Middle Range Theories

Middle-Range Theories
Roli Joseph Z. Monta

Middle-Range Theories
• Least abstract theory level for concrete practice applications
• Include the characteristics of nursing practice or situations
• Are theoretical evidence of applicability and outcomes
• Develop evidence for nursing practice outcomes
20XX presentation title

Ramona T. Mercer: Maternal Role Attainment- Becoming a
Mother
Major Assumptions:
• determines how a mother defines and perceives events; her perceptions of
her infant’s and others’ responses to her mothering, with her life situation,
are the real world to which she responds
• her developmental level and innate personality characteristics also
influence her behavioral responses
• the mother role’s partner, her infant, will reflect the mother’s competence
in the mothering role through growth and development

Mother
Major Assumptions:
• infant is considered an active partner in the maternal role-taking process,
affecting and being affected by the role enactment
• the father’s or mother’s intimate partner contributes to role attainment in a
way that cannot be duplicated by any other supportive person
• maternal identity develops concurrently with maternal attachment, and
each depends on the other

Mother
Major Assumptions:
Nursing
• “Nurses are the health professionals having the most sustained and intense
interaction with women in the maternity cycle”
• the kind of help or care a woman receives during pregnancyand the first
year after giving birth can have long-term effects for her and her child

Mother
Major Assumptions:
Person
• Mercer refers to the self or core self
• The concepts of self-esteem and self-confidence are important in
attainment of the maternal role
• The mother as a separate person interacts with her infant and with the
father or her significant other. She is both influential and influenced by
both of them

Mother
Major Assumptions:
Health
• Mother’s and Father’s perception of their prior health, current health,
health outlook, resistance-susceptibility to illness, health worry or
concern, sickness orientation, and rejection of the sick role
• Health is an important indirect influence on satisfaction with relationships
in childbearing families
• Health is viewed as a desired outcome for the child
• Stresses the importance of health care during the childbearing and child-
rearing processes

Mother
Major Assumptions:
Environment
• Bronfenbrenner’s ecological environment - the ecological interacting
environments in which maternal role attainment develops
• Stresses and social support within the environment influence both
maternal and paternal role attainment and the developing child

Mother
Mercer’s Original Model and Theory:
1. Microsystem is the immediate environment in which maternal role
attainment occurs
- it includes factors such as family functioning, mother-father relationships,
social support, economic status, family values, and stressors
2. Mesosystem encompasses, influences, and interacts with persons in the

microsystem
- includes day care, school, work setting, places of worship, and other
entities within the immediate community

Mother
Mercer’s Original Model and Theory:
3. Macrosystem refers to the general prototypes existing in a particular
culture or transmitted cultural consistencies.
- includes the social, political, and cultural influences on the other two
systems
- national laws regarding women and children and health priorities that
influence maternal role attainment

Mother
Stages of Role Acquisition:
a. Anticipatory
- begins during pregnancy and includes the initial social and psychological
adjustments to pregnancy
- the mother learns the expectations ofthe role, fantasizes about the role,
relates to the fetus in utero, and begins role-play
b. Formal
- begins with the birth of the infant and includes learning and taking on the
role of mother
- guided by formal, consensual expectations of others in the mother’s social
system
Mother
Stages of Role Acquisition:
c. Informal
- begins as the mother develops unique ways of dealing with the role not
conveyed by the social system
- the woman makes her new role fit within her existing lifestyle based on
past experiences and future goals
d. Personal
- occurs as the woman internalizes her role
- the mother experiences a sense of harmony, confidence, and competence
in the way she performs the role, and the maternal role is achieved

Mother
Maternal Role Attainment -an interactional and developmental process
occurring over time in which the mother becomes attached to her infant,
acquires competence in the caretaking tasks involved in the role, and
expresses pleasure and gratification in the role
Maternal Identity
having an internalized view of the self as a mother

Mother
Perception of Birth Experience
A woman’s perception of her performance during labor and birth
Father or Intimate Partner

The person who contributes to the process of maternal role attainment in a
way that cannot be duplicated by any other person

Mother
Infant Cues
Infant behaviors that elicit a response from the mother
Stress
Positively and negatively perceived life events and environmental variables

Mother
Social Support
the amount of help actually received , satisfaction with that help, and the
persons (network) providing that help

Mother
Four areas of social support:
1. Emotional - feeling loved, cared for, trusted and understood
2. Informational - helping the individual help herself by providing
information that is useful in dealing with the problem and/or situation
3. Physical - direct help
4. Appraisal - enables the individual to eveluate herself in relationship to
other’s performance in the role

