Overview of Selected Middle Range Nursing Theories

High Middle Range Theories The high middle range theories presented here are some of the most well-
known and 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.

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 Benner’s 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 grows “through experiential learning and through transmitting that
learning in practical settings” (Benner, 2001, p. vi). Expertise develops when the clinician tests and
refines propositions, hypotheses, and principle-based expectations in actual practice situations. Finally,
the model seeks to describe clinical expertise including six areas of practical knowledge (graded
qualitative distinctions; common meanings; assumptions, expectations, and sets; paradigm cases and
personal knowledge; maxims; and unplanned practices) (Benner, Tanner, & Chesla, 2009). The central
concepts of Benner’s model are those of competence, skill acquisition, experience, clinical knowledge,
and practical knowledge. She also identifies the following seven domains of nursing practice: Helping
role Teaching or coaching function 220 Diagnostic client-monitoring function Effective management of
rapidly changing situations Administering and monitoring therapeutic interventions and regimens
Monitoring and ensuring quality of health care practices Organizational and work-role competencies
(Benner, 2001) Context for Use and Nursing Implications The Benner model has been used extensively as
rationale for career development and continuing education in nursing. Areas specifically cited for
utilization include nursing management, career enhancement, clinical specialization, staff development
programs, staffing, evaluation, clinical internships, and precepting students and novice nurses (Benner,
2001; Benner et al., 2009). Evidence of Empirical Testing and Application in Practice Over the previous
decade, dozens of articles have been written based on Benner’s model, and a number of these were
research-based studies. For example, Wilson, Harwood, and Oudshoorn (2015) examined the “perpetual
novice phenomenon,” and Cates and colleagues (2015) employed a Delphi method to develop a
simulation-based competency assessment instrument for neonatal nurse practitioners, both based on
Benner’s model. In other research, Meretoja and Koponen (2012) used Benner’s model to compare
nurses’ optimal and actual competencies in clinical settings, and Abraham (2011) reported on a study to
evaluate a program based on Benner’s model, which was designed to develop leadership skills and
professionalism. Lastly, Homard (2013) reported on a correlational study which used Benner’s novice-to-
expert theory to compare exit examination scores and National Council Licensure Examination for
Registered Nurses (NCLEX-RN) pass rates among students in a prelicensure nursing program following
implementation of a program using standardized testing. Non–research-based articles included a report
by Woody and Davis (2013) which described how to use Benner’s model to develop and implement an
educational module designed to improve nurse competence in peripheral intravenous therapy. A fairly
common theme was noted as several writers discussed Benner’s applicability in development of
procedures and protocols for orientation of new graduates or nurses into new specialty areas. For
example, using Benner’s model, Koharchik, Caputi, Robb, and Culleiton (2015) presented a process
which can be used by clinical faculty and preceptors to develop clinical reasoning in nursing students;
Coyle (2011) discussed an internship program in home health for new graduates; and Dumchin (2010)
described a method for using online learning experiences to develop perioperative nurses. Finally,
Benner’s work was used in several articles (e.g., Bitanga & Austria, 2013; Haag-Heitman, 2012; Owens &
Cleaves, 2012) to discuss the development or updating of career enhancement or clinical ladder
programs. Leininger’s Cultural Care Diversity and Universality Theory Madeleine Leininger was
instrumental in demonstrating to nurses the importance of considering the impact of culture on health
and healing (Leininger, 2002). Prior to her death in 2012, Leininger was a prolific nursing researcher and
scholar, and she is credited with starting the specialty of transcultural nursing. In addition, she was a
leading proponent of the idea that nursing is synonymous with caring. Leininger reported that she
conceptualized transcultural nursing as a distinct area of nursing practice in the late 1950s during her
doctoral work in anthropology; she continued to study and develop a transcultural nursing conceptual
framework throughout the 1960s. In the mid-1970s, she presented a “transcultural health model” that
was expanded in 1978 and 1980. The Leininger Sunrise Model was first described as such in 1984 and
depicts the transcultural dimensions of culturologic interviews, assessments, and therapies (McFarland,
2014; McFarland & Wehbe-Alamah, 2015). Purpose and Major Concepts The purpose of Leininger’s
theory is to generate knowledge related to the nursing care of people who value their cultural heritage
and lifeways. Major concepts of the model are culture, culture care, and culture care differences
(diversities) and similarities (universals) pertaining to transcultural human care. Other major concepts
are care and caring, emic view (language expressions, perceptions, beliefs, and practice of 221
individuals or groups of a particular culture in regard to certain phenomena), etic view (universal
language expression beliefs and practices in regard to certain phenomena that pertain to several
cultures or groups), lay system of health care, professional system of health care, and culturally
congruent nursing care (Leininger, 2007; McFarland, 2014). Context for Use and Nursing Implications
The goal for application of Leininger’s theory is to provide culturally congruent nursing care to persons
of diverse cultures. A central tenet of the theory is that it is important for the nurse to understand the
individual’s view of illness. Also, the focus is on recognizing and understanding cultural similarities and
