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A Middle-Range Theory of
Psychological Adaptation in
Death and Dying
Marjorie C. Dobratz, RN, DNSc.
Professor Nursing Program
University of Washington Tacoma
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The University of
Washington,
Tacoma offers
undergraduate and
graduate
programs, and
shares CCNE
accreditation with
the UW School of
Nursing in Seattle.
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Middle-Range Theories (MRT’s)
Importance to Nursing
Predicted to be the “illusive practice theory” (Fawcett & Alligood, 2005, p. 229)
Provide “direction for nursing research” (Lasiuk & Ferguson, 2005, p. 130).
Can be applied “across several client populations and practice settings” (Lasiuk & Ferguson, 2005, p. 130).
“Contribute to understanding the human condition” (Graham, 2006, p. 276).
“Deal with limited sources of social phenomena” (Merton, 1968, p. 40).
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Middle-Range Theories (MRT’s)
Construction always “involves abstraction” (Merton, 1968, p. 39).
These abstractions form a “limited set of assumptions from which hypotheses can be derived and confirmed by empirical investigation” (Merton, p. 68).
MRT’s are empirically based and can fit with a conceptual model’s (CM) conceptual-theoretical structure (CTS).
A MRT is more specific than a conceptual model, as it describes, explains or predicts a CM phenomenon, and also limits the number of derived assumptions.
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Purpose
To present a MRT of psychological
adaptation in death and dying that was
abstracted from a series of quantitative and
qualitative research studies. The findings
were synthesized into limited number of
assumptions, testable hypotheses were
derived, and the constructed MRT was
linked to the conceptual-theoretical
structure of the Roy Adaptation Model.
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Roy Adaptation Model (RAM)
Middle-Range Theories
Adaptation to Diabetes Mellitus: Whittemore and Roy (2002) synthesized empirical evidence related to adaptation to this chronic disease.
Caregiver Stress: Tsai (2003) developed assumptions related to caregiver experience and linked them to the RAM’s conceptual framework.
Chronic Pain: Dunn (2004) reviewed the theoretical/empirical literature and developed six hypotheses that could be empirically tested.
Caregivers Psychological Distress: Five completed studies were linked to the RAM’s self concept model (Levesque et al., 1998).
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Abstracting a MRT of Psychological
Adaptation in Death and Dying
A quantitative, causal model study structured person-environment variables within the RAM framework: Dependent (psychological adaptation and well-being), independent variables were focal (physical function), contextual (pain, social support), and age, sex, length of illness were residual stimuli (Dobratz, 1993).
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Results of First Quantitative Study
The causal model study found that
the contextual stimuli of social
support (p <.001) and pain (p <. 05)
and the residual stimulus of age (p
<. 01) influenced the outcome of
psychological adaptation. Physical
function (focal stimulus) just missed
significance at (p < .07).
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Building a RAM-Based MRT
A second quantitative study compared the
same person-environment variables in
subjects who expressed spirituality (n = 44)
and 53 participants who did not express
spirituality (Dobratz, 2005). Only three
components of the McGill-Melzack Pain
Questionnaire: affective dimension, pain
rating index, and number of words
chosen were significantly higher for the
non-expressed spirituality group.
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Continuing to Build a MRT
A third study quantitative study involved statistical triangulation that compared numerical data from the causal model study and textual data from a concurrent grounded theory study in three patterns of the self-transacting dying: becoming, anguishing/agonizing, and avoiding (Dobratz, 2006)
A one-way analysis of variance confirmed that social support, physical functionand religious preference impacted end-of-life patterns.
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Further Building of the MRT
A qualitative study further described those 44 dying individuals who expressed spirituality (Dobratz, 2004). Life-closing spirituality was shaped by a core theme of believing, which was linked to comforting, releasing, connecting, giving, reframing, and requesting. The findings of this study also supported humanism and veritivity as defined in RAM theory.
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Continuing to Build the MRT
Although the grounded theory study
that was conducted in conjunction
with the causal model study emerged
seven patterns of the self-transacting
death and dying (Dobratz, 2002-03),
the becoming pattern was selected
for further analysis and abstracted to
build the MRT.
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The Importance of the Qualitative
Research in Developing MRT
More in-depth description of the Becoming-
Self determined that the 15 dying persons
in this pattern were self-integrated, created
personal meanings, used inner cognition,
and connected to others and a Higher
Being (Dobratz, 2002).
The pattern of the Becoming-Self also
supported humanism and veritivity as
defined within the philosophical
assumptions of the RAM.
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Conceptual Definition of Spirituality
Four themes that define spirituality:
1. Spirituality as religious systems or beliefs, 2. Spirituality as life meaning, purpose and connection to others, 3. Spirituality as non-religious systems of beliefs or values, 4. Spirituality as metaphysical or transcendental phenomena (Sessanna, Finnell, & Zezewski, 2007, p. 252). With this broader definition, spirituality rather than religion is the concept used in this MRT abstraction.
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Theoretical Assumptions from
Abstracted Findings
Psychological adaptation in death and dying is influenced by pain and physical function.
Psychological adaptation in death and dying is promoted by connecting to supportive others.
Psychological adaptation in death and dying is impacted by spirituality.
With age a residual stimulus in death and dying, no assumption can be made regarding this influence.
