MIDDLE-

RANGE
THEORIES
 Middle- Range Theories

A. Patricia Benner’s Model of Skill Acquisitions in

Nursing
B.Madeleine Leininger’s Cultural Diversity and
Universality Theory
C.Joyce Fitzpatrick: Life Perspective Rhythm Model
 PATRICIA
BENNER
Model of Skill Acquisitions in Nursing
P- Professor emerita from UCSF
A- A Distinguished Visiting Professor at Seattle University School of Nursing
T- The American Academy of Nursing’s “Living Legends” in August, 2011.
R- Retired from teaching in 2008
I- Introduced her “Novice to Expert” theory in 1982.
C-Continues to be involved in presentations and consultation, as well as
writing and research projects.
I-Introduce a well published journals and books
A- A transformation of their undergraduate and graduate curricula.

ABOUT THE THEORIST

From Novice to
Expert Nursing
Model
This concept explains that nurses
develop skills and an understanding of
patient care over time from a
combination of a strong educational
foundation and personal
experiences.”
Benner’s • Nursing practice has been studied primarily from
Motivation for a sociological perspective as opposed to the
Novice to Expert
study of nursing practice itself
• Nursing knowledge is accrued over time; it is
embedded in expertise. Thoughts are based on
the Dreyfus model.
• Knowledge has gone uncharted and unstudied
because differences between practical and
theoretical knowledge have been misunderstood
• Well charted nursing practice and observation
are essential for theory development
Benner’s
Philosophy
• Benner “proposed that a nurse could gain
knowledge and skills without actually learning a
theory”
Described as “knowing how” without “knowing
that”
• Development of knowledge in nursing is “a
combination of knowledge through research
and understanding through clinical experience”
Benner’s 1. Virginia Henderson
influences • Benner has acknowledged that her “thinking has been
influenced greatly by Virginia Henderson.”
2. Citing Kuhn (1970) and Polanyi (1958)
=philosophers of science
=Benner (1984a) emphasizes the difference between
“knowing how,” a practical knowledge that may elude
precise abstract formulations, and “knowing that,”
which lends itself to theoretical explanations.
= Knowing that is the way an individual comes to know
by establishing causal relationships between events.
3. Stuart Dreyfus, in operations research, and Hubert Dreyfus, in
philosophy, both professors at the University of California at Berkeley
= developed the Dreyfus Model of Skill Acquisition, which Benner
applied in her work, From Novice to Expert.
4. Jane Rubin’s = colleagueship as sources of inspiration and
influence, especially in relation to the works of Heidegger (1962) and
Kierkegaard (1962).
5. Richard Lazarus = mentored her in the field of stress and coping.
6. Judith Wrubel =has been a participant and co-author with Benner
for years, collaborating on the ontology of caring and caring
practices (Benner & Wrubel, 1989).
• Benner (1984a) adapted the Dreyfus model to clinical nursing practice.
• The Dreyfus brothers developed the skill acquisition model by
studying the performance of chess masters and pilots in emergency
situations
• Benner’s model is situational and describes five levels of skill
acquisition and development:
(1) novice,
(2) advanced beginner,
(3) competent,
(4) proficient,
(5) expert.
1. The • Begins with no prior experience
Novice
• Taught rules to perform tasks
Nurse
• Rule governed behavior is limited and
inflexible
• Being a novice is not exclusive to
students- any nurse entering a setting
without prior experience with that
particular patient population may be
limited to the novice level
(Benner, 2001, pp. 20-21)
2. The • Can demonstrate marginally
Advanced acceptable performance
Beginner • Has gained prior experience in actual
Nurse nursing situations
• Formulation of guidelines or
months principles from prior experiences
provide guidance in future
experiences
year
(Benner, 2001, pp. 22-23)
3. The • Aware of long term goals-- gain
Competent perspective from planning their own
Nurse actions
• Become more efficient and organized
• Consistency, predictability, and time
management are important in
to competent performance. A sense of
mastery is acquired through planning
years and predictability
(Nursing Theory, 2011)
4. The • New ability to see changing relevance
Proficient in a situation, including recognition
Nurse and implementation of skilled
responses to the situation as it
evolves.
• Views patients holistically (LTG)
• Has learned what to expect in certain
situations and how to modify plans as
years needed
(Nursing Theory, 2011)
5. The
Expert • No longer relies on principles,
Nurse rules or guidelines to connect
situations and determine actions
• Performances are fluid, flexible,
and highly proficient
• Expertise comes naturally
years
(Black 2011, p. 137)
(Nursing Theory, 2011)
Benner’s
Explanation
of the Four
Paradigms