differences and using this information to positively influence nursing care and health (McFarland &
Wehbe-Alamah, 2015). The theory has been widely used for research, and findings are appropriate for
nurses in any setting who work with individuals, families, and groups from a cultural background
different from the nurse’s. Evidence of Empirical Testing and Application in Practice Leininger (2007)
explained that her theory was derived and refined through a number of years of study. Over the past
two decades, research on various groups was conducted, and she listed cultural values and culture care
meanings and action modes for 23 cultural groups in her book. Many graduate students and nursing
scholars have used Leininger’s theory as a basis for research, and as a result, hundreds of examples of
articles can be located in the literature. Many of these used Leininger’s work as a conceptual framework
to study cultural implications of a variety of health problems. For example, J. M. Long and colleagues
(2012) examined health beliefs among four different Latino subgroups specifically related to type 2
diabetes; Gillum and colleagues (2011) researched cardiovascular disease in the Amish; Mixer,
Fornehed, Varney, and Lindley (2014) examined end-of-life care for people in rural Appalachia; and
López-Entrambasaguas, GraneroMolina, and Fernandez-Sola (2013) studied the incidence of HIV/AIDS
among a group of sex workers in Bolivia. Leininger’s model has also been used by many authors to
identify variables or characteristics of cultural groups or subcultures that might influence health. For
example, Farren (2015) performed a comprehensive literature review of research that examined cultural
differences in cancer survivors’ perceptions and experiences to promote patient-centered, culturally
congruent care for adult cancer patients, and Lee (2012) used Leininger-inspired “ethnonursing research
methods” to discover care meanings and expression among Appalachian mothers living with their
children in a homeless shelter. Other examples of research studies using Leininger’s model are listed in
Box 11-2.

A number of nonresearch articles describing aspects of transcultural nursing and focusing on Leininger’s
works have also been published in recent years. These include a review of a workshop to enhance
cultural awareness for nurse practitioners (Elminowski, 2015); a report on how to provide culturally
competent, patient-centered nursing care (Darnell & Hickson, 2015); and an article describing the
impact of international service learning on nursing student’s cultural competence (T. Long, 2016).
Pender’s Health Promotion Model Nola Pender began studying health-promoting behavior in the mid-
1970s and first published the Health Promotion Model (HPM) in 1982. She reported that the model was
constructed from expectancy-value theory and social cognitive theory using a nursing perspective. The
model was modified slightly in the late 1980s and again in 1996 (Pender, Murdaugh, & Parsons, 2015).
Purpose and Major Concepts The HPM was proposed as a framework for integrating nursing and
behavioral science perspectives on factors that influence health behaviors. The model is to be used as a
guide to explore the biopsychosocial processes that motivate individuals to engage in behaviors directed
toward health enhancement (Pender et al., 2015). The model has been used extensively as a framework
for research aimed at predicting health-promoting lifestyles as well as specific behaviors. Major
concepts of the HPM are individual characteristics and experiences (prior related behavior and personal
factors), behavior-specific cognitions and affect (perceived benefits of action, perceived barriers to
action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational
influences), and behavioral outcomes (commitment to a plan of action, immediate competing demands
and preferences, and health-promoting behavior). Figure 11-1 shows the HPM.

Context for Use and Nursing Implications Health promotion interventions are essential for improving the
health of populations everywhere. It is noted that people of all ages can benefit from health promotion
care, which should be delivered at sites where people spend much of their time (e.g., schools and
workplaces). Nurses can develop and execute healthpromoting interventions for individuals, groups, and
families in schools, nursing centers, occupational health settings, and the community at large. Per the
HPM, nurses should work toward empowerment for self-care and enhancing the client’s capacity for
self-care through education and personal development. Evidence of Empirical Testing and Application in
Practice Pender and colleagues (2015) wrote that the model has been used by a very significant number
of nursing scholars and researchers and has been useful in explaining and predicting specific health
behaviors. Indeed, in the last decade, more than 250 English language articles that reported using or
applying Pender’s HPM have been published. Most research studies used Pender’s work as one
component of a conceptual framework for study. For example, Park, Choi-Kwon, and Han (2015) used
the HPM to study health behaviors of Korean nursing students related to obesity and osteoporosis, and
Jackson and colleagues (2016) used the model to explain the relationship between several factors
including physical functioning, personal factors, and behavioral influences on physical activity between
prehypertensive and hypertensive African American women. Also focusing on physical activity, Hatzfeld,
Nelson, Waters, and Jennings (2016) used the HPM to examine factors influencing health behaviors
among active duty air force personnel. Other studies use health promotion as an outcome or to predict
behaviors. Burns, Murrock, and Graor (2012), for example, used the model to identify the relationship
between body mass and injury severity among adolescents, concluding that overweight/obese
adolescents may be at increased risk for serious injury. 224 Additional examples of recent research
studies using Pender’s HPM are listed in Box 11-3.

