INSTRUCITONSThe purpose of this assignment is to draft and submi.docx

INSTRUCITONS
The purpose of this assignment is to draft and submit a
comprehensive and complete rough draft of your Nursing
Theory Comparison paper in APA format. Your rough draft
should include all of the research paper elements of a final
draft, which are listed below. This will give you an opportunity
for feedback from your instructor before you submit your final
draft during week 7.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 6–9), select a grand nursing
theory.
·
After studying and analyzing the approved theory, write about
this theory, including an overview of the theory and
specific examples of how it could be applied in your own
clinical setting.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 10 and 11), select a middle-
range theory.
·
After studying and analyzing the approved theory, write about
this theory, including an overview of the theory and
specific examples of how it could be applied in your own
clinical setting.

The following should be included:
1.
An introduction, including an overview of both selected nursing
theories
2.
Background of the theories
3.
Philosophical underpinnings of the theories
4.
Major assumptions, concepts, and relationships
5.
Clinical applications/usefulness/value to extending nursing
science testability
6.
Comparison of the use of both theories in nursing practice
7.
Specific examples of how both theories could be applied in your
specific clinical setting
8.
Parsimony
9.
Conclusion/summary
10.
References: Use the course text and a minimum of three
additional sources, listed in APA format
The paper should be 8–10 pages long and based on instructor-

approved theories. It should be typed in Times New Roman with
12-point font, and double-spaced with 1" margins. APA format
must be used, including a properly formatted cover page, in-text
citations, and a reference list. The proper use of headings in
APA format is also required.
CHAPTER 6: Overview of Grand Nursing Theories
Evelyn M. Wills
Janet Turner works as a nurse on a postsurgical, cardiovascular
floor. Because she desires a broader view of nursing knowledge
and wants to become a clinical specialist or family nurse
practitioner, she recently began an online RN to BSN degree
program that would prepare her to enter a master’s degree
program in nursing. The requirements for a course entitled
“Scholarly Foundations of Nursing Practice” led Janet to
become familiar with some of the many nursing theories. From
her readings, she learned about a number of ways to classify
theories: grand theory, conceptual model, middle range theory,
practice theory, borrowed theory, interactive–integrative model,
totality paradigm, and simultaneous action paradigm. She came
to the conclusion that there is no cohesion among authors of
nursing theory and even wondered what relation theory had to
what she was doing in her critical care nursing practice.
Janet’s theory course was delivered through online distance
learning methods. To express her frustration and to try to
understand the material, she consulted with her theory professor
via the Web-based live chat room that was part of the course.
The entire class eventually logged on to the chat and a long
discussion resulted in which students shared their frustration
with these new and abstract ideas. The instructor, a teacher who
had come from an RN to BSN program herself, shared with
them that frustration and confusion were the normal feelings
one had when learning these abstractions. She presented them

with several interesting ways to conceptualize grand nursing
theories. The chat broke up with the agreement that each student
would review the assigned readings again and return to next
week’s live chat ready to discuss their findings.
Theories evolved from several schools of philosophical thought
and
differing
scientific traditions. To better understand the theories, Janet
looked for ways to group or categorize them based on
similarities of perspective. As she studied theories based on
similar perspectives, she was able to read and analyze the
theories more effectively, and to select three that she intended
to examine further.
In
Chapter 2
, the reader was introduced to grand nursing theories and given
a brief historical overview of their development. Fawcett and
DeSanto-Madeya (2013) distinguish between conceptual models
and grand theories, and this chapter discusses that
differentiation in an effort to assist nursing students to
understand the material. According to Fawcett and DeSanto-
Madeya (2013), conceptual models are broad formulations of
philosophy that are based on an attempt to include the whole of
nursing reality as the scholar understands it. The concepts and
propositions are abstract and not likely to be testable in fact.
Grand nursing theories, by contrast, may be derived from
conceptual models and are the most complex and widest in
scope of the levels of theory; they attempt to explain broad
issues within the discipline. Grand theories are composed of
relatively abstract concepts and propositions that are less
abstract than those of conceptual models (p. 15) and may not be
directly amenable to testing (Butts, 2011; Fawcett & DeSanto-
Madeya, 2013; Higgins & Moore, 2000). They were developed
through thoughtful and insightful appraisal of existing ideas as
opposed to empirical research and may provide the basis for
scholars to produce innovative middle range or practice theories

(
Figure 6-1
).
FIGURE 6-1: Relationship of conceptual model, theory, and
hypotheses.
The grand nursing theories guide research and assist scholars to
integrate the results of numerous diverse investigations so that
the findings may be applied to education, practice, further
research, and administration. Eun-Ok and Chang (2012), in their
review of literature, found support for the idea that grand
theories have an important place in nursing, for example, in
research and clinical practice. They also found that theorists are
further refining concepts and theories. They stated that theories
are “essential for our discipline at multiple levels” (p. 162).
Eun-Ok and Chang (2012) also noted that the grand theories
provide a background of philosophical reasoning that allows
nurse scientists to develop organizing principles for research or
practice, sometimes referred to as middle range theory (middle
range theories will be discussed in
Chapters 10
and
11
.) One of the most important benefits of invoking theories in
education, administration, research, and practice has been the
systematization of those domains of nursing activity.
Practitioners are more likely to succeed in analyzing research
results using meta-analysis for evidence-based practice (EBP)
when the research fits into a particular theoretical framework.
Cody (2003) stated that “nursing theory guided practice can be
shown to enhance health and quality of life when it is
implemented with strong, well-qualified guidance” (p. 167).
Mark, Hughes, and Jones (2004) echoed his beliefs and posited
that theory-guided research results not only in greater patient
safety but also in more predictable outcomes. These beliefs
among nursing scientists provide clear direction that theory-
guided research is necessary for evaluating nursing