Mother
4 stages of role acquisition:
a. Anticipatory - begins during pregnancy and includes the initial social
psychological adjustments to pregnancy
b. Formal - begins with the birth of the infant and includes the learning and
taking on the role of mother
c. Informal - begins as the mother develops unique ways of dealing with
the role not conveyed by the social system
d. Personal - woman internalizes her role

Mother
Examples of the infant’s developmental responses that interact with the
mother’s developing maternal identity:
a. Eye contact with the mother as she talks to her or him; grasp reflex
b. Smile reflex and quieting behavior in response to the mother’s care
c. Consistent interactive behaviors with the mother
d. Eliciting responses from the mother; increasing mobility

Mother
Proposed changes of stages leading to a maternal role identity:
• Commitment and preparation (pregnancy)
• Acquiantance, practice and physical restoration (first 2 weeks)
• Approaching normalization (seconde week to 4 months)
• Integration of maternal identity (approximately 4 months)

Mother
Acceptance by the Nursing Community:
Practice
• cited in many obstetrical books and have been used in practice by nurses
and in other disciplines
• serve as a framework for assessment and planning, implementing, and
evaluating nursing care of new mothers and their infants
• Neeson and colleagues (1983), were used in setting up a clinical practice
• Meighan and Wood (2005) used the theory to explore the effect of
hyperemesis gravidarum

Mother
Education
• has appeared extensively in both maternity and pediatric nurtud nursing
texts
• extremely valuable to nursing education
• serves as an example of nursing science development for nursing students
• have also been used by other disciplines as they relate to parenting and
maternal role attainment
• beneficail to students in psychology, sociology and education

Mother
Research
• Mercer advocated the involvement of students in faculty research
• Mercer’s work has served as a springboard for other researchers

Mother
Further Development:
Presented a model of the following four phases that occur during the first
year of motherhood:
1. Physical Recovery Phase (from birth to 1 month)

2. Achievement Phase (from 2 months to 4 or 5 months)
3. Disruption Phase (from 6 to 8 months)
4. Reorganization Phase (from aftre the eighth month and still in process at
1 year)

Mother
Critique:
Clarity
• The concepts, variables, and relationships were described and implied in
Mercer’s earlier work.
• The concepts were defined theoretically and operationalized consistently
• Continued work toward improving clarity is evident
• Concepts, assumptions, and goals have been organized into a logical and
coherent whole, , so understanding is relatively easy
• Maternal identity is sometimes substituted for maternal role attainment
• Mercer continued to work toward greater clarity and proposed using terms
derived from nursing reserachers that would be understood more clearly by
users of her theory.
Mother
Critique:
Simplicity
• Easily understood and useful form
• Theory is predictive in nature, and readily lends itself as a guide for
practice
• Concepts are not specific to time and place, and although abstract, they
are described and operationalized to the extent that meanings are not
easily misinterpreted

Mother
Critique:
Generality
• Specific to parent-child nursing and has also been used by other
disciplines concerned with mothring and parenting
• Generalized to all women during pregnancy through the first year after
birth, regardless of age, parity, or environment
• It is useful for studying and working with family members after birth

Mother
Critique:
Accessibility
• Mercer’s work has evolved from extensive research efforts
• The concepts, assumptions and relationships are grounded predominantly
in empirical observations and are congruent
• The degree of concreteness and the completeness of operational
definitions increase the empirical precision
• The continued scrutiny by Mercer has continually improved her theory
and solidified her concepts

Mother
Critique:
Importance
• The theoretical framework for maternal role attainment during the first
year has proved to be useful, practical and valuable to nursing
• Mercer’s work is used repeteadly in nursing research, practice and
education

Merle Mishel: Uncertainty of Illness Theory
Uncertainty is the inability to determine the meaning of illness-related
events, occurring when the decision-maker is unable to assign definite value
to objects or events, or is unable to predict outcomes accurately
Cognitive Schema is a person’s subjective interpretation of illness,

treatment and hospitalization
Stimuli Frame is the form, composition, and structure of the stimuli that a
person perceives, which are then structured into a cognitive schema

Symptom Pattern is the degree to which symptoms occur with sufficient
consistency to be perceived as having a pattern or configuration
Event Familiarity is the degree to which a situation is habitual or repetitive

or contains recognized cues
Event Congruence refers to the consistency between the expected and the
experienced in illness-related events

Structure Providers are the resources available to assist the person in the
interpretation of the stimuli frame

Theoretical Assertions:
• Uncertainty appraised as danger prompts coping efforts directed at
reducing the uncertainty and managing the emotional arousal generated by
it
• Uncertainty appraised as oppurtunity prompt coping efforts directedat
maintaining the uncertainty
• Prolonged exposure to uncertainty appraised as danger can lead to
intrusive thoughts, avoidance, and severe distress