Transitions Theory Meleis (2010) wrote that the Transitions Theory evolved over the course of about
four decades. She explained that it began in practice with her observations of the experiences that
humans face as they deal with changes relating to health, well-being, and their ability to care for
themselves. Meleis’s work moved through multiple steps, including concept analysis and several
comprehensive literature reviews. The result was a conclusion that “transitions” is a central concept in
nursing (Schumacher & Meleis, 1994). More focused attention through observation and research has
contributed to formal development, testing, and application of the theory (Meleis, 2010). Purpose and
Major Concepts Transitions Theory attempts to describe and attend to the interactions between nurses
and patients, suggesting that nurses are concerned with the experiences of people as they undergo
transitions whenever health and well-being are the desired outcome. The goal of “nursing therapeutics,”
then, is to conceptualize and address the potential problems that individuals encounter during
transitional experiences and develop preventative and therapeutic interventions to support the patient
during these occasions (George & Hickman, 2011; Im, 2014; Meleis, 2010). Meleis (2010) defined
transitions as “a passage from one fairly stable state to another fairly stable state, and it is a process
triggered by a change” (p. 11). Furthermore, transitions are characterized by different stages,
milestones, and turning points. These changes, or transitions, can be assisted or managed by nurses as
they care for patients. Numerous years of research and analysis into transitions led Meleis and her
colleagues to the identification “of four major categories of transitions that nurses tend to be involved
in” (Meleis, 2010, p. 3). These transitions and representative examples are: Developmental transitions—
birth, adolescence, menopause, aging, death Situational transitions—changes in educational and
professional roles, changes in family situations (e.g., divorce, widowhood), or changes in living
arrangements (e.g., move to a nursing home, homelessness) Health–illness transitions—recovery
process, hospital discharge, diagnosis of chronic illness Organizational transition—changing
environmental conditions that affect the lives of clients; may be social, political, or economic (Im, 2014)
Other key concepts include “patterns” and “properties” of the transitions. Patterns denote whether the
225 transitions are single, multiple, sequential, simultaneous, related, or unrelated. Properties of the
transition experience are often interrelated in a complex way and refer to awareness, engagement,
change/difference, time span, and critical points and events (Im, 2014). In Transitions Theory, the nurse
must consider the “facilitators” and “inhibitors” of the transition conditions. These include personal
meanings, cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge. Community
conditions and societal conditions may also facilitate or inhibit transitions (Im, 2014). “Nursing
therapeutics” are those activities and actions that nurses may take during times of transitions
(Schumacher & Meleis, 1994). These include assessment of readiness (assessment of each of the
transition’s conditions), preparation for transition (typically involves education to enhance optimal
conditions to prepare for transition), and role supplementation (use of education and practice to
facilitate the transitional process) (George & Hickman, 2011). The outcomes of transitions, and potential
for nursing therapeutics, include the “patterns of response” of the patient. These are designated as
process indicators (feeling connected, interacting, locating and being situated, developing confidence,
and coping) and outcome indicators (mastery and “fluid integrative identities”) (Im, 2014). Figure 11-2
shows the interaction of the major constructs of the theory.

Context for Use and Nursing Implications According to Meleis (2010), most nursing care occurs during a
transition that the patient is experiencing, and the goal of nursing care is to promote or encourage
health outcomes during these occasions. Indeed, Meleis and Trangenstein (1994) defined nursing as the
art and science of facilitation of the transitions of health and well-being and noted that nurses are
concerned “with the processes and experiences of human beings undergoing transitions where health
and perceived well-being is the outcome” (p. 257). Transitions Theory is widely applicable and provides
a comprehensive guide that considers cultural and social diversity. It was developed from multiple
research studies among very diverse groups of people, during many types of transitions. Additionally, it
has been shown repeatedly to be able to direct nursing practice, research, and education. Evidence of
Empirical Testing and Application in Practice Transitions Theory has been based in both research and
generated research (George & Hickman, 2011; Meleis, 2010). Meleis (2010) compiled and published a
history of the development of the theory along with multiple examples of research and application in
practice. Additional examples are becoming increasingly 226 evident in the literature. Some of these
focus on research examining patient transitions encountered by nurses in various specialty areas. For
example, Joly (2016) addressed supportive care for young people with medically complex needs as they
transition into adulthood; Rew, Tyler, Fredland, and Hannah (2012) examined adolescents’ concerns as
they transition through high school; Ekim and Ocakci (2016) looked at the transitions involved in
discharge planning for children with asthma; and Häggström, Asplund, and Kristiansen (2012)
researched patients’ transition from the intensive care unit (ICU). Several research studies using
Transitions Theory focused on the experience of caregivers. One (Beaudet & Ducharme, 2013) such
study identified transitions encountered by patients with Parkinson disease and their caregivers. The
intent was to develop more focused interventions to assist the caregivers. In another example, Dossa,
Bokhour, and Hoenig (2012) performed a grounded theory study that examined the transitions from
hospital to home for patients with mobility impairments and their family caregivers; they concluded that
health care providers need to improve systems to address patient concerns after discharge, focusing on
improving communication and coordination to facilitate recovery and prevent complications. Finally,
Geary and Schumacher (2012) presented an interesting look at the integration of Transitions Theory
with concepts from complexity science. They argued that the complexity of many of the transition
situations encountered by nurses today is better described when the theories are integrated, concluding
that the integration encourages recognition that transitions affect many, including the patients, their
caregivers, health care providers, and the health care system. Integration of the theories should
enhance dialogue and promote better understanding of the situations through changing outcomes for
the better. The Synergy Model The Synergy Model for Patient Care was developed in the mid-1990s by a
panel of nurses of the American Association of Critical-Care Nurses (AACN) Certification Corporation as a
framework for certified practice. The initial model was revised somewhat, and the revised version was
then used as the basis for the AACN’s certification examination (Curley, 2007; Hardin, 2017). Purpose
and Major Concepts The purpose of the Synergy Model is to articulate nurses’ contributions, activities,
and outcomes with regard to caring for critically ill patients. The model identifies eight patient needs or
characteristics and eight competencies of nurses in critical care situations (AACN, 2016; Pate, 2017). Of
the many unique characteristics nurses assess, the eight most consistently observed are listed in Box 11-
4. The nursing

Context for Use and Nursing Implications As mentioned, the Synergy Model was originally developed to
structure the AACN’s certification examination by identifying nursing competencies that are essential for
those providing care to the critically ill. In 2002, assumptions of the model were expanded to establish it
as a conceptual framework for designing practice and developing competencies required to care for
critically ill patients. Use of the Synergy Model in practice is designed to optimize patient outcomes.
