Advances in Nursing Science

Vol. 40, No. 1, pp. E16–E39

Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved.

An Analysis and Evaluation of

the Theory of Unpleasant
Symptoms
Seung Eun Lee, MSN, RN; Catherine Vincent, PhD, RN;
Lorna Finnegan, PhD, RN

The Theory of Unpleasant Symptoms was developed to enhance understanding of relation-

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ships among multiple symptoms and symptom experiences. Although the theory has been
used to guide research, no formal critique of the theory has been published since 2000.
This article comprehensively analyzes and evaluates the theory using Fawcett and DeSanto-
Madeya’s framework. Although its semantic clarity, semantic and structural consistency, and
parsimony could be improved, the theory demonstrates good social and theoretical signif-
icance, testability, and empirical and pragmatic adequacy. Understanding multiple patient
symptoms is essential, and the theory demonstrates that nurses should focus on multiple
rather than individual symptoms. Key words: framework, nursing, symptom, theory

T HE THEORY of Unpleasant Symptoms

(TOUS) was developed to enhance un-
derstanding of relationships among multi-
ple symptoms and symptom experiences to
manage unpleasant symptoms through effec-
tive interventions.1,2 Although the TOUS has
been used to guide studies in many areas of
nursing,3-7 no formal critique of the theory
has been published since 2000.8 Therefore,
using Fawcett and DeSanto-Madeya’s9 frame-
work for analysis and evaluation of nursing
theories, we conducted a comprehensive crit-
ical analysis and evaluation of the TOUS.
BACKGROUND
Understanding symptoms of patients is im-
portant because symptoms are among the
Author Affiliation: College of Nursing, University of
Illinois at Chicago, Chicago.
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Seung Eun Lee, MSN, RN, College of
Nursing, University of Illinois at Chicago, 845 South
Damen Ave, Chicago, IL 60612 (slee521@uic.edu).
DOI: 10.1097/ANS.0000000000000141
E16
most common reasons that patients seek
health care.10 Experiencing multiple concur-
rent symptoms, as opposed to single symp-
toms, has more negative effects on patient
outcomes.11,12 In addition, multiple symp-
toms can hinder accurate patient assessment,
diagnosis, and treatment,13 which in turn can
adversely affect symptom management. The
National Institute of Nursing Research has
emphasized the importance of understanding
multiple symptoms to improve clinical man-
agement of illness.14
The TOUS was developed in 19951 and
updated in 19972 to support understanding
of multiple symptoms that occur simultane-
ously. The theory has been used in nursing
and other areas of research but still requires
comprehensive examination to evaluate its
appropriateness for use in research. There-
fore, in this article we present a critique of
the TOUS.
DATA SOURCES
As sources of information for our study,
3 publications1,2,15 authored by the theo-
rists were reviewed. In addition, the elec-
tronic databases Google Scholar, PubMed, and

