1. Theory of Unpleasant Symptoms
Mary Hefferan
Ferris State University
Hello, my name is Mary Hefferan and in this presentation I will be discussing the Theory of Unpleasant Symptoms created by Elizabeth Lenz and Linda Pugh.

2. Objectives Overview of the theory Metaparadigm concepts Brief analysis
Person, environment, health, and nursing as defined by theory
Brief analysis
Basic concepts and description of components
The objectives for this presentation are: to discuss an overview of the theory of unpleasant symptoms, to explore the metaparadigm concepts person, environment, health, and nursing as they are defined and described by the theory. A brief analysis of the theory will be included that outlines the basic concepts and description of the main components of the theory of unpleasant symptoms.

3. Objectives Exploration of theory through research
Description of research article
How the theory is reflected in research
What the theory adds to the study
Application to nursing practice
Importance of theory to nursing practice
Also outlined in this presentation is an exploration of the theory through a current research study. A description of the research study will be included as well as how the theory is reflected in the research. I will also discuss how the study would have been different if the theory was not included and how it adds to the research. Application to nursing practice will be outlined by describing how it could relate to my current practice. And finally I will discuss the importance of theory to nursing practice and how it is important to differentiate this knowledge from other professions.

4. Overview Theory of Unpleasant Symptoms
Created by Elizabeth Lenz and Linda Pugh in 1995
Objective is to “integrate existing knowledge about a variety of symptoms” (Lenz, Pugh, Milligan, Gift, & Suppe, 1997, p. 14)
Improve understanding of the experience of symptoms in various contexts
Three major concepts:
The actual symptoms
Influencing factors
Performance outcomes
The theory of unpleasant symptoms was created by Elizabeth Lenz and Linda Pugh in They, along with two other researchers, were interested in the experience of symptoms in different contexts and the multidimensional factors that contribute to each symptom. The theory’s main objective is to “integrate existing knowledge about a variety of symptoms” and find commonalities among symptoms and guide research through these commonalities (Lenz, Pugh, Milligan, Gift, & Suppe, 1997, p. 14). This will in turn, potentially improve understanding of the experience of symptoms in various contexts of clinical practice. The theory contains three major overarching concepts: the actual symptoms experienced as perceived by the patient, the influencing factors that affect the experience of the symptoms, and the performance outcomes or the degree the symptoms affect a patient’s activities of daily living.

5. Metaparadigm Concepts: Defined by the Theory
Person: the patient who is exhibiting the symptoms and to whom the nurse is giving care
May also include family and/or friends
Environment: where the care is taking place and situational factors that contribute to the symptom experience
Employment status, marital status, social support, access to health care
When discussing a nursing theory, it is important to relate it to the four metaparadigms of nursing, person, environment, health and nursing. Since this theory focuses on the symptom experience, these concepts will be defined as they relate to and affect the symptom experience. The first metaparadigm of nursing, person, in Lenz and Pugh’s theory of unpleasant symptoms, would be the person who is exhibiting the symptoms that are being evaluated and to whom the nurse is giving care. It may also include those who are contributing to the symptoms and symptom experience like the family and friends of the patient.
The metaparadigm of environment is defined as where the care is taking place and in the theory of unpleasant symptoms, the situational factors that contribute to the symptom experience. These include the patients employment status, marital status, if they have any social support, and their level of access to health care. This theory broadens the concept of environment to included these factors, because the theory states they have a dramatic effect on the symptom and health outcomes of a patient.

6. Metaparadigm Concepts: Defined by the Theory
Health: absence of unpleasant symptoms
Symptoms are: “perceived indicators of change in normal functioning as experienced by patients” (Lenz, Pugh, Milligan, Gift, & Suppe, 1997, p. 14)
Nursing: care taker and evaluator of symptoms and contributing factors
Establishes a relationship with the patient to better evaluate symptoms
The metaparadigm, health, as defined by the theory of unpleasant symptoms would be the absence of any unpleasant symptoms. Since symptoms are the perceived indicators of change in normal functioning as experienced by patients, the absence of these, would be a healthy individual, functioning at the optimal level that is possible.
Nursing, as a metaparadigm, would be defined by the theory as the care taker and evaluator of symptoms and the contributing factors to the symptom experience. The nurse must establish a relationship with the patient in order to better evaluate symptoms. With a better relationship, the nurse can better assess a patients description of a symptom and ask the appropriate questions to elicit a better description of a symptom experience.

7. Analysis of the Theory of Unpleasant Symptoms
Three Major Concepts: Symptoms, influencing factors, and performance outcomes
1. The symptoms:
Change in normal functioning
More often occur simultaneously
Multiple symptoms occurring together results in a multiplying effect
Measured by their intensity, timing, and level of distress perceived
The theory of unpleasant symptoms, as mentioned previously, has three major concepts: the symptoms, influencing factors, and performance outcomes. The symptoms, the starting point of the theory, represent a change in normal, healthy functioning for an individual. For the purpose of this theory, Lenz and Pugh focused on the perceived, subjective symptoms as described by the patient. The theory proposes that rather than occurring in isolation, most often, symptoms occur simultaneously, in clusters. This results in a multiplying, catalyzing effect, rather than simply two symptoms occurring separately but at the same time. The symptoms are measured by their intensity, timing (the duration of the experience), and the level of distress as perceived by the patient.

