from practice to midrange theory and back again · midrange nursing theory. we demonstrate beck s...

Adi-ances in Nurstnn ScienceVol. 28, No. 2. pp. l27-liS6© 2(HIS Uppinc-oti WUIUma & Wilkins. tut

From Practice to MidrangeTheory and Back AgainBeck's Theory of PostpartumDepression . . ,

Gerri C. Lasiuk, MN, RN; Linda M. Ferguson, MN, RN

This article presents a brief overview of theory as background for a more detailed discussionof midrange theory—its origins, the critical role for midnmge theory in the development ofnursing practice knowledge, and the criteria for evaluating midrange theory. We then chron-icle Chery! Tatano Beck's program of research (jn postpartum depression (PPD) and advancethe thesis that her theory of PPD. titled Teetering on tbe Edge, is an exemplar of a substantivemidrange nursing theory. We demonstrate Beck s progression from identification of a clin-ical problem to exploratory-descriptive research, to concept analysis and midrange theorydevelopment, and fmally to the application and testing of the theory in the clinical setting,riirough ongoing refmement and testing of her theory. Beek has increased its genenilizabitityacross various practice settings and continually identifies new issues for investigation. Beck'sprogram of research on PPD exemplifies using nursing outcomes to build and test nursingpractice knowledge. Key words; Cheryl Tatano Beck, middle range theory, nursing prac-tice theory, nursing outcomes, nursing theory, pnstpartutn depression

IN today's world of evidence-based nurs-ing and kmm'ledge utilization, few ques-

tion the centrality of theory to nursing knowl-edge deveiopment and the importance of thatprocess to the ongoing evoltition of the dis-cipline. Although even Florence Nightingaleknew that the practice of nursing requiresspecialized, discipline-specific knowledge,' itwould be several decades before the scienceof nursing had evolved sufficiently to sys-tematically develop that knowledge. In theearly part of the last century, nursing prac-tice knowledge took the form of "rules, prin-ciples, and traditions"' P '*^ derived from ex-

From the Faculty of Nursing, llniuersity of Alberta,Edmonton, AH (Ms iMsiuk), and the CoUege ofNursing. University of Saskatchewan, Saskatoon, SK(Ms Ferguson), Canada.

Corrvsfxmding author: Gerri C. Lasiuk, MN, RN. Facultyof Nursing. Uniivrsity of Alberta, .ird Floor, Clinical Sci-ences lildg, Edmonton. AB, Canada T6G 2G3 (e-mail:gerri. lasiuk ® ualbertu. ca).

perience and taught by rote. Tlie compe-tent practitioner needed only a caring dis-position coupled with a handful of techni-cal skills, which were taught in hospital-basedapprenticeship-training programs. The littletheoretical knowledge that did exist in nurs-ing was co-opted from other disciplines.

This situation began to change when thepublic health movement took hold in theWestern world. By 1913, the National Leaguefor Nursing Education in the United Statesrecognized that the increasing scope andcomplexity of nursing practice required abroader knowledge base that must include"some knowledge of the scientific approachto disease, causes, and prevention "2(p60)The social upheaval that accompanied twoworld wars and the intervening Depressionyears spawned major shifts in the social or-der; changes to the delivery of healthcare; anda growing demand for skilled nurses. In re-sponse, national governments invested newresources into the study of nurse educationand work life. This was a critical juncture

127

128 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2005

for the discipline because it presented bothan opportunity and an imperative for nursesto articulate the nature of the discipline, todefine its domain, and to set a course forfuture development. Consideration of theseweighty issues precipitated a cascade ofevents that culminated in a consensus aboutthe need for a body of distinctly nursingknowledge, developed and tested throughresearch (for reviews, see references 1and 3).

