A Middle Range Theory of Nurses’ Psychological Trauma: Analysis and Evaluation

Candy Frank, University of Tennessee, Knoxville

Sandra P. Thomas, University of Tennessee, Knoxville

DOI: 10.58117/kzkd-6n69

INTRODUCTION

Healthy People 2030, a United States Department of Health and Human Services initiative, emphasizes the promotion of mental health, the reduction of burnout among healthcare professionals, and the development of resilient healthcare systems (Office of Disease Prevention and Health Promotion [ODPHP], 2020). Within this framework, the workforce domain identifies reducing health worker burnout and strengthening retention as national priorities. Nurses, by virtue of sustained exposure to human suffering, ethical conflict, and high-stakes clinical environments, are particularly vulnerable to unresolved psychological distress. When unaddressed, such distress contributes to anxiety, depression, burnout, and professional withdrawal, threatening both individual well-being and workforce sustainability.

Achieving Healthy People 2030 workforce objectives requires more than individual-level resilience strategies; it necessitates theoretical guidance capable of illuminating the structural and professional conditions that shape nurses’ psychological health. The Middle Range Theory of Nurses’ Psychological Trauma, developed by Dr. Karen Foli, offers such guidance by articulating a nursing-specific framework for understanding psychological trauma as a consequence of professional roles and organizational contexts. The theory identifies seven distinct trauma types and positions them within the ethical, relational, and institutional realities of nursing practice. In doing so, Foli shifts the discourse away from individual pathology toward recognition of organizational accountability and trauma-informed systems of support.

Rather than accepting psychological trauma as an inevitable aspect of nursing work, the theory challenges the normalization of nurse suffering and frames trauma as cumulative, contextual, and professionally mediated. This perspective underscores the ethical responsibility of healthcare organizations to acknowledge, assess, and respond to psychological injury among nurses.

The Middle Range Theory of Nurses’ Psychological Trauma addresses a theoretical gap in nursing by naming and explaining trauma experiences specific to nursing practice that are often obscured within broader psychological models. To determine its contribution to nursing science and its capacity to guide research, education, leadership, and policy, the theory warrants systematic analysis and evaluation. Accordingly, this paper applies Walker and Avant’s theory analysis method followed by evaluation using Fawcett and DeSanto-Madeya's criteria to assess the theory’s structure, clarity, testability, and practical utility within contemporary nursing contexts.

THEORY ANALYSIS

Theory serves as a foundational pillar in the advancement of nursing knowledge, guiding scholarly inquiry, practice, education, and leadership. Middle-range theories, which address specific phenomena within nursing practice, require systematic analysis to determine their conceptual clarity, disciplinary relevance, and applicability to nursing science. Walker and Avant’s (2018) theory analysis method was selected for the present study because it provides a structured and discipline-specific framework for evaluating middle-range nursing theories that address complex professional and clinical phenomena. The framework is particularly relevant to analysis of Foli’s Middle Range Theory of Nurses’ Psychological Trauma, which incorporates interrelated psychological, ethical, and organizational concepts requiring careful conceptual clarification and evaluation.

Walker and Avant’s six-step process examines a theory’s origins, meaning, logical adequacy, usefulness, generalizability and parsimony, and testability. Analysis of origins explores the intellectual and empirical foundations of the theory, whereas meaning focuses on conceptual definitions, clarity, and boundaries. Logical adequacy evaluates internal coherence and consistency among concepts and relational statements, while usefulness examines applicability to nursing practice, research, education, and leadership. Generalizability and parsimony assess the theory’s breadth of applicability and conceptual economy, and testability evaluates the extent to which concepts and relationships can be empirically examined.

This analysis utilized a structured theoretical review approach guided by Walker and Avant’s framework. Primary source materials included Foli’s original theory publication and scholarly literature describing the theory’s development and application. Additional supporting literature consisted of qualitative studies, narrative inquiry, integrative scholarship, and empirical nursing research related to psychological trauma, moral injury, secondary traumatic stress, workplace violence, organizational trauma, compassion fatigue, and nurse well-being. Inclusion criteria consisted of peer-reviewed scholarly sources that directly contributed to the conceptual development, empirical support, or practical application of Foli’s Middle Range Theory of Nurses’ Psychological Trauma. Included literature addressed nurse-specific psychological trauma, moral injury, secondary traumatic stress, workplace violence, organizational trauma, compassion fatigue, trauma-informed nursing practice, or related psychological outcomes within professional nursing contexts. Sources were also required to demonstrate relevance to nursing practice, leadership, education, workforce well-being, or healthcare organizational environments.

