The middle range theory of unpleasant symptoms in cancer patients

Nursing Theory

Within the field of nursing there are many theories that receive a great deal of attention for the manner in which they assist nurses in treating patients. The middle range theory of unpleasant symptoms was developed many years ago and has proved to be beneficial to nurses treating patients with various ailments. The purpose of this discussion is to investigate the middle range theory of unpleasant symptoms as it relates to cancer patients. This subject was chosen because of the substantial number of patients that are affected by cancer. As a result of the presence of so many cancer patients, Nurses must understand how to effectively treat people with this disease. The middle range theory of unpleasant symptoms is one of the tools that can assist in the treatment of cancer patients.

Overview of theory

According to Smith & Liehr (2008) Middle range theory is defined as "a set of related ideas that are focused on a limited dimension of the reality of nursing. These theories are composed of concepts and suggested relationships among the concepts that can be depicted in a model. Middle range theories are developed and grow at the intersection of practice and research to provide guidance for everyday practice and scholarly research rooted in the discipline of nursing (Smith & Liehr,2008)." The theory was created combine existing knowledge concerning many different symptoms. In addition Smith & Liehr report that the purpose of the theory is to "improve understanding of the symptom experience in various contexts and to provide information useful for designing effective means to prevent, ameliorate, or manage unpleasant symptoms and their negative effects (Smith & Liehr,2008)." In other words the purpose of the theory is to provide nurses and other healthcare professionals with the tools needed o prevent or relieve the unpleasant symptoms associated with various diseases and ailments experienced by patients. The theory is also designed to ensure that the nurse of medical professional takes into consideration all of the factors that contribute to unpleasant symptoms. The components of this theory will be addressed more thoroughly in the section to follow.

Description of components of the theory

The origin of the middle range theory began with theory of unpleasant symptoms developed by Lenz et al., (1995). The theory focused on "a model for the experience of, and relationships between, concurrent symptoms. The theory evolved from collaboration among three individual investigators who began work on two concepts that represent unpleasant symptoms, dyspnea and fatigue, simultaneously. The investigators noted commonalities between the two concepts and subsequently realized that a more general theoretical formulation would be appropriate for describing multiple symptoms, such as pain and other unpleasant symptoms, across different clinical populations (Myers, 2009)." This theory of unpleasant symptoms can be seen in the depiction above (taken from Myers, 2009). The model is divided into three sections which acknowledge factors associated with unpleasant symptoms: physiological, psychological, and situational. The authors also note that all of the symptoms may vary in their duration, distress, quality and intensity. In addition the unpleasant symptoms typically have an impact on the manner in which the patient performs as it relates to the following three levels: functional status, cognitive functioning, and physical performance.

Concepts: The theorists asserts that there are three factors associated with the unpleasant symptoms: physiological, psychological, and situational. Physiological factors are related to the normal systems of the body including the cardiovascular system. The physiological factor is also inclusive of pathological problems such as infection. The second factor is psychological and encompasses the mental state of the patient and can include such ailments are depression. Psychological factors are also inclusive of how a patient reacts to being ill; this reaction can have a great deal to do with the patient's support system. The final factor involves the situation that the patient is in and entails their lifestyle. Lifestyle factors encompass characteristics such as employment. In addition the situational factor is also inclusive of personal experiences. The theory then focuses on the distress, duration, intensity and quality of the unpleasant symptoms in relation to the aforementioned factors.

Analysis and evaluation of theory:

Clarity:

Concept map

Has the theorist identified any inadequacies in the theory?

There have been some inadequacies recognized by the theorists who developed middle range theory. For this reason the theory was updated in 1997. The theory updates were associated with both clinical practice and research measures. The update takes into consideration a more complex approach related to the correlations between the three factors and the features of the unpleasant symptoms.

What inadequacies in the theory have you identified?

The only inadequacies that I can identify have to do with the scope of the theory. I believe that the scope of the theory could be made broader so that issues such as the impact of spousal and familial support will also be explored. In the case of cancer patients such issues can help to lessen or increase unpleasant symptoms and their negative effects. As a result these issues should be explored more thoroughly.

Generalizability:

To what clinical situations or managerial systems can the theory be applied

This theory can be applied to clinical situations involving cancer patients and others with chronic and/or terminal illnesses. This theory can be utilized by nurses to develop a plan of treatment that is tailored to meet the specific needs of patients based on the underlying causes of their unpleasant symptoms. There have been several studies that have demonstrated the use of this theory in clinical situations. These studies will be reviewed in further detail in the evaluation section below.

