Discuss caring as a path to healing? name and briefly discuss the three structural criteria used for evaluating middle range theories.?Chapt1Nursingtheory.pdf

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CHAPTER 1 Disciplinary Perspectives Linked to Middle

Range Theory

Marlaine C. Smith

Each discipline has a unique focus for knowledge development that directs inquiry and distinguishes it from other fi elds of study. The knowledge that constitutes the discipline has organization. Understanding this organization or the structure of the discipline is important for those engaged in learning the theories of the discipline and for those developing knowledge expanding the discipline. Perhaps this need is more acute in nursing because the evolution of the professional practice based on tradition and knowledge from other fi elds preceded the emergence of substantive knowledge of the discipline. Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of the discipline. As a professional discipline this knowledge is important for guiding practice. Theory-guided, evidence-informed practice is the hallmark of any professional discipline. The purpose of this chapter is to elaborate the structure of the discipline of nursing as a context for understand- ing and developing middle range theories.

While the disciplinary focus of nursing has been debated for decades, there now seems to be a growing consensus. In 1978, Donaldson and Crowley stated that a discipline offers “a unique perspective, a distinct way of viewing . . . phe- nomena, which ultimately defi nes the limits and nature of its inquiry” (p. 113). They specifi ed three recurrent themes as the nexus of the discipline of nursing:

1. Concern with principles and laws that govern the life processes, well- being, and optimum functioning of human beings, sick or well;

2. Concern with the patterning of human behavior in interaction with the environment in critical life situations; and

3. Concern with the processes by which positive changes in health status are affected. (p. 113)

Nursing is a professional discipline (Donaldson & Crowley, 1978). Professional disciplines such as nursing, psychology, and education are dif- ferent from academic disciplines such as biology, anthropology, and econom- ics in that they have a professional practice associated with them. According to the authors, professional disciplines include the same knowledge, namely

Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0001

4 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

descriptive theories and basic and applied research, common to academic dis- ciplines. In addition to the knowledge inherent in academic disciplines, pro- fessional disciplines include prescriptive theories and clinical research. So the differences between academic and professional disciplines are the additional knowledge required for professional disciplines. This is important, because many refer to nursing as a practice discipline. This seems to imply that the knowledge is about the practice alone and not about the substantive phenom- ena of concern to the discipline.

Failure to recognize the existence of the discipline as a body of knowledge that is separate from the activities of practitioners has contributed to the fact that nursing has been viewed as a vocation rather than a profession. In turn, this has led to confusion about whether a discipline of nursing exists (Conway, 1985, p. 73).

Although we have made signifi cant progress in building the knowledge base of nursing, this confusion about the substantive knowledge base of nurs- ing lingers with nurses, other professions, and in the public sphere.

Fawcett’s (1984) explication of the nursing metaparadigm was another model for delineating the focus of nursing. According to Fawcett, the disci- pline of nursing is the study of the interrelationships among human beings, environment, health, and nursing. Although the metaparadigm is widely accepted, the inclusion of nursing as a major concept of the nursing discipline is tautological (Conway, 1985). Others have defi ned nursing as the study of the life process of unitary human beings (Rogers, 1970, 1992), human care or caring (Boykin & Schoenhofer, 2001, 2015; Leininger, 1978, 1984; Watson, 1985, 2008), human–universe–health interrelationships (Parse, 1998, 2014), and “the health or wholeness of human beings as they interact with their environment” (Donaldson & Crowley, 1978, p. 113). Newman, Sime, and Corcoran-Perry (1991) created a parsimonious defi nition of the focus of nursing that synthe- sizes the unitary nature of human beings with caring: “Nursing is the study of caring in the human health experience” (p. 3).

My defi nition uses similar concepts but shifts the direct object in the sen- tence: “Nursing is the study of human health and healing through caring” (M. C. Smith, 1994, p. 50). This defi nition can be stated even more parsimoni- ously: Nursing is the study of healing through caring. Healing comes from the same etymological origin as “health,” haelen, meaning whole (Quinn, 1990, p. 553). Healing captures the dynamic meaning that health often lacks; healing refl ects the wholeness of person–environment; healing implies a process of changing and evolving. Caring is the path to healing. In its deep- est meaning, it encompasses one’s connectedness to all, that is, a person– environment relatedness. Nursing knowledge focuses on the wholeness of human life and experience and the processes that support relationship, inte- gration, and transformation. This is the focus of knowledge development in the discipline of nursing.

