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LOOKING AT SYMPTOMS WITH A MIDDLE-RANGE THEORY LENS*
—
Patricia Liehr, PhD, RN†
ABSTRACT
One of the most challenging expectations for
nurses—in research or clinical settings—is the
translation of nursing theory for use in practice
and research. The Ladder of Abstraction is a construct depicting 3 different levels of ideas regarding a health issue, such as pain. The Ladder of
Abstraction has 3 rungs: the philosophical, theoretical, and empirical rungs—3 different ways to
think about and approach a health issue. The
higher the level on the ladder, the more abstract
the ideas. Middle-range theory exists on the middle rung and it is described as theory occurring
at the intersection of practice and research. For
this discussion, we consider chronic pain through
a middle-range lens using middle-range theories
from differing levels of abstraction. None of these
theories are more “correct” than the other, but
each theory provides a different lens for seeing
everyday nursing practice. It is up to the practicing nurse to choose a theory that fits her own personal values and to let the theory guide action,
enabling evaluation from the view with the middle-range theory lens.
(Adv Stud Nurs. 2005;3(5):152-157)
*Based on a presentation given by Dr Liehr at the Fourth
Annual Sigma Theta Tau International Chesapeake
Consortium Research Conference.
†Associate Dean for Nursing Research and Scholarship,
Christine E. Lynn College of Nursing, Florida Atlantic
University, Boca Raton, Florida.
Address correspondence to: Patricia Liehr, PhD, RN,
Associate Dean for Nursing Research and Scholarship,
Christine E. Lynn College of Nursing, Florida Atlantic
University, 777 Glades Road, Boca Raton, FL 33431.
E-mail: pliehr@fau.edu.
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O
ne of the most challenging expectations for nurses today—in research or
practice settings—is the translation of
nursing theory and science for use in
practice and research. There are many
ways to think about practice issues, such as symptom
experience, and nurse researchers and practitioners are
looking at frameworks to guide study and intervention
with people experiencing symptoms.
Symptoms are a subjective experience, appraised by
the patient. Examples of symptoms are pain, nausea,
or fatigue. By contrast, signs are observable indicators
of a change in health status. A nurse identifies a sign
through careful observation and evaluation. Pain, nausea, and fatigue may be evaluated as signs when measured as the amount of pain medication used, the
frequency of vomiting, and the number of hours spent
recumbent, respectively.
Chronic pain has recently been a common topic in
the lay press, in part because of the withdrawal of
cyclooxygenase-2 inhibitors.1 Chronic pain affects
approximately 1 in 6 Americans and costs the United
States approximately $100 billion annually.2,3 Most
people seek pain relief solely from medication (ie,
“pharmaceutical salvation”), but pain is affected by
many factors (physiologic and nonphysiologic), which
may demand pain management approaches other than
medication. Generally, pain is undertreated because
patients and physicians underestimate its effects on
functioning. Nonpharmacologic treatments for pain
have expanded to include interventions, such as
lifestyle changes, mindfulness therapy, or alternative
therapies (eg, vitamins and herbs).1 All of these interventions are within the realm of nursing practice and
could be considered in addition to traditional pharmacologic interventions. The effect of pain on psychosocial factors and the effect of psychosocial factors on
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pain can be difficult to quantify and assess, but this
reciprocal relationship falls squarely within the realm
of nursing practice. Nurses think about and approach
pain differently than other members of the healthcare
team, and nurses can have a significant impact on pain
experience when viewing pain through their disciplinary lens.
knowledge base for this paradigm is founded in social
sciences. The unitary-transformative world view suggests that change is unpredictable and constantly
evolving, and through a transformative process, people
find meaning. It suggests that people are capable of
awareness beyond just the physical (ie, more spiritual).
This paradigm is grounded in the human sciences.7
Most nurses practice in the interactive-integrative
world view, most of the time. However, from that
position, nursing practice routinely calls us to move to
the particulate-deterministic or the unitary-transformative world view.
