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Middle Range Theory Evaluation

Middle Range Theory Evaluation

Middle Range Theory Evaluation


Walden University

Theoretical and Scientific Foundations for Nursing Practice

NURS 8110



Middle Range Theory Evaluation

Ingenious words articulated by the Hmong people are as follows: “when crossing a river,

remove your sandals; when crossing a border, remove your crown (Lor, Xiong, Park, Schwei, &

Jacobs, 2017, p. 408).” This proverb is inspiratory pertinent to the objectives of this author in

pursuit of nursing excellence. What wisdom may be translated from this Hmong aphorism and

found useful to the nursing discipline? The elucidation here of Hmong insight is as if they

desired to paint a picture for the conscious efforts vital to the achievement of cultural humility.

How does this relate to middle range theory?

Cultural congruency, requisite of humility, is imperative to optimal outcomes in the

nurse-patient relationship (Elminowski, 2015). The practice of humility by the nurse in settings

of diversity of culture promotes understanding and circumvention of cultural impositioning

(Isaacson, 2014). The misperception of capacity to practice cultural competency facilitates

hierarchical care, power imbalances, social injustices, and health disparities (Foronda, Baptiste,

Reindholdt, & Ousman, 2015). In the vast multicultural modern realm, continuing a remiss quest

for cultural competency gravely hinders patient care outcomes, whereas, upholding a vision of a

preferred future of universality of care exempt from bias is the pathway to nursing excellence.

Critical to this conquest is the augmentation of pertinent nursing knowledge; the evaluation of

theory is elementary to the propositioned developments. The purpose of this paper is to evaluate

the Culture Care: Diversity and Universality Theory and the Interpersonal Relations in Nursing

Theory from the context of a petition for cultural humility as the alternative to the solecism of

cultural competency.


Theory of Culture Care: Diversity and Universality


Madeleine Leininger contributed to the progression of nursing with her innovative

conceptual framework and theoretical development of cultural awareness. Leininger’s research

resulted in the birth of transcultural nursing with a focus on improvements in nurse-client

relationship outcomes when culturally congruent holistic care is present (Sitzman &

Eichelberger, 2015). Her explicit theory is one of middle range upper level with the basic tenets

offered as care being the essence of nursing as well as a direct action and cultural care and

sensitivity as the understanding and incorporation of values and beliefs of the patient to

positively influence health or illness. Further tenets presented are diversity as respect for

practices within cultures and universality as acceptable practices across cultures (McEwen &

Wills, 2014). Leininger accentuated the cultural awareness of the nurse combined with co-

participation in decision making with the client as necessary for delivery of meaningful and well-

received care (Sitzman & Eichelberger, 2015). Although implicit, she thoroughly presented the

detrimental impact of cultural impositioning to nursing.


Social significance.

The importance of a theory to society is appraised by its ability to meet the criterion of

significance (Fawcett & Garity, 2009). The use of this model for research in cultural humility is

socially significant. The general public is culturally diverse. Nursing care receptive of cultural

differentiations without assumptions improves health outcomes of the vulnerable (Horvat, Horey,

Romios, & Kis-Rigo, 2014).


Theoretical Significance

The criterion of significance is further examined in the theory’s facilitation of novel

awareness pertinent to the proposed contextual application of the investigated problem (Fawcett

& Garity, 2009). Previous studies of the concept of cultural competency have revealed increased

unresponsiveness to the culturally diverse patient leading to potential adverse patient safety

issues (Isaacson, 2014). Bringing awareness to the mindful utilization of humility rather than the

unconscious act of superiority in the nurse-client relationship is theoretically significant.