Following theory analysis, evaluation was conducted using Fawcett and DeSanto-Madeya’s (2013) criteria to assess significance, internal consistency, empirical adequacy, and pragmatic adequacy. Through systematic analysis and evaluation, this paper examines Foli’s theory as a substantive contribution to nursing scholarship with relevance for trauma-informed practice, workforce well-being, organizational accountability, and future nursing research.

Origins

The Middle Range Theory of Nurses’ Psychological Trauma emerged from recognition that nurses experience distinctive forms of psychological trauma related to their caregiving roles that are insufficiently explained by existing psychological or nursing theories. Drawing on qualitative research, including interviews and narrative accounts across diverse clinical settings, Foli identified recurring patterns of psychological harm rooted in the professional, ethical, and organizational realities of nursing practice.

The theory is grounded in empirical inquiry and interdisciplinary synthesis. Foli integrated nurse narratives with concepts from trauma theory, nursing ethics, organizational science, and Watson’s Human Caring Science to articulate a nursing-specific framework. This synthesis reflects Foli’s scholarly focus on nurse mental health and trauma-informed practice (Morrow & Foli, 2024).

Foli’s earlier qualitative research also contributed significantly to the development of the theory. In a 2020 content analysis of 372 nurses’ narrative responses regarding personal and professional trauma, Foli and colleagues identified recurring patterns of psychological harm associated with secondary traumatic stress, workplace violence, second-victim trauma, and organizational conditions affecting nurses’ well-being (Foli et al., 2020). The study further identified ‘insufficient resource trauma,’ described as psychological trauma resulting from inadequate staffing, limited resources, and organizational barriers preventing nurses from delivering safe and ethical care. Findings from this research demonstrated that nurses frequently experienced trauma as cumulative, professionally mediated, and deeply influenced by healthcare systems and organizational responses. These qualitative insights provided important empirical and conceptual foundations for the subsequent development of the Middle Range Theory of Nurses’ Psychological Trauma.

The COVID-19 pandemic further illuminated the relevance of the theory by exposing longstanding, yet under-recognized forms of moral injury, emotional exhaustion, and institutional betrayal experienced by nurses. As a result, the theory’s origin is both empirically grounded and responsive to practice, developed in direct response to contemporary clinical realities.

Foli’s theory also builds upon and extends Conti-O'Hare's Nurse as Wounded Healer archetype (Conti-O'Hare, 1998). Whereas the wounded healer framework emphasizes how personal suffering may enhance empathy and caregiving capacity, Foli reorients the focus toward the nurse’s psychological well-being and differentiates unavoidable system-induced harms. This shift represents a conceptual advancement by positioning nurse trauma as a professional and organizational concern rather than an individual deficit (Foli, 2022).

Meaning

Walker and Avant (2018) describe the meaning of a theory as arising from the clarity of its concepts, definitions, boundaries, and empirical grounding. Foli’s Middle Range Theory of Nurses’ Psychological Trauma explicates the forms of psychological trauma experienced by nurses through a distinctly nursing-focused lens. Rather than conceptualizing trauma exclusively as a psychiatric diagnosis, the theory frames psychological trauma as a professional consequence of sustained caregiving within ethically complex and emotionally demanding environments. Central to the theory’s meaning is the designation of nurse-specific psychological trauma as a phenomenon arising primarily from professional role enactment and organizational context. Foli delineates seven trauma types relevant to nursing practice: vicarious trauma, secondary traumatic stress, insidious trauma, moral injury, workplace violence, system-induced trauma, and second-victim trauma. Within the boundaries of the theory, nurse-specific trauma is understood as psychological harm originating in professional responsibilities, ethical obligations, and workplace conditions rather than non-occupational life events.

The theory establishes clear conceptual boundaries by distinguishing antecedent events from trauma manifestations. Events such as workplace violence, disaster response, and medical error function as precipitating conditions, while the resulting psychological sequelae constitute the trauma experience itself. This distinction strengthens conceptual precision and prevents conflation of observable events with internal psychological responses.

