Middle Range Theory of Spiritual Well-Being in Illness

Introduction to Middle Range Theory in Nursing

Nurse meta-theorists have recently been deeply concerned with the different dimensions of patients' lives, which has supported and promoted the development of middle range theories in the field of nursing. This is because these theories focus on specific health and illness issues rather than general ones. The specific health and illness issues addressed in middle range theories are extremely important for practicing nurses, as they spotlight particular problems and their solutions.

History of Theory Development in Nursing

Practicing nurses began incorporating nursing theories into their research and applying them to real clinical situations during the 1970s and 1980s. The majority of early nursing theories fall into the category of grand theories of nursing, because the concepts that described those theories focused on overall nursing practices. Many nursing theory conferences were organized and held to discuss the use of these theories in research and practice, with key theorists presenting methods and ways of practically applying conceptual frameworks in clinical settings.

Some nurse researchers attempted to use grand theories of nursing in their studies but found application difficult due to the wide breadth of those models. As a result, meta-theorists worked further in this area and introduced middle range theories of nursing — theories that focus on specific phenomena of interest to practicing nurses, making them easier to apply in work settings.

The concept of middle range theory was initially introduced in the sociological literature by Robert Merton during the 1950s (Chinn and Kramer, 1995, p. 9). These theories were considered more useful because they focused on a limited number of variables compared to grand theories and could therefore be more easily subjected to empirical testing. Meleis (1997, p. 18) pointed out that middle range theories "focus on specific nursing phenomena that reflect clinical practice." 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 prominently addressed in grand and middle range nursing theories, but recent meta-theorists have begun attending to it. Some notable examples include the "construction of spirituality" in nursing theory (Henry, 2003, p. 50), a model of advanced spiritual care in nursing and healthcare (McSherry, 2006), and an evolving framework for understanding spirituality in nursing (Miner-Williams, 2006).

Miner-Williams (2006) explained the concept of spirituality using definitions drawn from the literature and by identifying components such as values, beliefs, emotions, energy, and connectedness (Miner-Williams, 2006, p. 811). He also presented six practical guidelines to assist nurses in addressing spirituality in clinical settings.

Several theories have been developed more recently in this area. One is the "Experiential Theory of Spiritual Care in Nursing Practice" (Burkhart and Hogan, 2008). Another is the "Theory of Family Interdependence among Family Caregivers and Their Elders," which focuses on the relationship between the spirituality of the caregiver and the spirituality of the care recipient (Kim, Reed, Hayward, Kang, and Koenig, 2011). A third is "T.R.U.S.T: An Affirming Model for Inclusive Spiritual Care" (Barss, 2012). This ongoing interest in nursing theory development in the domain of spirituality was encouraged and promoted by nurse philosopher Barbara Pesut, who focused on the current universal interest in spirituality — termed the "sacralization" of 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 healthcare setting where nursing staff attend not only to the physical needs of patients but also to their minds and spirits. This orientation is particularly important for nursing staff caring for patients suffering from life-threatening illness, long-term illness, or any illness that has altered the patient's life and badly affected his or her professional or personal goals. Such patients are deeply hurt and broken from within, and they struggle to find meaning in their disability or illness. Whether or not patients are affiliated with a religion, they seek a state in which they can accept reality and achieve peace alongside suffering. This theory is helpful for both nurse researchers and nurse practitioners working with seriously ill patients, enabling them to identify patients' spiritual needs and provide appropriate spiritual care interventions accordingly.

According to McEwen (2002, p. 207), "middle range theories generally emerged from combining research and practice and building on the work of others." Some nurse theorists also believe that middle range theories were formulated either from conceptual or grand theories (Ruland and Moore, 1998, p. 170) or through clinical procedures (Good, 1998, p. 120). The middle range theory of spiritual well-being in illness was derived with the initial concepts of spiritual well-being in mind, along with the nursing model developed by Joyce Travelbee, which focused primarily on finding meaning in illness.

The most important element and central idea of this middle range theory is the exploration of spiritual meaning during illness. Travelbee (1971) highlighted the importance of spiritual concerns and pointed out that a patient's spiritual values help identify his or her perception of illness. She created a framework grounded in human-to-human and nurse-to-patient relationships. Through this interactional framework, she described the nurse's role in helping "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 understood both objectively and subjectively (Chinn and Jacobs, 1987). According to her, the attitude and capacity of a person suffering from illness determines how effectively he or she copes with it (Meleis, 1997, p. 361). She further stated 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 acknowledged that this was not an easy task, but insisted that it must not be avoided because it is critical to patient well-being.

