A SPINNER prepares wool by combing, to discard debris and align the strands of a matted mass in much the same way as content is sifted to tease central ideas out of extraneous ones. Just as the spinner twirls strands to compose a single thread; the nurse theorist spins central ideas into a synthesized thread for research and practice. Twisting single threads with each other enhances the strength of the product; as does the crafting of research-practice links in the creation of strong middle range theory. The beauty of any woven article is dependent on its warp and weft; likewise, the esthetics of the discipline is dependent on its theories. Spinning, like theorizing, is rigorous work aimed at creating esthetic, useful products. This article describes and analyzes a decade of middle range theory products that establish a foundation for the new millennium. This foundation highlights the current structure of middle range theory and offers direction for 21st century spinning.
THE HISTORICAL CONTEXT OF MIDDLE RANGE THEORY
Modernism, postmodernism, and neomodernism are historical descriptors that represent change in the course of a developing discipline by influencing thinking and scholarship. Modernism espouses beliefs about human beings that affirm a unidimensional and stable existence, while post modernism adheres to views that affirm multidimensional, ever-changing, and complex human unfolding existence. 1 Watson 2 identified the postmodern for nursing as reconnecting with "the truths of unfoldment, an expansion and fusing of horizons of meaning, an attending to the authenticity, ethos, and ethic of caring relations, context, continuity, connections, aesthetics, interpretation and construction." 2(p63) She concludes that these postmodern dimensions tie directly to developing the art and science of nursing as a caring-healing transformative praxis paradigm. Reed 3 moves beyond postmodernism to neomodernism and calls for a synthesis of modernism and postmodernism. She describes the synthesis as a metanarrative reflecting the human development potential, transformation, and self-transcendent capacity for health and healing, including a recognition of the development histories of persons and their contexts. 3 It is expected that theories that offer direction for the new millennium will emerge from the historical context that defines the time. The current context urges a focus on the human development potential of health and healing and supports a nursing knowledge base that synthesizes art and science; practice and research. Theories at the middle range level of discourse are in keeping with the historical context launching the new millennium.
Merton describes theories of the middle range as those
that lie between the minor but necessary working hypotheses that evolve in abundance during day-to-day research and the all-inclusive systematic efforts to develop unified theory that will explain all the observed uniformities of social behavior, social organization and social change. 4(p39)
He goes on to describe the principle ideas of middle range theory as relatively simple. Simple, in this sense, means rudimentary straightforward ideas that stem from the perspective of the discipline. An example of such an idea is that when individuals tell their story to one who truly listens, a change takes place. This idea is central to the middle range theory of attentively embracing story. 5 The ideas of middle range theory are simple yet general and are more than mere empirical generalizations.
In keeping with the views of Merton, 4 the following descriptions of middle range theory are found in the nursing literature: testable and intermediate in scope, 6 adequate in empirical foundations, 7 neither too broad nor too narrow, 8 circumscribed and substantively specific, 9 and more circumscribed than grand theory but not as concrete as practice theory. 10 In 1974, Jacox 11 described middle range theories as those including a limited number of variables and focused on a limited aspect of reality. Each of these descriptions highlights a scope somewhere in the middle, allowing for broad definitions. Lenz 12 addresses the issue of definitional clarity and believes that although the definitions of middle range theory are consistent, theories of varying scope have been labeled middle-range and the discipline may be well served by recognizing levels of theory within the middle range. She states the challenge for the discipline will be to not generate a plethora of middle range theories, but to develop a few that are empirically sound, coherent, meaningful, useful, and illuminating. 12 To meet the challenge set by Lenz in the next century, it is essential that middle range theories emerge from the twisting of research and practice threads by nurse scholars who are building on the work of others and creating the future direction of the discipline. The spinning of middle range theory in the next century will be guided by the existing middle range theory foundation.
