explain prescriptions or modalities for practice.
Middle Range Theories The need for practice disciplines to develop middle range theories was first proposed in the field of sociology in the 1960s. In nursing, development of middle range theory is growing to fill the gaps between grand nursing theories and nursing practice.
Compared to grand theories, middle range theories contain fewer concepts and are limited in scope. Within the scope of middle range theories, however, some degree of generalization is possible across specialty areas and settings. Propositions are clear, and testable hypotheses can be derived. Middle range theories cover such concepts as pain, symptom management, cultural issues, and health promotion (Higgins & Shirley, 2000; Peterson, 2017; Walker & Avant, 2011). Chapters 10 and 11 provide a detailed discussion of middle range theories and their application in nursing.
Practice Theories Practice theories (microtheories, situation-specific, or prescriptive theories) explain prescriptions or modalities for practice. The essence of practice theory is a defined or identified goal and descriptions of interventions or activities to achieve this goal (Walker & Avant, 2011). Practice theories can cover particular elements of a specialty, such as oncology nursing, obstetric nursing, or operating room nursing, or they may relate to another aspect of nursing, such as nursing administration or nursing education. Such theories typically describe specific elements of nursing care, such as cancer pain relief, or a specific experience, such as dying and end-of-life care.
Practice theories contain few concepts, are narrow in scope, and explain a relatively small aspect of reality. They are derived from middle range theories, practice experiences, comprehensive literature reviews, and empirical testing (Peterson, 2017). Furthermore, when the concepts and statements are operationally defined, they may be tested by appropriate research strategies (Higgins & Shirley, 2000). Chapters 12 and 18 cover practice—or situation-specific—theories in more detail.
Relationship Among Levels of Theory in Nursing Walker and Avant (2011) state that the four levels of theory may be linked in order to direct and focus the discipline of nursing. As they describe, metatheory (worldview or philosophy) clarifies the methodologies and roles for each subsequent level of theory development (grand, middle range, and practice). Each level of theory provides material for further analysis and clarification at the level of metatheory. Grand nursing theories guide the phenomena of concern at the middle range level. Middle range theories assist in refinement of grand theories and direct prescriptions of practice theories. Practice theories are constructed from scientifically based propositions about reality and test the empirical validity of those propositions as they are incorporated into client care (Higgins & Shirley, 2000). Figure 4-1 illustrates the relationships among the levels of theory in nursing.
Figure 4-1 Relationship among levels of theory. (From Walker , L. O. , & Avant , K. C. Strategies for Theory Construction in Nursing, 5th ed., © 2011. Reprinted by permission of Pearson Education, Inc., New York, New York.)
Categorization Based on Purpose As discussed in Chapter 2, Dickoff and James (1968) described four kinds of theory: factor-isolating theories (descriptive theories), factor-relating theories (explanatory theories), situation-relating theories (predictive theories), and situation-producing theories (prescriptive theories). Each higher level of theory builds on the
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lower levels (Dickoff et al., 1968), and each is reviewed and expanded upon in the following sections.
Descriptive Theories Descriptive theories describe, observe, and name concepts, properties, and dimensions, but they typically do not explain the interrelationships among the concepts or propositions, and they do not indicate how changes in one concept affect other concepts. According to Barnum (1998), descriptive theory is the first and most important level of theory development because it determines what will be perceived as the essence of the phenomenon under study. Subsequent theory development expands or refines those elements and specifies relationships that are determined to be important in the descriptive phase. Thus, it is critical that the most significant constituents of the phenomenon be recognized and named in this earliest phase of theory development.
The two types of descriptive theory are naming and classification. Naming theories describe the dimension or characteristics of a phenomenon. Classification theories describe dimensions or characteristics of a phenomenon that are structurally interrelated and are sometimes referred to as typologies or taxonomies (Barnum, 1998; Fawcett, 1999).
Descriptive theories are generated and tested by descriptive or explanatory research. Techniques for generating and testing descriptive theory include concept analysis, case studies, comprehensive literature review, surveys, phenomenology, ethnography, grounded theory, and historical inquiry (Fawcett, 1999). Examples of descriptive theory found in recent nursing literature include the development of a conceptual model of “almost normal,” which describes the experience of adolescents living with implantable cardioverter defibrillators (phenomenology) (Zeigler & Tilley, 2011); development of a middle range theory describing the process of death imminence awareness by family members (grounded theory) (Baumhover, 2015); and a middle range theory of nursing presence (comprehensive literature review) (McMahon & Christopher, 2011). In other examples, concept analysis was used as the method to develop a theoretical model of food insecurity (Schroeder & Smaldone, 2015) and by Lindauer and Harvath (2014) who proposed a situation-specific theory of predeath grief among caregivers of dementia patients.
Explanatory Theories Explanatory theory is the second level in theory development. Once phenomena have been identified and named, they can be viewed in relation to other phenomena. Explanatory theories relate concepts to one another and describe and specify some of the associations or interrelations between and among the concepts. Furthermore, explanatory theories attempt to tell how or why the concepts are related and may deal with causality, correlations, and rules that regulate interactions (Barnum, 1998; Dickoff et al., 1968).
Explanatory theories can be developed only after the parts of the phenomena have been identified and tested, and they are generated and tested by correlational research. Correlational research requires collection or measurement of data gathered by observation or self-report instruments that will yield either qualitative or quantitative data (Fawcett, 1999). Explanatory theories may also be generated by processes involving in-depth integrative/systematic and rigorous review of extant research literature. Examples of explanatory theories from recent nursing literature include meta-synthesis of qualitative study data in development of a model describing the experience of cancer among teenagers and young adults (Taylor, Pearce, Gibson, Fern, & Whelan, 2013) and a model of nursing care dependence as experienced by adult patients (Piredda et al., 2015). Similarly, Carr (2014) synthesized findings from three qualitative studies to develop a middle range theory of family vigilance, which describes the day-to-day experiences of family members staying with hospitalized relatives.