Tlie importance of theorj' to nursingknowledge development received officialsanction in 1965 when the American NursesAssociation (ANA) issued a position paperdeclaring theory development to be the pri-mary goal of the profession.^ Nursing schol-ars responded and the earliest nursing the-ories went to press in the iate 1960s andthrough the 1970s. These highly abstractgrand theories and conceptual models de-fined the boundaries of the discipline andestablished the theoretical foundations fornursing curricula.'** While many practic-ing nurses saw them as having little directrelevance to their work, their articulationwas a necessary precondition for subsecjuentphases in nursing knowledge development.'In their seminal article, Dickoff et al" reit-erated the theory-practice gap and sketchedout a course for the development of research-based knowledge to guide nursing practice.At the same time, the sociologist Merton^' in-troduced the notion of middle-range theory asa means to guide empirical inquiry and to testthat discipline's organizing theories. Jacox^would later endorse middle-range theory de-velopment as an important vehicle for the de-veiopment of practice knowledge needed innursing.

By the late 1980s, nursing was primed torespond to Meleis'* ''' ^* impassioned plea fora "reVisioning" of the goals of nursing schol-arship. For the discipline to go forward, shesaid, it must refocus its efforts on developingsubstantive nursing knowledge built on con-cepts grounded in practice. This marked theentry of nursing into the current era, one inwhich the main thrust is toward the gener-

ation and testing of midrange and situation-specific theory.

This article opens with a brief review oftheory as a way to create a context for a moredetailed discussion of midrange theory—itsorigins, the critical role for midrange the-ory in the development of nursing prac-tice knowledge, and criteria for evaluatingmidrange theory. We then chronicle CherylTatano Beck's program of research on post-partum depression (PPD) and advance thethesis that her theory of PPD, titled Teeter-ing on the Edge, is an exemplar of a sub-stantive midrange nursing theor>'. We demon-strate Beck's progression from identificationof a clinical problem, to exploratory descrip-tive research.^"'- to concept analysis'^ andmidrange theory development,'^ and finallyto the application and testing of her theor\' inthe clinical setting.''^"'" Through ongoing re-finement and testing of the theory. Beck hasincreased its utility and applicability acrossvarious practice settings and continually iden-tifies new issues for investigation. This re-search program on PPD exemplifies of usingnursing outcomes to develop practice knowl-edge through midrange theory development.

THEORY: A PRIMER ' '•

Chinn and Kramer describe theory as the"creative and rigon)us structuring of ideasthat projects a tentative, purposeful, andsystematic view of phenomena."'*f'"* Morespecifically, it consists of concepts and therelationships among those concepts, for thepurpose of describing and explaining the phe-nomenon, predicting outcomes, or prescrib-ing nursing actions.-^''^^" Theory serves toorganize disciplinary knowledge and to ad-vance the systematic development of thatknowledge.^ It may also identify' the param-eters of a discipline; provide a means for ad-dressing disciplinary problems; furnish a lan-guage with which to frame ideas of interest toa discipline^; and provide unifying ideas aboutphenomena of interest to a discipline.'"

By its nature, theory' is abstract and doesnot exist in the material world per se; rather.

From Practice to Midrange Theory and Back Again 129

it is a mental conception or an idea that rep-resents things or events in that world. Be-cause it is abstract, theory does not necessar-ily represent a particular thing or event, butmay refer more generally to a class of simi-lar things or events. In contrast, somethingthat is concrete does exist in material formand "is embodied in matter, actual practice,or a particular example.'* ' In elucidating thenature of a particular theory, we might con-struct an imaginary line or continuum (an ab-straction in itself!) anchored on one end bythings or events thai are concrete and on theother by things or events that are abstract.Theories that are relatively more abstract arcbroader in scope and can be generalized to agreater number of things or events, whereasthose that are more concrete are narrowerin scope and applicable to a smaller range ofphenomena.

A concept is "a complex mental formula-tion of experience.""P**'* It is the totality ofa phenomenon, as it is perceived and—if itis empiric—can be verified by others. Liketheories, concepts also exist at varying lev-els of concreteness and abstractness. A con-cept such as "biological sex" is more con-crete (or empiric) because we can directlyt)bserve evidence of it. On the other hand,phenomena that can be measured only in-directly (such as depression) are somewhatmore abstract and exist somewhere in themiddle of our continuum. At the other endof the scale are highly abstract concepts like"self esteem" or "social support." Measure-ment of these concepts is also done indirectly,via agreed-upon indicators. The relationshipsbetween and among the concepts of a theoryare stated -AS propositions} These are "postu-lates, premises, suppositions, axioms, conclu-sions, theorems, and hypotheses,"'"' *** eachof which reflects the proposition's purpose,t>'pe of logic used in its construction, and thecontext in which the propositions occurs.