Major Assumptions:
Person
1. Uncertainty is a cognitive state
2. Uncertainty is an inherently neutral experience
3. Adaptation represents the continuity of an individual’s usual biophysical
behavior and is the desired outcome of coping efforts
4. The relationships among illness events, uncertainty, appraisal, coping,
and adaptation are linear and unidirectional

Major Assumptions:
Person
• People, as biophysical systems, typically function in far-from-equilibrium
states
• Major fluctuations, in a far-from-equilibrium system enhance the system’s
receptivity to change
• Fluctuations result in re-patterning, which is repeated at each level of the
system

Acceptance by the Nursing Community
Practice
- a phenomenon experienced by acute and chronically ill individuals and
their families
- focusing on events that seemed unimportant to those around him
- practice of critical, cardiac, medical-surgical, and enterostomal nursing
care

Education
- widely used by graduate students as the theoretical framework for theses
and dissertations
- Mishel presented lectures, seminars and symposia nationally and
internationally for faculty and students

Research
- a large body of knowledge has been generated by researchers using the
uncertainty in illness theory and scales

Critique
Clarity
- the framework is clear and easy to follow
- Organized in a linear model around the following 3 major themes:
1. Antecedents of uncertainty
2. Process of uncertainty appraisal
3. Coping with uncertainty

Critique
Clarity
- Uncertainty is the primary concept of this theory
- Appraisal involves 2 processes: inference and illusion
Based on appraisal processes, uncertainty is viewed as either danger or an
oppurtunity
- Coping is the third theme of the original model of uncertainty. Appraised
as a Danger or Oppurtunity

Critique
Simplicity
- the antecedents of unccertainty are concise, and their definitions are clear
and simple
- the appraisal component is complex because it considers cognitive
processes along with beliefs and values held by the individual
- the coping phase is also complex because it is dependent on the appraisal
portion of the model
- although the models can hardly be called simple, the concept definitions
and relationship are well operationalized and easily understood

Critique
Generality
- it is broad and generalizable and can be used with individuals
experiencing illness, as well as with spouses and parents of those
experirncing illness-related uncertainty
- can be applied in nursing practice and has been used by clinicians for
acute and chronic illnesses such as cancer, cardiac disease and multiple
sclerosis

Critique
Accessibility
- the concepts are well described, and their relationships are precisely
constructed with clear, tested operational definitions
- the theory led to the development and testing of nursing interventions to
manage uncertainty

Critique
Importance
- Mishel’s work represents an exemplar of middle-range theory that informs
clinical practice in the encompassing context of acute and chronic illness

Critique
Importance
- the theory has generated considerable empirical research with adults
dealing with illness and their family members and continues to stimulate
new research directions, such as uncertainty in ill children, in older men
electing watchful waiting as the treatment of choice for prostate cancer, and
in health care providers informing patients of treatment choices in
conditions with uncertain prognoses

Pamela G. Reed: Self-Transcendence Theory
Vulnerability refers to living with dificult or challenging experiences such
as life-threatening or chronic illness, loss, trauma, or an unhealthy
environment that in some way may threaten personal or physical well-being
Self-Transcendence is the expansion of personal boundaries in various and

multidimensional ways such as inwardly, outwardly, temporally and
transpersonally
Well-Being is a feeling of being healthy, happy, and whole in accordance

with one’s values and views

Major Assumptions
• Humans impose conceptual boundaries upon themselves to define their
reality and provide a sense of wholeness and connectedness within
themselves and their environment
• Self-transcendence is a developmental imperative

Theoretical Assertions
3 Basic Concepts
Vulnerability is the awareness of personal mortality or some risk to well-
being
Self-Transcendence refers to fluctuations in perceived boundaries that
extend persons beyond their immediate and constricted views of self and
world
Well-being refers to feeling healthy, happy and whole

4 major propositions:
1. Self-transcendence may be motivated by experiences of vulnerability
2. Self-transcendence is positively related to well-being
3. Self-transcendence is an underlying process or mechanism that explains
why some people attain well-being when confronted with increased
vulnerability
4. Ongoing person-environment process across the lifespan

Practice
Nurses influence self-transcendence through their therapeutic interactions
with patients and by implementing more formally designed interventions

Education
- Informs students about substantive nursing that facilitates well-being
through resources within the person and creative interactions with nurses
- Provides oppurtunity to learn about nursing knowledge articulated through
mid-range theory that is informed by and applied in nursing practice
- it has relevance for nurses’ well-being and socialization into the
professional role

