SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 17 Southeastern European Medical Journal, 2018; 2(2) Review Theory of Unpleasant Symptoms and Concept of Nursing Support 1 Štefica Mikšić 1, Marina Bošnjaković 2, Ivana Simić 3, Barica Stanić 3, Marina Stanković 3, Željka Stojkov3 1 Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia 2 Secondary Medical School Slavonski Brod, Slavonski Brod, Croatia 3 “Dr Josip Benčević” General Hospital, Slavonski Brod, Croatia Corresponding author: Štefica Mikšić, steficamiksic@gmail.com Received: Aug 16, 2017; accepted: Mar 10, 2019; published: Mar 31, 2019 KEYWORDS: theory, unpleasant symptoms, pain, dyspnea, healthcare Abstract Theory of unpleasant symptoms – TOUS – has been developing since the 1990s. TOUS is a theory in healthcare developed by healthcare workers and intended to be applied by them. According to this theory, multiple symptoms may occur simultaneously, interact with each other and be multiplicative. Several symptoms have been presented, including also psychological, physiological and cognitive aspects of a patient’s personality. Symptom models described in the TOUS are the nociceptive model of dyspnea, symptom interpretation model, model of chronic dyspnea and symptom management model. TOUS is the first model to describe multiple, mutually related symptoms. By studying this theory, it can be concluded that controlling a single symptom is beneficial for controlling other symptoms. TOUS views a set of occurring symptoms without isolating any of the symptoms, but allowing for each symptom to be monitored separately. The theory helps in planning nursing interventions and facilitates healthcare delivery in general. The purpose of this theory is to help healthcare workers understand the symptoms and the methods used for their management. TOUS has been developed through clinical research; it establishes a logical connection between the symptoms and extends theoretical knowledge by taking into account previous factors, experiences of single or multiple symptoms and their impact on performance. (Mikšić Š, Bošnjaković M, Simić I, Stanić B, Stanković M, Stojkov Ž. Theory of Unpleasant Symptoms and Concept of Nursing Support. SEEMEDJ 2018; 2(2); 17-22) SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 18 Southeastern European Medical Journal, 2018; 2(2) Introduction Nursing is a profession and an established scientific discipline that helps people achieve a healthy and productive life, or, rather, enables them to cope with particular deficiencies, poor health, illnesses and injuries the best way possible by using skill- based knowledge (1). The goal of nursing is not only to treat ill people, but to maintain good health, aid relaxation and provide relief and comfort. Every healthcare theory provides nurses with guidelines for providing healthcare and helping the patients. Theory of unpleasant symptoms (TOUS) was first mentioned in 1995 and revised in 1997. It advocates that particular symptoms frequently occur simultaneously and proposes monitoring of multiple symptoms. Application of the theory, combined with clinical observations and relevant literature, results in better understanding the patients experiencing those symptoms during their illness. To make the application of this theory as simple as possible in day-to-day work, it is necessary to study its core from the very beginnings, through its development, and up to contemporary experiences. This paper presents models of appearance of primary symptoms, such as pain and dyspnea, in chronically ill and oncological patients. Mental, physical and situational factors, as well as the sense of empathy, affect the development of such symptoms (2). The theory itself is aimed at investigating how to reduce the above-mentioned symptoms in order to achieve improvements in patients’ quality of life (3). Development and description of the theory Theory of unpleasant symptoms (TOUS) started developing in the 1990s, when Audrey Gift and Linda Pugh, its authors, wrote a book on clinical healthcare titled “Dyspnea and Fatigue”. Their work was first published in 1995, and revised in 1997 (3). TOUS is a theory in healthcare developed by healthcare workers and intended to be applied by them. According to this theory, multiple symptoms may occur simultaneously, interact with each other and be multiplicative. Group of symptoms affecting one another is called a symptom cluster (4). By controlling one symptom, we can control all the other symptoms. Appearance of symptoms is conditioned by physiological, psychological and environmental factors. The work of a nurse is based on monitoring symptoms for the purpose of diagnosing a disease as early as possible, but also to help patients reduce their health issues. To corroborate their theory, the authors used various scales while conducting their research and studying patients. Some of those were Visual Analogue Scale – VAS (5), Visual Analogue Scale Dyspnea – VASD (6), Numeric Rating Scale – NRS (7), McGill Pain Questionnaire (8), Brief Fatigue Inventory – BFI (9), Memorial Symptom Assessment Scale – MSAS (10) and Symptom