THE EXISTING MIDDLE RANGE THEORY FOUNDATION
To assess the current foundation of middle range theory, a CINAHL search of the past 10 years of nursing literature was done entering middle range theory, mid-range theory, and nursing as search terms. The search was conducted independently in two institutions. All papers written in English that surfaced from the combined search were evaluated for inclusion in the foundation list of middle range theories (Table 1). Criteria for inclusion were
- the theory was identified as middle range by its author;
- the theory name was accessible in the paper;
- concepts of the theory were explicitly identified or implicitly identified in propositions; and
- the development of the theory was the major focus of the paper.
These criteria represent an intent to be inclusive, providing the broadest view of available middle range nursing theory. However, some papers excluded were primarily methodological in focus. 13,14 These were identified in the literature search but did not meet the criteria. Table 1 describes the middle range theory foundation that has emerged during the past decade. Along with including identifying and locating information about the theory, it notes the inclusion of a diagrammed model and the approaches for theory generation identified by the author.
ANALYSIS OF THE MIDDLE RANGE THEORY FOUNDATION
The middle range theories
There are 22 middle range theories proposed as the current foundation. Two theories, Unpleasant Symptoms 7,15 and Balance between Analgesia and Side Effects, 16,17 are accompanied by two citations. Unpleasant Symptoms is the only theory to have documented, ongoing development in the past decade. The second citation for Balance between Analgesia and Side Effects provides examples of use of the theory for research but does not alter its original structure. Powell-Cope, 18 using Swanson's 19 theory of Caring-with the intent of extending it-derived yet another theory, Negotiating Partnerships. This was the only instance of one middle range nursing theory generating another. However, Levesque et al. 20 report that a foundation of middle range theories from other disciplines was the basis of their work.
Several theories that have been labeled middle range by persons who are not the primary author of the theory do not appear in the middle range foundation list. For instance, Fawcett 9 labels Orlando's Deliberative Nursing, Peplau's Interpersonal Relations, and Watson's Human Caring theory as middle range; however, none of these came up in the literature search for middle range theory. Nolan and Grant 21 labeled Chenitz's theory of Entry into a Nursing Home as Status Passage as middle range and reported a test of the theory with a respite care sample. Review of Chenitz's theory 22 indicated that it was labeled practice theory by the author even though it may be at the middle range level of discourse. There are other theories that seem to be at the middle range level of discourse but have not been so identified by the primary author. One example is the work of Beck, who has developed a theory of postpartum depression that includes initial quantitative inquiry 23 followed by qualitative study. 24-26 Although this body of work is at the middle range level of discourse, Beck has not labeled it as middle range theory.
Based on the identified foundation of middle range theory, as the decade unfolded, there appeared to be increased willingness to label theory as middle range. Seven of the theories in Table 1 were proposed in the 4-year span between 1988 and 1992 and 15 were proposed in the most recent 4 years of the decade, since 1994, with six middle range theory papers published in 1997 alone. Some of the 1997 proliferation can be attributed to an issue of Advances in Nursing Science devoted to middle range theory. Three of the middle range theories listed in 1997 were published in this issue. In her editorial for the issue, Chinn 27 highlighted a shift in nurses' scholarly endeavors to create possibilities for healing science-art as evidenced by the issue's middle range theories, which, she noted, defy a single, limited perspective definition. The question about what constitutes theory at the middle range is not a black and white issue for which a precise and clear definition can be offered. Middle range theory holds to a given level of abstraction. It is not too broad nor too narrow, but somewhere in the middle. It is expected that finding the middle will come as theory in the middle range is spun in the next millennium.
Naming the theory
Theory, especially at the middle range, is known to practitioners and researchers by the way it is named. It is essential that theories at the middle range be named in the context of the disciplinary perspective and at the appropriate level of discourse. Figuring out the name is a process of creative conceptualization that moves back and forth between putting together and pulling apart until the right name is found. Implicit in naming is a search for a conceptual structure as the theorist remembers and relives practice and research experiences, reflecting on the author's proposed meaning in relation to the literature. This is a creative, energy-demanding process intended to uncover the heart of the theory. The central theory core is molded by the conceptual structure that exposes it and is articulated at the middle range level of abstraction as the name of the theory.