interventions in practice.
Over the last five decades of theory development, review of the
health care literature demonstrates that changes in health care,
society, and the environment, as well as changes in population
demographics (e.g., aging, urbanization, and increase in
minorities), led to a need to renew or update existing theories
and to develop different theories. In fact, some theoretical
writers would exclude the grand theory–middle range theory–
microtheory relationship in favor of value-based and socially
attuned constructions of nursing knowledge that fit
contemporary understanding of human interactions (Risjord,
2010).
Health care delivery is a constantly changing process, and to be
relevant to health care, theories require constant renewal and
reevaluation. Indeed, many established nursing theorists
continue to write, reevaluate, and improve their theories in light
of these changes. Inspiration for many of the newer theories is
linked not only to the changes in the health sciences but also to
changes in society worldwide (Boykin & Schoenhofer, 2001).
Such theorists as Roper, Logan, and Tierney (2000) (United
Kingdom), Ray (Canada), and Martinson (Norway) have
achieved worldwide recognition. This chapter introduces
conceptual frameworks and grand nursing theories.
Chapters 7
through
9
provide additional information about some of the more
commonly known and widely recognized nursing frameworks
and theories. To better assist the reader in understanding the
conceptual frameworks and grand nursing theories, this chapter
presents methods for categorizing or classifying them and
describes the criteria that will be used to examine them in the
subsequent chapters.
Categorization of Conceptual Frameworks and Grand Theories
The sheer number and scope of the conceptual frameworks and
grand theories are daunting. Students and novice nursing

scholars are understandably intimidated when asked to study
them, as illustrated in the opening case study. To help
understand the formulations, a number of methods categorizing
them have been described in the nursing literature. Several are
presented in the following sections.
Categorizatio
CHAPTER 7: Grand Nursing Theories Based on Human Needs
Evelyn M. Wills
Donald Crawford is an intensive care unit (ICU) clinical nurse
specialist (CNS) who has just completed his graduate degree.
Donald strongly believes that evidence guiding nursing practice
should be experiential and measurable, and during his master’s
program, he derived a system for evaluation of the needs of the
seriously ill individuals for whom he cared. He also devised a
way to diagram the disease pathophysiology for many of his
patients based on the Neuman Systems Model (Neuman &
Fawcett, 2009).
During his graduate studies, Donald began to apply concepts
and principles from Neuman’s model in his practice with
encouraging results. He observed that the model helped predict
what would happen next with some patients and helped him
define patient’s needs, predict outcomes, and prescribe nursing
interventions more accurately. In particular, he appreciated how
Neuman focused on identification and reduction of stressors
through nursing interventions and liked the construct of
prevention as intervention. Using his position as CNS, he is
developing a proposal to implement his methods throughout the
ICU to help other nurses apply Neuman’s model in managing
patient care.
The earliest theorists in nursing drew from the dominant
worldviews of their time, which were largely related to the
medical discoveries from the scientific era of the 1850s through
1940s (Artinian, 1991). During those years, nurses in the United
States were seen as handmaidens to doctors, and their practice
was guided by disease theories of medical science. Even today,
much of nursing science remains based in the positivist era with

its focus on disease causality and a desire to produce
measurable outcome data. Evidence-based medicine is the
current means of enacting the positivist focus on research
outcomes for effective clinical therapeutics (Cody, 2013).
In an effort to define the uniqueness of nursing and to
distinguish it from medicine, nursing scholars from the 1950s
through the 1970s developed a number of nursing theories. In
addition to medicine, the majority of these early works were
strongly influenced by the needs theories of social scientists
(e.g., Maslow). In needs-based theories, clients are typically
considered biopsychosocial beings who are the sum of their
parts, who are experiencing disease or trauma, and who need
nursing care. Further, clients are thought of as mechanistic
beings, and if the correct information can be gathered, the cause
or source of their problems can be discerned and measured. At
that point, interventions can be prescribed that will be effective
in meeting their needs (Dickoff, James, & Wiedenbach, 1968).
Evidence-based nursing fits with these theories completely and
comfortably.
The grand theories and models of nursing described in this
chapter focus on meeting clients’ needs for nursing care. These
theories and models, like all personal statements of scholars,
have continued to grow and develop over the years; therefore,
several sources were consulted for each model. The latest
writings of and about the theories were consulted and are
presented. As much as possible, the description of the model is
either quoted or paraphrased from the original texts. Some
needs theorists may have maintained their theories over the
years with little change; others have updated and adapted theirs
to later ideas and methods. Nevertheless, new research has often
extended the original work. Students are advised to consult the
literature for the newest research using the needs theory of
interest.
It should be noted that a concerted attempt was made in this
book to ensure that the presentation of the works of all theorists
is balanced. Some theories (e.g., Orem and Neuman) are more

complex than others, and the body of information is greater for
some than for others. As a result, the sections dealing with some
theorists are a little longer than others. This does not imply that
shorter works are inferior or less important to the discipline.
Finally, all theory analysts, whether novice or expert, will
comprehend theories and models from their own perspectives. If
the reader is interested in using a model, the most recent edition
of the work of the theorist should be obtained and used as the
primary source for any projects. All further works using the
theory or model should come from researchers using the theory
in their work. Current research writings are one of the best ways
to understand the development of the needs theories.
Florence Nightingale: Nursing: What It Is and What It Is Not
Nightingale’s model of nursing was developed before the
general acceptance of modern disease theories (i.e., the germ
theory) and other theories of medical science. Nightingale knew
the germ theory (Beck, 2005), and prior to its wide publication
she had deduced that cleanliness, fresh air, sanitation, comfort,
and socialization were necessary to healing. She used her
experiences in the Scutari Army Hospital in Turkey and in other
hospitals in which she worked to document her ideas on nursing
(Beck, 2005; Dossey, 2000; Selanders, 1993; Small, 1998).
Nightingale was from a wealthy family, yet she chose to work in
the field of nursing, although it was considered a “lowly”
occupation. She believed nursing was her call from God, and
she determined that the sick deserved civilized care, regardless
of their station in life (Nightingale, 1860/1957/1969).
Through her extensive body of work, she changed nursing and
health care dramatically. Nightingale’s record of letters is
voluminous, and several books have been written analyzing
them (Attewell, 2012; Dossey, Selanders, Beck, & Attewell,
2005). She wrote many books and reports to federal and
worldwide agencies. Books she wrote that are especially
important to nurses and nursing include
Notes on Nursing: What It Is and What It Is Not
(original publication in 1860; reprinted in 1957 and 1969),