Types of theory

Having described key elements of theory,we can begin to label theories on the basis of

their nature and purpose. Here we will con-sider metatheories, grand theories, midrangetheories, and situation-specific theories.

Metatheory is global in nature and stipu-lates, in the broadest terms, the phenomenaof interest to a discipline. Because of its highdegree of abstraction, metatheory does notlend itself to empirical testing. This level oftheory furnishes the concepts and proposi-tions that are epistemological building blocksfor disciplinary knowledge development. Toa lesser degree than metatheory, grand the-ory is also very abstract. It offers conceptualframeworks, which define and organize disci-plinary knowledge into distinct, though stillbroad, perspectives.'

The sociologist Merton* introduced the no-tion of middle range theory as a tool for em-pirical inquiry. He described it a "limited set ofassumptions from which specific hypothesesare logically derived and confirmed by empir-ical investigation.• ' P' '*** Midrange theories areless abstract and more limited in scope thangrand theories. They involve fewer concepts,have clearly stated propositions, and readilytend themselves to the generation of testablehypotheses. ^

Situation-specific or microtheories focuson specific phenomena in a particular set-ting. They are very limited in scope andare not intended to transcend time, place,or social-political structure.^ Two such nurs-ing theories are Gilliland and Bush's^^ the-ory of social support for family caregivers andIm and Meleis' - theory of Korean immigrantwomen's menopausal transition.

MIDRANGE THEORY

A major limitation of grand-theory is that itsconcepts are too broad and abstract for em-pirical testing. In contrast, situation-specificor single-domain theories- contribute little tobuilding a cohesive and unified body of dis-ciplinary knowledge because they are veryconcrete and too narrow in scope. Merton*'argues that middle range theory circum-vents both of these problems. To his way of

130 ADVANCES IN NURSING SciENCE/APRa-JUNE 2005

thinking, efforts to explicate a unifying grandtheory in sociology had just the oppositeeffect. That is, they resulted in the proUf-eration of a "multiplicity of philosophicalsystems in sociology and, further, led to theformation of schools, each with its cluster ofnia.sters and disciples.•*^ '' * Merton believesthat sociology's advance as a discipline restson the development of middle-range theorywhereas continued focus on total sociologi-cal systems (ie, grand theories) impede thatprogress. In nursing, early efforts to definethe parameters of nursing's domain and toidentify its phenotnena of interest led tothe development of metatheory and grand-theory While these did serve to differenti-ate nursing from other disciplines and expli-cated the discipline's ontological values, theyprovided little direction for nursing researchto say nothing of the day-to-day practice ofnursing. •

According to Merton,*' middle range the-ory can be developed from grand-theory (de-ductively) or from empirically grounded con-cepts (inductively). He emphasized, however,that the strength of middle-range theor>' is itscapacity to describe, explain, and make pre-dictions about concrete phenomena of inter-est to a discipline. The range of theoreticalproblems and testable hypotheses generatedby middle range theory potentates its util-ity and productivity. While Merton beUevesthat the larger conceptual schemes of thediscipline should evolve from the concep-tual consolidation of tested middle-range the-ories, he does not advocate exclusive focus onthem.

Early nursing advocates of midrangetheory "* envisioned that a particularmidrange theory might support a singleor multiple grand-theories, thus coheringnursing knowledge. As well, Cody ** suggeststhat midrange theory testing provides a wayto analyze the adaptability of nonnursingtheories to nursing practice. On a cautionarynote, however, he adds that researchersand clinicians must first determine whetherthis borrowed theory is consistent with the

ontological values of nursing. If it is not, hewarns, it will not advance nursing science.