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Derived Hypotheses
Pain has a negative effect on psychological adaptation.
Pain has a negative effect on expressed spirituality.
Social support has a positive effect on psychological adaptation.
Physical function has a negative effect on psychological adaptation.
As a residual stimuli, the impact of age warrants further testing.
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Conceptual Definition of
Psychological Adaptation in Death
and Dying
Given the concepts abstracted from the quantitative and qualitative studies, “Psychological adaptation in death and dying is using spiritual and social resources, and managing physical symptoms to maintain self-integration”.
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Roy Adaptation
Model
Regulator
Physiologic - Physical
Pain, Physical
Function
Symptom
Management
Cognator
Self Concept Role Function Interdependence
Spirituality Social Support Social Support
Psychological Adaptation
in Death and Dying
Adaptive Modes
Coping Processes
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Coping Processes
Regulator Subsystem: The dying process
is impacted by neural and chemical
systems associated with pain and physical
function
Cognator Subsystem: The dying process
is linked to four cognitive-emotional
channels that affect perceptual and
information processing, learning, judgment,
and emotional
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Links to RAM Modes
Physiological-Physical Mode: Pain
and physical function include “the
physical and chemical processes
involved in the function and activities
of living organisms”(Roy, 2009. p. 89).
The Self-Concept Mode: Spirituality is
a part of the personal self that
includes a moral-ethical-spiritual
component (Roy, 2009, p. 96).
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Links to the RAM Modes
Role Mode: Social support and
connectedness to others relates to the
social integrity component and the “need to
know who one is in relation to others” (Roy,
2009, p. 98), even though life is ending.
Interdependence Mode: Social support
and connectedness to others involves the
willingness and ability to give and receive
love and nurturing at the end of one’s life.
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Conceptual Definition of Adaptation
Adaptation is defined as “the process
and outcome whereby thinking and
feeling people, as individuals or in
groups use conscious awareness and
choice to create human and
environment integration “ (Roy, 2009,
p.29).
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Links to Philosophic Assumptions
Dying persons have mutual relationship with others and a God-like figure.
Dying person find human meaningthat is rooted in an omega point convergence of the universe.
Dying persons use human creative abilities of awareness, enlightenment, and faith.
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Links to Scientific Assumptions
Dying persons use consciousness and meaning to maintain person self-integration.
Dying persons utilize processes of self-awareness that are rooted in thinking and feeling.
Dying person connect to others in relationships that accept, protect, and foster independence.
Dying persons integrate human and environment meanings that result in adaptation.
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Nursing’s Goal in Life-Closure
To promote adaptation for dying individuals and their families, thus contributing to health within dying, enhanced quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities (promoting spirituality and assuring social support) and by intervening in the environment to control pain and manage symptoms.
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References
Dobratz, M. C. (1993). Causal influences of
psychological adaptation in death and dying.
Western Journal of Nursing Research, 15 (6), 707-
722.
Dobratz, M. C. (2002). The pattern of the becoming-
self in death and dying. Nursing Science
Quarterly, 15 (2), 137-142.
Dobratz, M. C. (2003-03). The self-transacting dying:
Patterns of social-psychological adaptation in
home hospice patients. Omega: Journal of Death
and Dying, 46 (2), 147-163.
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References
Dobratz, M. C. (2004). Life-closing spirituality and the
philosophic assumptions of the Roy adaptation
model. Nursing Science Quarterly, 17 (4), 335-
338.
Dobratz, M. C. (2005). A comparative study of life-
closing spirituality in home hospice patients.
Research and Theory for Nursing Practice: An
International Journal, 19 (3), 241-254.
Dobratz, M. C. (2006). Enriching the portrait:
Statistical triangulation of life-closing theory.
Advances in Nursing Science, 29 (3), 260-270.
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References
Dunn, K. S. (2004). Toward a middle-range theory of adaptation to chronic pain. Nursing Science Quarterly, 17 (1), 78-84.
Fawcett, J., & Alligood, M. R. (2005). Influences on advancement of nursing knowledge. Nursing Science Quarterly, 18 (3), 227-232.
Graham, I. (2006). Letters to the editor. Nursing Science Quarterly, 19 (3), 276-277.
Lasiuk, G.C., & Ferguson, L. M. (2005). From practice to midrange theory and back again: Beck’s theory of postpartum depression. Advances in Nursing Science, 28 (2), 127-136.
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References
Levesque, et al. (1998). Empirical verification of a
theoretical model derived from the Roy adaptation
model: Findings from five studies. Nursing Science
Quarterly, 11 (1), 31-39.
Merton, R. K. (1968). Social theory and social
structure. New York, NY: The Free Press.
Roy, S. C. (2009). The Roy Adaptation Model (3rd
ed.). Upper Saddle River, NJ: Pearson Education,
Inc.
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References
Sessanna, L., Finnell, D., & Jezewski, M. A. (2007).
Spirituality in nursing and health-related literature.
Journal of Holistic Health, 25 (4), 252-262.
Tsai, P-F. (2003). A middle-range theory of caregiver
stress. Nursing Science Quarterly, 16 (2), 137-
145.
Whittemore, R. & Roy, S. C. (2002). Adapting to
diabetes mellitus: A theory synthesis. Nursing
Science Quarterly, 15 (4), 311-317.