The notion of time in symptom experiences

Symptom experience and self-management strategies of adults undergoing hematopoietic stem cell transplantation after hospital discharge: A longitudinal qualitative study

PURPOSE

To explore the symptom experience and self-management strategies of adults undergoing hematopoietic stem cell transplantation after hospital discharge.

METHODS

A longitudinal qualitative study was employed. A heterogeneous sample of 22 patients who underwent hematopoietic stem cell transplantation from August 2022 to April 2023 were included. Semi-structured interviews were conducted at three time points post-discharge and provided a dataset of 56 interviews. The content analysis method was used for manual analysis. This study followed the COREQ checklist.

RESULTS

The data from this study were categorized into four themes and 14 subthemes: (1) complexity and multidimensionality of symptom experience: diversity, dynamism, continuity, relatedness, and functional loading; (2) multiple variations in symptom self-management; (3) barriers to symptom self-management: limited access to information resources, insufficient awareness and skills in symptom self-management, lack of economic and social support, and difficulties in medical visits and reviews; and (4) facilitators of symptom self-management: perceived benefits, experience-driven, and peer experiences.

CONCLUSION

Patients undergoing hematopoietic stem cell transplantation experience multiple and complex symptom experiences after hospital discharge, and their symptom self-management remains challenging. The findings underscore the necessity for healthcare professionals to regularly and consistently evaluate the symptoms and self-management practices of patients undergoing hematopoietic stem cell transplantation and execute focused interventions to alleviate their symptom load and enhance their long-term well-being.

Subjective Cognitive Dysfunction in Chronic Illness: A Systematic Review and Meta-Synthesis

BACKGROUND

Qualitative studies have examined the experiences of subjective cognitive dysfunction in specific populations or specific disease stages, but there has not yet been a systematic synthesis and evaluation of findings related to perceptions of subjective cognitive dysfunction in nondementia-related chronic illnesses.

OBJECTIVE

The aim of this study was 2-fold: (1) to undertake a systematic review of experiences of subjective cognitive dysfunction in people with nondementia-related chronic disease and (2) to develop an explanatory framework to describe the experiences of living with subjective cognitive dysfunction.

METHODS

Four databases were systematically searched for studies on subjective cognitive dysfunction up to June 2023. Qualitative synthesis was conducted on the final sample (N = 25) using Sandelowski's adaptation of Nobilt and Hare's reciprocal transactional analysis method. Critical appraisal was completed using the Critical Appraisal Skills Programme checklist.

RESULTS

Through constant comparison of key concepts, findings were organized within 4 interrelated themes that informed a conceptual explanatory model of adapting to living with subjective cognitive dysfunction: (1) symptoms, (2) health care, (3) perceptions of self, and (4) relationships. Participants highlighted how subjective cognitive dysfunction affected interactions in health care settings and involved other symptoms that in turn complicated meaning, self-enhancement, and mastery.

CONCLUSIONS

Our model of the process of adapting provides a new way to conceptualize cognitive dysfunction in chronic illness and suggests opportunities for health care professionals to support patients and their families. The results highlight the need for more research to better understand the role of subjective cognitive dysfunction in nondementia-related chronic illnesses.The review protocol was registered in PROSPERO (CRD42021231410).

Cancer-Related Symptom Frameworks Using a Biopsychosocial-Spiritual Perspective: A Scoping Review

BACKGROUND

Research to understand and manage cancer-related symptoms continues to advance, yet work that more fully adopts a biopsychosocial-spiritual view of symptoms is needed.

OBJECTIVE

The purpose of this article is to review existing frameworks that have the potential to guide research on cancer-related symptoms, to explore the characteristics of each framework, and to appraise each using a biopsychosocial-spiritual lens.

METHODS

A scoping review was conducted to identify available frameworks that could be applied to guide cancer-related symptom research and to assess their characteristics. Research questions and criteria were formulated at the outset, followed by identifying relevant publications detailing novel frameworks, charting data, and collating results. Upon identification of available frameworks, each was appraised for alignment with a standard definition of "biopsychosocial-spiritual."

RESULTS

Eleven frameworks were identified to guide cancer-related symptom research. All were developed in the United States, led by nurse scientists, including symptom experiences as well as their antecedents and outcomes, and could be applied to one or more concurrent cancer-related symptoms. While all 11 frameworks included biopsychosocial dimensions, only 4 included spirituality.

CONCLUSIONS

Four biopsychosocial-spiritual frameworks offer unique insight to support advancement of cancer-related symptom research and practice from a holistic perspective. This foundational work could lead to development and validation of new frameworks and modification of existing frameworks to more closely align with a biopsychosocial-spiritual view of cancer-related symptoms. This review offers a starting point to carefully and explicitly adopt frameworks in research and practice with increased emphasis on considering spiritual dimensions of symptoms.

Exploring core symptoms and interrelationships among symptoms in children with acute leukemia during chemotherapy: A network analysis

PURPOSE

Children with acute leukemia have suffered from a considerable symptom burden during chemotherapy. However, few studies have focused on exploring the mechanisms among symptoms in children with acute leukemia. Our study aims to explore core symptoms and describe the interrelationships among symptoms in children with acute leukemia during chemotherapy.

