Discuss caring as a path to healing? Name and briefly discuss the three structural criteria used for evaluating middle-range theories. **All weekly posts must include at

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CHAPTER 3 Evaluation of Middle Range Theories for the

Discipline of Nursing

Marlaine C. Smith

Theories are patterned ideas that provide a coherent way of viewing complex phenomena. Middle range theories have a more limited view of circumscribed phenomena than do grand theories. However, because nursing is a professional discipline, all the theories within it should be evaluated from a perspective that considers the salient elements of the discipline in the evaluation. Although there are many sets of criteria for evaluating nursing conceptual models and grand theories (Chinn & Kramer, 2014; Fawcett & DeSanto-Madeya, 2013; Fitzpatrick & Whall, 2004; Parse, 1987; Stevens, 1998), few focus particularly on theories at the middle range. In addition, there has been little guidance for beginning nursing scholars on the purpose and the process of critical analysis and evaluation of theories. A common course assignment on the evaluation of nursing theory becomes a pedantic exercise, ending in a rather cynical view of theory development. One is reminded of the aphorism: When our only tool is a hammer, all we see are nails. In other words, the tool of critical evalua- tion taught to students is often weighted toward fi nding the faults, errors, and inconsistencies within the theoretic structures. It is no wonder that there is evidence of some devaluation of nursing theory and a reticence to engage in its development.

The theoretical measurement of outcomes of practice, while a worthy endeavor, has eclipsed the compelling need to create systems of thought with potential to describe and explain the nature of phenomena of concern to nurs- ing science. The nursing scholars who contribute to the development of theory for the discipline—including those who are featured in this text—are innova- tive pioneers who courageously offer their ideas for the advancement of the discipline and the betterment of healthcare. It is important, then, to balance the identifi cation of theoretic weaknesses with the aspects of appreciation, recog- nition, and affi rmation of strengths. The purpose of this chapter is to provide tools for a balanced and reasoned evaluation of middle range theory for the discipline of nursing. Describing the purposes of theory evaluation, articulat- ing a set of criteria to guide evaluation of middle range theory, and elaborating a process for conducting this evaluation organize this chapter.

Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0003

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

■ THE PURPOSE OF THEORY EVALUATION: TOWARD A POSTMODERN VIEW

Evaluation is one of the most popular indoor sports of the organizations in which we live. Because these organizations are accountable to various stake- holders, evaluation is used as a measure of assurance and accountability. The meaning of evaluation carries an onerous tone because of the baggage that is often attached to it. Students receive grades that refl ect evaluation of achievement in a course. A score or category is received when one is evalu- ated for job performance. Often this evaluation is attached to some reward. The memory of the evaluation of papers, projects, and practice may be more often marked by the red ink of what was done wrong than by what was achieved or done well.

The common, modern defi nition of evaluation is a process of determining or fi xing the value, worth, or signifi cance of something. This defi nition refl ects the anxieties that are experienced surrounding evaluation, connoting the determi- nation of a static and absolute outcome of worth or value. A postmodern mean- ing of evaluation is quite different. It refl ects the presence of subjectivity and contextuality, the diversity of opinions from a community, and, ultimately, the tentative nature of any outcome. It becomes an informed and fl awed opinion rendered at a particular moment in time by a person with inherent biases and values. This opinion, which one hopes is not arbitrary or capricious, is based on some sound, reasonable measures or criteria that can be applied consis- tently. However, it is important to note that the criteria and the evaluator’s application of them are value laden. In this way, they should be viewed not as absolute judgments of worth, but as one honest examination by a member of a community.

The evaluation of theory, then, is a process of coming to an opinion about its worth or value. Kaplan (1964)—in his discussion of the validation of theory— states that its purpose is to examine a theory’s value or worth for advancement by the scientifi c community. When evaluating nursing theory, we ask ques- tions about its worthiness to be used as a guide for inquiry and practice and to be taught to students.

Theory, by its defi nition in any paradigm of science, is a creative constella- tion of ideas, offered as a possible explanation or description of an observed or experienced phenomenon. In the process of evaluation, one is not determining the truth of the theory, but rather its value for further exploration within the scientifi c community. History affi rms the tentative nature of theory evaluation. Theories that were judged by the scientifi c community as valid were often later abandoned. Ptolemaic theory on the geocentric nature of the planetary system was abandoned later for the Copernican theory that the Earth and the planets revolve around the Sun.

Many revolutionary ideas of our time were evaluated initially as worth- less. Rogers’s (1970) conceptual system—describing the integral nature of

3 . EVALUAT ION OF M IDDLE RANGE THEOR IES FOR THE D ISC IPL INE OF NURS ING  35

human–environment energy fi elds—was an object of ridicule in the early 1970s. Nearly 50 years later, its correspondence to burgeoning contemporary thought is stunning.

