Middle Range Theories

"Transition Theory" as a collective has been critiqued by feminist scholars (Parratt & Fahy, 2011) Create assumptions about -----

"all women", which can be seen as disempowering

Middle Range theory production Derived from non-nursing disciplines Large amount of middle-range theories pull from non-nursing --------- Ex: Kolcaba's theory of comfort (covered next class) Ex: Michel's uncertainty theory (covered next class) Ex: Benner novice to expert (from Dreyfus's model of skill acquisition)

Behavioural science, sociology, physiology, anthropology

Mishel's Uncertainty in illness theory Adaptation

Biophysical behavior - within individually defined range of behaviors Neutral zone

Kolcaba's Theory of comfort Theoretical sources

Comfort Holism

Pender's health promotion Behaviour outcomes Commitment to a plan of action Engaging in health promoting behaviours Influenced by:

Competing demands (person thought to have low control over) Preferences (high control)

Pender's health promotion 2. Concepts and conceptual definitions 3 key concepts term-9

Individual characteristics and experiences Behaviour-specific cognitions and affect Behaviour outcomes

Mishel's Uncertainty in illness theory Appraisal

Inference General belief about oneself and r/s with environment Illusion Beliefs constructed out of uncertainty Based on appraisal, uncertainty is viewed as either danger or opportunity

Mishel's Uncertainty in illness theory Coping mechanisms

Opportunity appraisal - preoccupy self with + vs. - Buffering: Avoidance, selective ignoring, reordering priorities

Transitions, uncertainty, (dis)comfort

Origins Theoretical sources Assumptions/key concepts Use in research and practice & potential critique

Mercer's conceptualization of maternal role attainment/becoming a mother Purpose:

To better understand the maternal role, to identify the form and strength of the r/s between maternal and infant variables and maternal role attainment

Pender's health promotion model Purpose:

To explain and predict individuals health promotion behaviours

Mishel's Uncertainty in illness theory Purpose

To explain how clients cognitively process illness-related stimuli and construct meaning in these events To be used to develop nursing interventions that support adaptation following coping with uncertainty To support the production of positive coping and adaptation

Kolcaba's Theory of comfort Purpose

To explain how comfort is experienced in a holistic manner To be used to develop nursing interventions that provide holistic comfort: inclusive of physical, psycho-spiritual, social and environmental interventions To support the production of holistic comfort

Mishel's Uncertainty in illness theory Assumptions

Transition outcomes reflect patterns of response Process indicators Feeling connected, interacting, locating/being situated, developing confidence Outcome indicators Mastery and "fluid integrative identities"

Meleis - Transition theory

Transition: "a passage from one fairly stable state to another fairly stable state, a process triggered by change"

Middle Range theory production Derived from a grand theory Remember grand theories have abstract concepts that are sometimes hard to use in practice Use those concepts to create less abstract, middle-range theory Take the ------ Ex: Orem's theory of self-care for individuals with chronic illness (chronic illness is the new concept) Ex: Orem's theory of self-care for homeless youth (youth + homelessness are the new concepts) Middle Range theory production Created by combining existing nursing and non-nursing theories Combining concepts and/or elements from multiple theories Can use nursing and non-nursing Non nursing tend to be from psychologists & sociologist Middle Range theory production

abstract theory and narrow in a specific population, sometimes adding new concepts

Structure providers (resources)

credible authority (degree of confidence and trust patients have in HCPs) social support Education ( education associated with uncertainty)

Middle Range Theories To ------phenomena Must be----- Must be relevant to-----

describe, explain or predict socially relevant current nursing concerns Should be generalizable to some extent (main and most significant difference from practice theories) Define/refine nursing science/practice

Meleis - Transition theory 4 kinds

developmental (a person coming to terms with their own death) Situational (education level/professional roles, family structures, living arrangements) Health-illness (recovery process, discharge from hospital, disease diagnosis) Organizational (the repealing of funding for planned parenthood services in the USA under the Trump administration; travel ban implications for Canadian University students doing placements/co-ops in US)