Internal Consistency

Semantic clarity is present when there are theoretical and operational definitions of all

concepts (Fawcett & Garity, 2009). Leininger’s model is inclusive of both constitutive and

operational definitions of each of her concepts. Clarity is sustained in this theory with no

deviation in the above definitions thereby meeting semantic consistency. The propositions of this

theory are reasonable together with inductive and deductive observations thus giving structural



Is there elegance in simplifying the complexity of the theory while maintaining meaning

(Fawcett & Garity, 2009)? The Theory of Culture Care: Diversity and Universality is succinct

and supported by Leininger’s Sunrise Model (McEwen & Wills, 2014).


Leininger’s theory is able to be empirically tested. The model has been confirmed using

techniques in quantitative and qualitative research and is capable of meeting criterion with use of

the C-T-E structural diagram (Elminowski, 2015; Fawcett & Garity, 2009; Long, 2016; Yeager

& Bauer-Wu, 2013). The model continues to be tested with use of countless culturalogical


assessment tools (Ethnomed website, n.d.; University of Washington Medical Center website,

n.d.; U.S. Department of Health and Human Services, Health Resources and Services

Administration, n.d.). Additionally, be it noted hypotheses testing is profitable in determining the

truism of observable outcomes (Fawcett & Garity, 2009; Im, 2015). Leininger’s model is explicit

in hypothesizing positive change in outcomes in healthcare as having more than a chance

relationship with the variables of employed transcultural nursing concepts and research findings.

Theory of Interpersonal Relations in Nursing


The aftereffect of order change within the discipline of nursing cultivated by Hildegard

Peplau in 1952 has had substantial impact on the nurse-client relationship (D’Antonio, Beeber,

Sills, & Naegle, 2013). Prior to Peplau, nursing was focused on what nurses did to their patients;

Peplau transformed this emphasis to what nurses did with their patients (Sitzman & Eichelberger,

2015). Peplau propositioned the core of nursing to emanate from achievement of mutualistic

relationships cognizant of individual traits of clients and self-awareness of nurses. Thus, implicit

in her model may have been the most primitive attempt to embrace cultural diversity and

encourage humility through construct of collaborative relationships in trade for authoritative.

Peplau’s theory is middle range descriptive with influences from Henry Stack Sullivan and

Abraham Maslow (McEwen & Wills, 2014).


Social Significance

Use of Hildegard Peplau’s theory for research in cultural humility is socially significant.

The multiculturalism of the general public continues to breed concomitant with advancements in

global mobility. Reduction in health disparities amongst the vulnerable necessitates supportive


interpersonal relations inclusive of humble attitude, openness, and equitable belief in human

rights (Foronda et al., 2015).

Theoretical Significance

Peplau’s innovative insight into concentration on patient experiences and stories as

fundamental to nursing care provides theoretical significance (Hagerty, Samuels, Norcini-Pala,

& Gigliotti, 2017). Her philological of listening to the patient with reverence for dignity was

pioneering over 50 years ago and remains seminal today in theoretical developments and

researchability in nursing as well as other fields. Cultural sensitivity is offered as necessary to the

interpersonal relationship (Karnick, 2013).

Internal Consistency

Semantic clarity is present in this theory in a manner fairly divergent in that Peplau

identifies the major concepts and offers constitutive definitions; subconcepts are propositioned

with operational definitions (Sitzman & Eichelberger, 2015). Semantic consistency is peculiar in

this theory, yet, maintained as operational definitions are plural while upholding constitutive

measures (Fawcett & Garity, 2009). The propositions are reasonable in simplicity giving

generalizability with inductive reasoning, however, limited in precision and hypothetical testing

as deductive reasoning (Im, 2015).


Peplau’s theory is parsimonious. She offers a modest number of concepts and

propositions thereby capturing her essential features without loss of content (Fawcett & Garity,

2009). Her diagrams are supportive of said parsimony and the links within the nurse-patient

relationship (Hagerty et al., 2017).



There has not been an abundant amount of formal testing of Peplau’s theory (Karnick,

2013). Nonetheless, it is considered to have capacity for empirical testing (Hagerty et al., 2017).

