Middle-Range Theory Continues to Guide Nursing Practice

Middle Range Theory Continues to Guide Nursing Practice Lisa M. Sanford Maryville University Middle Range Theory Continues to Guide Nursing Practice Nursing theory has three distinct categories to describe the level of abstraction: Grand, Middle-Range, and Situation-Specific (Meleis, 2012, p. 33). Hugh McKenna (1997) defined these three categories, stating: Grand theory is highly abstract and is broad in scope. Middle-range theory is more focused and is normally the end product of a research study.

Narrow-range theory is even more specific and while also being based on research findings, it guides specific actions in the achievement of desirable goals (p. 17). When thinking about nursing theory, one might ask: What is the purpose of theory? Is it even relevant to current nursing practice? The best response to answer these questions I have found is from Meleis (2012): The primary uses of theory are to provide insights about nursing practice situations and to guide research. Through interaction with practice, theory is shaped and guidelines for practice evolve.

Research validates, refutes, and/or modifies theory as well as generates new theory. Theory then guides practice (p. 35). This explanation of theory by Meleis identifies nursing as a profession. Without theory to shape and guide nursing practice and research, nursing would not evolve and would remain stagnant. Additionally, without theory could nurses really claim that we are a profession? I think not. I believe that theory is necessary for the identity of nursing as a profession verses a vocation.

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The nursing profession as a whole has had issues with identity for various reasons. I believe this to be true in part due to the numerous educational ways of entering the profession. I cannot think of any other field where one could earn either a diploma, two-year associate’s degree or a four-year baccalaureate degree as a starting point into a profession. The educational debate still continues, however, in recent years more emphasis is being made to have the baccalaureate nurse the entry level of the nursing profession.

Evidence from research has suggested that the baccalaureate-prepared nurse is associated with a five percent lower mortality rates in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue in hospitalized clients (Aiken, Clarke, Cheung, Sloane, & Silber, 2003, p. 1617). This research study was conducted because nursing is a profession. Would research in nursing even exist if there were no theory? All in all, taken to its end, the loss of theory could mean the demise of nursing as a profession.

When reflecting on current trends of clinical practice, I feel that middle-range theories are more applicable. Middle-range theories are broad enough to incorporate in everyday clinical practice for the average floor nurse without being too narrow in scope as the situation-specific theories. Additionally, middle-range theories are less abstract than grand theories and are easier to relate to and put into practice (Liehr & Smith, 1999, p. 85). One example of applying middle-range nursing theory into practice is patient education. Patient education is a major focus of the clients I serve post transplant.

It is imperative that a newly transplanted client understand his/her medications that are such an integral part of their new life in order to maintain the transplanted organ. “Caring through Relation and Dialogue: A Middle-Range Theory for Patient Education is derived from the two disciplines of nursing and education” (Sanford, 2000, p. 8). According to Sanford (2000), A middle-range theory addressing the phenomenon of patient education through caring can add clarity and direction to this area of concern for nursing, and it can provide an opportunity to link theory, practice, and research (p. ). Caring and dialogue are described in this theory as follows: Dialogue is a process of naming our world. It is a process that opens the possibility for participants to pose problems, to critically reflect, and to perceive solutions not previously realized. This process occurs within a caring relation where the carer and the cared-for exhibit receptivity and engage in "reflection, invitation, assessment, revision, and further exploration" (p. 9). Another example of the applicability of middle-range theory is the theory of care transitions.

A hot topic in today’s times involves hospital acquired conditions (HACs) and readmission rates. Medicare expenditures are estimated at $15 billion annually due to readmissions (Averill, et al. , 2009, p. 1). As a result, policymakers have implemented the The Deficit Reduction Act of 2005, which eliminates any increase in hospital payments due to the occurrence of HACs. Furthermore, it is viewed that high readmission rates are a reflection of poor quality, and ospital payments for readmissions were recommended in the FY2010 budget from the Obama Administration to reduce payments for readmissions as one way of controlling Medicare expenditures (Averill, et al. , 2009, p. 1). As a staff nurse, I am all aware of the importance of HACs and the importance of diligent documentation. For example, when a client is admitted a thorough assessment is completed. Wounds and skin breakdown are crucial to document upon an admission or a transferred client to our division.

If the documentation of skin assessment is not completed correctly, then the “blame” is placed on our unit for an ulceration if it was not charted within 24 hours of admission. What are the causes or issues that surround care transitions? Increasingly fragmented care is one reason associated with hospital readmission rates. Issues include communication breakdowns related to plans of care, unclear expectations, uncertainty about illness trajectories, lack of continuity in medical follow-up, and incomplete or inaccurate understanding of medication regimens (Geary & Schumacher, 2012, p. 237).

In my practice of nursing, the utilization of inpatient care management for clients begins upon admission in preparation for discharge. A multidisciplinary approach of the transplant team includes the doctors, inpatient nurses, social workers, dieticians, case coordinators, post-transplant coordinators, and transplant pharmacists working together to coordinate and ensure continuity of care upon discharge. According to Geary & Schumacher (2012), “Through the transition process, agents act and interact within relationship with each other, causing emergence of new behaviors and outcomes.

Just as important, through supportive dialogue and discussion, sensemaking is enabled for everyone involved in the transition, effectively reenvisioning multiple understandings of the situation and changing outcomes for the better” (p. 246). Middle-range nursing theories can be viewed as a cookbook for nursing. There are many recipies in the middle-range theories which can be utilized by the average hospital-based nurse in a variety of ways. In any given 12-hour shift of a nurse, there are several theories which can be applied to specific situations.

I have unknowingly used nursing theory in my practice over the years. This course has brought to my attention the diverse ways in which I have used middle-range nursing theories and has given me a better understanding of how nursing theory is applied to current clinical nursing practice. It is my opinion that middle-range nursing theories will continue to guide nursing practice throughout the 21st Century. References Aiken, L. H. , Clarke, S. P. , Cheung, R. B. , Sloane, D. M. , & Silber, J. H. (2003).

Educational Levels of Hospital Nurses and Surgical Patient Mortality. The Journal of the American Medical Association, 290(12), 1617-1623. Averill, R. F. , McCullough, E. C. , Hughes, J. S. , Goldfield, N. I. , Vertrees, J. , & Fuller, R. L. (2009, Summer). Redisigning the Medicare Inpatient PPS to Reduce Payments to Hospitals with High Readmission Rates. Health Care Financing Review, 30(4), 1-15. Geary, C. R. , & Schumacher, K. L. (2012). Care Transitions: Integrating Transition Theory and Complexity Science Concepts.

Advances in Nursing Science, 35(3), 236-248. Liehr, P. , & Smith, M. J. (1999). Middle Range Theory: Spinning Research and Practice to Create Knowledge forthe New Millennium. Advances in Nursing Science, 21(4) 81-91. McKenn, H. (1997). Nursing Theories and Models. New York: Routledge. Meleis, A. I. (2012). Theoretical Nursing Development and Progress (5th ed. ). Philadelphia: Lippincott, Williams & Wilkins. Sanford, R. (2000, March). Caring through Relation and Dialogue: A Nursing Perspective for Patient Education. Advances in Nursing Science, 22(3), 1-15.

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