Middle range nursing theories are necessary for the advancement of the discipline

Jacqueline Fawcett i

i PhD, RN, FAAN. Professor College of Nursing and Health Sciences University of Massachusetts Boston, USA. jacqueline.fawcett@umb.edu
* Paper presented at a conference sponsored by Universidad de La Sabana. Facultad de Enfermería, Chía, Cundinamarca, Colombia, October 26, 2004.

ABSTRACT

This article tries to discuss general aspects on models of nursing knowledge, basic elements for its development and practice. First, it shows the importance of the development of knowledge sustained by the practice and the expression of it by means of four knowledge models: empirical or nursing science, ethical, esthetical or nursing art, and personal.

It presents the discussion on evolution of epistemological questions toward philosophy and ontology. It tries to progress in the knowledge of the self or essence of what is known, to end with a summary on repercussions of knowledge models inclusion in syntax of nursing discipline.

KEY WORDS: Nursing practice, knowledge model, personal knowledge model, empirical model or nursing science, ethical model and nursing moral, aesthetic model or nursing art.

Este artículo trata de discutir aspectos generales sobre los patrones de conocimiento de enfermería, y los elementos de fundamentación para el desarrollo del conocimiento y la práctica. En primera instancia muestra la importancia del desarrollo del conocimiento que sustenta la práctica, y cómo éste se expresa en cuatro patrones: empírico o ciencia de enfermería, ético, estético o arte de enfermería y el conocimiento personal.

Se hace asi mismo una descripción de cada patrón de conocimiento, comenzando por el personal. El significado de este patrón, el menos desarrollado de los cuatro, se muestra como algo básico para el desarrollo de los patrones ético y estético, ya que es casi condición sin la cual los mencionados patrones no pueden desarrollarse a plenitud ni ser expresados en la práctica de manera satisfactoria.

Se plantea la discusión de la evolución de las preguntas epistemológicas de los patrones hacia lo filosófico y ontológico. Es decir, se pretende progresar del conocer hacia el ser o esencia de lo conocido para terminar resumiendo las repercusiones que tiene la inclusión de los patrones del conocimiento en la sintaxis de la disciplina de enfermería.

PALABRAS CLAVE: Práctica de enfermería, patrón de conocimiento, patrón de conocimiento personal, patrón empírico o ciencia de enfermería, patrón ético y moral de enfermería, patrón estético o arte de enfermería.

The Structural Holarchy of Nursing Knowledge

I have identified a structural holarchy of nursing knowledge that differentiates five components of nursing knowledge according to their level of abstraction (1). A holarchy is made up of components that are whole within themselves but also part of a larger whole. In this case, the larger whole is nursing knowledge. Thus, each component of nursing knowledge is a complete whole but also is a part of a larger whole. As can be seen in Figure 1, the most abstract component is the metaparadigm and the most concrete component is the empirical indicator.

Components of nursing knowledge: metaparadigm

A metaparadigm is defined as the global concepts that identify the phenomena of central interest to a discipline, the global propositions that describe the concepts, and the global propositions that state the relations between the concepts (1). The concepts and propositions of a metaparadigm are admittedly extremely abstract and provide no definitive direction for such activities as research and practice. Rather, the function of a metaparadigm is to identify the basic subject matter of the discipline. The subject matter of nursing encompasses human beings, environment, health, and nursing (1).

Components of nursing knowledge: philosophy

Components of nursing knowledge: conceptual model

A conceptual model is defined as a set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe those concepts, and the propositions that state relatively abstract and general relations between two or more of the concepts (1). The function of each conceptual model is to provide a distinctive frame of reference that tells members of a discipline how to observe and interpret the phenomena of interest to the discipline. Although conceptual models address all of the concepts representing the subject matter of the discipline, as identified in the metaparadigm, each metaparadigm concept is defined and described in a different way in different conceptual models. The most widely recognized and utilized conceptual models of nursing in the United States of America, and perhaps in other countries, are Johnson's Behavioral System Model, King's Conceptual System, Levine's Conservation Model, Neuman's Systems Model, Orem's Self-Care Framework, Rogers' Science of Unitary Human Beings, and Roy's Adaptation Model (2-16).

