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Perspectives in Nursing Science
Strategies of Middle-range Theory Development in Nursing
Hesook Suzie Kim!)
Introduction
Theory development in nursing can be viewed to have progressed during the last 50 years in three periods: (a) the era of specifying theoretical orientations for nursing that occurred during the period of 1950s and 1960s, (b) the era of grand theorizing during the 1970s and 1980s, and (c) the era of middle-range theory development in the last two decades. The first era was characterized by the attempts of several nursing leaders and scholars to identify specific nursing orientations in an effort to disassociate and differentiate nursing from medicine. There were two distinct directions with which theoret- ical orientations for nursing were specified: one was the specification of what the focus of nurs- ing is in relation to clients, namely what has been identified as the patients' needs ori- entation advanced by Henderson, Abdellah, and others, and the other was the focus on nurs- ing's unique nature from the interaction per- spective as was done by such scholars as Peplau, Orlando, Travelbee, and Widenbach. By specifying the theoretical and professional ori-
entation of nursing in terms of patients' needs as with the 14 basic needs of patients by Henderson and the system of 21 nursing prob- lems by Abdellah, nursing leaders and scholars were attempting to shift from disease-orientation to nursing-specific problem orientation. On the other hand, the interaction perspective was an attempt to provide theoretical approaches regard- ing how nursing is done rather than what sorts of problems in patients nursing is oriented to solving. These two groups of theoretical work in nursing during this initial period were ori- ented to providing general frameworks and sys- tems of terminologies rather than in advancing specific theoretical systems. However, these proposals and developments were the impetus and foundation from which the second era of theoretical efforts emerged. The second era of grand theorizing was a critical development for nursing in several re- spects: (a) it provided unique nursing per- spectives and frameworks; (b) it placed the idea of theory firmly into the nursing culture espe- cially in relation to education and research, and
I) PhD, RN, Professor Emerita, University of Rhode Island College of Nursing and Professor, Institute of Health Studies, Buskerud University College, Norway
(c) it motivated nursing scholars to examine epistemological philosophies critically in order to understand the directions with which nursing was developing theories and examine the philo- sophical foundations for nursing theory development. During this era, the integration of holism into theoretical and conceptual frame- works became evident in different forms, and the theoretical attempts were oriented to ad- dress all aspects of nursing's concerns such as clients, nursing strategies, and processes of nursing practice. The grand theories and con- ceptual frameworks developed during this peri- od such as the science of unitary human beings by Rogers, the adaptation model of Roy, the Neuman Systems model, Orem's self-care mod- el, and Human becoming theory of Parse pro- vided general frameworks for conceptualizing and sometimes explaining phenomena in clients from the nursing perspective, and had been most instrumental in advancing ways of assess- ing clients and their problems. Although some of these models specify theoretically rigorous formulations, in general these models, being too abstract or too general, were often thought to be conceptual frameworks rather than theories as they were limited in providing specific theo- retical grounds for research and practice. This shortcoming in a way paved the way for nurs- ing's more recent attempts to develop mid- dle-range theories. Hence, the third era emerged with a focus on developing middle-range theories not only because of the failure of grand theories in pro- viding satisfactory explanations of nursing phe- nomena but also because of other developments such as the surge of empirical research drawing from middle-range level propositions and test-
ing theories developed in other disciplines, ad- vances in concept development in nursing, and an increase in systematic research programming by many researchers that resulted in progressive knowledge developments in various substantive areas (e.g., women's health, chronic illness, and infant care). There also was an increased inter- est in developing intervention theories, which was found to be difficult to do within the frameworks of grand theories. In addition, the exposure and training in various theory devel- opment strategies of nursing researchers and scholars added to the interest in developing middle-range theories during these decades. Lier and Smith (1999) identified 22 mid- dle-range theories in the nursing literature, and Benoliel (1996) in her review of grounded theory work in nursing from 1980 to 1994 identified a list of about 100 grounded theory research by nurse-researchers. In addition, there were 12 publications since 1999 in which the authors claimed to have developed mid- dle-range theories in nursing. While the fervor and interest with which nursing has put its efforts in developing mid- dle-range theories are evident in the number of such theories being published in the literature, there is a paucity of discussion regarding strat- egies of middle-range theory development. Walker and Avant (1995) have proposed the strategies of theory derivation and theory syn- thesis as approaches to theory development in nursing, although without eluding these to be specifically appropriate for middle-range theory development. Otherwise, there is no compen- dium that provides a comprehensive discussion of middle-range theory development strategies. This paper thus provides a review and compila-