METHODS

From January 2021 to March 2023, 469 children with acute leukemia were recruited from 20 Chinese cities. The Memorial Symptom Assessment Scale 10-18 (MSAS 10-18) was used to evaluate the prevalence and severity of symptoms during chemotherapy. A network analysis was performed by the R software based on 31 symptoms. Centrality indices and density were used to explore core symptoms and describe interrelationships among symptoms in the network during chemotherapy.

RESULTS

Worrying and feeling irritable were the central symptoms across the three centrality indices, including strength, closeness, and betweenness. Lack of energy was the most prevalent symptom; however, it was less central than other symptoms. The density of the "induction and remission" network significantly differed from other cycles' counterparts (p < 0.001). Global strength was greater in the " ≥ 8 years group " network than the " < 8 years group " network (p = 0.023).

CONCLUSION

Network analysis provides a novel approach to identifying the core symptoms and understanding the interrelationships among symptoms. Our study indicates the need to assess emotional symptoms in children with acute leukemia during chemotherapy, especially during the induction and remission phases, as well as in older children. Future research is imperative to construct trajectories of dynamic symptom networks and centrality indices in longitudinal data to investigate the causal relationships among symptoms.

A Concept Development for the Symptom Science Model 2.0

BACKGROUND

The National Institute of Nursing Research developed the National Institutes of Health symptom science model (SSM) in 2015 as a parsimonious conceptual model to guide symptom science research.

OBJECTIVES

This concept development paper synthesizes justifications to strengthen the original model.

METHODS

A literature review was performed, discussions with symptom science content expert stakeholders were held, and opportunities for expanding the current model were identified. Concept elements for a revised conceptual model-the SSM 2.0-were developed.

RESULTS

In addition to the four original concept elements (complex symptom presentation, phenotypic characterization, biobehavioral factors [previously biomarker discovery], and clinical applications), three new concept elements are proposed, including social determinants of health, patient-centered experience, and policy/population health.

DISCUSSION

There have been several calls to revise the original SSM from the nursing scientific community to expand its utility to other healthcare settings. Incorporating three additional concept elements can facilitate a broader variety of translational nursing research symptom science collaborations and applications, support additional scientific domains for symptom science activities, and produce more translatable symptom science to a wider audience of nursing research scholars and stakeholders during recovery from the COVID-19 pandemic. The revised SSM 2.0 with newly incorporated social determinants of health, patient-centered experience, and policy/population health components now empowers nursing scientists and scholars to address specific symptom science public health challenges particularly faced by vulnerable and underserved populations.

Approaches to improving symptom appraisal: a systematic literature review

OBJECTIVES

Poor symptom appraisal (detection, interpretation and response to symptoms) plays a major role in prolonged prediagnosis interval in various health conditions. Theories and models have been proposed to study the symptom appraisal process but how they could be employed to improve symptom appraisal remains unclear. We therefore aimed to review approaches to improving symptom appraisal in the literature and to develop a theoretical framework that could guide the development of approaches to improving symptom appraisal among individuals in the general population.

DESIGN

Systematic review.

DATA SOURCES

Medline, Web of Science, PsycINFO, Embase, CINAHL and Scopus were searched from inception to 30 March 2021.

ELIGIBILITY CRITERIA

We included original articles in English in which approaches to improve the detection, interpretation or response to symptoms for symptomatic individuals were described. We excluded articles in which approaches were developed to improve symptom appraisal among healthcare professionals.

DATA EXTRACTION AND SYNTHESIS

A predefined data extraction form was used to extract the development, characteristics and evaluation of approaches to improving symptom appraisal. This formed the basis for the narrative synthesis.

RESULTS

Of 19 046 publications identified from the literature search, 112 were selected for full-text review and 29 approaches comprising provision of knowledge of symptoms/signs and additional components (eg, symptom self-examination and comparison) for symptom appraisal were included in the synthesis. Less than half (41.4%) of these approaches were developed based on theories/models. Interestingly, despite the variety of theories/models adopted in developing these approaches, the components of these approaches were similar.

CONCLUSION

Symptom appraisal is an essential process in a patient's journey that can be targeted to facilitate early diagnosis but is largely unstudied. Building on the literature, we proposed a theoretical framework and approaches to improving symptom appraisal. This could facilitate early identification of a variety of health conditions in the general population.

TRIAL REGISTRATION NUMBER

CRD42021279500.

Symptom Management Theory: Analysis, Evaluation, and Implications for Caring for Adults With Cancer

A detailed analysis of Symptom Management Theory (SMT) along with its extent of use and implications for adults with cancer as demonstrated in 20 oncology research studies is reported. SMT provides useful guidance for adult oncology research and nursing practice. Theory dimension most researched in cancer was symptom experience. Although theory assertions were demonstrated in 80% of the studies, it was used to an adequate extent only in 35% of them. Comparisons between cancer-related clinical outcomes with and without use of SMT, certain theory modifications, and future SMT-based studies involving longitudinal designs in this population are warranted.

