Mid – Range Theory

Hi,

I am attaching the exact guidelines to this email. PLEASE look over them VERY CAREFULLY so the assignment is done correctly. The first attachment is the grading criteria. Please use the following theory as I was assigned it… I was assigned:

Shana Spratt

Leininger’s Cultural Care Theory

MID-RANGE or NURSING PRACTICE THEORY PRESENTATION
GRADING CRITERIA
PowerPoint Presentation: You should complete this assignment by preparing and presenting a
5-10 minute PowerPoint presentation with voiceover OR a recorded Zoom presentation. In
addition to your textbook, you must use two (2) additional references.
Avoid using only word-for-word information from the text – Use your own words, as well
as textbook information, to explain the following:
Background of the Theorist/Theory (brief synopsis) (15%)
Purpose and Major Concepts (20%)
Context for Use and Nursing Implications (20%)
Evidence of Empirical Testing and Application to Practice (20%)
Annotated Bibliography reference (5%)
• Identify a nursing research article that uses the mid-range or nursing practice
theory that your presentation discusses. Create an annotated bibliography on a
slide at the end of the presentation (before your reference slide).
•
Examples of annotated bibliographies:
http://guides.library.cornell.edu/annotatedbibliography
https://owl.english.purdue.edu/owl/resource/614/01/
APA & Grammar/Spelling (10%) You must include APA formatted citations within your
slides when warranted. Additionally, you should include an APA formatted reference
slide. No grammar or spelling errors.
Quality of PowerPoint slides (5%)
Slides are professional in appearance
Presentation Skills (5%)
Speaker uses a clear, audible voice. Delivery is poised, controlled, and smooth. Good
language skills and pronunciation are used. Length of presentation is within the assigned time
limits (5-10 minutes).
Elms College School of Nursing
MSN Program
NUR 5005 Nursing Knowledge and Practice – Fall 1 2023
Mid-Range and Nursing Practice Theory Presentation Assignment
Professor: Dr. Laurie Downes
Week 6 Presentation: Please create a PowerPoint with voice over or recorded Zoom presentation of
your assigned theory. Upload in Moodle.
Name
Shana Spratt
Theory
Leininger’s Cultural Care Theory
Kayla Cardona
Meleis Transitions Theory
Winnie Olivo
Kolcaba’s Theory of Comfort
Advances in Nursing Science
Vol. 42, No. 3, pp. 206–215
c 2019 The Authors. Published by Wolters Kluwer Health, Inc.
Copyright 
Integrating Symptoms Into the
Middle-Range Theory of
Self-Care of Chronic Illness
Downloaded from https://journals.lww.com/advancesinnursingscience by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3wX04VDhDA67eAI3DnCyu4CWEnAA9qjJGuH/5uHUzwvQ= on 09/08/2019
Barbara Riegel, PhD, RN, FAAN; Tiny Jaarsma, PhD, RN, FAAN;
Christopher S. Lee, PhD, RN, FAAN; Anna Strömberg, PhD, RN, FAAN
The Middle-Range Theory of Self-Care of Chronic Illness has been used widely since it was
first published in 2012. With the goal of theoretical refinement in mind, we evaluated the
theory to identify areas where the theory lacked clarity and could be improved. The concept
of self-care monitoring was determined to be underdeveloped. We do not yet know how
the process of symptom monitoring influences the symptom appraisal process. Also, the
manner in which self-care monitoring and self-care management are associated was thought
to need refinement. As both of these issues relate to symptoms, we decided to enrich the
Middle-Range Theory with knowledge from theories about symptoms. Here, we propose a
revision to the Middle-Range Theory of Self-Care of Chronic Illness where symptoms are clearly
integrated with the self-care behaviors of self-care maintenance, monitoring, and management.
Key words: nursing theory, self-care, symptoms
N
URSING theory and nursing research are
engaged in a dance that moves each forward with the goal of advancing nursing sci-
Author Affiliations: School of Nursing, University
of Pennsylvania, Philadelphia (Dr Riegel);
Department of Social and Welfare Studies
(Dr Jaarsma), and Department of Medical and
Health Sciences, Division of Nursing (Dr Strömberg),
Linköping University, Linköping, Sweden; and
Connell School of Nursing, Boston College, Boston,
Massachusetts (Dr Lee).
The authors gratefully acknowledge Karen Huss, PhD,
RN, FAAN, for her review of a prior version of this
article.
This is an open-access article distributed under the
terms of the Creative Commons Attribution-Non
Commercial-No Derivatives License 4.0 (CCBY-NC-ND),
where it is permissible to download and share the
work provided it is properly cited. The work cannot
be changed in any way or used commercially without
permission from the journal.
The authors have disclosed that they have no significant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Barbara Riegel, PhD, RN, FAAN,
School of Nursing, University of Pennsylvania,
418 Curie Blvd, Philadelphia, PA 19104 (briegel@
nursing.upenn.edu).
DOI: 10.1097/ANS.0000000000000237
206
ence. Nursing theory is defined as “a creative
and rigorous structuring of ideas that project a
tentative, purposeful, and systematic view of
phenomena.”1(p155) Nursing research refers to
research that provides evidence used to support nursing practice. Nursing theory needs
to be based on and driven by research, and,
in turn, nursing research needs to be derived
from and contribute to theory if we are to
successfully explain and predict patient experiences surrounding health and illness.
The theory-data cycle of development specifies that the empirical data derived from research serve to develop, revise, and refine
theory whereas theory helps shape research
questions, establish hypotheses, develop interventions, and select outcome variables
(Figure 1). Theoretical propositions posed to
describe or explain a complex reality can be
tested in research, and the results of these
studies can be used to further alter, expand,
modify, or refine theory. Even in established
and well-tested nursing theories, propositions
remain tentative. When new research accumulates, theories may be revised or refined
with the goal of creating solid evidence-based
Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness
Statement of Significance
• We know that self-care involves a
process of health maintenance,
monitoring for changes in signs
and symptoms, and management
of those changes when they
occur.
• We know that symptoms
influence self-care behaviors.
• This article describes how
symptoms influence self-care
behaviors. Specifically, this
article describes the importance
of symptom detection,
interpretation, and response as
core elements of the self-care
process.
knowledge useful for guiding clinical practice. In this approach to theory development,
there is a need for exploration, refinement,
and critical reflection on the place and value
of existing concepts and the need for expanding or developing others.