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 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
Statements of Significance
What is known or assumed to be true
about this topic:
• Use of sound theory is essential
in nursing research.
• Lenz and colleagues developed
the Theory of Unpleasant
Symptoms (TOUS) to support
understanding of multiple
symptoms that can be
experienced simultaneously.
• The theory has been used in
various studies, but no formal
critique of the TOUS has been
published since 2000. Thus,
there is a need to
comprehensively analyze and
evaluate its appropriateness for
use in nursing research.
What this article adds:
• Using Fawcett and DeSanto-
Madeya’s 2013 framework for
theory analysis and evaluation,
we found that the TOUS
demonstrates good social and
theoretical significance,
testability, and empirical and
pragmatic adequacy. However,
the theory’s semantic clarity,
semantic and structural
consistency, and parsimony
could be improved.
• We evaluated 31 TOUS-guided
studies of diverse populations
with various health conditions in
different countries.
• Only limited TOUS-based
intervention research was
identified. The reason may be
that the intervention component
is not clearly explained in the
theory or that the theory is more
useful for observing concepts
and their relationships than for
developing interventions.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E17
CINAHL were searched using the key word
“theory of unpleasant symptoms” to identify
relevant articles. Studies were selected for re-
view on the basis of the following criteria:
studies (a) in which the TOUS was used as a
conceptual or theoretical framework, (b) pub-
lished from 2000 to 2016 (because a formal
critique of the TOUS was published in 2000,
such studies reflected progress in use of the
TOUS in nursing research), and (c) written
in English. On the basis of Silva’s criteria,16
we excluded studies in which the theory was
“minimally used.”
ANALYSIS OF THE TOUS
Analysis of a nursing theory involves sys-
tematic scrutiny of what the author has pre-
sented about the theory.9 Theory analysis in-
volves an objective and thorough examina-
tion of a theory’s scope, context, and content.
These criteria are evaluated next.
Theory scope
The first step in theory analysis, classify-
ing the scope, involves examining the con-
cepts and propositions for abstractness and
breadth.9 A theory that includes more abstract
and broader concepts and propositions is a
grand theory, whereas a theory that consists
of relatively concrete and specific concepts
and propositions is a middle-range theory.
Middle-range theories can be further classi-
fied in terms of the way that a phenomenon is
addressed: descriptive, explanatory, and pre-
dictive theories.
Lenz et al2(p14) claimed that the TOUS is
a middle-range theory that “was proposed as
a means for integrating existing information
about a variety of symptoms.” The purpose
of the TOUS is to understand multiple symp-
toms that occur at the same time to explain
the symptoms as well as to guide research
and nursing practice.2,15 The TOUS has 3 ma-
jor concepts: influencing factors, symptoms,
and performance. Lenz et al described rela-
tionships among the 3 major concepts as well
as associations between subconcepts of the
 E18 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2017
major concepts, which indicate narrower
propositions between the concepts. The
TOUS was developed specifically for appli-
cation in nursing practice and research.2,15
Because the TOUS has relatively concrete
concepts and propositions and a goal of un-
derstanding multiple unpleasant symptoms,
the TOUS can be characterized as a middle-
range explanatory theory. In addition, the
theory can be used to develop preventive
interventions to adjust influencing factors for
multiple symptoms,1 and the effectiveness
of use of the TOUS in intervention on pa-
tient outcomes has been shown in research.17
Therefore, the theory can also be viewed as a
middle-range predictive theory.
Theory context
The second step in theory analysis, exam-
ining the context of a theory, includes de-
scription of 5 components: (a) metaparadigm
concepts and propositions, (b) philosophical
claims on which the theory is grounded, (c)
worldview that the theory reflects, (d) con-
ceptual model on which the theory is based,
and (e) previous knowledge from nursing
and other disciplines from which the theory
is derived.9 These components are applied
next.
Metaparadigm concepts and
propositions
The nursing metaparadigm concepts of
human beings, environment, health, and
nursing and the 4 relational propositions
between human beings and health; health
and environment; nursing and human beings;
and human beings, health, and environment9
are all addressed in the TOUS. Metaparadigm
concepts of human beings and health were
addressed through Lenz et al’s 2(p15) defini-
tion of symptoms as “perceived indicators of
change in normal functioning as experienced
by patients . . . they are the red flags of
threats to health.” In addition, Lenz et al2 ad-
dressed the nursing metaparadigm concepts
of human beings, health, and environment
by stating that an individual’s symptom expe-
riences can be affected by social and physical
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
environmental factors such as marital status,
social support, heat, noise, and light. On
the basis of the various assertions of Lenz
et al,2 the TOUS addresses the nursing
metaparadigm propositions of “patterning of
human health experiences within the context
of the environment,” “human processes of
living,” and recognition “that human beings
are in a continuous mutual process with
their environments.”9(p312) Moreover, Lenz
et al1 maintained that the TOUS can be used
to develop preventive interventions to alter
influencing factors for multiple symptoms.
Although the theorists did not explain the
interventions and did not use the word “nurs-
ing” for the interventions, they described the
TOUS as a middle-range nursing theory that
was developed for nursing practice. There-
fore, it is reasonable to assume that the inter-
ventions refer to nursing actions intended to
help patients suffering from multiple symp-
toms, and thus addressing the nursing meta-
paradigm proposition that deals with nursing
actions that are beneficial to human beings.
Philosophical claims and worldview
Philosophical claims, or philosophical
statements that explain beliefs and values of
nursing, include ontological, epistemic, and
ethical claims.9 The ontological and epistemic
claims reflect 3 contrasting worldviews: re-
action, reciprocal interaction, and simultane-
ous action. Although no philosophical claims
for the TOUS are explicitly stated, the evo-
lution of the TOUS reflects the reciprocal in-
teraction worldview. When Lenz et al devel-
oped the TOUS in 1995, they considered an
unpleasant symptom to be isolated and one-
dimensional. When they updated the TOUS in
1997, they incorporated multiple unpleasant
symptom experiences, including symptoms
that occur simultaneously and their interac-
tive effects (Figure). In the updated version
of the TOUS, Lenz et al2 considered the pa-
tient as a whole; they stated that “unpleas-
ant symptoms, in all their synergy, interac-
tion, and complexity, are what the whole
patient presents.”2(p25) The theorists empha-
sized the reciprocal interactions between
 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
individuals and their environments, the mul-
tidimensionality of symptom experiences of
individuals, and the interactive effects on the
symptoms.2,15
Conceptual model and antecedent
knowledge
Theory development is typically guided
by a conceptual model (a collection of ab-
stract concepts that apply to the topics of
primary interest to a discipline), proposi-
tions that define the concepts, and additional
propositions that identify relationships be-
tween the concepts.9 Theorists also use an-
tecedent or existing knowledge from nursing
and other disciplines to develop and refine
their theories.9
Although Lenz et al2 did not explicitly
identify a conceptual model for the TOUS,
they explained the process of TOUS devel-
opment from the single-concept level to a
middle-range theory.1 The TOUS was orig-
inally developed by nurse researchers who
shared an interest in patients’ experiences of
fatigue and dyspnea with an intention to de-
velop a relevant framework. The researchers
combined their clinical observations and
conducted a literature review on fatigue and
dyspnea to analyze these concepts. Even
though the researchers focused on different
symptoms in different populations, they
recognized that they conceptualized the con-
cepts in similar ways, and they analyzed com-
monalities between the symptoms. Beginning
with a multiple-concept (fatigue and dysp-
nea) model, the researchers examined other
concepts for potential incorporation into the
theoretical formulation. On the basis of this
effort, Lenz et al2 extended their model to
multiple symptoms in various populations,
resulting in the TOUS, a middle-range nurs-
ing theory. The researchers’ antecedent
knowledge (including their practice-based
observations, previous research, and review
of relevant literature) was used for TOUS
development.
Theory content
The third step of theory analysis in-
volves examining the theory’s content by
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E19
investigating concepts and propositions.9
Concepts are phrases that summarize an ab-
stract phenomenon, and propositions are
declarative statements that define a concept
or a relationship between concepts.9
Concepts
The TOUS has 3 main concepts: influenc-
ing factors, symptoms, and performance.2,15
Influencing factors include physiologic, psy-
chologic, and situational factors. Symptoms
encompass 4 dimensions: intensity, timing,
distress, and quality. Performance consists of
functional and cognitive activities. Concepts
and associated nonrelational propositions of
the TOUS are shown in Table 1.
Nonrelational propositions
Nonrelational propositions are definitions
or descriptions of concepts.9 The nonrela-
tional propositions of the 3 major concepts
and 8 of the 9 subconcepts are provided
in the TOUS. Even though Lenz et al2 de-
scribed the performance concept, they did
not specifically define or describe 1 of its 2
subconcepts—cognitive activities, for which
only examples are offered.
Relational propositions
Relational propositions describe the rela-
tionships or linkages between 2 or more
concepts.9 The TOUS has 7 main rela-
tional propositions and 1 additional relational
proposition as follows: One, “three types of
factors are now acknowledged to relate to
one another,”2(p19) showing relational interac-
tions among the 3 influencing factors (phys-
iologic, psychologic, and situational). Two,
“physiologic, psychologic, and situational fac-
tors can interact with one another in their rela-
tion to symptoms,”2(p19) illustrating the direc-
tional influence of the 3 factors on symptoms.
Three, “the experience of unpleasant symp-
toms can change one’s physiological, psy-
chological, and situation status . . . [and thus]
these relationships may be reciprocal.”2(p20)
Four, “symptoms can occur alone or in
isolation from one another but that, more
often, multiple symptoms are experienced
simultaneously . . . . The concurrence of
 E20 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2017

Table 1. Concepts and Nonrelational Propositions of the Theory of Unpleasant symptomsa