Foli further differentiates trauma from commonly associated outcomes such as burnout, compassion fatigue, and posttraumatic stress symptoms, which are conceptualized as downstream consequences of unresolved psychological trauma rather than trauma types themselves. This differentiation enhances theoretical clarity and supports appropriate operationalization in empirical research.

Overall, the meaning of Foli’s Middle Range Theory of Nurses’ Psychological Trauma is characterized by conceptual specificity, clear boundaries, and alignment with nursing’s professional and ethical domain. By defining trauma as cumulative, contextual, and professionally mediated, the theory advances disciplinary understanding of nurses’ psychological experiences and establishes a coherent foundation for subsequent conceptual analysis and empirical testing. These conceptual distinctions provide the foundation for examination of the theory’s primary trauma concepts.

Concepts

Walker and Avant (2018) emphasize that clearly defined and appropriately abstract concepts are essential to the integrity of middle-range theories. Foli’s Middle Range Theory of Nurses’ Psychological Trauma is organized around seven primary concepts, conceptualized as distinct trauma types that reflect the psychological consequences of nursing practice within ethically and organizationally complex environments. These concepts are articulated with sufficient abstraction to capture shared professional experiences while remaining amenable to empirical examination.

The seven primary concepts identified in the theory are vicarious trauma, secondary traumatic stress, insidious trauma, moral injury, workplace violence, system-induced trauma, and second-victim trauma (see Table 1). Supporting and related contextual constructs that influence the development and interpretation of nurses’ psychological trauma are summarized in Table 2. Each concept represents a distinct yet related form of psychological harm arising from nurses’ sustained exposure to suffering, ethical conflict, and organizational constraints. Although related, the concepts are differentiated by their sources, mechanisms, and psychological manifestations, thereby reducing conceptual overlap.

In addition to the seven primary trauma concepts, the theory also incorporates supporting contextual concepts that influence the development or intensification of nurses’ psychological trauma. Concepts such as institutional betrayal and historical trauma are positioned as secondary or contextual constructs rather than primary trauma types. Institutional betrayal refers to perceived organizational failure to prevent, acknowledge, or respond appropriately to nurses’ psychological harm, whereas historical trauma reflects the cumulative normalization of suffering and unresolved distress embedded within nursing culture and healthcare systems over time. These supporting concepts function as contextual influences that shape vulnerability, interpretation, and organizational response to trauma rather than serving as independent trauma categories within the framework.

Most of the concepts are abstract in nature, describing internal psychological, emotional, or moral experiences that cannot be directly observed. Consistent with middle-range theory development, concrete events such as workplace violence or medical error function as antecedent conditions, whereas the trauma concepts reflect the internal psychological sequelae of those events. This distinction preserves theoretical precision and supports empirical application.

The trauma concepts are not directly measurable in their organic forms; rather, they require qualitative inquiry or psychometric assessment to capture their manifestations within professional contexts. Existing instruments may serve as empirical indicators for related constructs. For example, secondary traumatic stress may be assessed using validated measures, and second-victim trauma through instruments such as the Second Victim Experience and Support Tool. As Vang et al. (2022) note, secondary traumatization represents an underlying condition that emerges cumulatively from ongoing occupational exposure and environmental stressors rather than from a single event. This underscores the appropriateness of modeling these trauma types as abstract professional phenomena rather than directly observable events. Outcomes such as burnout, compassion fatigue, and posttraumatic stress symptoms are conceptualized as consequences of unresolved trauma rather than primary concepts of the theory.

Overall, the concepts within Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrate an appropriate level of abstraction for a middle-range framework. They are sufficiently specific to guide empirical inquiry and practice application, yet broad enough to capture shared experiences across nursing roles and settings. While the theory maintains strong conceptual integrity, some constructs such as historical trauma and institutional betrayal may benefit from further refinement to enhance parsimony and empirical precision. Clarifying their placement would strengthen alignment with middle-range expectations while preserving explanatory depth.

Relational Statements

Within a well-developed middle-range theory, relational statements specify how concepts are connected and serve as the basis for hypothesis generation and practice application. Walker and Avant (2018) note that such statements may be explicit or implied, if relationships among concepts are logically coherent and theoretically defensible. Although Foli’s Middle Range Theory of Nurses’ Psychological Trauma does not present formal axioms, it articulates clear and consistent relational linkages among professional exposure, psychological trauma, and nurse outcomes.