1 . D ISC IPL INARY PERSPECT IVES L INKED TO M IDDLE RANGE  THEORY  5

Defi ning nursing as a professional discipline does not negate or demean the practice of nursing. Knowledge generated from and applied in practice is con- tained within this description. The focus of practice comes from the defi nition of the discipline. Nursing has been defi ned as both science and art, with sci- ence encompassing the theories and research related to the phenomena of con- cern (disciplinary focus) and art as the creative application of that knowledge (Rogers, 1992). Newman (1990, 1994, 2008) and others, perhaps infl uenced by critical/postmodern scholars, have used the term praxis to connote the unity of theory–research–practice lived in the patient–nurse encounter. Praxis breaks down the boundaries between theory and practice, researcher and practitioner, art and science. Praxis recognizes that the practitioner’s values, philosophy, and theoretical perspective are embodied in the practice. Chinn (2013) defi nes praxis as “thoughtful refl ection and action that occur in synchrony, in the direc- tion of transforming the world” (p. 10). Praxis refl ects the embodied knowing that comes from the integration of values and actions and blurs the distinctions among the roles of practitioner, researcher, and theoretician.

Middle range theories are part of the structure of the discipline. They address the substantive knowledge of the discipline by explicating and expanding on specifi c phenomena that are related to the caring–healing process. For exam- ple, the Theory of Self-Transcendence (Reed, 2015) explains how aging or vul- nerability propels humans beyond self-boundaries to focus intrapersonally on life’s meaning; interpersonally on connections with others and the environ- ment; temporally to integrate past, present, and future; and transpersonally to connect with dimensions beyond the physical reality. Self-transcendence is related to well-being or healing, one of the identifi ed foci of the discipline of nursing. This theory has been examined in research and used to guide nursing practice. With the expansion of middle range theories, nursing is enriched.

Several nursing scholars have organized knowledge of the discipline into paradigms (Fawcett, 1995; Newman et al., 1991; Parse, 1987). The concept of paradigm originated in Kuhn’s (1970) treatise on the development of knowl- edge within scientifi c fi elds. He asserted that the sciences evolve rather predict- ably from a preparadigm state to one in which there are competing paradigms around which the activity of science is conducted. The activity of science to which he is referring is the inquiry that examines the emerging questions and hypotheses surfacing from scientifi c theories and new fi ndings. Paradigms are schools of shared assumptions, values, and views about the phenomena addressed in particular sciences. It is common for mature disciplines to house multiple paradigms. If one paradigm becomes dominant and if discoveries within it challenge the logic of other paradigms, a scientifi c revolution may occur.

Parse (1987) described nursing with two paradigms: totality and simultane- ity. For her, the theories in the totality paradigm assert the view that humans are bio psycho social–spiritual beings responding or adapting to the environment,

6 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

and health is a fl uctuating point on a continuum. The simultaneity paradigm portends a unitary perspective. Unitary refers to the distinctive conceptualiza- tion of Rogers (1970, 1992) that human beings are whole and integral with their environment. Health is subjectively defi ned by the person (group or commu- nity) and refl ects well-being, the process of evolving or human becoming. Parse locates only two nursing conceptual systems/theories: the Science of Unitary Human Beings (Rogers, 1970, 1992) and the Theory of Human Becoming (Parse, 1998, 2014) in the simultaneity paradigm. For Parse, all nursing knowledge is related to the extant grand theories or conceptual models of the discipline. While she agrees that theories expand through research and conceptual devel- opment, she disagrees with the inclusion of middle range theories within the disciplinary structure if they are not grounded in the more abstract theoretical structure of an existing nursing grand theory or conceptual model.