Concept Definitions/Description of Concepts

Influencing factors “[Factors that influence] the occurrence, intensity, timing, distress level,
and quality of symptoms” (p. 18)
Physiologic factors “Physiologic factors include normally functioning bodily system, the
existence of any pathology, including the occurrence of trauma, and
the individual’s level of energy” (p. 18).
Psychologic factors “Psychologic factors include the individual’s mental state or mood,
affective reaction to illness and degree of uncertainty and knowledge
about the symptoms and their possible meaning” (p. 18).
Situational factors “Situational factors include aspects of the social and physical
environment that may affect the individual’s experience and
reporting of symptoms. Potentially relevant social situational
considerations include employment status, marital and family status,
social support, availability of and access to health care resources, and
lifestyle behaviors such as diet and exercise. Potentially relevant
physical environmental variables include heat, humidity, noise, light,
and air quality” (pp. 18-19).
Symptoms “[Symptoms are the] perceived indicators of change in normal
functioning as experienced by patients. They are the red flags of
threats to health” (p. 15).
Intensity “Intensity refers to the severity, strength, or amount of the symptom
experienced” (p. 15).
Timing “[Timing] includes the frequency with which an intermittent symptom
occurs, the duration of a persistent symptom, or a combination of
frequency and duration in symptoms that are intermittent but persist
over long periods of time or that are chronic but vary in intensity.
The time dimension can also refer to the timing of a symptom’s
occurrence relative to specific activities” (p. 15).
Distress “Distress . . . refers to the degree to which the person is bothered by it”
(p. 16).
Quality “Quality is often reflected by the vocabulary used to describe what the
symptom feels like” (p. 17).
Performance “[Performance refers to the] outcome or effect of the symptom
experience” (p. 19).
Functional activity “Functional performance is conceptualized broadly to include physical
activity, activities of daily living, social activities and interaction, and
role performance including work and other role-related tasks” (p.
19-20).
Cognitive activity “Examples of cognitive activity include concentrating, thinking, and
problem-solving” (p. 20).

a Definitions of nonrelational propositions were retrieved and are quoted verbatim (except where indicated) from Lenz

et al.2

multiple symptoms is likely to result in an merous or more severe symptoms tend to

experience that is multiplicative rather than have lower functional health status, less effec-
additive. That is, two or more symptoms oc- tive role performance, lower cognitive func-
curring at the same time are likely to catalyze tioning, lower quality of life, and lower physi-
each other.”2(p15) Five, “people with more nu- cal performance capabilities,”2(p20) showing

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 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
directional influence of symptoms on per-
formance. Six, “performance has a recipro-
cal relation to the symptom experience.”2(p20)
Seven, “decreased levels of performance can
have a feedback loop to the influential fac-
tors, with a negative impact on physiologi-
cal and psychological states and situational
conditions,”2(p20) describing a “reciprocal” as-
sociations between performance and influ-
encing factors. Eight, “an additional possibil-
ity is that the symptom experience can be a
moderating or mediating influence in the rela-
tionship between physiologic or psychologic
status and performance.”2(p20)
EVALUATION OF THE TOUS
Evaluation of a nursing theory involves
making judgments about the extent to which
the theory meets established criteria.9 These
judgments can be based on the results of an
analysis, a published critique of the theory,
and/or research articles describing use of the
theory in practice. Theory evaluation involves
use of 6 criteria: significance, internal consis-
tency, parsimony, testability, empirical ade-
quacy, and pragmatic adequacy.9 These crite-
ria are evaluated next.
Significance
Evaluating the context of a theory on the
basis of its significance is the first step in
theory evaluation.9 Two types of significance
need to be evaluated: social and theoretical
significance. Social significant of a nursing the-
ory is related to its importance to society, and
theoretical significant of a nursing theory is
related to knowledge development in nurs-
ing. The criteria of significance are met
if the nursing metaparadigm concepts and
propositions, philosophical claims, concep-
tual model, previous knowledge, and social
and theoretical contributions of the theory are
explicit.9
Our analysis of the TOUS indicates that
the theory meets some of the criteria of sig-
nificance. Lenz et al2 clearly addressed the
nursing metaparadigm concepts of human be-
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E21
ings, environment, health, and nursing as well
as the metaparadigm propositions of “pattern-
ing of human health experiences within the
context of the environment,” “human pro-
cesses of living,” and recognition “that human
beings are in a continuous mutual process
with their environments.” However, they did
not clearly address metaparadigm proposition
of “human process of dying.”
Although they did not explicitly state a
philosophical claim of the TOUS, their recip-
rocal interaction worldview is reflected in the
theory. In addition, they did not identify a spe-
cific conceptual model on which the theory
is based, but they clearly explained the TOUS
development process, which was based on
their antecedent knowledge from clinical ob-
servations, review of the literature, and previ-
ous research.
The theorists15,18 identified the social and
theoretical contributions of the theory. The
theory’s social significance, its importance to
society, is evident when the theory is about
people’s health experience and has an im-
pact on desired lifestyle. The TOUS develop-
ment to incorporate knowledge about mul-
tiple symptoms and to identify preventive
interventions for patients who suffer from
these symptoms provides evidence of social
significance. The TOUS has theoretical sig-
nificance because it contributes to the ad-
vancement of nursing knowledge by provid-
ing understanding of people’s health experi-
ence and in particular their symptom expe-
rience. The theory guides nursing practice
for symptom assessment and management for
various populations with different symptom
experiences.15,18 The theorists maintained
that the TOUS provides knowledge about
shared attributes among multiple symptoms
that cannot be obtained using a theory fo-
cused only on a single symptom.
Internal consistency
Assessing a theory’s internal consistency
in terms of its context and content is the
second step of theory evaluation.9 Internal
consistency is achieved when the philosoph-
ical claims, conceptual model, concepts, and
 E22 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2017