8. Analysis of the Theory of Unpleasant Symptoms
Influencing factors:
Physiological, psychological, and situational
Influence the symptoms alone or in concurrence
Performance outcomes:
Results of the symptom experience
Impact on ability to perform activities of daily living
The second major concept of the theory of unpleasant symptoms is the influencing factors on the symptom experience. These factors include: physiologic (any variables relating to anatomical anomalies, physical or genetic impairments, or illness related factors), psychologic (an individual’s mood or mental state relating to the illness) and situational (the environment surrounding the patient that may affect the symptom experience, such as their home life, if they are the sole provider for their household, and if they have any emotional or social support)
The final concept for this theory is the performance outcomes as a result of the symptom experience. These outcomes are the level of which the symptom experience has affected the patients activities of daily living and their ability to function physically, cognitively, and socially.

9. Theory in Research
Application of the Theory of Unpleasant Symptoms (TOUS) in Bariatric Surgery
Uses the TOUS during the management of patient post bariatric surgery
Case study of a 29 year old woman post bariatric surgery
Explored how the influencing factors affected her post-op outcomes
Showed that her situational factors contributed greatly to her overall health
The theory of unpleasant symptoms was explored in a research article by Renay Tyler and the co-creator of the theory itself, Linda Pugh. They used the theory and applied its concepts during the management of a patient post bariatric surgery. This was a case study of a 29 year old woman who underwent bariatric surgery and they followed her through her recovery experience. They describe her as being well prepared for the surgery and had no behavioral contra-indications prior to the procedure. Tyler and Pugh (2009) explored how the various influencing factors affected her post-op outcome. Her situational factors like being a single mother of 5, having the father of her children recently incarcerated, and worries over her employment, were found to have greatly affected her overall health post surgery. She was hospitalized several times for dehydration and nausea which prolonged her recovery period.

10. Theory in Research TOUS in Application Evaluated the factors
Physiological
Dehydration, malnutrition
Gastrointestinal dysmotility
Psychological
Adjustment to dietary changes
Situational
Lack of social support, work stressors, finances
In concurrence prolonged her recovery period
The researchers used the theory of unpleasant symptoms by applying its principles in evaluation of the physiological, psychological, and situational factors to evaluate how they impacted her performance outcomes. They wanted to create a better representation and understanding of symptoms using these principles. Her physiological factors were identified as dehydration, malnutrition, and gastrointestinal dysmotolity. The symptoms of these factors were constipation, nausea, emesis, and abdominal pain causing her to have delayed recovery and healing. Her psychological factors, her difficulty adjusting to the new dietary changes, resulted in her becoming depressed, irritable, and fatigued. This caused her to be unable to care for her family. The situational factors, her lack of family and social support, work stressors, and financial responsibilities were found to contribute to her non adherence to her regimens and appointments causing her to delay returning to work. All of these factors created or worsened her unpleasant symptoms and in concurrence, they prolonged her recovery period.

11. This figure is a visual representation of the three factors and how they interact and affected the patient in this case study. The interactions between the various symptoms and factors are represented by the connecting arrows.
Source:

12. Differences the TOUS Made
Theory in Research
Differences the TOUS Made
Created a framework for the evaluation of symptoms and their contributing factors
Helped in the approach to alleviating her unpleasant symptoms
Created a new method for treating symptoms rather than medication or hospitalization
The theory of unpleasant symptoms aided this research study because it created a framework for the evaluation of symptoms and their contributing factors. Tyler and Pugh (2009), used the concepts of the three factors to better evaluate how severe her symptoms were and how they interacted with each other. The theory of unpleasant symptoms also helped in the approach to alleviating her unpleasant symptoms. By considering all the potential factors and overlapping issues, they were able to identify factors outside of potential complications of her surgery and look at social support and how this could be influencing her recovery. By doing this, it created a new method for treating symptoms rather than simply prescribing medication of further hospitalization for management of symptoms. For example, the patient’s mother had resisted supporting her emotionally due to previous bias she had toward bariatric surgeries. Through counseling and social work support, she was able to provide support and assist her daughter in taking care of her family. This in turn, helped the patient alleviate some of the stresses and fatigue of taking care of her family while recovering and the negative effects it was having on her recovery.

13. Differences the TOUS Made
Theory in Research
Differences the TOUS Made
Once the factors were addressed
Symptoms improved
Assessment of entire picture
Created awareness to approach willingness to change
“Understanding where patients are in their willingness to change those factors…will assist clinician in understanding expectations and moving patients to healthier levels of recovery” (Tyler, R., & Pugh, C. L., 2009, p. 276)
Manages expectations of health outcomes
Once the three factors were assessed in this case study and interventions were made to improve her situational factors, Tyler and Pugh (2009) found that the patient’s symptoms began to improve and she was adhering to the care plan with awareness. By assessing the entire picture of the patient’s life, and using the theory’s guidance, they were able to council the patient and create appropriate goals specific to the patient’s needs. Such as creating a return to work date, and counseling her on appropriate food choices and when she can start to incorporate a normal diet. The theory also aids the patient in creating awareness of how their situational and psychological factors are affecting their recovery. It helps the clinician in guiding care by evaluating the patient’s willingness to change the factors that are contributing to their symptoms and better manages the expectations of health outcomes and expected level of recovery.

