Grand or Mid Range Theory

¶ … Range Theory

MID RANGE THEORY OF SPIRITUAL WELL BEING

Middle Range Theory of Spiritual Well Being in Illness

Nurse meta-theorists have recently been very much concerned about the different seasons of the patient's life, which has supported and promoted the development of middle range theories in the field of nursing. This is due to the reason that these theories focus on the specific health and illness issues instead of discussing the general issues. These specific health and illness issues focused in the mid range theories are extremely important for the practicing nurses as they spotlight on the particular problem and its solution.

History of Theory Development in Nursing

The practicing nurses started incorporating the nursing theories into their research and practically applying them to real situations during 1970s and 1980s. Majority of the early nursing theories fall in the category of grand theories of nursing because the concepts that described the theories focused on the overall nursing practices. Many nursing theory conferences were organized and held by the nurses to discuss the use of these theories in research and practice. The key theorists presented the methods and ways of practically applying these conceptual frameworks in the practical settings.

Some of the nurse researchers also tried to use the grand theories of nursing in their studies but found their application difficult due to the wide breadth of the models. Therefore, meta-theorists worked further on this area and introduced the middle range theories of nursing. These are the theories that focus on specific phenomena of interest to the practicing nurses and therefore nurses find it easy to practically apply these theories in the work settings.

The concept of middle range theory was initially introduced in the sociological literature by Robert Merton during 1950s (Chinn and Kramer, 1995, p.9). These theories were considered more useful because these were the bodies of knowledge that focused on a limited number of variables than the grand theories and therefore these could also be easily empirically tested. Meleis (1997, p.18) pointed out that middle range theories "focus on specific nursing phenomena that reflect clinical practice." The grand theories on the other hand cover the "full range of phenomena that are of concern within the discipline" (Chinn and Jacobs, 1987, p. 205).

Construction of Spiritual Theory in Nursing

The concept of spirituality was initially not focused much in the grand and middle range theories of nursing but the recent meta-theorists started addressing this concept. Some of the examples that focused on this topic are the "construction of spirituality" in nursing theory (Henry, 2003, p.50); model of advanced spiritual care in nursing and healthcare (McSherry, 2006) and a presentation of evolving framework for knowing the concept of spirituality in nursing (Minner-Williams, 2006).

Miner-Williams (2006) explained the concept of spirituality with the help of definitions given in the literature and through identifying the components like values, beliefs, emotions, energy and connectedness (Minner-Williams, 2006, p.811). In addition, he also presented the six practical guidelines to assist nurses in the area of spiritual in a clinical setting.

Some theories have been developed recently for the spirituality in nursing. One of these theories is the "Experimental Theory of Spiritual Care in Nursing Practice" (Burkhart and Hogan, 2008) and another is the "Theory of Family Interdependence among Family Caregivers and Their Elders." This theory focuses on the relationship between the spirituality of the person who provides care and the spirituality of the person who receives care (Kim, Reed, Hayward, Kang and Koenig, 2011). A third recent theory in spirituality is "T.R.U.S.T": An affirming model for inclusive spiritual care" (Barss, 2012). This continous interest in the nursing theory development in the field of spirituality was encouraged and promoted by the nurse philosopher Barbara Pesut, who focused on the current universal interest in spirituality, termed as "sacralzation" of the society.

The Middle Range Theory of Spiritual Well Being in Illness

The middle range theory of spiritual well being in illness can be useful in any nurse health care setting where nurse staff gives importance and attention to not only the body needs of the patients but also to their minds and spirits. This orientation is important particularly for the nursing staff which is taking care of patients that are suffering from life threatening illness, long-term illness or any illness that has changed the life of the patient and badly affected his professional or personal goals. These types of patients are badly hurt and broken from inside and they struggle to look for a meaning in their disability or illness. Whether patients are affiliated with religion or not, in both cases they look for a state where they can accept the reality and achieve peace along with suffering. This theory is helpful for both the nurse researchers as well as nurse practitioners while working with seriously ill patients. It enables them to find out the spiritual needs of the patients and provide appropriate spiritual care intervention to them according to their needs.

Development of Theory of Spiritual Well Being in Illness

According to McEwen (2002, p.207) "middle range theories generally emerged from combining research and practice and building on the work of others." However, some nurse theorists also believe that the middle range theories were formulated either from the conceptual or grand theories (Ruland and Moore, 1998 p. 170) or with the help of clinical procedures (Good, 1998, p.120). The middle range theory of spiritual well being in illness was obtained keeping in mind the initial concepts of spiritual well being. In addition the nursing model made by Joyce Travelbee, which mainly focused on the concept of find out the meaning from an illness, also helped in deriving this theory.

The most important element and main idea of this mid range theory of spiritual well being in illness is to explore the spiritual meaning during the time of illness. Travelbee "(1971) also highlighted the importance of spiritual concerns and pointed out that spiritual values of the patient helps in identifying the patient's perception of illness. She created a frame work that was based on the relationships between human to human and nurse to patient. She described through this interactional framework, the nurse's role in helping out the "the ill patient to experience hope as a means of coping with illness and suffering" (Chinn and Kramer, 1995, p.176). She defined illness as a "spiritual, emotional and physical" experience that can be defined objectively as well as subjectively (Chinn and Jacobs, 1987). According to her, the ability and attitude of a person suffering from illness determines how good he is at coping with the illness (Meleis, 1997, p.361). She pointed out that "the professional nurse practitioner must be prepared to assist individuals and families not just to cope with the illness and suffering but to find meaning in these experiences" (p.13). She also admitted that it was not an easy task of professional nursing but it must not be avoided because it is extremely important for the betterment of the patients.