' -• r

Evaluating Midrange Theory

In a 1993 address to the ANA's Councilof Nurse Researchers Symposium, Suppe pro-posed that midrange theory is identifiable byits scope, level of abstraction of the concepts,and testability.-'' The scope or generalizahil-ity of a theory refers to the range of phe-nomena to which the theory applies' or tothe number of situations addressed by a par-ticular theory.^ Because midrange theory ismore concrete than grand theory—but lessso than situation-specific theory—it appliesacross several client populations and practicesettings, but not to all.'•'''•^^ The concepts of amidrange must be clearly delineated and suf-ficiently concrete as to be testable.''''•^"•^'''^"Testability requires that these concepts can becoded objectively, as operational definitions,empirical measures, or hypothesized relation-ships, and that researchers can test the rela-tionships between and among these conceptsunder different conditions.'''-''••^^

In the following section, we exatnineCheryl Tatano Beck's theor)' of PPD. Ourmethod for doing this is adapted from anapproach to theory analysis described byMeleis^ and on the more specific crite-ria for analysis and evaluation of midrangetheory proffered by Whall. ' Meleis' ap-proach encourages attention to the tbeorist's background and important life influ-ences; the paradigmatic origins of the theory;as well as analysis of the theory's nitionale,scope, goal, and system of relations amongother factors. This provides a context forthe theory, locates the theorist in the largerscientific community, and fosters an under-standing of where their work resides withinthe disciplinary knowledge structure. On theother hand, Whail s approach to theory eval-uation is more directly oriented to an analy-sis of whether or not a theory bears the char-acteristics of a midrange theory. The latterconsiders (1) the assumptions underlying the


theory; (2) the relationship of the theory tophilosophy of science; (3) any loss of infor-mation due to concepts not being interrelatedvia propositions; (4) presence/absence of in-ternal consistency and congruence among allcomponents of the theory; (5) empirical ad-equacy of the theory; and (6) evidence as towhether it has been tested in practice and/orthrough research and has held up to tliatscrutiny.

TEETERING ON THE EDGE: IS IT AMIDRANGE NURSING THEORY?

Beck's background and life influences

According to her curriculum vitae,^" Beckreceived a bachelor s degree in nursing in1970 from Western Connecticut State Univer-sity. Two years later, she earned a master'sdegree in both maternal-newborn nursingand nurse-midwifery from Yale University.She specifically chose the Yale program be-cause of this blend of research training andclinical specialization (written communica-tion, November 25, 2002). A decade later, in1982, Beck completed a doctorate in nurs-ing science from Boston University. Duringthat time, we see foreshadowing of Beck'slater interest in PPD. The firsi of these is anarticle^' examining the contributions of roleconflict and learned helplessness to women'sdepression. The second comes during herdoctoral research (involving time perceptionduring labor and delivery) when she is in-trigued to discover a link between depressionand alterations in time sensibility (writtencommunication, November 25, 2002). Tenyears later, in an analysis of maternal-newbornnursing Htenitiire published between 1977and 1986.' Beck concluded that nurse re-searchers need to aim for methodological con-gruence in their choice of researeh designs;that the reliability and validity of instrumentsemployed in maternal-child research must beevaluated; and that maternal-child nurse re-searchers need to identify areas of potentialresearch.

Paradigmatic origins of the theory

Beck's initial study in the area of PPD ex-plored early discharge programs in the UnitedStates through a literature review and cri-tique, in which she identified a significant gapin maternal care. She wrote:

What has not been given equal priority in post-partum follow-up care, however, is the mother'spsychological status, more spccificaUy, the phe-nomenon of maternity blues. Early discharge moth-ers are at home when the blues usually occurduring the first week after delivery. Specific assess-ments for maternity blues should routinely be partof the nurse s assessment of these mothers duringhome visits.