A central causal relationship within the theory links sustained exposure to ethically and emotionally challenging clinical situations with the development of nurse-specific psychological trauma. Repeated encounters with suffering, moral conflict, and high-stakes decision-making are positioned as antecedent conditions that precipitate trauma types such as moral injury, vicarious trauma, and secondary traumatic stress. Conditional and associative relationships are also evident. Psychological trauma may arise through both direct experiences, such as workplace violence or medical error, and indirect exposure, including repeated witnessing of patient suffering. These pathways reflect the multifaceted nature of trauma exposure in nursing practice and underscore the cumulative nature of psychological harm.

The theory further implies a cumulative and correlational relationship among multiple trauma types over time. Exposure to unresolved trauma across professional roles may compound psychological burden, increasing vulnerability to downstream outcomes such as compassion fatigue, burnout, and professional disengagement. A salient relational statement within the theory links professional identity and moral agency to trauma intensity. When institutional actions or constraints conflict with nurses’ ethical commitments, moral injury is intensified. This relationship highlights how organizational context mediates the psychological impact of ethical conflict.

Organizational response is positioned as a critical modifying variable. Lack of institutional acknowledgment, support, or remediation contributes to system-induced trauma and institutional betrayal, thereby exacerbating psychological injury. Conversely, trauma-informed organizational practices, peer support, and reflective interventions function as mitigating conditions that promote healing and resilience.

Finally, the theory implies a consequential relationship between unrecognized psychological trauma and adverse professional outcomes. When trauma remains unidentified or unaddressed, nurses are more likely to experience burnout, compassion fatigue, and withdrawal from the profession. Collectively, these relational statements establish the theory’s explanatory and predictive capacity and support its application in research, leadership, and practice. The coherence of these relational pathways further supports examination of the theory’s empirical grounding.

Empirical Support

Empirical support refers to the extent to which a theory is grounded in evidence and informed by systematic inquiry. Although empirical adequacy is more fully addressed during theory evaluation, theory analysis examines whether a theory is rooted in observable phenomena and supported by data that justify its conceptual structure (Walker & Avant, 2018).

Foli’s Middle Range Theory of Nurses’ Psychological Trauma is grounded primarily in qualitative research and narrative inquiry. The theory emerged from in-depth interviews, reflective accounts, and thematic analysis of nurses’ lived experiences across diverse clinical settings. These data revealed recurring patterns of psychological harm linked to professional roles, ethical conflict, and organizational conditions, forming the empirical basis for identifying nurse-specific trauma types (Foli, 2022).

The theory also integrates established empirically supported constructs from nursing and psychological literature. Concepts such as secondary traumatic stress, moral injury, burnout, compassion fatigue, and posttraumatic stress symptoms are well documented in healthcare populations and are incorporated as related phenomena. This integration situates the theory within an existing evidence base while extending it through a nursing-specific conceptual framework. For example, Xu et al. (2024) report a high prevalence of secondary traumatic stress among emergency nurses and identify organizational and exposure-related risk factors, supporting the theory’s emphasis on cumulative, role-based psychological trauma.

Foli’s theory has further been applied as an interpretive framework in emerging empirical studies. Research examining nurses’ psychological experiences during the COVID-19 pandemic has utilized the theory to explain moral distress, cognitive strain, and perceptions of institutional betrayal (Gill & Foli, 2024, Yu-Chin et al., 2023). These applications provide preliminary support for the theory’s explanatory relevance in high-stress clinical contexts.

Although instruments specifically designed to measure each trauma type have not yet been developed, existing validated tools may serve as empirical indicators. Measures such as the Secondary Traumatic Stress Scale developed by Bride et al. (2004), the Professional Quality of Life Scale developed by Stamm (2010), and healthcare-adapted moral injury instruments support the feasibility of empirical testing. Collectively, empirical support for the theory derives from qualitative evidence, integration with established psychological and nursing constructs, and early empirical application, providing a sufficient foundation for continued theoretical and empirical investigation.

Logical Adequacy

Logical adequacy refers to the extent to which a theory’s concepts, assumptions, and relational statements are internally consistent, non-contradictory, and coherently organized. Walker and Avant (2018) emphasize that a logically adequate theory demonstrates clear alignment among its components and supports explanatory and predictive reasoning.