Joyce Travelbee was recognized as a deeply spiritual woman, educator, and psychiatric nurse practitioner. Her vision of human-to-human nursing practice was greatly influenced by her early education and training. She gained knowledge from the work of nurse theorist Ida Orlando and received training at Charity Hospital in New Orleans under the supervision of psychotherapist Viktor Frankl. Unfortunately, she passed away at the age of 47 and was unable to further elaborate on her interactional model. Nevertheless, her foundational work on the concept of an ill person deriving meaning from the experience of illness, pain, and suffering provided a strong basis for the development of this middle range nursing theory of spiritual well-being in illness.

Travelbee's contributions provided a strong foundation for nurse researchers and practitioners to build upon. A significant body of nursing studies has inductively derived this theory and investigated its importance in helping patients cope with disabilities and chronic illnesses. Studies demonstrated both qualitative and quantitative positive associations between the spiritual well-being of ill persons and their quality of life. Theorists and nurse practitioners found that patients who possessed strong faith, spiritual satisfaction, and engaged in religious practices tended to be more optimistic and contented with other aspects of life. They also maintained higher hope for a positive future, despite continuous suffering from painful illnesses.

This is evident from the examples of several severely ill patients: an 82-year-old Lutheran parishioner, Mrs. Manley, who had multiple diseases including diabetes, heart failure, and osteoporosis; Mr. Jones, a 62-year-old Methodist parishioner suffering from leukemia; and Mrs. McDermott, a 75-year-old Roman Catholic parishioner disabled by rheumatoid arthritis and other conditions. All three subjects were assessed using a spiritual assessment scale measuring spiritual well-being. The results showed that all three scored positively on items measuring religious practice, faith, and spiritual satisfaction. All three responded positively regarding their quality of life and hope for the future. For instance, they were optimistic about managing pain and difficulties, felt satisfied with love received and given, and agreed that they were "just as happy as when younger" (O'Brien, 2001) and quite well satisfied with their lives.

References

Barss, K. (2012). T.R.U.S.T: An affirming model for inclusive spiritual care. Journal of Holistic Nursing, 30(1), 23–35.

Burkhart, L., and Hogan, N. (2008). An experiential theory of spiritual care in nursing practice. Qualitative Health Research, 18(7), 929–940.

Chinn, L., and Jacobs, K. (1987). Theory and nursing: A systematic approach (2nd ed.). St. Louis.

Chinn, L., and Kramer, K. (1995). Theory and nursing: A systematic approach (4th ed.). St. Louis.

Good, M. (1998). A middle range theory of acute pain management: Use in research. Nursing Outlook, 46(3), 119–125.

Henry, N. (2003). Construction of spirituality in contemporary nursing theory. Journal of Advanced Nursing, 46(3), 121–125.

Kim, S., Reed, P., Hayward, R., Kang, Y., and Koenig, H. (2011). Spirituality and psychological well-being: Testing a theory of family interdependence among family caregivers and their elders. Research in Nursing and Health, 34(2), 102–117.

McEwen, M. (2002). Middle range nursing theories. In M. McEwen and E. M. Wills (Eds.), Theoretical basis for nursing (pp. 202–225). Philadelphia: Lippincott, Williams and Wilkins.

McSherry, W. (2006). The principal components model: A model for advancing spirituality and spiritual care within nursing and health care practice. Journal of Clinical Nursing, 15, 904–910.

Meleis, I. (1997). Theoretical nursing: Development and progress (3rd ed.). Philadelphia: Lippincott.

Miner-Williams, D. (2006). Putting a puzzle together: Making spirituality meaningful for nursing using an evolving theoretical framework. Journal of Clinical Nursing, 15, 812–822.

O'Brien, E. (2001). Spiritual well being in chronic illness. Unpublished study report, Catholic University of America. Washington, DC.

Ruland, M., and Moore, M. (1998). Theory construction based on standards of care: A proposed theory of the peaceful end of life. Nursing Outlook, 46(4), 169–175.

Travelbee, J. (1971). Interpersonal aspects of nursing. Philadelphia, PA: F. A. Davis.

Walker, L., and Avant, K. (1995). Strategies for theory construction in nursing (3rd ed.). Norwalk, CT: Appleton and Lange.