Nursing Unpleasant Symptoms Middle Range Theory
Unpleasant Symptoms Middle Range Theory
middle range theory of unpleasant symptoms was created for application with a
broad range of diseases whenever unpleasant symptoms demand nursing attention.
The original theory was published nearly a decade ago (Lenz, Suppe, Gift, Pugh,
& Milligan, 1995) as a result of collaboration between faculty and
graduates of the doctoral program at the University of Maryland School of
Nursing.
Each of the graduates had studied an unpleasant symptom for
dissertation research. Gift had studied dyspnea; both Milligan and Pugh had
studied fatigue (Lenz & Pugh, 2003). The individuals who developed the
theory had collaborated in dyads or triads on various empirical studies and
theoretical articles.
They shared geographic proximity, which facilitated
collaboration, and, by virtue of their common association with one PhD program
in nursing, they also shared exposure to the same philosophical and
metatheoretical perspectives regarding the development and substance of nursing
science (Lenz & Pugh, p. 70)
Scholarly Work
A
philosopher of science who taught in the doctoral program at the University of
Maryland, Frederick Suppe, coauthored the manuscript which introduced the
theory.
Two years after its first publication, a refined version of the theory,
which emphasized the reciprocity between the concepts of the theory, was
introduced into the nursing literature (Lenz, Pugh, Milligan, Gift, &
Suppe, 1997).
Concepts in the Theory
The
theory of unpleasant symptoms has three major concepts: symptoms, influencing
factors (physiological, psychological, and situational), and performance
outcomes (Lenz & Pugh, 2003).
- A symptom is defined as an individually
perceived indicator of aberration in normal function, which may occur in
isolation or in combination with other symptoms and is characterized by
intensity. distress, duration/frequency, and quality. which refers to the
nature of the symptom or how it is manifested (Lenz & Pugh). - Influencing
factors are physiological (e.g., anatomic/ structural, genetic, bodily
processes), psycho- logical (affective and cognitive), or situational (social
and physical environment) qualities that can influence and be influenced by
symptom experience. In addition, the theory suggests that when more than one
symptom is experienced, the symptom experiences influence each other,
emphasizing a reciprocal nature depicted by the model. The authors (Lenz &
Pugh) give the example of nipple pain and fatigue, common symptoms for nursing
moms which can exacerbate each other and lead to premature termination of
breast feeding, an undesirable performance outcome. - Performance outcomes are
the consequences of the symptom experience. “Quite simply, the theory
asserts that the experience of symptoms can have an impact on the individual’s
ability to function, with function including motor skills, social behaviors and
cognition” (Lenz & Pugh, p. 78).
Lenz and Pugh Outcomes
Lenz
and Pugh (2003) report that research related to the middle-range theory of
unpleasant symptoms is just recently beginning to be reported in the
literature, with much of their search being done by the developers of the
theory themselves.
Some of this research has examined interventions to diminish
symptoms and therefore improve performance outcomes; some has examined the
relationship between influencing factors which impact symptom experience.
Some
of the unpleasant symptom research completed by people other than the
developers of the theory has examined symptoms in cancer patients undergoing
chemotherapy, people with heart lung transplants, end stage renal disease
patients, and people with Alzheimer’s disease (Lenz & Pugh).
Use of the
theory for research has resulted in critique of the theory which was considered
and applied when the developers refined the theory (Lenz et al., 1997).
Limited Area of Theory Implementation
Lenz
and Pugh (2003) note that published reports of use of the theory in practice are
few. This is surprising given the fact that unpleasant symptoms are a common
experience for most patients whom nurses encounter.
Unlike theories at a lower
level of abstraction which focus on one symptom, such as pain, the more generic
theory of unpleasant symptoms guides approach for more complex symptom
combinations, as often occur in real world practice situations.
For instance,
the theory emphasizes the importance of indepth assessment of symptoms which
considers the contribution of influencing factors,
Versatility and Dynamicity of Theory
It
suggests that multiple management strategies may need to be applied
simultaneously, given the multivariate nature of the factors influencing
symptoms.
It also emphasizes the importance of considering the effect of
several symptoms, occurring together, on patient’s functioning, and encourages
assessment of functional patient outcomes. (Lenz & Pugh, pp. 85-86)
Final Results
Thus
far, the research guided by the middle- range theory of unpleasant symptoms has
addressed the symptoms of pain, dyspnea, nausea, vomiting, and fatigue (Lenz
& Pugh, 2003). Clearly, there are more symptoms to be explored.
Likewise,
there is need for further elaboration of the relationship between the
influencing factors and how the factors relate with the symptom experience.
Finally, Lenz and Pugh note the potential for further development of the
performance component of the model, suggesting the consideration of primary and
secondary outcomes as well as temporally proximal and distal outcomes.
There is
no question that the middle range theory of unpleasant symptoms is a work in
progress, which could benefit practicing nurses, undergraduate and graduate
students, and researchers if used as a guiding frame work.
Likewise, the theory
could benefit from use in practice and research so that continued empirically
based development would further enhance the usefulness of the theory.