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Middle Range Theory

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The above poem reflects an offer for an intentional dialogue by Robin Hood to a troubled youth. The offer takes place after others have gone away, and the two are alone. Robin is the encouraging nurse, setting the stage for a dyadic conversation. He is offering to be an attentive listener to the youth’s embracing story. Robin warmly supports the youth towards creative ease by encouraging the youth to speak freely. Speaking freely is like opening the flood gates of a dam and allowing the waters of sorrow to pour out until the water calms. The purpose or meaning of the intentional dialogue is to ease the youth’s sorrowful heart and to promote health and human development. Robin again encourages the youth by offering a seat beside him. He is offering his presence and is willing to wait for the youth to start telling his story. Putting emotionally upsetting experiences into words can affect a person’s thoughts, feelings, and physical health. Mary Jane Smith and Patricia Liehr are theorists who believe in the healing power of story-sharing.

The importance of story for promoting health and human development created the core and the fundamental concept of the theory of attentively embracing story. The main ideas of the theory are nurse, client (storyteller), health challenge, and story. Attentively embracing story is a nurse-client process encompassing the concepts of intentional dialogue, connecting with self-in-relation, and creating ease in the midst of a health challenge (Smith & Liehr, 2003). In this relationship the nurse gathers a story about a health situation that matters to the person. There are two processes of intentional dialogue: true presence and querying emergence. (Smith & Liehr, 2003). The nonjudgmental nurse pays close attention to the unique life experiences of the storyteller’s pain, confusion, joy, broken relationships, satisfactions, or suffering. The nurse does not become involved, but does ask for clarification to keep the story flowing from beginning to middle to end. The nurse tries to understand the story from the storyteller’s perspective and actively listens as long as the storyteller desires to tell the story. Only the storyteller knows the details of the never-ending story.

Connecting with self-in-relation is composed of personal history and reflective awareness (Smith & Liehr, 2003). Personal history is the story of the storyteller’s past life experiences and events as told by the person from the person’s perspective. The storyteller becomes aware of their strengths and weaknesses and, with the nurse’s guidance, strives to find meaning in past experiences, thoughts, and feelings. Reflective awareness produces meaning that is applied to present challenges and future hopes and dreams. Meaning establishes ease. Creating ease is energizing. Two dimensions of creating ease are re-membering disjointed story moments and flow in the midst of anchoring (Smith & Liehr, 2003). The storyteller re-members story moments by connecting events in time through realization, acceptance, and understanding as the health story comes together. Patterns surface as the storyteller explains the meaning of important experiences. The storyteller re-members the health story in the presence of a caring nurse. Meaning is applied to the present health challenge, giving the storyteller purpose and vision for the future.

Comprehending a meaning to the present health challenge is called anchoring. The harmony that the storyteller experiences during anchoring is flow. Simply, flow is the ability to envision the positive side, the value, of the health challenge. Flow can be illustrated in the grief process. Flow is the ability of a person to grieve and integrate the value of grief. When a person is first confronted by a medical diagnosis, there may be a degree of shock and uncertainty. A change in the person’s life occurs. Pastor Ted Trout Landen, Director of Pastoral Care for Wellspan Health, observed that people tell the story about the death over and over again at a funeral viewing. He explains change equals loss, equals grief, equals growth. For every stage of the grief process, there is a spiritual value. For example, the first stage of grief is shock and denial. The benefit of allowing time for shock and denial is to insulate the body. Insulation gives the person experiencing the first stage of grief a chance to tell the story over and over again. Telling the story enables the mind to believe the experience is happening. (personal communication, October, 2008).

When the mind accepts that the experience is happening, this is flow. Attentively embracing story is connecting with self-in-relation through intentional dialogue to create ease (Smith & Liehr, 2003). This description explains the relationship among the concepts. It is imperative to understand that the dynamic relationship between the concepts takes place all at once. The relationship is not linear. For example, a moment of ease is visualized when a person with chronic pain becomes less tense, relaxes shoulder muscles, and takes a sigh of relief as the nurse acknowledges the person’s pain, rather than the nurse requiring the person to verbalize the intensity of the pain. This brief encounter with the caring person, the nurse, enables a connection between the nurse and client about the health challenge, pain, before the story parts come together. Human interaction defies a linear continuum. Origins of the Theory

