Describe the internal and external criticism used to assess middle-range theories.

Gender Roles And Travel
September 16, 2022

Describe the internal and external criticism used to assess middle-range theories.


It is critical to determine whether a theory can be adapted for use in research. Describe the internal and external criticism used to assess middle-range theories.
Describe the internal and external criticism used to assess middle-range theories.

Nursing theories have traditionally taken the form of rules, beliefs, and customs (Chinn and Kramer, 2004) without questioning the routine practice. As a result, the experienced nurse was evaluated based on a combination of a caring attitude and some technical skills gained through hospital-based training (Lasiuk and Ferguson, 2005). Furthermore, the nursing discipline relied on a few theories borrowed from other domains [ibid]. Nonetheless, a significant revolution in the field occurred in 1965, when the American Nurses Association formally declared theory development as the profession’s goal (Meleis, 1997). A few years after this declaration, grand theories and conceptual models were published, serving as nursing programs’ theoretical foundations.
Meleis’ (1997: 128) passionate appeal for a “reVisioning” of nursing research goals resulted in current trends toward developing and testing middle range and practice theories. To achieve professional accountability in nursing, theory, practice, and research must be integrated (Gortner, 1973). This is because both are necessary and mutually beneficial. The approach provides a framework for directing practice and study and can lead to theory generation (McEwen, 2007). (Chinn and Kramer, 2004).

I am a general nurse who worked at the Komfo Anokye Teaching Hospital recently. It is Ghana’s second largest hospital and serves as the primary referral center for the Ashanti Region as well as parts of the Eastern, Central, Northern, and Western Regions (Buabeng, Matowe, and Plange-Rhule, 2004). I was working in a general surgical ward, dealing with preoperative and postoperative patients. In my practice, I discovered that despite advances in pain management, postoperative pain was a common problem among surgical patients (Carr and Goudas, 1999, Donovan, 1990; Long, 2000). Kolcaba’s middle-range theory of comfort has been very useful in my search for a nursing theory that can be applied in my clinical setting (surgery) because it addresses patients’ comfort needs.


The purpose of this essay is to apply a nursing theory to a phenomenon of interest in my clinical practice. It will begin with a case study from my practice, followed by a critical reflection on Carper’s epistemological patterns in nursing. The essay will then proceed with a brief literature review on the main concepts identified in the reflection. Following that, Kolcaba’s Comfort Theory will be described, analyzed, and applied to my practice area (surgical setting). Finally, I’ll summarise my thoughts on this nursing theory.


CASE STUDY (Refer to Appendix 1 for an extended description).


Baba Musah, 34, was admitted to the ward following an emergency appendicectomy. He was assessed and managed in accordance with the hospital’s postoperative patient management protocol. However, he continued to complain of pain, which was accompanied by unstable vital signs. When I approached him and discussed some of his problems, he seemed very relaxed. As a result, his vital signs stabilized, and he verbalized an improvement in his pain.



According to Carper (1978, 1992), there are four ways to acquire knowledge: aesthetically, personally, empirically, and ethically.


Carper (1978) defines aesthetics as the perception gained from observing an event at a specific time. Aesthetics, in its most developed form, is the ability to understand a situation and act without much thought (Slevin, 2003). I approached Baba Musah because I could tell there was more to it than postoperative pain. This is what Polanyi (1966) refers to as tacit knowledge, or Benner’s (1984) intuitive expert practitioner; it is the knowledge that cannot be explained. I then introduced myself and assured him of my confidentiality. I continued by inquiring about his problems. As he began to speak, he began to cry, but I supported and consoled him. He then relaxed and resumed his narration. I inquired about his problems because he appeared worried and helpless. I had no idea this could make someone cry. Regardless, it compelled me to sit by his bedside and inquire further about his condition.


As a result of the incident, I realized that people react differently in different situations. I initially felt guilty because I believed my efforts had exacerbated his problem. Furthermore, I was unsure of how I would communicate with Baba in order to provide him with the support and comfort he required. I hoped he felt I was of assistance and that he could place his trust in me. The nurses I worked with were overjoyed with the outcome of the intervention, as evidenced by their facial and verbal expressions. It’s difficult for me to say how Baba felt in that situation, but he later expressed his gratitude to me. I could tell he was upset at first, but after the conversation, he appeared relaxed and at ease in bed.


Perceptual knowledge is the awareness of oneself and others during an interaction (Carper, 1978, 1992). When dealing with his tears, I was initially surprised and uneasy. This is because men in Ghanaian culture do not usually cry in public. As a result, I was perplexed and unsure of what was going on. This viewpoint is shared by Zborowski (1952), who proposed that certain pain beliefs are held by people based on their socialization culture. Despite this, I expressed empathy and cared for Baba because of my own personal experiences with pain during trauma. This is also consistent with the findings of a survey, which revealed that care-providers previous pain experiences influence their attitudes toward others in pain (Brunier, Carson, and Harrison, 1995; O’Brien, S., Dalton, J., Kinsler, G., and Carlson, 1996). The knowledge and attitude of experienced oncology nurses toward the management of cancer-related pain. Oncology Nursing Forum 23, pp. 515-521. O’Brien, Dalton, Kinsler, and colleagues, 1996). Baba was embarrassed to cry in public after the incident, but I assured him that he would be fine.


