Nursing Theory – Theory of Unpleasant Symptoms

Nursing Theory – Theory of Unpleasant Symptoms

The proponents of the theory of unpleasant symptoms, Lenz and Hugh, sought to explain symptoms of a disease as the experienced abnormality in the body’s functioning. Therefore, this paper aims to give a brief history of the theory and its areas of concern and the historical evolution of this theory. It will also explain the concepts of the theory and their consistency throughout the years. Lastly, the paper will look at how valid the argument is in the modern world.

Theory and Theorists

The earliest version of this theory was developed in 1995 by Milligan, Lenz, Pugh, and Gift. The theory sought to come up with interventions to reduce or eradicate the unpleasant symptoms in patients. It was, consequently, developed for a broad range of diseases whenever the symptoms required the consideration of the nurses. All the students in University of Maryland School of Nursing had done research on unpleasant symptoms as a course requirement. And because of the extensive research on the various symptoms such as fatigue by Milligan and Pugh and dyspnea by Gift, the proponents realized that the symptoms were the same. The two topics had both looked at the factors causing and affecting the symptoms and the effects of the symptoms on performance. It is for this reason that the two merged their research to form TOUS (Smith & Parker, 2015). Given that they were all based in the same university, shared the same data and findings and to add to that, they had the similar philosophical reasoning; they were able to come up with the middle range theory that is used to this day. In short, necessity was the mother of this theory. However, the students could not publish their journal and so they went to Elizabeth Lenz to help them publish the findings in a manner that is accepted. Lenz was an expert in theory development and had conducted research about pain in

cardiac patients, and so this new development was a pedestal for her work. Using their expertise Pugh and Lenz developed TOUS. Later in 1997, Lenz and Pugh developed the theory into a cyclical theory that sought to look at the symptoms of all the diseases.

Lenz was a nurse by profession and always wanted to make the patients more comfortable. She was passionate about easing the pain in her patients. In the time of the development of the TOUS, Lenz had done research on pain in cardiac patients where the findings were crucial. By her joining in the TOUS development, the theory became substantial supported by real life situations and experiences.

Analysis of the theory

The theory of unpleasant symptoms is classified as a middle range theory because it links the research to practice. Its practicability makes it a theory that is practiced by many nurses around the world (Smith & Liehr, 2014). This theory puts its emphasis on the symptom experience of the patient. Conversely, the difference in this is that instead of looking at one particular symptom at a time, the nurse is encouraged to look at the several symptoms occurring in tandem. The nurse has to be careful to see similarities between the symptoms to ensure that he/she gets the full picture of the symptoms or the explosive symptom. The theory also deals with a symptom or symptoms that have the multiplicative effect on the patient. The effects will, in turn, influence the symptom experience, individual’s performance and the distress in the patient.

In 1995, the proponents only looked at one symptom at a time and also lacked components. Concepts such as the distress and timing were added to the two concepts of fatigue and dyspnea with the revision done by Elizabeth Lenz and Linda Pugh in 1997 (Ingham, 2015).

They came up with the three components namely, symptom experience, factors influencing the experience and the outcomes of the symptom experience.

Symptoms from one cause can be linked to other symptoms from another source. The factors can also be linked to bringing forth a set of symptoms not seen before. The symptoms can be looked at from a common point of view or just looking at one cause at a time. A symptom according to Lenz is the alteration of the normal body functioning of a patient (Lenz, et al. 1997). From the earlier scrutiny of TOUS, the analysis was of a linear nature meaning that each symptom was looked at independently causing a mix-up and a misinterpretation of some of these symptoms.

The error happened because the human beings experience same symptoms but to a different degree. The symptoms are further classified into four distinct scopes namely, intensity, time, distress, and quality of the symptoms. The intensity just means the severity or the strength of the symptom experience. Meaning different individuals will experience the pain in different magnitudes and those who have the highest magnitude will require the assistance of the nurse. In time, the nurse has to look at the duration of the symptom occurrence as well as the frequency at which the symptom will manifest itself. The patient might experience a high magnitude of pain but for a short period while another might experience pain throughout the day and night.