propositions of the theory are consistent. This
internal consistency criterion also requires se-
mantic clarity and consistency of the theory
concepts and structural consistency of the
theory propositions.9
The TOUS partially meets the internal con-
sistency criterion. Although the philosophical
claims and conceptual model are not explic-
itly presented, the theorists clearly explained
the TOUS conceptual development process
and their reciprocal worldview.2,15 This con-
ceptual effort and their worldview are con-
gruent with the TOUS concepts (influencing
factors, symptoms, and performance), their
subconcepts, and the unidirectional or bidi-
rectional relationships among the concepts
and subconcepts.
The TOUS partially displays semantic clar-
ity. Although clear descriptions of the 3 main
concepts are provided, not all of the sub-
concepts are explicitly described. For ex-
ample, Lenz et al2(pp19, 20) defined perfor-
mance as the “outcome or effect of the symp-
tom experience” and stated that the concept
includes functional and cognitive activities.
They then provided examples of cognitive
activities but did not provide a clear defini-
tion or explanation of this subconcept. For
instance, they stated that “examples of cogni-
tive activity include concentrating, thinking,
and problem-solving”2(p20) ; however, they did
not explicitly define the concept. Moreover,
the 2 subconcepts—functional and cognitive
activities—are not illustrated in the TOUS
(Figure).
The semantic consistency of the TOUS is
somewhat problematic. In general, Lenz et al2
did not use consistent terms for the concepts.
For instance, they used the terms “symptoms”
and “symptom experience” interchangeably
for the concept of symptoms. They also used
the terms “functional activities,” “functional
performance,” and “functional status” for the
concept of functional activity, and “perfor-
mance” and “performance outcomes” for the
concept of performance. For the concept
of influencing factors, they used the terms
“physiologic factors” and “physiological
states,” “psychologic factors” and “psycho-
logic status,” and “situational factors” and “sit-
uational conditions” interchangeably. These
inconsistencies result in some lack of clarity.
Although there are no contradictions
across most of the relational propositions in

Figure. Updated version of the middle-range theory of unpleasant symptoms. Adapted from “The middle-range
theory of unpleasant symptoms: an update” by Lenz et al.2 Copyright 1997 by Aspen Publishers, Inc. Published
by Lippincott Williams & Wilkins, Inc. Used with permission.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
the TOUS (structural consistency), there is
a contradiction between propositions 2 and
3. That is in the second proposition, Lenz
et al2 indicate directional influence from fac-
tors to symptoms, whereas in the third propo-
sition, they indicate a reciprocal relationship
between the 2 concepts. Both directional and
reciprocal (feedback) relationships are shown
in the Figure.
The propositions of the TOUS are reason-
able (they are sensible), supporting structural
consistency. However, Lenz et al2 could have
more clearly addressed one of their relational
propositions in the TOUS. Specifically, they
stated that there was a possible mediating
or moderating effect of symptoms on the re-
lationships between influencing factors and
performance.2 Mediating variables are used
to explain the process by which 2 variables
are related, and moderating variables inter-
act with the relationship between 2 variables,
thus modifying the form or strength of the
relationship.19 The conceptual diagram of the
TOUS shown in the Figure depicts symptoms
in a mediating relationship between influenc-
ing factors and performance, but a moderat-
ing effect of symptoms on the relationship be-
tween influencing factors and performance is
not shown in the conceptual diagram. How-
ever, this relationship could be inferred and
tested using interaction terms composed of
symptom variables and influencing factor vari-
ables. The limitations in semantic consistency
of the presentation of the TOUS concepts and
limitations in structural consistency in the re-
lational propositions detracted from overall
internal consistency of the theory.
Parsimony
Assessing the clarity and conciseness of
the theory content, or its parsimony, is the
third step in theory evaluation. Parsimony is
achieved when a theory explicitly explains
phenomena of interest using as few concepts
and propositions as possible.9 Overall, the
TOUS is parsimonious in its inclusion and ex-
planation of 3 main concepts, 9 subconcepts,
their nonrelational propositions, and 8 rela-
tional propositions that indicate the relation-
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E23
ships among the concepts and subconcepts.
However, the number of relational proposi-
tions could have been reduced if the recipro-
cal relationships had been clearly explained
and depicted as bidirectional rather than as 2
separate relationships, as discussed above.
Testability
Assessing the testability of a middle-range
theory is the fourth step in theory evaluation.9
Testability is achieved when a theory can be
empirically tested so as to demonstrate its
scientific usefulness. The criterion of testa-
bility is met when specific instruments are
developed to allow observation of concepts
and statistical techniques are used to test
propositions.9 Evaluation of the testability of
a middle-range theory calls for careful review
of the methodological literature related to the
theory.9
To examine the testability of the TOUS,
we searched Google Scholar, PubMed, and
CINAHL using “theory of unpleasant symp-
toms” as the key word. The search was limited
to peer-reviewed research articles published
in English between 2000 and March 2016. A
total of 152 abstracts were identified for ini-
tial review. We then reviewed the 31 articles
whose authors stated that their studies were
conceptually or theoretically guided by the
TOUS. The 31 articles reviewed are summa-
rized in Table 2.
As shown in Table 2, the TOUS has
been used as a conceptual or theoretical
framework in studies of different populations
in multiple countries. Research has shown
that the concepts in the TOUS can be oper-
ationalized. For example, physiologic factors
were operationalized as preexisting health
conditions such as breast cancer,6,7 chronic
obstructive pulmonary disease (COPD),5 and
menopausal status.20 Psychologic factors
were operationalized as depressive mood and
food cravings.21 Situational factors were op-
erationalized as demographic variables such
as age, gender, and level of education.22
Performance was operationalized as
cognitive performance,23 symptom self-
management,18 psychologic functioning,24
 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa

Author Purpose Sample Concept Measure Analytic Technique Main Results E24
Parshall et al46 To examine the effect 57 patients with HF Interviews; Specific Content analysis Dyspnea was the
of duration, Activity Scale most distressing
distress, and symptom for
intensity of decisions for
ADVANCES

dyspnea of patients emergency

IN

with heart failure department visits.

on their decision High levels of
making about dyspnea distress
emergency and intensity were
department visits found regardless of
dyspnea duration.
Gift et al12 To examine changes 112 patients with Physical Symptom Correlation ANOVA The symptom cluster
in symptom lung cancer in the Experience tool Logistic regression of fatigue,
experiences United States (α = .90) weakness, weight
(symptom cluster, loss, appetite loss,
severity, and nausea, vomiting,
individual and altered taste
symptom) in remained over
patients with lung time. Symptom
cancer severity decreased
NURSING SCIENCE/JANUARY–MARCH 2017

over time.
Carpenter To compare sleep 15 breast cancer PSQI, POMS-SF; Chi-square Compared with
et al20 quality and survivors and 15 CESD; Skin Mann-Whitney test healthy women,
disturbance, healthy women Conductance breast cancer
fatigue, and Monitoring survivors reported
depressive shorter sleep
symptoms between duration and more
breast cancer nighttime flashes.
survivors and No differences
healthy women were reported in
experiencing hot fatigue or
flushes depressive
symptoms between
the 2 groups.
(continues)

