Chapter 11

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 11Chapter 11
Overview of Selected MiddleOverview of Selected Middle
Range Nursing TheoriesRange Nursing Theories

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 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

High Middle Range Theories
• Nearest to grand theories
• Some may be considered grand theories or conceptual
frameworks.
• Include some of the best known and most frequently
used of the nursing theories
– Pender—Health Promotion
– Leininger—Culture
– Transitions
– Synergy Model

Pender’s Health Promotion Model
• Developed by Nola Pender to study health promotion
behaviors; initially published in 1982
• Explores biopsychosocial processes that motivate
individuals to engage in behaviors that promote health

Health promotion model.
(Adapted from Pender, N. J.,
Murdaugh, C. L., & Parsons, M. A.
[2011]. Health promotion in
nursing practice [6th ed.].
Reprinted by permission of
Pearson Education, Inc., Upper
Saddle River, NJ.)

Pender’s Health Promotion Model—(cont.)
• Major Concepts
– Individual characteristics and experiences
• Prior related behavior and personal factors
– Behavior-specific cognitions and affect
• Perceived benefits of action
• Perceived barriers to action
• Perceived self-efficacy
• Activity-related affect
• Interpersonal influences
• Situation influences
– Behavior outcomes

• Used by nurses to develop and execute health-promoting
interventions
• Used to develop research studies focusing on one aspect
of health promotion
• Used frequently as a framework for research studies

• CINAHL search produced 148 articles describing use of
the HPM in practice or research.
• http://nolapender.weebly.com/

Question
Tell whether the following statement is true or false:
Nola Pender is the theorist credited with the development
of The Omaha System.

Answer
False
Rationale: Nola Pender is credited with the development of
Pender’s Health Promotion Model. The Omaha System
was developed by the nurses of the Visiting Nurses
Association.

Leininger’s Culture Care Theory
• Madeleine Leininger first presented the “transcultural
health model” in the mid-1970s; it has been modified and
updated several times.
• Purpose of the theory is to generate knowledge related to
caring for persons considering their cultural heritage and
values.
• Goal is to provide “culturally congruent” nursing care to
persons of diverse cultures.

Leininger’s Culture Care Theory—(cont.)
• Leininger was an anthropologist as well as a nurse by
education.
• Major concepts of the model are culture, culture care,
cultural differences (diversities), and cultural similarities
(universals).

• During the past two decades, research on 23 different
cultural groups has been conducted using her theory.
• Many graduate students and nursing scholars have used
her theory as a basis for research.

• Central tenet of the theory is that it is important for the
nurse to understand the individual’s view of illness.
• Understanding cultural similarities and differences will
allow the nurse to positively influence health.
• More info: http://www.tcns.org/

• One of the most frequently cited theories in nursing
literature—197 citations of Leininger’s theory in CINAHL
during the past 10 years.
• Dr. Leininger died in 2012 (87 years old).

Transitions Theory
• Afaf Meleis developed Transitions Theory over about four
decades.
• Began with observations of experiences faced as people
deal with changes related to health, well-being, and
ability to care for themselves
• “Transitions” is a central concept in nursing.

Transitions Theory.
(From Meleis, A. I., Sawyer, L. M., Im, E. O., Messias, D. K. H., & Schumacher, K.
[2000]. Experiencing transitions: An emerging middle range theory. Advances in
Nursing Science, 23[10], 12–28. Used with permission.)

Transitions Theory—(cont.)
• Purposes
– Attempts to describe the interaction between nurses
and patients
– Nurses are concerned with people as they undergo
transitions.

• Purposes—(cont.)
– Goal of nursing therapeutics is to recognize and
address potential problems encountered during
transitional experiences.
– Develop preventive and therapeutic interventions to
support patients during these occasions

• Transitions are viewed as a passage from one fairly
stable state to another fairly stable state; process is
triggered by a change.
– Transitions are characterized by different stages,
milestones, and turning points.
– Transitions can be assisted or managed by nurses.
• Categories of transitions
– Developmental
– Situational
– Health–illness
– Organizational

• Nurses should consider “facilitators” and “inhibitors” of
transitions.
• “Nursing therapeutics” are activities and actions.
– Readiness
– Preparation for transition
– Role supplementation
• Relatively new theory but becoming increasingly
recognized in the literature
• Widely applicable and used in both practice and research

Transitions Theory—Resource
• http://www.upenn.edu/almanac/v48/n03/Meleis.html

Synergy Model
• The Synergy Model for Patient Care was developed in the
mid-1990s by the AACN Certification Corporation.
• Designed to be a framework for certified practice

Synergy Model—(cont.)
• Purpose is to describe nurses’ contributions, activities,
and outcomes related to caring for critically ill patients.
• Model intended to be a conceptual framework for
designing practice and competencies.
• Also used for research

The Synergy Model
delineates three levels
of outcomes: Those
derived from the
patient, those derived
from the nurse, and
those derived from the
health care system.
(From Curley, M. A. Q. [1998].
Patient–nurse synergy:
Optimizing patients’ outcomes.
American Journal of Critical
Care, 7[1], 69. Used with
permission of American
Association of Critical-Care
Nurses.)