Photo courtesy http://www.emporia.edu/nursing/nursing-mission.html

1. Nursing • Nursing is described as a caring
relationship, an “enabling condition of
connection and concern” (Benner &
Wrubel, 1989, p. 4).
• “Caring is primary because caring sets
up the possibility of giving help and
receiving help” (Benner & Wrubel,
1989, p. 4).
• “Nursing is viewed as a caring practice
whose science is guided by the moral
art and ethics of care and
responsibility”
2. Person “…the person does not come into the world
predefined but gets defined in the course of
living a life”
Benner believed that there are significant
aspects that make the being. She
conceptualized these as the roles of:
• the situation
• the body
• personal concerns
• temporality (Nursing Theories, 2013)
Photo courtesy http://www.bing.com/images/search?q=nurse+images&qs=HS&form=QBIR&pq=&sc=8-
0&sp=2&sk=HS1#view=detail&id=8B0FC4FBC4E9A78296B556430D55638F7399DF6D&selectedIndex=832
3. Health
Benner focused “on the lived experience of
being healthy and being ill”
• Health can be assessed
• Well-being is the human experience
of health or wholeness
• Illness is the human experience of
loss or dysfunction
(Tomey & Alligood, 2006, p. 151)
Photo courtesy http://learningfundamentals.com.au/resources/
4. Environment Benner uses the term situation
rather than environment. “Personal
interpretation of the situation is
bounded by the way the individual
is in it.”

A person’s past, present, and future

influences their current situation

(Tomey & Alligood, 2006, p. 151)

Photo courtesy http://www.howtolearn.com/2012/01/what-did-
we-learn-about-health-and-happiness-in-2011 http://bizchicks.org/2011/02/the-emotion-health-connection/
Using
Benner’s Examples of use in practice:

Model in • Preceptorship
Practice • Orientation processes
• Nursing educational programs
• Professional advancement ladders
• Interdepartmental job changes (e.g.
medical-surgical nurse transitioning
to an intensive care unit)
http://www.galaxyhealth.net/
 Benner in
Action
Clinical Ladder Programs
• Most are based on stages of
clinical competence of
Benner’s (Murphy, 2012)
• Intention of the ladder is to
retain experienced nurses
• Greater rewards at the expert
levels than the novice level
Conclusion
This model can be applied to all areas
of nursing. It looks at the education
and development of a nurse and how
they become an expert.

Patricia Benner examined how nurses

learn to nurse (Nursingtimes.net, 2010)
Photo courtesy http://depositphotos.com/9744222/stock-illustration-Nursing-home-logo.html Photo courtesy http://nursesaidetraining.blog.com/
 Nurse Kim has learned skill in clinic side
through principles and based on
experiences. She was able to identify a
patient with appendicitis as she compare
the signs and symptoms to one of their
patient earlier.