Nineteen ninety-nine was a year of memorable news events. All of these events affect people who have their individual dynamic stories to tell. The following are specifics events of 1999 that may have influenced the theory of attentively embracing story: • Public concern over school violence rose in the wake of tragic shootings at Columbine High School in Littleton, Colorado. (Messenger, 2000). • The Nursing Leadership Academy in End-of-Life care was developed in response to great demand from within the nursing profession. The need for increased leadership capacity was defined as a strategic priority at the 1999 Nursing Leadership Consortium on End-of-Life Care. “Nurses in all practice settings and roles are faced with the daily challenges of providing humane, dignified end-of-life care to patients and their families. This issue is shared by the entire nursing profession,” says Cynthia Rushton, DNSc, RN, assistant professor at the Johns Hopkins University School of Nursing and Academy organizer (Sabatier, 2000). • By 1999, scientists had cataloged more than 4,000 hereditary diseases, and researchers were engaged in one of the most important medical research projects of all time: the Human Genome Project (Bushie, 2000). The remarkable advances in genetics and genomics over the last three decades have necessitated initiatives on the part of all healthcare disciplines to assist providers in applying this new knowledge in practice.

Nursing has responded by planning and implementing a number of projects that address the challenging issues created by genetic and genomic advances. Nurses are applying the emerging science and technology in genetics and genomics to advance the nursing profession and provide competent nursing care to patients faced with genetic and genomic healthcare concerns (Badzek, et al., 2008). • Events of 1999 cannot be discussed without mentioning that people in America and worldwide celebrated the new century and millennium as the clocks struck midnight throughout the day. The new millennium brings with it hope in the future concerning all aspects of life. More specifically, the new millennium allows nurses to influence the evolutionary story of nursing practice. Of paramount importance is the question: Will people affected by these news events or challenges have the opportunity to tell their embracing stories to an attentive, caring person? Smith and Liehr (2003) had a long-term relationship and shared common values about nursing practice and research. Both authors come from educational backgrounds that taught nursing theory.

Smith and Liehr believe in the healing potential of story sharing and recognize the importance of building theory as the intersection of practice and research. They based their knowledge about the theory of story on their dissertation research. Smith wrote her dissertation on rest, and conceptualized rest as “easing with the flow of rhythmic change in the environment” (Smith, 1986, p. 23). Liehr’s (1992) dissertation examined the blood pressure effects of talking about a usual day and listening to a story. Smith & Liehr (2003), cite support for their theory. Sandelowski evaluated the research (1991) and practice (1994) merits of the human story. Burkhardt and Nagai-Jacobson (2002) call attention to the power of story: “In the process of telling and hearing stories, persons often come to new insights and deeper understandings of themselves.…” (p. 296). McAdams (1993) describes the processes occurring when interpreted meaning supports healing: “Stories help us organize our thoughts… In some instances, stories may also mend us when we are broken, heal us when we are sick” (p. 31).

After a long separation, the authors were reunited, and in their excitement rehashed common interests from their past nursing experiences. Motivated by their excitement and based on their past dissertation research, the two theorists discussed the importance of story for promoting health and human development. They realized commonalities from gathering stories about clients telling their stories when confronted with a health challenge. When people were listened to attentively, story-sharing mattered. During the authors’ discussion, critically thinking about people and their story sharing, the two energized theorists became excited about a theory of story. They decided that story would be the basis of a theory to guide nursing practice and further their research. The theory of attentively embracing story was birthed. Because the motivation to develop the theory of attentively embracing story came from within, Smith and Liehr used an inductive approach to theory development. Usefulness

Listening to client’s stories about their health condition is a common experience in nursing practice. The theory of attentively embracing story has developed a nurse-client process that makes use of this experience and gives direction to nursing practice (Smith & Liehr, 2003). It offers understanding as to how the nurse, offering true presence in attentively listening, can guide clients through their stories, inviting reflection so that new meaning and changed perceptions of the health condition may occur. These may in turn facilitate growth and change, improving outcomes. Listening in this way has become a holistic intervention applicable across many clinical settings, situations, and time spans, because story can be conveyed through words, behaviors, and physiological changes (Summers, 2002). It has been used in exploring clients’ experiences of new territory of calmness, setting aside life’s burdens, finding adolescent voice in abusive relationships (Smith & Liehr, 2003), lowering blood pressure (1999), and in drinking and driving situations (2005).

Inviting story is always a possible nursing intervention. Liehr et al. (2006) state that clients will talk about their health challenge within three minutes, if given the opportunity. Their study found that health stories can be gathered in five minutes.