Uncertainty develops when a person

does not form a cognitive schema for illness events

Use in research and practice Most nursing care occurs ------ Meleis and Trangesnstein defined nursing as:------- Therefore, Transition theory is widely applicable Guides nursing practice, research and education

during periods of patient transition "art and science of facilitation of the transition of health and well-being and note"

Meleis - Transition theory Properties

Awareness, engagement, change/difference, time span, critical points and events Nursing Therapeutics

Pender's health promotion Identify central relationships

1. Individual characteristics and experiences impact (+/-) health promotion behaviours 2. Behaviour-specific cognitions and affect impact (+/-) health promotion behaviours 3. Behaviour outcomes are impacted (+/-) by relationship 1 and 2

Concepts and relationships for Middle Range Theories

2 or more concepts Must be abstract enough to be applied across multiple settings A relationship between the 2 concepts must exist or be hypothesized and tested Most often casual (X causes Y under certain conditions; a change in X will cause a change in Y)

Mishel's theory re-conceptualized Examined theory as it r/t chronic uncertainty Uncertainty experienced later in illness (chronic illness) becomes foundation for new sense-making -------- New theoretical sources ---- ----- New assumptions

Abandoned expectations of certainty and predictability Critical Social Theory Chaos theory People function in far from equilibrium states Major fluctuations in equilibrium system enhance receptivity to change Fluctuations result in re-patterning

Mishel's Uncertainty in illness theory Assumptions Uncertainty is a part of the illness experience, caused by: --------- Adaptation is the desired outcome of coping efforts

Ambiguity r/t state of illness, complexity regarding treatment options & HC system, lack of info r/t diagnosis and seriousness of illness, unpredictability of the course of the disease and prognosis

Mishel's Uncertainty in illness theory May lead to adaptation

Appraisal Coping mechanisms Adaptation Biophysical behavior

Meleis - Transition theory Purpose

Describe and attend to the interactions between nurses and patients, suggesting that nurses are concerned with the experiences of people as they undergo transitions whenever health and well-being are the desired outcome Develop preventative and therapeutic nursing interventions to recognize and support patients during transition

Mishel's Uncertainty in illness theory Origins ------------------ Part of Mishel's PhD dissertation Started with development of Uncertainty in Illness scale (1981 - see next slide) For adults, communities and parents r/t child illness Produced as a theory in 1988, reconceptualised in 1990

Desire to understand stress that results from hospitalization

Pender's health promotion Identify direction, strength, and quality of relationships

Direction: Linear Strength: equal amongst 1 & 2 Quality: Strong Must explain why concepts have specific relationships (next week) Theory is derived from Bandura's social cognitive theory, so Behaviour is multidimensional, so is determined within a complex interplay between individual agency and social structure (Bandura, 1997) People have power to shaper their own destiny and control outcomes (Bandura, 1997)

Middle Range Theories More specific than grand theories

Have fewer concepts Encompass more limited aspects of the real world Relatively concrete concepts Can be operationally defined Propositions between concepts are relatively concrete and can be empirically tested Qualitative or quantitative Good for addressing specific patient populations

Kolcaba's Theory of comfort

Health care needs Needs (4 categories of previous slide taxonomy) for comfort arise from stressful health care situations that can't be met by current support systems Nursing interventions (comfort care & comfort measures) Nursing actions to address comfort needs Patient comfort Immediate state of being strengthened by having all 4 comfort needs met Intervening variables Interacting forces that influence perceptions of total comfort (adequate staffing, patient acuity) Health seeking behaviors Outcomes r/t pursuit of health, accurate indicator of nurse productivity

Pender's health promotion Existence statements

Health promotion exists and the following concepts are present in the phenomena Individual characteristics and experiences Behaviour-specific cognitions and affect Behaviour outcomes

Pender's health promotion Order of appearances of relationships:

If individuals describe HP prior related behaviours (often tied to high socioeconomic status) they are more likely to have behaviour specific cognitions and affects that better support HP behaviours, which means committing to a plan and action will be easier, and these individuals will exhibit more health promoting behaviours