Case Study #1
Mrs. Walsh is in her 70s in critical condition following repeat coronary artery
bypass graft surgery. She remained critically ill and unstable for several weeks
before her death. Her family was very anxious, a family member was always with
her 24hrs/day for the first week. The nurse met family and offered to go into
operating room to talk with the cardiac surgeon to better inform the family of
their mother's status, the nurse provided the family with a consistent group of
nurses to work with Mrs.Walsh. So that the family could trust and feel confident
about the care their mother was receiving. Helped family members and nurses to
be more satisfied and less anxious.
The nurse helped the family, by telling them things that they could do to help
their mother (ex: bathing her.) The nurse believes that development process is
involved when nurses learn to work with families. The nurse invited the family to
come in and participate while preparing Mrs.Walsh's body for the morgue, when
she passed away because she learned that families of ill patients need care as
well.

Case Study #2
 NOVICE
AN EXPERIENCED OPERATING
ROOM NURSE CHOOSES TO
NOW PRACTICE IN HOME CARE
 PROFICIENT
THIS NURSE PERCEIVES A PATIENT'S
CLINICAL SITUATION AS A WHOLE, IS
ABLE TO ASSESS AN ENTIRE
SITUATION, AND CAN READILY
TRANSFER KNOWLEDGE GAINED
FROM MULTIPLE PREVIOUS
EXPERIENCES TO A SITUATION
 EXPERT
NURSE WITH DIVERSE EXPERIENCE
WHO HAS AN INTUITIVE GRASP OF
AN EXISTING OR POTENTIAL
CLINICAL PROBLEM
 ADVANCE BEGINNER
A NURSE WHO MAY HAVE
THE EXPERIENCE BUT
MUST NOT LEAVE
UNATTENDED
 NOVICE
“TELL ME WHAT TO DO AND I’LL DO
IT”
 COMPETENT
THE NURSE LACKS MULTI-TASKING
TALENTS AND FLEXIBILITY, BUT IS ABLE
TO CONSCIOUSLY PLAN USING
ABSTRACT AND ANALYTIC PRINCIPLES
THAT FOCUS ON LONG-TERM GOALS
OR PLANS
 Madeleine
Leininger’s
Cultural Diversity and
Universality Theory
L- labeled as a distinguished visiting scholar and lecturer at 85 universities
in the United States and worldwide and was a visiting professor at
universities in Sweden, Wales, Japan, China, Australia, Finland, New
Zealand, and the Philippines.
E- Eastern Highlands of New Guinea (Gadsup people), ethnographical and
ethnonursing study of two villages. (Culture Care Theory of Diversity and
Universality (Culture Care Theory) and the ethnonursing method)
I- Introduced as 1st professional nurse with graduate preparation in nursing
to hold a PhD in cultural and social anthropology Leininger (1991b)
developed her Theory of Culture Care Diversity and Universality
N- Noted as founder of transcultural nursing and a leader in transcultural
nursing and human care theory.

About the theorist

I- instructor, staff nurse, and head nurse on a medical surgical unit and opened a
psychiatric unit while director of nursing service at St. Joseph’s Hospital in Omaha.
N-Notes on psychiatric nursing text with Hofling entitled “Basic Psychiatric
Concepts in Nursing”, which was published in 1960 and in 11 languages
G- going to Cincinnati, she discovered staff lacked understanding of cultural factors
influencing the behavior of children.
E- each children was observed by her where differences in responses to care and
psychiatric treatments that deeply concerned her.
R- result: She became increasingly concerned that her nursing decisions and actions,
and those of other staff, did not appear to help these children adequately.