Newman et al. (1991) and Newman (2008) identifi ed three paradigms. These paradigms are conceptualized as evolving because the more complex para- digms encompass and extend the knowledge in a previous paradigm. The three paradigms are particulate–deterministic, integrative–interactive, and unitary–transformative. From the perspective of the theories within the par- ticulate–deterministic paradigm, human health and caring are understood through their component parts or activities; there is an underlying order with predictable antecedents and consequences; and knowledge development pro- gresses to uncover these causal relationships. Reduction and causal inferences are characteristics of this paradigm. The integrative–interactive paradigm acknowledges contextual, subjective, and multidimensional relationships among the phenomena central to the discipline. The interrelationships among parts and the probabilistic nature of change are assumptions that guide the way phenomena are conceptualized and studied. The third paradigm is the unitary–transformative. Here, the person–environment unity is a patterned fi eld within larger patterned fi elds. Change is characterized by fl uctuating rhythms of organization disorganization, toward more complex organization. Subjective experience is primary and refl ects a pattern of the whole (Newman et al., 1991, p. 4).

Fawcett (1995, 2000) joined the paradigm dialogue with her version of three paradigms. She named them: reaction, reciprocal interaction, and simultane- ous action. This model was synthesized from the analysis of views of mecha- nistic versus organismic, persistence versus change, and Parse and Newman and colleagues’ nursing paradigmatic structures. In the reaction worldview, humans are the sum of the biological, psychological, sociological, and spiri- tual parts of their nature. Reactions are causal and stability is valued; change is a mechanism for survival. In the reciprocal interaction worldview, the parts are seen within the context of the whole, and human–environment relation- ships are reciprocal; change is probabilistic based on a number of factors. In the simultaneous action worldview, human beings are characterized by pattern

1 . D ISC IPL INARY PERSPECT IVES L INKED TO M IDDLE RANGE  THEORY  7

and are in a mutual rhythmic open process with the environment. Change is continuous, unpredictable, and moves toward greater complexity and organi- zation (Fawcett, 2000, pp. 11–12).

Each middle range theory has its foundations in one paradigmatic perspec- tive. The philosophies guiding the abstract views of human beings, human– environment relationships, and health and caring are refl ected in each of the paradigms. This infl uences the meaning of the middle range theory, and for this reason, it is important that the theory has a philosophical link to the para- digm clearly identifi ed.

Figure 1.1 illustrates the structure of the discipline of nursing. This is adapted from an earlier version (M. C. Smith, 1994). The fi gure depicts the structure as clusters of inquiry and praxis surrounding a philosophic paradigmatic nexus. The levels of theory within the discipline, based on the breadth and depth of focus and level of abstraction, are represented. Theory comes from the Greek word, theoria, meaning “to see.”

A theory provides a particular way of seeing phenomena of concern to the discipline. Theories are patterns of ideas that provide a way of viewing

FIGURE 1.1 Structure of the discipline of nursing.

Nursing Metaparadigm Person Environment Health Caring

Focus of the Discipline Caring in the human health experience

healing through caring

Research tradition

Practice tradition

Particulate –deterministic

paradigm

Research tradition

Practice tradition

Unitary –transformative

paradigm

Research tradition

Practice tradition

Integrative –interactive paradigm

Grand theory

Middle range theory

Grand theory

Middle range theory

Grand theory

Middle range theory

Grand theory

Middle range theory

Grand theory

Middle range theory

Grand theory

Middle range theory

Middle range theory

Grand theory

8 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

a phenomenon in an organized way. Walker and Avant (2010) describe these levels of theory as metatheory, grand theory, middle range theory, and practice theory.

The fi gure depicts fi ve levels of abstraction. The top oval includes the nurs- ing metaparadigm and focus of the discipline of nursing. These are the agreed- upon phenomena of concern that delineates nursing from other disciplines. Grand theories are at the next level of the fi gure and include the abstract con- ceptual systems and theories that provide perspectives on the central phenom- ena of the discipline, such as persons as adaptive systems, self-care defi cits, unitary human beings, or human becoming. These grand theories are frame- works consisting of concepts and relational statements that explicate abstract phenomena. In the fi gure, the grand theories cluster under the paradigms. Middle range theories are more circumscribed, elaborating more concrete concepts and relationships such as uncertainty, self-effi cacy, meaning, and the other middle range theories addressed throughout this text. The number of middle range theories is growing. Middle range theory can be specifi cally derived from a grand theory or can be related directly to a paradigm. At the bottom level of the fi gure are the research and practice traditions related to grand and middle range theories. Walker and Avant (2010) refer to this most specifi c level of theory as practice theory. Practice theories specify guidelines for nursing practice; in fact, the authors state that the word “theory” may be dropped to better conceptualize this level as “nursing practices” (p. 12) or what can be considered practice traditions. Both grand theories and middle range theories have practice traditions associated with them.