A Proposed Theory of Symptom Cluster Management

Background

Symptom cluster management is in its early stages in many chronic and debilitating illnesses. The development of a proposed theory should be an initial step in advancing this area of interest.

Objective

This article presents the development of a Proposed Theory of Symptom Cluster Management.

Methods

The concept analysis, statement synthesis, and theory synthesis by Walker and Avant were used in the development of this proposed theory. A search from July to September 2020 for published empirical and theoretical articles was conducted in scientific databases, expanded on the web, and secondary references from identified articles.

Results

The Proposed Theory of Symptom Cluster Management is both a descriptive and explanatory theory. The defining characteristics of symptom cluster management include the basic and effectiveness components. Antecedents for symptom cluster management include socio-demographic characteristics, symptom cluster characteristics, individual clinical characteristics, individual illness factors, and situational factors or symptom experience. The consequences are clustered as personal-related, health-related, social-related outcomes, and existential outcomes. Measurement tools for the antecedents and outcomes in symptom cluster management and the analytical and statistical strategies were considered. Relational statements were also identified. Theoretical assertions were advanced.

Conclusion

The Proposed Theory of Symptom Cluster Management may provide a holistic approach because it integrates both the symptom cluster and management strategies. The concepts, statements including the complete representation of the proposed theory identified in this article, may provide cues to policymakers and clinical researchers towards the development of tailored interventions and programs.

Analysis of Delirium From the Dynamic Symptoms Model: A Literature Review

Delirium is a manifestation of brain injury or acute and generalized dysfunction of the upper cerebral cortical processes. In this way, it is important to analyze delirium more broadly as a symptom to understand and intervene taking into account that it is manifesting the presence of brain lesions whose consequences are deleterious to the neurological performance of patients. This article is intended to present a comprehensive approach of delirium analyzed from a symptom perspective and from theoretical and conceptual structure, such as the Dynamic Symptoms Model, specific to the nursing practice. A literature review related to delirium and components of Dynamic Symptoms Model was carried out. We searched the MEDLINE, ScienceDirect, SciELO, and Scopus databases using the terms Delirium, Intensive Care Units, Nursing, and Risk Factor. The existing literature provides evidence of the antecedents, experience, interventions, interactions, and consequences of delirium, which are components of the Model. Thus, the analysis from the Dynamic Symptoms Model perspective bears relevance and contributes to the understanding and approach of delirium.

Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness

The Middle-Range Theory of Self-Care of Chronic Illness has been used widely since it was first published in 2012. With the goal of theoretical refinement in mind, we evaluated the theory to identify areas where the theory lacked clarity and could be improved. The concept of self-care monitoring was determined to be underdeveloped. We do not yet know how the process of symptom monitoring influences the symptom appraisal process. Also, the manner in which self-care monitoring and self-care management are associated was thought to need refinement. As both of these issues relate to symptoms, we decided to enrich the Middle-Range Theory with knowledge from theories about symptoms. Here, we propose a revision to the Middle-Range Theory of Self-Care of Chronic Illness where symptoms are clearly integrated with the self-care behaviors of self-care maintenance, monitoring, and management.

An integrated model of multimorbidity and symptom science

BACKGROUND

Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature.

PURPOSE

Introduce an Integrated Model of Multimorbidity and Symptom Science.

METHODS

Critical integrative review and synthesis process.

FINDINGS

The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes.

DISCUSSION

The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.

The Theory of Unpleasant Symptoms in Pediatric Oncology Nursing: A Conceptual and Empirical Fit?

Symptom management knowledge is a priority for pediatric oncology nursing research. Theories and models can frame the studies of symptoms experienced during childhood cancer. This article describes and analyzes the middle-range theory, theory of unpleasant symptoms (TOUS), for its conceptual and empirical fit with pediatric oncology nursing based on its current use in adult oncology research and its limited use to date in pediatric oncology. Searches in PubMed and CINAHL databases using the keywords theory of unpleasant symptoms and cancer and covering the time period 2000 to 2017 yielded 103 abstracts for review. Twenty published reports met eligibility criteria for review; only one included pediatric oncology patients. No study to date has tested all the components of the TOUS in pediatrics. The TOUS component of performance appears to be underaddressed across completed studies that instead include a focus on patient-reported quality of life rather than on perceived behavioral or performance indicators concurrent with the subjective symptom reports. Additionally, the influence of family, essential in pediatric oncology, is absent in the majority of studies guided by the TOUS. The TOUS is a structurally complicated framework that would be a conceptual fit for pediatric oncology if family influence and perceived function were included. Studies across this population and guided by the TOUS are needed, although testing all the theorized linkages in the TOUS would likely require a large sample size of patients and, thereby, multisite approaches given that cancer is a rare disease in childhood.

Introducing a model for emotional distress in respiratory disease: A systematic review and synthesis of symptom management models

AIM

To undertake a theoretical systematic review to develop a conceptual model of illness-related emotional distress in the context of symptom management in chronic respiratory disease.

DESIGN

We performed a systematic search to identify conceptual models.

DATA SOURCES

Electronic databases MEDLINE, CINAHL, EMBASE and PsycINFO were searched and papers included from inception of the search term until June 2017.