Joyce Travelbee was famous as a very spiritual woman, educator and a psychiatric nurse practitioner. She had a vision of human to human nursing practice which was very much influenced by her early education and training. She gained knowledge from the written work of nurse theorist Ida Orlando and training from Charity Hospital in New Orleans under the supervision of famous psychotherapist Viktor Frankl. Unfortunately she passed away at the age of 47 and could not live to further elaborate and work on her interaction model. However, her starting work on the concept of an ill person giving a meaning to his illness during his experience of illness, pain and suffering has provided a solid and strong basis for the development and exploration of this mid range nursing theory of spiritual well being in illness.

Mid Range Theory of Spiritual Well Being in Illness - Description

As stated above, efforts of Travelbee provided strong base to the nurse researchers and practitioners to further work on this concept. Therefore, a significant number of nursing studies inductively derived this theory and also investigated the importance of this mid range theory of spiritual well being in helping patients to fight and cope with the disabilities and chronic illnesses. Studies showed qualitative as well as quantitative positive associations between the spiritual well being of the ill persons and the quality of life. Theorists and nurse practitioners found out those patients who possessed a strong faith, spiritual satisfaction and performed religious practices to be more optimistic and contended with the other aspects of life. In addition, they had higher hope for positive future, despite the fact that they continuously suffered from painful illnesses.

This is also evident from the example of several severely ill patients like an 82 years old Lutheran parishioner Mrs. Manley who had multiple diseases; including diabetes, heart failure and osteoporosis. Similarly Mr. Jones, a 62 years old Methodist parishioner suffering from leukemia and another 75 years old lady Mrs. McDermott, who was a Roman Catholic parishioner and disabled due to rheumatoid arthritis and other problems. All of these three subjects were passed through the spiritual assessment scale which is used for measuring the spiritual well being. The results showed that all three subjects had positive scores on the items that measured religious practice, faith and spiritual satisfaction. All three gave positive responses regarding the quality of their life and hope for the future. For instance, they were optimistic about dealing with the pains and difficulties, feeling satisfied with love and being loved. Indeed they agreed that they were "just as happy as when younger" (O'Brien, 2001) and quite well satisfied with their lives.

Philosophy and Key Concepts of the Theory

The middle range theory of spiritual well being in illness is based on the idea that a human person who possesses a psychosocial and physical nature is also a spiritual being that has ability to accept or transcend the experiences of suffering and pain according to his nature. Nurses have witnessed several cases in which disabled or severely ill patients who have psychosocial and physical deficits, live very productive and positive lives. This is because they have the ability not only to accept but also to hold their illness through their spiritual resources. Therefore, it is necessary to identify, support and strengthen the influence of these spiritual resources when relating to chronic illness or disability. The importance of spiritual resources in the improvement of lives of patients resulted in the development of the nursing theory of spiritual well being in illness.

The focal point and the core key concept of the mid range theory of spiritual well being in illness is obviously the spiritual well being. The model shown below is the conceptual model which shows that a sick person has an ability to find spiritual meaning in the experience of his illness which leads to the outcome of spiritual well being for him. The capacity of the ill person to find the spiritual meaning from his time of suffering illness is affected by a number of different factors.

A Conceptual Model of Spiritual Well Being in Illness

Source: Jones and Bartlett Learning, Chapter 4

The first and most important factor is the personal religious and spiritual attitude and behaviour of the ill person which affects his perception of the spiritual meaning. These behaviors and attitudes include those variables that are related to the personal faith of the person, his spiritual satisfaction and religious practices. The personal faith of the person not only means his belief in God but his trust in the powers of God and God's ability to provide health and strength. If an ill person believes in God but lacks trust or does not have a feeling to accept God's love, then he may consider this illness as an unwanted burden on him or a punishment.

The spiritual contentment includes having feeling of being close to the God and security in the God's love and inner satisfaction with the faith. A sick person, who believes in the existence of God, his powers and care for the people, might be fearful from God instead of feeling security in his love. This feeling or situation makes it difficult for the person to perceive his experience of illness as something for betterment. He only considers it as a punishment of his past sins and keeps suffering emotionally.

In case of religious practices, it is not necessary for someone to attend the services at Church or at some other Holy place. The religious practices actually include having support of a community that has strong faith, receiving encouragement from the spiritual companions and maintaining a relationship and communication with God with the help of religious activities and practices. Patients who have relations with faith community with whom they have spent time worshipping together or communities who pray for the sick parishioners during their worships are found to be very positive during the time of suffering and illness.

When a sick person finds spiritual meaning in illness, his religious and spiritual attitude and behaviour is also affected by variables like degree of illness, level of social support from family & friends, care providers and the events that bring stress in his life; for instance financial, emotional and socio-cultural events.

The first and most important step for developing middle range theory is to perform a deep analysis of the key concepts in the model. There are a series of steps identified by nurse metatheorist Walker and Avant (1995) for doing the concept analysis which help in finding out the i) aim/purpose of the analysis, ii) determining the uses of this concept and iii) explaining the empirical referent. The main purpose or aim behind knowing the concept of spiritual well being is to find out and explain its meaning keeping in mind its current usage in relation to the cases experiencing pain and illness. The uses of the concept and it empirical referents can be examined from the current literature, nursing research and practice.