Therefore, the one that only experiences the pain in short periods of time will only require help from the nurse for a shorter time as compared to the one in constant pain. Another scope of symptom experience is the distress of the patient. Here, the nurse looks at the degree of reaction that the patient portrays. The reaction is mainly psychological and the exposure to symptom experience. The nurse at this point is supposed to help the patient to gain knowledge about the symptom to put his or her mind at rest. Lastly, there is the quality of the symptom/s.

Here the nurse is to be keen on the words and the vocabulary employed by the patient. It is the description used by the patient to explain the symptom felt. The description again looks at the intensity and the psychological view of the symptom that the individual has about the occurrence.

The second component is the factors or causes that increase or influence the symptom experience (Cherry & Jacob, 2014). They are divided into three main factors, psychological, physiological and situational. Psychological factors are those that are likely to influence the level of the symptoms. For example, the mood that the patient is in, the information and the ignorance about the symptoms faced. It is also in this sector that the nurse looks at the mental health of the patient, perception and response of the patient to the symptoms suffered. The main aim of the nurse here is to make sure that the client gets enough information to put them at ease and in turn, reduce the symptoms that they have.

In physiological factors, Lenz looked at the variation in the body functioning such as fatigue, headaches, and weakness in the joints. These occur as a direct linkage to the symptom and are used to determine the severity of the symptoms. Some of these physiological changes cannot be seen therefore the use of laboratories comes in handy to ensure that every physiological problem has been captured. Through the utilization of the technology, the nurses can also predict the next symptom helping the patient cope better or just lessen the symptoms.

Finally, there is the situational or the environmental factors. Here the proponents looked at both the physical and social environments that are likely to influence a person’s symptoms. The environment has to be conducive for healing and reduction of the symptoms and the friends, and social conditions have to be supportive and encourage healing in the patient. These factors

mingle in the symptom experience, and the elimination of one factor that leads to the symptom might result in the elimination of other factors and in turn the eradication of the symptoms.

The last component of this theory is the outcomes of the experience which are also the performance. The component is, as well, divided into two, physical performance and cognitive execution. The physical performance looks at how the symptoms have affected the daily activities and social contact, for example, the interaction of the individual in the workplace. Some of the activities that are hindered with the onset of the symptoms are the cognitive execution involves the thinking processes alteration, concentration, and problem-solving abilities (Giallo et al., 2016). So these two will be magnified and manifested depending on the nature and the degree of the symptoms.

By looking at these three components, symptom experiences, the factors affecting the symptoms and the outcomes, it is clear to see the relationship between them. The symptoms are brought forth by the physiological, psychological and situational factors which, in turn, causes the difficulty in the physical and cognitive execution of activities. People can also see the reversal of the factors and that without the causes, the symptoms cannot manifest. All this was made prominent after the revision of the theory. In the earlier version of the theory, such components were not clearly defined, and the relationship between them was shaky. Nonetheless, there are very few changes that took place in the terminology and the meaning of the concepts. The theory can also be considered reliable since there has just been one major adjustment which was done by Lenz and Pugh and few done to help in the adaptation of different settings.

The first assumption that this theory has is that there is a commonality in the symptoms among all the people with different diseases. It emphasizes on various symptoms and not just one

symptom making it versatile to all the people (Lubkin & Larsen, 2013). The theory, for example, has the same factors for different types of symptoms exhibited by all the patients. By removing it from the earlier linear dimension to one that is interactive, the theory brought about the understanding of the symptoms, their causes and possible outcomes to the patient. The theory can be used in all parts of the world because the human beings experience the same kind of symptoms and by using the influential factors some of the symptoms can easily be understood and dealt.

The second assumption is that the theory is practicable in all fields of nursing. This assumption was proven right by establishing a reciprocal link between the symptoms and the performance of the individuals. It was also confirmed to be practicable when the nurses used this theory to classify the symptoms and by using the same relaxation techniques for the different patients that they had. The theory’s functionality demonstrated beyond reasonable doubt that it could be utilized with the patients to enhance and better their stay in the hospitals. The growing number of clinical studies conducted about the theory of unpleasant symptoms and the adaptation of this theory to many of the hospitals has shown that the use of this theory is efficient and reliable. The commonality of human symptoms has also been a contributing factor to this success.