Utility:

How could this theory guide your clinical or managerial practice?

This theory would be vitally important in an oncology setting. The theory will provide a mechanism through which the patient can be evaluated holistically and the unpleasant symptoms that are being experienced can be managed utilizing the proper tools. Those tools might be medication (physiolocal), behavior modification/meditation/counseling (psychological) or a support group (situtational). All of these solutions to the problems that cancer patients are likely to face are essential to assisting the patient and treating the whole person. This particular theory can also be used as a preventative measure within the context of clinical practice. Nurses should consider the factors presented by the theory early on in the treatment process and develop strategies that will prevent unpleasant symptoms from ever occurring.

Evaluating the theory as used in research:

How have the authors proposed that the theory will guide the research?

As it pertains to middle range theory of unpleasant symptoms there have been several studies that have researched the theory in cancer patients. In fact the theory is often used to guide specific types of research into various forms of cancer. For instance, Dirksen et al. (2009) evaluated fatigue-Based Subgroups of Breast Cancer Survivors with Insomnia. The authors explain that one of the unpleasant symptoms experienced by women who have completed treatment for breast cancer is fatigue. Additionally, "Concomitant to the fatigue experienced during survivorship, studies have also found that insomnia, anxiety, and depression are often present and can negatively impact quality of life (Dirksen et al., 2009, 404)." As part of the theoretical framework the authors assert that the theory of unpleasant symptoms conforms to the idea that multiple symptoms can share certain commonalities. As such within the context of the study the theory is utilized to examine "Relationships among patient factors, symptoms, and performance outcomes are viewed as reciprocal, for example severe fatigue may create increased anxiety, leading to difficulties in problem solving (Dirksen et al., 2009, 405)." The finding of this particular study revealed that there are benefits associated with determining the symptoms associated with fatigue. The authors explain that "patient care will benefit through a shift in focus from treatment of a single symptom such as fatigue to the delivery of a tailored intervention that targets multiple symptoms (Dirksen et al., 2009)."

Barsevick & Kim (2009) also utilized middle range theory of unpleasant symptoms in a study entitled "Predictors of the Intensity of Cluster Symptoms in Patients with Breast Cancer." In this particular study the theory was utilized to explore the "relationship between demographic and clinical factors and the intensity of individual symptoms." These are factors that had not been considered in prior studies and the unpleasant symptoms theory provides an appropriate framework for exploring the topic. The findings of this particular study indicate that

"Baseline physical performance status was a consistent predictor of symptom intensity in the psychoneurological cluster across time whereas age and treatment modality were consistent predictors of symptom intensity in the upper gastrointestinal cluster. Poor physical performance at baseline predicted more intense psychoneurological symptoms. Young women and women undergoing chemotherapy experienced more intense gastrointestinal symptoms. In addition, at the second follow-up treatment modality also influenced intensity of symptoms in the psychoneurological cluster and race and baseline physical performance status also influenced the intensity of symptoms in the upper gastrointestinal cluster (158)."

The final study was conducted by Otte et al. (2009) and examined various theories related to Sleep-Wake Disturbances in the Context of Cancer. Amongst these theories was the theory of unpleasant symptoms. The purpose of this particular study was to determine the ways in which the model could explain sleep disturbances in cancer patients. The study found that the features that contribute to sleep-wake disturbances tend to be nonlinear. In addition these factors usually change over time and are inclusive of predisposing, precipitating, and perpetuating factors. Additionally the issues that contribute to sleep disturbance may differ from the factors that contribute to chronic sleep disturbances Otte et al. (2009). With this understood, the model asserts that contributing factors out to be reassessed periodically.

Conclusion

The purpose of this discussion is to investigate the middle range theory of unpleasant symptoms as it relates to cancer patients. The research indicates that the theory is important for clinical practice as it pertains to cancer patients and preventing and/or decreasing unpleasant symptoms. The theory is not difficult to understand or apply in the clinical setting; however, it can be useful in understanding some of the complex reasons from the unpleasant symptoms that cancer patients experience. Nurses who implement this particular theory into practice may be able to assist patients in a more holistic way therefore making them more comfortable which will assist in their ability to survive.