Middle-range theory sits on the middle rung of the
ladder between microrange and grand theory (Figure
1).4 Microrange theory is situation-specific and limited to particular populations or fields of practice, such
as menopausal transition of African-American women
or learned response to chronic illness in patients with
multiple sclerosis.8 Grand theories are broad in scope,
such as theories of human becoming, adaptation, and
THE LADDER OF ABSTRACTION
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Figure 1.The Ladder of Abstraction
more abstract
Philosphical level
Particulatedeterministic
Interactiveintegrative
Unitarytransformative
Middlerange theory
Microrange
theory
Grand
theory
more abstract
Theoretical level
more concrete
Each discipline offers its own constructs for considering theories and theory applications. The Ladder of
Abstraction is a construct depicting 3 different levels of
ideas regarding a health issue, such as pain. As shown
in Figure 1, the Ladder of Abstraction has 3 rungs: the
philosophical, theoretical, and empirical rungs—3 different ways to think about and approach a health issue.4
The higher the level on the ladder, the more abstract
are the ideas. Hence, philosophical levels of thought are
more abstract than theoretical levels, which in turn are
more abstract than empirical levels. A brief overview is
given later in this section, followed by an example of
how it applies to the symptom of pain.4
The philosophical level of thought is a global view,
which guides perspectives about health issues. A philosophy is based on and represents well-accepted ways
of viewing the world. The theoretical level is expressed
as symbols, ideas, and concepts. Middle-range theory
resides at this level. The empirical level represents what
can be observed (eg, self-reports, behavior, biologic
indicators, and personal stories). Empirical thinking is
concrete.5,6
At the philosophical level of the ladder, world views
are described. For instance, Newman et al describes 3
world views: particulate-deterministic, interactiveintegrative, and unitary-transformative.7 Of these 3
world views, unitary-transformative is most abstract
(Figure 1)4 and particulate-deterministic is most concrete. Each world view incorporates values regarding
health and healthcare, which guide nurse-patient
interaction. The particulate-deterministic world view
revolves around cause and effect and is often considered to be the medical model of patient care. The
patient is considered as an isolated entity and change
in health status emerges from specific causes (eg, taking a drug); the knowledge base is founded in biophysical science. In the interactive-integrative world
view, patients are viewed as interacting with (influencing and being influenced by) their surroundings; the
Empirical level
Questionnaire
Physiological
indicators
Interview
Observation
Narrative
more concrete
Reprinted with permission from Smith and Liehr.4
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the science of unitary human beings.9-11 Middle-range
theories are broader than microrange, but they are
more focused than grand theories. Middle-range theories emerge at the intersection of research and practice,
when theory guides practice, practice generates
research questions, and research informs understanding of theory and practice.
Importantly, the names of constructs on the
Ladder of Abstraction are not intended to indicate that
one construct is more important or more correct than
another (eg, grand theory is no better than middle- or
microrange theory). There are no inherent value judgments attached to constructs, and each serves a purpose in understanding the health experience. For
example, a patient who is coding in the emergency
room would not benefit from application of self-efficacy theory, but rather demands astute observation of
indicators, such as heart rate, blood pressure, and electrocardiogram readings, guided by the particulatedeterministic world view.
MIDDLE-RANGE THEORIES
To merge the Ladder of Abstraction constructs
with symptom content, consider pain through 3 middle-range theories (ascending order of abstraction):
symptom management theory, unpleasant symptom
12-15
Symptom management
theory, and story theory.
theory uses a systematic approach to determine intervention strategies through questions, such as who
delivers the intervention, and how and when the intervention is delivered. This approach is taken to affect
symptom experience and patient outcomes (eg, selfcare, costs, and functional status). In this model, person, environment, and health state are interrelated
(Figure 2).12 Within the symptom experience, evaluation, perception, and response are interrelated. For
example, the patients’ perception of pain will affect
evaluation (eg, the patient says, “It’s not so bad.”) and
response to the symptom (eg, the patient says, “I don’t
need pain medication yet.”). These ideas of the symptom management theory (ie, the interrelatedness of
patient, environment, and health status) are not
intended to be novel, but rather to simply provide a
structure for guiding nursing practice decisions when
approaching patients experiencing pain.
Figure 3 places the symptom management theory
on the Ladder of Abstraction.4 The assumptions about
symptom management (ie, the philosophical level of
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Figure 2. Symptom Management Model
Person
Demographic, psychological, sociological
physiological, and developmental
Symptom
Management
Strategies
Symptom
Experience
Perception
Evaluation
Who?
What?
Response
How?
To whom?
When?
Where?
How much?
Why?