Components of nursing knowledge: theory

A theory is defined as one or more relatively concrete and specific concepts that are derived from a conceptual model, the propositions that narrowly describe those concepts, and the propositions that state relatively concrete and specific relations between two or more of the concepts (1). The functions of a theory are to narrow and more fully specify the phenomena contained in a conceptual model and to provide a relatively concrete and specific structure for the interpretation of initially puzzling behaviors, situations, and events.

Theories vary in their level of abstraction and scope. Grand theories are relatively abstract and broad, though less abstract than conceptual models. Widely used nursing grand theories include Leininger's (17) theory of culture care diversity and universality, Newman's (18, 19) theory of health as expanding consciousness, and Parse's (20, 21) theory of human becoming.

Frederick Suppe, a philosopher of science from the United States of America, has pointed out that "As science matures, the development of knowledge moves from the [conceptual models and] grand theories to the development of middle-range theories that are less abstract and more empirical or practice based" (Suppe, as cited in Schmidt, p. 9) (22). Given our interest in the advancement of the discipline of nursing, this presentation focuses on middlerange theories.

Many other middle-range nursing theories exist. Indeed, one can argue that the product of every nursing study represents a middle-range theory (28). Several explicit middle-range theories have been presented in two recently published books. One book includes chapters addressing a theory of pain, the theory of unpleasant symptoms, the theory of self-efficacy, the theories of reasoned action and planned behavior, a theory of empathy, the theory of chronic sorrow, a theory of social support, the theory of interpersonal relations, the theory of modeling and role-modeling, the theory of comfort, a theory of health-related quality of life, the theory of health promotion, the theory of the deliberative nursing process, a theory of self-efficacy, a theory of planned change, and a theory of resilience (29). The other book includes chapters addressing the theories of uncertainly in illness, a theory of selfefficacy, the theory of unpleasant symptoms, a theory of family stress and adaptation, a theory of community empowerment, a theory of meaning, the theory of self-transcendence, and a theory of attentively embracing story (30). Although all of the theories included in the two books have been tested in studies conducted by nurses, I am not convinced that all of them are middle-range nursing theories. For example, the theories of social support, self-efficacy, reasoned action, and planned behavior were initially developed within the discipline of social psychology. One could, however, argue that as the result of their testing in nursing situations, those theories may be regarded as shared theories (31, 32). But do shared theories advance our discipline? Perhaps they do but not, I think, as much as nursing discipline-specific theories.

Components of nursing knowledge: empirical indicator

An empirical indicator is defined as a very concrete and specific real world proxy or substitute for a middle-range theory concept; an actual instrument, experimental condition, or procedure that is used to observe or measure a middle-range theory concept (1). The information obtained from empirical indicators typically is called data. The function of empirical indicators is to provide the means by which middle-range theories are generated or tested. Empirical indicators that are instruments yield data that can be sorted into qualitative categories or calculated as quantitative scores. For example, responses to an interview schedule made up of open-ended questions can be analyzed to yield categories or themes, and responses to questionnaires made up of fixed-choice items can be subjected to mathematical calculations that yield a number or score. Empirical indicators that are experimental conditions or procedures tell the researcher or practitioner exactly what to do. They are protocols or scripts that direct actions in a precise manner. Empirical indicators, then, are needed to generate and test middle-range theories.

Types of Middle-Range Theories

There are three types of middle-range theories. Middle-range descriptive theories are the most basic type of middle-range theory. Each descriptive theory describes or classifies a phenomenon and, therefore, may encompass just one concept. When a middle-range descriptive theory describes a phenomenon, it simply names the commonalities found in discrete observations of individuals, groups, situations, or events. When a middle-range descriptive theory classifies a phenomenon, it categorizes the described commonalities into mutually exclusive, overlapping, hierarchical, or sequential dimensions. A middle-range classification theory may be referred to as a typology or a taxonomy. Middle-range descriptive theories are generated and tested by means of descriptive research, which may be qualitative or quantitative in design. Peplau's theory of interpersonal relations is an example of a middle-range descriptive classification theory.