Foli’s Middle Range Theory of Psychological Trauma demonstrates strong logical adequacy through consistent use of concepts and alignment between assumptions, relational statements, and proposed outcomes. The theory assumes that psychological trauma among nurses is cumulative, contextual, and mediated by professional roles and organizational conditions. These assumptions are reflected in the delineation of nurse-specific trauma types and in the pathways linking exposure, trauma, and professional consequences.

Conceptual coherence is evident in the differentiation of trauma types and their placement within the theoretical structure. Each trauma type is defined in relation to distinct sources of psychological harm while remaining logically connected to the professional and ethical context of nursing. The theory maintains internal consistency by distinguishing antecedent events, trauma manifestations, and downstream outcomes such as burnout and compassion fatigue.

The relational structure follows a clear and logical progression. Exposure to ethically and emotionally demanding clinical situations precedes the development of psychological trauma, which increases vulnerability to adverse professional outcomes. Organizational conditions are consistently positioned as modifying variables that may either exacerbate or mitigate psychological harm. This sequencing strengthens explanatory coherence and internal consistency within the framework.

The theory’s assumptions are congruent with nursing ethics and trauma literature reinforcing its logical integrity. Professional identity, moral agency, and healing are integrated without contradiction, strengthening the theory’s explanatory coherence. Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates strong logical adequacy, providing a stable and coherent foundation for empirical testing and application in nursing research, education, and practice.

Usefulness

Walker and Avant (2018) describe usefulness as a theory’s capacity to inform nursing practice, guide research, and stimulate further theoretical development. A useful middle-range theory provides explanatory insight into a phenomenon of concern to nursing while offering direction for empirical inquiry and practical application. Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates strong usefulness by offering a coherent framework for understanding psychological trauma as a professional and organizational phenomenon rather than an individual deficit. The theory provides a structured vocabulary through which nurses’ experiences of moral injury, cumulative distress, and system-induced harm can be named, examined, and addressed.

In nursing practice, the theory offers conceptual guidance for recognizing trauma manifestations that may otherwise be misattributed to burnout or individual vulnerability. By differentiating trauma types and identifying organizational antecedents, the theory supports trauma-informed approaches to staffing, peer support, debriefing, and leadership decision-making.

The framework further supports nursing inquiry by providing clearly articulated concepts and relational pathways suitable for qualitative, quantitative, and mixed-methods investigation. The clearly articulated concepts and relational pathways support hypothesis generation and mixed-methods inquiry examining relationships among exposure, trauma, organizational context, and professional outcomes. The framework provides a foundation for operationalizing nurse-specific trauma constructs and for evaluating interventions designed to mitigate psychological harm.

In nursing education and leadership development, the theory offers a lens for preparing nurses to anticipate, recognize, and respond to psychological trauma embedded within professional roles. Integrating the theory into curricula and leadership training supports ethical reflection, organizational accountability, and professional sustainability. Collectively, these applications underscore the theory’s usefulness within contemporary nursing practice, research, education, and leadership.

Generalizability and Parsimony

Walker and Avant (2018) describe generalizability as a theory’s capacity to be applied across populations, settings, and contexts beyond those in which it was initially developed, while parsimony refers to the degree to which a theory explains a phenomenon using the fewest necessary concepts and relationships. In middle-range theory development, these criteria must be balanced to ensure both applicability and conceptual clarity.

Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates moderate to strong generalizability across nursing roles and practice settings. The trauma types articulated within the theory, such as vicarious trauma, moral injury, and second-victim trauma, are not confined to a single specialty or clinical environment. Rather, they reflect psychological responses that may occur across acute care, critical care, long-term care, community health, mental health, education, and leadership contexts.

Applicability of the framework extends across multiple levels of nursing practice. Nurses functioning in bedside, advanced practice, educational, administrative, and leadership roles may experience psychological trauma through distinct yet conceptually aligned mechanisms. By grounding trauma in professional role enactment and ethical responsibility rather than task-specific activities, the theory maintains applicability across diverse scopes of practice.

Although the theory was developed within Western healthcare systems, its core concepts, ethical conflict, cumulative exposure to suffering, and organizational response, are not restricted to a single cultural or institutional context. These phenomena are evident across global healthcare environments, supporting conceptual transferability while allowing for contextual adaptation.