Empirical knowledge is factual and impersonal knowledge gained from principles, laws, theories, and science. (Carper, 1978; 1992). Baba Musah was assessed and managed in accordance with hospital protocol for postoperative patients. As a result, his vital signs were monitored on a regular basis until he stabilized. Pain medication (intravenous pethidine) was administered based on the pain score. In the absence of significant improvement in his condition, I considered the value of communication as a therapeutic tool. This influenced me to approach him to find out what was causing his pain. We talked about how to deal with his main concerns after we explored them. Baba was educated on the disease process, management, and outcomes. Following the interaction, subsequent assessments revealed pain improvement and stable vital signs.


Ethical knowledge entails a reasonable and moral assessment of what is considered right or wrong (Carper, 1978, 1992). Baba Musah was treated with dignity and respect by addressing him by title, attending to his needs, and providing him with the privacy he requested. Regardless, some of the ethical issues that arise concern the rightfulness or wrongfulness of nurses in turning away from a patient in pain in order to attend to other patients who also require care. Another ethical quandary raised by this case study is the provision of adequate information prior to an emergent operation in order to reduce the fear of unknown outcomes. However, after assessing the patient, this conundrum can be resolved successfully.



Some of the key concepts that emerge from this reflection are pain management, communication, and comfort. Morris (1991) defines pain management as “the reduction of an individual’s pain to an acceptable level.” Communication is the reciprocal process of conveying information through verbal and nonverbal means (Arnold and Boggs, 1995; Balzer-Riley, 1996). Slater (1985) defines comfort as a pleasant state of physiological, psychological, and physical harmony between a person and their surroundings.


The therapeutic nurse-patient relationship is essential for successful pain management (Briggs, 1995). This implies that positive communication is essential in pain management. As a result, when pain is effectively managed, patients become more comfortable. I will select “comfort” as the main concept from the list above because it is a broader construct that includes pain management. Furthermore, nurses become aware of the patient’s comfort through communication.


For many years, various authors have defined comfort from various perspectives. Some regard it as a necessary factor for patients (Nightingale, 1859), while others regard it as the primary concern of nursing (Harmer, 1926). Although the meaning of comfort is implied in these descriptions, it is clear that it is the primary focus of nursing. Thus, Harmer (1926) emphasizes the importance of maintaining a comfortable environment when providing care.


Morse (1983) considers comfort to be an important nursing action and responsibility (Van Blarcom, 1953). As a result, nurses are evaluated based on their ability to make their patients comfortable (Goodnow, 1935). As a result, the American Nurses Association (1987) emphasized the importance of treating patients with dignity and comfort until death. Without a doubt, nurses are the most effective people at providing comfort to patients (Funk and Tornquist, 1989). Nonetheless, comfort is a subjective state that is best determined by the patient (Richards, 1980; Paterson and Zderad, 1988). Furthermore, the goal of comfort helps people achieve a state of well-being (Gropper, 1992).


Comfort could be used as a noun, verb, adjective, or gerund in relation to a process or an outcome. However, the term is defined in nursing practice as a state of satisfaction following stressful health care conditions (Kolcaba, 1994). Because of the controversies surrounding this contested concept, it is clear that the concept of “comfort is multi-dimensional, meaning different things to different people” (Hamilton, 1985: 32). Personally, I define comfort as the satisfaction of needs, expectations, or desires that, when received, rouse an individual to a sense of well-being. motivate



Theory context

Katharine Kolcaba began developing theories during her master’s program in nursing (MSN) and completed them over a ten-year period while pursuing her doctorate degree. She received her Ph.D. in 1997 from Case Western University and published a book on comfort theory in 2003. The theory of comfort was developed through induction, concept analysis, deduction, and retroduction (Kolcaba, 2003).


Kolcaba incorporated comfort into her framework for dementia care during the inductive stage. She studied comfort for two years and came up with three types of comfort (relief, ease, and renewal). This was later modified to produce the current taxonomic structure of comfort, which defines comfort as the state of satisfying needs for relief, ease, and transcendence in physical, psychospiritual, environmental, and sociocultural contexts (Kolcaba 1991).


At the deductive stage, comfort was linked to other nursing concepts to generate a theory. Murray’s (1938) work provided a framework for accommodating Kolcaba’s nursing concepts, whereas the three types of comfort were derived from the work of other nursing theorists. Orlando (1961) defined relief, Henderson (1966) defined ease, and Paterson and Zderad defined transcendence (1976). Schlotfeldt’s concept of health-seeking behaviors (HSBC) was also used (1975). During the reproductive stage, Kolcaba incorporated the concept of institutional integrity into her middle-range theory of comfort (Kolcaba, 2003). Comfort theory describes individualized patient care and predicts the benefits of continuous comfort measures, comfort, and involvement in health-seeking behaviors (Kolcaba, 2003).