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

Beck et al40 To examine whether 84 patients with BPI-SF (α = .87); Correlation ANOVA Some of the effect of
sleep disturbance cancer in the PSQI (α = .83); pain on fatigue was
mediates the United States POMS (α = .93) mediated by sleep
relationship disturbance, but
between pain and pain also had a
fatigue direct effect on
fatigue.
Chan et al44 To examine the 27 patients with lung VAS to measure the MANOVA A symptom cluster of
existence of a cancer in Hong intensity of breathlessness,
symptom cluster of Kong anxiety, breath- fatigue, and anxiety
breathlessness, lessness, and existed in patients
fatigue, and anxiety fatigue with lung cancer
in patients with before radio-
lung cancer over therapy and at wk
time 3 and 6 of therapy.
Corwin et al39 To examine 42 community- MFSC (α = .81-.91); Correlation ANOVA PPF was positively
relationships dwelling CESD (α = .77-.91); correlated with
among PPF, PPD, women PSS (α = .70-.84) PPD. Stress was
and stress during positively related
prenatal weeks and to PPD.
after birth
Crane38 To examine factors 84 women, ages Revised PFS (α = Correlation Multiple Depression and sleep
related to fatigue in 65-85 y, 6-12 mo .97); Modified regression disturbance were
women after MI, post-MI BRFSS; Epworth positively related
and examine the Sleepiness Scale; to fatigue. Fatigue
relationship Geriatric Depre- was not signific-
between fatigue ssion Scale; Social antly related to
and physical Provisions Scale physical activity.
An Analysis and Evaluation of the Theory of Unpleasant Symptoms

activity
(continues)
E25

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 E26
Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

45
Jablonski To examine 130 patients on Symptom tool Factor analysis Symptoms rated by
ADVANCES

symptoms hemodialysis in the developed by the patients as being

IN

experienced by United States researcher the most severe

patients on (α = .67) were not
hemodialysis necessarily the
most frequent, the
longest-lasting, or
the most
distressing.
Duncan et al23 To examine Residents with (n = MDS (α = .71-.85); Generalized Physical dependence
physiologic, 1022) and without Indicators of estimating and deteriorating
psychologic, and cancer (n = 9910) Delirium (α = .79); equations clinical status were
situational factors in the United States Self-Performance associated with
potentially related Hierarchy pain, shortness of
to symptoms in (α = .92); CCI breath, and weight
nursing home loss.
residents with
NURSING SCIENCE/JANUARY–MARCH 2017

cancer
Motl and To examine the 292 patients with MS ActiGraph (α = .92); Covariance modeling Fatigue, depression,
McAuley32 symptom cluster of in the United States GLTEQ; FSS (α = Cluster analysis and pain clustered
fatigue, pain, and .93); HADS (α = together. A strong
depression, and its .82); MPQ-SF negative predictive
direct and indirect (α = .88); ESES relationship was
prediction of (α = .99); Late-Life found between the
physical activity FDI symptom cluster
behavior in and physical
patients with activity behavior.
multiple sclerosis
(continues)

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

33
Runquist et al To identify whether 43 postpartum MFSC (α = .85-93); Correlation ANOVA Severely fatigued
severe postpartum women in the Edinburgh Paired t test women at both
fatigue at 1 and 3 Midwestern United Postpartum 1 and 3 mo
mo postpartum States Depression Scale postpartum were
relates to (α = .87-.90) more likely to
depressive experience
symptom 6 mo in depressive
lower-income symptoms at 6 mo.
women
Rychnovsky To examine the 109 postpartum Verran and Correlation Tukey’s A positive
and Hunter3 relationship women in the US Snyder-Halpern post hoc relationship was
between sleep military Sleep Scale; Fatigue found between
characteristics and Continuum Form fatigue and sleep
postpartum fatigue disturbance at 1-2 d
during the first 6 after delivery, 2 wk
wk after delivery postpartum, and 6
wk postpartum. A
negative relation-
ship was found
between fatigue
levels and sleep
effectiveness at the
3 time points.
(continues)
An Analysis and Evaluation of the Theory of Unpleasant Symptoms
E27

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 E28

Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

ADVANCES
IN

Wilmoth et al34 To provide validation 183 women with PFS (α = .97); Simple linear The symptom cluster
of a symptom breast cancer in POMS(α = .93); regression included fatigue,
cluster of fatigue, the United States Wilmoth Sexual weight gain,
weight gain, Behaviors psychologic
psychologic Questionnaire distress, and
distress, and (α = .94); FACT altered sexuality. A
altered sexuality in (α = .90) positive relation-
breast cancer ship was found
survivors between altered
sexual behaviors
and QOL.
Abbott et al24 To identify the 226 elderly patients CSS (α = .85-.98); Cluster analysis Three cluster types
symptom clusters after coronary CCI; Activity Status Chi-square ANOVA were identified:
of elderly patients artery bypass Index; BEES (α = low, low-moderate,
after coronary surgery .93); HADS (α = and moderate
NURSING SCIENCE/JANUARY–MARCH 2017

artery bypass .67-.93); MOS SF-36 symptom burden

surgery, and to (α = .67-.93) clusters. Patients
examine the with low symptom
clusters’ impacts burden had better
on psychosocial mental health
functioning over functioning than
time those with mode-
rate symptom
burden.
(continues)