Distress Scale – SDS (11). Symptom models Most symptom theories in medical literature mainly focus on the experience of symptoms, but not on their control. TOUS describes four symptom models. Nociceptive model of dyspnea is determined by environmental factors corresponding individually to the severity of illness. It provides answers to healthcare delivery from a psychological perspective. Symptom interpretation model requires knowledge, understanding and identification of symptoms. There are three main criteria in this model – input, interpretation and outcome. Input needs to have a strong influence in order to encourage thinking about something different. Interpretation relates to making a differentiation on the basis of experiential reasoning. Comparison between interpretations of symptoms is made by contrasting the most severe symptoms to typical symptom patterns, which is, at the same time, the only way they can be interpreted correctly. Outcome is the third and the most important aspect of this model, as it reveals how patients actually feel and what they are willing to accept to be able to receive help. Through interpretation, patients decide how they will control the symptoms they experience. SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 19 Southeastern European Medical Journal, 2018; 2(2) Model of chronic dyspnea is the first model for monitoring changes in behaviour. Its course is easier to follow using a longitudinal curve. Initially, it suddenly increases, then it returns to its initial state, and with time it rises again and reaches its peak. The model consists of physiological factors, dyspnea and, finally, its consequences. Chronic dyspnea is increased when influenced by episodes of acute dyspnea. Fatigue, depression, irritability, fear, reduced physical activity and social isolation appear as consequences. Symptom management model is the most effective model for symptom control. Patients’ experience of symptoms, symptom control and outcome of symptoms are interconnected. Symptoms are not controlled only by patients, but also by their families and healthcare workers. Quality of life, emotional and functional status and morbidity in use of healthcare services depend on the outcomes of symptom control. This model is important because it can assist doctors and nurses in helping patients control the symptoms they experience. Theory analysis Comprehensibility of the theory of unpleasant symptoms is observed through description of definitions and technical terms. Theorists have described techniques for overcoming unpleasant symptoms through clinical practice. All constituents of the theory, as well as key concepts, are described in a clear and understandable manner. Symptom models have been described starting from simple to complex ones. The relationship between clinical practice, research and theory is understandable. It is clear that all models argue for existence of multiple symptoms and suggest that controlling one symptom helps control the other ones. Use of key concepts both in explaining the theory and presenting the details of symptom models is also consistent. High level of consistency can be seen in the relationship between all the constituents, as all of them mutually support each other. The theory is applicable to all the patients experiencing the appearance of unpleasant symptoms. It was developed based on clinical practice and revised with the help of relevant literature. Interpretation of symptoms is monitored and symptoms can be observed separately or collectively. Numerous instruments are used for assessment of symptoms, such as the Numeric Rating Scale (NRS), McGill Pain Questionnaire (MPQ), and Brief Fatigue Inventory (BFI). There are also various scales for assessment of multiple symptoms, for instance the Memorial Symptom Assessment Scale and Symptom Distress Scale. TOUS was developed with help from healthcare workers and their observations. According to its criteria, it is consistent with the middle-range theory. It is used to examine the relations between patients’ symptoms and their everyday cognitive functions. The theory can be used as an educational and a research tool in all areas and fields of healthcare. Concept of nursing support The term support has multiple meanings and may signify some kind of help, support and relief. It is commonly used in the healthcare system without a clear description of what is meant by it. Research of the term “support” in the context of nursing has resulted in a wide range of its definitions. Authors Ellis, Jackson and Stevenson state that dictionaries and related literature offer a wide range of meanings of the word, from “preventing a person to give up” to “encouraging statements” (12). By analysing those different meanings, we come to other related concepts such as help, safety, and empathy, which can be independently subjected to analysis of the concept, but in practice they are identical to the concept of support. Support/care that nurses provide to a patient is undoubtedly an important factor of healthcare, but providing support is in fact very complex, because patients