Members of a disciplinary community bear the responsibility to participate in authentic dialogue around ideas within the fi eld of study. The purpose of evaluation of theory in this context is to share in the evolution of the discipline through refl ection and comment on the ideas offered within the community. The greater value of evaluating theory is to participate as individuals in the community’s structuring of ideas. Although the theory is given to the com- munity, the community reforms it through critique, testing, and application. The life of any theory is determined by the scientifi c community’s engagement with it. Evaluation of theory is essential to the life of the theory, leading to its extension, revision, and refi nement. Based on the preceding discussion, it is important that the evaluator stay true to the purpose of evaluation of theory. The stance of one who is evaluating theory from a postmodern perspective is characterized by intellectual empathy, curiosity, honesty, and responsibil- ity. The empathic stance is the attempt to understand the perspective of the theorist and is defi ned by Paul (1993) as “to imaginatively put oneself in the place of others in order to understand them” (p. 261). Here, the evaluator lis- tens carefully to the point of view. Listening is being aware of one’s own biases but trying to put them aside to thoughtfully consider others’ ideas, even if the evaluator does not share them. The stance of empathy requires an appreciation of others’ points of view and a seeking out of the origin and context of those points of view. Curiosity is the second characteristic of the critical stance. Here, the evaluator raises questions in the process of studying the theory that are born from a quest to understand. The evaluator plays with the theory in dif- ferent circumstances and imagines ways of testing or understanding it more deeply. The evaluator engages fully in trying to understand and acquire a range of sources on the theory and its application. The third stance is one of honesty. The evaluator trusts individual inner wisdom and recognizes the need to honor that wisdom in sharing the evaluation. Knowing personal biases and limita- tions, the evaluator is still willing to share refl ections on the theory. One of the major hurdles in learning to evaluate theory is to rely on one’s own opinions rather than jumping on the bandwagon of others who are considered wiser or more learned. From the postmodern perspective, each evaluation should stand on its own, one voice among many diverse ones in the community. It may be diffi cult to publish negative comments, but it is important to remember that these may be the needed stimuli to make important clarifi cations or changes in the theory. Finally, the evaluator must be a responsible steward of the disci- pline. As a member of the scientifi c community, the evaluator has an obligation to care about the nature of evolution of nursing knowledge. That responsibility entails a thoughtful and scholarly response to the critique, applying the criteria fairly and drawing conclusions that can be useful in the revision or extension

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

of the theory as others use it. Once a theory is published, it no longer belongs to the theorist. The voice of the theorist becomes one of many in the community using the theory to guide processes of knowledge development and practice.

In summary, the purpose of a postmodern approach to the evaluation of middle range theory in nursing is to come to a decision about the merits and limitations of the theory for nursing science. The evaluator approaches the evaluation from a stance of empathy, curiosity, honesty, and responsibility. Evaluation of theory is acknowledged as necessary to the evolution of the the- ory in the context of the scientifi c community.

■ THE ORIGIN OF EVALUATIVE FRAMEWORKS

Theories are the language of science. “Science is the process of systematically seeking an understanding of phenomena through creating some unifying or organizing frameworks about the nature of those phenomena. In addition, sci- ence involves the evaluation of these frameworks for their credibility and empir- ical honesty” (M. C. Smith, 1994, p. 50). The organizing or unifying frameworks of science are theories. Rigorous and systematic standards of inquiry govern the development and testing of theories. Theories are evaluated for their credibility and empirical honesty by judging them against established standards.

The nature of science and, therefore, the theories of science have under- gone change. Philosophies of science have evolved from a sole reliance on the assumptions of logical–positivist views toward expanding philosophies of the postpositivist or postmodern era (M. C. Smith, 1998). For example, the tradi- tional or empirical–analytic view of science defi nes theories as sets of interre- lated propositions that describe, explain, or predict the nature of phenomena (Kerlinger, 1986). In the human science view, which encompasses phenomenol- ogy, hermeneutics, and critical and poststructural perspectives, the purpose of theory is to create an understanding of phenomena through description and interpretation. Therefore, the structural rules, which apply to traditional sci- ence, do not apply to human science. For this reason, the frameworks used to evaluate theories must be inclusive enough to encompass these differences.

Kaplan’s (1964) perspective on the “validation” of theories is open enough to encompass a diversity of theoretic forms. He emphasizes that the evalua- tion of any theory is not a matter of pronouncement of its truth: “At any given moment a particular theory will be accepted by some scientists, for some of their purposes, and not by other scientists, or not for other contexts of possible application” (p. 311).