About the theorist

Major Concepts 1. Transcultural Nursing
of the =is defined as a learned subfield or branch of nursing
Transcultural which focuses upon the comparative study and analysis
Nursing Theory
of cultures with respect to nursing and health-illness
caring practices, beliefs, and values with the goal to
provide meaningful and efficacious nursing care services
to people according to their cultural values and health-
illness context.
2. Ethnonursing
• This is the study of nursing care beliefs, values, and
practices as cognitively perceived and known by a
designated culture through their direct experience,
beliefs, and value system (Leininger, 1979).
3. Nursing
• is defined as a learned humanistic and scientific profession and discipline
which is focused on human care phenomena and activities in order to
assist, support, facilitate, or enable individuals or groups to maintain or
regain their well-being (or health) in culturally meaningful and beneficial
ways, or to help people face handicaps or death.
4. Professional Nursing Care (Caring)
• defined as formal and cognitively learned professional care knowledge and
practice skills obtained through educational institutions that are used to
provide assistive, supportive, enabling, or facilitative acts to or for another
individual or group in order to improve a human health condition (or well-
being), disability, lifeway, or to work with dying clients.
5. Cultural Congruent (Nursing) Care
=is defined as those cognitively based assistive, supportive, facilitative, or
enabling acts or decisions that are tailor-made to fit with individual, group,
or institutional cultural values, beliefs, and lifeways in order to provide or
support meaningful, beneficial, and satisfying health care, or well-being
services.
6. Health
=It is a state of well-being that is culturally defined, valued, and practiced,
and which reflects the ability of individuals (or groups) to perform their
daily role activities in culturally expressed, beneficial, and patterned
lifeways.
7. Human Beings
=believed to be caring and to be capable of being concerned about the
needs, well-being, and survival of others. Leininger also indicates that
nursing as a caring science should focus beyond traditional nurse-patient
interactions and dyads to include families, groups, communities, total
cultures, and institutions.

8. Society and Environment

These terms are not defined by Leininger; she speaks instead of
worldview, social structure, and environmental context.
9. Worldview
=is the way in which people look at the world, or at the universe, and form
a “picture or value stance” about the world and their lives.

10. Cultural and Social Structure Dimensions

=are defined as involving the dynamic patterns and features of interrelated
structural and organizational factors of a particular culture (subculture or
society) which includes religious, kinship (social), political (and legal),
economic, educational, technological and cultural values, ethno historical
factors, and how these factors may be interrelated and function to
influence human behavior in different environmental contexts.
11. Environmental Context
• is the totality of an event, situation, or particular experience that gives meaning to
human expressions, interpretations, and social interactions in particular physical,
ecological, sociopolitical and/or cultural settings.
12. Culture
• is the learned, shared and transmitted values, beliefs, norms, and lifeways of a
particular group that guides their thinking, decisions, and actions in patterned ways.
13. Culture Care
• is defined as the subjectively and objectively learned and transmitted values, beliefs,
and patterned lifeways that assist, support, facilitate, or enable another individual or
group to maintain their well-being, health, improve their human condition and lifeway,
or to deal with illness, handicaps or death.
14. Culture Care Diversity
• indicates the variabilities and/or differences in meanings, patterns,
values, lifeways, or symbols of care within or between collectives that
are related to assistive, supportive, or enabling human care expressions.

15. Culture Care Universality

• indicates the common, similar, or dominant uniform care meanings,
pattern, values, lifeways or symbols that are manifest among many
cultures and reflect assistive, supportive, facilitative, or enabling ways
to help people. (Leininger, 1991)
 Three modes of nursing care decisions and actions

1. Cultural care
preservation/maintenance
• includes those assistive, supporting,
facilitative, or enabling professional
actions and decisions that help people of
a particular culture to retain and/or
preserve relevant care values so that
they can maintain their well-being,
recover from illness, or face handicaps
and/or death.
2. Cultural care accommodation/
negotiation
=includes those assistive, supportive,
facilitative, or enabling creative
professional actions and decisions that
help people of a designated culture to
adapt to or negotiate with others for a
beneficial or satisfying health outcome
with professional care providers.
3. Culture care repatterning/
restructuring
=includes those assistive, supporting,
facilitative, or enabling professional
actions and decisions that help a clients
reorder, change, or greatly modify their
lifeways for new, different, and
beneficial health care pattern while
respecting the clients cultural values and
beliefs and still providing a beneficial or
healthier lifeway than before the changes
were co-established with the clients.
 • The Sunrise Model is relevant
Sunrise Model because it enables nurses to
of Madeleine
develop critical and complex
Leininger’s
Theory thoughts towards nursing
practice.
• These thoughts should consider,
and integrate, cultural and social
structure dimensions in each
specific context, besides the
biological and psychological
aspects involved in nursing care.
• it is evident that each of the above
concepts can influence a person,
directly affecting their care
expressions, patterns, and
practices

