MIDDLE RANGE

NURSING THEORIES
Maternal Role Attainment –
Becoming a Mother
Molly Meighan
Ramona T. Mercer
Born on October 4, 1929
Earned a diploma from St.
Margaret’s School of Nursing in
Montgomery, Alabama (1950)
Worked in areas of obstetrical,
pediatric, and contagious diseases
Ph.D. in maternity nursing from
University of Pittsburgh
Professor at University of California
Retired yet remains active in writing
and consultations (1987)
Major Concepts & Definitions
Maternal Role Attainment. An interactional and developmental
process occurring over time in which the mother becomes attached
to her infant, acquires competence in the caretaking tasks involved
in the role, and expresses pleasure and gratification in the role.

Maternal Identity. Defined as having an internalized view of the

self as a mother.

Perception of Birth Experience. A woman’s perception of her

performance during labor and birth is her perception of the birth
experience.

Self-esteem. An individual’s perception of how others view oneself

and self-acceptance of the perceptions.
Major Concepts & Definitions
Self-Concept (Self-Regard). The overall perception of self that includes
self-satisfaction, self-acceptance, self-esteem, and congruence or
discrepancy between self and ideal self.

Flexibility. Roles are not rigidly fixed; therefore, who fills the roles is not
important. “Flexibility of childrearing attitudes increases with increased
development… Older mothers have the potential to respond less rigidly to
their infants and to view each situation in respect to the unique nuances.”

Child-Rearing Attitudes. Maternal attitudes or beliefs about child

rearing.

Health Status. The mother’s and father’s perception of their prior health,
current health, health outlook, resistance-susceptibility to illness, health
worry concern, sickness orientation, and rejection of the sick role.
Major Concepts & Definitions
Anxiety. A trait in which there is specific proneness to perceive
stressful situations as dangerous or threatening, an as a situation-
specific state.

Depression. Having a group of depressive symptoms and in

particular the affective component of the depressed mood.

Role Strain-Role Conflict. The conflict and difficulty felt by the

woman in fulfilling the maternal role obligation.

Gratification-Satisfaction. The satisfaction, enjoyment, reward, or

pleasure that a woman experiences in interacting with her infant and
in fulfilling the usual tasks inherent in mothering.
Major Concepts & Definitions
Attachment. Component of the maternal role and
identity. It is viewed as a process in which an enduring
affectional and emotional commitment to an individual
is formed.

Infant Temperament. Infant send hard-to-read cues,

leading feelings of incompetence and frustration in the
mother.

Infant Health Status. Illness causing maternal-infant

separation, interfering with the attachment process.
Major Concepts & Definitions

Infant Cues. Infant behaviors that elicit a response

from the mother.

Family. A dynamic system that includes subsystems –

individuals (mother, father, child) and dyad (mother-
infant, mother-father) within the overall family system.

Family Functioning. Individual’s view of the

activities and relationships between the family.
Major Concepts & Definitions
Father or Intimate Partner. Maternal role attainment in a
way that can not be duplicated by any other person.

Stress. Made up of positively and negatively perceived life

events and environmental variables.

Mother-Father Relationship. Perception of the mate

relationship that includes intended and actual values, goals,
and agreements between the two.

Social Support. Amount of help actually received.

FOUR AREAS OF SOCIAL SUPPORT
1. Emotional Support: “Feeling loved, cared for, trusted,
and understood”

2. Informational Support: “Helping the individual help

herself by providing information that is useful”

3. Physical Support: A direct kind of help.

4. Appraisal Support: A support that tells the role taker

how she is performing in the role.
Maternal Role Attainment
Developed to serve as a framework for nurses to
provide appropriate health care interventions for
non-traditional mothers in order for them to develop
a strong maternal identity.

The primary concept of this theory is the

developmental and interactional process, which
occurs over a period of time. In the process, the
mother bonds with the infant, acquires competence
in general caretaking tasks, and then comes to
express joy and pleasure in her role as a mother.
 Maternal Role Attainment:
Mercer’s Original Model
Microsystem. Immediate environment in which maternal role
attainment occurs: family functioning, mother-father relationships,
social support, economic status, family values, and stressors. It is the
most influential on maternal role attainment.