• Involves three levels of outcomes—relating to the
patient, nurse, and the system
• Patient outcomes include functional and behavioral
change, trust, satisfaction, comfort, and quality of life.
• Nurse outcomes include physiological changes,
complications, and attainment of objectives.
• System outcomes include recidivism, costs, and resource
utilization.

Question
Which of the following is NOT one of the levels of outcomes
included in the Synergy Model?
A. Outcomes of the nurse
B. Outcomes of the patient
C. Outcomes of the system
D. Outcomes of the provider

Answer
D. Outcomes of the provider
Rationale: The Synergy Model does not include the
outcomes of the provider in the three levels of outcomes
of the model.

• Use of the Synergy Model is designed to optimize
outcomes.
• When patient characteristics and nurse competencies
match and “synergize,” outcomes for the patient are
optimal.

• The model has been used for about a decade.
• Many articles have been published; most describe
practice application, some research.
• Also considerable indication that it can be used in
practices other than critical care

Examples of Other Middle Range Theories
• High middle range theories
– Model of Skill Acquisition in Nursing (Benner, 2001)
– Omaha System
– Tidal Model (psychiatric nursing) (Baker, 2001)
– Occupational Health Nursing (Rogers, 1994)

Middle Middle Range Theories
• Most frequently identified theories as “middle range”
• Not as broadly applicable as the “high” middle range
theories but do relate to multiple settings and
populations
• Frequently used examples
– Uncertainly of Illness Theory
– Theory of Comfort
– Theory of Unpleasant Symptoms

Uncertainty in Illness Theory
• Develop by Merle Mishel in the early 1980s
• Intent to explain stress resulting from hospitalization
• Theory explains how clients cognitively process illness-
related stimuli and construct meaning in these events.
• Uncertainty is the inability to structure meaning and
develops if the person does not form a “cognitive
schema” for the illness.

Uncertainty in Illness Theory—(cont.)
• Individuals cognitively process illness-related stimuli.
• Explains how they structure meaning for the illness
stimuli
• Adaptation is the desirable end state.
– Achieved after coping with the uncertainty
• Nursing should develop interventions to influence the
person’s cognitive process to address the uncertainty,
thus producing positive coping and adaptation.

Model of perceived uncertainty in illness.
(From Mishel, M. H. [1990]. Reconceptualization of the uncertainty in illness theory.
Image: Journal of Nursing Scholarship, 22[4], 256–262. Used with permission of
John Wiley & Sons, Ltd.)

Question
Tell whether the following statement is true or false:
According to Mishel in the Uncertainty in Illness Theory, the
clients’ cognitive process and understanding of their
illness construct the meaning of events.

Answer
True
Rationale: In the theory by Mishel, Uncertainty in Illness,
the patient’s cognitive ability and understanding has an
impact on the constructed meaning of the situation.

Uncertainty in Illness Theory—(cont.)
• Forty-six articles were identified using this theory in
practice or research.
• Examples—studies looked at:
– Quality of life among elder breast cancer survivors
– Use of social support to reduce illness uncertainty
– Examination of effect of illness uncertainty on anxiety
and depression in adolescents with asthma

Comfort Theory
• Katherine Kolcaba started developing the Theory of
Comfort as a concept analysis while she was a graduate
student.
• The Theory of Comfort was initially published in 1994 and
later modified.
• Comfort theory observes that patients experience need
for comfort in stressful health care situations.

Comfort Theory—(cont.)
• Comfort is the “satisfaction of the basic human needs for
relief, ease, or transcendence arising from health care
situations that are stressful.”
• Increasing comfort can result in having negative tensions
reduced and positive tensions engaged.
• Comfort is an outcome of care that can promote or
facilitate health-seeking behaviors.

Comfort Theory—(cont.)
• Needs of the patient are identified by the nurse, who
then implements interventions to meet them.
• Outcomes of comfort can be measurable, holistic,
positive, and nurse sensitive.
• Several research studies by Dr. Kolcaba and her
associates have been published.

