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N U R S I N G T H E O R Y A N D C O N C E P T D E V E L O P M E N T O R A N A LY S I S

Advancing the science of symptom management

Marylin Dodd RN PhD FAAN
Professor and Associate Dean, San Francisco School of Nursing, University of California, CA, USA

Susan Janson RN NP DNSc FAAN

Professor, San Francisco School of Nursing, University of California, CA, USA

Noreen Facione RN PhD FNP

Assistant Adjunct Professor, San Francisco School of Nursing, University of California, CA, USA

Julia Faucett RN PhD

Associate Professor, San Francisco School of Nursing, University of California, CA, USA

Erika S. Froelicher RN PhD FAAN

Professor, San Francisco School of Nursing, University of California, California, CA, USA

Janice Humphreys RN CS PhD PNP

Assistant Professor, San Francisco School of Nursing, University of California, CA, USA

Kathryn Lee RN PhD FAAN

Professor, San Francisco School of Nursing, University of California, CA, USA

Christine Miaskowski RN PhD FAAN

Professor, San Francisco School of Nursing, University of California, CA, USA

Kathleen Puntillo RN DNSc FAAN

Associate Professor, San Francisco School of Nursing, University of California, CA, USA

Sally Rankin RN-C PhD FAAN

Associate Professor, San Francisco School of Nursing, University of California, CA, USA

and Diana Taylor RN NP PhD

Associate Professor, San Francisco School of Nursing, University of California, CA, USA

Submitted for publication 22 June 2000

Accepted for publication 12 November 2000

Correspondence: D O D D M ., J A N S O N S ., F A C I O N E N ., F A U C E T T J ., F R O E L I C H E R E . S . ,
Marylin Dodd, H U M P H R E Y S J ., L E E K ., M I A S K O W S K I C ., P U N T I L L O K ., R A N K I N S . &
School of Nursing, TAYLOR D. (2001) Journal of Advanced Nursing 33(5), 668676
Box 0610,
Advancing the science of symptom management
University of California,
Abstract. Since the publication of the original Symptom Management Model
San Francisco,
CA 94143-0610,
(Larson et al. 1994), faculty and students at the University of California, San
USA. Francisco (UCSF) School of Nursing Centre for System Management have tested this
E-mail: marylin.dodd@nursing.ucsf.edu model in research studies and expanded the model through collegial discussions and
seminars.

668 2001 Blackwell Science Ltd

Nursing theory and concept development or analysis Symptom management

Aim. In this paper, we describe the evidence-based revised conceptual model, the
three dimensions of the model, and the areas where further research is needed.
Background/Rationale. The experience of symptoms, minor to severe, prompts
millions of patients to visit their healthcare providers each year. Symptoms not only
create distress, but also disrupt social functioning. The management of symptoms
and their resulting outcomes often become the responsibility of the patient and his
or her family members. Healthcare providers have difculty developing symptom
management strategies that can be applied across acute and home-care settings
because few models of symptom management have been tested empirically.
To date, the majority of research on symptoms was directed toward studying a
single symptom, such as pain or fatigue, or toward evaluating associated symptoms,
such as depression and sleep disturbance. While this approach has advanced our
understanding of some symptoms, we offer a generic symptom management model
to provide direction for selecting clinical interventions, informing research, and
bridging an array of symptoms associated with a variety of diseases and conditions.
Finally, a broadly-based symptom management model allows the integration of
science from other elds.

Keywords: concepts/constructs related to health, symptom management model,

1 symptom management theory

the interrelatedness of the symptom experience, symptom

Overview of the symptom management model
management strategies and outcomes.