Middle-range theory creates a link between research and practice which is a creative force for developing nursing knowledge (Smith & Liehr, 1999).The nurse-client relationship is critical to nursing practice scholarship (2005). Simultaneity paradigms value human narratives for nursing knowledge development (1999). Smith & Liehr devised a systematic process of inquiry that elevates stories heard by nurses in everyday practice to scholarly narratives which may be useful in developing nursing knowledge (2005). The research method has seven phases:

1. Gather the story about a complicating health challenge.
2. Compose the reconstructed story.
3. Connect existing literature to the health challenge.
4. Name the complicating health challenge.
5. Describe the developing story plot.
6. Identify movement toward resolving.
7. Collect additional stories about the complicating health challenge. Using this approach enables nurses to take the stories from the context of everyday practice and create meaningful practice scholarship. Stories, seen through the lens of theory in this way, give nurses the opportunity to grow as scholars and contribute to the body of nursing knowledge.

The theory of attentively embracing theory has been useful in clarifying the concept of mutual timing in communication process as described by Summers (2002). The model for Summers’s concept where the therapeutic intervention of a helping relationship may produce a “difference-making moment” was built on the foundation of story theory (p. 23).

“One can never be certain about the way that the storyteller will embrace story to enable human development” (Smith & Liehr, 1999, p. 202).When a client tells a story to a nurse in true presence, a change in perspective may occur, or may not. Will the nurse realize when a change has occurred? Will a change be lasting? Will a change bring a shift in behavior? Will the patient’s outcome be changed? Who can say?

If a new awareness in meaning and a shift in perspective have occurred in the client and the client expresses this to the nurse, an improvement in outcomes may be predicted and understood to some degree. If the client does not verbalize a shift to the nurse or processes the story-telling experience slowly so that a shift in perspective crystallizes after their meeting, it seems unlikely that a prediction of outcomes could be made and or an understanding of outcomes be significantly correlated to the story-telling experience.

Smith & Liehr (1999) present a case study which shows how the theory of attentively embracing story may be used. It involves a 38-year-old African-American woman who has been recently diagnosed with hypertension. She is involved in a program to help her make lifestyle changes to lower her blood pressure. In this case, blood pressure changes are seen as a language of self-awareness and are monitored every three to five minutes during the shared story. In her first session, she told her story rapidly and loudly with one sentence rushing on to the next. Systolic blood pressure ranged from 149 to 172 mm Hg and diastolic blood pressure ranged from 96 to 128 mm Hg. The nurse suggested she slow her speech and breathe after every sentence. The nurse asked if the client could identify any particular sensations when the monitored blood pressures were high. When she stated she felt a “heaviness in her breast” at these times, the nurse instructed her to choose a calming image to reflect on while slowing her breathing (p. 195). She chose the image of clinging to the feet of Jesus. When the client slowed her breathing and visualized the calming image, her blood pressures dropped from 170/112 mm HG to 156/98 mm Hg and the heavy feeling abated. The nurse’s aim in this session was to teach the client to pay attention to her way of being in her everyday situations.

During the second visit, the client stated that, although it took a conscious effort to practice the nurse’s suggestions, she felt “more aware” and that a “clean slate” had been created, giving rise to a future with possibilities she had yet to identify (Smith & Liehr, 2003, p. 196). The nurse used a drawing exercise which enabled the client to re-member past events in her story-telling which connected to future aspirations she had as a younger woman to pursue a career in her church. This dream which offered hope connected to her calming image of the feet of Jesus, allowing that to become a broader image encompassing her hopes and dreams. In this session, her systolic ranged from 131 to 156 mm Hg and the diastolic from 83 to 102 mm Hg. Intentional dialog made connections to self-in-relation and brought ease which improved this client’s outcomes. Testability

The phenomenological method has been the accepted method of analyzing data collected from the narratives of client/participants (Smith & Liehr, 1999). However, in the nine years since the inception of story theory, advancements have been made in ways to analyze the data in studies that are testing this theory. Qualitatively, stories are broken down into story moments which are distilled into themes. These are brought together into a coherent, synthesized story which captures the meaning of the experience of the health challenge (2003).

Smith & Liehr (2003) developed a quantitative approach for their theory using the Linguistic Inquiry and Word Count software which considers 72 dimensions of language. These dimensions include sentence punctuation, affective, cognitive, sensory, and social words, and words that reflect relativity and personal concerns. This software interfaces with the Statistical Package for the Social Sciences, enabling statistical analysis.

Several studies were found using the theory of attentively embracing story. These include the experiences of recovering from a cardiac event (Smith & Liehr, 2003) a drinking and driving situation (2005) and becoming pregnant in high school (1999). It has been used in developing other concepts to be used in research, such as mutual timing (Summers, 2002) and finding adolescent voice in abusive situations (Jolly, Weiss, & Liehr, 2007). The theory has informed a study based on Jean Watson’s theory which involved a story-telling intervention for clients with cancer (Evans, Crogan & Bendel, 2008; Crogan, Evans & Bendel, 2008).