Middle-range explanatory theories specify relations between two or more concepts. Each explanatory theory explains why and the extent to which one concept is related to another concept. Middle-range explanatory theories are generated and tested by means of correlational research, which typically is quantitative in design. Watson's theory of human caring is an example of a middle-range explanatory theory.

Middle-range predictive theories move beyond explanation to the prediction of precise relations between concepts or the effects of one or more concepts on one or more other concepts. This type of middle-range theory addresses how changes in a phenomenon occur. Middle-range predictive theories are generated and tested by means of experimental research, which typically is quantitative in design. Orlando's theory of the deliberative nursing process is an example of a middle-range predictive theory.

Middle-Range Theories and Conceptual Models

The definition of a theory given earlier indicates that a conceptual model always is the precursor to a theory. Indeed, the British physicist and philosopher of science Sir Karl Popper (33) maintained that inasmuch as "we approach everything in the light of a preconceived theory (33), the belief held by some that theory development proceeds outside the context of a conceptual frame of reference is "absurd" (34). Indeed, "all theories … stem from cultural and historic contexts that lend them meaning and influence how they are understood and implemented" (35). The particular cultural and historical context from which a theory stems is evident in the conceptual models from which the theory was derived.

Many middle-range theories are needed to deal with all of the phenomena encompassed by any one conceptual model because each theory deals with only a limited aspect of the total reality encompassed by a conceptual model. Each conceptual model, then, is more fully specified by several middle-range theories (Figure 2).

Approaches to connecting conceptual models and middle-range theories

Three approaches to connecting conceptual models and middlerange theories have been identified. One approach is the direct derivation of a middle-range theory from a conceptual model. For example, two theories of family health have been directly derived from King's Conceptual System (36-39). This approach assures a logical linkage between the conceptual model and the middle-range theory. The logic is assured because the world view (reaction, reciprocal interaction, simultaneous action) undergirding the conceptual model and the world view undergirding the theory are the same.

The second approach is to link an existing middle-range nursing theory with a conceptual model of nursing. For example, a researcher might want to link the nursing theory of uncertainty in illness with Johnson's Behavioral System Model. This approach is problematic in that the world view undergirding Johnson's conceptual model and the world view undergirding the conceptual model from which the theory was derived may not be logically congruent. Logical congruence would be evident only if the world view undergirding Johnson's conceptual model and the world view undergirding the conceptual model from which the theory was derived are the same.

The third approach is to link an existing middle-range theory borrowed from another discipline with a conceptual model of nursing. For example, the theory of planned behavior, from the discipline of social psychology, has been linked with Neuman's Systems Model and with Orem's Self-Care Framework (32). As with the second approach, this approach is problematic in that the world view undergirding the Orem's conceptual model and the world view undergirding the conceptual model from which the theory was derived may not be logically congruent. Logical congruence would be evident only if the world view undergirding Orem's conceptual model and the world view undergirding the conceptual model from which the theory was derived are the same.

Grafting a particular borrowed theory onto a nursing conceptual model may be a questionable exercise. … Rather the emphasis could be placed on creating distinctive cognitive approaches with the parameters of nursing. … Nursing research will not advance knowledge if it continues to hang on the coattails of other disciplines. (40).

Roy's Adaptation Model and Middle-Range Theories

Early in te 21st century, Watson (41) declared, "It seems that nursing's very survival is at stake at this moment in history" (41). She went on to issue a "call for nursing to reconsider the very source and core of its existence and whether it is grounded enough to survive" in the reality of modern healthcare (41). I believe that Roy's Adaptation Model provides the necessary grounding for the survival of the discipline of nursing. This conceptual model of nursing, which was first presented almost 35 years ago (42), continues to be widely used by nurses in many countries as a guide for nursing research, nursing practice, nursing education, and administration of nursing services.