Notes on Hospitals
(published in 1863), and
Sick-Nursing and Health-Nursing
, originally published in Hampton’s
Nursing of the Sick
, 1893) (Reed & Zurakowski, 1996) and reprinted
in toto
in Dossey et al. (2005a), to name but a small portion of her
great body of works. Much of her work is now available, where
once it was kept out of circulation; perhaps because of the sheer
volume and perhaps because she originally asked that her papers
all be destroyed at her death. She later recanted that request
(Bostridge, 2011; Cromwell, 2013).
Background of the Theorist
Nightingale was born on May 12, 1820, in Florence, Italy; her
birthday is still honored in many places. She was privately
educated in the classical tradition of her time by her father, and
from an early age, she was inclined to care for the sick and
injured (Bostridge, 2011; Dossey, 2000, 2005a; Selanders,
1993). Although her mother wished her to lead a life of social
grace, Nightingale preferred productivity, choosing to school
herself in the care of the sick. She attended nursing programs in
Kaiserswerth, Germany, in 1850 and 1851 (Bostridge, 2011;
Dossey et al., 2010; Small, 1998), where she completed what
was at that time the only formal nursing education available.
She worked as the nursing superintendent at the Institution for
Care of Sick Gentlewomen in Distressed Circumstances, where
she instituted many changes to improve patient care (Cromwell,
2013; Dossey, 2000; Selanders, 1993; Small, 1998).
During the Crimean War, she was urged by Sidney Herbert,
Secretary of War for Great Britain, to assist in providing care
for wounded soldiers. The dire conditions of British servicemen
had resulted in a public outcry that prompted the government to
institute changes in the system of medical care (Small, 1998).
At Herbert’s request, Nightingale and a group of 38 skilled
nurses were transported to Turkey to provide nursing care to the

soldiers in the hospital at Scutari Army Barracks. There, despite
daunting opposition by army physicians, Nightingale instituted
a system of care that reportedly cut casualties from 48% to 2%
within approximately 2 years (Bostridge, 2011; Dossey, 2000,
2005a; Selanders, 1993; Zurakowski, 2005).
Early in her work at the army hospital, Nightingale noted that
the majority of soldiers’ deaths was caused by transport to the
hospital and conditions in the hospital itself. Nightingale found
that open sewers and lack of cleanliness, pure water, fresh air,
and wholesome food were more often the causes of soldiers’
deaths than their wounds; she implemented changes to address
these problems (Small, 1998). Although her recommendations
were known to be those that would benefit the soldiers,
physicians in charge of the hospitals in the Crimea blocked her
efforts. Despite this, by her third trip to the Crimea, Nightingale
had been appointed the supervisor of all the nurses (Bostridge,
2011; Dossey, 2000).
At Scutari, she became known as the “lady with the lamp” from
her nightly excursions through the wards to review the care of
the soldiers (Audain, 1998; Bostridge, 2011). To prove the
value of the work she and the nurses were doing, Nightingale
instituted a system of record keeping and adapted a statistical
reporting method known as the
polar area diagram
(Audain, 2007; O’Connor & Robertson, 2003), or Cock’s Comb
model, to analyze the data she so rigorously collected (Small,
1998). Thus, Nightingale was the first nurse to collect and
analyze evidence that her methods were working.
On her return to England from Turkey, Nightingale worked to
reform the Army Medical School, instituted a program of record
keeping for government health statistics and assisted with the
public health system in India. The effort for which she is most
remembered, however, is the Nightingale School for Nurses at
St. Thomas’
n Based on Scope
One of the most logical ways to categorize grand nursing

theories is by scope. For example, Alligood and Tomey (2010)
organized theories according to the scope of
CHAPTER 8: Grand Nursing Theories Based on Interactive
Process
Evelyn M. Wills
Jean Willowby is a student in an RN to master of science in
nursing program. She is working to become a pediatric nurse
practitioner. For one of her practicum assignments, she must
incorporate a nursing theory into her clinical work, using the
theory as a guide. During an earlier course on theory, Jean read
several nursing theories that focused on interactions between
the client and the nurse and between the client and the health
care system. She remembered that in the interaction models and
theories, human beings are viewed as interacting wholes and
client problems are seen as multifactorial.
The theories that stress human interactions best fit Jean’s
personal philosophy of nursing because they take into account
the multitude of factors she believes to be part of clinical
nursing practice. Like the perspective taken by interaction
model theorists, Jean understands that, at times, the results of
interventions are unpredictable and that many elements in the
client’s background and environment have an effect on the
outcomes of interventions. She also acknowledges that there are
many interactions between clients and their environments, both
internal and external, some of which cannot be measured.
To better prepare for the assignment, Jean studied several of the
human interaction models and theories, focusing most of her
attention on the works of Roy and King. But after discussing
her thoughts with her professor, she was referred to the Artinian
Intersystem Model (AIM), a relatively new model by Barbara
Artinian. After reviewing some of the precepts of the model,
she thought that it appeared to best fit her pediatrics practice
and determined that she would learn more about it.
As discussed in
Chapter 6

, interactive process nursing theories occupy a place between
the needs-based theories of the 1950s and 1960s, most of which
were philosophically grounded in the positivist school of
thought, and the unitary process models, which are grounded in
humanist philosophy, which expresses the belief that humans
are unitary beings and energy fields in constant interaction with
the universal energy field. The interactive theories are grounded
in the postpositive schools of philosophy.
The theorists presented in this chapter believe that humans are
holistic beings who interact with and adapt to situations in
which they find themselves. These theorists ascribe to systems
theory and agree that there is constant interaction between
humans and their environments. In general, human interaction
theorists believe that health is a value and that a continuum of
health ranges from high-level wellness to illness. They
acknowledge, however, that people with chronic illnesses may
have healthy lives and live well despite their illnesses.
Nursing models that can be described as interactive process
theories include Levine’s Conservation Model; Artinian’s
Intersystem Model; Erickson, Tomlin, and Swain’s Modeling
and Role-Modeling; King’s Systems Framework and Theory of
Goal Attainment; Roy’s Adaptation Model; and Watson’s
Philosophy and Science of Caring. Each is discussed in this
chapter. The models treated in this chapter are not arranged
historically; some date back to the 1960s, whereas some are
relatively new. Levine’s model is placed early in the chapter
because it is one of the classic models.
An attempt was made to ensure that a balanced approach was
used in presenting the works of these theorists. However, some
of the theories are quite complex (e.g., those of Erickson,
Tomlin, and Swain; King; and Roy), whereas others are quite
parsimonious (e.g., those of Levine and Watson). Additionally,
some of the models have been revised repeatedly (e.g., Artinian,
King, Roy, and Watson). As a result, the sections dealing with
some models are longer or more involved than others, but this
does not imply that the works of any of the theorists discussed