Liehr et al. (2006) conducted a study which addressed the effect of adding story-centered nursing care to a lifestyle intervention for 24 client/participants with Stage 1 hypertension. Half of the participants were randomly chosen to receive intentional dialog from advanced practice nurses regarding their adjustments to their diagnosis. There were four one-hour sessions of dialog at eight-week intervals. Blood pressures were monitored before and after each session and every five minutes during the sessions and participants were encouraged to observe the blood pressure measurements. Dialog topics included managing the challenge of integrating lifestyle changes into daily life, linking everyday experiences with bodily cues, considering ways to change behavioral patterns, and considering what mattered most in the present moment to the participants regarding altering their lifestyles. The data showed that the participants receiving the intervention of intentional dialog showed greater decreases in blood pressure than those who did not.

According to McEwen & Wills (2007) propositions are statements in a theory that describe a “constant relationship between two or more concepts or facts” (p. 81). The statements relating the concepts of the theory of attentively embracing story are axiomatic rather than propositional since their relationship is general and abstract. Smith & Liehr (2003) state that “the relationship among the concepts appears linear; however, the intent is that these concepts are in a dynamic interrelationship (p. 174). They depict a human condition which is complex and nonlinear. Therefore, the statements are not propositions. Overall Evaluation

The theory of attentively embracing story is an explanatory theory which may be categorized in the group of “middle middle range” theories. It correlates in level of abstraction to Mishel’s uncertainty of illness theory (McEwen & Wills, 2007). It is comprehensive in scope because it can be widely applied to many patient populations with varying health challenges. All patients have stories to tell which they may choose to express, reflect upon, and use for growth and development. Story theory has been found to be generalizable as it can be adapted for use in many settings and time frames. Variables for measuring results of an intervention based on the theory include words, gestures, symbolic references, perceptions, behaviors, and physiologic changes, among others (Smith & Liehr, 1999). This makes the theory broadly applicable.

The theory’s strengths lie in its comprehensiveness and generalizability as shown in its usefulness in many practice situations to draw out the meaning of the experience of health challenges. It may be used in varying degrees, as a stand-alone nursing intervention or as an adjunct to other types of medical or nursing care. Its weakness may be that the theory is not a strong predictor of outcomes. The nurse can never be certain whether patterns will surface offering new meaning to the client and a shift in perspective, improving outcomes. Application-Carol Jones

Pain management programs are often based on the theory that complementing traditional physical pain management with positive therapies and actively involving patients in their care, shifts patients’ focus away from their chronic pain. Focusing on positive activities and thoughts promotes the potential for healing. For that reason The theory of attentively embracing story is a perfect match for the patients participating in the Pain Management Program at the York Hospital’s Pain Relief Center, the location of my advanced practice. In 2002, a Pain Management Program that educates participants to actively manage their chronic pain was started at the York Hospital Pain Relief Center. Active patient participation in the Pain Management Program includes learning about and using positive therapies such as journaling, storytelling, and art. Participants are offered a safe, nourishing environment to tell their stories about their complicated health condition called “pain.” Pain is the symptom.

The participants are given an assignment to find an object from their environment that represents their lives before they encountered chronic pain, and a second object that represents their lives since dealing with chronic pain. The participants use the articles to make a collage and use the collage to engage in intentional dialogue about their health story. The advanced practice nurse facilitates healing and promotes health byattentively listening to each participant’s embracing story as a story plot  is developed. The participants connect with self-in-relation to their past, become more aware of themselves, and find meaning in their present complicated health situation, dealing with chronic pain on a day-to-day basis. As the participants become more aware of themselves, they relax, ease is created, and they move toward resolving their pain. The concepts are intentional dialogue about a complicating health challenge, connecting with self-in-relation by developing a story-plot, and creating ease in the midst of a health challenge to find meaning and resolution. For example, one participant who is confronted with chronic pain is a watchmaker. He is presently on leave of absence from work. Returning to work as soon as possible is what matters to him. Internal parts from damaged watches were brought from home to use in his collage.

