Nursing theory analysis and applications

Nursing Theory Analysis Paper: The Theory of Unpleasant Symptoms
Introduction
The middle-range theory of unpleasant symptoms was developed by Lenz, Suppe, Gift, Pugh and Milligan (1995) in an article entitled “Collaborative Development of Middle-Range Nursing Theories: Toward a Theory of Unpleasant Symptoms” and updated in a follow-up article entitled “Middle-Range Theory of Unpleasant Symptoms: An Update” (Lenz, Pugh, Milligan, Gift & Suppe, 1997). The theory holds that three categories of variables are responsible for affecting the occurrence, intensity, timing, level of distress, and quality of symptoms: 1) physiological factors, 2) psychological factors, and 3) situational factors. In doing so, the theory of unpleasant symptoms addresses the four concepts of nursing metaparadigm: person, environment, health, and nursing. This theory is especially useful in the emergency department (ER), which is the current field in which I work.
Background
The background of the theory of unpleasant symptoms is situated in the need identified by Lenz et al. (1995) for a mid-range approach to nursing theory-research and theory-based practice to help provide a more substantive underpinning for nurses in the real-world. As Lee, Vincent and Finnegan (2017) state, “understanding multiple patient symptoms is essential, and the theory [of unpleasant symptoms] demonstrates that nurses should focus on multiple rather than individual symptoms” (p. 16). By identifying the complex array of symptoms that patients often present with in today’s health care environment—as the Institute of Medicine (IOM, 2012) has pointed out—nurses can be better prepared to address patients’ needs and provide the type of quality care that the patients seek. The theory of unpleasant symptoms was developed as a way to help nurses apply the nursing metaparadigm to the complexity of patients’ presentations.
The theorists behind the theory of unpleasant symptoms—Lenz, Suppe, Gift, Pugh and Milligan—all have backgrounds in nursing scholarship, each being the author of a variety of works and publications on nursing. For example, Lenz is currently the Dean and Professor at the College of Nursing at Ohio State University, and Pugh is a professor at Johns Hopkins University School of Nursing. Thus, the backgrounds of the theorists are situated in the academic field of nursing education (“E. Lenz & L. Pugh,” 2010). Their experiences in interacting with students as well as other health care professionals convinced them of the need to develop a new approach to nursing that would them “to place greater emphasis on developing and using theories of the middle range to underpin nursing research and practice” (Lenz et al., 1995).
The theory has been assessed by both the originators of the theory (Lenz et al., 1997) and other researchers who have assessed its utility (Lee et al., 2017). According to Lee et al. (2017), the theory of unpleasant symptoms “demonstrates good social and theoretical significance, testability, and empirical and pragmatic adequacy” (p. 16). In other words, the theory has substantial use in the field of nursing, has been proven to be effective in providing greater quality care to patients through empirical analysis, and is supported by solid results. Lee et al. (2017) note that the theory was designed in order to help nurses understand how various symptoms relate to one another and how symptom experiences can be better understood by viewing them as a whole instead of compartmentalizing them or viewing them individually as though they were not connected to one another. The researchers also pointed out, however, that while the theory has been utilized as a guide in recent research, there had never been a formal critique of theory conducted for more than a decade and a half. Thus, Lee et al. (2017) saw fit to update the literature on the theory of unpleasant symptoms by applying the framework of Fawcett and DeSanto-Madeya to it. What the researchers concluded was that while the theory in and of itself, as expressed by Lenz et al. does pose some clarity and language structure issues, the ideas and concepts in the theory itself are significant, provable via testing, and do have utility in nursing. The positive approach to nursing that the theory yields is the concept that nurses should focus not just on individual symptoms when tending to a patient but rather on multiple symptoms and what that multitude can mean. Lenz et al. (1997) likewise discuss the “interactive nature of the symptom experience” in their review of their own theory, two years after first publishing it in 1995, to show that the symptoms presented by patients are not to be understood in isolated contexts but rather as part of a total phenomenon of the patient’s health state.