are more or less important to the discipline than others.
Myra Estrin Levine: The Conservation Model
The ideal of conservation pervades the background of some
nurses’ ideas (Mefford, 2004). Myra Levine (1973) stated that
“nursing is a human interaction” (p. 237). Her model deals with
the interactions of nurse and client. It considers multiple
factorial interactions, which may produce predictable effects
using probability as the reality.
Myra Levine earned a diploma in nursing from Cook County
School of Nursing in Chicago, Illinois, in 1944; a bachelor’s
degree in science at the University of Chicago in 1949; and a
master of science in nursing from Wayne State University in
Detroit, Michigan, in 1962. She held numerous clinical and
education positions during her long career (Schaefer, 2010). She
published
An Introduction to Clinical Nursing
in 1969; this work was revised in 1973 and again in 1989
(Levine, 1989). Levine enjoyed a long and productive career,
which included a distinguished publication record. She died in
1996, at age 75, leaving a legacy to nursing of education,
administration, and scholarship (Schaefer, 2002).
Philosophical Underpinnings of the Theory
Levine (1973) based the Conservation Model on Nightingale’s
idea that “the nurse created an environment in which healing
could occur” (p. 239). She drew from the works of Tillich on
the unity principle of life, Bernard on internal
environment, Cannon on the theory of homeostasis, and
Waddington on the concept of homeorrhesis. The works of other
scientists were also used. Four conservation principles form the
basis of the model; these were synthesized from her scientific
study and practice (Levine, 1990).
Major Assumptions, Concepts, and Relationships
The following four conservation principles are the major
principles around which the model is constructed:
·

The principle of the conservation of energy
·
The principle of the conservation of structural integrity
·
The principle of the conservation of personal integrity
·
The principle of the conservation of social integrity (Levine,
1990, p. 331)
According to Levine’s model, nursing interventions are based
on conservation of the client’s integrity in each of the
conservation domains. The nurse is seen as a part of the
environment and shares the repertoire of skill, knowledge, and
compassion, assisting each client to confront environmental
challenges in resolving the problems encountered in the client’s
own unique way. The effectiveness of the interventions is
measured by the maintenance of client integrity (Levine, 1973,
1990).
Assumptions About Individuals
·
Each individual “is an active participant in interactions with the
environment constantly seeking information from it” (Levine,
1969, p. 6).
·
The individual “is a sentient being and the ability to interact
with the environment seems ineluctably tied to his sensory
organs” (Levine, 1973, p. 450).
·
“Change is the essence of life and it is unceasing as long as life
goes on. Change is characteristic of life” (Levine, 1973, p. 10).

Assumptions About Nursing
·
“Ultimately the decisions for nursing intervention must be
based on the unique behavior of the individual patient” (Levine,
1973, p. 6).
·
“Patient-centered nursing care means individualized nursing
care. It is predicated on the reality of common experience:
every man is a unique individual, and as such he requires a
unique constellation of skills, techniques and ideas designed
specifically for him” (Levine, 1973, p. 23).
Concepts
Many concepts are discussed in the model. Major concepts are
listed in
Table 8-1
.
Table 8-1: Major Concepts of the Conservation Model
Concept
Definition
Environment
Includes both the internal and external environment.
Person
The unique individual in unity and integrity, feeling, believing,
thinking, and whole.
Health
Patterns of adaptive change of the whole being.
Nursing
The human interaction relying on communication, rooted in the
organic dependency of the individual human being in his [sic]
relationships with other human beings.
Adaptation
The process of change and integration of the organism in which
the individual retains integrity or wholeness. It is possible to
have degrees of adaptation.

Conceptual environment
The part of the person’s environment that includes ideas,
symbolic exchange, belief, tradition, and judgment.
Conservation
Includes joining together and is the product of adaptation
including nursing intervention and patient participation to
maintain a safe balance.
Energy conservation
Nursing interventions based on the conservation of the patient’s
energy.
Holism
The singular, yet integrated response of the individual to forces
in the environment.
Homeostasis
Stable state normal alterations in physiologic parameters in
response to environmental changes; an energy-sparing state, a
state of conservation.
Modes of communication
The many ways in which information, needs, and feelings are
transmitted among the patient, family, nurses, and other health
care workers.
Personal integrity
A person’s sense of identity and self-definition. Nursing
intervention is based on the conservation of the individual’s
personal integrity.
Social integrity
Life’s meaning gained through interactions with others. Nurses
intervene to maintain relationships.
Structural integrity
Healing is a process of restoring structural integrity through
nursing interventions that promote healing and maintain
structural integrity.
Therapeutic interventions
Interventions that influence adaptation in a favorable way,
enhancing the adaptive responses available to the person.
Source: Adapted from Levine (1973).