The structure of the model has been utilized in quantitative and qualitative research testing in

less than excessive amounts with good fit outcomes (Hagerty et al., 2017). Peplau’s interpersonal

theory has performed well in testing of pedagogical application in practice (Reid Searl et al.,

2014). Explicit hypothetical testing is limited due to inability to rule out chance difference versus

relational difference in patients who are not able to return communication.

Theoretical Selection

It is conceivable that either of the theories evaluated above may be suitable for the

investigation of cultural humility and its influence on nursing and healthcare. Both theories are

observed in their evaluations to be well-executed, have significance to the nurse and the patient,

and exhibit call for our discipline to transform from merely disease orientation to psychodynamic

nursing interventions (Foronda et al., 2015; Hagerty et al., 2017; Isaacson, 2014). Both theorists

incorporate the concept of individual culture of the patient as components in their philosophies.

Hildegard Peplau’s limelight on collaborating as one with the patient, devising care apropos to

the individuality of the patient, and nurse self-awareness does implicitly address culture. The

propositions of Madeline Leininger’s theory, inclusive of Peplau’s trinity above, are more easily

defined or explicit of cultural integration and its prominence on nurse-patient outcomes.

Leininger’s theory is not more correct than Peplau’s nor is the contrary accurate. Both

ladies’ theoretical contributions have revolutionized the practice of nursing with expansion of

concepts not considered prior, enhancement of research, and reflection-stimulated modifications

in patient care (Sitzman & Eichelberger, 2015). As a lifelong learner, it is this author’s


responsibility to systematically evaluate which theory offers the most usefulness in fortifying

personal professional practice (Sitzman & Eichelberger, 2015).

The Theory of Culture Care: Diversity and Universality is deemed most appropriate for

exploration of the clinical practice problem of awareness, comprehension, and application of

cultural humility as opposed to the unbefitting and antiquated schooling of cultural competency.

As above, Leininger’s propositions are precise, thus, allowing for objectification of criteria and

hypotheses testing of the conceptual framework of cultural humility. The theory-testing research

encompassing of these propositions are anticipated to generate said hypotheses that are found

falsifiable in regards to the assertion of the duty of the nurse to provide cultural humility,

thereby, giving truism to the vision of the author (Fawcett & Garity, 2009). Peplau’s

propositions, although profound, have confines relative to testability apposite of culture leading

to reduction in generalizability. As a doctoral candidate, this author is attentive to the impending

capstone resulting in local practice generalizability that is correspondingly worthy of

contribution to the nursing profession (Walden University, 2015).

Refinement of Clinical Practice Question

At commencement of assignment, the intent of this author was to delineate the betterment

of cultural congruence with adoption of cultural humility as alternative to cultural competence.

The labors invested here in the scholarly evaluations of theory produced an opinion that is more

informed regarding progression of the approaching doctoral study. As such, the amended and

now well-formulated PICOT is as below. Noted is the adjustment is surmised compulsory

pertinent to deductive reasoning and generalizability (Fawcett & Garity, 2009; Im, 2015;

Karnick, 2013; McEwen & Wills, 2014; Sitzman & Eichelberger, 2015). Further noted is the

clinical inquiry to be formatted as an intervention PICOT (Melnyk & Fineout-Overholt, 2014).


Patient population: Patients of culturally diverse backgrounds incongruent with nurse

Intervention: Staff education program to improve cultural awareness and cultural


Comparison: No education (no comparison group as all staff will be offered education).

Outcome: Evaluation of knowledge pre-and post-education.

Clinical practice question: In patients of culturally diverse backgrounds incongruent with

the nurse (P), how does an education program aimed at improving staff education by the nurse

(I) improve staff knowledge regarding cultural sensitivity? (O)


It is the long-term ambition of this author to alter the delivery of nursing care to that

which is congruent with the process of cultural humility; courage to remove one’s crown

becomes an expectation of the healthcare professional. Perceptions of hierarchy and pretense no

longer exist in a preferred future of nursing excellence. Values, beliefs, and practices of all

patients are explored and embraced with tender of egoless tactics. Advanced practice nurses are

stellar advocates of cultural humility recognizing its exercise as not only duty but privilege.