Although the theory demonstrates potential applicability across international healthcare settings, cultural and organizational differences may influence how nurses experience, interpret, express, and respond to psychological trauma. Variations in cultural norms related to emotional expression, hierarchy, collectivism, stigma surrounding mental health, professional identity, and perceptions of organizational authority may shape both recognition and reporting of trauma experiences. Additionally, differences in healthcare infrastructure, staffing models, resource availability, and societal expectations of nurses may influence the manifestation and interpretation of concepts such as moral injury, institutional betrayal, and system-induced trauma. Consequently, while the theory’s core concepts demonstrate broad relevance, future cross-cultural research is warranted to examine contextual variations in trauma experiences and to support culturally responsive application of the framework.

With respect to parsimony, the theory demonstrates conceptual economy by organizing nurses’ psychological trauma around a finite set of clearly defined trauma types. The seven trauma concepts are distinct yet logically related, capturing the complexity of nurses’ experiences without unnecessary conceptual proliferation. This structured approach enhances clarity and usability while preserving explanatory depth.

Importantly, the theory maintains clear boundaries by focusing exclusively on psychological trauma arising from professional nursing roles. This bounded scope strengthens both generalizability and parsimony by preventing conceptual overextension and maintaining analytic focus. Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates a balanced integration of generalizability and parsimony consistent with middle-range theory expectations.

Testability

Testability refers to the extent to which a theory’s concepts and relational statements can be operationalized and examined through empirical research (Walker & Avant, 2018). Building upon the conceptual coherence established in the theory’s logical adequacy, Foli’s framework demonstrates strong potential for empirical investigation across qualitative, quantitative, and mixed-methods approaches. Foli’s theory demonstrates strong potential for empirical testing. The theory’s core concepts are explicitly defined and conceptually distinct, allowing for operationalization through established qualitative approaches and psychometric measures. Although the trauma types are abstract and not directly observable, they manifest through psychological, emotional, and behavioral indicators that can be examined empirically.

Relationships among exposure to ethically and emotionally challenging clinical situations, nurse-specific psychological trauma, and professional outcomes may be examined through hypothesis-driven and exploratory empirical designs. These relationships may be examined using cross-sectional, longitudinal, and mixed-methods designs to assess cumulative effects and contextual influences.

Existing validated instruments provide feasible avenues for testing components of the theory. Measures assessing secondary traumatic stress, moral injury, burnout, and compassion fatigue may serve as empirical indicators of trauma manifestations, while organizational variables such as leadership support, staffing adequacy, and institutional response may be examined as modifying conditions.

The theory is also amenable to qualitative inquiry. Narrative interviews, focus groups, and phenomenological approaches may be used to explore nurses’ lived experiences of trauma, explore nurses’ interpretations of their experiences, and refine conceptual boundaries. Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates testability consistent with middle-range theory expectations, supporting its application in empirical research aimed at advancing trauma-informed nursing science.

THEORY EVALUATION

Walker and Avant (2018) distinguish theory analysis from theory evaluation, emphasizing that evaluation involves judgment regarding a theory’s overall quality, usefulness, and contribution to the discipline. Whereas theory analysis emphasizes clarification of conceptual structure and relationships, theory evaluation examines the extent to which a framework meets disciplinary standards for scholarly and practical utility.

Fawcett and DeSanto-Madeya (2013) propose six criteria for evaluating nursing theories: significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. Consistent with Fawcett and DeSanto-Madeya’s (2013) evaluative framework, the present evaluation focuses on significance, internal consistency, empirical adequacy, and pragmatic adequacy. Parsimony and testability are not re-addressed in detail within the evaluation section because these criteria were systematically examined during the preceding theory analysis, consistent with Walker and Avant’s analytic approach to conceptual structure, scope, and empirical applicability.

Applying these criteria enables a systematic appraisal of the Middle Range Theory of Nurses’ Psychological Trauma and its contribution to nursing knowledge. This evaluation examines whether the theory addresses a phenomenon of central importance to nursing, demonstrates internal coherence, is supported by empirical evidence, and is useful in advancing nursing practice, education, leadership, and research.

Significance

Fawcett and DeSanto-Madeya (2013) define significance as the extent to which a theory addresses phenomena of central importance to nursing and contributes meaningfully to the discipline’s knowledge base. A significant theory advances understanding of nursing phenomena and informs practice, education, and research. Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates strong significance by addressing psychological trauma as a pervasive yet historically under-theorized phenomenon within nursing. By conceptualizing trauma as a consequence of professional roles, ethical obligations, and organizational conditions, the theory aligns directly with core nursing concerns related to caregiver well-being, ethical practice, and workforce sustainability.