• It is important for nurses to look at

all of those factors, as well as the
individuals, their families, their
groups, their communities, etc in
order to provide holistic care to
their patients
• Cultural assessment by Leininger that
would include the following 5 phases:

1. “recording of observations using all

five senses;
2. paying close attention and listening,
including for generic folk practices;
3. identification of patterns and
narratives;
4. synthesis of themes and patterns;
5. development of a culturally congruent
care plan jointly with the client”
The following 1. Different cultures perceive, know, and practice care in
are the different ways, yet there are some commonalities about care
among all cultures of the world.
assumptions of
2. Values, beliefs, and practices for culturally related care are
Madeleine shaped by, and often embedded in, “the worldview, language,
Leininger’s religious (or spiritual), kinship (social), political (or legal),
theory: educational, economic, technological, ethno-historical, and
environmental context of the culture.
3.While human care is universal across cultures, caring may be
demonstrated through diverse expressions, actions, patterns,
lifestyles, and meanings.
4. Cultural care is the broadest holistic means to know, explain,
interpret, and predict nursing care phenomena to guide
nursing care practices.
• Strengths
• Leininger has developed the Sunrise Model in a logical order to demonstrate the
interrelationships of the concepts in her theory of Culture Care Diversity and
Universality.
• Leininger’s theory is essentially parsimonious in that the necessary concepts are
incorporated in such a manner that the theory and its model can be applied in
many different settings.
• It is highly generalizable. The concepts and relationships that are presented are at
a level of abstraction which allows them to be applied in many different
situations.
• Though not simple in terms, it can be easily understood upon the first contact.
• Weakness
• The theory and model are not simple in terms.
Conclusion
Cultural knowledge plays a very important role for nurses on how to deal
with the patients. To start off, it helps nurses to be aware of the ways in
which the patient’s culture and faith system provide resources for their
experiences with illness, suffering, and even death. It helps nurses to be
understanding and respectful of the diversity that is often very present in a
nurse’s patient load. It also helps strengthen a nurse’s commitment to
nursing based on nurse-patient relationships and emphasizing the whole
person rather than viewing the patient as simply a set of symptoms or illness.
Finally, using cultural knowledge to treat a patient also helps a nurse to be
open-minded to treatments that can be considered non-traditional, such as
spiritually based therapies like meditation and anointing.
 Nowadays, nurses are required to be sensitive to their
patients’ cultural backgrounds when creating a nursing
plan. This is especially important since so many people’s
culture is so integral in who they are as individuals, and it
is that culture that can greatly affect their health, as well
as their reactions to treatments and care. With these,
awareness of the differences allows the nurse to design
culture-specific nursing interventions.
• An elderly Arab-American Muslim man who spoke little
English was admitted to the hospital for increasing pain in his
left foot while at rest. His foot was cool and pale, and he had a
history of vascular surgical procedures. He had many chronic
health problems, including type 2 diabetes, hypertension, and
chronic obstructive pulmonary disease. He also had had a
myocardial infarction and several cerebral vascular accidents.
While in the hospital, he developed abdominal pain and
underwent a cholecystectomy. This elderly grandfather had a
large family, including a wife, nine children, and many
grandchildren.
His wife insisted that all family members visit him every day while he
was in the hospital. The family wanted the man’s face turned toward
Mecca (toward the East) while they prayed with him. They brought
tape-recorded passages from the Koran, which they played at his
bedside. Other families who were visiting their sick relatives
complained to the nurses that the Arab family was taking up the
entire waiting room, and there was no place for anyone else to sit. As
a nurse, how might you use the three modes from the Theory of
Culture Care Diversity and Universality to provide culturally
congruent care for this elderly man and his family, as well as for the
other clients and their families in the critical care unit?
 JOYCE
FITZPATRICK
Life Perspective Rhythm Model
Dr. Fitzpatrick, who based her theory
on Rogers’s (1983), postulated
correlates of human development as
the basis for differentiating, organizing,
and ordering life’s reality.
Key Concepts