Reed's self transcendence (ST) theory Purpose:

Improve understanding of transcendence & provide nurses with a framework to provide spiritual & psychosocial expressions of ST at EOL Eakes, Burke & Hainsworth theory of chronic sorrow Purpose: To help analyze individual responses of people experiencing ongoing disparity r/t chronic illness, caregiving responsibilities, loss of the "perfect" child, or bereavement

Mishel's Uncertainty in illness theory ------ between illness events, uncertainty, coping and adaptation

Linear relationships

Pender's health promotion 4. Structure and Linkages

Logical arrangement and linkage Order of appearances of relationships Identify central relationships Identify direction, strength, and quality of relationships

Pender's health promotion Perceived self-efficacy Very important concept Has 4 sources (Bandura, 1997)

Mastery experience Repeated successes or setbacks (prior related behaviour) Physiological and affective states Stress, pain, moods that influence self-efficacy (activity related affect) Vicarious experience Learning occurs through observation and subsequent role modeling (actually interpersonal influence) Verbal persuasion Praise, encouragement, methods used to convince people they have the ability to perform certain behaviours (actually interpersonal influence)

Does Pender's theory exhibit:

Meaning/logical adequacy, operaterm-23tional/empirical adequacy, testability

Categorizing Middle Range Theories

More specific than grand theory Abstract enough to generalize the theory and operationalize the concepts to apply across range of populations Not as specific as practice theory

Middle Range theories What makes them unique?

More specific than grand theory, but abstract enough to support both generalization and operationalization across a RANGE of populations Sets Middle range apart from Practice theories Not comprehensive, but not narrowly focused Some generalizations across settings and specialties Limited # of concepts Clearly stated propositions Can be empirically tested and generate testable hypothesis

Meleis - Transition theory Assumptions

Nurses are concerned with the experiences of people as they undergo transition whenever health and well-being are the desired outcome. Transitions can be assisted or managed by nurses as they care for patients Transition conditions are impacted by facilitators and inhibitors Personal meanings, cultural beliefs and attitudes, socioeconomic status, preparation and knowledge Community conditions, social conditions Nursing therapeutics are important activities during times of transition Assessment of readiness, preparation for transition, role supplementation How could a nurse exemplify these nurse-therapeutics in practice?

Pender's health promotion Behaviour-specific cognitions and affect Influenced by:

Perceived benefits of action Perceived barriers to action Perceived self-efficacy Activity-related affect Interpersonal influences (peers, family), norms, support systems Situational influences (options available for health promotion activity involvement, demands; on time; finances)

Mishel's Uncertainty in illness theory Theoretical sources Information processing models

Personality research (psychology) Stress-appraisal-coping-adaption model Revision to include chronic uncertainty used chaos theory

Pender's health promotion Assumptions

Prior behaviour and inherited and acquired characteristics influence beliefs, affect, and enactment of health-promoting behaviour. Persons commit to engaging in behaviours from which they anticipate deriving personally valued benefits. Perceived barriers can constrain commitment to action, a mediator of behaviour as well as actual behaviour. Perceived competence or self-efficacy to execute a given behaviour increases the likelihood of commitment to action and actual performance of the behaviour. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behaviour. Positive affect toward a behaviour results in greater perceived self-efficacy, which can in turn, result in increased positive affect. When positive emotions or affect are associated with a behaviour, the probability of commitment and action is increased. Persons are more likely to commit to and engage in health-promoting behaviours when significant others model the behaviour, expect the behaviour to occur, and provide assistance and support to enable the behaviour. Families, peers, and health care providers are important sources of interpersonal influence that can increase or decrease commitment to and engagement in health-promoting behaviour. Situational influences in the external environment can increase or decrease commitment to or participation in health-promoting behaviour. The greater the commitments to a specific plan of action, the more likely health-promoting behaviours are to be maintained over time. Commitment to a plan of action is less likely to result in the desired behaviour when competing demands over which persons have little control require immediate attention. Commitment to a plan of action is less likely to result in the desired behaviour when other actions are more attractive and thus preferred over the target behavior. Persons can modify cognitions, affect, and the interpersonal and physical environment to create incentives for health actions.