When patient characteristics and nurse competencies match and synergize, outcomes for the patient
are optimal (Curley, 2007; Hardin, 2017). In addition, the model can be used for developing nursing
curricula and for conducting research (Curley, 2007; Hardin, 2017). Evidence of Empirical Testing and
Application in Practice Although the Synergy Model is relatively new, a significant number of articles
have been published describing its use in practice. Identified were two articles that tested application of
the model in critical care situations. For example, Swickard, Swickard, Reimer, Lindell, and Winkelman
(2014) described the process of development of a tool to determine the appropriate level of care
needed for interfacility patient transport, using the Synergy Model as a guide. In another work, Stacy
(2011) used the Synergy Model as a framework when reporting on “progressive care units,” which are
increasingly being used to bridge the gap between ICUs and medical-surgical units. A few works (Hardin,
2012; Hart, Hardin, Townsend, Ramsey, & Mahrle-Henson, 2013; Tejero, 2012) described research
studies using the Synergy Model as a framework. Box 11-5 shows several examples of articles describing
the model’s use in leadership/administration, practice, and education

Mishel’s Uncertainty in Illness Theory Merle Mishel began studying the concept of uncertainty in illness
in the early 1980s when she desired to explain the stress that results from hospitalization (Mishel, 1981,
1984). In the late 1980s, she formally developed the theory, which she then revised in the early 1990s
(Mishel, 2014). The Mishel Uncertainty in Illness Scale was created to better examine the concept, and
since that time, her model and instruments have been used in numerous nursing studies (Bailey &
Stewart, 2014; Mishel, 2014). Purpose and Major Concepts According to Mishel (1999, 2014), the
Uncertainty in Illness Theory explains how clients cognitively process illness-related stimuli and
construct meaning in these events. Uncertainty is seen as “the inability to structure meaning of illness-
related events inclusive of inability to assign definite value and/or to accurately predict outcomes”
(Mishel, 2014, p. 56). The early iteration of the model (Mishel, 1988) described the concepts of “stimuli
frame” (symptom pattern, event familiarity, event congruency), “cognitive capacities,” and “structure
providers” (credible authority, social support, education) that may lead to uncertainty. Other concepts
include appraisal, inference, illusion, and opportunity as well as coping mechanisms; these may lead to
adaptation. In 1990, the process of theory derivation was used to update and revise the theory to
address issues related to chronic uncertainty. Interestingly, chaos theory was used in this process
(Mishel, 1990). Figure 11-3 shows the Uncertainty in Illness Theory.

Context for Use and Nursing Implications The Uncertainty in Illness Theory explains how individuals
cognitively process illness-related stimuli and how they structure meaning for those events. In the
theory, adaptation is the desirable end-state achieved after coping with the uncertainty. Nurses may
develop nursing interventions that attempt to influence the person’s cognitive process to address the
uncertainty. This, in turn, should produce positive coping and adaptation (Mishel, 1999, 2014). Evidence
of Empirical Testing and Application in Practice During the process of theory development and
refinement, Mishel developed and tested several research instruments. These are the Adult Uncertainty
in Illness Scale and the Adult Uncertainty in Illness Scale— Community Form, the Parents’ Perception of
Uncertainty in Illness Scale, the Parents’ Perception of Uncertainty in Illness Scale—Family Member
(Mishel, 2014), and the Uncertainty Scale for Kids (Stewart, Lynn, & Mishel, 2010). The Uncertainty in
Illness Theory is becoming increasingly recognized in nursing literature as a resource for research and
practice. A significant number of research studies were identified using Mishel’s theory or instruments
or both in addressing health issues among a wide variety of groups and covering many different health
problems. For example, in a longitudinal study, Bailey, Kazer, Polascik, and Robertson (2014) used
Mishel’s theory as part of the conceptual framework that examined uncertainty experienced by men
who must have their prostate-specific antigen levels monitored following prostate cancer surgery. Other
research employing Mishel’s instruments included works by Kurita, Garon, Stanton, and Meyerowitz
(2013), who studied uncertainty among patients with lung cancer and their psychological adjustment,
and Cypress’s (2016) examination of the uncertainty experienced by patients in the ICU. Interestingly,
many studies using Mishel’s theory were directed at patients and their families or caregivers. For
example, White, Barrientos, and Dunn (2014) examined uncertainty experienced by stroke survivors and
family caregivers; Unson, Flynn, Glendon, Haymes, and Sancho (2015) studied the stress and uncertainty
of the caregivers of persons with dementia; and Germino and colleagues (2013) looked at uncertainty of
breast cancer survivors and their families. Mishel’s work has achieved worldwide recognition, and her
instruments have been translated into several languages including Italian (Giammanco, Gitto, Barberis,
& Santoro, 2015), Persian (Saijadi, Rassouli, Abbaszadeh, Alavi Majd, & Zendehdel, 2014), and French (C.