With the goal of theoretical refinement
in mind, the purpose of this article was to
evaluate the Middle-Range Theory of Self-Care
Figure 1. Graphic illustration of the manner in which
the theory-data cycle of development builds science.
Research questions are derived primarily from existing research literature. When these questions are
tested empirically, the research findings are used to
develop, revise, and refine theory. Theory helps shape
subsequent research questions, establish hypotheses,
develop interventions, and select outcome variables.
207
of Chronic Illness2 to identify areas where
empirical tests of the theory are likely to be
problematic. We used Weber’s3 framework
for theory development and evaluation to
determine where the Middle-Range Theory
of Self-Care of Chronic Illness2 lacked clarity
so that we could rectify issues by integrating
concepts from other models and theories.
CURRENT STATE OF THE
MIDDLE-RANGE THEORY OF SELF-CARE
OF CHRONIC ILLNESS
The Middle-Range Theory of Self-Care of
Chronic illness has gained the attention of
clinicians and researchers worldwide, already
resulting in 244 citations in the 6 years since
publication. Work to date on the theory has
successfully described the process of self-care
behaviors in various populations and identified numerous factors affecting the self-care
process.4-6
As described in the original theory, self-care
is performed in both healthy and ill states. It
is important to note that everyone engages in
some level of health-promoting self-care daily.
However, self-care might have another meaning to patients with a chronic illness, since
living optimally with a chronic illness often requires a set of behaviors to control the illness
process, decrease the burden of symptoms,
and improve survival.
Self-care is essential in the long-term management of chronic illnesses, and the purpose of the Middle-Range Theory of Self-Care
of Chronic Illness2 was to capture a holistic
view of the manner in which patients with
varied or multiple chronic conditions care
for themselves. Self-care influences both clinical and person-centered outcomes in patients
with chronic conditions. Those who engage
more effectively in self-care have better quality of life,7-9 lower hospitalization rates,10-13
and less mortality than those who report poor
self-care.14
In the Middle-Range Theory of Self-Care
of Chronic Illness,2 self-care is defined as a
process of maintaining health—the central
208
ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2019
phenomenon—through
health-promoting
practices and managing illness. These behaviors are performed in both healthy and ill
states. Self-care can be seen as an overarching
construct built from the 3 key concepts
of self-care maintenance (eg, adherence to
self-care behaviors such as regular exercise
and taking medication as prescribed), selfcare monitoring (eg, regular measurement
of changes, routine testing), and self-care
management (eg, changing the diet or
medication dose based on detection and
interpretation of symptoms). The 3 concepts
of self-care maintenance, monitoring, and
management are closely related; therefore,
the performance of sufficient self-care
encompasses all 3 behaviors.
For patients with chronic disease, it may
be necessary to regulate and adapt self-care
during the course of the disease, for example, with illness exacerbation, if a comorbid
illness occurs, or if an advanced treatment is
needed.2 The goal of self-care maintenance is
to maintain health and prevent symptom exacerbations, the goal of self-care monitoring is
recognition that a change has occurred, and
the goal of self-care management is effective
treatment of symptoms.
Self-care behaviors reflect a sequence that
builds on a foundation of self-care maintenance. That is, most patients first master selfcare maintenance and later build expertise in
self-care monitoring and management. People
who perform all 3 behaviors are most proficient in self-care. However, for a variety of reasons, people with chronic illness often skip
elements of the process, leading to problems
in the successful performance of self-care.
After a thorough analysis of existing parts
of the theory (eg, concepts, associations), we
identified 2 important issues needing further
development. First, the concept of self-care
monitoring was determined to be underdeveloped. Relatively, little research has been conducted on the process of self-care monitoring,
so more research may reveal what patients
think about monitoring (eg, their response
to engagement in body listening and routine
appraisal for bodily changes) if monitoring of
signs (eg, blood pressure) differs from that of
symptoms (eg, fatigue). We do not yet know
how the process of monitoring interacts with
the appraisal process. Are patients who monitor routinely more adept at judging changes?
We anticipate that more research will lead to
further revisions of the theory in the area
of self-care monitoring. Second, the manner
in which self-care monitoring and self-care
management are associated is underdeveloped in the existing theory. Logically, those
who do not monitor well probably do not
management well, but this hypothesis has not
been tested. As the Middle-Range Theory of
Self-Care of Chronic Illness aims to describe
and explain the process of maintaining health
within the context of the symptom management required of those with a chronic illness
and their families,2 we decided to enrich the
theory with knowledge from other theories
about symptoms.
DESCRIPTION OF SYMPTOM THEORIES
There are numerous classic symptom theories used to guide research in nursing
and related disciplines. We considered the
Dynamic Symptom Model,15,16 the Theory
of Unpleasant Symptoms,17 the Model of
Pathways to Treatment,18 the Illness Action
Model,19 the Symptoms Experience in Time
Model,20 the Situational Adaption Model,21
Self-Regulation Theory,22 the Symptom Interpretation Model,23 the Cognitive Perceptual
Model of Symptom Perception,24 Cue Competition Theory,25 Kolk’s Symptom Perception Model,26 and the Psychophysiological
Comparison Theory,27,28 because they complement the central arguments of the MiddleRange Theory of Self-Care of Chronic Illness in
their description of symptoms or position selfcare as an antecedent or consequence related
to symptoms. Below we describe elements of
the major symptom theories in nursing.17,29,30
In general, these theories aim to explain and
predict symptoms as well as to describe how
patients and caregivers appraise and act to
control symptoms when they occur.
Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness
209
Self-care and symptom theories often address the same concepts. In the Dynamic
Symptom Model,15,16 self-care is described
as an antecedent of the symptom experience, symptom trajectory, and symptom consequences. However, self-care is not specially
mentioned as an element of the intervention
strategy to relieve symptoms. In the MiddleRange Theory of Self-Care of Chronic Illness,
symptoms are described as important to monitor and as giving direction to self-care management behavior. That is, when symptoms
increase, patients can use different management strategies, such as changing medication
or diet or consulting a clinician. Detection, interpretation, and response are important elements of many symptom appraisal theories,31
and these concepts are vital parts of self-care
monitoring and management in the MiddleRange Theory of Self-Care of Chronic Illness.
the detection of bodily changes.31 Bodily
changes may be localized (eg, mid-sternal
chest pain) or generalized (eg, fatigue) and
can be detected by any of the body’s senses.