When used as a guide for all those nursing activities, Roy's Adaptation Model must be connected with one or more middlerange theories. The first approach to connecting conceptual models and middle-range theories has been used for more than 20 years by nurses who have adopted Roy's model.

Roy and Roberts (43) developed a general theory of the person as an adaptive system, which may be considered a grand theory (44) and separate middle-range theories of the four modes of adaptation the theory of the physiological mode, the theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode. The theory of the person as an adaptive system considers the person holistically. The theory of the physiological mode encompasses regulator subsystem responses related to exercise and rest, nutrition, elimination, fluid and electrolytes, oxygen and circulation, temperature, the senses, and the endocrine system. The theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode consider those modes as systems "through which the regulator and cognator subsystems act to promote adaptation" (43). Each theory describes the relevant system in terms of its wholeness, subsystems, relation of parts, inputs, outputs, and self-regulation and control. The hypotheses derived from the propositions of each theory still have not been tested empirically. However, Roy and Roberts recognized the need for a systematic program of research to test the hypotheses they formulated, as well as other hypotheses that could be derived from the theories. They also recognized the need to further develop and test the theory of the person as an adaptive system. They commented, "We must look at the theory of the adaptive person to further explain the interrelatedness of the adaptive modes. In this process we must also search for multivariable and nonlinear relationships. Cognator and regulator processes must be studied to discover the proposed hierarchy of processes" (43).

Roy and Roberts' (43) pioneering work paved the way for derivation of many other middle-range nursing theories. The nursing model of cognitive processing (45,46), which actually is a rudimentary middle-range theory of information processing, focuses attention on the basic cognitive processes of arousal and attention, sensation and perception, coding, concept formation, memory, language, planning, and motor responses. The model proposes that the basic cognitive processes, which occur within the field of consciousness, are dependent on neurological and neurochemical functions. The model further proposes that cognitive processes are directed toward dealing with the focal stimulus of the immediate sensory experience, taking the contextual and residual stimuli of the person's education and experience into account.

Roy (47) has extended the theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode by introducing middle-range theories of processes. She proposed that within the self-concept mode of adaptation, theories about the physical self and personal self address processes of developing self; theories about self consistency address processes of focusing self, theories about self ideal address processes of choosing self, and theories about the moral-ethicalspiritual self address processes of valuing self. Within the role function mode, theories about primary, secondary, and tertiary roles address processes of developing roles; theories about role transition address processes of role taking; and theories about role set address processes of integrating roles. Within the interdependence mode, theories about significant others address processes of giving and receiving, as well as processes of learning and maturing in relationships, and theories about support systems address processes of securing resources.

Other few explicit middle-range theories that have been derived from the Roy Adaptation Model are:

Theory of caregiver stress (48, 49). ]]> Theory of adapting to diabetes (50).
Theory of psychosocial adaptation to termination of pregnancy for fetal anomaly (51).
Theory of adaptation during childbearing (52).
Additional theory development work stemming from the Roy Adaptation Model includes the construction of explicit conceptual-theoretical-empirical structures for several studies, including:

Preparation for cesarean childbirth (53).
Correlates of functional status in normal life situations and serious illness (54-56).
Adaptation to chronic illness (57).
Cross-cultural responses to pain (58).
Stress experiences of spouses of coronary artery bypass graft patients (59, 60).
Correlates of physiological and psychosocial adaptation in spinal cord-injured persons (61). ]]> Correlates of psychological distress and life satisfaction in diverse caregiver populations (62, 63).
Effects of walking exercise for women with breast cancer (64, 65).
The theoretical component of each of those conceptual theoretical-empirical structures now needs to be formalized as an explicit middle-range theory.