intent was the discovery of theory regarding so- cial processes embedded in people's experi- ences in social life viewed from the perspective of symbolic interactionism. However, with the publication of a book by Strauss and Corbin (1990) in proposing grounded theory procedure as a strategy in qualitative research devoid of its original orientations in symbolic interaction- ism and social processes, it became necessary to consider grounded theory encompassing two separate strategies as suggested by Benoliel (1996): grounded theory research and grounded theory "approach". The basic tenets of grounded theory re- search are its commitment to symbolic inter- actionism with which social processes and peo- pie's experiences are understood and explained, and direct exposure to on-going social proc- esses and experiences. In grounded theory re- search, various sorts of data from direct ex- posure of researchers to on-going social life, in- cluding those from participant observation and interviews, are used. Hence, discovered ground- ed theories emerge through interpretations of social data from this theoretical perspective, and are derived from meanings of social life as it is experienced by people. Benoliel (1996) thus insists that grounded theory research should be thought of as an interpretive theory discovery method rather than as an inductive process. On the other hand, research applying the grounded theory procedures is usually from the postpositivistic orientation. Theories result- ing from the application of grounded theory "approach" as suggested by Strauss and Corbin are not committed to symbolic interactionism and are basically open to various theoretical orientations. Sometimes, researchers applying
grounded theory procedures in qualitative re- search do not present theory as results of studies. When theories are the products of such research, they usually confirm only to the form of theory consisting of antecedents and consequences. In both modes of application of grounded theory the major processes originally identified by Glaser and Strauss are used: namely, theo- retical sampling, various levels of coding, con- stant comparison, and theoretical memoing. Among many grounded theories that have been developed and published (see Benoliel, 1996), the most recent ones are by Wuest (2001) and Kearney (2001).
- Fieldwork/Ethnography
The fieldwork approach, as a versIOn of ethnography without the ethnographic (i.e., an- thropological) focus on discovering a culture theory as its aim, has been popular as a meth- od of theory generation in nursing. However, a specific fieldwork approach in clinical nursing has not been well illustrated in the literature, thus most nurse-researchers rely on the method as described and discussed in sociology and an- thropology (for example, Emerson, 2001; Atkinson, 2001; Hammersley & Atkinson, 1995; and Polkinghorne, 1983). The approach in general begins with a commitment to a theo- retical framework, a worldview, or an ex- planatory model, which provides a framework for determining a direction of investigation and scope of data collection and analysis. The ana- lytic orientation is ampliative induction, and the approach relies on various data sources through participant observation, various forms of inter- views, and records. Since the method is ori-
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ented to ampliative induction, data collection and analysis occur concurrently for a continu- ing and emergent interplay between data and analysis, which results in theory generation. The common orientation in fieldwork is an in- tegration of emic and etic perspectives (see Emerson, 200 I). In nursing, Schwartz-Barcott (1998) gives an illustration of three fieldwork studies for theory development. The concept differentiation ap- proach (Kim, 1992) drawing from the hybrid model of concept development (Schwartz-Barcott and Kim, 2000) is based on the fieldwork ap- proach, emphasizing clinical practice as the be- ginning step in theory generation in nursing.
- Epidemiological Approach
Epidemiological approach of theory gen- eration relies on an analysis of quantitative data from the perspective of open induction for theory generation. It is based on the assumption of enumerative induction. The starting point for this approach is a selection or determination of a phenomenon for explanation, that is, a deter- mination of a dependent variable for which an explanation is sought. The model of explanation adopted for this approach is a multi-cause, structural model, with an aim for identifying as complete a list of causal factors as possible from a comprehensive set of data. Most com- monly the theoretical model is a bio-behav- ioral-psycho-socio-ecological explanation of hu- man phenomena. This approach relies on stat- istical procedures for theoretical conclusions, thus calls for a collection of various sorts of quantitative data thought to be relevant to the phenomenon of concern. Ryan (1982) suggests this method as consisting of several steps with
an orientation for causal inference. The theoret- ical explanations advanced for low-birth weight infants and patients' fall have relied on this approach. Lunney and colleagues (2003) devel- oped an explanation for functional decline at the end of life through this approach.
Deductive/Analytic Approaches
The basis of deductive/analytic approaches for middle-range theory development is the reli- ance on analytic arguments, most often with the application of deductive logic, rather than on data as the primary source for generation of theoretical ideas. However, there must be em- pirical relevance in applying any of the ap- proaches in this category, and theories devel- oped through these approaches should have heuristic values in their explanations. There are six approaches found to be useful in developing middle-range theories in nursing: (a) deductive derivation, (b) systematic inventorying and ana- lytic derivation, (c) theory synthesis, (d) theo- retical modeling, (e) qualitative synthesis, and (f) prescriptive theory derivation. These ap- proaches are not purely deductive in the philo- sophical definition of deduction, but rely on an- alytical procedures as the primary method for arriving at theoretical conclusions. In this sense, theories that are developed through these ap- proaches may be called "deductive/analytic" theories.