A practice tradition contains the activities, protocols, guidance, and practice wisdom that emerge from these theories. Models such as the LIGHT Model (Andersen & Smereck, 1989) or the Attendant Nurse Caring Model (Watson & Foster, 2003) are examples. M. J. Smith and Liehr (2013) refer to these as micro- range theories, those that closely refl ect practice events or are more readily operational and accessible to application in the nursing practice environment. Research traditions are the associated methods, procedures, and empirical indicators that guide inquiry related to the theory.

Some differentiate between grand theories and conceptual models. Fawcett (2000) differentiates them by how they address the metaparadigm concepts as she has defi ned them. Those that address the metaparadigm of human beings, environment, health, and nursing are labeled conceptual models, whereas those that do not are considered grand theories. Using Fawcett’s criteria, Human Caring Theory (Watson, 1985, 2008) and Health as Expanding Consciousness (Newman, 1986, 1994) are considered grand theories. Walker and Avant (2010) include conceptual models under the classifi cation of grand theories, and it seems more logical to defi ne conceptual models by scope and level of abstrac- tion instead of their explicit metaparadigm focus. In this chapter, the grand theories are referred to as theories rather than conceptual frameworks.

1 . D ISC IPL INARY PERSPECT IVES L INKED TO M IDDLE RANGE  THEORY  9

The grand theories developed as nursing’s distinctive focus became more clearly specifi ed in the 1970s and 1980s. Earlier nurse scholars contributed to theoretical thinking without formalizing their ideas into theories. Nightingale’s (1860/1969) assertions in Notes on Nursing about caring for those who are ill through attention to the environment are often labeled theoretical. Several grand theories share the same paradigmatic perspective. For example, the theories of Person as Adaptive System (Roy, 1989, 2008), Behavioral Systems (Johnson, 1980), and the Neuman (1989; Fawcett & DeSanto-Madeya, 2013; Newman & Fawcett, 2010) Systems Model share common views of the phenom- ena central to nursing that might locate them within the integrative–interactive paradigm. Others, such as the Science of Unitary Human Beings (Rogers, 1970, 1992), Health as Expanding Consciousness (Newman, 1986, 1994), and Human Becoming (Parse, 1998, 2014), cluster in the unitary–transformative paradigm.

There may be an explicit relationship between some grand theories and mid- dle range theories. For example, Reed’s (1991, 2015) middle range theory of Self- Transcendence and Barrett’s (1989, 2015) Theory of Power are directly linked to Rogers’s Science of Unitary Human Beings. Other middle range theories may not have such direct links to grand theories. In these instances, the philosophi- cal assumptions underpinning the middle range theory may be located at the level of the paradigm rather than of the grand theory. Nevertheless, this linkage is important to establish the theory’s validity as a nursing theory. Theoretical work is located in the discipline of nursing when it addresses the focus of the discipline and shares the philosophical assumptions of the nursing paradigms or the grand theories.

Some grand theories in nursing have developed research and/or practice traditions. Laudan (1977) asserts that sciences develop research traditions or schools of thought such as “Darwinism” or “quantum theory.” In addition, Laudan’s view includes the “legitimate methods of inquiry” open to the researcher from a given theoretical system (p. 79). Research traditions include appropriate designs, methods, instruments, research questions, and issues that are at the frontiers of knowledge development. The traditions refl ect logi- cal and consistent linkages among ontology, epistemology, and methodology. Ontology refers to the philosophical foundations of a given theory and is the essence or foundational meaning of the theory. Epistemology is about how one comes to know, and incorporates ways of understanding and studying the theory. Methodology is a systematic approach for knowledge generation and includes the processes of gathering, analyzing, synthesizing, and interpreting information. The correspondence among ontology (meaning), epistemology (knowing), and methodology (investigating) gives breadth and depth to the theory.

