Middle Range Theory’s Influence on Modern Nursing

Middle Range Theory’s Influence on Modern Nursing

Nursing 500

Middle Range Theory’s Influence on Modern Nursing

Theory is defined as a “systematic explanation of an event and a set of interpretive assumptions and propositions that help explain or guide an action” (McEwen &Wills, 2014, P. 25). Nursing theories are the backbone of the nursing practice which provides practicing nurses and Advance Nurse Practitioners with rationales that guide their respective clinical practices while providing quality care and positive patient outcomes. The nursing theory that best suit my area of practice in an Acute Medicine unit is middle range theory. I chose a middle-range theory because they are more concrete and have narrowed concepts that could be applicable to specific settings or levels of nursing. Fawcett (2005) states that “as science matures, the development of knowledge moves from the grand theories to the development of middle range theories that are less abstract and more empirical or practical based.” Middle range theories were adapted from the grand theories which are comparatively abstract and broad in nature in order to improve patient care with the changing dynamic of healthcare (Fawcett, 2005). Some of the middle range theories include Dorothea Orem’s self-care theory and Peplau’s interpersonal theory that are significantly used in different levels of nursing to name a few theories.

A theory that relates to my nursing practice is Madeleine Peplau’s theory of interpersonal relations. The theory is categorized as a middle range theory which is focused on the relationship between the nurse and the patient (Fernandes & Naidu, 2017). Its scope is narrower than conceptual model or grand theory and clearly addresses defined number of measurable concepts (McEwen &Wills,2014). The interpersonal theory is a holistic approach that facilitates effective communication between the nurse and the patient and it establishes trust which promotes quality of life. The focus of this theory allows for the nurse and the client to work together as partners in solving problems and the patient would be willing to inform the nurse about the effectiveness of interventions being administered. 

Through interpersonal relationship, nurses assist patients to achieve healthy healing by implementing therapeutic communication as a nursing method to help manage patients’ anxiety about their care and disease process (Fernandes & Naidu, 2017).  I would definitely continue to use Peplau’s interpersonal theory in my advanced practice setting. This model would promote and improve communication with patients, hence, improving patients’ adherence to prescribed treatment (Fernandes &Naidu, 2017). Fernandes and Naidu (2017) state that nurses play an important role in stimulating or inhibiting patients’ participation in self-care through providing patients with information and updating them with their plan of care. I have implemented this theory in my practice because it encourages patients to participate in their care and it also keeps them at ease when they understand their plan of care. Patients are empowered to learn about their disease processes and treatment and participate in their care once they are discharged in order to improve health outcomes and decrease hospital readmissions. 

According to Meleis, “middle range theories will further lead the way for situation specific theories that will focus on specific nursing phenomena that reflect clinical practice and are limited to a specific population or a particular field of practice.” (Meleis, 2012). Middle range theories focus primarily on client problems and expected outcomes, as well as the effects of nursing interventions on client outcomes. middle range theories are specific to nursing and may specify an area of practice, age range of the client, nursing actions or interventions, and proposed outcomes (Meleis, 2012). When reflecting on current trends of clinical practice, I feel that middle-range theories are more applicable. Middle-range theories are broad enough to incorporate in everyday clinical practice for the average floor nurse without being too narrow in scope as the situation-specific theories. McEwen and wills (p.214, 2014) states that “ many researchers prefer to work with middle range theories rather than grand theories or conceptual frameworks because they provide a better basis for generating testable hypotheses and addressing particular client populations.” Middle range theories are constantly used as a basis for investigations as they become enhances on the basis of research results.

Theory evaluation is defined as a process of systematic examination of a theory’s origins, meaning, logical adequacy, usefulness, generalizability and testability (McEwen &Wills, 2017, p.95). Theory evaluation does not generate new information outside the confines of the theory but it often leads to insights about the examined theory. Evaluation determines the degree of usefulness of a theory to guide clinical practice, research, education and administrative work. Allows the reviewer to determine the strengths and weakness of a theory. Assists in identifying the need for additional theory development or refinement.

p. 96 In nursing theory evaluation may provide clinicians with additional knowledge about the soundness of the theory. It also helps identify and provide guidance for the choice of appropriate intervention, gives some indications for their efficacy. In research, theory evaluation helps clarify the forms and structure of a theory being tested or will allow the researcher to determine relevance pf the content of a theory for use a conceptual framework. Evolution also identifies inconsistency and gaps in the theory when used in practice.

Additionally, middle-range theories are less abstract than grand theories and are easier to relate to and put into practice One example of applying middle-range nursing theory into practice is patient education. Patient education is a major focus of the clients I serve post- transplant. It is imperative that a newly transplanted client understand his/her medications that are such an integral part of their new life in order to maintain the transplanted organ.

Middle range theories can provide structure for the interpretation of behavior, situations, and events. They support understanding of the connections between diagnosis and outcomes, and between interventions and outcomes (McEwen and Wills, 2014)
Middle range theories are more useful in research than grand theories because of their low level of abstraction and ease of operationalization. They tend to support prediction better than grand theories due to circumscribed range and specificity of the concepts. They are more likely to be adopted in practice because their relative simplicity eases the process of developing interventions for identified health problems (McEwen &wills, 2014).