Relationships
Relationships are not specifically stated but can be extracted
from the descriptions given by Levine (1973). The relationships
serve as the basis for nursing interventions and include:
·
1.
Conservation of energy is based on nursing interventions to
conserve energy through a deliberate decision as to the balance
between activity and the person’s available energy.
2. Conservation of structural integrity is the basis for nursing
interventions to limit the amount of tissue involvement.
CHAPTER 9: Grand Nursing Theories Based on Unitary
Process
Evelyn M. Wills
Kristin Kowalski is a hospice nurse who wishes to expand the
scope of her therapeutic practice. She desires to delve more
deeply into holistic health care, having recently completed
courses of study in herbal medicine, touch therapy, and holistic
nursing. Kristin is aware that to practice independently, she
needs professional credentials that will be widely accepted;
therefore, she applied to the graduate program of a nationally
ranked nursing school at a large state university.
Because Kristin believes strongly in holistic nursing practice,
for her master’s degree she decided to focus her study of
nursing theories on those that look at the whole person and have
a broad, nontraditional view of health. She is particularly
interested in Rosemarie Parse’s Humanbecoming Paradigm
because this viewpoint stresses the individual’s way of being
and becoming healthy and the nurse as an intersubjective
presence.
Kristin is attracted to Parse’s idea of true presence and wishes
to further explore this concept as well as the rest of the
perspective. She hopes to eventually apply it to her practice and
use it as the research framework for her thesis. For her thesis,
Kristin wants to examine the experiences of nurses who practice

therapeutic touch. She desires to learn their perceptions of how
therapeutic touch interventions help their clients. She also
wants to learn more about Parse’s research method and hopes to
use it for her study.
The term
simultaneity paradigm
was first coined by nursing theorist Rosemarie Parse (1987) to
describe a group of theories that adhered to a unitary process
perception of human beings. This group of theorists believed
that humans are unitary beings: energy systems embedded in the
universal energy system. Within this group of theories, human
beings are seen as unitary, “whole, open and free to choose
ways of becoming” (Parse, 1998, p. 6), and health is described
as continuous human environmental interchanges (Newman,
1994).
The unitary process nursing model and two corollary theories
are described in this chapter: Science of Unitary Human Beings
(Rogers, 1994), Health as Expanding Consciousness (Newman,
1999), and Humanbecoming School of Thought (Parse, 1998,
2010). The three are grouped together because they are
significantly different in their concepts, assumptions, and
propositions when compared to the theories described in
Chapters 7
and
8
. They are universal in scope and relatively abstract.
Martha Rogers: The Science of Unitary and Irreducible Human
Beings
Martha E. Rogers first described her Theory of Unitary Man in
1961, and almost from the first, there has been widespread
controversy and debate among nursing theorists and scholars
regarding her work (Phillips, 1994). Prior to Rogers, it was rare
that anyone in nursing viewed human beings as anything other
than the receivers of care by nurses and physicians.
Furthermore, the health care system was organized by
specialization, in which nurses and other health providers

focused on discrete areas or functions (e.g., a dressing change,
medication administration, or health teaching) rather than on the
whole person. As a result, it took many professionals working
in isolation, none of whom knew the whole person, to care for
patients. Rogers’ (1970) insistence that the person was a
“unitary energy system” in “continuous mutual interaction with
the universal energy system” (p. 90) dramatically influenced
nursing by encouraging nurses to consider each person as a
whole (a unity) when planning and delivering care.
Martha Rogers was born on May 12, 1914 (the anniversary of
Florence Nightingale’s birth) (Dossey, 2000) in Dallas, Texas.
She earned a diploma in nursing from Knoxville General
Hospital in 1936 and a bachelor’s degree from George Peabody
College in Nashville, Tennessee in 1937. She later received a
master’s degree in public health nursing from Teachers College,
Columbia University in New York, and a master’s degree in
public health and a doctor of science from The Johns Hopkins
University in Baltimore, Maryland (Gunther, 2010).
Rogers became the head of the Division of Nursing of New
York University (NYU) in 1954, where she focused on teaching
and formulating and elaborating her theory (Hektor, 1989). She
was teacher and mentor to an impressive list of nursing scholars
and theorists, including Newman and Parse, whose works are
described later in the chapter. Rogers continued her work and
writing until her death in March, 1994.
Philosophical Underpinnings of the Theory
The Science of Unitary and Irreducible Human Beings started as
an abstract theory that was synthesized from theories of
numerous sciences; therefore, it was deductively derived. Of
particular importance was von Bertalanffy’s theory on general
systems, which contributed the concepts of entropy and
negentropy and posited that open systems are characterized by
constant interaction with the environment. The work of
Rapoport provided a background on open systems, and the work
of Herrick contributed to the premise of evolution of human

nature (Rogers, 1994).
Rogers’ synthesis of the works of these scientists formed the
basis of her proposition that human systems are open systems,
embedded in larger, open environmental systems. She also
brought in other concepts, including the idea that time
is unidirectional, that living systems have pattern and
organization, and that man is a sentient, thinking being capable
of awareness, feeling, and choosing. From all these theories,
and from her personal study of nature, Rogers (1970) developed
her original Theory of Unitary Man. She continuously refined
and elaborated her theory, which she retitled Science of Unitary
Humans (Rogers, 1986) and finally, shortly before her death,
the Science of Unitary and Irreducible Human Beings (Rogers,
1994).
Major Assumptions, Concepts, and Relationships
Assumptions
Rogers presented several assumptions about man. These are as
follows:
·
Man is a unified whole possessing integrity and manifesting
characteristics that are more than and different from the sum of
his parts (Rogers, 1970, p. 47).
·
Man and environment are continuously exchanging matter and
energy with one another (Rogers, 1970, p. 54).
·
The life process evolves irreversibly and unidirectionally along
the space–time continuum (Rogers, 1970, p. 59).
·
Pattern and organization identify man and reflect his innovative
wholeness (Rogers, 1970, p. 65).
·