Theoretical discussions of symptoms specify
that detection of bodily changes may reflect a
difference in intensity and/or frequency of the
patient’s normal sensations that is sufficient
in magnitude, novelty, or significance to be
perceived.18,31 Detection of bodily changes
causes a disturbance in equilibrium19 that
drives patients to engage in self-care.32 As
symptoms are detected, they must be interpreted with meaning applied to bodily
changes, labeling them as symptoms. By definition, if a bodily change is not perceived, it
is not a symptom.
The symptom experience
The interpretation of bodily changes frequently involves characterizing the change
and applying meaning. As an example of characterization, Lenz et al17 defined symptoms as
entailing intensity (ie, severity, strength, and
amount), quality (ie, what a symptom feels
like, and location), duration (ie, frequency
and duration of intermittent and persistent
symptoms, and the temporal relationship between symptoms and activity), and distress
(ie, the degree to which the person is bothered by the symptom(s)—reflective of how
the patient interprets and experiences the
meaning he or she assigns to it). Armstrong30
defined the symptom experience as the perception of the frequency, intensity, distress,
and meaning of symptoms as they are produced and expressed. Furthermore, Henly
et al20 defined the symptom experience as
a flow process of evaluating and reevaluating
symptom perception, timing, distress, intensity, and quality.
A salient theme across multiple symptom
theories is that multiple symptoms frequently
occur simultaneously and are multiplicative17
or catalytic in effect.30 Moreover, certain
symptoms (particularly those that are serious, unpleasant, or inexplicable)20 draw
Across existing symptom theories, symptoms are defined as subjective physical or
mental experiences, appraised and defined by
the patient, and reflective of an altered health
state or change therein. For example, Lenz
et al17 defined symptoms as subjective experiences and indicators of change in function
as experience by the person. Dodd et al29 defined symptoms as based on the perception of
the individual experiencing the symptom and
his or her self-report. Armstrong30 stated that
each symptom was individually defined by the
patient. Insights from numerous lines of inquiry related to symptoms can be synthesized
into the categories of detecting, interpreting,
and responding to bodily changes (ie, symptoms). In the following section, we focus our
attention on the detection and interpretation
of bodily changes as symptoms. We address
the response to symptoms as they occur during self-care, as described in the Middle-Range
Theory of Self-Care of Chronic Illness.
Detecting bodily changes as symptoms
Several symptom theories are explicitly focused on symptom appraisal and start with
Interpreting bodily changes
as symptoms
210
ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2019
more energy in interpretation and eventual
management.
With respect to the meaning applied to
symptoms, bodily changes may be interpreted within social and cultural norms21 ;
this can lead to stoicism or concealment of
certain symptoms and overexpression of others as a function of what is perceived to
be acceptable. Bodily changes may be interpreted as a function of emotion and illness
representations22 including attribution (eg, fatigue from heart failure vs pulmonary disorder vs a normalized function of aging).22-24
Thus, the condition to which a symptom is attributed by the patient is inextricably linked
to the meaning that is applied to the experience. Bodily changes may be interpreted
differently depending on cognitive resources
and external sensory input24-26 ; this includes
external stress that may cause patients to be
unaware of major body changes. Finally, bodily changes may be interpreted on the basis of motivation to maintain physiological
stability.27,28
Recently, Whitaker et al31 harmonized findings across many symptom theories to
categorize antecedents preceding the detection and interpretation of bodily changes
as knowledge (ie, familiarity, awareness,
or understanding of bodily sensations acquired through experience or education),
attention (ie, focusing on relevant stimuli
while ignoring distractors), expectation
(preexisting beliefs, contextual biases,
and general heuristics or shortcuts), and
identity (ie, distinct characteristics of an
individual and his or her role in society).
Specific to nursing symptom management
theories, antecedents to interpreting bodily
changes have been categorized as being
physiological/disease-health related,17,20,29,30
personal,20,29,30 psychological,17,29 situational/ environmental,17,20 sociological,29
and developmental factors.29
Simply put, the process of detection, characterization, and meaning applied to bodily
changes as symptoms is complicated. Hence,
it is not surprising that the interpretation of
bodily changes may be inaccurate (ie, mis-
interpretation of a bodily change or the absence thereof as a symptom)25,31 and highly
variable among patients living with the same
condition. Importantly, there is room for improvement in how the detection and interpretation of bodily changes as symptoms are
incorporated into theories of self-care, which
we address further in our discussion of future
research.
Example integration of self-care and
symptom theories
In the following, we provide an example
to illustrate how to link the self-care perspective with the symptom management perspective. What would it look like if we studied
heart failure from a self-care perspective? The
patient with heart failure commonly experiences a variety of disabling symptoms that
are exacerbated by missing medication doses,
dietary indiscretions, and failure to maintain
an active lifestyle. Using a self-care perspective, the patient and the clinician would focus on self-care with the goal of preventing symptoms. That is, symptoms are something to be avoided and self-care is a primary
means of doing so. If symptoms occur, poor
self-care might be suspected. The clinician
might focus an assessment on reasons for poor
self-care and interventions to improve various aspects of self-care, including monitoring of symptoms and responding to symptoms
when they occur. Without more in-depth information on the symptoms experience, the
patient and the clinician might overlook the
complexity of symptom clusters33,34 and the
different dimensions of the symptom experience. Advice might be focused on “what
actions to take with this specific symptom”
without seeing the total picture of how symptoms and the management of symptoms with
self-care might interact. For example, increasing diuretics in response to dyspnea—a common self-care intervention—without considering the diurnal variation of the symptom
experience could affect sleep patterns.
What would it look like if we studied
heart failure from a symptom perspective?
Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness
Using symptom theory to guide care, attention would be given to the symptom itself
(eg, severity and interference thereof) rather
than addressing why it occurred. As noted in
the National Institutes of Health (NIH) Symptom Science Model, complex symptoms,
sequelae, and clusters of symptoms are
studied through a disease agnostic lens.35
The symptom phenotype is characterized
using physiologic and biologic measures
derived from genomics, proteomics, and
metabolomics (ie, omics). Thorough understanding of the symptom experience may result, but the patient and the clinician also
might overlook other important aspects of
the situation that are not directly related to
the symptom experience. For example, as described in a recent qualitative study, missing
medication doses or dietary indiscretions may
not be suspected if not temporally related to
the symptom experience.36
What would it look like if we studied heart
failure from an integrated approach? An
integrated approach might entail a more complete appreciation of the impact of symptoms
on self-care and the influence of self-care
on symptoms. For example, in the SituationSpecific Theory of Heart Failure Self-Care,37
the concept of self-care monitoring from the
Middle-Range Theory of Self-Care of Chronic
Illness was operationalized in a unique and
specific fashion for patients with heart failure
because of their symptom issues. In the
Middle-Range Theory, self-care monitoring is
defined as the process of “observing oneself
for changes in signs and symptoms.”2(p196)
But heart failure causes problems with the
ability of patients to detect and interpret
changes in signs and symptoms. Specifically,
the insular cortex is the area of the brain responsible for interoception or the perception
of sensations originating within the body.38
However, lesions of the insular cortex have
been found in patients with heart failure.39
Even those patients with heart failure who are
diligent in observing themselves for changes
may not be successful in self-care monitoring
because of these cognitive changes. Thus, we
proposed a process that we named symptom
211
perception in the Situation-Specific Theory
of Heart Failure Self-Care.37 In that theory,
symptom perception was said to involve body
listening, monitoring, recognition, interpretation, and labeling of signs and symptoms. This
is an example of how self-care and symptom
theories can be integrated to achieve a more
complete theory relevant to patients with
heart failure. Importantly, an integrated
approach would involve robust measurement
of both symptoms and self-care, as advocated
in the NIH Symptom Science Model.35
PROPOSING A REVISION OF THE
MIDDLE-RANGE THEORY INTEGRATING
SYMPTOMS
At this point, recognizing the role of
symptoms in patients’ decisions regarding
self-care behaviors, we propose that incorporating symptoms more explicitly into the
Middle-Range Theory of Self-Care of Chronic
Illness can help refine the theory and improve
our ability to explain self-care and predict
performance of self-care and the outcomes
achieved. In the following, we use existing
research to support proposed associations in
the revised theory.
Self-care is fundamentally a decisionmaking process influenced by reflection.40
Self-care theory is broader than symptom theory, but here we acknowledge the strong influence of symptoms on the self-care decisionmaking process. Symptoms themselves can
be indicators of a bodily change, but research has confirmed that changes in the illness may not always cause symptoms.41,42 We
also note that symptoms may or may not reflect an objective change in the chronic illness because detection and interpretation of
bodily changes are complicated and imprecise processes.43,44 That is, some people may
not be aware of changes in illness by objective measures because they do not detect or
interpret those changes as symptoms. Conversely, symptoms may escalate in frequency
and/or intensity in the absence of an objective change in illness. It is not unusual to see a
212
ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2019
patient presenting to the clinician with a complaint of symptoms that cannot subsequently
be attributed to a change in objective data. All
of these factors influence the decisions that
people make about self-care.
As shown in Figure 2 illustrating a proposed integration of symptoms into the
Middle-Range Theory of Self-Care of Chronic
Illness, symptoms influence various element
of the self-care process. Specifically, people
may be more willing to perform self-care
maintenance and follow the treatment plan
if they have symptoms. Research has shown
that the experience of having symptoms can
motivate chronically ill individuals to perform
self-care.32 However, depressive symptoms
and cognitive decline can blunt self-care by
decreasing motivation to engage in healthy
behaviors.45-47
We propose that symptoms interact
most directly with self-care monitoring and
self-care management. Active monitoring
for symptoms is needed for awareness and
interpretation of bodily changes as symptoms. At this point, we have integrated these
processes into self-care monitoring. That is,
even in someone who engages in tracking
of his or her activity, signs, and symptoms,
the self-care management response is not
generated without awareness and interpretation of bodily changes as symptoms and the
recognition of symptoms as being linked to
or attributed to a chronic condition. These
processes have been shown to differ by clinical phenotype.48,49 For example, personality
traits, gender, and age are known to influence symptom awareness, interpretation,
and recognition.50 Aging may blunt symptom
perception.51 Somatic awareness has been
found to be blunted in older persons with
heart failure.52,53 Cultural and societal factors
may influence the expression of symptoms.54
There are also gender differences. For
example, women may be more willing to
acknowledge symptoms than men.55
Logically, without symptom detection and
interpretation, self-care management or the
response to symptoms will not occur. Ideally, any self-care management behavior is followed by evaluation—a process of judging
whether the behavior was helpful and should
be repeated. The evaluation process is better
in patients with better somatic awareness.50
To summarize, symptoms are both an antecedent and a consequence of self-care. The
experience of having symptoms can build
skill in self-care maintenance, monitoring,
and management.56 As an antecedent, symptoms often motivate individuals to engage
in self-care behaviors. Other antecedents include experience,57 skill,58 and self-care confidence or self-efficacy,59 all of which can be
influenced by the symptom experience, as
described later. Cultural beliefs,60 values,61
Figure 2. Model integrating symptoms with self-care as defined by the Middle-Range Theory of Self-Care of
Chronic Illness. Although depicted here as linear, we see the self-care process as including feedback loops. Note
that the overlap between the bottom arrows and core self-care model is both theoretical and imperfect and
indeed a target of further refinement.
Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness
reflection,40 habits,62 cognitive and functional
abilities,63 support from others,63-65 and access to health care60 all influence the self-care
process.
Consequences of self-care are shown in
Figure 2 as outcomes. These outcomes
include illness stability,63 health,66 well-being,
quality of life,7 perceived control,67 and
clinical outcomes such as the need for
hospitalization,63 health care costs,68 and
symptom burden.69 Mortality risk is lower
in patients receiving longer duration selfcare interventions.70 Perceived health, wellbeing, and quality of life are largely a function of symptoms. Although many people
with chronic illness tolerate symptoms, severe symptoms were associated with poor
quality of life.7 In another sample, symptoms
were the primary reason why patients sought
acute care.71 Thus, the control of costs associated with chronic illness may be addressed
with symptom management strategies.
CONCLUSION
Weber3 argues that the most important
contributions to knowledge development are
theories that are developed sufficiently to
allow for explanation and prediction. Thus,
213
our goal was to refine the Middle-Range Theory of Self-Care of Chronic illness to address
2 identified issues: (1) further development
of the concept of self-care monitoring, and
(2) further development of the manner in
which self-care monitoring and self-care
management are associated. We approached
these issues by integrating symptom theory
into the Middle-Range Theory of Self-Care
of Chronic Illness.2 The 2 perspectives—
self-care and symptoms—are clearly related.
By explicitly integrating them, our hope is
that the contribution of symptom theory to
self-care theory will be further developed and
the ability of self-care to mitigate symptoms
will be appreciated. Both perspectives are
central to a holistic approach to patient care.