REVIEW METHODS

The review was conducted following Pound and Campbell's and Turner's theory synthesis. Conceptual models were appraised using Kaplan's criteria. Models were excluded if they referred to a specific condition and/or lacked clarity.

RESULTS

This synthesis, which includes five models and additional evidence, yielded a new conceptual model describing the processes of regulation and symptom self-management in chronic respiratory disease. Identified sources of illness-related emotional distress are new or increased symptoms, additional treatment, new restrictions in performance of daily life roles and increased unpredictability. People goals and self-efficacy were identified as further drivers of symptom self-management. The regulation process is embedded in contextual factors.

CONCLUSION

Theory synthesis provided transparent guidance in developing a model to understand of the factors driving self-management decisions. Therefore, the model has the potential to guide development of interventions that support symptom self-management in chronic respiratory disease.

IMPACT

This newly presented conceptual model of illness-related emotional distress provides an understanding of the factors that drive self-management decisions when peoples experience new or increased symptoms. Such understanding is critical for nursing practice to developing appropriate interventions, especially in support of people decision-making.

THEORY OF UNPLEASANT SYMPTOMS: CRITICAL ANALYSIS

ABSTRACT Objective: to analyze the Theory of Unpleasant Symptoms according to the model proposed by Walker and Avant. Method: a descriptive-reflexive study developed in the first half of 2016. He used the first five phases proposed by the Walker and Avant model: identification of the origins of the theory; examination of the meaning of the theory; logical adequacy; utility; degree of generalization and parsimony of theory. Results: the study allowed the reflection on the Theory of Unpleasant Symptoms, considering the multidimensionality of the symptoms and the potential stimulation between them. It was identified the relations between the main concepts used to construct the theory: physiological, psychological and situational factors, followed by performance, suffering, duration, quality, intensity and unpleasant symptoms. Conclusion: the Theory of Unpleasant Symptoms presents a structured theoretical framework, presenting logical meaning, through well-defined concepts and relations, which make possible its use in practice, teaching and nursing research.

Evolution of the Dynamic Symptoms Model

Theories and conceptual models can be thought of as broad nets that attempt to rationalize, explain, and master a phenomenon within clinical nursing and interdisciplinary care. They can be used to guide a review of the literature and to formulate and organize research variables and relationships. Gaps in the literature can be identified and opportunities for additional research revealed (Fawcett, 2005). A variety of symptom models or theories exist, including the Theory of Symptom Management (Dodd et al., 2001), Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997), Symptoms Experience Model (Armstrong, 2003), and Symptom Experiences in Time Theory (Henly, Kallas, Klatt, & Swenson, 2003). Most recently, the National Institute of Nursing Research identified a new National Institutes of Health Symptom Science Model to guide symptom science research (Cashion & Grady, 2015).
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Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

Symptom-reducing actions: a concept analysis in the context of chronic obstructive pulmonary disease

Patients with Chronic Obstructive Pulmonary Disease (COPD) have multiple symptoms. Nursing care is based on six core competencies and one of them is person-centred care that includes the aspect of professional symptom relief. The aim was to clarify a meaning of the concept of Symptom-reducing actions in the context of COPD. Databases MEDLINE and CINAHL were searched between 1982 and February 2016 and 26 publications were found. Two dictionaries and three books were investigated. The method of Walker & Avant was followed. The use of the concept of Symptom-reducing actions may be categorized by the sub-concepts of supervision, information, and patient education. Exploration of defining attributes was symptom management, instructions, support, motivation, explanation, advice, teaching, and learning. Antecedent occurrences were related to factors that affect the patient's level of function such as physical performance and cognitive function. Symptom-reducing actions offer a way to support patients with COPD in self-management. Symptom-reducing actions can mediate facts in a purposeful process performed by the nurse to enable the patient to take control over and manage unpleasant symptoms by a person-centred, planned process. The nurse can achieve this via supervision, information, and patient education with an integrated emotional component. Evaluating the outcomes is needed.

Spasticity over time during acute rehabilitation: a study of patient and clinician scores

AIMS

The aims of this study were to describe spasticity trajectories as a function of time, gender, and diagnosis and to explore the correspondence between patient and clinician scores of spasticity.

BACKGROUND

Discrepancy between examiner assessment and patient rating of spasticity exists. Assessments that include the patient perspective are critical for patient safety. This mixed-method study provided patient descriptors of spasticity integrated with clinical scales.

METHOD

Twenty-three participants provided spasticity descriptors and rated their spasticity based on Numeric Rating Scale (NRS) scores. A clinician evaluated spasticity daily using the Modified Ashworth Scale (MAS). This resulted in 1976 points of data for analysis.

RESULTS

Spasticity was highly variable over time. The empirical correspondence between the clinician-rated MAS and the patient-rated NRS revealed that patient and examiner understanding of spasticity were diverged considerably.

CONCLUSIONS

Clinical evaluation protocols should include patient reports on spasticity. Knowledge about patient word choice can enhance patient-provider communication.