Man is characterized by the capacity for abstraction and
imagery, language and thought, sensation, and emotion (Rogers,
1970, p. 73).
Rogers (1990) later revised the term
man
to
human being
to coincide with the request for gender-neutral language in the
social sciences and nursing science.
Concepts
In Rogers’ work, the unitary human being and the environment
are the focus of nursing practice. Other central components are
energy fields, openness, pandimensionality, and pattern; these
she identified as the “building blocks” (Rogers, 1970, p. 226) of
her system. Rogers also derived three other components for the
model, which served as a basis of her work. These were based
on principles of homeo dynamics and were termed
resonancy, helicy
, and
integrality
(Rogers, 1990) (
Box 9-1
). Definitions of the nursing metaparadigm concepts and other
important concepts in Rogers’ work are listed in
Table 9-1
.
Box 9-1: Principles of Homeodynamics Applied in Rogers’
Theory
·
1. Resonancy is continuous change from lower to higher
frequency wave patterns in human and environmental fields.
·
2. Helicy is continuous innovative, unpredictable, increasing

diversity of human and environmental field patterns.
·
3. Integrality is continuous mutual human and environmental
field processes.
Source: Rogers (1990, p. 8).
Table 9-1: Central Concepts of Rogers’ Science of Unitary
Human Beings
Concept
Definition
Human–unitary human beings
“Irreducible, indivisible, multidimensional energy fields
identified by pattern and manifesting characteristics that are
specific to the whole and which cannot be predicted from the
knowledge of the parts” (p. 7).
Health
“Unitary human health signifies an irreducible human field
manifestation. It cannot be measured by the parameters of
biology or physics or of the social sciences” (p. 10).
Nursing
“The study of unitary, irreducible, indivisible human and
environmental fields: people and their world” (p. 6). Nursing is
a learned profession that is both a science and an art.
Environmental field
“An irreducible, indivisible, pandimensional energy field
identified by pattern and integral with the human field” (p. 7).
Energy field
“The fundamental unit of the living and the non-living. Field is
a unifying concept. Energy signifies the dynamic nature of the
field; a field is in continuous motion and is infinite” (p. 7).
Openness
Refers to qualities exhibited by open systems; human beings
and their environment are open systems.
Pandimensional
“A nonlinear domain without spatial or temporal attributes” (p.
28).

Pattern
“The distinguishing characteristic of an energy field perceived
as a single wave” (p. 7).
Source: Rogers (1990).
Relationships
The Science of Unitary and Irreducible Human Beings is
fundamentally abstract; therefore, specifically defined
relationships differ from those in more linear theories. The
major components of Rogers’ model revolve around the building
blocks (energy
CHAPTER 10: Introduction to Middle Range Nursing Theories
Melanie McEwen
Annette Cohen is a second-year graduate nursing student
interested in starting her major research/scholarship project. For
this project, she would like to develop some of her experiences
in hospice nursing into a preliminary middle range theory of
spiritual health. Annette has studied spiritual needs and
spiritual care for many years but believes that the construct of
spiritual health is not well understood. She views spiritual
health as the result of the interaction of multiple intrinsic values
and external variables within a client’s experiences, and she
believes that it is a significant contributing factor to overall
health and well-being.
After reviewing theoretical writings dealing with spiritual
nursing care, Annette found a starting point for her work in Jean
Watson’s Theory of Human Caring (Watson, 2005) because of
its emphasis on spirituality and faith. From Watson’s work, she
was particularly interested in applying the concepts of “actual
caring occasion” and “transpersonal” care. To develop the
theory, Annette obtained a copy of Watson’s most recent work
and performed a comprehensive review of the literature
covering theory development and the Theory of Human Caring.
She then did an analysis of the concept of spiritual health.
Combining the concept analysis and the literature review of
Watson’s work led to the development of assumptions and
formal definitions of related concepts and empirical indicators.

After conversing with her instructor, she concluded that her
next steps were to construct relational statements and then draw
a model depicting the relationships among the concepts that
comprise spiritual health.
As discussed in
Chapter 2
, middle range nursing theories lie between the most abstract
theories (grand nursing theories, models, or conceptual
frameworks) and more circumscribed, concrete theories
(practice theories, situation-specific theories, or microtheories).
Compared to grand theories, middle range theories are more
specific, have fewer concepts, and encompass a more limited
aspect of the real world. Concepts are relatively concrete and
can be operationally defined. Propositions are also relatively
concrete and may be empirically tested.
The discipline of nursing recognizes middle range theory as one
of the contemporary trends in knowledge development, and
there is broad acceptance of the need to develop middle range
theories to support nursing practice (Alligood, 2010;
Fitzpatrick, 2003; Kim, 2010; Peterson, 2013). According to
Morris (1996) and Suppe (1996), this call to develop middle
range theory is consistent with the third stage of legitimizing
the discipline of nursing. The first stage focuses on
differentiation of the perspective of the emerging discipline,
which is characterized by separation from antecedent disciplines
(i.e., medicine) and the establishment of university-based
education, which in nursing occurred during the 1950s and
1960s. The second stage is marked by the quest to secure
institutional legitimacy and academic autonomy. This stage
characterized nursing during the 1970s and through the 1980s,
when pursuit of nursing’s unique perspective on and
clarification of the phenomena of interest to the discipline were
stressed. The third stage began in the 1990s and is distinguished
by increased attention to substantive knowledge development,
which includes development and testing of middle range
theories. This stage is expanding and evolving further to include

evidence-based practice and situation-specific theories (see
Chapter 12
).
Middle range theories are increasingly being used in nursing
research studies. 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.
A review of nursing research journals and dissertation abstracts
indicates that nursing research is currently being used in the
development and testing of a number of middle range theories,
and middle range theories are frequently being used as
frameworks for investigation. Furthermore, middle range
theories are presently being refined on the basis of research
results.
Despite the promotion of middle range theories in recent years,
there is a lack of clarity regarding what constitutes middle
range theory in nursing. According to Cody (1999), “It appears
that almost any theoretical entity that is more concrete than the
broadest of grand theories is considered middle range by
someone” (p. 10). It has been noted that nursing theory
textbooks (e.g., Alligood, 2010; Chinn & Kramer, 2011;
Fawcett & DeSanto-Madeya, 2013; Parker & Smith, 2010)
disagree to some degree on which theories should be labeled as
middle range. Indeed, some authors list a few of the readily
accepted grand theories (e.g., Parse, Newman, Peplau, and
Orlando) as middle range. Others consider somewhat more
circumscribed theories (e.g., Leininger, Pender, Benner and
Erickson, Tomlin, and Swain) to be middle range, although the
theory’s authors may not agree. In essence, there has been a
paucity of discussion on the subject and therefore there is little
consensus. This issue is discussed in more detail later in the
chapter.
Purposes of Middle Range Theory
Middle range theories were first suggested in the discipline of
sociology in the 1960s and were introduced to nursing in 1974.

At that time, it was observed that middle range theories were
useful for emerging disciplines because they are more readily
operationalized and addressed through research than are grand
theories. More than 15 years elapsed, however, before there was
a concerted call for middle range theory development in nursing
(Blegen & Tripp-Reimer, 1997; Meleis, 2012).
Development of middle range theories is supported by the
frequent critique of the abstract nature of grand theories and the
difficulty of their application to practice and research. The
function of middle range theories is to describe, explain, or
predict phenomena, and, unlike grand theory, they must be
explicit and testable. Thus, they are easier to apply in practice
situations and to use as frameworks for research studies. In
addition, middle range theories have the potential to guide
nursing interventions and change conditions of a situation to
enhance nursing care. Finally, a major role of middle range
theory is to define or refine the substantive component of
nursing science and practice (Higgins & Moore, 2000). Indeed,
Lenz (1996) noted that practicing nurses are actually using
middle range theories but are not consciously aware that they
are doing so.
Each middle range theory addresses relatively concrete and
specific phenomena by stating what the phenomena are, why
they occur, and how they occur. In addition, 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 (Fawcett & DeSanto-Madeya,
2013).
Enhancing the focus on middle range theories in nursing is
supported by several factors. These include the observations
that middle range theories
·
are more useful in research than grand theories because of their
low level of abstraction and ease of operationalization

·
tend to support prediction better than grand theories due to
circumscribed range and specificity of the concepts
·
are more likely to be adopted in practice because their relative
simplicity eases the process of developing interventions for
identified health problems (Cody, 1999; Peterson, 2013)
Like theory in general, middle range theory has three functions
in nursing knowledge development. First, middle range theories
are used as theoretical frameworks for research studies. Second,
middle range theories are open to use in practice and should be
tested by research. Finally, middle range theories can be the
scientific end product that expresses nursing knowledge (Suppe,
1996).
Characteristics of Middle Range Theory
Several characteristics identify nursing theories as middle
range. First, the principal ideas of middle range theories are
relatively simple, straightforward, and general. Second, middle
range theories consider a limited number of variables or
concepts; they have a particular substantive focus and consider
a limited aspect of reality. In addition, they are receptive to
empirical testing and can be consolidated into more wide-
ranging theories. Third, middle range theories focus primarily
on client problems and likely outcomes, as well as the effects of
nursing interventions on client outcomes. Finally, 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; Peterson,
2013).
The more frequently used middle range theories tend to be those
that are clearly stated, easy to understand, internally consistent,
and coherent. They deal with current nursing perspectives and
address socially relevant topics that solve meaningful and
persistent problems. In summary, middle range theories for

nursing combine postulated relationships between specific,
well-defined concepts with the ability to measure or objectively
code concepts. Thus, middle range theories contain concepts
and statements from which hypotheses may be logically derived
and empirically tested, and they can be easily adopted to guide
nursing practice.
Table 10-1
compares characteristics of grand theory, middle range theory,
and practice/situation-specific theory, and characteristics of
middle range theory are shown in
Box 10-1
.
Table 10-1: Characteristics of Grand, Middle Range, and
Practice/Situation-Specific Theories
Characteristic
Grand Theories
Middle Range Theories
Practice/Situation-Specific Theories
Complexity/abstractness, scope
Comprehensive, global viewpoint (all aspects of human
experience)
Less comprehensive than grand theories, middle view of reality
Focused on a narrow view of reality, simple and straightforward
Generalizability/specificity
Nonspecific, general application to the discipline irrespective of
setting or specialty area
Some generalizability across settings and specialties, but more
specific than grand theories
Linked to special populations or an identified field of practice
Characteristics of concepts
Concepts abstract and not operationally defined
Limited number of concepts that are fairly concrete and may be
operationally defined
Single, concrete concept that is operationalized
Characteristics of propositions
Propositions not always explicit

Propositions clearly stated
Propositions defined
Testability
Not generally testable
May generate testable hypotheses
Goals or outcomes defined and testable
Source of development
Developed through thoughtful appraisal and careful
consideration over many years
Evolve from grand theories, clinical practice, literature review,
and practice guidelines
Derived from practice or deduced from middle range or grand
theory
Box 10-1: Characteristics of Middle Range Nursing Theory
·
Not comprehensive, but not narrowly focused
·
Some generalizations across settings and specialties
·
Limited number of concepts
·
Propositions that are clearly stated
May generate testable hypotheses
CHAPTER 11: Overview of Selected Middle Range Nursing
Theories
Melanie McEwen
Elaine Chavez is employed as a nurse at a public health clinic in
an urban area. She is also in her second semester of a graduate
nursing program preparing to become a mental health nurse
practitioner. In her practice, Elaine has worked with a number
of women who have been abused by their partners, and she has

observed a pattern of comorbidities in these women, including
depression, alcoholism, substance abuse, and suicide attempts.
Over the last few months, Elaine has reviewed the nursing
literature and identified several intervention strategies that have
been effective in working with women who have been victims of
domestic violence. Using this information, she would like to
implement a program to promote early identification of abuse
and multiple-level interventions. This is a project that will work
well with one of her master’s portfolio assignments.
From her literature review, Elaine identified several theories
related to her study. She was particularly interested in
examining the set of circumstances that would cause the women
to seek help. For this, she performed a more detailed literature
review and identified Kolcaba’s (1994, 2003, 2013) Theory of
Comfort, which helped her conceptualize many of the issues
that the women faced. Indeed, the theory described individual
characteristics that contributed to health-seeking behavior.
These were stimulus situations, which can cause negative
tension. By providing comfort measures, the nurse can help
decrease negative tensions and promote positive tension. Elaine
wanted to continue to identify comfort measures that would
encourage the women to seek care for their problems.
For the next phase of her project, Elaine collected all of the
information she could find on Kolcaba’s theory. This included
studies that had used the model as a conceptual framework and
studies that had tested the model. From that information and the
articles she had gathered previously about issues related to
domestic violence, she was able to draft a set of interventions
that she hoped to implement at the clinic following approval by
her supervisor.
Previous chapters have described the growing emphasis on the
development and testing of middle range theories in nursing. As
a result, during the past two decades, a significant number of
these theories have been presented in the nursing literature. The
purpose of this chapter is to introduce some of the commonly
used middle range nursing theories as well as some of the