The evaluation of theory involves the exercise of good judgment in deter- mining a relative and tentative truth, and is by its nature normative in that the community ultimately determines the outcome. “The validation of a theory is not the act of granting an imprimatur but the act of deciding that the theory is worth being published, taught, and above all, applied—worth being acted on

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in contexts of inquiry or of other action” (Kaplan, 1964, p. 312). Kaplan identi- fi es three major philosophical conceptions or norms of truth that can be exer- cised in the process of evaluating theory: correspondence or semantic norms, coherence or syntactic norms, and pragmatics or functional norms.

The norm of correspondence refers to the substantive meaning of the theory. Through application of this norm, one judges the degree to which the theory fi ts the facts. Although facts are in themselves understood through a theoretic lens, Kaplan argues that this does not necessarily present a tautology. Any the- ory must in some way pass the test of common sense. Although he acknowl- edges that signifi cant discoveries have fl own in the face of common sense, these discoveries in some way could be explained through their relationship to accepted knowledge or some convergence of evidence that supported the plausibility of the theory. Through the norm of correspondence, one evaluates the extent to which the theory fi ts comfortably within the nexus of existing knowledge.

The norm of coherence relates to the integrity of the theory’s structure. Kaplan describes the experience of the “click of relation, when widely different and separate phenomena suddenly fall into a pattern of relatedness, when they click into position” (p. 314).

This experience of truth or wholeness occurs when all the fragments of the theory come together to form an integrated whole. Simplicity is the most widely applied norm of coherence. Descriptive simplicity is the quality of expressing the complex ideas of the theory parsimoniously. Inductive sim- plicity refers to the phenomenon being described by the theory. The theory must encompass a manageable number of ideas; too many will overwhelm the capacity of the theory to serve its purpose to provide a framework for understanding. Kaplan warns that a theory can be too simple in that it goes too far in reducing the complexities. Theories should introduce the degree of complexity necessary for clear understanding, nothing more. He quotes Whitehead’s axiom: “Seek simplicity and distrust it” (p. 318). Another norm of coherence is aesthetics, that is, the beauty perceived upon the contempla- tion of the theory. The beauty of the theory involves some sense of symmetry and balance, but Kaplan warns, “Beauty is not truth” (p. 319). The process of developing theory is creative and that creativity is expressed in a product that possesses an aesthetic quality.

The fi nal norm is pragmatics and refers to the effectiveness or functional capability of the theory. In a professional discipline, the norm of pragmatics instructs us to consider the degree to which the theory can guide practice and research to advance the goals of the discipline. On the other hand, Kaplan states that the theory is not judged by the extent to which it makes some exter- nal difference alone; he acknowledges that other factors might interfere with or enhance the success of application. The theory is also judged by what it can do for science, “how it guides and stimulates the ongoing process of sci- entifi c inquiry” (pp. 319–320). So the degree to which the theory has spawned

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

research questions is relevant: “The value of the theory lies not only in the answers it gives but also in the new questions it raises” (p. 320).

A theory is validated when it is put to good use in the application of con- cerns to the discipline. The evaluative framework for middle range theories is based on these norms. Criteria will be clustered into the following three cat- egories: substantive foundation, structural integrity, and functional adequacy.

A plethora of evaluative frameworks for nursing theories, some mentioned earlier in this chapter, have evolved over the past several decades. Some of these frameworks are applicable to middle range theories, whereas others are not. Liehr and Smith (1999; M. J. Smith & Liehr, 2013) summarized the liter- ature about the nature of middle range theories and concluded that middle range theories are identifi ed by their scope, level of abstraction, and proximity to empirical fi ndings. Scope refers to the breadth of phenomena addressed by the theory. Compared to conceptual models and grand theories, middle range theories offer constellations of ideas or concepts about more circumscribed phenomena of concern to the discipline. In this way, they are intermediate in scope, focusing on a limited number of concepts focused on a limited aspect of reality (Liehr & Smith, 1999; M. J. Smith & Liehr, 2013). Level of abstraction locates middle range theories between the abstract level of conceptual mod- els and grand theories and situation-specifi c theories. The language of middle range theories describes concepts and relationships between them more con- cretely. Finally, middle range theories are more proximal to empirical fi ndings than conceptual models and grand theories. They are developed through an analysis of empirical fi ndings or at a level of immediate testability. These three qualities of middle range theories should be represented in the evaluative frameworks for them.