Environment
Sympom outcomes
Functional status
Emotional
QOL
status
Symptom
Costs
Status
Self-care
Physical, social,
and cultural
Health service
use
Mortality
Adherence
Health and Illness
Morbidity &
comorbidity
Risk factors,
health status,
disease, and injury
QOL = quality of life
Adapted with permission from Dodd et al. J Adv Nurs. 2001;33:668-676.12
Figure 3. Ladder of Abstraction: Symptom Management
Assumptions
Gold standard is perception of patient
Nonverbal patients may experience symptoms
Management may be targeted at individual, group, family, work
Symptom management is dynamic
Concepts
Symptom experience
Components of symptom management strategies
Outcomes
Practice
Research
-Assessment of symptom
experience
-Functional status
-Symptom management via
answering questions, such
as who, where, what
-Emotional status
-Quality of life
-Morbidity and mortality
-Health service use
Reprinted with permission from Smith and Liehr.4
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thought) are the patient’s perception is the gold standard; nonverbal patients may experience symptoms;
management of the symptom may be targeted to any
or all of the following: the individual, a group, the
family, or work environment; and symptom management is dynamic (ie, it is not a static entity that is
“fixed”). The concepts of this theory are the symptom
experience, the components of symptom management
strategies, and the outcomes of symptom management. In practice, symptom management is determined though a series of questions which enable
assessment and define the intervention. In research,
symptom management can be evaluated by functional
status, quality of life, emotional status, morbidity and
mortality, and health service use.12
The theory of unpleasant symptoms is slightly
more abstract than symptom management theory.
Unpleasant symptoms are subjectively experienced
indicators affecting performance, which are described
specifically by timing, quality, intensity, and distress
and are influenced by physiological, psychological,
and situational factors (Figure 4).4,13,14 The performance outcomes can, in turn, influence the symptom
experience and the factors affecting that experience.
Although Dodd et al introduced the idea of symptom
clusters into the nursing literature, the theory of
unpleasant symptoms actually models symptom clusters.15 The assumptions for this theory (Figure 5) are
that persons in varied situations can experience common symptoms, and that symptoms are individual
phenomena occurring in family and community contexts.4 The concepts include symptoms, the influencing factors, and performance as an outcome. In
practice, unpleasant symptoms are operationalized by
symptom assessment, symptom management, and
symptom relief intervention. In research, symptoms
can be described using a symptom scale, which measures duration, quality, and intensity of the symptom,
and the symptom experience.
Story theory, the most abstract of these 3 theories,
defines “story” as the active process of recognizing self
in relation to others through intentional nurse-patient
dialogue.16 The story emerges through purposeful conversation between the nurse and the patient about a
health challenge (Figure 6).4 For example, a nurse may
say, “Tell me about the nausea you’ve been experiencing,” and then really be there to hear about the complex story of the nausea, including what makes it
better or worse and who provides the most help in get-
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Figure 4.Theory of Unpleasant Symptoms
Physiologic
factors
Psychologic
factors
Situational
factors
Performance
timing
intensity
distress
quality
Symptom 1
Key:
Symptom 2
Influences
intensity
distress
quality
Interacts with
Symptom 3
Feedback (reciprocal
influence on factor or
symptoms)
Reprinted with permission from Smith and Liehr4; Lenz et al. Adv Nurs Sci.
1997;19:14-27.14
Figure 5. Ladder of Abstraction: Unpleasant Symptoms
Assumptions
There are commonalities across different symptoms experienced
by persons in varied situations.
Symptoms are individual subjective phenomena occurring in
family and community contexts.
Concepts
Symptom(s)
Influencing factors
Performance
Practice
Research
Assessment of symptom
Symptom scale
Symptom management
Duration, intensity, and quality
Symptom relief intervention
Symptom experience
Reprinted with permission from Smith and Liehr.4
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ting through it. The purpose of story gathering is to
create ease—the feeling of relief when pieces of a story
come together to create a bigger picture (sometimes
experienced as an “Aha!” moment). The assumptions
grounding this theory (Figure 7) are that each person
lives in the moment influenced by the present, the
past, and the future, and that each person changes as
he or she interacts with the world.4,16 Each person also
creates and experiences meaning. The concepts that
form this theory are intentional dialogue (or purposeful conversation), connecting with self in relation (ie,
we are not alone), and creating ease by “putting the
story pieces together.” In practice, story theory guides
story gathering through approaches, such as a story
path or a family tree. In research, story theory relies on
narrative as data, enabling analysis through qualitative
methods or linguistic analysis.16
As mentioned earlier in this article, no theory is
more correct than another. Each theory offers a point
of view (or pair of glasses) through which a health situation can be assessed and addressed. Different theories may highlight different pieces of the often
complex health situation.