recently published ones to familiarize readers with these works
and direct them to resources for more information. An attempt
was made to include works from a variety of areas and from
many scholars, but by no means is the list presented here
exhaustive. Nor does inclusion or exclusion relate to the quality
or significance of the theory or its usefulness in research or
practice.
To assist with organization of the chapter, the theories are
divided into sections based on whether they appear to be “high,”
“middle,” or “low” middle range theories. As explained in
Chapter 10
, the high/middle/low distinction relates to the level of
abstraction as posed by Liehr and Smith (1999), with the “high”
middle range theories being the most abstract and nearest to the
grand theories. The “low” middle range theories, on the other
hand, are the least abstract, and they are similar to practice or
situation-specific theories. It is noted that these designations
are arguably arbitrary and that one theory that is listed here as
“high middle” may be considered by others to be a grand theory.
Likewise, another theory listed here as “middle middle” might
be considered by others to be a high middle range theory, and so
forth.
Elements of theory description and theory analysis as explained
in
Chapter 5
serve as the basis for the more detailed discussions of selected
theories. Each will include a brief overview, an outline of the
purpose and major concepts of the theory, and context for use
and nursing implications. Finally, evidence of empirical testing
and application in practice are described.
High Middle Range Theories
The high middle range theories presented here are some of the
more well known and most widely used theories in nursing.
Included are the works of Benner, Leininger, Pender, and
Meleis. These theories may be considered grand theories or
conceptual frameworks by other nursing scholars and possibly

by the author of the theory. These theories, however, do not
totally fit with the criteria for grand theories as outlined in this
text and therefore are not covered in the chapters dealing with
that content. In addition, the Synergy Model, a nursing model
that is widely used in research and practice, particularly in
critical care, will be discussed.
Table 11-1
lists other high middle range theories or conceptual models,
their purposes, and major concepts.
Table 11-1: High Middle Range Nursing Theories
Theory/Model
Purpose
Major Concepts
Tidal model (psychiatric and mental health nursing) (Barker,
2001a, 2001b)
Describes psychiatric nursing practice focusing on three care
processes; emphasizes the fluid nature of human experience
characterized by change and unpredictability
Personhood (dimensions—world, self, others), discrete holistic
(exploratory) assessment; focused (risk) assessment,
empowerment, narrative as the medium of self
Parish nursing (Bergquist & King, 1994)
Describes the integration of physical, emotional, and spiritual
components in provision of holistic health care in a faith
community
Client (spiritual, physical, emotional components), parish nurse
(spiritual maturity, pastoral team member, autonomy, caring,
effective communication), health (physical, emotional, and
spiritual wellness and wholeness), environment (faith
community)
Parish nursing (Miller, 1997)
Integrates the concepts of evangelical Christianity with
application of parish nursing interventions
Person/parishioner, health, nurse/parish nurse,
community/parish, the triune God
Neal theory of home health nursing (Neal, 1999a, 1999b)

Describes the practice of home health nurses as they use process
of adaptation to attain autonomy
Autonomy, three stages (dependence, moderate dependence, and
autonomy), logistics, client’s home, client’s resources, client’s
needs, and learning capacity
Occupational health nursing (Rogers, 1994)
Shows how the occupational health nurse works to improve,
protect, maintain, and restore the health of the
worker/workforce and depicts how practice is affected by both
external and internal work setting influences
Work setting influences (corporate culture/mission, resources,
work hazards, workforce characteristics), external factors
(economics, population/health trends, legislation/politics,
technology), occupational health nursing practice (health
promotion, workplace hazard detection, case
management/primary care, counseling, management, research,
legal/ethical monitoring, community orientation)
Omaha System (Martin, 2005)
Comprehensive classification system that promotes
documentation of client care, generally in community and home
health nursing practice
Depicts the nursing process as circular rather than linear; steps
are: collect and assess data, state problems, identify admission
problem rating, plan and intervene, identify interim/dismissal
problem rating, and evaluate problem outcomes.
Schuler Nurse Practitioner Practice Model (Schuler & Davis,
1993).
Integrates essential nursing and medical orientations to provide
a framework for holistic practice for nurse practitioners (NP)
Patient and NP inputs (noted as episodic and comprehensive
with and without health problem); data gathering/role modeling;
patient and NP throughputs include identification of problems
and diagnosing, contracting, and planning and implementing of
the plan of care. Outputs involve comprehensive evaluation of
patient and NP outcomes.
Public health nursing practice (Smith & Bazini-Barakat, 2003)

Guides public health nurses to improve the health of
communities and target populations
Interdisciplinary public health team, standards of public health
nursing practice, essential public health services, health
indicators, population-based practice (systems, community,
individual, and family focus), healthy people in health
communities
Rural nursing (Weinert & Long, 1991)
Guides rural nursing practice, research, and education by
understanding and addressing the unique health care needs and
preferences of rural persons
Health (health as ability to work), environment (distance and
isolation), person (self-reliance and independence), nursing
(lack of anonymity, outsider/insider, and old-timer/newcomer)
Benner’s Model of Skill Acquisition in Nursing
Patricia Benner’s theoretical model was first published in 1984.
The model, which applies the Dreyfus model of skill acquisition
to nursing, outlines five stages of skill acquisition: novice,
advanced beginner, competent, proficient, and expert. Although
her work is much more encompassing in regard to nursing
domains and specific functions and interventions, it is the five
stages of skill acquisition that has received the most attention
with regard to application in administration, education, practice,
and research.
Purpose and Major Concepts
Benner’s model delineates the importance of retaining and
rewarding nurse clinicians for their clinical expertise in practice
settings because it describes the evolution of “excellent caring
practices.” She notes that research demonstrates that practice
·
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