Examples of the connection among ontology, epistemology, and methodol- ogy are evident in several grand theories. For instance, the research-as-praxis method was developed by Newman (1990, 2008) for the study of phenomena

10 I . SETT ING THE STAGE FOR M IDDLE RANGE THEOR IES

from the Health as Expanding Consciousness perspective, and a research method was developed from the theory of Human Becoming (Parse, 1998, 2014). Tools have been developed to measure theoretical constructs such as self-care agency (Denyes, 1982) or functional status within an adaptive systems perspective (Tulman et al., 1991), and debates on the appropriate epistemology and methodology in a unitary ontology (Cowling, 2007; M. C. Smith & Reeder, 1998) characterize the research traditions of some extant theories. These exam- ples refl ect the necessary relationship among theory, knowledge development, and research methods.

Practice traditions are the principles and processes that guide the use of a theory in practice. The practice tradition might include a classifi cation or label- ing system for nursing diagnoses, or it might explicitly eschew this type of labeling. It might include the processes of living the theory in practice such as Barrett’s (2015) health patterning, or the developing practice traditions around Watson’s theory such as ritualizing handwashing and creating quiet time on nursing units (Watson & Foster, 2003). Practice traditions are the ways that nurses live the theory and make it explicit and visible in their practice.

Middle range theories have direct linkages to research and practice. They may be developed inductively through qualitative research and practice observations, or deductively through logical analysis and synthesis. They may evolve through retroductive processes of rhythmic induction–deduc- tion. As scholarly work extends middle range theories, research and practice traditions continue to develop. For example, scholars advancing Uncertainty Theory will continue to test hypotheses derived from the theory with dif- ferent populations. Nurses in practice can take middle range theories and develop practice guidelines based on them. Oncology nurses whose world- views are situated in the integrative–interactive paradigm may develop protocols to care for patients receiving chemotherapy using the Theory of Unpleasant Symptoms. The use of this protocol in practice will feed back to the middle range theory, extending the evidence for practice and contrib- uting to ongoing theory development. The use of middle range theories to structure research and practice builds the substance, organization, and inte- gration of the discipline.

The growth of the discipline of nursing is dependent on the systematic and continuing application of nursing knowledge in practice and research. Few grand theories have been added to the discipline since the 1980s. Some suggest that there is no longer a need to differentiate knowledge and establish disciplin- ary boundaries because interdisciplinary teams will conduct research around common problems, eliminating the urge to establish disciplinary boundar- ies. Even the National Institutes of Health rewards interdisciplinary research enterprises. This emphasis can enrich perspectives through interdisciplinary collaboration, but it is critical to approach interdisciplinary collaboration with a clear view of nursing knowledge to enable meaningful weaving of disciplin- ary perspectives that can create new understandings.

1 . D ISC IPL INARY PERSPECT IVES L INKED TO M IDDLE RANGE  THEORY  11

Nursing remains on the margin of the professional disciplines and is in dan- ger of being consumed or ignored if suffi cient attention is not given to the uniqueness of nursing’s fi eld of inquiry and practice. There are hopeful indi- cators that nursing knowledge is growing. The blossoming of middle range theories signifi es a growth of knowledge development in nursing. Middle range theories offer valuable organizing frameworks for phenomena being researched by interdisciplinary teams. These theories are useful to nurses and persons from other disciplines in framing phenomena of shared concern. Hospitals seeking Magnet® status are now required to articulate some nursing theoretic perspective that guides nursing practice in the facility. The quality of the practice environment is important for the quality of care and the retention of nurses. Theory-guided practice elevates the work of nurses leading to fulfi ll- ment, satisfaction, and a professional model of practice.

The role of the doctor of nursing practice has the potential to enrich the current level of advanced practice by moving it toward true nursing prac- tice guided by nursing theory. The movement toward translational research and enhanced integration of research fi ndings into the front lines of care will demand practice models that bring coherence and sense to research fi ndings. Isolated, rapid cycling research can result in confusion and chaos if not sensi- bly synthesized into a model of care that is informed not only by evidence but also guided by a compass of values and a framework that synthesizes research into a meaningful whole. This is the role of theory. With this continuing shift to theory-guided practice and research, productive scientist–practitioner partner- ships will emerge committed to the application of knowledge to transform care and to improve quality of life for patients, families, and communities.

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