Tlie next year, she reviewed the existing lit-erature on maternity blues" and began clar-ifying the differences among the conceptsof postpartum psychosis, postpartum deptvs-sion, and maternity blues- She also identi-fied the need to improve the instruments em-ployed in this area and called for "both quali-tative and quantitative research designs . . . tocompletely investigate the phenomenon ofthe blues. ""<P2' ">

Beck ' takes exception to the notion thatqualitative research belongs exclusively to theearly stage of a re.search program. She con-tends that at the initset of a research pro-gram it is impossible to predict its trajectory.Rather, she says, the "path of a nurse scien-tist's research program is truly determined bythe state of knowledge that is known at eachjuncture when the research questions for thenext study are being determined."^-'f'-*''" Inresponse to Morse s ^ caution against inves-tigators moving back and forth between in-ductive and deductive research approachesat the expense of methodological rigor. Beckcounters that researchers can acquire theknowledge and skills about a variety of re-search methods through continuing educa-tion and/or via collaboration with others whohave the methodological expertise neededfor a particular study. In her rejection ofthe incommensurability of different inquiryperspectives, she provides the basis for her


program of research: the need to address thequestion that arises with the most appropri-ate research method.

Philosophical foundations

Beck reflects characteristics of a postmod-ern philosophy of science. Many postmod-ernists are also constructivists who believethat each of us constructs an imderstandingof the material world on the basis of ourperceptions of it. Because observation andperception are fallible, these understandingsare inviiriably incomplete. Our best hope forapproximating a full understanding of phe-nomena of interest, is through systematic re-search employing multiple methods. Accord-ing to Beck. "Each successive research projectshould be guided by the previous researchstudy. Tlie objective of this systematic, con-tinuous inquiry is the cumulative productionof new knowledge in a substantive area ofnursing. " <P '' >

1

Scope of the theory

In 1992, Beck'^ published a phenomeno-logical study of the lived experience of PPD.Data for the study were the text of tran-scribed interviews with women attending aPPD support group, which Beck cofacilitatedfor a number of years. From those. Beckidentified 45 significant statements about thewomen s experience of PPD and clusteredthem into the following 11 themes, which ex-plicate the "fundamental structure of postpar-tum depression"' ' ***:

1. Unbearable loneliness2. Contemplation of death provides a

glimmer of hope3. Obsessive thoughts about being a bad

mother4. Haunting fear that "normalcy" is irre-

trievable5. Life is empty of all previous interests

and goals6. Suffocating guilt over thoughts of

harming their infants7. Mental fogginess

8. Envisioning self as a robot, just goingthrough the motions

9. Feeling on the edge of insanity due touncontrollable anxiety

10. Loss of control of emotions11. Overwhelming feelings of insecurity

and the need to be motheredThe next year Beck'^ extended those find-

ings into a grounded theory of PPD, titled Tee-tering on tbe Edge. She chose a qualitativeapproach to the topic because she believedthat the Beck Depression Inventory (BDl),^' awidely used instrument to detect depression,failed to accurately capture the "horrifving ex-periences" (written communication, Novem-ber 25, 2002) of PPD that she saw in her clini-cal practice. Research evidence corroboratedBeck sobservations,'''-^'^' calling into questionthe content validity of the BDI for PPD andidentified a need for further investigation.

Beck s grounded theory inquiry involveda purposive sample of women attending herPPD support group. Data were collected overa period of 18 months and included fieldnotes from the support group meetings andtranscriptions of in-tlepth interviews with 12of the group s participants, liirough con-stant comparative analysis. Beck identified thecore variable or basic psychological problemin PPD as being ioss of control, which thewomen experienced as teetering on the edgeof insanity. Participants' attempt to cope withPPD through 4 stages—encountering terror,dying of self struggling to survive, and re-gaining control (Fig I).

In the first stage of PPD, encountering ter-ror, the women live with horrifying anxiet),relentless obsessive thinking, and envelojving fogginess. During the stage of dying ofself they experienced alarming unrealness,isolation, and thoughts/attempts at self-harm.The third stage of PPD, struggling to sur-vive, reflects the women's attempts to sur-vive by praying for relief, battling the sys-tem, and seeking solace in support groups.In the final stage, regaining control, partici-pants experience unpredictable tmnsitioning,mourning of lost time, and guarded recovery.These 4 stages of PPD subsume the 11 themes

Stage 1

From Practice to Midrange Theory and Back Again

Stage 2 Stage 3 Stage 4

133

Horrifyinganxieiyattacks

CONDITIONS CONSEQUENCES STRATEGIES

1. The 4-stage process of Teetering on the Edge.

CONSEQIENCES

generated in Beck's earlier phenomenologicalstudy,' which, according to Beck,'"* extendsand enhances the trustworthiness of her con-ceptualization of PPD.