Comparison of groups with different patterns of symptom cluster intensity across the breast cancer treatment trajectory

BACKGROUND

Comparing subgroups with different patterns of change in symptom intensity would assist in sorting out individuals at risk for more severe symptoms and worse functional outcomes.

OBJECTIVES

The objectives of this study were to identify and compare subgroups of breast cancer patients with different patterns of change in a psychoneurological symptom cluster intensity across the treatment trajectory.

METHODS

This secondary analysis used the data from 160 breast cancer patients undergoing chemotherapy or radiation treatment. Psychoneurological symptom cluster intensity was a composite score of 5 symptoms (depressed mood, cognitive disturbance, fatigue, insomnia, and pain) in a psychoneurological cluster at each of 3 time points (ie, at baseline and at 2 follow-ups after chemotherapy or radiation treatment).

RESULTS

Five distinct subgroups representing different patterns of psychoneurological symptom cluster intensity during breast cancer treatment were identified: the gradually increasing pattern subgroup (group 1), the constantly low pattern subgroup (group 2), the start low with dramatic increase and decrease pattern subgroup (group 3), the constantly high pattern subgroup (group 4), and the start high with dramatic decrease and leveling pattern subgroup (group 5). Patients without previous cancer treatment experience, with higher level of education, treated with chemotherapy, and/or with more limitations at the baseline were more likely to follow the pattern group 4. Patients in group 4 had the most serious functional limitations measured at the second follow-up time point.

CONCLUSION

The results suggest the need to evaluate interventions for specific subgroups and to examine the causal mechanisms underlying a psychoneurological symptom cluster.

IMPLICATION

Clinicians should consider these diverse symptom experiences for assessment/management.

The influence of oxidative stress on symptom occurrence, severity, and distress during childhood leukemia treatment

PURPOSE/OBJECTIVES

To explore the symptom trajectory during the first 16 months of childhood leukemia treatment and any associations with the oxidative stress pathway measured by cerebrospinal fluid (CSF) concentration of oxidized phosphatidylcholine (PC), the predominant glycerophospholipid in the brain and cell membranes.

DESIGN

Prospective, longitudinal design.

SETTING

Two cancer centers in the southwestern United States.

SAMPLE

36 children (aged 3-14 years) newly diagnosed with acute lymphoblastic leukemia.

METHODS

Symptoms were measured using the Memorial Symptom Assessment Scale at six specific time points during treatment. Biochemical changes in oxidative stress were measured by oxidized PC in the CSF.

MAIN RESEARCH VARIABLES

Childhood cancer symptoms, oxidized PC.

FINDINGS

Significant differences were found in the number of symptoms experienced during the three phases of treatment. Symptom trajectory changes and influence of the oxidative stress pathway on symptom experiences were identified.

CONCLUSIONS

Symptoms experienced during treatment for childhood leukemia are associated with increased oxidative stress.

IMPLICATIONS FOR NURSING

Children with leukemia experience symptoms throughout treatment. Physiologic measures indicate the influence of oxidative stress on symptoms.

Symptom clusters in children

PURPOSE OF REVIEW

Researchers have focused on identifying and describing symptom experiences among children with various diseases but symptoms can have a synergistic and/or an antecedent effect that must be evaluated. This review reports the current knowledge of symptoms among various pediatric diseases and highlights symptom cluster research.

RECENT FINDINGS

Symptoms of depression and anxiety are the most prevalent variables studied across pediatric disease studies followed by pain, fatigue, and quality of life. Although previous pediatric symptom research provides a foundation for understanding the complexities of these symptoms, there is limited evidence on symptom cluster research in pediatrics. Pain and fatigue are the most common symptoms analyzed for correlations, and relationships among symptoms that have been evaluated in children with juvenile idiopathic arthritis, HIV, cancer, cardiac disease requiring an implantable cardioverter defibrillator, and at end of life. Pain and fatigue have been associated with sleep disturbances, anxiety, depression, anorexia, and nausea/vomiting.

SUMMARY

Pediatric oncology researchers are leading the way with symptom cluster studies; however, this work remains in the early stages. There is great potential to advance the state of the science with cluster analysis. Future research work should focus on evaluating symptoms and their interactions.

Time issues in multilevel interventions for cancer treatment and prevention

The concept of time introduces important complexities in estimating intervention effects, program and evaluation design, and measurement and analysis of individual change in multilevel interventions (MLIs). Despite growing recognition that time is a critical element for assessing both individual-level outcomes and higher-level changes in organizational, community, and policy contexts, most MLI designs and evaluations have not addressed these issues. In this chapter we discuss 1) conceptualizing disease life-course and treatment theory in MLIs, 2) approaches to incorporating time in research and program design for MLIs in cancer treatment and prevention, 3) analysis of time-varying multilevel data in the context of cancer treatment and prevention, and 4) resource considerations and trade-offs of incorporating time as a dimension of MLIs and analysis. Although analytic techniques for analyzing time-related phenomena are becoming more available and powerful, there has not been corresponding progress made in the development of theory to guide the application of these techniques in program design and implementation.