Middle range theories address phenomena (concepts) that are toward the middle of a continuum of scope with the metaparadigm concepts (nursing, person, health, environment) at one end and specific concrete actions or events (medication administration, preoperative teaching, electrolyte management, fall prevention) at the other. The concepts should be discrete, observable, and sufficiently abstract to be applied across multiple settings and used with clients with differing problems. Examples from the nursing literature include theories describing health promotion, comfort, coping, resilience, uncertainty, pain, grief, fatigue, self-care, adaptation, self-transcendence, and transitions (Meleis, 2012). (McEwen 216-217)

Middle range theory describes a view which deals with a specific phenomenon and comes from a nurse’s clinical experiences and they are usually influenced from grand theories. The theory of selfcare of chronic illness was influenced from grand theory of selfcare Dorothea Orem. Since it is a middle range theory, it is focused specifically on chronic illness. goal of theory was to categorize behavior and activities used by people with chronic illness. Th authors describe self- care as process of maintaining health promoting practices and managing an illness. the theory evolved from the experience of caring for patients with heart failure. challenges were seen around patients caring for themselves and the choices they made in their daily lives needed to be consistent with the needs of their chronic condition. The authors wanted to evolve their work so that it can be applied to different patients diagnosed with different chronic illness. This theory acknowledged that most patients seeks care because they are looking for relief from their symptoms. The theory requires providers to partner with patients and work diligently to motivate patients to be involved in their self- care activities which can be done as part of daily living making them active participants in their own care.

theory of self-care of chronic illness developed in 2012()-came from middle range theory.

The theory operates on 3 assumptions. There is a difference between self-care of chronic illness and daily self-care. Decision making requires certain cognitive level and self-care is complex when patients have multiple comorbidities. Self-care maintenance, self-care managements and self-care monitoring are interrelated. patients can move in and out of different concepts of the model

Self-care maintenance –behaviors performed to improve wellbeing , preserve health or to maintain physical and emotional wellbeing. It could be performing tasks recommended by the health care provider, family or even things the patients think they should be doing. For example, preparing health meals and taking meds as prescribed (Riegel, Jaarsma &Stomberg, 2012)

Self-care monitoring -process of routine, vigilant body monitoring, surveillance or body listening. (Dickson, Deatrick &Riegel, 2008). 3 criteria for effective body monitoring-clinically significant changes overtime, reliable method of testing is required and a reasonable action response, goal is to be able to recognize that a change has occurred , for example performing regular AccuCheck for diabetic or monitoring blood pressure for hypertensive patients.

Self-care management-involves an evaluation of changes, physical and emotional signs and symptoms to determine if an action is needed (Riegel, Jaarsma, Stomberg, 2012) if a person becomes skilled in self-care management, they can carefully think of an action plan. Action will be specific to the chronic disease. For example, if someone with asthma has SOB, they may take a bronchodilators (albuterol) and if another person with HF has SOB, they may require an increase in Lasix. This phase requires a patient to work closely with their HCP to come up with a plan and be able to evaluate the effectiveness of therapy offered.

References

Crown, S., & Vogel, J. A. (2017). Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis: A Pilot Study Using Motivational Interviewing. Nephrology Nursing Journal44(1), 49–56. Retrieved from https://search-ebscohost-com.prx-herzing.lirn.net/login.aspx?direct=true&db=rzh&AN=121353762&site=ehost-live

Dorsey CJ, & Murdaugh CL. (2003). The theory of self-care management for vulnerable populations. Journal of Theory Construction & Testing7(2), 43–49. Retrieved from https://search-ebscohost-com.prx-herzing.lirn.net/login.aspx?direct=true&db=rzh&AN=106743978&site=ehost-live

Fawcett, J.(2005). Middle-range nursing theories are necessary for the advancement of the discipline. Vol 5.pp.32-43

McEwen, M. & Wills, E.M. (2014). Theoretical basis for nursing. (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Meleis, A. (2012). Theoretical nursing development and progress (5 ed.). Philadelphia: Wolters Kluwer, Lippincott, Williams & Wilkins.

Surucu, H. A., & Kizilci, S. (2012). Use of Orem’s Self-Care Deficit Nursing Theory in the Self-Management Education of Patients with Type 2: A Case Study. Self-Care, Dependent-Care & Nursing19(1), 53–59. Retrieved from https://search-ebscohost-com.prx-herzing.lirn.net/login.aspx?direct=true&db=rzh&AN=104432019&site=ehost-live

White, M. L. (2013). Spirituality Self-care Effects on Quality of Life for Patients Diagnosed with Chronic Illness. Self-Care, Dependent-Care & Nursing20(1), 23–32. Retrieved from https://search-ebscohost-com.prx-herzing.lirn.net/login.aspx?direct=true&db=rzh&AN=104207323&site=ehost-live

Reedy S, & Blum K. (2010). Applying middle-range nursing theory to bariatric surgery patients: experiencing transitions. Bariatric Nursing & Surgical Patient Care, 5(1), 35–43. https://doi.org/10.1089/bar.2009.9940

Riegel, B., Jaarsma, T., & Strömberg, A. (2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science, 35(3), 194–204. Retrieved from https://search-ebscohost-com.prx-herzing.lirn.net/login.aspx?direct=true&db=rzh&AN=108146608&site=ehost-live

Fernandes, S., & Naidu, S. (2017). Promoting Participation in Self Care Management among 

Patients with Diabetes Mellitus: An Application of Peplau’s Theory of Interpersonal

 Relationships. International Journal Of Nursing Education9(4), 129-134. 

doi:10.5958/0974-9357.2017.00109.X

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