Internal consistency

The major concepts in Beck's theory ofPPD {loss of control, encountering terror, dy-ing of self struggling to surinve, and regain-ing control) are moderately abstract and rela-tively narrow in scope. All of the importantconcepts in Beck's theory are clearly iden-tified, as are the propositions that explicatethe relationships among them. The authorexplains each of the concepts and supportsthem with direct quotes from participants.With respect to the concept of dying to selfBeck furnishes'"* '"*'** a partial audit trail illus-trating how she derived the concept fromthe data. The fact that the 11 themes fromher phenomenologicai study'^ readily sub-sume into the codes in her grounded theorystudy'** indicates a high degree of transfer-

ability, dependability, and congruence of re-sults between the studies. Not only is infor-mation not lost, but the findings from a priorphenomenological study'^ are integrated intoBeck's'^ ground theory research project. Tliissuggests a high degree of internal consis-tency and congruence among elements of thetheory.

An assumption underlying Beck's theory isthat PPD is a significant women s health prob-lem that not only affects individual womenbut also has deleterious effects on their chil-dren's health and development.*^"'" Despitethe fact that PPD had received considerableresearch attention by 1993, little of it wasqualitative in nature. That being the case.Beck believed that some aspects of tlie ex-perience of PPD remained underexplored.As well, because previous studies had neverdemonstrated an unequivocal link betweenPPD and the physiological changes associatedwith pregnancy and childbirth, there were un-doubtedly other factors at play (eg, psychoso-cial, environmental, etc).


Other assumptions supporting Beck's the-or>' of PPD are those embedded in the qual-itative inquiry paradigm, which is consistentwith nursing's values. Participants in qualita-tive research are viewed as competent know-ers of their own experience and, as such,are collaborators in the inquiry process. Inthis tradition, there is emphasis on under-standing phenomena by attending closely toparticipants' lived experience. Furthermore,because qualitative research is discursive innature and emergent in design, the researcherexamines data for patterns of meaning withthe aim of objectifying those patterns for sci-entific inquiry, while at the same time en-deavoring to remain true to the participants'construction of their experience. Qualitativeresearch arises from traditions of human sci-ence inquiry in which the intent is to con-struct a holistic and ecological understandingof the phenomenon in question.

Empirical adequacy and testingThe empirical adequacy of Beck's theory

of PPD becomes apparent in her subsequentwork. She went on to develop the PostpartumDepression Predictors Inventor}'"' (PDPI), atool to identify women at risk for develop-ing PPD. The PDPI is a checklist of 8 risk fac-tors, determined through 2 meta analyses^^- 'to relate to PPD. These factors include pre-natal depression, prenatal anxiety; history ofprevious depression, social support, maritalsatisfaction, life stress, childcare stress, andmaternity blues. The PDFI is used in clin-ical settings across North America and inIceland."* In 2002, Beck published a revisedversion of the PDPI—the PDPI-R. which in-corjiorates the results of another, more recentmeta-analysis.'

Beck has also collaborated with(lable' " '" ^ "* to develop the PostpartumScreening Scale (PDSS) for detection ofPPD. The PDSS is a 35-item, Ukert-type,self-report instrument whose psychometricproperties are supported in the literature andby content experts.'"^ Confirmatory factoranalysis of the scale supports the existenceof its 7 hypothesized dimensions. Analyses

of the 5-point response categories supportedmeaningful score interpretations and theinternal reliability ranged from 0.83 to 0.94.Recently Beck'* published a Spanish versionof the PDSS.