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

Chen et al4 To explore the 105 patients with HF Modified PFS (α = Stepwise linear Patients with higher
potential factors in Taiwan .85); Symptomatic regression levels of fatigue
influencing fatigue Distress Index (α = had worse physical
.85); HADS (α = functioning and
.78); Barthel’s ADL more severe
Index Social symptomatic and
Support Scale psychologic
(α = .91) distress.
Symptomatic
distress was the
strongest predictor
of fatigue.
Wong et al5 To examine different 42 patients with Multidimensional Correlation High levels of fatigue
dimensions of COPD in Canada Fatigue Inventory Chi-square were related to
fatigue and their (α = .86); HADS, reduced activity
relationships to PSQI and reduced
dyspnea, mental motivation.
health, sleep, and Anxiety was related
physiologic factors to decreased
in individuals with motivation.
COPD
Wu et al35 To explore the 14 children and Focus group Content analysis Fatigue had a
real-life adolescent with interviews negative effect
experiences of leukemia in China on physical,
fatigue from the psychologic, and
perspectives of cognitive well-
Chinese children being and can
with leukemia impact family,
school, and social
An Analysis and Evaluation of the Theory of Unpleasant Symptoms

interaction.
(continues)
E29

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued) E30

Author Purpose Sample Concept Measure Analytic Technique Main Results

Matthews et al6 To determine 93 women with Symptom Distress Confirmatory factor The pain-insomnia-
symptom clusters breast cancer in Scale; Positive and analysis fatigue and
ADVANCES

during the United States Negative Affect Correlation cognitive

IN

radiotherapy in Scale (α = .81-.90); disturbance-

women with breast Life Orientation outlook clusters
cancer and Test (α = .86); were related to
significant Self-Transcendence individual
correlations among Scale (α = .79) characteristics,
the symptoms, optimism,
individual self-transcendence,
characteristics, and and positive and
mood negative mood.
Park et al22 To examine Korean adults with VAS (α = .77); Factor analysis Three “factors”
concurrent asthma or COPD in MSAS (α = .88); Regression emerged. Age,
symptoms, the western United POMS-SF (α = .94); educational levels,
symptom clusters, States MOS-SS(α = .97); mood, working
and the effects of FPI-SF (α = .73) status, and
symptoms on acculturation level
NURSING SCIENCE/JANUARY–MARCH 2017

functioning in were associated

Korean immigrants with functional
with asthma or performance.
COPD
Phligbua et al28 To explore symptom 112 women with Modified MSAS (α = Factor analysis Five symptom
clusters and breast cancer in .68-.82); FACT Regression clusters identified.
influences on QOL Bangkok (α = .80-.86) “I don’t look like
among women myself,” worrying,
with stage I-IIIA and feeling drowsy,
breast cancer were found to be
undergoing the strongest
chemotherapy predictors of QOL.
(continues)

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

So et al7 To examine the 279 patients with BPI (α = .95); BFI Structural equation Social support acted
interrelationship of breast cancer (α = .95); HADS modeling on the different
social support, patients in Hong (α = .74-.80); MOS-SS domains of
prevalent Kong (α = .83-.93); health-related QOL
symptoms, and FACT (α = .80-.88) directly and
health-related QOL indirectly via
among patients anxiety,
with breast cancer depression, fatigue,
and pain.
Eckhard et al29 To determine 102 patients with Fatigue Symptom t test Compared with men,
whether specific stable coronary Inventory (α = Correlation women reported
demographic or heart disease in the .93-.95); Patient Narrative analysis higher fatigue
psychologic United States Health intensity and more
variables were Questionnaire-9; interference from
correlated with SF-36 (α = .79-.88); fatigue. Depressive
fatigue Interviews symptoms were
the predictor of
fatigue intensity
and interference.
Hsiao et al18 To explore the 53 patients with Symptoms and Correlation Symptoms were
association nonmetastatic symptom distress Regression correlated with
between prostate cancer (α = .80-.86); distress. Frequency
symptoms, Strategy and of symptoms was
symptom distress, Effectiveness of significantly
and symptom Symptom associated with
self-management Self-Management symptom
(α = .93) self-management
strategies for
urinary, bowel, and
An Analysis and Evaluation of the Theory of Unpleasant Symptoms

sexual problems.
(continues)
E31

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)
E32
Author Purpose Sample Concept Measure Analytic Technique Main Results

Wang and Fu30 To explore the 183 patients with M.D. Anderson Exploratory factor Three symptom
symptom clusters lung cancer in Symptom analysis clusters included
and quality of life China Inventory gastrointestinal,
ADVANCES

in patients with (α = .82-.94); emotional, and

IN

lung cancer FACT (α = .82) fatigue-related

undergoing symptoms. A
chemotherapy negative
relationship was
found between the
symptom clusters
and QOL.
Ensari et al25 To explore reciprocal 269 people with MS HADS; Multiple Longitudinal panel Baseline depressive
relationship over 2 y in the Sclerosis Walking analysis symptoms
between United States Scale-12; GLTEQ; predicted change
depressive Patient-Determined in walking
symptoms and Disease Steps Scale impairment at 1-y
walking follow-up, and the
impairment in predicted change
patients with MS in depressive
NURSING SCIENCE/JANUARY–MARCH 2017

symptoms at 2-y
follow-up.
Herr et al27 To identify symptom 117 patients with HF BFI (α = .81-89); Factor analysis Three symptom
clusters in patient in the United States Food, Eating Regression clusters identified.
with HF, and Experiences and Sickness behavior
examine the Diet General Sleep cluster (anxiety,
relationship of Disturbance Scale depression,
them to functional (α = .74); MOS sleepiness,
status (α = .65-.91) cognitive
dysfunction, and
fatigue) was related
to limited mobility.
(continues)

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 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)

Author Purpose Sample Concept Measure Analytic Technique Main Results

Kim et al36 To the predictors of 167 patients with M.D. Anderson t test ANOVA Higher level of
symptom cancers receiving Symptom Regression depression and
experience in chemotherapy in Inventory lung cancer
patients with Korea (α = .82-.95); predicted symptom
cancer undergoing HADS (α = .92); severity. Higher
chemotherapy MOS (α = .98) level of depression,
lower level of
fighting spirit, and
third or fourth-line
chemotherapy
predicted symptom
interference.
Loutzenhiser To assess fatigue in 108 mother/father CESD (α = .88); Multilevel modeling Poor sleep quality,
et al37 first-time mothers couples PSS(α = .85); VAS stress, and
and fathers across (α = .95-.96); GSDS depression were
the first 6 mo of (α = .76) associated with
the transition to maternal and
parenthood paternal fatigue.
Tankumpuan To identify predictors 88 patients with brain M.D. Anderson Correlation Recovery symptoms,
et al26 of physical tumor in Thailand Symptom Regression total mood
functioning in Inventory disturbance,
patients who (α = .86); POMS fatigue, and vigor
underwent surgery (α = .81); Sickness were predictors of
for brain tumor Impact Profile physical
(α = .82) functioning.
(continues)
An Analysis and Evaluation of the Theory of Unpleasant Symptoms
E33

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Table 2. Studies Guided by the Theory of Unpleasant Symptomsa (Continued)
E34
Author Purpose Sample Concept Measure Analytic Technique Main Results
Wu et al31 To describe the 102 patients with M.D. Anderson ANOVA t-test A negative relationship
symptom distress and esophageal cancer Symptom Correlation was found between
QOL in Chinese in China Inventory Regression symptom distress and
ADVANCES

esophageal cancer; (α = .77); HADS QOL scores.