Mesosystem encompasses, influences, and interacts with persons in

the microsystem: day care, school, work setting, places of worship,
and other entities within the immediate community.

Macrosystem refers to the general prototypes existing in a

particular culture or transmitted cultural consistencies: social,
political, and cultural influences on the two other systems.
Mercer’s original model of Maternal Role Attainment Theory
Maternal Role Attainment
STAGES OF ROLE ACQUISITION

a. Anticipatory. Begins during pregnancy and include the initial

social and psychological adjustments to pregnancy.

b. Formal. Begins with the birth of the infant and includes learning
and taking on the role of the mother.

c. Informal. Begins as the mother develops unique ways of dealing

with the role not conveyed by the social system.

d. Personal. Also called as “role identity” stage occurs as the

woman internalizes her role. The mother experiences a sense of
harmony, confidence, and competence in the way she performs
the role, and the maternal role is achieved.
Acceptance by the Nursing Community

Practice. Both the theory and the model are capable of serving
as a framework for assessment, planning, implementing, and
evaluating nursing care of new mothers and their infants.

Education. It has been shown to be helpful to students in

psychology, sociology, and education

Research. Mercer’s work has served as a springboard for other

researchers. The theoretical framework for her correlational
study exploring the differences between three age groups of first
time mothers (15 to 19, 20 to 29, and 30 to 42 years of age).
 Critique
Clarity. She has proposed using terms derived from
nursing researchers that would be understood more clearly
by users of her theory.

Simplicity. The theory is predictive in nature and readily

lends itself as a guide for practice.

Generality. The theory can be generalized to all women

during pregnancy through the first year after birth,
regardless of age, parity, or environment.
 Critique

Accessibility. The theoretical framework for

exploring differences among age groups of first-time
mothers lends itself well to further testing and is being
used by others for this purpose.

Importance. Mercer’s work is used repeatedly in nursing

research, practice, and education. The framework is applicable
to any discipline that works with mothers and children during
the first year of motherhood.
Uncertainty in Illness
Theory
Merle H. Mishel
 Merle H. Mishel
 Born in 1939 in Boston, Massachusetts
Master's degree in psychiatric nursing
from UCLA in 1966
PhD in social psychology in 1980
 Kenan Distinguished Professor of
Nursing
 Director of doctoral and postdoctoral
programs
 University of North Carolina at Chapel
Hill
Uncertainty in Illness Theory
Provides a comprehensive framework
within which to view the experience of
acute and chronic illness and to organize
nursing interventions to promote optimal
adjustment.

The reconceptualized theory addresses the

unique context of continual uncertainty and
thereby expands the original theory to
encompass the ongoing uncertain trajectory
of many life-threatening and chronic
illnesses.
Theory Development
1. Antecedents of Uncertainty. Anything that
occurs prior to the illness experience that affects the
patient’s thinking.

2. Appraisal of Uncertainty. The process of

placing a value on the uncertain situation.

3. Coping with Uncertainty. Activities that are

used in dealing with uncertainty.
 Antecedents of Uncertainty
1. Stimuli Frame. The form, composition, and structure
of the stimuli that a person perceives.

ELEMENTS:
• Symptom Pattern. The degree to which symptoms occur
with sufficient consistency to be perceived as having a
pattern or configuration
• Event Familiarity. The degree to which a situation is
habitual or repetitive, or contains recognized cues.
• Event Congruence. The consistency between the
expected and the experienced in illness-related events.
 Antecedents of Uncertainty
2. Cognitive Capacities. The information-processing abilities of
a person, reflecting both innate capabilities and situational
constraints.

3. Structure Providers. The resources available to assist the

person in the interpretation of the stimuli frame.

ELEMENTS:
• Credible Authority. The degree of trust and confidence a person has in his
or her health care providers.
• Social Supports. Influence uncertainty by assisting the individual to
interpret the meaning of events.
Appraisal of Uncertainty
1. Uncertainty. The inability to determine the
meaning of illness-related events.

2. Inference. The evaluation of uncertainty using

related, recalled experiences.

3. Illusion. Beliefs constructed out of uncertainty.

 Coping with Uncertainty
1. Adaptation. Reflects biopsychosocial behavior
occurring within persons’ individually defined range of
usual behavior.