Predictive Theories Predictive theories describe precise relationships between concepts and are the third level of theory development. Predictive theories presuppose the prior existence of the more elementary types of theory. They result after concepts are defined and relational statements are generated and are able to describe future outcomes consistently. Predictive theories include statements of causal or consequential relatedness (Dickoff et al., 1968).
Predictive theories are generated and tested by experimental research involving manipulation of a
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phenomenon to determine how it affects or changes some dimension or characteristic of another phenomenon (Fawcett, 1999). Different research designs may be used in this process. These include pretest–posttest designs, quasi-experiments, and true experiments. These research studies produce quantifiable data that are statistically analyzed. Metasynthesis of research studies or comprehensive reviews of research can also be the source of predictive theories. Examples of predictive theories include a model describing the health-related outcomes of resilience in adolescents (Scoloveno, 2015), a theory of family interdependence that predicted the relationships between spirituality and psychological well-being among elders and their family caregivers (Kim, Reed, Hayward, Kang, & Koenig, 2011), and a model predicting emotional exhaustion among hemodialysis nurses (Hayes, Douglas, & Bonner, 2014). In an interesting work, Tourangeau (2005) synthesized research literature from multiple sources to propose a theoretical model predicting patient mortality. She identified the following contributing or determining factors to mortality: nurses’ staffing, burnout, satisfaction, skill mix, experience, and role support as well as such factors as physician expertise, hospital location, and patient characteristics (e.g., age, gender, comorbidity, socioeconomic status, and chronicity).
Prescriptive Theories Prescriptive theories are perceived to be the highest level of theory development (Dickoff et al., 1968). Prescriptive theories prescribe activities necessary to reach defined goals. In nursing, prescriptive theories address nursing therapeutics and predict the consequence of interventions (Meleis, 2012). Prescriptive theories have three basic components: (1) specified goals or outcomes, (2) explicit activities to be taken to meet the goal, and (3) a survey list that articulates the conceptual basis of the theory (Dickoff et al., 1968).
According to Dickoff and colleagues (1968), the outcome or goal of a prescriptive theory serves as the norm or standard by which to evaluate activities. The goal must articulate the context of the situation, and this provides the basis for testing to determine whether the goal has been achieved. The specified actions or activities are those nursing interventions that should be taken to realize the goal. The goal will not be realized without the activity, and prescriptions for activities directly affect the goals.
The survey list augments and supplements the prescribed activities. In addition, it serves to prepare for future prescriptive activities. The survey list asks six questions about the prescribed activity that relate to the delineated goal (Box 4-1). In current vernacular, as practice guidelines based on research, evidence-based practice (EBP) consists of many attributes of prescriptive theory. This will be discussed in more detail in Chapter 12.
Box 4-1 Survey List of Questions for Prescriptive Theories 1. Who performs the activity? (agency) 2. Who or what is the recipient of the activity? (patiency) 3. In what context is the activity performed? (framework) 4. What is the end point of the activity? (terminus) 5. What is the guiding procedure, technique, or protocol of the activity? (procedure) 6. What is the energy source for the activity? (dynamics)
Source: Dickoff et al. (1968).
Examples of prescriptive theory are becoming more common in the literature, enhanced by the expanding volume of nursing research and increasing calls for EBP. In one work, Ade-Oshifogun (2012) presented a research-tested and research-supported model to assist and support clinicians to develop interventions to reduce or minimize truncal obesity in people with chronic obstructive pulmonary disease (COPD). The descriptions of feeding, pelvic floor exercise, therapeutic touch, and latex precautions are only a few of many excellent examples of nursing interventions presented by Bulechek, Butcher, Dochterman, and Wagner (2012). Lastly, Finnegan, Shaver, Zenk, Wilkie, and Ferrans (2010) developed the “symptom cluster experience profile” framework to anticipate symptom clusters and derive interventions and clinical practice guidelines among survivors of childhood cancers.
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Categorization Based on Source or Discipline Theories may be classified based on the discipline or source of origin. As briefly discussed in Chapter 1, many of the theories used in nursing are borrowed, shared, or derived from theories developed in other disciplines. Because nursing is a human science and a practice discipline, incorporation of shared theories into practice and modification of them for use and testing are common.
Nurses use theories and concepts from the behavioral sciences, biologic sciences, and sociologic sciences as well as learning theories and organizational and management theories, among others. In many cases, these concepts and theories will overlap. For example, adaptation and stress are concepts found in both the behavioral and biologic sciences, and multiple theories have been developed using these concepts. Additionally, some theories defy placement in one discipline but relate to many. These include such basic concepts as systems theory, change theory, and chaos.
This book discusses a number of theories and concepts organized in terms of sociologic sciences, behavioral sciences, biomedical sciences, administration and management sciences, and learning theories. Table 4-1 presents examples of theories from each of these areas. Although by no means exhaustive, Chapters 13 through 17 provide information on many of the shared theories commonly used in nursing practice, research, education, and administration.
Table 4-1 Shared Theory Used in Nursing Practice and Research Disciplines Examples of Theories Used by Nurses
Theories from sociologic sciences Family systems theory Feminist theory Role theory Critical social theory
Theories from behavioral sciences Attachment theory Theories of self-determination Lazarus and Folkman’s theory of stress, coping, and
adaptation Theory of planned behavior
Theories from biomedical sciences Pain Self-regulation theory Immune function Symptomology Germ theory