IN

and identify the (α = .77); Medical Occupation after

factors that influenced
symptom distress and
the relationship
between symptom
distress and QOL
Moriarty To examine the LUTS
et al41 experiences in men
with Parkinson disease
Coping Modes illness, anxiety, types
Questionnaire of surgery, whether
(α = .60-.76); chemotherapy was on
FACT (α = .86) schedule, and
confrontation coping
strategies were factors
that influenced
symptom distress.
11 men with Structured interviews Template organizing Three dimensions of the
Parkinson disease analytic approach LUTS experiences
included cognitive,
affective, and
behavioral
dimensions.
NURSING SCIENCE/JANUARY–MARCH 2017

Embarrassment from
leakage and odor were
distressing men,
which had a negative
effect on QOL.

Abbreviations: ANOVA, analysis of variance; BEES, Barnason Efficacy Expectation Scale; BFI, Brief Fatigue Inventory; BPI, Brief Pain Inventory; BRFSS, Behavioral Risk
Factor Surveillance Survey; CCI, Charlson Comorbidity Index; CESD, Center for Epidemiologic Studies Depression Scale; COPD, chronic obstructive pulmonary disease;
CSS, cardiac symptom survey; ESES, Exercise Self-Efficacy Scale; FACT, Functional Assessment of Cancer Therapy; FPI, Functional Performance Inventory; GLTEQ, Godin
Leisure-time Time Exercise Questionnaire; GSDS, General Sleep Disturbance Scale; HF, heart failure; Late-Life FDI, Late-Life Function and Disability Instrument; LUTS, lower
urinary tract symptoms; MANOVA, multivariate analysis of variance; MDS, Minimum Data Set; MFSC, Modified Fatigue Symptom Checklist; MI, myocardial infarction; MOS-SS,
Medical Outcomes Study Social Support Survey; MPQ, McGill Pain Questionnaire; MS, multiple sclerosis; MSAS, Memorial Symptom Assessment Scale; PFS, piper fatigue
scale; POMS, Profile of Mood States; PPF, postpartum fatigue; PPD, postpartum depression; PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Index; QOL, quality
of life; SF, short from; VAS, Visual Analogue Scale.
a α reported in the studies.