We believe that this integrated theory will
be of use to both clinicians and scientists.
Clinicians working with people with chronic
illness are encouraged to embrace an assessment and intervention approach that integrates the impact of symptoms on self-care.
Scientists are encouraged to test hypotheses
derived from this refined theory to further
our understanding of how the detection, interpretation, and response to symptoms can
and should be incorporated into interventions
designed to improve self-care.
REFERENCES
1. Chinn P, Kraemer M. Integrated Theory & Knowledge Development in Nursing. 8th ed. St Louis, MO:
Mosby; 2010.
2. Riegel B, Jaarsma T, Stromberg A. A Middle-Range
Theory of Self-Care of Chronic Illness. ANS Adv Nurs
Sci. 2012;35(3):194-204.
3. Weber R. Evaluating and developing theories in the
information systems discipline. J Assoc Inf Syst.
2012;13(1):1-30.
4. Ausili D, Rossi E, Rebora P, et al. Socio-demographic
and clinical determinants of self-care in adults with
type 2 diabetes: a multicentre observational study.
Acta Diabetol. 2018;55(7):691-702.
5. Iribarren S, Siegel K, Hirshfield S, et al. Selfmanagement strategies for coping with adverse
symptoms in persons living with HIV with HIV associated non-AIDS conditions. AIDS Behav. 2018;22(1):
297-307.
6. Lycholip E, Thon Aamodt I, Lie I, et al. The dynamics
of self-care in the course of heart failure management:
data from the IN TOUCH study. Patient Preference
Adherence. 2018;12:1113-1122.
7. Auld JP, Mudd JO, Gelow JM, Hiatt SO, Lee CS.
Self-care moderates the relationship between symptoms and health-related quality of life in heart failure.
J Cardiovasc Nurs. 2018;33(3):217-224.
8. Buck HG, Lee CS, Moser DK, et al. Relationship between self-care and health-related quality of life in
older adults with moderate to advanced heart failure. J Cardiovasc Nurs. 2012;27(1):8-15.
9. Lee CS, Mudd JO, Hiatt SO, Gelow JM, Chien C, Riegel
B. Trajectories of heart failure self-care management
and changes in quality of life. Eur J Cardiovasc Nurs.
2015;14(6):486-494.
10. Vellone E, Fida R, Ghezzi V, et al. Patterns of selfcare in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a
cluster analysis. J Cardiovasc Nurs. 2017;32(2):
180-189.
214
ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2019
11. Xu J, Gallo JJ, Wenzel J, et al. Heart failure rehospitalization and delayed decision making: the impact of self-care and depression. J Cardiovasc Nurs.
2018;33(1):30-39.
12. Lee CS, Bidwell JT, Paturzo M, et al. Patterns of selfcare and clinical events in a cohort of adults with
heart failure: 1 year follow-up. Heart Lung. 2018;
47(1):40-46.
13. Lee CS, Moser DK, Lennie TA, Riegel B. Event-free
survival in adults with heart failure who engage in
self-care management. Heart Lung. 2011;40(1):1220.
14. Kessing D, Denollet J, Widdershoven J, Kupper N.
Self-care and all-cause mortality in patients with
chronic heart failure. JACC Heart Fail. 2016;4(3):
176-183.
15. Brant JM, Beck S, Miaskowski C. Building dynamic
models and theories to advance the science of symptom management research. J Adv Nurs. 2010;66(1):
228-240.
16. Brant JM, Dudley WN, Beck S, Miaskowski C. Evolution of the dynamic symptoms model. Oncol Nurs
Forum. 2016;43(5):651-654.
17. Lenz ER, Pugh LC, Milligan RA, Gift A, Suppe F. The
middle-range theory of unpleasant symptoms: an update. ANS Adv Nurs Sci. 1997;19(3):14-27.
18. Scott SE, Walter FM, Webster A, Sutton S, Emery J.
The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health
Psychol. 2013;18(1):45-65.
19. Dingwall KM, Cairney S. Detecting psychological
symptoms related to substance use among Indigenous Australians. Drug Alcohol Rev. 2011;30(1):3339.
20. Henly SJ, Kallas KD, Klatt CM, Swenson KK. The
notion of time in symptom experiences. Nurs Res.
2003;52(6):410-417.
21. Alonzo AA. Everyday illness behavior: a situational
approach to health status deviations. Soc Sci Med.
1979;13A(4):397-404.
22. Leventhal H, Benyamini Y, Brownlee S, et al. Illness
representations: theoretical foundations. In: Petrie
KJ, Weinman JA, eds. Perceptions of Health and Illness: Current Research and Applications. London,
England: Hardwood Publishers; 1997:19-45.
23. Teel CS, Meek P, McNamara AM, Watson L. Perspectives unifying symptom interpretation. Image J Nurs
Sch. 1997;29(2):175-181.
24. Cioffi D. Beyond attentional strategies: cognitiveperceptual model of somatic interpretation. Psychol
Bull. 1991;109(1):25-41.
25. Pennebaker JW. The Psychology of Physical Symptoms. New York, NY: Springer-Verlag; 1982.
26. Kolk AM, Hanewald GJ, Schagen S, Gijsbers van Wijk
CM. A symptom perception approach to common
physical symptoms. Soc Sci Med. 2003;57(12):23432354.
27. Cacioppo JT, Andersen BL, Turnquist DC, Petty
RE. Psychophysiological comparison processes: in-
terpreting cancer symptoms. In: Andersen BL, ed.
Women With Cancer: Psychological Perspectives.
New York, NY: Springer; 1986:142-171.
28. Andersen BL, Cacioppo JT. Delay in seeking a cancer
diagnosis: delay stages and psychophysiological comparison processes. Br J Soc Psychol. 1995;34(pt 1):
33-52.
29. Dodd M, Janson S, Facione N, et al. Advancing
the science of symptom management. J Adv Nurs.
2001;33(5):668-676.
30. Armstrong TS. Symptoms experience: a concept analysis. Oncol Nurs Forum. 2003;30(4):601-606.
31. Whitaker KL, Scott SE, Wardle J. Applying symptom appraisal models to understand sociodemographic differences in responses to possible cancer symptoms: a research agenda. Br J Cancer.
2015;112(suppl 1):S27-S34.
32. Auld JP, Mudd JO, Gelow JM, Lyons KS, Hiatt SO,
Lee CS. Patterns of heart failure symptoms are associated with self-care behaviors over 6 months. Eur J
Cardiovasc Nurs. 2018;17(6):543-551.