The criteria in Table 3.1 have been developed from Kaplan’s norms for vali- dating theories and are informed by the essential qualities of middle range theories to create an evaluative framework specifi c to theories of the middle range.

Substantive Foundation

Substantive foundation is the fi rst category of criteria for the evaluation of middle range theory in nursing. This category includes criteria based on Kaplan’s norm of correspondence and leads to questions about the meaning or semantic elements of the theory. A middle range theory in nursing contributes to the knowledge of the discipline of nursing and is developed from assump- tions that are clearly specifi ed. The theory provides knowledge that is at the middle range level of abstraction. There are four major criteria related to sub- stantive meaning: (1) the theory is within the focus of the discipline of nurs- ing; (2) the assumptions are specifi ed and are congruent with the focus of the discipline of nursing; (3) the theory provides a substantive description, expla- nation, or interpretation of a named phenomenon at the middle range level of

3 . EVALUAT ION OF M IDDLE RANGE THEOR IES FOR THE D ISC IPL INE OF NURS ING  39

discourse; and (4) the origins are rooted in practice and research experience. Each of these criteria and the questions that guide the application of the crite- ria in evaluating the theory are discussed. The fi rst criterion emphasizes that a middle range theory in nursing is judged by its location in and contribution to the discipline of nursing. The question “What makes a middle range theory in nursing a nursing theory?” is interesting to consider. Some (Fawcett, 2004; Parse, 1987) assert that nursing theories are only those identifi ed as the con- ceptual models and grand theories developed by nurses in the 1960s through the 1980s. From this perspective, legitimate middle range theories in nursing are those deduced from or inductively developed within existing conceptual models and grand theories of nursing. This is problematic in that it fi xates theory development in what has been considered legitimate in the past. It is important to leave space for the possibility of emergent conceptual models or grand constructions that may be articulated as sets of foundational assump- tions on which middle range theories are constructed. The evaluator should expect that a middle range theory in nursing contributes to knowledge about human–environment–health relationships, caring in the human health experi- ence, and/or health and healing processes (Fawcett, 2004; Newman, Sime, & Corcoran-Perry, 1991; M. C. Smith, 1994). It should be possible to locate the theory within a paradigmatic perspective endorsed by nursing, such as the particulate–deterministic, integrative–interactive, or unitary–transformative schemas (Newman et al., 1991), the totality or simultaneity paradigm (Parse, 1987), or the reaction, reciprocal interaction, or simultaneous action world- view (Fawcett, 2004).

TABLE 3.1 Framework for the Evaluation of Middle Range Theories

Substantive Foundation 1. The theory is within the focus of the discipline of nursing. 2. The assumptions are specifi ed and congruent with focus. 3. The theory provides a substantive description, explanation, or interpretation of a

named phenomenon at the middle range level of discourse. 4. The origins are rooted in practice and research experience.

Structural Integrity 1. The concepts are clearly defi ned. 2. The concepts within the theory are at the middle range level of abstraction. 3. There are no more concepts than needed to explain the phenomenon. 4. The concepts and relationships among them are logically represented with a

model.

Functional Adequacy 1. The theory can be applied to a variety of practice environments and client groups. 2. Empirical indicators have been identifi ed for concepts of the theory. 3. There are published examples of use of the theory in practice. 4. There are published examples of research related to the theory. 5. The theory has evolved through scholarly inquiry.

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

The second criterion regarding the specifi cation of assumptions in the cat- egory of substantive foundation is that the origins and ontological foundations of the theory are specifi ed. The developer of the middle range theory holds philosophical assumptions that are either explicitly stated or implied by the meaning of the theory. Fawcett (2004) argues that the belief that middle range theory is developed outside the context of a conceptual frame of reference is absurd. She emphasizes the contextual nature of theory building. The assump- tions of a middle range theory identify the context for theory building and should be identifi able. A stronger middle range theory would explicate the assumptions.

The ideas of parent theories or models should be clearly identifi ed in the explication of the meaning of the theory. The developers should cite primary sources from any parent theories that may be accessed for greater depth in understanding. Although some middle range theories will not be explicitly derived from nursing conceptual models or grand theories, parent ideas that shaped theory development would be clearly described.

Finally, the meaning of the theory should be consistent with its founda- tional assumptions. This consistency is essential. If Rogers’s Science of Unitary Human Beings (SUHB) forms the assumptions of a middle range theory, the meaning of the concepts within the theory should not violate these assump- tions. One would not use the language of adaptive responses in a theory pur- portedly derived from the SUHB. If the assumptions are not derived from an existing conceptual model/grand theory, one is left to analyze inferred founda- tions about how the assumption corresponds with the meaning of the middle range theory.