Research
- Depression
- Life-threatening or chronic illness
- Successful aging
- a component of older adults’ inner strength
- long-term care
- promotes self-care and engagement in ADLs in noninstitutionalized older
adults and healthy middle-aged adults
- has practice implications for family caregivers

Critique
Clarity
Nurses have been able to appreciate and identify with this concept through their
practice experiences and knowledge
Simplicity
Allows for wider application across populations and health experiences, and for
innovation in designing strategies to promote well-being
Generality
The scope and purpose of Reed’s theory is general enough for application to a
variety of health-related situations
Critique
Accessibility
STS has been translated into many languages, including Spanish, Swedish,
Korean, Mandarin, Turkish, French, Persian and Japanese
Importance
The theory provides insight into human developmental capacities for well-
being across health situations relevant to nursing care
Nurses and patients face events that challenge their well-being

Critique
Accessibility
STS has been translated into many languages, including Spanish, Swedish,
Korean, Mandarin, Turkish, French, Persian and Japanese
Importance
The theory provides insight into human developmental capacities for well-
being across health situations relevant to nursing care
Nurses and patients face events that challenge their well-being

Carolyn L. Wiener and Marylin J. Todd: Theory of Illness
Trajectory
- This theory refers to theoretical formulations regarding coping with
uncertainty through the cancer illness trajectory
- Coping is best viewed as change over time that is highly variable in
relation to biographical and sociological influences
- The illness trajectory organizes insights to better understand the dynamic
interplay of the disruption of illness within the changing concepts of life

Trajectory
Identity: The concept of self at a given time that unifies multiple aspects of
self and is situated in the body
Temporality: Biographical time reflected in the continuous flow of the life

course events; perceptions of the past, present, and possible futture
interwoven into the conception of self
Body: Activities of life and derived perceptions based in the body
Total organization: the person and all others with whom he or she
interacts, including family, and health care providers
Trajectory
Types of work are organized around the following four lines of trajectory
work performed by patients and families:
1. Illness-related work: Diagnostics, symptom management, care regimen,

and crisis prevention
2. Everyday-life work: ADL, keeping a household, maintaining an
occupation, sustaining relationships, and recreation
3. Biographical work: exchange of information, emotional expressions,
and the division of tasks through interactions within the total organization
4. Uncertainty abatement work: activities enacted to lessen the impact of
temporal, body, and identity uncertainty

Trajectory
Read Tables 30:1&2

Trajectory
Major Assumptions:
Person
- Patient is the “central worker” in the illness trajectory
- The illness trajectory is not limited to the person who suffers the illness.
Rather, the total organization involves the person with the illness, the
family, and health care professionals who render care.

Trajectory
Practice
provides a framework for nurses to understand how cancer patients tolerate uncertaintyas
a loss of control
Education
Wiener and Todd are highly respected educators who shared their ongoing work through
internationala conferences, seminars, consultations, graduate thesis advising and course
offerings
Research
Thetheory has been referenced in a limited number of concept analyses or state-of-the-art
science papers addressing uncertainty
Trajectory
Critique
Clarity
- Propositional clarity is achieved in the logical presentation of
relationships and linkages between concepts
- Conceptual derivation of managing illness as work is well developed and
provides unique insight into the meaning of living through chemotherapy
during cancer treatment
Simplicity
Highly relevant to oncology nursing practice

Trajectory
Critique
Generality
- the authors have limited the scope of this theory to patients and families
progressing through chemotherapy for initial treatment or recurrence of
cancer
Accessibility
- The theory is useful to clinicians and holds promise for further research
application

Trajectory
Critique
Importance
The importance of the theoretical contributions made by this work,
especially types of work and uncertainty abatement strategies during
chemotherapy has been established

Eakes, Burke and Hainsworth: Theory of Chronic Sorrow
Chronic Sorrow is the ongoing disparity resulting from a loss
characterized by pervasiveness and permanence
Symptoms of grief recur periodically, and these symptoms are potentially
progressive
Loss occurs as a result of disparity between the “ideal” and real situations
or experiences
Example, there is a “perfect child” and a child with a chronic condition who
differs from that ideal

Trigger Events are situations, circumstances, and conditions that highlight
the disparity or the recurrent loss and initiate or exacerbate feelings of grief
Management Methods are means by which individuals deal with chronic

sorrow
These may be internal (personal coping strategies) or external (health care
practitioner or other person’s interventions)

Ineffective Management results from strategies that increase the
individual’s discomfort or heighten the feelings of chronic sorrow
Effective Management results from strategies that lead to increased

comfort of the affected individual

Major Assumptions
Nursing
Diagnosing chronic sorrow and providing interventions are within the scope
of nursing practice
The primary roles of nurses include empathetic presence, teacher-expert,
and caring and competent caregiver
Persons
Humans have an idealized perception of life processes and health