The Concept of Time in Rehabilitation and Psychosocial Adaptation to Chronic Illness and Disability

Human fascination with the concept of time can be traced to antiquity. Time has been viewed as fundamental to all human experience, and efforts to understand its nature, structure, and relationship to the human experience have generated a burgeoning body of literature, over the past two millennia, among philosophers, astronomers, physicists, and more recently psychologists. Yet, the field of rehabilitation counseling has been rather silent on the role of time and especially its place in understanding psychosocial adaptation to chronic illnesses and disabilities. In the first part of this article, the author seeks to (a) provide a brief review of the current understanding of the nature and structure of time and (b) explore the role that time plays in the context of personality theories and the therapeutic approaches spawned by them. Implications to the study of chronic illnesses and disabilities are discussed throughout the narrative.

Understanding spasticity from patients' perspectives over time

AIM

  The purpose of this paper was to report patients' understanding and perceptions of personal spasticity experiences over time.

BACKGROUND

  Spasticity is an unpleasant and poorly understood experience associated with upper motor neuron disease.

DESIGN

  An original qualitative study was conducted in 2008-2009.

METHOD

  Content analysis was used to extract meaning from the responses of 23 patients to semi-structured interviews during 7 days of acute rehabilitation for neurological diseases associated with spasticity. Findings.  Patients used words reflecting muscle tone and spasms to describe spasticity. Themes reflecting the spasticity experience over time were Ambiguous Experiences, Navigating Symptom Experience, Wounded Self, and Unending Journey.

CONCLUSION

  Spasticity as experienced is complex, involving a wide range of unusual sensations sensitive to stressors in everyday life. Clinical evaluation of spasticity should include patient reports. Knowledge about patient word choice used to describe spasticity can enhance communication with healthcare providers.

Factors related to daily life interference in lung cancer patients: a cross-sectional regression tree study

PURPOSE

To identify the symptom combination patterns and symptom severity levels that induce severe symptom interference in daily life activities, including physical and psychological activity interference in lung cancer patients.

METHODS

In a cross-sectional descriptive study using convenience sampling, 131 participants were recruited at a medical center in northern Taiwan. The Eastern Cooperative Oncology Group (ECOG) performance status was used to assess performance status, and the Taiwanese version of the M.D. Anderson Symptom Inventory (MDASI-T) was used to assess symptom severity and symptom interference in daily life activities including physical and psychological activities. Regression tree models were applied to examine variable combinations for symptom interference level in daily life activities, including physical and psychological activity interference.

RESULTS

Study results revealed that the performance status is the key discriminator of the symptom interference level in daily life and physical activities, but distress severity is the key discriminating factor of the symptom interference level in psychological activities. The performance status and distress severity, plus other factors, further specifically show the discrimination paths and interactions between the risk groups.

CONCLUSIONS

This study provided an alternative approach to identify low- and high-risk groups of symptom interference among lung cancer patients in Taiwan. Increased awareness and further understanding of the risk combinations and discriminate levels of symptom severity that induced high symptom interference offer different perspectives to develop patient-centered care planning for lung cancer patient rehabilitation.

Health and illness over time: the trajectory perspective in nursing science

BACKGROUND

Understanding change in health and illness over time is central to creating and evaluating interventions for individuals, families, and populations. The term health trajectory is a succinct and useful way to describe change in health status over time.

OBJECTIVES

The aims of this article were to define the notion of a health trajectory; comment on the usefulness and current status of health trajectory research for nursing science and practice; and identify and illustrate the key elements of theory, design, and statistical models for health trajectory research.

APPROACH

Constructs in theory about individual change are summarized, synthesized with characteristics of longitudinal design and statistical models for change, and discussed in light of current and emerging health care priorities and trends in nursing research.

RECOMMENDATIONS

Health trajectory research is person focused and congruent with the person-centered emphasis of nursing practice. The contribution of nursing science to the overall effort to improve health will be enhanced when change over time is explicit in nursing theory, longitudinal designs are used, and contemporary statistical approaches for modeling change in health status are incorporated into research plans.

Modeling trajectories and transitions: results from the New York University caregiver intervention

BACKGROUND

Current research fails to capture the temporal dynamics of chronic disease in favor of cross-sectional snapshots of symptoms and outcomes.

OBJECTIVE

The aim of this study was to estimate the effects of comprehensive psychosocial support on trajectories of spouse caregivers' well-being related to the nursing home placement transition.

METHOD

Data from the New York University Caregiver Intervention, a randomized controlled trial of a comprehensive support program for spouse caregivers of persons with Alzheimer's disease, were utilized. A convenience sample of 406 spouse caregivers of community-dwelling persons with Alzheimer's disease was enrolled over a 9.5-year period in an Alzheimer's disease research center in New York City. Outcome measures, including the Zarit Burden Inventory and Geriatric Depression Scale, were used to assess the differential effects of nursing home placement and of the intervention on spouse caregivers. In-person interviews of spouse caregivers took place every 4 months during the first year of participation and every 6 months thereafter for up to 16 years; 385 caregivers provided sufficient follow-up data for all analyses.

RESULTS

Longitudinal models found that wives were more likely than husbands to indicate reductions in burden in the months after placement in an institution. Wives also reported greater decreases in depressive symptoms after placement in an institution when compared with husbands.