The theory contributes to nursing knowledge by distinguishing nurse-specific psychological trauma from general psychological distress. By naming trauma types that arise uniquely within nursing practice and situating them within professional identity and moral agency, the framework provides nursing with a coherent conceptual language to examine psychological harm that has often been normalized within healthcare systems. This contribution is reinforced by empirical applications of the theory, including its use to examine nurses’ psychological trauma, cognitive strain, and moral distress during the COVID-19 pandemic (Foli et al., 2020).

The significance of the theory is further reflected in its applicability across multiple domains of nursing. In practice and leadership, the theory has informed trauma-informed approaches to organizational support, peer interventions, and system-level accountability for nurse well-being (Foli & Reddick, 2021). In education, it provides a foundation for preparing nurses to recognize and respond to psychological trauma embedded in professional roles. In research, the theory guides inquiry into workforce well-being, ethical distress, and organizational responsibility.

Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma meets the criteria for significance outlined by Fawcett and DeSanto-Madeya (2013). By addressing a phenomenon of central concern to nursing and demonstrating relevance across research, practice, and leadership contexts, the theory represents a substantive contribution to nursing science and warrants continued scholarly attention.

Internal Consistency

Fawcett and DeSanto-Madeya (2013) define internal consistency as the degree to which a theory’s concepts, assumptions, definitions, and relational statements are logically congruent and mutually reinforcing. A theory that demonstrates internal consistency presents concepts that are clearly defined, non-contradictory, and systematically linked.

Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates strong internal consistency. The theory’s core assumptions—that nurses’ psychological trauma is cumulative, context-dependent, and shaped by professional roles and organizational conditions—are consistently reflected in the definition and organization of its trauma concepts. Each trauma type is aligned with these assumptions and situated within the ethical and professional context of nursing practice.

The theory’s concepts are articulated with sufficient clarity to prevent conceptual overlap or contradiction. Distinctions among trauma types such as moral injury, secondary traumatic stress, and system-induced trauma are maintained throughout the framework, while their interrelationships are logically specified. Antecedent events, trauma manifestations, and downstream outcomes are clearly differentiated, preserving conceptual coherence.

Relational statements within the theory are congruent with its assumptions and conceptual definitions. The progression from exposure to ethically and emotionally challenging conditions, to psychological trauma, and subsequently to professional consequences is logically sequenced. Organizational factors are consistently positioned as contextual modifiers, reinforcing internal alignment rather than introducing competing explanations.

The theory also demonstrates consistency across its scholarly applications. Use of the framework in research and practice literature reflects stable definitions and conceptual boundaries, supporting interpretive coherence over time (Foli et al., 2020; Foli & Reddick, 2021). Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma meets the criterion of internal consistency outlined by Fawcett and DeSanto-Madeya (2013), supporting its continued use in nursing scholarship.

Empirical Adequacy

Fawcett and DeSanto-Madeya (2013) define empirical adequacy as the degree to which a theory’s concepts and relational statements are supported by empirical evidence. A theory demonstrates empirical adequacy when research findings substantiate its propositions and when its concepts can be examined using observable indicators.

Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates emerging empirical adequacy. Evidence supporting the theory is evident in qualitative investigations, integrative scholarship, and early empirical applications that align with its conceptual structure. These studies substantiate the theory’s central propositions regarding cumulative exposure, organizational context, and nurse-specific psychological trauma.

Empirical adequacy is supported through qualitative research underlying the theory’s development. Nurse narratives and thematic analyses have consistently documented experiences of moral injury, secondary traumatic stress, and system-induced harm, corresponding directly to the trauma types articulated within the framework (Foli, 2022). These findings provide foundational evidence that the theory’s core concepts reflect observable phenomena in nursing practice.

Quantitative and mixed-methods studies further support empirical adequacy by demonstrating relationships consistent with the theory’s relational statements. Research examining nurses during the COVID-19 pandemic identified associations among institutional stressors, psychological trauma, and cognitive or emotional consequences, supporting the theory’s emphasis on organizational and ethical antecedents (Foli et al., 2020). Similarly, applications of the framework in practice scholarship have linked system-level conditions to nurse well-being outcomes, reinforcing its explanatory propositions (Foli & Reddick, 2021).