Major Assumptions
Health
A person’s health is dependent on adaptation to disparities associated with
loss. Effective coping results in a normal response to life losses
Environment
Interactions occue within a social context, which includes family, social
work, and health care environments

- Chronic sorrow is a normal human response related to ongoing disparity
created by a loss situation
- Chronic sorrow is cyclical in nature
-Humans have inherent and learned coping strategies that may or may not
be effective in regaining normal equilibrium

Practice
Provides suggestions for nurses to assist individuals and family caregiversto
manage the milestones or triggering events effectively
Identifies nursing roles as empathetic presence, teacher-expert, and caring
and competent professional
Education
Used in undergraduate, graduate research, and continuing education
education lends support for its acceptance by the educational community

Research
Researchers have extended the work through studies conducted with
representatives of populations studied previously and with the new
populations from international researchers

Critique
Clarity
This theory clearly describes a phenomenon that is observed in the clinical
area when loss occurs, and it is certainly evident that it is accepted in
nursing practice
Simplicity
With this model, it is clear that chronic sorrow is cyclical in nature,
pervasive, and potential progressive.
It is useful for research design and practice guidance

Critique
Generality
Applies to a wide range of losses and is applicable to the affected individual as well
as to the caregivers and the bereaved
Accessibility
The limited scope readily allows researchers to study the phenomenon
Importance
Included in NANDA-I diagnoses
Nurses and other health care professionals have found validity for their experiences
with loss in the clinical arena
Phil Barker: The Tidal Model of Mental Health Recovery
The Ten Tidal Commitments: Essential Values of the Tidal Model
1. Value the Voice - the person’s story
2. Respect the language - unique ways of expressing their life stories
3. Develop genuine curiosity - reflects an interest in the person and the
person’s unique experience
4. Become the apprentice - we need to learn from the person what needs to
be done, rather than leading
5. Use the available toolkit -”what has worked” or what might work”;
evidence-based practice

6. Craft the step beyond - the professional helper and the person work
together to construct an appreciation of what needs to be done “now”
7. Give the gift of time - the time the helper and the person spend time
together
8. Reveal personal wisdom - help the person reveal and come to value the
wisdom so that it might be used to sustain the person to recovery
9. Know that change is constant - nurses help the person steer out of
danger and distress, keeping on the course of reclamation and recovery
10. Be transparent

Self-domain is the private place where the person experiences, thoughts,
feelings, beliefs, values, and ideas that are known only to the person
- focus of the nurse’s attempts to help the person feel safe and secure
World domain is the place where the person shares some of the
experiences from the self domain with other people in the person’s social
world
Health Assessment - helping the person begin to identify and address
specific problems of living on an everyday basis through one-to-one
sessions
Others domain - dedicated forms of group work - discovery, information
sharing and solution finding

Water - A metaphor
“storms at sea” = problems of living
“piracy” = experience of rape
“robbery of the self” = severe distress
“drowning” = experience of distress
“shipwreck” = acute psychiatric unit
“psychiatric rescue” = “lifesaving” = “safe haven”

Getting in the Swim - Engagement Beliefs
• Recovery is possible
• Change is inevitable - nothing lasts
• People know what is best for them
• People possess all the resources they need to begin the recovery journey
• The Person is the teacher, and Nurses, the helpers, are the pupils
• Nurses need to be creatively curious to learn what needs to be done to
help the person now

Therapeutic Philosophy
1. Why this - Why now?
2. What works?
3. What is the person’s personal theory?
4. How do we limit restrictions?

Major Assumptions
Nursing
Nursing is a process and nurses are involved in the process of working with
people, of working with people, their environments, their health and their
need for nursing (Barker, 1996a)
Person
Interest is directed toward a phenomenological view of the person’s lived
experience and his or her story (Barker, 1999a, 2000d)

Major Assumptions
Health
Holistic view
Health means whole
Environment
The environment is largely social in nature
Nurses create “space” for growth and development
Therapeutic relationships are used in ways to enhance persons’ relationships
with their environment

Practice
The Tidal Model is a person-centered model of mental health care delivery, which is
respectful of culture and creed
Education
Holds great promise for inclusion in educational programs concerned with theory-
based practice and person-centered care
Research
Developed from a clinical research program and evaluated
What happens?
Critique
Clarity
This easily understood theory is accessible conceptually and linguistically
through the use of everyday language
Simplicity
Based upon a few simple ideas about being human and helping one another
Generality
International in scope, suggesting its relevance, cross-culturally and cross-
nationality
Critique
Accessibility
The Tidal Model suggest its utilityand precision and provide confidence
that the theory is useful, practical and accessible.
Importance
an important and essential theory to develop and guide practice in
psychiatry and mental health care