DISCUSSION

The inclusion of transitions and health trajectories in a randomized controlled trial offers an intriguing picture of how comprehensive psychosocial interventions can help families navigate the challenges of chronic disease care. The results also indicate how advances in nursing science can facilitate future research in the modeling of trajectories and transitions in the dementia care context.

Symptoms, psychological distress, and supportive care needs in lung cancer patients

PURPOSE

The purpose of this study was to examine the level of symptoms, psychological distress, and supportive care needs and factors related to five unmet need domains in lung cancer patients.

METHODS

A cross-sectional study of 152 lung cancer patients at a medical center in Taiwan assessed their symptoms, psychological distress, and unmet supportive needs in five major care domains. Logistic regression was applied to examine the related factors of unmet supportive care needs.

RESULTS

In general, patients had mild-to-moderate levels of symptoms and high prevalence of psychological distress. Regardless of their treatment status, they reported high levels of supportive care needs. The top three need domains were: (1) health system and information, (2) psychological, and (3) patient care and support. Levels of symptoms, anxiety, and depression were the most significant factors in unmet supportive care needs.

CONCLUSION

The effect of symptoms and psychological distress on unmet supportive care needs is substantial. Therefore, a systematic assessment of patients' distress and care needs is important for clinical lung cancer care. Further intervention consisting of symptom management, continuing counseling, and preparation for transition from active treatment to the follow-up stages are essential in improving quality of care.

Analysis of the UCSF Symptom Management Theory: implications for pediatric oncology nursing

Symptom management research is a priority for both children and adults with cancer. The UCSF Symptom Management Theory (SMT) is a middle range theory depicting symptom management as a multidimensional process. A theory analysis using the process described by Walker and Avant evaluated the SMT with attention to application in research involving children with cancer. Application of the SMT in studies involving children has been limited to descriptive studies testing only portions of the theory. Findings of these studies have provided empiric support for the relationships proposed within the SMT. Considerations for future research involving children include attention to measurement of symptoms and clarity regarding the location of the parents and family within the model. With additional testing and refinement, the SMT has the potential to guide nursing research and practice to improve symptoms for children with cancer.

Building dynamic models and theories to advance the science of symptom management research

AIM

This paper is a description, comparison, and critique of two models and two theories used to guide symptom management research, and a proposal of directions for new theory or model development.

BACKGROUND

Symptom management research has undergone a paradigmatic shift to include symptom clusters, longitudinal studies that examine symptom trajectories, and the effects of interventions on patient outcomes. Models and theories are used to guide descriptive and intervention research. Over the past 15 years, four conceptual models or theories (i.e. Theory of Symptom Management, the Theory of Unpleasant Symptoms, the Symptoms Experience Model and the Symptoms Experience in Time Model) were used in a variety of symptom management studies.

DATA SOURCES

Literature searches were performed in Medline and the Cumulative Index of Nursing and Allied Health Literature between 1990 and 2008 for models and theories that guide symptom management research. Related papers and book chapters were used as supporting documentation.

DISCUSSION

Comparison and critique of the models and theories revealed important gaps including lack of consideration of symptom clusters, failure to incorporate temporal aspects of the symptom experience and failure to incorporate the impact of interventions on patient outcomes.

CONCLUSION

New models and theories should incorporate current trends in symptom management research, capture the dynamic nature of symptoms and incorporate concepts that will facilitate transdisciplinary research in symptom management. Researchers and clinicians need to build more expansive and dynamic symptom management models and theories that parallel advances in symptom research and practice.

Time and bodily changes in advanced prostate cancer: talk about time as death approaches

The disease trajectory of living with incurable cancer is characterized by increasing bodily deterioration and problems. In this paper, we have focused on the change in temporal awareness as manifested in the narrations of two men with hormone refractory prostate cancer and skeletal metastases as they approach death. The two men participated in in-depth research interviews during the last part of their lives, sharing a similar disease trajectory with increasing bodily change and decreasing physical function. Both died a lingering, cancer-related death. The first and last research interviews were analyzed using a discourse analytic method. Findings show that the temporal awareness in the interviews changes as the illness progresses and death approaches. In the last interviews, the present is flooded with bodily problems; the past and the future are hardly present except for the future beyond the men's own deaths. Pain, fatigue, nausea, and other symptoms figure largely in this change, and there is no time for much more than attending to bodily needs in a present that is dominated by problems. Here, the importance of alleviating bodily problems once again becomes paramount, and two questions are raised: Is the often reported withdrawal from life, when death is imminent, a physical necessity rather than a psychological one, and is it possible to free time from the time-consuming problems of the present by means of a more concentrated attempt to alleviate these problems?

Childbirth-related fatigue trajectories during labour

AIM

This paper is a report on a study identifying trajectories of childbirth-related fatigue intensity changes over time and the influencing factors related to specific trajectory patterns.

BACKGROUND

Childbirth is a period of time that encompasses considerable physiological and psychological fatigue, often having an adverse impact on women in labour. Empirical studies on this issue are scarce. How childbirth-related fatigue changes over time, and factors influencing fatigue development, remain unclear.