Dr. Fitzpatrick introduced the dynamic concepts of congruency,

consistency, and integrity as complementary with rhythmic patterns.
She offered heightened awareness of the meaningfulness of life as
an example of a more fully developed phase of human health.
Nursing interventions were interpreted as facilitating the
developmental process toward health so that individuals might
develop their human potential. The meaningfulness of life is
manifest through a series of life crisis experiences with potential for
growth in one’s meaning for living.
Life Perspective Rhythm Model

Life Perspective Rhythm Model is a construct to assist with

the professional practice of nursing. Theorist Dr. Joyce
Fitzpatrick based her model of practice on Martha Rogers’
theory of Unitary Human Beings. While Rogers’ theory covered
eight separate areas, Dr. Fitzpatrick has built her nursing
theory on four subdivisions involving the delivery of nursing
care.
Rhythm
Let’s look at rhythm itself. A good definition from the Merriam-Webster
Dictionary is “movement, fluctuation or variation marked by regular
recurrence or natural flow.” It also offers this definition “a regularly
recurrent quantitative change in a variable biological process.” Rhythms
can be described, measured and will be repeated. Thus, the stages of life
and illness can be equated to rhythms.
Areas of the Life Perspective Rhythm Model
The model frames itself around four separate areas. Understanding these areas
in each person’s life will lead to successful outcomes for clients. This model is
also useful to communicate treatment techniques to other cultures. Dr.Joyce
Fitzpatrick has done research on health care in other countries besides the
United States and proposed this model because it included elements of the
client’s culture. She defines a major concept of human development that is
important to nursing as the value each person places on their life. This
knowledge drives how the client responds to changes in their life.
Person
The first of her four areas are the concept of person. The person not only includes
the client but all people whom he or she interacts with in their environment. She
considers a human an open system with a set group of rhythmic behaviors. These
behaviors are drawn from a variety of fields, including biology, psychology, human
development, theology, philosophy and the culture of the client with their
surrounding society. Clearly, this involves a large area to assess.
Health
This is an area that focuses on the health of the client and their surroundings.
Health includes all the people and society that affect the client. To maintain
optimum health requires the assistance of care providers, a client willing to change
and follow guidelines for a healthful life and surrounding the client with supportive
family and friends. Optimum health is the goal of nursing interactions which goes
beyond professional interactions that occur only when the client is distressed by
their unhealthy state. Nursing professionals strive to improve health through any
interaction with clients.
Wellness
Professional nursing has matured into its current focus of promoting wellness.
Wellness is the state of optimum health. Essentially, the focus of health exams has
become preventative care. Not only do health professionals treat illnesses, they
promote lifestyle changes and habits that will lower the chances of experiencing
illness during one’s lifetime. Health workers need to learn techniques to promote
wellness.
Metaparadigm of Nursing
Metaparadigm is a structure that states how a profession should function. Nursing
metaparadigms consistently cover four areas. These are:
• The totality of the person or client – everything known about the client and his life
• The environment of the client – the social construct that surrounds the client and
its effect on the client
• Client’s current level of wellness – this establishes which items of health that
health care workers need to address
• Nursing’s responsibility and duty toward the client – the nursing theory, actions and
treatments that the nurse needs to bring to bear to return the client to the top level of
wellness possible.
The life perspective rhythm model is a newer theory that is
still being integrated into the profession. It remains to be
seen the effect of this theory on moving the profession to a
world-wide model. Many nursing theories do not take one of
her four areas into consideration, and thus are difficult to
translate to a new culture, environment or a different level of
health. This model is a complex attempt to solve this issue in
the nursing profession.