Katharine Kolcaba: Theory of Comfort
Health Care Needs are comfort needs arising from stressful health care
situations that cannot be met by recipients’ traditional support systems.
The needs may be physical, psychospiritual, sociocultural or environmental
They become apparent through:

a. Monitoring; verbal or non-verbal reports
b. Needs related to pathophysiological parameters
c. Needs for education and support
d. Needs for financial counseling and intervention

Comfort interventions are intentional nursing actions and referrals
designed to address specific comfort needs of recipients, including
physiological, social, cultural, financial, psychological, spiritual,
environmental and physical needs
Intervening variables are interacting forces that influence recipients’

perceptions of total comfort.
They consist of past experiences, age, attitude, emotional state, support
system, prognosis, finances, education, cultural background and the totality
of elements in the recipients experience

Comfort is the immediate state experienced by recipients of comfort
interventions
The three types of comfort are relief, ease, and transcendence
The four contexts are physical, psychospiritual, sociocultural and

environmental

Health-seeking behaviors compose a broad category of outcomes related to the
pursuit of health as defined by the recipient/s in consultation with the nurse
Internal behaviors are those we cannot see, such as surgical healing, T-cell
formation, or electrolyte balance
External behaviors are those we can see directly, such as ambulation or indirectly
such as blood pressure
Institutional Integrity
Corporations, communities, schools, hospitals, regions, states, and countries that
posses the qualities of being complete, whole, sound, upright, appealing, ethical
and sincere possess institutional integrity

Major Assumptions
1. Human beings have holistic responses to complex stimuli
2. Comfort is a value-added holistic outcome that is germane (applicable) to
the discipline of nursing
3. Comfort is a basic human need that persons strive to meet or have met
4. Enhanced comfort strenghtens patients to engage in health-seekinh
behaviors of their choice
5. Patients who are empowered to actively engage in health-seeking
behaviors aresatisfied with their health care
6. Institutional integrity is based on a value system oriented to the recipients
of care

Nursing is the intentional assessment of comfort needs, the design of
comfort interventions to address those needs, and reassessment of comfort
levels after implementation compared with a baseline
Person
Recipients of care may be individuals, families, institutions or communities
in need of health care
Nurses may be recipients of enhanced workplace comfort when initiatives
to improve working conditions are undertaken

Environment is any aspect of patient, family, or institutional settings
thatcan be manipulated by the nurse/s, loved one/s, or the institution to
enhance comfort
Health is optimal functioning of a patient, family, health care provider or

community as defined by the patient or group

Part 1 states that comforting interventions, when effective, result in
increased comfort for recipients (patients and families)
Part 2 states that increased comfort of recipients of care results in increased

engagement in health-seeking behaviors (goals) that are negotiated with the
recipients
Part 3 states that increased engagement in health-seeking behavior results

in increased quality of care, benefiting the institution and its ability to
gather evidence for best practices and best policies

Practice
Students, practicing nurses, and nurse researchers have selected this theory
as a guiding framework for their studies, reviews, or innovative works such
as efficacy of hand massage
Education
Comfort theory is incorporated in the Nursing Intervention Classification
and Nursing Outcome Classification handbooks
Bice and Bramlett (2019) argued the unique position that faculty have in
applying a holistic comfort pedagogy

Research
An entry in the Encyclopedia of Nursing Research speaks to the importance
of measuring comfort as a nursing-sensitive outcome

Critique
Clarity
Her book clearly presents the theory and her articles leading to it
Simplicity
The theory of comfort is simple, as it is basic to nursing care and the
traditional mission of nursing
The main thrust of the theory is for nurses to return to a practice focused on
the holistic needs of patients inside or outside institutional walls.
Its simplicity allows students and nurses to learn and practice the theory
easily
Critique
Generality
Kolcaba’s theory has been applied in numerous research settings, cultures, and age
groups
Accessibility
The first part of the theory, asserting that effective nursing interventions offered over time
demonstrate enhanced comfort, has been tested and supported with numerous studies.
Importance
The theory of comfort is dedicated to sustaining nursing by bringing the discipline back
to its roots

Cheryl Tatano Beck: Postpartum Depression Theory
Postpartum Depression is a nonpsychotic major depressive disorderwith
distinguishingdiagnostic criteria that often begins as early as 4 weeks after
birth and may also occur anytime within the first year after childbirth