A. Miller, 2015). Finally, Christensen (2015) described development of the Health Change Trajectory
Model—a new middle range theory—integrating concepts and relationships from Mishel’s Uncertainty
in Illness Theory and the Corbin and Strauss Chronic Illness Trajectory Framework (Corbin, 1998).
Kolcaba’s Theory of Comfort Katherine Kolcaba (2017) wrote that the first step in developing the Theory
of Comfort was a concept 231 analysis conducted in 1988 while she was a graduate student. Following a
number of steps over several years, the Theory of Comfort was initially published in 1994 and later
modified (Kolcaba, 1994, 2001). Purpose and Major Concepts Kolcaba (1994) defined comfort within
nursing practice as “the satisfaction (actively, passively, or cooperatively) of the basic human needs for
relief, ease, or transcendence arising from health care situations that are stressful” (p. 1178). She
explained that a client’s needs arise from a stimulus situation that can cause negative tension. Increasing
comfort measures can result in having negative tensions reduced and positive tensions engaged.
Comfort is viewed as an outcome of care that can promote or facilitate health-seeking behaviors. It is
posited that increasing comfort can enhance health-seeking behaviors. One proposition notes that “if
enhanced comfort is achieved, patients, family members and/or nurses are strengthened to engage in
HSBs [health-seeking behaviors], which further enhance comfort” (Kolcaba, 2017, p. 200). Major
concepts described in the Theory of Comfort include comfort, comfort care, comfort measures, comfort
needs, health-seeking behaviors, institutional integrity, and intervening variables. There are also eight
defined propositions that link the defined concepts (Box 11-6) (Kolcaba, 2001, 2017). Figure 11-4
presents the Theory of Comfort.

Evidence of Empirical Testing and Application in Practice The General Comfort Questionnaire (GCQ) is a
48-item Likert-type scale that was developed to measure concepts and propositions described in the
theory. The GCQ has been modified to be used for different populations in a number of studies, and a
shortened GCQ (28 items) is also in use (Kolcaba, 2017). Kolcaba (2017) described development of other
tools to assist in research and practice application for the Theory of Comfort. These include the Verbal
Rating Scale Questionnaire, the Radiation Therapy Comfort Questionnaire, the Hospice Comfort
Questionnaire, the Urinary Incontinence and Frequency Comfort Questionnaire, and the Healing Touch
Comfort Questionnaire. In addition, the Comfort Behaviors Checklist was developed to measure comfort
in patient who can’t use traditional questionnaires or other instruments. A number of research studies
have been conducted by Kolcaba and her colleagues using the instruments listed earlier. For example,
Andersen, Jylli, and Ambuel (2014) used Kolcaba’s Comfort Behaviors Checklist to evaluate the comfort
care provided by a group of health providers and Seyedfatemi, Rafii, Rezaei, and Kolcaba (2014) used
her instruments to study comfort and hope among preoperative patients. Whitehead, Anderson,
Redican, and Stratton (2010) reported using Kolcaba’s instruments to study the effects of an endof-life
nursing education program on nurses’ death anxiety, knowledge of the dying process, and related
concerns. Also examining nursing care at the end of life, Murray (2010) used Kolcaba’s instruments to
assess spiritual beliefs and practices of nurses caring for patients at the end of life, along with similarities
and differences in spiritual beliefs and practices comparing hospice nurses and nurses working on
oncology and other special care units. In practice-specific examples, Marchuk (2016) described how
Comfort Theory can be applied in end-oflife care in the neonatal intensive care unit (NICU), and Krinsky,
Murillo, and Johnson (2014) explained how comfort measures can be used to improve nursing care for
cardiac patients. Finally, Boudiab and Kolcaba (2015) presented a comprehensive look at the application
of Comfort Theory in directing holistic, quality care for veterans and their families. Lenz and Colleagues’
Theory of Unpleasant Symptoms The Theory of Unpleasant Symptoms was developed by a group of
nurses interested in a variety of nursing issues, including symptom management, theory development,
and nursing science (Lenz, Pugh, Milligan, & Gift, 2017). The theory was initially published in the nursing
literature in the mid-1990s (Lenz et al., 1995) and then updated a few years later (Lenz et al., 1997). The
theory was based on the premise that there are commonalities in experiencing different symptoms
among different groups and in different situations. The theory was developed to integrate existing
knowledge about a variety of symptoms to better prepare nurses in symptom management. Purpose
and Major Concepts The purpose of the Theory of Unpleasant Symptoms is “to improve understanding
of the symptom experience in various contexts and to provide information useful for designing effective
means to prevent, ameliorate, or manage unpleasant symptoms and their negative effects” (Lenz &
Pugh, 2014, p. 166). Lenz and colleagues (1997) reported that the theory has three major components:
(1) the symptoms that the individual is experiencing, (2) the influencing factors that produce or affect
the symptom experience, and (3) the consequences of the symptom experience. Within the theory,
symptoms are described in terms of duration, intensity, distress, and quality. Influencing factors can be
physiologic factors, psychological factors, and/or situational factors. Performance is described in terms
of functional status, cognitive functioning, or physical performance (Lenz et al., 2017). Figure 11-5
depicts the Theory of Unpleasant Symptoms.