Overall model
A symptom is dened as a subjective experience reecting
changes in the biopsychosocial functioning, sensations, or
cognition of an individual. In contrast, a sign is dened as any
abnormality indicative of disease that is detectable by the
individual or by others (Harver & Mahler 1990). In the
University of California, San Francisco (UCSF) model, signs
are incorporated when they are needed to assess disease
status and to evaluate and verify the effectiveness of man-
agement strategies. Both signs and symptoms are important
cues that bring problems to the attention of patients and
clinicians. Ideally, patients should be taught the importance
of signs, which may have little relevance to the layperson
until their meaning and relationship to an underlying cause
is understood. The absence of signs or symptoms, however,
does not necessarily imply the optimal health and well-being
of an individual.
The UCSF School of Nursing Symptom Management
Model is based on the premize that effective management
of any given symptom or group of symptoms demands that
all three dimensions be considered. The interrelatedness of
these three dimensions of symptom management is rarely
taken into account in research, even though its importance is
acknowledged (Lenz et al. 1997). Later in this article,
ndings from recent research will be used to demonstrate
Relationships within the model
The dimensions of the symptom management model have
conceptualized relationships to one another depicted in both
the original and revised model (see Figure 1) shown with bi-
directional arrows. The relationships among these dimen-
sions were revised based on research and experiential ndings
and on further conceptualizations by the faculty and graduate
students of the UCSF Symptom Management Center.
Model assumptions
The symptom management model is based on six assump-
tions:
That the gold standard for the study of symptoms is based
on the perception of the individual experiencing the symptom
and his/her self-report.
That the symptom does not have to be experienced by an
individual to apply this model of symptom management. The
individual may be at risk for the development of the symptom
because of the inuence (impact) of a context variable such as
a work hazard. Intervention strategies may be initiated before
an individual experiences the symptom.
That nonverbal patients (infants, poststroke aphasic per-
sons) may experience symptoms and the interpretation by the