Loss of Control - feelings of “teetering on the edge”
4 stages:
1. Encountering terror - horrifying anxiety attacks, enveloping fogginess,
relentless obssesive thinking, various somatic expressions
2. Dying of self- sense of “unrealness” about oneself, contemplating and
attempting self-destructive behaviors, isolating oneself, and dealing with
consequences
3. Struggling to survive-battling the system, seeking solace at a support
group, praying for relief, and developing strategies
4. Regaining control- evidenced by unpredictable transitioning, guarded
recovery, mourning lost time, and subsequent consequences

Prenatal Depression during any or all of the trimesters of pregnancy has
been found to be the strongest predictor of postpartum depression
Child Care Stress pertains to stressful events related to child care such as
infant health problems and difficulty in infant care pertaining to feeding and
sleeping
Prenatal Anxiety refers to feelings of uneasiness or apprehension

concerning a vague, nonspecific threat

Difficult Temperament describes an infant who is irritable, fexplosive anger, and
fear of never being happy againussy, unpredictable, and difficult to console
Maternity Blues. Prolonged episodes , lasting more than 10 days may predict
postpartum depression
Unplanned or Unwanted Pregnancy refers to a pregnancy that was not planned

or wanted
Emotional Lability has a sense that her emotions are unstable and out of control.
Commonly characterized as crying for no particular reason, irritability, explosive
anger and fear of never being happy again

Mental Confusion is characterized by a mark inability to concentrate, focus
on a task, or make a decision
May be understood as post-traumatic stress syndrome
Loss of Self. Women sense that the aspect of self that reflected their personal
identity have changed since the birth of their infant, so that they cannot
identify who they really are and are feraful that they might never be able to be
their real selves again
Guilt of Shame. A woman experiences guilt and shame when she perceives
that she is performing poorly as a mother and has negative thoughts regarding
her infant
Suicidal Thoughts when thet have frequent thoughts of harming
themselves or ending their lives to escape the living nightmare of
postpartum depression

• Women’s unique and normal brain and hormonal chemistry result in a
vulnerability to mood disorders at critical times in their lives, including
after giving birth
• Postpartum depression is caused by a combination of biological (including
genetic), psychological, social, relational, economic, and situational life
stressors
• A number of biological, sociological, and psychological issues and
challenges are entirely normal in all pregnancies. This may include
fatigue, sleep alterations, questioning one’s abilities, and the like.

Logical Form:
Beck’s goal has been to understand postpartum depression in a way that
would allow professionals to develop adequate prevention strategies,
develop screening programs for early intervention, and develop adequate
treatment strategies to prevent harm to women, their children, and their
families

Kristen M. Swanson: Theory of Caring
Caring is a nurturing way of relating to a valued other toward whom one
feels a personal sense of commitment and responsibility
Knowing is striving to understand the meaning of an event in the life of the

other, avoiding assumptions, focusing on the person cared for, seeking cues,
assessing meticulously, and engaging both the one caring and the one cared
for in the process of knowing
Being With means being emotionally present to the other.

It includes being there in person, conveying availability and sharing
feelings without burdening the one cared for

Kristen M. Swanson: Theory of Caring
Doing For means to do for others what one would do for self if at all possible,
including anticipating needs, comforting, performing skillfully and competently,
and protecting the one cared for while preserving his or her dignity
Enabling is facilitating the other’s passage through the transitions and

unfamiliar events by focusing on the event, informing, explaining, supporting,
validating feelings, generating alternatives, thinking things through and giving
feedback
Maintaining Belief is sustaining faith in the other’s capacity to get through an

event or transition and face a future with meaning, believing in other’s capacity
and holding him or her in high esteem

Cornelia M. Ruland and Shirley M. Moore: Peaceful End of
Life Theory
Not Being in Pain was defined as “not having the experience of pain”
Being free ofthe suffering or symptom distress is the central part of many
patients’ end-of-life experience
Pain is an unpleasant sensory or emotional experience that may be
associated with actual or potential tissue damage

Life Theory
Experience of Comfort
Comfort is defined inclusively as “relief from discomfort, the state of ease
and peaceful contentment, and whatever makes life easy or pleasurable”
Experience of Dignity and Respect

Each terminally ill patient is “respected and valued as a human being”
Personal worth + Autonomy or Respect for Persons

Life Theory
Being at Peace
Peace is a “feeling of calmness, harmony, and contentment, free of anxiety,
restlesssness, worries and fear”
A peaceful state includes physical, psychological, and spiritual dimensions
Closeness to Significant Others

Closeness is “the feeling of connectedness to other human beings who
care”
It involves a physical or emotional nearness that is expressed through
warm, intimate relationships