Context for Use and Nursing Implications The Theory of Unpleasant Symptoms helps nurses recognize
the need to assess multiple aspects of symptoms, including characteristics of the symptom(s) itself; the
underlying disease or other cause; as well as the frequency, intensity, duration, quality, and distress felt
by the patient due to the symptom(s) (Lenz et al., 2017). The developers of the Theory of Unpleasant
Symptoms note that it is clinically applicable to multiple client situations because it should stimulate
nurses to consider factors that might influence more than one symptom and the ways in which
symptoms interact with each other (Lenz et al., 1997). The theory’s developers noted that it has been
used in an emergency department (ED) to develop a symptom assessment scale for cardiac patients and
has been useful in predicting the need for hospitalization among patients with chronic obstructive
pulmonary disease (COPD). Evidence of Empirical Testing and Application in Practice A growing number
of research studies using the Theory of Unpleasant Symptoms as a conceptual or organizing framework
have been conducted. One study by Kim, Oh, Lee, Kim, and Kim (2015) used the theory in their
investigation of predictors of symptoms and symptom experience among cancer patients undergoing
chemotherapy. Also studying cancer patients, Hsu and Tu (2014) used the Theory of Unpleasant
Symptoms to evaluate the effects of cancer treatments on functional status, depressive symptoms,
fatigue, and quality of life. Other works applied the Theory of Unpleasant Symptoms in caring for
patients undergoing bariatric surgery (Tyler & Pugh, 2009), patients with coronary heart disease
(Eckhardt, Devon, Piano, Ryan, & Zerwic, 2014), and patients with inflammatory bowel disease (Farrell &
Savage, 2010). Reed’s Self-Transcendence Theory Pamela Reed first wrote about the concept of self-
transcendence in 1983 and formally outlined her theory in 1991 (Reed, 1991b). She reported that she
used “deductive reformulation” of theories of life span development in constructing the theory. These
she integrated with Rogers’s conceptual system, clinical experience, and empirical work (Reed, 1991b).
Self-transcendence is developed by introspective activities and concerns about the welfare of others and
by integrating perceptions of one’s past and future to enhance the present (Reed, 1991a). Purpose and
Major Concepts Self-transcendence is considered to be a “characteristic of developmental maturity
whereby there is an expansion of self-boundaries and orientation toward broadened life perspectives
and purposes” (Reed, 1991b, 234 p. 64). Self-transcendence moves the individual beyond the immediate
or constricted view of self and the world (Reed, 1996). Within self-transcendence, there is “an expansion
of personal boundaries outwardly (toward others and the environment), inwardly (toward greater
awareness of beliefs, values, and dreams), and temporally (toward integration of past and future in the
present)” (Reed, 1996, p. 3). Other central concepts of the theory include well-being (a sense of
wholeness and health) and vulnerability (awareness of personal mortality) (Coward, 2014; Reed, 2014).
Context for Use and Nursing Implications Reed (1991b) reported that a theory of self-transcendence
may be used by nurses to attend to spiritual and psychosocial expressions of self-transcendence in
clients who are confronted with end-of-life issues. To promote self-transcendence, nurses may use
interventions such as meditation, self-reflection, visualization, religious expression, counseling, and
journaling to expand the individual’s boundaries. Evidence of Empirical Testing and Application in
Practice A number of nursing research studies have used the theory of self-transcendence. In an early
work, Reed (1991a) found support for the theory in an examination of the mental health of older adults.
In the study, she identified a relationship between self-transcendence and mental health and an inverse
relationship between self-transcendence and depression. More recently, studies have been undertaken
to examine selftranscendence and its effect on well-being or other variables. These studies are
conducted among those with health issues such as spinal muscular atrophy (Ho, Tseng, Hsin, Chou, &
Lin, 2016), Alzheimer disease (Walsh et al., 2011), hypertension (Thomas & Dunn, 2014), and at the end
of life (Shockey-Stephenson & Berry, 2015). Several projects have looked at self-transcendence among
nurses and/or nursing students. For example, Hunnibell and colleagues (2008) studied differences in
self-transcendence between hospice and oncology nurses, analyzing how it influenced burnout in those
groups. In similar works, Palmer, Quinn Griffin, Reed, and Fitzpatrick (2010) studied self-transcendence
and engagement in acute care registered nurses (RNs), and Haugan (2014) examined whether student
nurses’ self-transcendence could positively influence their attitudes toward caring for older adults.
