Analysis of Middle Range Theory

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Table of Contents

Abstract
Original Theory
Revised Theory
Unpleasant Symptoms: Basic Considerations
Internal analysis & evaluation
External Analysis & Evaluation
Summary
References

Abstract

This paper presents an analysis and evaluation of the middle range theory of unpleasant symptoms, which utilizes the criteria developed by Fitzpatrick and Wall (2005). First, basic considerations will be presented, to gain a clearer understanding of the major concepts and theoretical statements. A critical analysis is conducted and the theory is evaluated from both the internal and external perspectives. After the analysis, a summary is drawn, which examines the merits of the theory when applied to practice and research.

Original Theory

The theory of unpleasant symptoms (TOUS) provides a model for the experience concurrent symptoms and relationship between them (Lenz et al., 1995). The theory was developed by collaboration among three researchers who initially were working with two concepts of dyspnea and fatigue. The investigators acknowledged shared categories between the dyspnea and fatigue that led to the ideas of developing an inclusive theory that addresses multiple unpleasant symptoms across clinical populations.

The original theory included influencing acknowledge influence factor: physiologic, psychological, and situational factors. The investigators emphasized that symptoms vary in several components: duration, intensity, quality, and distress. The experience of the symptoms ultimately produced an effect on a patient’s level of performance across three domains of functional status, cognitive functioning, and physical performance (Lenz et al., 1995).

After the development the original theory, the authors recognized that further refinements in the theory were necessary to address the possibility of experiencing several symptoms at the same time. Furthermore, they acknowledged the need to include the possibility for the experience of several symptoms to have a multiple effect (Lenz et al., 1995). Lenz et al. (1995) acknowledged that this was a middle-range theory and discussed the process of developing theory at the level of single concepts.

Revised Theory

A revision of the TOUS was published in 1997 (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). The revision reemphasized the three major components of the theory: the symptoms, the influencing factors which affect the symptom experience, and the consequences of the symptom experience. The revised theory is useful in describing the possibility for interactions between the influencing factors. Lenz et al. (1997) stated that the symptom experience might have an effect on influential factors and that there is a reciprocal relationship between influencing factor and symptoms. The TOUS has been applied to research and practice.

Therefore, this paper presents a theory analysis and evaluation of the middle range TOUS that utilized the criteria developed by Fitzpatrick and Wall (2005). First, basic considerations will be presented, to gain a clearer understanding of the major concepts and theoretical statements. A critical analysis is conducted and the theory is evaluated from both the internal and external perspectives. After the analysis, a summary is drawn, which examines the merits of the theory when applied to practice and research.

Unpleasant Symptoms: Basic Considerations

Major concepts

The TOUS has three major concepts: the symptoms, influencing factors, and performance of outcomes. First, symptoms in the updated version are conceptualized as a multidimensional experience, which can be conceptualized and measured separately or in combination with other symptoms (Lenz et al., 1997). The dimensions of the symptom experience are: Intensity which refers to strength or severity, timing which refers to duration and frequency of occurrence, level of distress perceived which refers to degree of discomfort, and Quality which refers to the patient’s description of what the symptom feels like. Lenz et al. (1997) stated that the dimensions are separable but related.

Each symptom can be conceptualized and measured separately or in combination with other symptoms. Quality is frequently the most difficult to discern because of individuals’ varying levels of ability to describe a symptom or their ability to pinpoint or differentiate one symptom from another (Lenz et al., 1997).

The second concept is influencing factors. Three categories of variables have been identified that influence the symptoms: physiological, psychological, and situational factors. In the updated version of the theory, the authors acknowledged the need to consider several interrelated aspects within each factor, in addition to the relations between these factors and their interactions that could influence the symptom experience in return (Lenz et al., 1997).

The third concept is performance of outcomes or effects of the symptom experience. The authors conceptualized performance to include functional and cognitive activities. While functional performance was conceptualized generally to include physical activities, activities of daily living, social activities, and role performance such as work related roles (Lenz et al., 1997).