Additional empirical support is drawn from studies examining related trauma constructs in nursing populations. Xu et al. (2024), for example, reported a high prevalence of secondary traumatic stress among emergency nurses and identified cumulative exposure and organizational factors as significant correlates. Such findings align closely with the theory’s assumptions and provide indirect empirical validation.

Although empirical testing of the theory remains in an early stage, the convergence of qualitative evidence, applied empirical studies, and supportive findings from related trauma research indicates adequate empirical grounding. Continued theory-driven measurement development and longitudinal testing will further strengthen empirical adequacy. At present, the theory meets the criterion of empirical adequacy as outlined by Fawcett and DeSanto-Madeya (2013) and warrants continued scholarly use and investigation.

Pragmatic Adequacy

Fawcett and DeSanto-Madeya (2013) define pragmatic adequacy as the extent to which a theory is useful in guiding nursing actions and improving outcomes in practice, education, administration, and research. A theory demonstrates pragmatic adequacy when it can be readily applied to real-world settings and meaningfully informs decision-making.

Foli’s Middle Range Theory of Nurses’ Psychological Trauma demonstrates strong pragmatic adequacy. The theory translates conceptual understanding of nurse-specific psychological trauma into actionable guidance for recognizing, addressing, and mitigating trauma within professional and organizational contexts. Its emphasis on role-based and system-mediated trauma aligns closely with contemporary nursing challenges.

In practice and leadership contexts, the theory provides a framework for developing trauma-informed organizational responses. Applications of the theory have informed peer support initiatives, reflective debriefing practices, and leadership strategies aimed at reducing system-induced harm and promoting psychological safety among nurses (Foli & Reddick, 2021).

In nursing education, the theory demonstrates pragmatic adequacy by offering a conceptual lens through which students and practicing nurses can be prepared for the psychological demands of professional caregiving. Integrating the theory into curricula supports early recognition of trauma, ethical reflection, and professional sustainability.

The theory has also demonstrated pragmatic relevance in research and policy-adjacent contexts. Empirical applications of the framework have guided investigation into nurse well-being during the COVID-19 pandemic and informed discourse on organizational accountability and workforce sustainability (Foli et al., 2020).

Overall, Foli’s Middle Range Theory of Nurses’ Psychological Trauma meets the criterion of pragmatic adequacy outlined by Fawcett and DeSanto-Madeya (2013). Its demonstrated applicability across practice, education, leadership, and research supports its continued use as a guide for trauma-informed nursing action and organizational change.

CONCLUSION

Dr. Foli’s Middle Range Theory of Nurses’ Psychological Trauma presents a timely and conceptually robust framework that addresses a critical phenomenon within contemporary nursing practice. Collectively, the theory demonstrates coherence, internal consistency, emerging empirical adequacy, and pragmatic relevance for nursing scholarship and practice.

Application of Walker and Avant’s theory analysis method established the theory’s conceptual clarity, structure, and testability, while evaluation using Fawcett and DeSanto-Madeya’s criteria confirmed its significance, internal consistency, empirical grounding, and pragmatic adequacy. Collectively, these findings position the theory as a substantive middle-range contribution capable of guiding research, education, leadership, and organizational decision-making related to nurse well-being.

The theory’s relevance is further underscored by its capacity to account for psychological trauma revealed and intensified during the COVID-19 pandemic, while recognizing that such trauma predates crisis conditions. By naming nurse-specific trauma types and situating them within professional and organizational contexts, the theory challenges the normalization of suffering and reframes psychological trauma as a legitimate focus of nursing science and ethics.

Ultimately, the Middle Range Theory of Nurses’ Psychological Trauma offers a framework through which psychological trauma can be systematically identified, examined, and addressed within nursing practice. By extending the same analytic rigor applied to patient care toward nurses’ psychological well-being, the theory supports professional sustainability and organizational accountability. As Foli (2022) suggests, the articulation of this middle-range theory may “provide an opening for real change in nurses’ well-being” (p. 96). Continued empirical testing and theory-guided intervention development are warranted to further advance trauma-informed nursing systems and support the longevity of the nursing workforce.

Generative AI Statement

No generative artificial intelligence tools were used in the editorial process of manuscript preparation.

References

Appendix

Tables