2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676 669
M. Dodd et al.
parent or caregiver is assumed to be accurate for purposes
of intervening. That all troublesome symptoms need to be
managed.
That management strategy may be targeted at the individ-
ual, a group, a family, or the work environment.
That symptom management is a dynamic process; that is, it
is modied by individual outcomes and the inuences of the
nursing domains of person, health/illness, or environment.
The domains of nursing science as they relate
to the model
In the revised model the recognized domains of nursing
science, person, health/illness and environment are con-
textual variables inuencing all three dimensions of the
model: symptom experience, management strategies and
outcomes.
Person domain
Person variables demographic, psychological, sociological
and physiological are intrinsic to the way an individual
views and responds to the symptom experience. Develop-
mental variables include the level of development or matur-
ation of an individual. When the model is used, person
variables may be expanded or contracted depending on the
symptom(s) and the population of interest.
The impact of developmental stage in the person domain is
illustrated in a study of midlife women where menopausal
symptoms affect quality of sleep as an outcome (Lee &
Taylor 1996). Premature infants may have under-treated pain
670 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
Figure 1 Revised Symptom Management
6 Conceptual Model.
due in part to the clinician's reliance on behavioural rather
than physiological cues (Franck & Miaskowski 1998).
Gender affects cardiovascular outcomes with women having
greater morbidity and mortality after coronary bypass graft
surgery (Rankin 1990) and after myocardial infarction
(Rankin et al. 1997). Gender also appears to affect the
physiologic response to analgesic medications (Gear et al.
1996). Chemically dependent patients treated in emergency
departments get more analgesics while elderly patients often
receive lower amounts of analgesics for pain management
(Puntillo et al. 1999).
Health and illness domain
The domain of health and illness is comprised of variables
unique to the health or illness state of an individual and
includes risk factors, injuries, or disabilities.
Our studies showed that variables included in the health
and illness domain have direct and indirect effects on
symptom experience, management and outcomes. For
example, different types of pulmonary disease produce
quantitatively and qualitatively different experiences of
dyspnea (Janson & Carrieri 1986). People with Type I
and Type II diabetes mellitus differ in types and presen-
tation of symptoms and in outcomes of the disease even
with similar management strategies (Hunt et al. 1998,
Rankin 1998). Stage of progression of diabetes-related
peripheral perfusion problems determines the selection of
preventive or remedial therapies (Karam 1996). Women
who develop nonpainful breast abnormalities (signs and/or
symptoms) are much less likely to seek early treatment
 Nursing theory and concept development or analysis
than those with painful breast abnormalities with resulting
poor outcomes (Facione & Giancarlo 1998). The type and
extent of cancer dictates the choice of treatment and this in
turn affects the risk factors of treatment-related morbidity.
For example, persons who are being treated for head and
neck cancer have different risks for developing painful oral
mucositis based on the type of therapy received (Shiba
1997, Beck 1999, Dodd et al. 1999).
Individuals may be at risk for symptoms related to such
environmental factors as occupational hazards, or from the
side-effects of treatment for a disease or condition, or as a
result of symptom sequelae that are associated with the
persistent primary symptoms of disease. These symptoms can
be anticipated, prevented, or diminished through interven-
tion. For example, many ergonomic hazards can be identied,
measured and corrected to prevent musculoskeletal symp-
toms (Faucett 1997, Faucett & Werner 1998). In addition,
the model allows for the assessment of factors that may
inuence the perception, evaluation and response of an
individual at risk for potential symptoms.
Environment domain
The environment refers to the aggregate of conditions or the
context within which a symptom occurs; that is, it includes
physical, social and cultural variables. The physical environ-
ment may encompass home, work and hospital. The social
environment includes one's social support network and
interpersonal relationships. Cultural aspects of the environ-
ment are those beliefs, values and practices that are unique to
one's identied ethnic, racial, or religious group.
In our studies, the setting where symptoms are experi-
enced affected both selection of management strategies and
outcomes. For example, being housed in a temporary
shelter has a marked impact on the person's perception of
fatigue, sleep and outcomes (Humphreys et al. 1999). A
patient who is receiving outpatient cancer therapy and who
develops painful oral mucositis will receive self-care sug-
gestions to manage this condition at home (Beck 1999,
Dodd et al. 1999). The biomechanical, organizational and
psychosocial aspects of the work environment offer poten-
tial intervention targets for the control of musculoskeletal
pain and related disability (Faucett 1997, Faucett &
Werner 1998). People with a chief complaint of insomnia
may have very different sleep patterns when studied in a
sleep laboratory compared with their sleep at home (Lee
et al. 2000). Patients who are taught asthma self-manage-
ment in individual sessions show improved adherence to
therapy as compared with those taught in groups and
medication skills improved more in groups than in indi-
2 vidual sessions (Wilson et al. 1993, Janson et al. 1999).
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
Symptom management
In summary, in the revised model, the three domains of
nursing science (person, health/illness and environment)
affect and modify all three dimensions of the UCSF symptom
management model. This revision is an expansion of the
theory base underlying the model and is based on original
research.
Symptom experience
The symptom experience includes an individual's perception
of a symptom, evaluation of the meaning of a symptom and
