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A Middle-Range Theory of

Psychological Adaptation in

Death and Dying

Marjorie C. Dobratz, RN, DNSc.

Professor Nursing Program

University of Washington Tacoma

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The University of

Washington,

Tacoma offers

undergraduate and

graduate

programs, and

shares CCNE

accreditation with

the UW School of

Nursing in Seattle.

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Middle-Range Theories (MRT’s)

Importance to Nursing

Predicted to be the “illusive practice theory” (Fawcett & Alligood, 2005, p. 229)

Provide “direction for nursing research” (Lasiuk & Ferguson, 2005, p. 130).

Can be applied “across several client populations and practice settings” (Lasiuk & Ferguson, 2005, p. 130).

“Contribute to understanding the human condition” (Graham, 2006, p. 276).

“Deal with limited sources of social phenomena” (Merton, 1968, p. 40).

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Middle-Range Theories (MRT’s)

Construction always “involves abstraction” (Merton, 1968, p. 39).

These abstractions form a “limited set of assumptions from which hypotheses can be derived and confirmed by empirical investigation” (Merton, p. 68).

MRT’s are empirically based and can fit with a conceptual model’s (CM) conceptual-theoretical structure (CTS).

A MRT is more specific than a conceptual model, as it describes, explains or predicts a CM phenomenon, and also limits the number of derived assumptions.

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Purpose

To present a MRT of psychological

adaptation in death and dying that was

abstracted from a series of quantitative and

qualitative research studies. The findings

were synthesized into limited number of

assumptions, testable hypotheses were

derived, and the constructed MRT was

linked to the conceptual-theoretical

structure of the Roy Adaptation Model.

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Roy Adaptation Model (RAM)

Middle-Range Theories

Adaptation to Diabetes Mellitus: Whittemore and Roy (2002) synthesized empirical evidence related to adaptation to this chronic disease.

Caregiver Stress: Tsai (2003) developed assumptions related to caregiver experience and linked them to the RAM’s conceptual framework.

Chronic Pain: Dunn (2004) reviewed the theoretical/empirical literature and developed six hypotheses that could be empirically tested.

Caregivers Psychological Distress: Five completed studies were linked to the RAM’s self concept model (Levesque et al., 1998).

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Abstracting a MRT of Psychological

Adaptation in Death and Dying

A quantitative, causal model study structured person-environment variables within the RAM framework: Dependent (psychological adaptation and well-being), independent variables were focal (physical function), contextual (pain, social support), and age, sex, length of illness were residual stimuli (Dobratz, 1993).

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Results of First Quantitative Study

The causal model study found that

the contextual stimuli of social

support (p <.001) and pain (p <. 05)

and the residual stimulus of age (p

<. 01) influenced the outcome of

psychological adaptation. Physical

function (focal stimulus) just missed

significance at (p < .07).

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Building a RAM-Based MRT

A second quantitative study compared the

same person-environment variables in

subjects who expressed spirituality (n = 44)

and 53 participants who did not express

spirituality (Dobratz, 2005). Only three

components of the McGill-Melzack Pain

Questionnaire: affective dimension, pain

rating index, and number of words

chosen were significantly higher for the

non-expressed spirituality group.

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Continuing to Build a MRT

A third study quantitative study involved statistical triangulation that compared numerical data from the causal model study and textual data from a concurrent grounded theory study in three patterns of the self-transacting dying: becoming, anguishing/agonizing, and avoiding (Dobratz, 2006)

A one-way analysis of variance confirmed that social support, physical functionand religious preference impacted end-of-life patterns.

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Further Building of the MRT

A qualitative study further described those 44 dying individuals who expressed spirituality (Dobratz, 2004). Life-closing spirituality was shaped by a core theme of believing, which was linked to comforting, releasing, connecting, giving, reframing, and requesting. The findings of this study also supported humanism and veritivity as defined in RAM theory.

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Continuing to Build the MRT

Although the grounded theory study

that was conducted in conjunction

with the causal model study emerged

seven patterns of the self-transacting

death and dying (Dobratz, 2002-03),

the becoming pattern was selected

for further analysis and abstracted to

build the MRT.

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The Importance of the Qualitative

Research in Developing MRT

More in-depth description of the Becoming-

Self determined that the 15 dying persons

in this pattern were self-integrated, created

personal meanings, used inner cognition,

and connected to others and a Higher

Being (Dobratz, 2002).

The pattern of the Becoming-Self also

supported humanism and veritivity as

defined within the philosophical

assumptions of the RAM.

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Conceptual Definition of Spirituality

Four themes that define spirituality:

1. Spirituality as religious systems or beliefs, 2. Spirituality as life meaning, purpose and connection to others, 3. Spirituality as non-religious systems of beliefs or values, 4. Spirituality as metaphysical or transcendental phenomena (Sessanna, Finnell, & Zezewski, 2007, p. 252). With this broader definition, spirituality rather than religion is the concept used in this MRT abstraction.

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Theoretical Assumptions from

Abstracted Findings

Psychological adaptation in death and dying is influenced by pain and physical function.

Psychological adaptation in death and dying is promoted by connecting to supportive others.

Psychological adaptation in death and dying is impacted by spirituality.

With age a residual stimulus in death and dying, no assumption can be made regarding this influence.

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Derived Hypotheses

Pain has a negative effect on psychological adaptation.