I. Deductive Derivation The deductive derivation as a method be- gins with an assumption that it is possible to extract sub-theories from a general theory by applying appropriate deductive logic. Thus, the
Perspectives in Nursing Science
transitions (Meleis, et al., 2000), resilience (Polk, 1997), and uncertainty (Mishel, 1988).
- Theoretical Modeling Theoretical modeling is an approach used often in social sciences to arrive at a refine- ment and consolidation of theoretical ideas that are loosely formed and are used as guides for empirical research. It is a method of theoretical representation of elements, characteristics, struc- tures, and processes of a set of factual entity. Models developed are to include "hypotheses" about the underlying and inaccessible structure of reality, often in a casual structure. In this approach theoretical models are considered to be sets of instructions for generating behavioral or structural data that can represent the behav- iors or the structures of a real system. Therefore, a theoretical model results from an analytical thinking that systematizes under- standings about a given phenomenon revealed from a comprehensive review of the literature, an exposure to various theoretical explanations, and personal knowledge gained from research and clinical experiences. Theoretical modeling includes several steps: an identification of the patterns of behavior of the concerned phenom- ena, clarification of one's own "world" model, derivation of assumptions and premises from known theories and empirical findings, identi- fication of the phenomena for explanation, identification of entities that will provide ex- planations, specification of descriptive variables for each component, identification of relation- ships (form and nature), and formalization of the model (Asher, 1976; Blalock, 1985; & Dwyer, 1983). Theoretical modeling has been used in constructing and testing models, for ex-
ample, for perimenstrual syndrome, menopause, compliance, and coping with chronic illness.
- Qualitative Synthesis
A growing body of literature m nursmg from various qualitative methods has provided an impetus for a development of an approach to synthesize findings from such studies for theory development. Because often qualitative studies represent results that are limited by small sample sizes and study subjects' contexts, researchers have been reluctant to specify theo- ry generation as outcomes of their studies. Qualitative synthesis as a method of theory generation is an approach for an integration of findings into a system of generalizations about specific phenomena (see Morse, 1997; and Morse, et al., 2002). Estabrooks and colleagues (1994) suggest one approach, while other re- searchers have presented theories developed ap- plying various methods of qualitative synthesis, such as the theory of chronic sorrow (Eakes, et al., 1998), Finfgeld's work (1999) on "courage as a process of pushing beyond the struggle", the model of caring and comfort developed by Jenny and Logan (1996), and the model of epi- leptic stigma specified by Scambler and Hopkins (1990). The major problems with this approach are: (a) Often various qualitative re- search reports on a given phenomenon are like- ly to have adopted different philosophical ori- entations regarding the nature of reality and in- terpretation, meaning that such diverse philoso- phies may not be coherent with each other; and (b) Theory-generating researchers applying qualitative synthesis are likely not to have an access to original qualitative data, making theo- retical efforts to rely only on original re-
searchers' interpretations and analyses of data. One solution to these criticisms has been to en- courage qualitative researchers to synthesize their own works or work in teams. There is a need to identify specific analytic procedures that are appropriate for qualitative synthesis, addressing the issues of selective integration, clustering, and expansion.
- Prescriptive Theory Derivation Nursing's interest in developing intervention theories has spurred proposals for various tech- niques of prescriptive theory derivation, such as the method proposed by Moore and colleagues for the use of practice guidelines to delineate middle-range theories (Good & Moore, 1996; Ruland & Moore, 1998; and Huth & Moore, 1998), and the method proposed by Blegen and Tripp-Reimer (1997) for the use of NANDA, NIC, and NOC to make linkages among these three components into theories. These proce- dures need to be examined further as they rely on conclusions that have been drawn from the literature and represent many theories rather than a single theory of prescription. These are approaches identified as having inductive or deductive perspectives, that is, within the two main perspectives of theory development. Some of these represent responses to and innovations based on the changing phi- losophies, attitudes, and scholarly culture. The movement from positivism to postpositivism and relativism has been responsible for the loosening of ideas regarding what is the nature and structure of scientific theories.