Life Theory
1. Monitoring and administering pain relief and applying pharmacological
and nonpharmacological interventions contribute to the patient’s experience
of not being in pain
2. Preventing, monitoring, and relieving physical discomfort; facilitating
rest, relaxation and contentment; and preventing complications contribute to
the patient’s experience of comfort
3. Including the patient and significant others in decision making regarding
patient care; treating the patient with dignity, empathy and respect; and
being attentive to the patient’s expressed needs, wishes, and prefernces
contribute to the patient’s experience of dignity and respect

Life Theory
4. Providing emtional support, monitoring and meeting the patient’s need
for antianxiety medications, inspiring trust, providing the patient and
significant others with guidance in practical issues, and providing the
physical presence of another caring person if desired contribute to the
patient’s experience of being at peace
5. Facilitating participation of significant others in patient care; attending to
significant other’s grief, worries, and questions; and facilitating
opportunities for family closeness to significant others or persons who care
6. The patient’s experiences of not being in pain, comfort, dignity, respect,
being at peace and closeness to significant others or persons who care
contribute to the peaceful end of life

INTRODUCTION
3
PRIMARY GOALS
4
agenda AREAS OF GROWTH

5
TIMELINE
10
SUMMARY
13
introduction
At Contoso, we empower organizations to
foster collaborative thinking to further drive
workplace innovation. By closing the loop and
leveraging agile frameworks, we help business
grow organically and foster a consumer-first
mindset.

primary goals
quarterly performance
Q1
Q2
Q3
Q4
- 1.0 2.0 3.0 4.0 5.0 6.0
Series 1 Series 2

areas of growth
B2B SUPPLY CHAIN ROI E-COMMERCE
Q1 4.5 2.3 1.7 5.0
Q2 3.2 5.1 4.4 3.0
Q3 2.1 1.7 2.5 2.8
Q4 4.5 2.2 1.7 7.0

RICHARD BRANSON
“Business opportunities are like buses.

There's always another one coming.”

meet our team
TAKUMA HAYASHI MIRJAM NILSSON FLORA BERGGREN RAJESH SANTOSHI

president chief executive officer chief operations officer vp marketing

meet our extended team
TAKUMA HAYASHI MIRJAM NILSSON FLORA BERGGREN RAJESH SANTOSHI

president chief executive officer chief operations officer vp marketing
GRAHAM BARNES ROWAN MURPHY ELIZABETH MOORE ROBINE KLINE

vp product SEO strategist product designer content developer
PLANNING synergize scalable e-commerce
plan for product launch

MARKETING disseminate standardized metrics
DESIGN coordinate e-business applications
STRATEGY foster holistically superior methodologies
LAUNCH deploy strategic networks with compelling e-business needs

timeline
NOV 20XX
disseminate standardized metrics
SEP 20XX
synergize scalable e-commerce
JAN 20XX
coordinate e-business applications
MAR 20XX MAY 20XX

foster holistically superior deploy strategic networks with
methodologies compelling e-business needs
areas of focus
B2B MARKET SCENARIOS
o Develop winning strategies to keep ahead of the competition
o Capitalize on low-hanging fruit to identify a ballpark value
o Visualize customer directed convergence
CLOUD-BASED OPPORTUNITIES
o Iterative approaches to corporate strategy
o Establish a management framework from the inside

how we get there
ROI NICHE MARKETS SUPPLY CHAINS
o Envision multimedia- o Pursue scalable customer o Cultivate one-to-one

based expertise and cross- service through customer service with
media growth strategies sustainable strategies robust ideas
o Visualize quality o Engage top-line web o Maximize timely

intellectual capital services with cutting-edge deliverables for real-time
deliverables schemas
o Engage worldwide
methodologies with web-
enabled technologies

summary
At Contoso, we believe in giving 110%. By
using our next-generation data architecture, we
help organizations virtually manage
agile workflows. We thrive because of our
market knowledge and great team behind our
product. As our CEO says, "Efficiencies will
come from proactively transforming how we
do business."

thank you
mirjam nilsson
mirjam@contoso.com
www.contoso.com

Middle Range Theories

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Middle Range Theories

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Middle-Range Theories

Roli Joseph Z. Monta

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2. Mesosystem encompasses, influences, and interacts with persons in the

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Father or Intimate Partner

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1. Physical Recovery Phase (from birth to 1 month)

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Cognitive Schema is a person’s subjective interpretation of illness,

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Event Familiarity is the degree to which a situation is habitual or repetitive

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Self-Transcendence is the expansion of personal boundaries in various and

Well-Being is a feeling of being healthy, happy, and whole in accordance

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Temporality: Biographical time reflected in the continuous flow of the life

Body: Activities of life and derived perceptions based in the body

1. Illness-related work: Diagnostics, symptom management, care regimen,