2. Coping Mobilizing Strategies. It is associated with

emotion-based coping strategies.

3. Coping Buffering Strategies. It is the coping selecting

ignoring and reordering the priorities.
Major Concepts & Definitions
Cognitive Schema. A person’s subjective interpretation
of illness, treatment, and hospitalization.

New View of Life. The formulation of a new sense of

order, resulting from the integration of continual
uncertainty into one’s self-structure.

Probabilistic Thinking. A belief in a conditional world

in which the expectation of continual certainty and
predictability is abandoned.
Model of Perceived Uncertainty in Illness
Acceptance by the Nursing Community
Practice. The theory has its beginning in Mishel’s own experience
with his father’s battle with cancer. She knew early in the
development of her concept and theory that nurses could identify
the phenomenon from their experiences in caring for patients.

Education. The theory has been widely used by graduate students

as the theoretical framework for these and dissertations, as the topic
of concept analysis and for the critique of middle-range nursing
theory.

Research. The scales and theory used by nurse researchers and

scientists from other disciplines describe and explain psychological
responses of people experiencing uncertainty due to illness and test
interventions to manage uncertainty in illness contexts.
 Critique
Clarity
• Despite the complex nature that uncertainty plays in the patient’s
illness, concepts of this model are presented clearly and they are easily
comprehended.
• The model translates easily into clinical and research practice.

Simplicity
• The antecedents of uncertainty are concise and their definitions are
clear and simple.
• The appraisal of uncertainty is complex it considers cognitive
processes along with the beliefs and values held by the
individual.
 Critique
Generality
The theory can be applied in many areas of nursing
practice and has been used by clinicians for acute and chronic
illnesses such as cancer, cardiac disease, and multiple sclerosis.

Accessibility
With the use of this theory, it’s been shown that
uncertainty is indeed a phenomena that patients experience and
specifies what areas of the illness may be responsible for
uncertainty. With the application of this theory, a goal of
increased coping mechanisms for patient comfort is made
attainable.
 Critique
Importance
Nurses can assist the patient by constructing a
personal scenario for the illness which includes:
1. Why or how the illness began;
2. How it will progress; and
3. How the patient can recover.

Incorporating the uncertainty is an approach where

there is a change in the patient’s and family’s perspective
in life, away from an orientation to control and predict
toward an acceptance of unpredictability and uncertainty as
normal.
Self-Transcendence Theory
Pamela G. Reed
Pamela Reed
 Born in 1952 in Detroit,
Michigan
Faculty at the University of
Arizona College of Nursing in
Tucson
 Master's Degree as Clinical
Nurse Specialist in Child and
Adolescent Psychiatric Mental
Health Nursing
Major Concepts & Definitions
Vulnerability. One’s awareness of personal mortality

Self- Transcendence. Refers to fluctuation of perceived

boundaries that extend the person (or self) beyond the
immediate and constricted views of self and the world.

“..self-conceptual boundaries multi-dimensionally:

inwardly (e.g. through introspective experiences),
outwardly (e.g. by reaching out to others) and temporally
(whereby past and future are integrated to present)..”
Major Concepts & Definitions

Well-Being. Sense of feeling whole and healthy, in accord

with one’s own criteria for wholeness and well-being.

Moderating-Mediating Factors. Influence the process of

self-transcendence as it contributes to well-being.
Self-Transcendence Theory

The goal of the theory was to provide nurses with

another perspective on the human capacity for well-
being.
Self-Transcendence Theory
1. Increased vulnerability is related to increased self-
transcendence.

2. Self-transcendence is positively related to well-

being and functions as a mediator between
vulnerability and well-being.

3. Personal and contextual factors may influence the

relationship between vulnerability and self-
transcendence and between self-transcendence and
well-being.
Acceptance by the Nursing Community
Practice. Nurse activities that promote the activities of
self-reflection, altruism, hope, and faith in vulnerable
persons are associated with an increased sense of well-
being.

Education. Community senior centers is designed to

develop more positive attitudes in nursing students when
caring for them.

Research. Research studies now provide evidence

relation to self-transcendence and increased well-being.
Critique

Clarity. Reed presented varying definitions and

numerous examples may confuse some readers.

