Middle Range Theory Evaluation
Theoretical and Scientific Foundations for Nursing Practice
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
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.
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).
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.
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).
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).
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).
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.
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 academicguides.waldenu.edu
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,
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Isaacson, M. (2014). Clarifying concepts: cultural humility or competency. Journal of
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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]
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: