Theory of Unpleasant Symptoms: A Nursing Theory Analysis

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 addresses the four concepts of the 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, in order to 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 healthcare 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 patients seek. The theory 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 having authored a variety of works and publications on nursing. For example, Lenz served as 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 interacting with students as well as other healthcare professionals convinced them of the need to develop a new approach to nursing that would allow 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 both by the originators of the theory (Lenz et al., 1997) and by other researchers who have evaluated 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 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 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, rather than compartmentalizing them or treating them as though they were unconnected.

The researchers also pointed out, however, that while the theory had been utilized as a guide in recent research, no formal critique of the theory had been conducted for more than a decade and a half. Lee et al. (2017) therefore saw fit to update the literature on the Theory of Unpleasant Symptoms by applying the framework of Fawcett and DeSanto-Madeya to it. Their conclusion was that while the theory as expressed by Lenz et al. does pose some clarity and language structure issues, the ideas and concepts within the theory are significant, provable via testing, and have utility in nursing. The positive contribution the theory yields is the concept that nurses should focus not just on individual symptoms when tending to a patient but on multiple symptoms and what their combined presentation can mean. Lenz et al. (1997) likewise discuss the "interactive nature of the symptom experience" in their review, two years after first publishing the theory in 1995, to demonstrate 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 an answer based on prior knowledge and understanding of the elements involved. The researcher then tests that answer to determine whether it correctly addresses the problems or issues identified. In this sense, the theorists involved in developing the Theory of Unpleasant Symptoms used inductive reasoning to gauge the issue, identify a 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, and by utilizing their research skills to test the validity of their theoretical approach to understanding the complexity of patients' symptoms.

Their tests led them to revise their original thesis and modify it to account for new evidence 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 grounded in inductive reasoning, their revisions utilized deductive reasoning. The researchers also applied deductive reasoning by approaching the phenomenon from a different angle following their initial inductive work — that is, they drew on available evidence explaining why nurses were not responding adequately to patients' symptom complexity and used that evidence to develop a solution based on empirical data, which they then confirmed through their theoretical framework.

Reductive reasoning was also evident in the sense that the theorists could argue that ignoring symptom complexity — or viewing each symptom as isolated from the others — would be analogous to taking the patient apart piece by piece and assessing each part separately (Lenz et al., 1997). This approach is neither holistic nor consistent with treating the patient as a whole person. In order to appropriately treat the whole person, the nurse must come to grips with the full, complex, interacting aspects of a patient's symptoms and develop a deeper understanding of that interaction. Lenz et al. (1997) supplied numerous examples in their revised theory "to demonstrate the implications of the revised theory for measurement and research, and its application in practice" (p. 14), manifesting reductive reasoning by showing how, without the theory's application, nurses would fail to provide adequate scope and understanding of the patient's issues.

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., & 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.

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.