14. Neonatal Nursing Environment
Use in Practice
Neonatal Nursing Environment
Evaluation of family impact on health outcomes
Nervousness, uncomfortable with their baby
Could have a negative physiological impact
Aids nurse with appropriate interventions
The use of theory of unpleasant symptoms in my current practice in neonatal nursing, could be beneficial as it was in the case study. With a broader view of the factors that influence symptoms, as a registered nurse, I could evaluate the impact the family has on the health outcomes of their baby. For example, if a parent was absent during most of the time their baby was in intensive care, they may be nervous holding or changing their infant. This in turn may cause stress to the baby and possibly delay post surgical healing, exacerbate withdrawal symptoms, or elicit other physiological symptoms of stress. This would then lead me to create appropriate interventions and assist the family and encourage them to be more present so they can become more comfortable with their baby.

15. Neonatal Nursing Environment
Use in Practice
Neonatal Nursing Environment
Manages expectations of outcomes
Less social support may change health outcomes
Guides appropriate creation of goals
Allows for a different perspective on assessing symptoms
“Symptom clusters”
Catalyzing effect of symptoms
The theory would also be helpful in managing expectations of the health outcomes for a patient in the neonatal environment. Based on the situational and psychological factors of the family of the infant, the nurse can create achievable goals for the patient and the family. An example would be if a parent has limited social support and a patient in the neonatal intensive care unit (NICU) requires extensive at home care; the expectations for this patient would be different from that of a patient who had extensive support at home; the single parent would require more support from the nurse and more resources from the social worker. The patient may require a longer hospital stay in order to achieve proper parent education to make the transition home.
The theory of unpleasant symptoms also allows for a different perspective on assessing symptoms, especially when related to a NICU environment. It proposes the idea of “symptom clusters” and how symptoms and influencing factors may intensify when occurring in concurrence. If a patient in the NICU was experiencing post operative incision pain that caused irritability and poor feeding, this patient would have very different outcome expectations due to their catalyzing effect. The poor nutrition as a result of the poor feeding would in turn delay incisional healing and prolong recovery; showing that these two symptoms are not occurring simply in isolation, but affect and interact with each other.

16. It is important to understand theories like the theory of unpleasant symptoms because they explain, describe, predict, and prescribe nursing care.
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17. Importance to Nursing
Nurses assess and approach symptoms differently than other members of the healthcare field
Holistic approach
Guides nurse-patient interactions
View patients in an interactive-integrative view versus isolated cause effect health interactions
This theory is important to the nursing profession because it addresses the unique way nurses approach assessing symptoms that is different from other members of the health care field. Nurses use a holistic approach to assessing symptoms, requiring an “understanding of the person’s experience and the meaning associated with each symptom” (Haworth & Dluhy, 2001, p. 302). Theories like this also guide nurse-patient interactions and create a framework for integrating values within health care (Liehr, 2005). It directs nurses to view patients in an interactive-integrative view (viewing patients as interacting with their environment and each other) rather than a simple cause and effect interaction (Liehr, 2005).

18. Importance to Nursing Broad but focused theory
Can be used as a base for designing interventions
Uses subjective symptom experience data
Creates connections between social environments and symptom experience
This theory adds to nursing and guides practice because it is broad and applies to many aspects of nursing. From the bariatric patient in the previous article to new mothers attempting to breastfeed. It is broad but focused on a specific aspect of nursing care; symptom management. It can be used as a base for designing interventions and care plans. During the theory’s development, it was used to design “an intervention to address the influential factors and symptoms that had been identified as decreasing the likelihood that mothers would initiate and succeed at breastfeeding” (Lenz, Pugh, Milligan, Gift, & Suppe, 1997, p. 19). The theory also uses the subjective symptom data, usually observed and elicited by the nurse, and creates connections between social environments and the symptom experience.

19. References
1, Haworth, K. S., & Dluhy, M. N. (2001). Holistic symptom management: Modeling the interaction phase. Journal of Advanced Nursing 36(2), Retrieved from: 2. Lenz, R. E., Pugh, L., Milligan, A. R., Gift, A., Suppe, F. (1997). The middle range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), Retrieved from: 3. Liehr, P. (2005). Looking at symptoms with a middle-range theory lens. Advance Studies in Nursing, 3(5), Retrieved from: 4. Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3), Retrieved from: 5. Tyler, R., & Pugh, C. L. (2009). Application of the theory of unpleasant symptoms in bariatric surgery. Bariatric Nursing and Surgical Patient Care. 4(4), doi: /bar
Thank you for listening to this presentation about the Theory of Unpleasant symptoms and its usefulness to nursing practice.