A theory name was accessible in each of the papers in Table 1, although some names were more accessible than others. A few theorists announced the presentation of a middle range theory and provided a name in the title of the paper, 7,15,28-31 while others were embedded the name in the body of the paper. Facilitating Growth and Development 32 and Affiliated Individuation 33 both emerge from Modeling and Role-Modeling theory. 34 While each is described as a model at the middle range level of abstraction, distinguishing the unique name from the parent theory was difficult. The challenge of naming a middle range theory resides in determining the middle as sufficiently abstract to allow a breadth of application yet narrow enough to permit guidance in research and practice. Table 2 organizes the existing middle range theories into the high-middle, middle, and low-middle level of abstraction, using the theory name. The theories were grouped, relative to each other, based on the generality or scope of the theory indicated by the name. Using the theory name to distinguish the level of abstraction has inherent limitations because the name may not reflect theory content. However, the theory name is its guiding label and this analysis highlights the importance of the theory name. It also highlights the existence of multiple levels of abstraction within the middle range, a fact introduced by Lenz, 12 for further recognition and development. To name a middle range theory is to locate it at an appropriate level of abstraction and to commit to a conceptual structure. Capturing a conceptual structure and expressing theory at the middle range level of abstraction will enable 21st century scholars to recognize, use, and critique the theory for practice and research applications.
Inclusion of a model
Chinn and Kramer 35 define theory as "a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena." 35(p106) They include purpose, concepts, definitions, relationships, structure, and assumptions as components of theory suggested by their definition, noting that purpose and assumptions may be implicit rather than explicit. So, concepts with their definitions-and relationships expressed as structure-are the core components expected to be made explicit regardless of the theory's level of abstraction. One of the criteria for theories in the foundation list was the presentation of concepts. The relationship and structure components were evaluated by determining whether the theorist included a diagrammed model in the paper. Of the 22 theories in the foundation list, only 5 did not diagram a model. 18,19,32,36,37 Three 18,19,36 did not explicitly address relationships between concepts. One 37 specified relationships through propositions; one 32 described middle range relationships between concepts of a parent theory. All middle range theories since 1995 have included a diagrammed model.
APPROACHES FOR GENERATING MIDDLE RANGE THEORY
Lenz 12 has identified six approaches for generating middle range theory; these were used to categorize the methods used by the creators of the 22 theories identified in the foundation. The categories are not mutually exclusive because theorists often used more than one approach. Lenz's approaches are
- inductive theory building through research,
- deductive theory building from grand nursing theories,
- combining existing nursing and non-nursing theories,
- deriving theories from other disciplines,
- synthesizing theories from published research findings, and
- developing theories from clinical practice guidelines.
A review of the foundation theories indicates that fourteen * appeared to use inductive theory building through research. Three derived the theory from grand nursing theory, 20,29,43 two combined nursing and non-nursing theories, 30,37 four derived theories from those of other disciplines, 20,28,37,44 and two 16,45 developed theory from practice guidelines. The approach of synthesizing theories from published research identified by Lenz was difficult to determine when categorizing the theories. No middle range theory was cited that was generated only by published research. Even when not stated explicitly, there were implicit indications that every theory had referred to published research when generating the theory. Two theories 32,46 fit into none of the approaches described by Lenz. Ruland and Moore 46 recently have proposed using standards of care to generate middle range theory and Kinney 32 describes a practice example to demonstrate a middle range model. Including Kinney, seven theories 7,15,32,36,37,40,42,44 explicitly cited personal practice experiences as contributing to middle range theory development. Only four 7,15,36,40,42 of the seven also described research threads, thus enabling the spinning of research with practice in the building of middle range theory.