The major theoretical statements

The main difference is that the original model represents a unidirectional influence moving from the influencing factors to the symptom experience to the performance or consequences. On the other hand, the revised model is more detailed and represents a bidirectional influence among all the three major components of the model: influence, interaction, and feedback. Additionally, the revised model advocates the experience of multiple symptoms at the same time. It also advocates that one or more symptoms may aggravate effects on performance and provide a reciprocal influence on the influencing factors. Interaction occurs among symptoms, allowing for the multiplicity or additive nature of the symptom experience when more than one symptom is involved (Lenz et al., 1997).

It was emphasized by the authors that the experience of unpleasant symptoms could change the physiological, psychological, and situational status of a person. Therefore, the major theoretical statements of updated version of the theory are as follows:

The performance has a reciprocal relation to the symptom experience (Lenz et al., 1997).
The decreased levels of performance can have a feedback loop to the influential factors, with a negative impact on physiological and psychological states and situational conditions (Lenz et al., 1997).
The influential factors can display an interaction effect in their relation to the symptom experience (Lenz et al., 1997).
Additionally, the symptom experience can have a moderating or mediating influence in the relationship between physiological or psychological status and performance (Lenz et al., 1997). These theoretical statements were clearly stated and explained the relations and interrelations between the major components of the TOUS.

Internal analysis & evaluation

Underlying Assumptions

The authors emphasized that the assumption behind the theory is that “there are sufficient commonalities among symptoms to warrant a theory that is not limited to one symptom, but can explain and guide research and symptoms” (Lenz et al., 1997, p.).

Internal consistency

The concepts are related and interrelated via theoretical statements and are consistently used throughout the literature of the theory. The updated revised version addresses the relationship between concepts more explicitly, which adds more depth and understanding of the theory. The terms are used in a congruent matter.

Empirical Adequacy

The development of theory of unpleasant symptoms was based on research, which generated and tested previous conceptual models of the concepts of dyspnea and fatigue. The elements of the theory provide such a perspective for research in both the basic and the clinical science of nursing. It was examined in research in different populations such as pregnancy, childbirth, and the postpartum period, dyspnea in patients with chronic obstructive pulmonary disease and asthma (Gift, 1990; Pugh & Milligan, 1993).

Additionally, findings of several published studies about other symptoms such as on cardiac patients were consistent with the theory (Lenz et al., 1997). The theory has demonstrated its usefulness in research to date. As the model continues to develop, it will serve as a framework for both quantitative and qualitative research.

The usefulness of the TOUS in practice has been demonstrated in a variety of clinical settings and various populations. In addition, TOUS has been beneficial in an emergency department setting with cardiac patients to develop a symptom assessment scale that includes all components included in the theory: intensity, duration, distress, and quality of the symptom (Lenz et al., 1997).

In practical applications, the TOUS highlighted the significance of performing assessments of multiple dimensions that account for influential factors, performance outcomes and multiple symptoms. Pugh and Milligan (1993) also used it to identify possible reasons why mothers might or might not succeed in breastfeeding. They conceptualized breastfeeding as a performance outcome and identified the possible reasons for not breastfeeding as experiencing fatigue and pain, which are the most common reported unpleasant symptoms. They also identified influential factors contributing to the experience of fatigue and pain. Furthermore, the theory was used in identifying interventions targeting the influential factors and symptoms to help mothers in breastfeeding (Lenz et al., 1997)

External Analysis & Evaluation

The TOUS presents a holistic, comprehensive and dynamic view of the unpleasant symptoms experienced. Managing the care for patient experiencing unpleasant symptoms contribute to the real world of nursing and what patients encounter. This model helps in increasing insight into the reality of unpleasant symptoms experienced, and hopefully provides direction for management and relief of unpleasant symptoms. There is congruence with other theories such as symptom management theory and research internal and external to nursing. This theory contributes to other disciplines such as psychology and medicine and can be readily applied in clinical settings guided by other disciplines.

