Development of Middle Range Theory to Guide Practice in a Nurse-led Symptom Evaluation and Management Clinic

Purpose: To develop a middle range theory (MRT) of symptom management to guide the assessment and management of patients in a nurse-led symptom management clinic in the NIH (National Institutes of Health) campus. Specific aims Phase I are: 1) to identify and retrieve the studies that relate to the 5 cardinal symptoms of chronic conditions; 2) to analyze and critique the studies to create a MRT;  and 3) to select major concepts to create a schema of the MRT.  

Methods: The literature review was carried out to identify publications for the years 2001-2014 using the search words “symptom management” and “symptom assessment.” Data bases searched included: CINAHL, MEDLINE, PubMed, International Nursing Library (STT), ProQuest, Web of Science, Social Services Abstracts, Sociological Abstracts, Psych INFO and Google Scholar. The initial sample included 350 publications in English that are primary research reports, a research review article, a theoretical synthesis, thesis, or dissertation. The publications were examined by the criteria for usefulness for the purpose of the study. The initial sample was reduced to 214 research articles relating specifically to the 5 cardinal symptoms: pain, fatigue, sleep disturbance, psychological distress, and difficulty concentrating. Critique of both the qualitative and quantitative research included commonly accepted issues of method and design, including threats to internal and external validity, subjects, and validity and reliability of measurement.

Results and Conclusions:  The authors developed a framework that included ten categories of major concepts. The 10 categories are: physiologic factors, environmental factors, person factors, systemic stress, symptom experience, behavioral response of coping, assessment of symptom clusters, management of symptom clusters, outcomes, adapting to chronic condition. The framework guided the development of propositions connecting the concepts.  Finally, the authors created a pictorial schema of the MRT for symptom assessment and management for persons and families as adaptive systems.

Implications: The MRT will be used to guide and inform practice in a nurse-led symptom assessment and management clinic on the NIH campus.