Pender's health promotion Relational statements

Prior behaviours and personal characteristics (acquired and inherited) influence beliefs, affect, and the enactment of health behaviors. Largely non-modifiable Individuals commit to behaviours that they believe will benefit their lives Largely modifiable and should be the target of HP interventions Perceived barriers can constrain individuals engagement in HP behaviours

Pender's health promotion Individual characteristics and experiences Influenced by:

Prior related (health) behaviours Personal factors Biological Psychological Sociocultural

Pender's health promotion Logical arrangement and linkage:

Prior related behaviours and personal factors (biological, physiological, sociocultural) influence an individuals behaviour specific cognition and affect.

Beck's postpartum depression theory Purpose:

Provide insight in to the experience of PPD & to propose nursing interventions that recognized and intervened with high risk for PPD mothers

Comfort previously defined: Nightingale Types of comfort have been theorized

Relief Ease Transcendence

Meleis - Transition theory Theoretical sources ----(Meleis) ------(exposure during her PhD)

Role insufficiency theory Symbolic interactional theories from sociology

Meleis - Transition theory Patterns

Single, multiple, sequential, simultaneous, related or unrelated

Mishel's Uncertainty in illness theory Key Concepts May lead to uncertainty

Stimuli frame Cognitive capacities Structure providers Uncertainty

Evaluation of Pender's theory using Hardy

generality, contribution to understanding, predictability, pragmatic adequacy, models to explain/relate concepts (use of symbols)

Lenz & Colleagues theory of Unpleasant symptoms Purpose:

improve understanding of the symptom experience in various contexts & provide useful information to guide effective means of preventing, alleviating or managing unpleasant symptoms

Uncertainty

inability to structure meaning

Cognitive capacities is -----

information processing abilities of the person Idea of cognitive overload

Kolcaba's Theory of comfort A middle range theory because of

it's scope - comfort is an universal experience But, concrete enough to be tested

Meleis - Transition theory A "high-middle range theory" Evolved over 4 decades Began in practice with ------ How the theory began... Concept analysis, several comprehensive lit review Are these in line with some of the requirements of theory development we've discussed?

observations of human experience

Cognitive schema: -------- The meaning of events is constructed through the ------- Uncertainty can be appraised as ------ People can adapt to uncertainty

patient's subjective interpretation of illness, treatment & hospitalization cognitive processing and understanding of illness danger or opportunity

Mishel's theory re-conceptualized Implications for practice Encourage patients to create broader ------ Increase knowledge r/t treatment S/E's, what to expect t/o disease course Seeking information as means to coping Provide guidance in problem identification/definition Explore solutions Encourage social support Initiate conversations around patient concerns

perception of life - growth and opportunity versus losses

"comfort is more than the absence of --------" (p. 185) Idea of comfort in this study

physical pain but includes emotional and spiritual suffering

Derived from ----- Least common source for nursing theory development RNAO Best practice guidelines would be an example of standards of practice that could drive theory in Ontario

practice guidelines or standards of care

Middle Range theory production Derived from research and/or practice Most common in Nursing Most often combine ----- Ex: wound care theories Ex: theory describing humor use in nurse-patient interactions (McCraddie & Wiggins, 2009)

qualitative research with literature review, concept analysis and synthesis practice guidelines or standards of care

Specific approaches to Middle Range theory production Derived from

research and/or practice a grand theory non-nursing disciplines Created by combining existing nursing and non-nursing theories

Meleis - Transition theory Origins Meleis educational background: ------

sociology psychology Early research looked at role insufficiency of new mothers Role insufficiency Symbolic interactional theories from sociology

Uncertainty is the inability to

structure meaning

Stimuli frame

symptoms pattern (degree of symptom pattern consistency) event familiarity (habitual/repetitive nature of the structure o HC environment) event congruency (congruency between what is expected and what is experienced in illness events)