Theory Description
The theory uses reductive reasoning, which includes a mixture of inductive and deductive reasoning. Inductive reasoning is applied when a researcher observes a phenomenon and intuits the answer based on prior knowledge and understanding of the elements involved in the phenomenon. The researchers then test the answer to see if it is the correct one for addressing the problems or issues identified in the phenomenon. In this sense, the theorists involved in the development of the theory of unpleasant symptoms used inductive reasoning to gauge the issue, identify the solution, and test the solution to establish its merit. They did this by applying their background knowledge and experience of nursing and the nursing environment in their professional and educational careers and utilizing their research skills to test the validity of their theoretical approach to the problem of understanding the complexity of patients’ symptoms. Their tests led them to revise their original thesis and modify it so as to account for the new evidence that was obtained—and in this sense their research was deductive as well. As Lenz et al. (1997) reported, “revisions have resulted in a more accurate representation of the complexity and interactive nature of the symptom experience” (p. 14). So while their initial theory was based on inductive reasoning, their revisions utilized deductive reasoning.
The researchers utilized deductive reasoning by approaching the phenomenon separately as well—i.e., from a different angle, following their initial inductive approach to the phenomenon in question. That is, they used evidence available on why nurses were not responding adequately to patients’ symptom complexity and used that evidence to develop a solution based on empirical data. Then they confirmed their theoretical approach.
Reductive reasoning was also evident in the sense that the theorists could argue that for nurses to ignore the complexity of symptoms or to view each symptom as though it were isolated from the others would be like dissecting the patient in the waiting room and then taking each part of the patient back for assessment one piece at a time (Lenz et al., 1997). This approach is not holistic or corresponding with the treatment of the patient as a whole person. In order to appropriately treat the whole person, the nurse must come to grips with the whole, complex, interacting aspects of the patients’s symptoms and more deeply understand that interaction. In doing so, the nurse can apply the nursing metaparadigm more effectively. Lenz et al. (1997) supplied numerous examples in their revised approach to the theory “to demonstrate the implications of the revised theory for measurement and research, and its application in practice” (p. 14) and in doing so the researchers manifested reductive reasoning, showing how without the theory as applied in the examples, nurses would fail to provide adequate scope and understanding to the patient’s issues.
Major Concepts
The major concepts of the theory are defined both theoretically and operationally so as to provide the theory with proper theoretical and pragmatic basis in reality. The main concept that the theory espouses is that symptoms are not disconnected one from the other, as they are all a part of the total patient’s experience. They may seem to stem from different ailments—but in reality they are felt and experienced as a single phenomenon and their interrelatedness can also be interpreted from this perspective. Therefore, instead of trying to treat each symptom or the underlying issue of the individual symptoms, the theory of unpleasant symptoms stipulates that the nurse view the symptoms together and take a more holistic approach to the patient’s care.
Indeed, the concept of holistic care is very important to the theory, as it emphasizes the value of comprehensive care and awareness of a patient’s total experience and sense. The treatment of the whole person by taking into consideration not just the physical factors but also the mental factors that impact a person’s well-being, and that can be affected by a complex array of symptoms, is vital for a nurse trying to provide a high level of quality care in today’s health care environment.
Lenz et al. (1995) and (1997) are very consistent with their use of terms and concepts throughout the development and description of their theory. They define the concepts of the theory both in theoretical terms (identifying the theoretical basis of their conception) and real-world terms (offering pragmatic, real-world examples of how the concepts may be demonstrated). Their overall approach to defining the major concepts of the theory is thus well-grounded.
The concepts are defined both implicitly and explicitly in various cases. In some instances, Lenz et al. (1995) demonstrate more focus on identifying the characteristics of a concept and its ultimate meaning than in other instances, wherein a minor concept’s meaning is only implicitly suggested. In neither case is the reader of the article at a loss as to what the meaning of the concepts is, as both implicit and explicit definitions are sufficient within the context of the work as a whole.