Simplicity. Major concepts: Vulnerability, Self-

Transcendence, and well-being.

Generality. Continued development on direct

relationship of self-transcendence and well-being.
Critique

Accessibility. The concept of Self-Transcendence

lends itself to a variety of approaches.

Importance. Knowledge of developmental

resources can be engaged for persons to expand
nurses facilitating well-being in times of
vulnerability.
Theory of Illness Trajectory
Carolyn L. Wiener & Marylin J. Dodd
 Carolyn L. Wiener
 Born 1930 in San Francisco, California
 Bachelor’s degree in interdisciplinary social
science from San Francisco State University
(1972)
 Master’s degree in sociology from the University
of California, San Francisco (UCSF) (1975)
 Ph.D. in sociology in (UCSF) (1978)
 Assistant research sociologist at UCSF after her
Ph.D.
 The Elusive Quest (2000)
 Emeritus professor in the Department of Social
and Behavioral Sciences at the School of Nursing
at UCSF
 Marylin J. Dodd
Born in 1946 in Vancouver, Canada
Qualified registered nurse from Vancouver
General Hospital in British Columbia, Canada
Earned bachelor’s and master’s degree in nursing
from the University of Washington (1971,1973)
Instructor in nursing at the University of
Washington (1973)
Ph.D. in nursing from Wayne State University
(1977)
Assistant professor at UCSF
Director for the Center for Symptom
Management at UCSF
PRO-SELF Program
Theory of Illness Trajectory
Theoretical formulations regarding
coping with uncertainty through the
cancer illness trajectory.

Organizes insights to better understand

the dynamic interplay of the disruption
of illness within the changing contexts
of life.
Major Concepts & Definitions
Biography. Understood to consist of "conception s of self," a
self-classification of who one is at a particular point in one's
life's course.

ELEMENTS IN THE BIOGRAPHICAL CONTEXT:

• Identity. The conception of self at a given time that unifies

multiple aspects of self and is situated in the body.

• Temporality. Biographical time reflected in the continuous flow

of the life course events (past, present, and possible future).

• Body. Activities of life and derived perceptions based in the body.

Major Concepts & Definitions
TYPES OF WORK:

1. Illness-related work. Diagnostics, symptom management, care

regimen, and crisis prevention.

2. Everyday-life work. Activities of daily living.

3. Biographical work. Exchange of information, emotional

expressions, and the division of tasks through interactions within
the total organization.

4. Uncertainty Abatement work. Activities enacted to lessen the

impact of temporal, body, and identity uncertainty.
 Uncertainty Abatement Work
Type of Activity Behavioral Manifestations
Pacing Resting or changing usual activities
Using terminology related to illness and treatment
Becoming “professional” patients Directing care
Balancing expertise with super-medicalization
Comparing self with persons who are in worse condition to reassure self that
Seeking reinforcing comparisons
it is not bad as it could be
Looking back to reinterpret emergent symptoms and interactions with others
Engaging in reviews
in the organization
Setting goals Looking toward the future to achieve desired activities
Masking signs of illness or related emotions
Covering up
Bucking up to avoid stigma or to protect others

Establishing a place where, or people with whom, true emotions and

Finding a safe place to let down
feelings could be expressed in a supportive atmosphere

Choosing a supportive network Selective sharing with individuals deemed to be positive supporters

Taking charge Asserting the right to determine the course f treatment

Acceptance by the Nursing Community
Practice. Schlairet and colleagues (2010) examined the needs of
cancer survivors receiving care in a cancer community center
using the Theory of Illness Trajectory as a framework. They
concluded that nurses need to be aware of the specific needs of
the cancer survivors so that interventions can be developed to
meet their need.

Education. Wiener and Dodd are highly respected educators

who share their ongoing work through international conferences,
seminars, consultations, graduate thesis advising, and course
offerings. Incorporation of this work into these presentations not
only advances knowledge related to the utility of illness
trajectory models but also, perhaps more importantly,
demonstrates how data-based theoretical advancement
contributes to an evolving program of research in cancer care.
Acceptance by the Nursing Community

Research. The variation and range of

abatement strategies identified in this
theory are a unique and significant
contribution to the body of research in
coping with the uncertainty of illness.
 Critique
Clarity
• The theory is delineated clearly and well-supported by
previous works in illness trajectories.
• Propositional clarity is achieved in the logical presentation
of relationships and linkages between concepts.