The second and third approaches to connecting conceptual models and middle-range theories also can be used to link Roy's Adaptation Model with existing middle-range theories. The second approach is evident in the linkage of Orlando's (23) theory of the deliberative nursing process with Roy's model. That linkage gives nurses a theoretical basis for validating their perceptions, thoughts, and feelings about relevant stimuli with patients (66). Inasmuch as the reciprocal interaction world view undergirds both Roy's Adaptation Model and the conceptual model from which Orlando's theory was derived (1), the linkage of the conceptual model and the theory is logically congruent. Other existing middle-range nursing theories that are logically congruent with Roy's Adaptation Model are uncertainty in illness, unpleasant symptoms, and community empowerment. Smith and Liehr (30) indicated that those theories were developed within the philosophic context of the interactive-integrative paradigm, which is similar to the reciprocal interaction world view.

Logical congruence in the use of the third approach would be evident if a theory borrowed from another discipline but derived from a conceptual model undergirded by the reciprocal interaction world view were to be linked with Roy's Adaptation Model. Two such theories are self-efficacy and family stress and adaptation. Those theories, according to Smith and Liehr (30), were developed within the philosophic context of the interactive-integrative paradigm.

Advancing the discipline of nursing

Given Latham's (40) objection to creating linkages between conceptual models of nursing and middle-range theories by using theories borrowed from other disciplines, and the extensive work required to identify the world view undergirding existing middlerange nursing theories and theories from other disciplines, we may want to focus our future efforts on deriving middle-range theories directly from a conceptual model of nursing. That first approach to connecting conceptual models and middle-range theories virtually assures logical congruence between the conceptual model and the theory. Furthermore, the language of the theory, that is, the terms used for the theory concepts and the meaning of each concept, will be in keeping with the distinctive language of the conceptual model.

The importance of and need for a distinctive nursing language is mandatory if nursing is to advance as a discipline. More specifically, the vocabulary of each conceptual model and each theory should not be considered unnecessary jargon. Rather, the terminology used by the author of each conceptual model and each theory is the result of considerable thought about how to precisely convey the meaning of that particular perspective to others (67). Nurses have long understood the need for a distinctive vocabulary that differentiates nursing from other sciences and especially from medicine (27). "Language", Batey and Eyres (68) explained, "is fundamental to the evolution of all disciplines and within any discipline, selected terminology evolves to become the concepts that denote the specific knowledge domains and methodologies of that discipline" (68). Akinsanya (69) added, "Every science has its own peculiar terms, concepts and principles which are essential for the development of its knowledge base. In nursing, as in other sciences, an understanding of these is a prerequisite to a critical examination of their contribution to the development of knowledge and its application to practice" (69). And, Barrett (70) commented, "How would one understand anatomy and physiology, microbiology, pharmacology, … without the precise use of language reflecting those domains of knowledge? … Yet various professional groups and consumers may be able to grasp the meaning precisely due to the specificity of description. How else is substantive knowledge to be communicated without saying … what it is …!" (70). Finally, Watson (71) declared, "The attention to language is especially critical to an evolving discipline in that during this postmodern era, one's survival depends upon having language; writers in this area remind us 'if you do not have your own language you don't exist'" (71).

In conclusion, I urge you to select a conceptual model of nursing that interests you and derive middle-range theories from that conceptual model, so that you, too, will contribute most directly to the survival and advancement of our discipline. The widespread use of Roy's Adaptation Model, as well as other conceptual models of nursing, indicates that they are appropriate guides for nursing activities in diverse cultures. Thus, you may select from among several conceptual models as you begin your journey toward middlerange theory development. Taylor's (72) comments about Orem's Self-Care Framework are equally applicable to many other conceptual models of nursing, including Roy's Adaptation Model. She noted, "For years there have been references to a cultural bias in Orem's work. Yet at our conferences and in visits to countries other than the United States of America, there is evidence that Orem's Self- Care Framework has an appeal and universality that extends to all cultures. The requirement, in using [the model], that the unique aspects of various cultures and practices be considered is a part of what makes this so" (73).

Thank you very much for this opportunity to share my ideas about nursing knowledge with you. It is an honor to be part of this wonderful and important nursing conference.

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