Paternalistic behaviors are shunned practices of the past. In their shoes, respect, equality, social

justice, and elimination of health disparities walk freely.



D’Antonio, P., Beeber, L., Sills, G., & Naegle, M. (2013). The future in the past: Hildegard

Peplau and interpersonal relations in nursing. Nursing Inquiry, 21(4), 311-317. doi:


Elminowski, N. S. (2015). Developing and implementing a cultural awareness workshop for

practitioners. Journal of Cultural Diversity, 22(3), 105-113. Retrieved from

Fawcett, J., & Garity, J. (2009). Evaluation of middle-range theories. In Evaluating research for

evidence-based nursing (Ch. 6). Retrieved from

Foronda, C., Baptiste, D., Reindholdt, M. M., & Ousman, K. (2015). Cultural humility: a concept

analysis. Journal of Transcultural Nursing, 27(3), 210-217. doi:

Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2017). Peplau’s theory of

interpersonal relatons: an alternate factor structure for patient experience data. Nursing

Science Quarterly, 30(2), 160-167. doi: 10.1177/089-4318417693286

Horvat, L., Horey, D., Romios, P., & Kis-Rigo, J. (Eds.). (2014). Cultural competence education

for health professionals. Cochrane Database of Systematic Reviews, 1-100. Retrieved


Im, E. (2015). The current status of theory evaluation in nursing. Journal of Advanced Nursing,

71(10), 2268-2278. doi:

Isaacson, M. (2014). Clarifying concepts: cultural humility or competency. Journal of

Professional Nursing, 30(3), 251-258. doi:


Karnick, P. M. (2013). The importance of defining theory in nursing: is there a common

denominator? Nursing Science Quarterly, 26(1), 29-30. doi: 10.1177/0894318412466747

Long, T. (2016). Influence of international service learning on nursing students’ self-efficacy

towards cultural competence. Journal of Cultural Diversity, 23(1), 28-33. Retrieved from


Lor, M., Xiong, P., Park, L., Schwei, R. J., & Jacobs, E. A. (2017). Western or traditional

healers? Understanding decision making in the Hmong population. Western Journal of

Nursing Research, 39(3), 400-415. doi:

McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA:

Wolters Kluwer/Lippincott Williams & Wilkins.

Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing &

healthcare: a guide to best practice (3rd ed.). Philadelphia, PA: Wolters

Kluwer/Lippincott Williams & Wilkins.

Reid Searl, K., McAllister, M., Dwyer, T., Krebs, K., Anderson, C., Quinney, L., & McLellan, S.

(2014). Little people, big lessons: an innovative strategy to develop interpersonal skills in

undergraduate students. Nurse Education Today, 34(9), 1201-1206. Retrieved from

Sitzman, K. L., & Eichelberger, L. W. (2015). Understanding the work of nurse theorists: a

creative beginning (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.

Walden University. (2015, September). Doctoral project premise: doctor of nursing practice

(Educational Standard). Retrieved from Walden University website:


Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: essential foundation for clinical

researchers. Applied Nursing Research, 26, 251-256. doi:


NURS 8110 Grading Rubric Week 10 Application 5: Middle Range or Interdisciplinary Theory Evaluation [MA3]

Points Possible

Points Earned

Briefly describe your selected clinical practice problem. 3

Summarize the two selected theories. Both may be middle range theories or interdisciplinary theories, or you may select one from each category.


Evaluate both theories using the evaluation criteria provided in the Learning Resources.


Determine which theory is most appropriate for addressing your clinical practice problem. Summarize why you selected the theory. Using the propositions of that theory, refine your clinical / practice research question.


Cover Page/Overall APA/Reference Page 5 Total Points 26 Comments:

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