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 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
physical functioning,25-27 and quality of
life.28-31
Research has also shown that the TOUS
concept of symptoms is measurable using
valid and reliable instruments. Multiple instru-
ments have been developed to measure symp-
toms, in particular fatigue.3-5,32-39 In addition,
sleep disturbance was measured using the
Pittsburgh Sleep Quality Index5,40 and pain
was measured using the Brief Pain Inventory.7
Moreover, the Functional Assessment of Can-
cer Therapy for Breast Cancer was used to
measure functional well-being as a perfor-
mance outcome.7
As shown in Table 2, different types of data
analysis techniques were used to examine re-
lationships among theoretical concepts, iden-
tify symptoms that clustered together, and
examine effects of one symptom on other
symptoms. The chi-square test, correlation
analysis, analysis of variance, cluster analysis,
structural equation modeling, and factor anal-
ysis are examples of data analysis techniques
identified in the literature. In addition, con-
tent analysis was used in a qualitative study
to examine experience of fatigue in children
with leukemia.19 Furthermore, a “template an-
alytic approach” was used in another quali-
tative study to investigate the experience of
lower urinary tract symptoms in men with
Parkinson disease.41
Empirical adequacy
Examining a theory’s empirical adequacy
is the fifth step in theory evaluation.9 This
examination involves comparison of the the-
ory’s assertions with the findings of studies
guided by the theory. The empirical adequacy
criterion is met when the theoretical asser-
tions are supported by research findings. As
shown in Table 2, the findings of various re-
search studies support the TOUS’s assertions
regarding influencing factors, symptoms, and
performance and their relationships.
One assertion of the TOUS is that symp-
toms can be experienced simultaneously. Al-
though investigators did not report “simul-
taneously” occurring symptoms, they did re-
port occurrence of symptoms in clusters. For
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E35
example, fatigue, pain, and depression were
observed together as a symptom cluster in
patients with cachexia.42 In cancer studies,
researchers found correlations between fa-
tigue, pain, anxiety, weakness, weight loss,
nausea, vomiting, appetite loss, and depres-
sion and concluded that symptom clusters
existed.43,44
Another TOUS assertion is that symptoms
have 4 dimensions (timing, intensity, quality,
and distress); the dimensions can be sepa-
rate or related. This assertion is somewhat
supported by research findings. For instance,
researchers for patients on hemodialysis re-
ported that symptoms rated by patients as be-
ing the most intense were not necessarily the
most frequent, the longest-lasting, or the most
distressing.45 This example supports that in-
tensity was closely related to the other dimen-
sions. In addition, other investigators for pa-
tients with heart failure found that dyspnea
was a highly distressing symptom, and high
levels of dyspnea distress and intensity were
found regardless of the symptom’s duration.46
This example also supports that the 4 dimen-
sions are not always related to each other.
The TOUS also asserts that influencing fac-
tors (physiologic, psychologic, and situation)
are related to symptom experiences of in-
dividuals, which is consistent with research
findings. For instance, researchers have used
depression as a psychologic factor and found
a strong relationship between depression and
fatigue.4,47 In a case study in the management
of a bariatric surgery patient in the United
States, poor adjustment to dietary changes has
used as a psychologic factor and found an in-
teraction of the factor and the symptoms of
nausea, fatigue, and bloating.13
The empirical adequacy of the TOUS is
further evidenced by a study in which a re-
searcher examined the relationship between
symptoms and functional performance. For
example, in patients with COPD,48 re-
searchers found a negative association be-
tween fatigue and functional performance.
Although limited research was identified for
cognitive activity, researchers found posi-
tive relationships between symptoms of pain,
 E36 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2017
shortness of breath, and edema; and cogni-
tive activity (cognitive impairment) in nursing
home residents with cancer.23
Pragmatic adequacy
Examination of a theory’s utility for prac-
tice is the final step in theory evaluation. The
theory’s pragmatic adequacy is evaluated on
the basis of (a) the required education and
training before application in nursing prac-
tice, (b) the theory’s application in the real-
world nursing practice, (c) feasibility to im-
plement activities based on the theory, (d)
the practitioners’ legal ability to implement
the activities, (e) the theory’s compatibility
with public and health care system expecta-
tions for nursing practice, and (f) favorable
outcomes from the theory-based activities.9
To apply a theory in nursing practice,
nurses require suitable educational prepara-
tion and skill training.9 Lenz et al2 stated that
the TOUS was developed to guide activities
such as developing a symptom assessment
scale and a nursing intervention for symptom
management in different clinical settings. Ba-
sic nursing education provides nurses with di-
rection about how to use theory in practice.
Furthermore, the basic nursing education pro-
vides nurses with skills for symptom assess-
ment and management. However, nurses will
need education about concepts and relation-
ships of the TOUS for its application.
Real-world application of the theory in
nursing practice is essential for pragmatic
adequacy.9 The TOUS has been used in
many symptom-related nursing research stud-
ies, which were conducted in practice set-
tings for various populations such as patients
with COPD and heart failure, cancer sur-
vivors, and postpartum women in countries
such as the United States, Canada, and Tai-
wan for symptom assessment and manage-
ment. Moreover, researchers showed the ef-
fectiveness of use of the TOUS in intervention
on patient outcomes.17
Feasibility for implementation of the theory
in the real world of nursing practice needs to
be determined.9 Implementing TOUS-based
practical activities is feasible. However, this
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
process requires multiple resources such
as knowledgeable nurses who can apply
the TOUS in their practice. Therefore, the
process requires adequate funding to educate
and train nurses to better understand multiple
symptoms, their interrelationships, and the as-
sociations between the symptoms and their
influencing factors and performance.
It is necessary that practitioners have the
legal ability to control the application of
theory-based practical activities and to mea-
sure their effectiveness, and the sources of
resistance against implementation of the ac-
tivities should be examined.9 Assessing mul-
tiple symptoms is a part of nursing practice,
and nurses need to understand the symptoms
that occur together instead of focusing on
individual symptoms to apply theory-based
practical activities. Nurses have the legal abil-
ity to control the theory application and to
measure the efficiency of such application in
their practice and meeting this needs is one of
the TOUS’s purposes. Moreover, most nurses
and other health care professionals would not
be expected to resist implementation of the
theory in practice because the need to un-
derstand the multidimensionality of multiple
symptoms is widely understood. In addition,
public and health care system expectations
are compatible with nursing practice expec-
tations.
Compatibility of the theory-based practical
activities with nursing practice expectations
should be evaluated.9 The TOUS can be ap-
plied to different patient populations with var-
ious health conditions.2 Given this flexibility
of the TOUS, theory-based nursing activities
focused on assessment of influencing factors
on symptoms, interaction among symptoms,
and their effect are compatible with nursing
practice expectation.
Favorable outcomes of the theory-based
practical activities need to be examined.9
Nurses’ performance of TOUS-based practical
activities can produce positive outcomes.2 Be-
cause the TOUS is not a symptom-specific the-
ory, it allows both researchers and clinicians
to consider multiple symptoms and suitable
interventions.2 Moreover, the theorists assert
 An Analysis and Evaluation of the Theory of Unpleasant Symptoms
that symptom experiences can differ for indi-
viduals, and thus the theory can help nurses
to identify individualized interventions that in
turn should produce favorable outcomes such
as decreased symptom burdens and increased
physical functions of the individuals.
IMPLICATIONS FOR NURSING
The TOUS has been used to guide nurs-
ing research for various populations with di-
verse health conditions in different countries.
The theory was based on empirical evidence,2
and the concepts of the theory have been
supported in nursing research. Therefore, the
theory can be applied in nursing research and
practice to examine the complex interactions
of multiple symptoms, their influencing fac-
tors, and their outcomes.
In addition, the TOUS can be applied for
symptom assessment of individual patients in
clinical practice. Various influencing factors
can differently affect the symptom experi-
ences of patients depending on their circum-
stances, and thus nurses should assess for the
factors—physiologic, psychologic, and situa-
tional; these factors may include their disease,
severity of illness, comorbidity, age, gender,
social support, family support, and lifestyle.
The TOUS can advance clinical nurses’ under-
standing of complex symptom experiences
through assessment of various influencing fac-
tors, symptoms, and outcomes. Thus, nurses
can improve their symptom assessment and
management for patients on the basis of their
individual circumstances.
The TOUS emphasizes the understand-
ing of multiple symptoms that can be ex-
perienced together; the associations among
the symptoms; and the physiologic, psycho-
logic, and situational factors that influence
the symptoms. Therefore, use of the theory
can help practitioners to assess not only in-
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Collaborative development of middle-range nursing
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E37
dividual symptoms but also related factors to
manage the collective symptom experience
of patients.
Lenz et al2 maintained that the TOUS can
be used to develop preventive interventions.
However, in a recent article, Lenz and Pugh15
noted that only limited published evidence
is available regarding testing of clinical
interventions on the basis of the TOUS. The
intervention component is not further ex-
plained or described by Lenz et al and is not
included in the TOUS model (Figure). These
omissions may partially explain why few
TOUS-based intervention studies have been
conducted. In addition, the limited TOUS-
based intervention research may indicate
that the theory is more useful for observing
concepts, examining their relationships, and
developing instruments to measure the con-
cepts and relationships than for developing in-
terventions. However, because the TOUS pro-
motes integrated understanding of the com-
plexity of multiple symptoms and their expe-
rience in individuals, researchers and practi-
tioners could use the theory to design indi-
vidualized interventions for improving assess-
ment and management of patient symptoms.
CONCLUSION
The TOUS is a sound middle-range nursing
theory. Although the theory’s semantic clar-
ity, semantic consistency, structural consis-
tency, and parsimony could be improved, the
TOUS demonstrates good social and theoreti-
cal significance, testability, and empirical and
pragmatic adequacy, all of which support the
strength of the theory. Moreover, it is impor-
tant for practicing nurses to understand that
multiple symptoms can be experienced to-
gether and can interact with each other. The
TOUS demonstrates that nurses should focus
on multiple rather than individual symptoms.
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