Reconstructive Approaches
Theory development has flourished from the perspective of reconstruction in the recent decades because of various reasons: (a) many researchers and theoreticians have to find ways to deal with rich evidential bases of theoretical and empirical work in a given substantive area, which are sometimes complementary, com- petitive, or conflictive; (b) there has been a great deal of discussion regarding paradigm shift and paradigm integration; and (c) plural- ism has to be addressed in relation to heuristic consequences and practice implications. There are three forms of reconstruction in theory building appropriate for nursing.
- Theory Integration
Approaches to theory integration are based on the assumption that synthesizing two or more theories or aspects of theories can result in more comprehensive or heuristically superior theories. There are three distinct theory in- tegration methods: complementary synthesis, se- lective integration, and additive integration. An approach of complementary synthesis has been proposed by Turner (1989) in which two or more theories can be coalesced to clarify and elucidate processes that are embedded and not well-articulated in an original theory. The meth- od of selective integration refers to a process of theory reconstruction in which certain aspects of given theories are selected for integration and reconciliation, specified as theory-knitting by Kalmar and Sternberg (1988) for example. The aspects selected for integration are those considered to be theoretically strong and con- firmed parts of given theories and which are
identifying this approach for theory re- construction, many researchers have applied a relaxed version of this in their proposals for theory revision in dealing with findings that are contrary to the predictions by theoretical propositions. Retroductive reconstruction is thus a method that can be specified as analytically rigorous approach for theory revision in nurs- ing, especially III dealing with aberrant findings.
Interpretive Approaches for
Theory Building
The concept of scientific theories has gone through a vast revision during the past three decades from one that was strictly oriented to explanation and prediction within the pos- itivistic philosophy (especially in logical positi- vism) to ones that embrace the notions of un- derstanding and description. Acceptance of pure descriptions and contextually based under- standings as legitimate orientations for scientific theories have also expanded the ideas regarding how theories can be developed in sciences in general and more particularly in the human sciences. From this shift in thinking and philos- ophy, many forms of theories such as theories of description, understanding, meaning, critique, and emancipation are accepted, and different approaches to developing these sorts of theories have been advanced. Most of these approaches apply interpretation as the method of analysis. There are four somewhat distinct approaches within this orientation: (a) phenomenological approaches, (b) hermeneutic approaches, (c) critical approaches, and (d) poststructuralist ap- proaches (see Denzin & Lincoln, 2000 for oth-
er approaches). The starting points for these ap- proaches are the philosophical assumptions un- dergirding them, and because of the differences in the philosophical assumptions for them the nature of theories emerging from these are different. The starting point for the phenomenological approaches is in the philosophic assumption of "essences" of phenomena and the primacy of subjectivity in terms of consciousness, percep- tion, and meaning. Hence, theories emerging from phenomenology are theories of description regarding phenomenal essences as revealed through consciousness and meaning. Although there are various procedural proposals from phenomenologists such as by Giorgi, Collazzi, and VanMannen, which have been applied in nursing studies, the variations in the phenom- enological methods are not critical. What is critical is the conception of the nature of theo- ries emerging from this perspective. Hermeneutic approaches based within the works especially by Gadamer, Ricouer, and Heidegger have been applied in nursing. The starting point for hermeneutic approaches is the assumption of historicity, contextuality, and meaning constructions regarding both subjects' experiences and researchers' interpretation. Hence the results of hermeneutic research are theories of understanding and meaning through interpretation of human experiences. Given this, theories developed through hermeneutic ap- proaches are contextually bound. Theories of meaning and understanding from hermeneutic approaches are therefore non-absolute, but enlightening. Critical philosophy and poststructuralism as two variant philosophical positions within the
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postmodernism orient us to different sorts of theories in human sciences. Critical philosophy is based on a general theory that identifies sys- tematic domination in social life and proposes a project of emancipation. Theories from this philosophical perspective developed through such methods as critical action research or crit- ical ethnography are theories of domination and emancipation for specific forms of social life. On the other hand, poststructuralism assumes the principal role of investigation to be in re- vealing and examining the nature and forms of systematic distortions brought on by language and power, and is oriented to developing knowledge through critique. Hence, the ori- entation is a theory of critique. As revealed in the preceding discussions, there are many approaches to middle-range theory development applicable to nursing. Which method or approach to adopt in theoret- ical work has to be determined both by the na- ture of phenomena and the philosophical as- sumptions held by researchers (Kim, 1993). It is also important to realize how critical a re- searcher's model of explanation (or form of theoretical understanding) is in influencing a type of theory that is developed (Kim, 2000). In applying a specific strategy of theory devel- opment the nurse-researcher must understand the assumptions and procedural requirements of the selected method so that there is no mis- construal both in the process and productions.
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