Figure 6. Story Theory with Method
Connecting with Self-in-Relation
Developing story plot
Intentional Dialogue
Nurse
Person
Complicating health challenge
Creating Ease
Movement toward resolving
Reprinted with permission Smith and Liehr.4
A CASE HISTORY USING MIDDLE-RANGE THEORIES
Figure 7. Laddder of Abstraction: Story Theory
The following case history was originally described
in reference to using a story path approach to gather a
health challenge story.17 It will be used here as a realworld example that enables application of differing
theoretical views. Mr. T is a 55-year-old AngloAmerican who woke to “grasping” chest pain. He presented to his cardiologist who performed angioplasty,
followed by a coronary artery bypass graft 6 months
later. He currently attends cardiac rehabilitation and
continues to complain of chest pain, which limits his
exercise sessions. He was married for the first time at
age 54 years—2 years after the death of his mother. He
is currently employed as a construction field manager.
When evaluating this patient using symptom management theory, the nurse would ask specific questions
to assess the symptom experience and identify
approaches for symptom management. To assess the
experience, the nurse may ask, “What is the chest pain
experience like for you? What is the sensation? How
do you judge it? What do you usually do when it happens? What effect does it have on you?” Information
regarding these questions could also be gleaned from
the patient’s wife. To develop the symptom manage-
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Assumptions
Persons live in an expanded present
Persons change as they interrelate with their world
Persons experience meaning
Concepts
Intentional dialogue
Connecting with self-in-relation
Creating ease
Practice
Health Story
• Story path
• Family tree
• Present focus
Research
Health Story
• Phenomenological analysis
• Linguistic analysis
• Case study analysis
Reprinted with permission from Smith and Liehr.4
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ment plan, the nurse may ask, “What will the intervention be? Who will do the intervention? When will the
intervention be applied? How will it be performed?”
Unpleasant symptoms theory suggests performance
will be affected as symptom quality, intensity, timing,
and distress are altered, and attention to physiological,
psychological, and situational factors will influence the
symptom’s quality, intensity, timing, and distress.
Evaluating this patient through unpleasant symptoms
theory, the nurse would ask questions, such as “What
is the chest pain experience like for you?” (listening for
quality, intensity, timing, and distress); “Are there
other symptoms that happen when you are having
chest pain?”; “What contributes to making the pain
better or worse?” (physiological, psychological, and situational factors); or “What effect does the pain have
on your everyday living?” (performance).
Story theory suggests that there is the potential for
creating ease as the story unfolds and there is movement
toward resolving the health challenge the patient is facing. The nurse evaluating this patient with story theory
as a guide would speak with the patient or ask questions,
such as “What is hard about living with this pain?” (the
complicating health challenge); “Tell me the story of the
pain, when did it start?”; “How is the pain now?” (developing a story plot); or “What are you expecting as you
look ahead?” (movement toward resolving).
When story theory was used in working with this
patient, he revealed that he had “just gotten out from
under the control” of his mother when she died and now
feels controlled by having to take medication for heart
problems. He admitted to struggling with the unfairness
of his situation (continuing chest pain in spite of intervention), trying to reconcile the life he had envisioned
with the one he had now. This information was offered
during 4 sessions with the nurse. Although no treatment
plan was developed, the pain subsided over time as the
patient shared his story with someone who really took
time to listen.
CONCLUSIONS
In brief, none of these theories is more correct than
the other, but different theories guide different actions. It
is up to the practicing nurse to choose a theory that fits
with her own personal values and to let the theory guide
action, enabling evaluation from the view with the middle-range theory lens. To make the most of what middle-
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range theory has to offer, it is essential that advanced
practice nurses be skilled in moving up, down, and
across the Ladder of Abstraction when studying, practicing, or researching the science of nursing. It is this
flexibility and exploration that fosters the development
and implementation of new and better ideas about
caring for patients to promote health and healing.
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