33. Lee KS, Song EK, Lennie TA, et al. Symptom clusters in men and women with heart failure and their
impact on cardiac event-free survival. J Cardiovasc
Nurs. 2010;25(4):263-272.
34. Song EK, Moser DK, Rayens MK, Lennie TA. Symptom clusters predict event-free survival in patients
with heart failure. J Cardiovasc Nurs. 2010;25(4):
284-291.
35. Cashion AK, Grady PA. The National Institutes of
Health/National Institutes of Nursing Research intramural research program and the development of
the National Institutes of Health Symptom Science
Model. Nurs Outlook. 2015;63(4):484-487.
36. Sevilla-Cazes J, Ahmad FS, Bowles KH, et al. Heart
failure home management challenges and reasons
for readmission: a qualitative study to understand
the patient’s perspective. J Gen Intern Med. 2018.
doi:10.1007/s11606-018-4542-3.
37. Riegel B, Dickson VV, Faulkner KM. The SituationSpecific Theory of Heart Failure Self-Care: revised and
updated. J Cardiovasc Nurs. 2016;31(3):226-235.
38. Hassanpour MS, Simmons WK, Feinstein JS, et al.
The insular cortex dynamically maps changes in cardiorespiratory interoception. Neuropsychopharmacology. 2018;43(2):426-434.
39. Woo MA, Yadav SK, Macey PM, Fonarow GC, Harper
RM, Kumar R. Brain metabolites in autonomic regulatory insular sites in heart failure. J Neurol Sci.
2014;346(1/2):271-275.
40. Sethares KA, Asselin ME. The effect of guided reflection on heart failure self-care maintenance and
management: a mixed methods study. Heart Lung.
2017;46(3):192-198.
41. Skrzypek M. The social origin of the illness
experience—an outline of problems. Ann Agric Environ Med. 2014;21(3):654-660.
42. Skotzko CE. Symptom perception in CHF: (why mind
matters). Heart Fail Rev. 2009;14(1):29-34.
Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness
43. Hui D, dos Santos R, Chisholm GB, Bruera E. Symptom expression in the last seven days of life among
cancer patients admitted to acute palliative care
units. J Pain Symptom Manage. 2015;50(4):488494.
44. Lee CS, Hiatt SO, Denfeld QE, Mudd JO, Chien
C, Gelow JM. Symptom-hemodynamic mismatch
and heart failure event risk. J Cardiovasc Nurs.
2015;30(5):394-402.
45. Lee KS, Lennie TA, Yoon JY, Wu JR, Moser DK. Living arrangements modify the relationship between
depressive symptoms and self-care in patients with
heart failure. J Cardiovasc Nurs. 2017;32(2):171179.
46. Chang LY, Wu SY, Chiang CE, Tsai PS. Depression
and self-care maintenance in patients with heart
failure: a moderated mediation model of self-care
confidence and resilience. Eur J Cardiovasc Nurs.
2017;16(5):435-443.
47. Egede LE, Osborn CY. Role of motivation in the relationship between depression, self-care, and glycemic
control in adults with type 2 diabetes. Diabetes Educ.
2010;36(2):276-283.
48. Russell MA, Smith TW, Smyth JM. Anger expression, momentary anger, and symptom severity in patients with chronic disease. Ann Behav Med. 2016;
50(2):259-271.
49. Lindley SE, Carlson EB, Hill KR. Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress
disorder. J Nerv Ment Dis. 2014;202(2):91-96.
50. Jurgens CY. Somatic awareness, uncertainty, and delay in care-seeking in acute heart failure. Res Nurs
Health. 2006;29(2):74-86.
51. Khalsa SS, Rudrauf D, Tranel D. Interoceptive
awareness declines with age. Psychophysiology.
2009;46(6):1130-1136.
52. Riegel B, Dickson VV, Cameron J, et al. Symptom
recognition in elders with heart failure. J Nurs Scholarsh. 2010;42(1):92-100.
53. Jurgens CY, Hoke L, Byrnes J, Riegel B. Why do elders
delay responding to heart failure symptoms? Nurs
Res. 2009;58(4):274-282.
54. Zhou X, Peng Y, Zhu X, et al. From culture to symptom: testing a structural model of “Chinese somatization.” Transcult Psychiatry. 2016;53(1):3-23.
55. Kim YS, Kim N, Kim GH. Sex and gender differences
in gastroesophageal reflux disease. J Neurogastroenterol Motil. 2016;22(4):575-588.
56. Dickson VV, Melkus GD, Dorsen C, Katz S, Riegel
B. Improving heart failure self-care through a
community-based skill-building intervention: a study
protocol. J Cardiovasc Nurs. 2015;30(4)(suppl 1):
S14-S24.
57. Cameron J, Worrall-Carter L, Page K, Stewart S. Selfcare behaviours and heart failure: does experience
with symptoms really make a difference? Eur J Cardiovasc Nurs. 2010;9(2):92-100.
215
58. Dickson VV, Riegel B. Are we teaching what patients
need to know? Building skills in heart failure self-care.
Heart Lung. 2009;38(3):253-261.
59. Vellone E, Pancani L, Greco A, Steca P, Riegel B.
Self-care confidence may be more important than
cognition to influence self-care behaviors in adults
with heart failure: testing a mediation model. Int J
Nurs Stud. 2016;60:191-199.
60. Dickson VV, McCarthy MM, Howe A, Schipper J, Katz
SM. Sociocultural influences on heart failure self-care
among an ethnic minority black population. J Cardiovasc Nurs. 2013;28(2):111-118.
61. Karimi M, Clark AM. How do patients’ values influence heart failure self-care decision-making? A
mixed-methods systematic review. Int J Nurs Stud.
2016;59:89-104.
62. Ruiz-Palomino E, Gimenez-Garcia C, Ballester-Arnal
R, Gil-Llario MD. Health promotion in young
people: identifying the predisposing factors of
self-care health habits. J Health Psychol. 2018.
doi:10.1177/1359105318758858.
63. Bidwell JT, Vellone E, Lyons KS, et al. Determinants of
heart failure self-care maintenance and management
in patients and caregivers: a dyadic analysis. Res Nurs
Health. 2015;38(5):392-402.
64. Fivecoat HC, Sayers SL, Riegel B. Social support predicts self-care confidence in patients with heart failure. Eur J Cardiovasc Nurs. 2018;17(7):598-604.
doi:10.1177/1474515118762800.
