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702 UNIT V Middle Range Nursing Theories

University. She received her diploma in nursing from philosophers to explain and define quality of life
the Youngstown Hospital Association School of Nurs- (Sandoe, 1999), a concept that is significant in end-
ing (1969) and her bachelor’s degree in nursing from of-life research and practice. In preference theory,
Kent State University (1974). She earned a master’s the good life is defined as getting what one wants, an
degree in psychiatric and mental health nursing approach that seems particularly appropriate in end-
(1990) as well as a Ph.D. in nursing science (1993) at of-life care. It can be applied to both sentient per-
Case Western Reserve University. She has taught sons and incapacitated persons who have previously
nursing theory and nursing science to all levels of provided documentation related to end-of-life deci-
nursing students and conducts a program of research sion making. Quality of life, therefore, is defined and
and theory development that addresses recovery after evaluated as a manifestation of satisfaction through
cardiac events. Early in her doctoral study, Moore was empirical assessment of such outcomes as symptom
encouraged by nurse theorists Joyce J. Fitzpatrick, relief and satisfaction with interpersonal relation-
Jean Johnson, and Elizabeth Lenz to not only use ships. Incorporating patient preferences into health
theory but to develop it as well. The Rosemary Ellis care decisions is considered appropriate (Ruland &
Theory Conference, held annually for several years at Bakken, 2001; Ruland, Kresevic, & Lorensen, 1997)
Case Western Reserve University, offered Moore an and necessary for successful processes and outcomes
opportunity to explore theory as a practical tool for (Ruland & Moore, 2001).
practitioners, researchers, and teachers. Influenced This theory was derived in a doctoral theory course
by these experiences, Moore has assisted in the devel- in which Ruland was a student and Moore was fac-
opment and publication of several theories (Good ulty. Middle-range theories were just emerging, and
& Moore, 1996; Huth & Moore, 1998; Ruland & there were few good definitions or examples. The class
Moore, 1998). Moore considers theory construction was challenged to think about the future use and de-
an essential skill for doctoral students. velopment of middle range theory for nursing science
and practice. The students discussed knowledge
sources from which they could derive middle range
Theoretical Sources theory, such as empirical knowledge, clinical practice
The Peaceful End-of-Life Theory is informed by a knowledge, and synthesized knowledge. Each student
number of theoretical frameworks (Ruland & Moore, was asked to derive a middle range theory from a
1998). It is based primarily on Donabedian’s model of knowledge source of choice. Ruland had just com-
structure, process, and outcomes, which in part was pleted a major project to develop a clinical practice
developed from general system theory. General sys- standard for peaceful end of life with a group of can-
tem theory is pervasive in other types of nursing cer nurses in Norway. The standard was synthesized
theory, from conceptual models to middle-range and into the theory of peaceful end of life by Ruland
micro-range theories—an indicator of its usefulness and later was refined with Moore’s assistance. This
in explaining the complexity of health care interac- is an example of middle range theory developed by
tions and organizations. In the Peaceful End-of-Life doctoral nursing students as they study knowledge
Theory, the structure-setting is the family system development methods. This theory is also an example
(terminally ill patient and all significant others) that of middle range theory development using a standard
is receiving care from professionals on an acute care of practice as a source.
hospital unit, and process is defined as those actions
(nursing interventions) designed to promote the
positive outcomes of the following: (1) being free Use of Empirical Evidence
from pain, (2) experiencing comfort, (3) experienc- The Peaceful End-of-Life Theory is based on empiri-
ing dignity and respect, (4) being at peace, and cal evidence from direct experience of expert nurses
(5) experiencing a closeness to significant others and review of the literature addressing components of
and those who care. the theory. The group of expert practitioners who
A second theoretical underpinning is preference developed the standard of care for peaceful end of life
theory (Brandt, 1979), which has been used by had at least 5 years of clinical experience caring for