and nurses may, considering different predisposing factors, perceive support differently. Some of those factors can be patients’ age and/or education or particular organisational factors, such as the ratio between nurses and hospitalised patients (13). Providing support carries a different meaning for different people in different environments, but does not diminish its value. A SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 20 Southeastern European Medical Journal, 2018; 2(2) nurse may think she is providing support, while the patient may at the same time, due to his/her upbringing, assume that it is the nurse’s duty to act in such manner only because she is required to do so. Both male and female nurses should not have a fixed attitude in their relationship with patients and assume that what they provide is support. They should rather adopt a flexible approach and try to clarify, define and eventually provide a particular kind of support. Built on an open and collaborative relationship, this kind of approach would ensure there are no ambiguities in its perception. Measuring support is extremely complex because it is limited to a feeling expressed by a patient. Any stay in hospital, regardless of the severity of symptoms, causes emotional difficulties, as well as anxiety and depression. Moreover, each patient must go through all the stages of adaptation to a disease (shock, denial, bargaining, depression, adaptation) (14). In their day-to-day work, nurses notice the aforementioned difficulties – phenomena and, aside from physical help, they often provide patients with psychological, spiritual and social support. Physical help can pertain to assistance with walking, while emotional support can refer to support provided when somebody is grieving. As already stated, the phenomena can be different, ranging from worry, fear and helplessness to physical limitations and cognitive impairments. When these phenomena are present, the patient also needs individual help from a nurse. Nurses meet patients’ needs when they provide care using a holistic approach. In order for a nurse to cater to those needs in a satisfactory manner, it is necessary that both the nurse and the patient cooperate and negotiate on the type of help required by the patient. As a result, an important factor emerges in the process of providing healthcare, namely the need for specificity in determining a proper healthcare plan. As the actual purpose of nursing in this context is to create a common meaning for the term support, this is an extremely important factor for ensuring that healthcare is provided in a proper and satisfactory manner. Connection between the theory of unpleasant symptoms and concepts of nursing support in practice Male and female nurses are faced with increasingly complex requests to recognise and solve the patients’ issues. That requires solid theoretical knowledge applicable in practice, a holistic approach, experience, skills, competence, and motivation. Application of practical clinical skills based on theory and relevant concepts is precisely what is unfailing in effectiveness. Understanding their relations based on scientific facts and research conducted by nurses will create the preconditions for emergence of theories and concepts in nursing practice applicable to day- to-day nursing tasks. The opinion held by the author of the book Nursing theories, J. B. George, is that concepts such as support produce nursing theories and that therefore, for some theories, a detailed description of a concept serves as the basis for its development (15). Theory of unpleasant symptoms and concept of nursing support have a very high level of applicability. Besides helping male and female nurses to use a comprehensive approach to symptom appearance and to plan nursing interventions, they also facilitate healthcare delivery in general. Authors tested their theory on patients suffering from a malignant disease, patients with chronic pulmonary disease and patients in the terminal phase of lung cancer. In accordance with our previous work, we saw that the theory and the concept can also be applied to cardiac patients. In this case, it was applied to a patient suffering from an acute myocardial infarction. Case report: Patient N.N., aged 43, was admitted to the Coronary Unit of “Dr. Josip Benčević” General Hospital Slavonski Brod, diagnosed with an acute myocardial infarction. Upon admission he was pale, his skin was cold, he was sweating, he was scared and expressed concern for his condition. He was complaining about the pain in his chest that was spreading to his shoulders and back and was suffering from shortness of breath. Based on the above-mentioned, the following issues can be identified: SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 21 Southeastern European Medical Journal, 2018; 2(2) ● Pain – reaction to one’s physiological state. Presence of other unpleasant symptoms also depends on the intensity of pain. ● Shortness of breath (dyspnea) – increases as the pain increases. ● Fear/concern - affective reaction to current condition, “I am afraid I am going to