Simplicity
• The Theory of Illness Trajectory adopts a sociological
framework that is applied to a phenomenon concern to nursing:
chemotherapeutic treatment of cancer patients and their families.
• The theory presents an eloquent and parsimonious
interpretation of the complexity of cancer work using key concepts
with adequate definition.
 Critique
Generality
• The authors have limited the scope of this theory to patients
and families progressing through chemotherapy for initial treatment or
recurrence of cancer.
• Further theory-building work may produce a broader scope
that permits application of the theoretical propositions in other contexts
of illness trajectories.

Accessibility
• The derived theory is rooted in the experiences expressed in
the hundreds of interviews of cancer patients and their families. Thus,
the theory is useful to clinicians and hold promise for further research
application.
 Critique

Importance
The utility of the theory is apparent
in cancer treatment, and further theoretical
development holds a promise of being
generalizable to other contexts within
cancer care and other illness trajectories.
 Theory of
Chronic Sorrow
Georgene Gaskill Eakes
Mary Lemann Burke
Maragaret Hainsworth
Mary Lermann Burke
 Born in 1941 in Sandusky, Ohio.
Burke graduated Summa Cum Laude
with a bachelor’s degree in nursing from
Rhode Island College in Providence.
 Early practice in pediatric nursing then
involved in clinical practicum at the
Child Development Center of Rhode
Island Hospital in her master’s degree.
 Currently, active in numerous
professional and community
organization.
Georgene Gaskill Eakes
 Born in 1945 in New Bern, North
Carolina.
 Graduated Summa Cum Laude from
North Carolina Agricultural and Technical
State University with a baccalaureate in
Nursing
 In her professional career Eakes worked
in acute and community-based psychiatric
and mental health settings
 Director of Clinical Education at Vidant
Medical Center in Greenville, NC
Margaret Hainsworth
 Born in 1931 in Brockville, Ontario,
Canada
 Received diploma in public health
nursing, baccalaureate degree in
nursing, master’s degree in psychiatric
and mental health nursing and a doctoral
degree in education administration
 Lecturer in the Department of Nursing
in Rhode Island College then became a
full professor.
 Employed for 13 years and entered
private practice in 1993.
Major Concepts & Definitions

Chronic Sorrow. Ongoing disparity resulting from a loss

characterized by pervasiveness and permanence.

Loss. Result of disparity between the “ideal” and real

situations or experiences.

Trigger Events. Situations or conditions that initiate or

exacerbate feelings of grief.
Major Concepts & Definitions

MANAGEMENT METHODS. How individuals deal

with chronic sorrow.

1. Ineffective Management: Strategies that increase the

individual’s discomfort or heighten the feelings of
chronic sorrow.

2. Effective Management. Strategies that increase the

comfort of the affected individual.
 Theory of Chronic Sorrow
1. Describes the phenomenon of chronic sorrow as a
normal response to the ongoing disparity created
by the loss.

2. Health care professionals’ interventions may or

may not be effective in assisting the individual to
regain normal equilibrium.

3. The disparity between the real and the ideal leads

to feelings of pervasive sadness and grief.
Acceptance by the Nursing Community
Practice. Suggestions are provided on how nurses may
assist individuals and family caregivers to effectively
manage the milestones or triggering events.

Education. Literature on standardized nursing languages

reveals that chronic sorrow is a diagnostic category with
related outcomes and suggested interventions.

Research. Served as basis for international and

interdisciplinary research.
Critique
Clarity. The overlap between external versus internal
management raises a question when the word
interpersonal is used to describe seeking professional
help.

Simplicity. It is clear that health providers may use

different managements to prevent chronic sorrow from
being progressive

Generality. Theory applies to a wide range of losses and

is applicable to the affected individual as well as to the
caregivers.
Critique

Accessibility. The limited scope readily allows

researchers to study clinical phenomenon.

Importance. As a consequence of the rich body of

research surrounding the theory, chronic sorrow is
a widely accepted phenomenon.