METHOD

A prospective, correlational design with repeated measures was used. Data were collected by self-reported measures and laboratory analysis of blood specimens. From December 2004 to November 2005 a convenience sample of 209 low-risk pregnant Taiwanese women was followed throughout the labour process. Repeated measures of fatigue were analysed by using a semiparametric mixture model. Variables explaining trajectory class membership were identified by means of logistic regression.

RESULTS

Two distinct trajectories of childbirth-related fatigue were identified: low intensity (30.8% of women) and high intensity (69.2% of women). Fatigue level of both classes intensified following labour. The fastest period of fatigue-increasing rate was in the active phase. After birth, fatigue levels in the high-fatigue intensity class remained high. Primiparas in the high-fatigue intensity class experienced significantly more anxiety and higher lactate concentration at admission than the low-intensity class.

CONCLUSION

Caregivers should endeavour to prevent high levels of fatigue once women enter the labour phase. Women who present with high fatigue at onset of labour should be targeted for early intervention, especially in the period of rapid fatigue increase.

Physical activity behaviors in individuals with multiple sclerosis: roles of overall and specific symptoms, and self-efficacy

Multiple sclerosis (MS) is associated with a large reduction in physical activity behavior, and emerging evidence indicates that this reduction might be correlated with symptoms and self-efficacy. The present study examined the nature of the associations among MS-related symptoms, exercise self-efficacy, and physical activity behavior in 80 individuals with a definite diagnosis of MS. Participants completed a measure of MS-related symptoms and self-efficacy and then wore an accelerometer for seven days. Both the frequency of overall symptoms and the frequency of motor symptoms had significant moderate inverse relationships with physical activity behavior (r=-0.47, P<0.0001 and r=-0.49, P<0.0001, respectively). Additionally, exercise self-efficacy was significantly and moderately correlated with physical activity (r=0.39, P<0.0001) and had significant and moderate inverse relationships with overall symptom frequency (r=-0.40, P<0.0001) and motor symptom frequency (r=-0.30, P=0.008). Path analysis demonstrated that both overall symptoms and motor symptoms had direct effects on physical activity as well as indirect effects on physical activity by way of self-efficacy. Such results suggest that the management and monitoring of MS-related symptoms may play an important role in encouraging physical activity adoption and maintenance in individuals with MS.

Complementary Alternative Medical Therapies for Heart Surgery Patients: Feasibility, Safety, and Impact

BACKGROUND

Complementary therapies (touch, music) are used as successful adjuncts in treatment of pain in chronic conditions. Little is known about their effectiveness in care of heart surgery patients. Our objective is to evaluate feasibility, safety, and impact of a complementary alternative medical therapies package for heart surgery patients.

METHODS

One hundred four patients undergoing open heart surgery were prospectively randomized to receive either complementary therapy (preoperative guided imagery training with gentle touch or light massage and postoperative music with gentle touch or light massage and guided imagery) or standard care. Heart rate, systolic and diastolic blood pressure, and pain and tension were measured preoperatively and as pre-tests and post-tests during the postoperative period. Complications were abstracted from the hospital record.

RESULTS

Virtually all patients in the complementary therapy group (95%) and 86% in standard care completed the study. Heart rate and blood pressure patterns were similar. Decreases in heart rate and systolic blood pressure in the complementary therapies group were judged within the range of normal values. Complication rates were very low and occurred with similar frequency in both groups. Pretreatment and posttreatment pain and tension scores decreased significantly in the complementary alternative medical therapies group on postoperative days 1 (p < 0.01) and 2 (p < 0.038).

CONCLUSIONS

The complementary medical therapies protocol was implemented with ease in a busy critical care setting and was acceptable to the vast majority of patients studied. Complementary medical therapy was not associated with safety concerns and appeared to reduce pain and tension during early recovery from open heart surgery.

Symptoms in patients with lung carcinoma

BACKGROUND

The patient perspective on distress associated with lung carcinoma is important, yet understudied. Previous research on symptom experience generally had not differentiated the dimension symptom intensity/frequency from which symptoms are associated with most distress. The objective of the current study was to determine whether patterns of symptom intensity were similar to patterns of symptom distress, whether patterns were consistent at different time points, whether patterns varied by subgroups, and whether high symptom intensity was equivalent to distress.

METHODS

Four hundred adults who were newly diagnosed with inoperable lung carcinoma completed a measure of symptom intensity/frequency and a new measure of distress associated with symptoms at six time points during the first year after diagnosis. These data were supplemented by field notes by research nurses and by less structured, qualitative interviews.

RESULTS

The mean ranking of distress in the total group and in all subgroups remained constant at all time points, with breathing, pain, and fatigue associated with the most distress. In contrast, the pattern of mean rank order of symptom intensity showed little consistency; however, fatigue had the highest intensity scores at all time points.

CONCLUSIONS

The current data challenged the uncritical use of summated scores of different symptom items in the context of lung carcinoma. Breathing and pain appeared to function as icons representing threats associated with lung carcinoma, with distress described as related to the past and the present and to expectations for the future. One of the most promising implications of these data was in fostering a preventive paradigm for symptom palliation.