The analysis of approaches for generating middle range theory suggests that Lenz's listing generally is comprehensive. The elimination of the approach noting synthesis from published research findings may be appropriate, and an expansion of "clinical practice guidelines" to "practice guidelines and standards" will cover the recent work by Ruland and Moore. 46 Inclusion of the practice thread is critical for 21st century spinning. Therefore, the following five approaches are proposed for middle range theory generation in the new millennium:
- induction through research and practice;
- deduction from research and practice applications of grand theories;
- combination of existing nursing and non-nursing middle range theories;
- derivation from theories of other disciplines that relate to nursing's disciplinary perspective; and
- derivation from practice guidelines and standards rooted in research.
It is unlikely that any of these theory generation approaches will stand alone as nursing moves into the next century. Each will need to be combined to most effectively guide the discipline. Guidance for the new millennium is most likely to emerge from theories that spin research and practice to focus on the human developmental potential of health and healing.
JUXTAPOSITION WITH GRAND NURSING THEORY
As middle range theory is generated for the new millennium, it is essential that it move beyond the polarities often created between it and grand theories. The all-embracing grand theories were espoused by individuals who attempted to create a view of the whole of nursing. Groups have developed into small circles of schools of thought in which an all-or-nothing adherence to the perspective is advocated strongly. This approach has advanced the discipline through generation of scholarly pursuits and offers a grounding for middle range theory. It is not separate nor antithetical to middle range theory development. Merton 4 identifies the following criticisms of middle range theory leveled by those who advocate grand approaches: (1) conceptualizing middle range theory is low in intellectual ambitions; (2) it completely excludes grand theory; (3) it will fragment the discipline into unrelated special theories; and (4) a positivist conception of theory will be the result. There is no evidence that these criticisms have been realized. Nursing's current middle range theory foundation: reflects scholarly work conceptualized at a lower level of abstraction that rises to intellectual challenge; builds on' grand theory that continues to offer a foundation for development; and projects a historical context to begin the millennium with theories at the middle range in the perspective of the discipline.
DISCIPLINARY PERSPECTIVE OF THE MIDDLE RANGE THEORY FOUNDATION
An association between the existing middle range theory foundation and the disciplinary perspective synthesized as a caring, healing process in which the human developmental potential for health and transformation emerge 2,3 is depicted in Table 3. Through the reflective process of dwelling with the essence of the disciplinary perspective and the middle range theories as named, two themes surfaced. These themes were caring-healing processes and transforming struggle-growth. These themes offer a view of the existing middle range theory foundation in the context of a disciplinary perspective as well as an integrated paradigm for spinning middle range theory in the new millennium.
THE FUTURE: WHERE DOES NURSING THEORY GO FROM HERE?
In conclusion, a lot of thoughtful spinning of middle range theory has been done in the past decade; and although knots and tangles have been created along the way, one must remember that spinning theory is a creative human endeavor that can best be described as a work in progress. It is expected that the knots and tangles will be sorted out with the spinner's persistence and careful attention to creating and combining fibers. Based on the description and analysis of the current middle range theory foundation, several recommendations are presented for developing middle range theory in the future. The recommendations are that the creators of middle range theory:
- take care to clearly articulate the theory name and approach used for generating the theory;
- strive to clarify the conceptual linkages of the theory in a diagrammed model;
- give deliberate attention to articulating the research-practice links of the theory;
- create an association between the proposed theory and a disciplinary perspective in nursing; and
- move middle range theory to the front lines of nursing practice and research for further analysis, critique, and development.
Twenty-first century theorists are offered the challenge of these recommendations. The challenge is to move nursing theory forward by spinning research and practice in the creation of middle range theories congruent with the current historical context. It is this forward movement that will give substance and direction to the discipline. Middle range theory will create the disciplinary fabric of the new millennium as nurse theorists spin and twist fibers from the past-present into the future.
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