The conceptual framework for the theory of comfort.
(© Kolcaba, 2007. Used with permission.) http://thecomfortline.com

Comfort Theory—Resource
• http://www.thecomfortline.com/theory.html

Theory of Unpleasant Symptoms
• The Theory of Unpleasant Symptoms was developed in
the mid-1990s by a group of nurses interested in
symptom management.
• It is based on the premise that there are commonalities
in experiencing different symptoms in and among
different groups and in different situations.
• Developed to integrate existing knowledge about a
variety of symptoms to improve symptom management

Theory of Unpleasant Symptoms—(cont.)
• The Theory of Unpleasant Symptoms helps nurses
recognize the need to assess multiple aspects of
symptoms including characteristics of the symptom(s),
the underlying disease, or other cause.
• The frequency, intensity, duration, quality, and distress
felt by the patient
• Several articles addressing both research and practice
have been published.

Updated version of the middle range theory of
unpleasant symptoms.
(From Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. [1997].
The middle range Theory of Unpleasant Symptoms: An update. Advances in
Nursing Science, 19[3], 14–27. Used with permission.)

• Three major components
– Symptoms that the individual is experiencing
– Influencing factors that produce or affect the
symptom experience
– Consequence of the symptom experience
• Symptoms are described in terms of duration, intensity,
distress, and quality.
• Influencing factors can be physiologic, psychological,
and/or situational.

• Growing number of research articles in the nursing
literature

• Middle middle range theories
– Chronic illness trajectory framework (Corbin &
Strauss, 1991)
– Client interaction model of health behavior (Cox,
1982)
– Motivation in health behavior (Cox, 1985)
– Theory of care-seeking behavior (Lauver, 1992)

—(cont.)
• Middle middle range theories—(cont.)
– Self-efficacy (Lenz and Shortridge-Bagget)
– Social support (Norbeck, 1981)
– Self-transcendence (Reed)

Low Middle Range Theories
• The number of low middle range theories in nursing is
growing.
• These theories are much more focused; deal with one
specialty practice, age range, or situation.
• Examples
– Theory of Chronic Sorrow
– Postpartum Depression

Theory of Chronic Sorrow
• Concept of chronic sorrow was first coined in the early
1960s in psychology to describe the grief of parents of
children with mental deficiencies.
• Later research indicated similar patterns in parents of
mentally or physically disabled children.
• The Nursing Consortium for Research on Chronic Sorrow
expanded the concept to include individuals who
experience a variety of loss situations and their
caregivers.

Theory of Chronic Sorrow—(cont.)
• The Theory of Chronic Sorrow was first published in
1998.
• Derived and validated through a series of research
studies and review of existing research
• Chronic sorrow is the “periodic recurrence of permanent,
pervasive sadness or other grief related feelings
associated with a significant loss.”

• The theory was developed to help analyze individual
responses of people experiencing ongoing disparity due
to chronic illness, caregiving responsibilities, loss of the
“perfect” child, or bereavement.
• The sorrow is cyclic or recurrent and brings to mind a
person’s losses, disappointments, or fears.

• Antecedent to chronic sorrow is experiences of a
significant loss.
• The loss is ongoing with no predictable end.
• Disparity is created when the reality is different from the
idealized.
• Trigger events (e.g., milestones, situations, and
conditions that create negative disparity) exacerbate the
experience of disparity.

• Nurses need to view chronic sorrow as a normal response
to loss.
• They should foster positive coping strategies and
encourage activities that increase comfort.
• Interventions include listening, offering support and
reassurance, providing information, and appreciating the
uniqueness of each individual.

• Individuals and groups from the Nursing Consortium for
Research on Chronic Sorrow have published several
research studies using the theory.

Beck’s Theory of Postpartum Depression
• Cheryl Beck developed a theory regarding postpartum
depression using a grounded theory approach.
• The purpose of the theory was to provide insight into the
experience of postpartum depression.

Beck’s Theory of Postpartum Depression—
(cont.)
• Concepts or stages
– Encountering terror (anxiety attacks, obsessive
thinking)
– Dying of self (“unrealness,” isolation, contemplating
self-destruction)
– Struggling to survive (prying for relief, seeking
solace)
– Regaining control (making transitions, attaining
recovery)

Beck’s Theory of Postpartum Depression—
(cont.)
• Nursing intervention should alert nurses to incidence and
impact of postpartum depression.
• Stresses the importance of identifying mothers who
might be suffering from postpartum depression
• Although the theory is relatively new, it has been used in
several studies.

• Low middle range theories
– Theory of adaptation to chronic pain (Dunn, 2004)
– Maternal role attainment/becoming a mother
(Mercer, 1980s)
– Theory of the peaceful end of life (Ruland & Moore,
1998)
– Theory of caregiver stress (Tsai, 2003)

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