Concepts and propositions

The theory of comfort describes major concepts such as comfort needs, comfort measures, intervening variables, comfort, health-seeking behavior, and institutional integrity. Comfort needs arise as a result of stressful healthcare situations that cannot be met by a patient’s support system. Nursing measures are designed to meet these needs while taking into account patient factors (past experience, age, attitude, emotional state, support system, finances) that can affect the perception of comfort (Kolcaba 1994).


Comfort is a holistic experience that can be provided in the physical, psychospiritual, environmental, and sociocultural contexts of life (Kolcaba, 1994; Kolcaba and Fox, 1999). Kolcaba (2001) defines three types of comfort as follows: relief as the provision of a specific health care need; ease as a state of steadiness or happiness. And transcendence is a state in which one rises above life’s challenges.


The table below depicts the comfort needs I identified using Kolcaba’s (1991) taxonomic structure in my case study.


Table 1.1





Pain after surgery




“How can I tolerate pain when I get up?” thinks the patient.





Crying, uncertainty about prognosis


need for emotional and spiritual support.



A noisy ward is surrounded by other surgical patients in a large ward.


Lack of privacy.


A calm and familiar environment is required.



Absence of usual routines, family, and education.


The absence of family


I need assistance from staff and significant others. Information is needed.


Health-seeking behaviors refer to the outcomes that occur when comfort is achieved; they can be internal or external or lead to a peaceful death (Schlotfeldt, 1975). Kolcaba (2001) defines institutional integrity as the totality of an organization’s elements and expresses a recursive relationship between comfort and institutional integrity.


Major Assumptions

Kolcaba (2001) defines metaparadigm concepts as follows: Nursing is the deliberate assessment of comfort needs before and after comfort interventions. A patient is a person, family, or community that requires comfort. The external background of a patient can be controlled to increase comfort. A patient’s health is their best performance.


According to Kolcaba (1994), the theory’s basic assumptions are that: comfort is the desired outcome; humans actively strive to meet their comfort needs; patients are strengthened when their comfort needs are met.



According to Barnum (1990), when analyzing a theory, its internal and external aspects should be considered; internal criticism refers to the inner structure, while external criticism describes its peripheral relationship.


Internal Criticism

Clarity refers to how a theory is presented and how the reader understands it (Barnum, 1990). Aside from the article on concept analysis, which is difficult to read (Dowd, 2006), the theory is well presented in the literature and is simple to grasp (Wilson, 2009). Kolcaba clearly presents the theory’s evolution for additional acknowledgment and comprehension (Wilson, 2009).


Consistency: A consistent theory maintains consistency in its definitions, principles, and interpretations (Barnum, 1990). It is clear that the definitions of concepts, derivations, propositions, and assumptions are undifferentiated throughout the literature (Wilson, 2009).


Adequacy: The theory’s concepts, propositions, and assumptions are nursing-specific and easily operationalized in a variety of settings (Dowd, 2006; Wilson, 2009). The theory not only describes what nurses do, but it also accounts for outcomes that are important to patients, their health, and the integrity of institutions (Kolcaba, 1994; 2001; 2003). According to Wilson (2009), each type and context of comfort has been thoroughly explained and relates to the provision of care for any patient.


Logical development is determined by the coherent presentation of arguments that leads to the conclusions of a theory (Barnum, 1990). Kolcaba thoroughly discusses the evolution of the theory in the literature (Wilson, 2009). Her conclusions are supported by detailed arguments (Wilson, 2009) and research using appropriate tools such as visual analog scales, the Comfort Behaviour Checklist, and various questionnaires adapted from the General Comfort Questionnaire to suit the target population (Kolcaba, 2001).


Comfort theory conforms to the standards of a middle range due to its a limited number of concepts and propositions, minimal degree of abstraction, and application in practice (Wilson, 2009). Some studies have tested and supported the theory (Kolcaba and Fox, 1999; Dowd, Kolcaba, and Steiner, 2000), while others have found little significance (Kolcaba, Schirm, and Steiner, 2006).


External Criticism

Complexity is determined by the relationship between variables in theory (Barnum, 1990). The theory’s six concepts are well related in a conceptual framework (Wilson, 2009), which facilitates its application in both practice and research. The theory is straightforward, precise, and well-explained (Dowd, 2006). As a result, nurses and nursing students can quickly learn and apply it in practice (Panno, Kolcaba, and Holder, 2000).


Discrimination: refers to the uniqueness of a theory to a practical discipline (Barnum, 1990). The four contexts of comfort experience depict the holistic nature of nursing (Wilson, 2009). The theory is prevalent in the nursing world, but it can be applied in a variety of settings (Dowd, 2006; Wilson, 2009). Regardless of the variations in its definition, comfort has been defined as a desirable state and outcome (Kolcaba, 1994).

Describe the internal and external criticism used to assess middle-range theories.