Pain has a negative effect on expressed spirituality.

Social support has a positive effect on psychological adaptation.

Physical function has a negative effect on psychological adaptation.

As a residual stimuli, the impact of age warrants further testing.

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Conceptual Definition of

Psychological Adaptation in Death

and Dying

Given the concepts abstracted from the quantitative and qualitative studies, “Psychological adaptation in death and dying is using spiritual and social resources, and managing physical symptoms to maintain self-integration”.

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Roy Adaptation

Model

Regulator

Physiologic - Physical

Pain, Physical

Function

Symptom

Management

Cognator

Self Concept Role Function Interdependence

Spirituality Social Support Social Support

Psychological Adaptation

in Death and Dying

Adaptive Modes

Coping Processes

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Coping Processes

Regulator Subsystem: The dying process

is impacted by neural and chemical

systems associated with pain and physical

function

Cognator Subsystem: The dying process

is linked to four cognitive-emotional

channels that affect perceptual and

information processing, learning, judgment,

and emotional

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Links to RAM Modes

Physiological-Physical Mode: Pain

and physical function include “the

physical and chemical processes

involved in the function and activities

of living organisms”(Roy, 2009. p. 89).

The Self-Concept Mode: Spirituality is

a part of the personal self that

includes a moral-ethical-spiritual

component (Roy, 2009, p. 96).

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Links to the RAM Modes

Role Mode: Social support and

connectedness to others relates to the

social integrity component and the “need to

know who one is in relation to others” (Roy,

2009, p. 98), even though life is ending.

Interdependence Mode: Social support

and connectedness to others involves the

willingness and ability to give and receive

love and nurturing at the end of one’s life.

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Conceptual Definition of Adaptation

Adaptation is defined as “the process

and outcome whereby thinking and

feeling people, as individuals or in

groups use conscious awareness and

choice to create human and

environment integration “ (Roy, 2009,

p.29).

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Links to Philosophic Assumptions

Dying persons have mutual relationship with others and a God-like figure.

Dying person find human meaningthat is rooted in an omega point convergence of the universe.

Dying persons use human creative abilities of awareness, enlightenment, and faith.

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Links to Scientific Assumptions

Dying persons use consciousness and meaning to maintain person self-integration.

Dying persons utilize processes of self-awareness that are rooted in thinking and feeling.

Dying person connect to others in relationships that accept, protect, and foster independence.

Dying persons integrate human and environment meanings that result in adaptation.

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Nursing’s Goal in Life-Closure

To promote adaptation for dying individuals and their families, thus contributing to health within dying, enhanced quality of life, and dying with dignity by assessing behaviors and factors that influence adaptive abilities (promoting spirituality and assuring social support) and by intervening in the environment to control pain and manage symptoms.

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References

Dobratz, M. C. (1993). Causal influences of

psychological adaptation in death and dying.

Western Journal of Nursing Research, 15 (6), 707-

722.

Dobratz, M. C. (2002). The pattern of the becoming-

self in death and dying. Nursing Science

Quarterly, 15 (2), 137-142.

Dobratz, M. C. (2003-03). The self-transacting dying:

Patterns of social-psychological adaptation in

home hospice patients. Omega: Journal of Death

and Dying, 46 (2), 147-163.

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References

Dobratz, M. C. (2004). Life-closing spirituality and the

philosophic assumptions of the Roy adaptation

model. Nursing Science Quarterly, 17 (4), 335-

338.

Dobratz, M. C. (2005). A comparative study of life-

closing spirituality in home hospice patients.

Research and Theory for Nursing Practice: An

International Journal, 19 (3), 241-254.

Dobratz, M. C. (2006). Enriching the portrait:

Statistical triangulation of life-closing theory.

Advances in Nursing Science, 29 (3), 260-270.

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References

Dunn, K. S. (2004). Toward a middle-range theory of adaptation to chronic pain. Nursing Science Quarterly, 17 (1), 78-84.

Fawcett, J., & Alligood, M. R. (2005). Influences on advancement of nursing knowledge. Nursing Science Quarterly, 18 (3), 227-232.

Graham, I. (2006). Letters to the editor. Nursing Science Quarterly, 19 (3), 276-277.

Lasiuk, G.C., & Ferguson, L. M. (2005). From practice to midrange theory and back again: Beck’s theory of postpartum depression. Advances in Nursing Science, 28 (2), 127-136.

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References

Levesque, et al. (1998). Empirical verification of a

theoretical model derived from the Roy adaptation

model: Findings from five studies. Nursing Science

Quarterly, 11 (1), 31-39.

Merton, R. K. (1968). Social theory and social

structure. New York, NY: The Free Press.

Roy, S. C. (2009). The Roy Adaptation Model (3rd

ed.). Upper Saddle River, NJ: Pearson Education,

Inc.

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References

Sessanna, L., Finnell, D., & Jezewski, M. A. (2007).

Spirituality in nursing and health-related literature.

Journal of Holistic Health, 25 (4), 252-262.

Tsai, P-F. (2003). A middle-range theory of caregiver

stress. Nursing Science Quarterly, 16 (2), 137-

145.

Whittemore, R. & Roy, S. C. (2002). Adapting to

diabetes mellitus: A theory synthesis. Nursing

Science Quarterly, 15 (4), 311-317.