Finally, several works were identified that sought to enhance selftranscendence or to associate it with
successful ageing. These included a study by McCarthy, Ling, and Carini (2013) and a second study by
McCarthy, Ling, Bowland, Hall, and Connelly (2015). Low Middle Range Theories The number of low
middle range theories appears to be growing as nursing researchers and nursing scholars describe
phenomena directly related to practice. Three theories are examined in the following sections. They are
Eakes, Burke, and Hainsworth’s (1998) Theory of Chronic Sorrow; Beck’s (1993) Postpartum Depression
Theory; and Mercer’s (1981) Conceptualization of Maternal Role Attainment/Becoming a Mother. Table
11-3 lists other low middle range theories.

Purpose and Major Concepts The Theory of Chronic Sorrow was developed to help analyze individual
responses of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities,
loss of the “perfect” child, or bereavement. Chronic sorrow was characterized as pervasive, permanent,
periodic, and potentially progressive in nature. The person has a perception of sadness or sorrow over
time in a situation with no predictable end. The sadness or sorrow is cyclic or recurrent and brings to
mind a person’s losses, disappointments, or fears (Eakes, 2017). The primary antecedent to chronic
sorrow is involvement in an experience of significant loss. The loss is often ongoing with no predictable
end. Disparity is a second antecedent and is created by loss experiences when the individual’s current
reality differs from the idealized. Trigger events (e.g., milestones, circumstances, situations, and
conditions that create negative disparity resulting from the loss experience) focus or exacerbate the
experience of disparity. The “lack of closure associated with ongoing disparity sets the stage for chronic
sorrow, with the loss experienced in bits and pieces over time” (Eakes, 2017, p. 95). Context for Use and
Nursing Implications Chronic sorrow is commonly experienced by individuals across the life span who
have encountered significant loss or experience ongoing loss. The theory’s developers suggest that
nurses need to view chronic sorrow as a normal response to loss and provide support by fostering
positive coping strategies and encouraging activities that increase comfort. Interventions that
demonstrate an empathic presence and a caring professional are helpful. These include taking time to
listen, offering support and reassurance, recognizing and focusing on feelings, and appreciating the
uniqueness of each individual. Other interventions include providing information in a manner that can
be understood and offering practical tips for dealing with the challenges of caregiving. Evidence of
Empirical Testing and Application in Practice Eakes and colleagues (1998) reported that a number of
research studies were used to develop and support the theory. Several recent research studies were
identified using the Theory of Chronic Sorrow as a conceptual framework. These include Vitale and
Falco’s (2014) examination of parental chronic sorrow experienced with the premature birth of their
infants; Nikfarid, Rassouli, Borimnejad, and Alavimajd’s (2015) study of chronic sorrow in mothers of
children with cancer; and Bowes, Lowes, Warner, and Gregory’s (2009) study of chronic sorrow in
parents of children with type 1 diabetes. Other works focused on how to care for those experiencing
chronic sorrow. Among them, Glenn (2015) described the use of online health communication
technology to help mothers of children with rare diseases manage chronic sorrow. Also, Joseph (2012)
described the importance of ED nurses recognizing chronic sorrow among family member of patients
seen in the ED. Beck’s Postpartum Depression Theory Building on a background of research on
postpartum depression (Beck, Reynolds, & Rutowski, 1992), Cheryl Beck (1993) developed a theory
regarding postpartum depression. A grounded theory approach was used to formulate the theory, which
she described as a four-stage process of “teetering on the edge” into postpartum depression. Purpose
and Major Concepts 237 The purpose of the theory was to provide insight into the experience of
postpartum depression. The concepts or stages in Beck’s (1993) theory were defined as encountering
terror (horrifying anxiety attacks, obsessive thinking, and enveloping fogginess), dying of self (alarming
“unrealness,” isolation of self, and contemplation of self-destruction), struggling to survive (battling the
system, praying for relief, and seeking solace), and regaining control (making transitions, mounting lost
time, and attaining a guarded recovery). A metasynthesis of postpartum depression by Beck (2002a)
produced a list of predictors or risk factors, including prenatal depression, child care stress, life stress,
social support, prenatal anxiety, marital satisfaction, history of depression, infant temperament,
maternity blues, self-esteem, socioeconomic status, marital status, and whether the pregnancy was
planned. Distillation of predictors and risk factors of postpartum depression added these
stressors/potential consequences: sleeping and eating disturbances, anxiety and insecurity, emotional
lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts (Maeve, 2014). Context for
Use and Nursing Implications The model proposed nursing interventions to alert nurses to the incidence
and impact of postpartum depression. Beck stressed the importance of identifying new mothers who
might be suffering from postpartum depression and suggested interventions such as referral to
postpartum depression support groups (Beck et al., 1992). Evidence of Empirical Testing and Application
in Practice Beck’s theory has been used in a significant number of nursing studies and in practice
situations (Marsh, 2013). To further examine the concept of postpartum depression, Beck (1995, 1998)
performed a metaanalysis to document its effects. Based on the information from a meta-analysis, Beck
and Gable (2000) developed the Postpartum Depression Screening Scale (PDSS) to improve detection of
the disorder. The tool was revised in 2002 (Beck, 2002b), translated into Spanish (Beck & Gable, 2003),