The story plot developed as he explained the timeline from when his pain started to the present. He was asked to talk about past events that contributed to his present experience. Several related story-plot dimensions surfaced: his pain, the fact that he knew his significant other for only 3 months before his pain started, the jobs that he did in the past, and that he loves his present job and wants to return to work. Difficult finances were another issue. The nurse asked if the issues that mattered most to him had been identified. He became thoughtful and started talking about the negativism in society, and how he can only work for short periods and then he has to rest. The nurse reinforced the importance of rest. He continued to explain that he enjoys listening to talk radio, but it gets controversial. When that happens, he changes the station to classical music and he feels better. He became more self aware of his behavior pattern, moving toward resolving his pain. “Making this collage was fun! It helped me to take a look at watch parts that I haven’t looked at for a long time. I am scheduled to return to work Monday, and I believe I am ready!” Application: Sherry Lookofsky

I have used the theory of attentively embracing story in my practice as case manager in the brain injury program at an acute rehabilitation hospital. Clients in rehabilitation are often experiencing a life transition. Something has occurred that may prevent them from returning home or returning to their former level of function. Aside from their need for the physical rehabilitative therapies, clients need to process the crisis that has befallen them. Applying story theory may help clients reconcile themselves to their “new normal” or to their future discharge destination.

The theory of attentively embracing story is “connecting with self-in-relation through intentional dialog to create ease” (Smith & Liehr, 1999, p. 174). The components of intentional dialog are true presence and querying. The components of connecting with self-in-relation are personal history and reflective awareness. The components of creating ease are re-membering disjointed story moments and flow in the midst of anchoring. These components are non-linear and parts can occur simultaneously.

One case where story theory was helpful to me in practice was in the case of Terry Lewis, a 52-year-old victim of a one-motorcycle accident resulting in a severe brain injury, multiple fractures, nerve and soft tissue injuries, and a vision deficit. My goal as case manager was to encourage his insurance payer to continue to cover Terry’s stay in rehabilitation as long as he needed it and to secure a discharge plan for him at the end of his stay. The story-telling experience occurred with Terry’s father, Shawn, as it was some weeks before Terry was able to participate in simple conversation. At first, when Terry was in a post-coma confusional state, Shawn would not enter his son’s room. When I introduced myself to him, Shawn stated that he knew his son would always need to be in an institution. As time went on and Terry slowly showed progress, I began to engage his father in intentional dialog. I showed true presence by meeting with him in a quiet, private environment where I could listen at length and maintain eye contact. I allowed him to establish the rhythm and flow of the dialog as he expressed his disbelief and sadness at his son’s condition. Querying Shawn brought out that he now saw his son as “other,” a person he did not know. He had no hope for his son’s recovery.

As weeks went by and Terry showed continuing improvement, I engaged Shawn in dialog several times a week. I was connecting with Shawn’s self-in-relation to his son and thereby connecting to Terry’s self-in-relation to others in the only way possible. Bits of Terry’s personal history began to emerge: his choice to go into “blue-collar” work despite his family’s wishes, the loss of his mother one year before, his calls to his father every Sunday. Patterns surfaced: Terry’s love for partying and drinking, his committed serial girlfriends and his beloved dogs. Shawn’s personal history also began to emerge: he had money; he had a girlfriend in Baltimore that he visited twice a week; he still lived in the family home and Terry’s room was still intact.

Dialog enabled reflective awareness where Shawn could begin to see the present moments of his son’s life and of his own newly-widowed life. He became in touch with his place in and his view of the present moment of his son’s health challenges. As our dialogs continued I could hear that meanings were integrating and cohering for Shawn and hope began to emerge. Ease had been created. He began to think that his son might someday emerge from “a hospital.”

Terry became able to eat and drink, walk, and help bathe, toilet, and dress himself. He started to recognize individuals on the care team. My dialogs with Shawn continued with flow in the midst of anchoring. In my mind, the anchor of our conversations was the fact that I had to solidify an acceptable discharge plan in this highly emotional situation. Flow was enabled by the ongoing insurance coverage based on the progress Terry was making. Shawn’s flow may have been his love for his son. The flow of our dialogs was centered on the dynamic process Shawn was experiencing as he re-membered disjointed story moments of his and Terry’s past. Values, ideas, and context surfaced and cohered into a meaningful whole. This process created ease for him and brought release. He conceived of a possibility—Terry might be able to move home with him, back into his old room.

We explored other discharge options but Shawn’s idea turned into a plan. Eventually, Terry was able to participate in our dialogs to a degree. Terry was finally discharged to his father’s home with supervision and assistance from his father, and rehabilitation therapies and support in place. What was at first not even dreamed of became a reality. There is no question in my mind that ongoing intentional dialog in true presence, connecting with self-in-relation created ease that brought human development and changed the outcome of this case for the better. I hope to further use the theory of attentively embracing story.


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