The relationships (propositions) among the major concepts work fluidly well, as there is a logical progression from premise to conclusion. In the case of showing how the holistic model of care applies appropriately to nursing via the theory of unpleasant symptoms, Lenz et al. (1997) establish a concrete theoretical approach to providing quality care that is rational, empirically tested and proven, pragmatic and effective for both patient and nurse.
Evaluation
Explicit assumptions (values/beliefs) underlying the theory of unpleasant assumptions is that the holistic approach to patient care is required and that this approach is rooted in the concept of patient-centered care. Implicit assumptions underlying the theory are that nurses want to adopt the best strategy in providing care to patients rather than the simplest or easiest approach. The assumption here is one that views human nature somewhat idealistically—i.e., the ideal nurse will want to adopt a holistic approach to care because it is most helpful for the patient. The theory of unpleasant symptoms helps because it allows the nurse to take a comprehensive approach to the patient’s problems. It avoids the issue that some nurses may not have interest, time, energy or capacity to adopt the approach due to personal or external factors.
The theory does have a description of the four concepts of the nursing metaparadigm—person, environment, health and nursing—within its explanation of the theory of unpleasant symptoms. The theory describes how nurses must consider the physiological, psychological and situational variables that may be impacting a patient’s presentation and how those symptoms are being experienced. This theory correlates substantially well with the nursing metaparadigm, and though the connection is only implicitly established, it can be seen and understood all the same. So while the metaparadigm is not explained explicitly, all four of the elements are relevant to the theory—i.e, the person as a whole is what needs to be considered by the nurse—both in terms of physiological issues and psychological issues; the person’s environment has to be considered as impactful in understanding the patient’s symptoms (which the theory describes as the situational variables that play a role); the health of the patient is of course the overall aim or goal, which is equally true of the theory espoused by Lenz et al. (1997), and the nursing implications of the approach are discussed in detail as they get to the heart of what it means to be a nurse who can provide quality of care in the 21st century. As a result, the theory is clear and constructed and communicated with enough lucidity and consistency that it can be understood—with the help of examples—by the nursing student.
Application
The theory of unpleasant symptoms would guide nursing actions by providing the nurse with an approach to patient presentation that informs the nurse of the considerations to make before diagnosing and treating. The considerations that the nurse should make include understanding the physical, mental and environmental issues that are impacting the patient’s life and health. This understanding can be obtained through direct observation, interviewing, and discussing factors from various points of view with the patient to see how he or she responds. After considering the symptoms from this holistic point of view, the nurse is placed in a better position to provide quality care that focuses on treating the whole person rather than just one symptom after another, which can have more of a negative impact than if the nurse were to view the patient’s treatment more holistically.
This theory can be specifically applied to the ER, which is my area of nursing practice, as patients often present with a complex array of symptoms that are hard to isolate, diagnose and treat. Instead of approaching the patients as though each symptom had to be accounted for on its own, the theory of unpleasant symptoms allows the nurse to consider a variety of other factors prior to diagnosing and treating the patient. These factors provide the nurse with a better understanding of why the patient is at the ER and what factors have come together to lead the patient to the hospital at this point in time. Understanding these factors can help nurses to see more clearly the source of the problems that the patient is having and implement a treatment that more effectively targets the source of the underlying problems. In other words, rather than patching band-aids over the patient’s issues in the ER and sending him on his way, the nurse can develop a broader and deeper understanding of the patient’s needs and respond accordingly.

References
IOM. (2010). The future of nursing. Retrieved from
http://nacns.org/wp-content/uploads/2016/11/5-IOM-Report.pdf
E. Lenz & L. Pugh. (2010). Nurses info. Retrieved from
http://www.nurses.info/nursing_theory_midrange_theories_lenz_pugh.htm
Lee, S., Vincent, C., & Finnegan, L. (2017). An analysis and evaluation of the theory of
unpleasant symptoms. Advances in Nursing Science, 40(1), 16-39.
Lenz, E. R., Suppe, F., Gift, A. G., Pugh, L. C., & Miligan, R. A. (1995). Collaborative
development of middle-range nursing theories: Toward a theory of unpleasant symptoms. Advances in Nursing Science, 17(3), 1-13.
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.