Beck's research program clearly adopts aholistic approach to understanding the expe-rience of PPD. consistent with the perspec-tive and values of nursing. She explores viewsabout women as w hole beings operating inthe context of a person-health-environment-nursing complex. In all of her writing. Beckdiscusses the implications of the work fornursing care. At the same time, her work res-onates "with those in other clinicians and re-searchers who work in the area of PPD. Wefind evidence of this in the congruence be-tween Beck's theory with the work of Sicheland Driscoll (cited in reference 18) "earth-quake model" of PPD. Tlie latter explains thata woman's vulnerability to PPD reflects herunique genetic, hormonal, and reproductivemakeup in the context of her life stressors.Depression, like an earthquake, can eruptwhen pressures increase at already highlystressed points of the system.

CONCLUSION

This article reviewed the basic elementsof theory and chronicled the development ofTeetering on the Edge. Cheryl Tatano Beck'stheory of PPD." We argue that Beck's the-ory is an exemplar of substantive midrangenursing theory. Through ongoing refinementand testing of her theory of PPD, Beckhas increased its generalizability across var-ious practice settings and continually iden-tifies new issues for investigation. Becksprogram of research on PPD represents asignificant contribution to nursing practiceknowledge tlirough midrange theory develojvment, which, in turn, advances the disciplineof nursing.

Midrange theory has the potential to ad-dress the theory-practice gap that continuesto plague nursing and to develop the substan-tive practice knowledge needed to advancenursing as a discipline.


REFERENCES

1. (.:hinn PL. Knimer MK. Integrated Knowledge l)et>el-opmenl in Nursing. 6th ed. St Louis, M«: Mosby;200-i.

2. Gortner SR. Knowledge dcvclopmenl in nursing: ourhistorical roots and future opportunities. Nurs Out-look. 2(K)2;4H:f><>-67.

3. Mt'tfis AI. Theoretical Nursing: Deivloimient andI'rogivss. . rd ed. Philadelphia: Lippincotl Williams &Wilkins: 1997.

-1. Ulegen MA. Tripp-Reimer T. Implications of nursingtaxonomies for middlf-rairfie theor)' development.Adi'NursSci. 1997;19:37-19.

5. Dickoff J, James R Wiedenbach E. Theory in a prac-tice discipline, Pt 1: practice oriented theory. NursRes. 1968;17:415-'i3'>.

6. Merton RK. Social Theory and Social Structure.New York: Tlie Free Prt-ss: 19(>8.

7. Jacox A. Theory construction in nursing: anoverview. Nurs Hes. 1974;23:4-13.

8 Meleis AI. Revisions in nursing knowledgf devel-opment: a passion tor substance In: Nicoll LJi. ed.Perspectives on Nursing Theor)'. 3rd ed. Philadel-phia. Pa: Uppincott Williams & Wilkins; 1997:12.5-132.

9. Beck err. Maternal-newborn tiursing research pub-lished from 1977 to 1986. West J Nurs Res. 1989;11:621-626.

II). Iteck CT. Early postpartum discharge: litera-ture review and critique. Women atid Health.1991;17:125-138.

11. lJeck f:T. Maternity blues rcsearcli: a critical review.Issues Mental Health Nurs. 1991; 12:291-300.

12. Beck CT. Po.stpartum depres.sion: a meta-synthesis.Qual Health Rus. 2OO2:12:4'>3-472.

13. Beck err. Tlie lived experience of postpartum de-pression: a plienomenological study. Nurs Res.1992:41:166-170.

I (. Beck CT. Teetering on the edge: a substantive theor>'of postpartum depression. Nurs Res. 1993:42:42-48.

15. Beck CT, Gable RK. Postpartum Depression Screen-ing Scale: development and psychometric testing.Nurs Res. 2(H)():49:272 282.

16. Beck (T. Predictors of postpartum depression: an up-date. Nurs Res. 2(H)l;5():27S-2HS.

I"". Ikck CT. Gable RK. Further validation of thePostpartum Depression Screening Scale. Nurs Res.20OI;5O:!55-l64.

18. Beck <T, Gable RK. Cxiniparative analysis of the per-formance of the Postpartum Depression ScreeningScale with two other depression instruments. NursRes. 2001:50:242-250.

19. Faweett J. Analysis and Evaluation of Contempo-rary Nursing Krioivledge: Nursing Models and Tbe-ories. Philadelphia: FA Davis; 2(XK).