Finally, there is an assumption that the individuals will give an accurate account of the symptoms experienced. The intensity, time, level of distress, and the quality are all taken from the description of the patient. The symptom analysis might pose a problem because of the different perceptions and the exaggeration that some of the people portray. For example, the best candidates to look at an exhaustion checklist are those who work for long hours standing as opposed to those that work for five hours. The intensity will not be the same but for a person

who is not used to strenuous activities might check the intensity of fatigue at the highest for walking for a few meters which are wrong. It is entirely subjective and even though the nurses will have the checklist of the appropriate symptoms the patient is the one with the last word.

Evaluation of the theory of unpleasant symptoms

In a study conducted by Riegel in 2009, the major goal was to identify multiplicative symptoms of heart failure. The researcher used a sample size of 687 patients with heart failure and found that there are symptoms that occur in tandem. For example, she discovered that fatigue and shortness of breath occurred simultaneously. Since the symptoms did not bring a lot of distress to the patients, they were considered acute. However, the acute symptoms brought forth the development of the chronic symptoms characterized by swelling, increased bed rest and dyspnea. The performance of the patients was disrupted in that their daily activities were rapidly minimized. The changes were only observed after the patients had reached the chronic phase of heart failure and needed a lot of rest (Riegel, 2009). Those that were going to work stopped altogether and the relationships were hurt as a result of the disease.

Riegel also noticed that there were factors that aggravated the situation further such factors are like the physiological changes. The physiological changes are the biological changes that took place in the body such as the increased dyspnea in the body of the patients. When the patients experienced the chronic symptoms, they would be increased depending on the emotional factors such as depression and anxiety. Through the identification of the factors the researcher found that there is a common cause of the heart failures and that affects how the intervention is managed. The implication of multiplicative symptoms is that the nurses can solve the causal issues adequately as compared as treating them as different or individual entities.

As seen in the study above, the TOUS theory is used in the research field in nursing. The researchers use the model in understanding of multiplicative impacts of the symptoms, the factors affecting the symptoms and the effects of the symptoms on the performance of the individuals. (Meleis, 2011). The research that was used in the earlier version of the theory used the deductive and inductive analysis where only two concepts were looked at dyspnea and fatigue. However, this has changed in the recent developments where there are several components which relate to one another and the factors that influence the symptom are looked at keenly. These factors (physiological, psychological and situational) are used to determine the interventions and to predict the symptom experience of a patient. The interventions, in this case, help to reduce the symptom distress, timing, quality and intensity to make the patient as comfortable as possible (Jurgens & Pastor, 2015). The TOUS theory is also used in research to determine the group and individual relaxation methods to be utilized by the nurses for the different influential factors.

In practice, such cases that cause a dilemma for the nurses arise. The nurses can use the theory to understand the management of underlying factors to make the patients more comfortable. The nurse will hence seek to establish the psychological, physical and situational factors that to come into play for this decision to happen. Interventions can then be arranged according to the symptoms that the patient feels before and after the surgery (Wilson, 2014). It is also paramount for the nurse to accurately record the symptoms by use quantification of the symptom timing, intensity, distress, and quality. The quantification is put in place to ensure that proper and adequate interventions for the influential factors practiced.

The advantage of this theory is that it can be used for almost all symptoms as seen in the new developments. It can also be used by all people around the world because the symptoms of

diseases are usually the same for all and what differs from one individual to the other is the physiological, psychological and situational factors which can be dealt with once the nurse finds out about the background. The interventions that have been generated can also be adopted depending on the environment that the nurse finds him/herself. For example, during the immunization periods of a child, the child must have some social support from parents to lessen the symptoms of the pain brought about by injections. For psychological factors, the best intervention is a distraction either by bringing toys for children and music and movies for the adult patients. Lastly, physiological factors require medication intervention for the patient to feel better and forget about distress he or she is going through.

Conclusion

This paper has looked intensively at the theory of the unpleasant symptoms. It has looked at the development and factors that led to its existence. It has also looked at the main concepts of TOUS both in the original and developed version, and it has looked at other areas that are being enhanced for better interventions for the patients. Lastly, the paper has given a detailed overview of how the theory is used in research and nursing today.

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