and revised further in 2006 (Beck, Records, & Rice, 2006). These tools have been validated (Beck et al.,
2006; Clemmens, Driscoll, & Beck, 2004) and used by nurses in a growing list of research studies in many
countries and in additional languages (Maeve, 2014). In one example, Le, Perry, and Sheng (2009) used
the PDSS to examine the feasibility of using the Internet to screen for postpartum depressive symptoms,
concluding that it is viable and feasible tool to screen for postpartum depression. In another work,
Logsdon, Tomasulo, Eckert, Beck, and Dennis (2012) presented guidelines for hospital-based postpartum
depression screening using the PDSS. A team lead by Thomason (Thomason et al., 2014) used the PDSS
to examine parenting stress and depressive symptoms, and Lucero, Beckstrand, Callister, and Sanchez
Birkhead (2012) used the Spanish version of the PDSS to examine the prevalence of postpartum
depression among Hispanic immigrants in the United States. Mercer’s Conceptualization of Maternal
Role Attainment/Becoming a Mother Ramona Mercer first described a theoretical framework for the
maternal role in the early 1980s; she expanded on the process in a subsequent publication in 1985. She
reported that the theory was based on role theory, knowledge of the infant’s traits, and a review of the
literature to identify variables that influence or are influenced by maternal roles. She defined maternal
role attainment as a process “in which the mother achieves competence in the role and integrates the
mothering behaviors into her established role set so that she is comfortable with her identity as a
mother” (Mercer, 1985, p. 198). Following a review and synthesis of research related to the concept of
“maternal role attainment,” Mercer (2004) proposed changing the name of her theory to “Becoming a
Mother.” This change was later expanded on (Mercer, 2006), and a number of related nursing
interventions were identified supporting the change (Mercer & Walker, 2006). Purpose and Major
Concepts Mercer attempted to identify the “form and strength of the relationships between key
maternal and infant variables and maternal role attainment” as well as “other factors that appear to
influence maternal role attainment” (Mercer, 1981, p. 73). She proposed that the variables of age,
perception of the birth experience, early maternal–infant separation, social stress, support system, self-
concept and personality traits, maternal 238 illness, childrearing attitudes, infant temperament, infant
illness, culture, and socioeconomic level affect the maternal role. In the more recent iteration of her
theory, Mercer (2004) explains that the process of establishing maternal identity in becoming a mother
is (1) commitment, attachment, and preparation (during pregnancy); (2) acquaintance, learning, and
physical restoration (in the first 2 to 6 weeks following birth); (3) moving toward a new normal (2 weeks
to 4 months); and (4) achievement of the maternal identity (around 4 months). She noted that these
stages may overlap and may be highly variable due to maternal and infant variables as well as the
social/environmental context. Additional key concepts and ideas identified in Mercer’s works include
infant temperament, infant health status, infant characteristics, and infant cues as well as family, family
functioning, father or intimate partner, mother–father relationship, and social support (Meighan, 2014).
Context for Use and Nursing Implications Nurses in postpartum situations should recognize that
competency in the maternal role toward “becoming a mother” increases with age and experience. Also,
the demands on first-time mothers challenge the nurse to be active in anticipatory socialization and
guidance to prepare for the realities of the maternal role. Interventions suggested in Mercer’s works
include promoting parenting groups to highlight maternal needs during the first months (Noseff, 2014).
Evidence of Empirical Testing and Application in Practice In early works, Mercer (1985) reported that
mothering over the first year presents similar challenges for all groups, and a study by Fowles (1994)
used Mercer’s theory as part of her conceptual framework to examine the relationship between
maternal attachment, postpartum depression, and maternal role attainment. More recently, a
comprehensive study of maternal role attainment with medically fragile infants was undertaken to
examine the quality of parenting (Holditch-Davis, Miles, Burchinal, & Goldman, 2011) and characteristics
that influenced maternal role attachment longitudinally (Miles, Holditch-Davis, Burchinal, & Brunssen,
2011). In other works, Kinsey, Baptiste-Roberts, Zhu, and Kjerulff (2014) studied the effect of miscarriage
history on maternal–infant bonding, and Sriyasak, Akerlind, and Akhavan (2013) examined childrearing
among Thai teenage mothers using Mercer’s theory as a framework. Lastly, Fouquier (2013) performed
a comprehensive literature review to evaluate the applicability of Mercer’s theory to African American
women. She determined that the homogeneity of the samples for most of the research on Mercer’s
theory is not necessarily generalizable to African American women and concluded that more research is
needed to identify attributes that influence maternal role attainment to that population. Summary This
chapter presented a wide variety of middle range nursing theories. Because of space limitations, the
descriptions are very brief and are intended to merely introduce the theories. The readers are directed
to original and supporting sources for more information. Elaine Chavez, the graduate student from the
opening case study, saw how one of the numerous middle range nursing theories that have been
published in recent years could be used to develop interventions in her practice. All nurses should
likewise continue to review current nursing literature for new theories and ideas that are being
presented to remain current and knowledgeable about nursing practice. To illustrate, Link to Practice
11-1 provides some thoughts on how nurses can apply middle range theories in their daily p