20. Walker LC), A\ant KC:. Strategies for Theory Con-struction in Nursing. 3rd ed. Norwalk, C^onn: Apple-ion & Lange: 1995.

21. Oxford University Press. Oxford University Dictithnary. Available at: http://dictionar>.oed.com/. Ac-cessed April 16. 20(t5.

22. GilJiland MR Hush HA. SiKrial support for family care-givers: toward a siluation-specifie theory, y TheoryConstr Testing. 2(H)l;5:53-62.

23. Im E, Meleis AI. Situation-specific theories: philo-sophical roots, properties, and approach. ANS.I999;22:lI-24.

24. Suppe F. Jacox AK. Philosophy of science and thedevelopment of nursing theory. Ann Rev Nurs Res.1985;3:241-267.

25. Cody WK. Middle-range theories: do they fosterthe deveiopment of nursing science? Nurs Sci Q.1999:12:9-14.

26. Higgins PA. MtMirc SM. Levels of theoretical think-ing in nursing. Nurs Outlook. 2OOO;48:179-183.

27. Lenz ER. .Suppe E Ciift AG, Pugh LC:. Milligan RA. Col-laborative development t)f middle-range nursing the-ories: toward a theory of unpleasant symptoms. ANS.1995;17:1-13.

28. Len/ ER, Pugli LC. Milligan RA, Gift A, Suppe E Themiddle-range theory of unpleasant symptoms: an up-date. AV5. 1997;l9:l4-27.

29. Wliall AL. The structure of nursing knowledge: anal-ysis and evaluation of practice, middle-range, andgrand theory. In: Fitzpatrick JJ, Whall AL, eds. Con-ceptual Models of Nursing: Anatt'Sis and Applica-tion. Stamford, C;onn: Appleton & I-ange: l9'Xi:I3-25.

30. Cheryl Tatano Beck's Web Page. Available at: http://www.nursing.Liconn.edu/FACULTY/CherylT.html.Accessed April 6. 2(M)5.

31. Beck CT. Tlie occurrence of depression in womenand the effect of the women s movement, y PsychNurs Mental Health Sen'. 1979; 17:14-16.

32. Beck (T. Developing a research program tising qual-itative and quantitative approaches. Nurs Outlook.1997;45:265-269.

33. Morse J. Qualitative nursing research: a free tor all?In: Morse J, ed. Qtuilitatliv Nursing Research: AContemporary' Dialogue. Newbury Park, C alif: Sage;1991:14-22.

34. Beck AT, Ward C;H, Mendelson M. MockJ, ErbaugbJ. An inventory for measuring depression. Arcb GenF^chiatry. 19C)1;4:561-571.

35. O'Hara MW, Neunaber DJ. Zekoski EM. Prospec-tive study of postpartum depres.sion: prevalence,course, and predictive factors. J Abnortn Psychol.1984;93:158-171.

36. Whiffen VE. Screening fior postpartum depression: a


methodological note. J Clin Psycbol. 1988;44:367-371.

37. Beck CT. The effects of postpartum depression onmatemal-infant interaction: a meta-analysis. NursRes. 1995;44:298-304.

38. Beck CT. Postpartum depressed mothers' experi-ences interacting with their children. Nurs Res.1996;4'>:98-iO4.

39. Beck <T. A meta-analysis of the relationship be-tween postparttim depression and infant tempera-ment. Nurs Res. 1996;45:225-23O.

40. Beck CT. Maternal depression and child behaviorprohlems: a meta-analysis. jMN. 1999;29:623-629.

41. BeckCT. A meta-analysisof predictors of postpartumdepression. Nurs Res. 1996;45:297-3O3.

42. Stefansdottir H. Eiriksdottir IK, Karlsdottir S, Ingolfs-dottir E. How Do Icelandic Wbtnen Ex/nvss TheirFeelings During the Last Trimester of Ptx'gnancy'!'iunpublished BS dissertation). University of Iceland;

43- Beck CT. Postpartum Depression Screening Scale(Spanish version). Nurs Res. 2003; 5 2:296-306.

from practice to midrange theory and back again · midrange nursing theory. we demonstrate beck s...

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