65. Salyer J, Schubert CM, Chiaranai C. Supportive relationships, self-care confidence, and heart failure selfcare. J Cardiovasc Nurs. 2012;27(5):384-393.
66. Clark AP, McDougall G, Riegel B, et al. Health status
and self-care outcomes after an education-support
intervention for people with chronic heart failure. J
Cardiovasc Nurs. 2015;30(4)(suppl 1):S3-S13.
67. Kidd L, Hubbard G, O’Carroll R, Kearney N.
Perceived control and involvement in self care
in patients with colorectal cancer. J Clin Nurs.
2009;18(16):2292-2300.
68. Aboagye E, Karlsson ML, Hagberg J, Jensen I. Costeffectiveness of early interventions for non-specific
low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care
advice. J Rehabil Med. 2015;47(2):167-173.
69. Deng J, Radina E, Fu MR, et al. Self-care status, symptom burden, and reported infections in individuals
with lower-extremity primary lymphedema. J Nurs
Scholarsh. 2015;47(2):126-134.
70. Jonkman NH, Westland H, Groenwold RH, et al.
What are effective program characteristics of selfmanagement interventions in patients with heart failure? An individual patient data meta-analysis. J Card
Fail. 2016;22(11):861-871.
71. Kociol RD, McNulty SE, Hernandez AF, et al. Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart
failure. Circ Heart Fail. 2013;6(2):240-245.
Chapter 11:
Overview of Selected Middle Range
Nursing Theories
Levels of Middle Range Theory
• May be categorized as “high,” “middle,” and “low” middle
range theories
– High middle range theories include broad, fairly
abstract concepts
• Caring, transcendence, adaptation, culture
– Middle middle range theories generally consist of
theoretically defined, fairly specific constructs
• Uncertainty in illness, unpleasant symptoms,
chronic sorrow
– Low middle range theories are more defined and
specific
• Women’s anger, acute pain management, intervention
for postsurgical pain
Copyright © 2019 Wolters Kluwer · All Rights Reserved
High Middle Range Theories
• Nearest to grand theories
• Some may be considered grand theories or
conceptual frameworks
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Benner’s Model of Skill Acquisition in
Nursing
• Seven domains
– Helping role
– Teaching or coaching function
– 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)
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Leininger’s Cultural Care Diversity and
Universality Theory
• Madeleine Leininger first presented the “transcultural
health model” in the mid-1970s; it has been modified
and updated several times
• Purpose of the theory is to generate knowledge
related to caring for persons considering their cultural
heritage and values
• Goal is to provide “culturally congruent” nursing care
to persons of diverse cultures
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Leininger’s Cultural Care Diversity and
Universality Theory—(cont.)
• Leininger was an anthropologist as well as a nurse
by education
• Major concepts of the model are culture, culture
care, cultural differences (diversities), and cultural
similarities (universals)
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Leininger’s Cultural Care Diversity and
Universality Theory—(cont.)
• During the past two decades, research on 23
different cultural groups has been conducted using
her theory
• Many graduate students and nursing scholars have
used her theory as a basis for research
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Leininger’s Cultural Care Diversity and
Universality Theory—(cont.)
• Central tenet of the theory is that it is important for
the nurse to understand the individual’s view of
illness
• Understanding cultural similarities and differences
will allow the nurse to positively influence health
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Pender’s Health Promotion Model
• Developed by Nola Pender to study health
promotion behaviors; initially published in 1982
• Explores biopsychosocial processes that motivate
individuals to engage in behaviors that promote
health
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Pender’s Health Promotion Model—(cont.)
•
Major Concepts
– 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
• Situation influences
– Behavior outcomes
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Pender’s Health Promotion Model—(cont.)
• Used by nurses to develop and execute healthpromoting interventions
• Used to develop research studies focusing on one
aspect of health promotion
• Used frequently as a framework for research studies
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Question
Tell whether the following statement is true or false:
Nola Pender is the theorist credited with the
development of the Omaha System.
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Answer
False
Rationale: Nola Pender is credited with the
development of Pender’s Health Promotion Model.
The Omaha System was developed by the nurses of
the Visiting Nurses Association.
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Transitions Theory
• Afaf Meleis developed Transitions Theory over about
four decades
• Began with observations of experiences faced as
people deal with changes related to health, wellbeing, and ability to care for themselves
• “Transitions” is a central concept in nursing
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Transitions Theory—(cont.)
• Purposes
– Attempts to describe the interaction between
nurses and patients
– Nurses are concerned with people as they
undergo transitions
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Transitions Theory—(cont.)
• Purposes—(cont.)
– Goal of nursing therapeutics is to recognize and
address potential problems encountered during
transitional experiences
– To develop preventive and therapeutic
interventions to support patients during these
occasions
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Transitions Theory—(cont.)
• Transitions are viewed as a passage from one fairly
stable state to another fairly stable state; process is
triggered by a change
– Transitions are characterized by different stages,
milestones, and turning points
– Transitions can be assisted or managed by
nurses
• Categories of transitions
– Developmental
– Situational
– Health–illness
– Organizational
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Transitions Theory—(cont.)
• Nurses should consider “facilitators” and “inhibitors”
of transitions
• “Nursing therapeutics” are activities and actions.
– Readiness
– Preparation for transition
– Role supplementation
• Relatively new theory but becoming increasingly
recognized in the literature
• Widely applicable and used in both practice and
research
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Synergy Model
• The Synergy Model for Patient Care was developed
in the mid-1990s by the AACN Certification
Corporation
• Designed to be a framework for certified practice
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Synergy Model—(cont.)
• Purpose is to describe nurses’ contributions,
activities, and outcomes related to caring for
critically ill patients
• Model intended to be a conceptual framework for
designing practice and competencies
• Also used for research
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Synergy Model—(cont.)
• Involves three levels of outcomes—relating to the
patient, nurse, and the system
• Patient outcomes include functional and behavioral
change, trust, satisfaction, comfort, and quality of
life
• Nurse outcomes include physiologic changes,
complications, and attainment of objectives
• System outcomes include recidivism, costs, and
resource utilization
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Question
Which is NOT one of the levels of outcomes included
in the Synergy Model?
A. Outcomes of the nurse
B. Outcomes of the patient
C. Outcomes of the system
D. Outcomes of the provider
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Answer
D. Outcomes of the provider
Rationale: The Synergy Model does not include the
outcomes of the provider in the three levels of
outcomes of the model.