die” Nursing interventions were aimed at assessing the intensity and character of pain. On a scale from 0 to 10, the patient rated pain as 8 (VAS pain scale). Monitoring of vital functions, nasal catheter oxygenation and application of prescribed therapy were performed. During the nursing interventions, all the procedures were explained to the patient and nurses attempted to comfort him, i.e. to provide support. Through the application of the prescribed therapy and through decreasing the intensity of the pain, dyspnea also decreased and the patient was less scared. From all of the above, it can be concluded that the theory of unpleasant symptoms and the concept of nursing support were both applied in this case. By affecting a physical symptom (pain decrease) and providing psychological support, other unpleasant symptoms that were present also decreased. Discussion Nursing theories represent a tool for development of knowledge and are not designed as a recipe applicable in practice. They should be developed in accordance with nurses’ creative thinking and their interaction with a patient (16). TOUS was created by taking the results obtained from practice and linking them to scientific literature. Many authors in the nursing science have developed models of patient care based on the existing nursing theories. By analysing the theory according to the criteria established by McKenna, it was noted that this theory is applicable both in practice and in further research. The advantage of the TOUS is that it helps nurses identify the objectives of nursing practice, which are, in this case, to decrease unpleasant symptoms and monitor the effect of one symptom on the other, and thus improve the quality of healthcare. Regarding the provision of nursing support of any kind, it is equally ambiguous as the term “providing care for” or “taking care of” a patient. Support measurement and assessment in a healthcare plan is a very complex issue. In healthcare, the term “support” is often used without a clear description of what is actually meant by it. What we conceptualise as nursing support is the product of a relationship between a nurse and an individual within a particular context. Different meanings arising from interpersonal communication exist simultaneously at different contextual levels. When it comes to providing support, the goal of nursing is to create a common meaning for the term “support”, which requires mutual cooperation and a flexible approach. By accepting the ambiguity in the perception of the term “support” or “assistance”, a nurse is able to cooperate with individuals and patients to create a common meaning for the word “support” in practice. In other words, together they can reach an understanding regarding what “support” actually means to that person. The concept of support as a method demonstrates the complexity of communication and different meanings that people may assign to it depending on the context and previous experiences. Conclusion The theory of unpleasant symptoms (TOUS) is a middle-range theory, i.e. a healthcare theory intended to be applied by healthcare workers. It includes specific concepts and connects them. Based on its interpretation, it can be concluded that unpleasant symptoms are interconnected and affected by various psychological, physical and situational factors. The work of a nurse is based on monitoring symptoms for the purpose of diagnosing a disease as early as possible, but also on helping patients reduce their health issues. This theory is acceptable because it helps in planning of nursing interventions and facilitates healthcare delivery in general. Knowledge and skills gained through education and research are important to successfully perform nursing practice, achieve compliance with nursing principles and fulfil any SEEMEDJ 2018, VOL 2, NO. 2 Theory of Unpleasant Symptoms 22 Southeastern European Medical Journal, 2018; 2(2) expectations the community may have of male and female nurses, as well as the expectations they have of themselves based on their own professional ethics (17). An important aspect of the work of each nurse, as well as of healthcare in general, should be to provide patients with support, regardless of how complex that may be. TOUS and the concept of nursing support have a very high level of applicability. Based on personal experience at our workplace, we have come to know that this theory and concept are also applicable to patients suffering from diseases other than those investigated in this paper. Therefore, there is potential for their further development and research in nursing. Acknowledgement. None. Disclosure Funding. No specific funding was received for this study. Competing interests. None to declare References 1. 1. Gavranić D., Iveta V., Sindi J. Konceptualni modeli sestrinstva i načela sestrinske prakse. Pregledni članak. 2016; 21: 148-52. 2. Peterson S.J., Bredow S.T. Middle Range Theories. Application to Nursing Research. 2nd ed. Wolters Kluwer/Lippincott Williams and Wilkins. Philadelphia; 2009. 3. Resnick B. Self-efficacy. 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