The theory supports the development of research questions and study of the components of the TOUS. It was evident through research that it was applied to several populations in acute and chronic settings, and most interestingly, also applied to caregivers who take care of patients suffering from unpleasant symptoms. Research has helped in the refinement of the original theory, and interactions among components and their interrelationships with other components were incorporated in the revised version of TOUS, which added a valuable strength.

The TOUS is an inclusive and interactive dynamic theory, which lends a unique perspective to nursing by incorporating multiple concepts in one encompassing model. The theory is useful in that it can range from simple to complex and that depends on the number of unpleasant symptoms and variables a researcher decides to study. Additionally, the theory seems relevant to many cultural groups and it can be applied to many situations in acute and chronic settings.

Most importantly is the inclusion of multiple influencing factors that influence the patients’ symptom experience, this inclusion is very unique because it makes the theory valuable for developing interventions that are individualized for each patient’s characteristics and patterns of symptoms. One of Nursing’s ultimate goals is to accomplish better outcomes and increase patients’ satisfaction and with this theory, by individualizing the care, nurses can ensure to accomplish this goal.

There are social policy issues related to theory since Nursing’s Policy Statement claims that theory’s application in nursing is an essential tool that provides nurses with the framework for their clinical decision-making and ensures accountability by increasing transparency of their actions (Meleis, 2007). The TOUS can be useful for organizing, classifying, and interpreting information used to guide practice as shown in literature. Theories are tools that render practice more effective and efficient by identifying the means and goals of practice, in addition to identifying outcomes (Meleis, 2007). The society is more likely to seek and respond effectively to nursing care when nursing goals driven by nursing knowledge are clearly articulated (Meleis, 2007).

Finally, the TOUS has many practice implications and can be used to identify preventive interventions or develop innovative treatments that could be applied across similar symptoms. However, more attention needs to be paid to symptom assessment and management where recent findings suggest potentially useful interventions. These interventions need to be addressed and examined.

Summary

In analyzing and evaluating the middle range theory of Unpleasant Symptoms developed by Lenz et al. (1997), all criteria outlined by Fitzpatrick and Wall (2005) were met. Each category met the requirement. The developed theory demonstrated a tremendous commitment to scholarly inquiry and reflected the authors’ dedication to the profession. This theory had a timely influence on nursing situations with the work used in initial research after the development of the original theory and promptly continued with the revised version.

This theory has positively-influenced researchers’ viewpoint on many issues related to symptom management, which they are accounting for in their research. Further refinement will likely be needed as researchers learn more about physiologic and psychological aspects and the experience of unpleasant symptoms. In general, the TOUS continues to make a significant contribution to the nursing body of knowledge.

References

Chinn, P. & Kramer, M. (2008). Integrated Theory and Knowledge Development (7^thEdition). St Louis: Mosby.

Fitzpatrick, J. & Whall, A. (2005). Conceptual Model of Nursing. New Jersey: Prentice Hall.

Gift, A. G. & McCrone, S. (1993). Depression in patients with COPD: state of the science. Heart Lung Journal, 22:289-297.

Gift, A. G. (1990). Dyspnea. Nursing Clinical North American Journal, 25, 944-965.

Gift, A. G. (1991). Physiologic and psychological aspects of acute dyspnea in asthmatics. Nurse Res Journal, 40:196-199.

Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of Unpleasant Symptoms: An update. Advances in Nursing Science, 19(3), 14–27.

Lenz, E. R., Suppe, F., Gift, A. G., Pugh, L. C., & Milligan, R. A. (1995). Collaborative development of middle-range nursing theories: Toward a Theory of Unpleasant Symptoms. Advances in Nursing Science, 17(3), 1–13.

Meleis, A. (2007). Theoretical Nursing, Development and Progress (4^th edition). Philadelphia: Lippincott, Williams & Wilkins.

Milligan, R. A., Flenniken, P., Pugh, L. C. (1996). Positioning intervention to minimize fatigue. Appl Nurse Res. Journal, In press.

Pugh, L. C. & Milligan, R. A. (1993). A framework for the study of childbearing fatigue. Advances in Nursing Science, 15, 60-70.

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