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Synergy Model—(cont.)
• Use of the Synergy Model is designed to optimize
outcomes
• When patient characteristics and nurse
competencies match and “synergize,” outcomes
for the patient are optimal
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Synergy Model—(cont.)
• The model has been used for about a decade
• Many articles have been published; most describe
practice application, and some research
• Also considerable indication that it can be used in
practices other than critical care
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Middle Middle Range Theories
• Most frequently identified theories as “middle range”
• Not as broadly applicable as the “high” middle range
theories but do relate to multiple settings and
populations
• Frequently used examples
– Uncertainly of Illness Theory
– Theory of Comfort
– Theory of Unpleasant Symptoms
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Uncertainty in Illness Theory
• Developed by Merle Mishel in the early 1980s
• Intent to explain stress resulting from
hospitalization
• Theory explains how clients cognitively process
illness-related stimuli and construct meaning in
these events
• Uncertainty is the inability to structure meaning and
develops if the person does not form a “cognitive
schema” for the illness
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Uncertainty in Illness Theory—(cont.)
• Explains how they structure meaning for the illness
stimuli
• Adaptation is the desirable end state
– Achieved after coping with the uncertainty
• Nursing should develop interventions to influence
the person’s cognitive process to address the
uncertainty, thus producing positive coping and
adaptation
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Question
Tell whether the following statement is true or false:
According to Mishel in the Uncertainty in Illness
Theory, the clients’ cognitive process and
understanding of their illness construct the meaning
of events.
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Answer
True
Rationale: In the theory by Mishel, Uncertainty in
Illness, the patient’s cognitive ability and
understanding has an impact on the constructed
meaning of the situation.
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Comfort Theory
• Katherine Kolcaba started developing the Theory of
Comfort as a concept analysis while she was a
graduate student
• The Theory of Comfort was initially published in
1994 and later modified
• Comfort Theory observes that patients experience
need for comfort in stressful health care situations
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Comfort Theory—(cont.)
• Comfort is the “satisfaction of the basic human
needs for relief, ease, or transcendence arising from
health care situations that are stressful”
• Increasing comfort can result in having negative
tensions reduced and positive tensions engaged
• Comfort is an outcome of care that can promote or
facilitate health-seeking behaviors
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Comfort Theory—(cont.)
• Needs of the patient are identified by the nurse,
who then implements interventions to meet them
• Outcomes of comfort can be measurable, holistic,
positive, and nurse sensitive
• Several research studies by Dr. Kolcaba and her
associates have been published
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Unpleasant Symptoms
• The Theory of Unpleasant Symptoms was developed
in the mid-1990s by a group of nurses interested in
symptom management
• It is based on the premise that there are
commonalities in experiencing different symptoms in
and among different groups and in different
situations
• Developed to integrate existing knowledge about a
variety of symptoms to improve symptom
management
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Unpleasant Symptoms—(cont.)
• The Theory of Unpleasant Symptoms helps nurses
recognize the need to assess multiple aspects of
symptoms including characteristics of the
symptom(s), the underlying disease, or other cause
• The frequency, intensity, duration, quality, and
distress felt by the patient
• Several articles addressing both research and
practice have been published
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Unpleasant Symptoms—(cont.)
• Three major components
– Symptoms that the individual is experiencing
– Influencing factors that produce or affect the
symptom experience
– Consequence of the symptom experience
• Symptoms are described in terms of duration,
intensity, distress, and quality
• Influencing factors can be physiologic,
psychological, and/or situational
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Reed’s Self-Transcendence Theory
• 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)
• 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)
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Reed’s Self-Transcendence Theory—
(cont.)
• Other central concepts of the theory include wellbeing (a sense of wholeness and health) and
vulnerability (awareness of personal mortality)
(Coward, 2014; Reed, 2014)
• Reed (1991b) reported that a theory of selftranscendence may be used by nurses to attend to
spiritual and psychosocial expressions of selftranscendence 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
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Low Middle Range Theories
• The number of low middle range theories in nursing
is growing
• These theories are much more focused; deal with
one specialty practice, age range, or situation
• Examples:
– Theory of Chronic Sorrow
– Postpartum Depression
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Chronic Sorrow
• Concept of chronic sorrow was first coined in the
early 1960s in psychology to describe the grief of
parents of children with mental deficiencies
• Later research indicated similar patterns in parents
of mentally or physically disabled children
• The Nursing Consortium for Research on Chronic
Sorrow expanded the concept to include individuals
who experience a variety of loss situations and their
caregivers
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Chronic Sorrow—(cont.)
• The Theory of Chronic Sorrow was first published in
1998
• Derived and validated through a series of research
studies and review of existing research
• Chronic sorrow is the “periodic recurrence of
permanent, pervasive sadness or other grief related
feelings associated with a significant loss”
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Chronic Sorrow—(cont.)
• The theory 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
• The sorrow is cyclic or recurrent and brings to mind
a person’s losses, disappointments, or fears
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Chronic Sorrow—(cont.)
• Antecedent to chronic sorrow is experiences of a
significant loss
• The loss is ongoing with no predictable end
• Disparity is created when the reality is different
from the idealized
• Trigger events (e.g., milestones, situations, and
conditions that create negative disparity) exacerbate
the experience of disparity
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Theory of Chronic Sorrow—(cont.)
• Nurses need to view chronic sorrow as a normal
response to loss
• They should foster positive coping strategies and
encourage activities that increase comfort
• Interventions include listening, offering support and
reassurance, providing information, and
appreciating the uniqueness of each individual
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Beck’s Theory of Postpartum Depression
• Cheryl Beck developed a theory regarding
postpartum depression using a grounded theory
approach
• The purpose of the theory was to provide insight
into the experience of postpartum depression
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Beck’s Theory of Postpartum Depression—
(cont.)
• Concepts or stages
– Encountering terror (anxiety attacks, obsessive
thinking)
– Dying of self (“unrealness,” isolation,
contemplating self-destruction)
– Struggling to survive (prying for relief, seeking
solace)
– Regaining control (making transitions, attaining
recovery)
Copyright © 2019 Wolters Kluwer · All Rights Reserved
Beck’s Theory of Postpartum Depression—
(cont.)
• Nursing intervention should alert nurses to incidence
and impact of postpartum depression
• Stresses the importance of identifying mothers who
might be suffering from postpartum depression
• Although the theory is relatively new, it has been
used in several studies
Copyright © 2019 Wolters Kluwer · All Rights Reserved