The third criterion related to substantive foundation states that the middle range theory provides substantive knowledge about a named circumscribed phenomenon of concern to nursing. Liehr and Smith (1999) contend that a middle range theory is known by the way it is named and that it should be “named in the context of the disciplinary perspective and at the appropriate level of discourse” (p. 86). Middle range theory is defi ned by its focus on providing knowledge about a specifi c phenomenon of concern to nursing. The theory should offer a substantive description, explanation, or interpre- tation of this particular phenomenon that leads to a new understanding or different way of considering the phenomenon. It is incumbent on the devel- oper of the theory to provide adequate explanation substantiated by logical reasoning and reference to existing knowledge sources that lead to a full understanding of the meaning of the concepts and their relationships to each other.

Finally, the theory should capture the complexities of the phenomenon that it addresses. A theory is a map of some aspect of reality; like a map, it can- not capture the landscape. However, to the extent possible, the theory should approximate the fullest range of conceptual relationships that it addresses.

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The fourth criterion deals with the rooting of the origins of the theory in prac- tice and research experience. Middle range theory grows out of the research and practice experiences of nurses, who articulate a set of concepts to describe and explain a phenomenon that they have observed in their work. The evalu- ator will seek out the practice and research roots of the theory. It may be that one set of roots (practice or research) is sturdier than the other. This assess- ment may indicate the next direction for further application of the theory. Well- developed middle range theory will have documented development related to both practice and research that evolves over time.

Structural Integrity

A middle range theory is a framework that organizes ideas. Like any frame- work, it has a structure. The structure provides strength, balance, and the aes- thetic qualities that ensure its integrity. Structural integrity is the category that was derived from Kaplan’s (1964) norm of coherence. There are four criteria for evaluation of the structural integrity of middle range theories: (a) the concepts are clearly defi ned; (b) the concepts of the theory are at the middle range level of abstraction; (c) there are no more concepts than are needed to explain the phenomenon; and (d) the concepts and relationships among them are logically represented with a model. The four criteria for structural integrity and their application are discussed in the following.

The fi rst criterion is that the ideas and the relationships among them are clearly presented within the theory. Concepts are the names given to the abstract ideas that constitute the theory. The relationships among the ideas are developed into statements or propositions. In any middle range theory, the concepts within it should be clearly defi ned. Any neologisms (newly coined terms) should be adequately defi ned. The relationship statements, whether called propositions or not, should articulate the relationships among the cen- tral ideas or concepts within the theory. Concepts, even within the context of middle range theory, are abstractions, and, as such, it takes some willingness to understand them. However, the defi nitions should lead to this understanding and provide precise meaning.

The second criterion related to structural integrity is that the ideas of the the- ory are at the middle range level of abstraction. All concepts should be on the ladder of abstraction at a similar level. For example, health may be considered a concept at the metaparadigm level; adaptation, at the level of grand theory; and anxiety, at the level of the middle range. Mixing these as concepts within one theory would be an example of concepts at differing levels of abstraction. Similarly, the concepts in the theory should consistently be presented at the middle range level, more concrete and circumscribed than concepts at a higher level of abstraction. The deductive or inductive processes of theory develop- ment should be transparent in the presentation of the theory. Movement up the

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

ladder of abstraction to paradigms or down the ladder to empirical indicators should be logical, reasoned, and clear.

The third criterion is that there should be no more concepts than necessary to describe the theory as named. The theory should be organized and presented parsimoniously. That means that the ideas should be synthesized and com- municated in the simplest, most elegant way possible. Extraneous concepts or unclear differentiation of concepts creates complexity that confuses rather than clarifi es.

The fourth or fi nal criterion is that the ideas of the theory are integrated to create an understanding of the whole phenomenon, which is presented in a model. This criterion leads to consideration of the internal consistency, balance, and aesthetics of the theory. The concepts and statements of the theory should be logically ordered so that they lead to an appreciation and apprehension of the theory’s meaning. The relationships among the ideas can be represented in a schema, a model, or a list of logically ordered statements. In any case, it is the responsibility of the developer to make these relationships accessible. All ideas (concepts and related statements) in the theory should have semantic congru- ence, that is, the meanings should not be contradictory. Middle range theories are creative products of science. As such, there should be balance and harmony in the way they are presented.

Functional Adequacy

For a professional discipline, functional adequacy is arguably the acid test of a middle range theory. Middle range theories are closely tied to research and practice. They may be generated from research fi ndings or deduced from larger models to form a set of testable hypotheses. They may have been developed in relation to a practice dilemma and can be used to create practice guidelines. Middle range theories build nursing knowledge and are valuable i

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