the theory.
• Explain the association between the theory and the
discipline of nursing.

Levels of Middle Range Theory
• May be categorized as “high,” “middle,” and “low” middle
range theories
– High middle range theories include broad, fairly
abstract concepts.
• Caring, transcendence, adaptation, culture
– Middle range theories generally consist of
theoretically defined, fairly specific constructs.
• Uncertainty in illness, unpleasant symptoms,
chronic sorrow
– Low middle range theories are more defined and
specific.
• Women’s anger, acute pain management,
intervention for postsurgical pain

Middle Range Theory—Future Directions
• Middle range theory development and application will and
should be increasingly emphasized in nursing.
• Attention to middle range theory in practice and research
in particular will assist evolution of the discipline’s
science.

Chapter 10

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