response to a symptom. Perception of symptoms refers to
whether an individual notices a change from the way he or
she usually feels or behaves. People evaluate their symptoms
by making judgements about the severity, cause, treatability
and the effect of symptoms on their lives. Responses to
symptoms include physiological, psychological, sociocultural
and behavioural components. Understanding the interaction
of these components of the symptom experience is essential if
symptoms are to be effectively managed.
There are bi-directional relationships among the compo-
nents of the symptom experience dimension. For example,
both evaluation and response can modify perception (Facione
& Dodd 1995, Jayne 1996). If an individual believes that the
symptom has ominous signicance, the perception of inten-
sity may well be heightened. In the revised model (Figure 1),
these processes are conceived to be iterative and may occur
simultaneously.
Perception of symptoms: new insights
Recent advances in brain imaging (i.e. positron emission
tomography [PET] and functional magnetic resonance
imaging [fMRI]) make it possible to `image' pain sensations
(Duncan et al. 1998, Paulson et al. 1998). However, the
technology required to perform these diagnostic pain tests is
cumbersome and not easily adaptable to inpatient or out-
patient assessments.
For a valid self-report of symptoms, the person reporting
must be responding to a perception of a symptom. Rating
scales, often used for quantication or characterization of
symptoms, are inherently limited by boundaries imposed by
the instrument, its measurement characteristics and the
capacity of the person to report. As these processes are
internal neurophysiological functions, we must ask, `Can the
internal dimensions of the symptom experience (perception,
evaluation and responses) be modied or inuenced by the
condition of the person and/or the treatments?' Such a
modication could be negative as well as positive. For
example, critically ill patients on mechanical ventilation who
671
M. Dodd et al.
receive paralytic agents to control ventilation are no longer
capable of demonstrating behavioural responses to pain, yet
they can still perceive the sensation.
The source of the report of symptom perception becomes
more complex when viewed in the context of multiple
perceivers. For example, when a child with asthma begins
wheezing and coughing, the child undoubtedly perceives
respiratory distress but, in addition, the parent perceives the
child in distress and attaches meaning to this perception.
The healthcare provider perceives the responses of child and
parent, interprets them and makes a management decision.
When the perceptions are congruent, then the management
approaches will not conict, but if they are not, then
problems arise in devising an appropriate management
solution (Koenig 1999).
In some instances, technology provides useful means to
describe a symptom experience when perception is subcon-
scious. For example, in a study of the symptoms of human
immunodeciency virus-infected (HIV) children, Franck and
colleagues (Franck et al. 1999) used wrist actigraphy to
quantitatively measure sleep, in addition to self-reports on
sleep quality by both the child and parents. Children and
parents both reported generalized `problems sleeping', with
few night awakenings, but actigraphic monitoring revealed
frequent night waking that resulted in overall poor sleep
efciency.
Culture and developmental stage will inuence an individ-
ual's symptom perception. Taylor, Lee and Berg have exam-
ined the perimenstrual and perimenopausal symptom
experiences of young and midlife women across multiple
cultures (Taylor & Bledsoe 1986, Taylor & Woods 1991,
Rittenhouse & Lee 1993, Taylor 1995, Lee & Taylor 1996,
Berg & Taylor 1999, Berg 1999). What is evident from their
studies are the important differences in perception, evalu-
ation and responses to symptoms, reecting cultural inuen-
ces on explanatory models of menstruation, childbearing and
midlife.
Evaluation of symptoms
Evaluation of symptoms entails a complex set of factors
that characterize the symptom experience, including its
intensity, location, temporal nature, frequency and affective
impact. It also includes evaluation of the threat posed by a
symptom, such as whether or not it is dangerous or has a
disabling effect. Recently, in another study of the reasons
why patients with acute asthma delay treatment, 865%
reported that seeking treatment would disrupt the social
situation or expectations of family members (Janson &
Becker 1998).
672 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
Both sexual assault history and a pattern of severe,
multiple perimenstrual symptoms have a profound impact
on women. Because little is known about the relationship
between them, Golding and Taylor (1996) evaluated the
association of sexual assault history and circumstances with
the prevalence, onset, type, severity and course of perimen-
strual symptom experience. In two national samples, women
with a history of sexual assault had more than a twofold
increase in risk for premenstrual disturbance when demogra-
phic characteristics were controlled.
Finally, an `experienced' individual, i.e. one with a long-
term history of a specic symptom, often learns to catalogue
various, discrete and subtle sensations associated with the
symptom. His or her description of the symptom's quality
can be expected to be fuller and richer than that of the same
symptom experienced by a `naive' individual (Lenz et al.
1997).
Response to symptoms
As indicated earlier, response to a symptom includes physio-
logic, psychological, sociocultural and behavioural compo-
nents. One or more of any of these responses may be seen
with a single symptom.
Physiologic responses to symptoms can include alterations
in functioning that may accentuate the symptom. For
example, the patient who experiences dyspnea and who
evaluates it as a threat, may respond by increasing minute
ventilation (respiratory rate or tidal volume). The resulting
increase in afferent neural trafc to the central nervous
system results in increased perception of dyspnea, thus
worsening the overall perception of threat. Physiologic
responses to the symptom may, in turn, activate other
negative physiological responses.
Remaining issues and limitations: symptom experience
As mentioned earlier, self-report of symptoms is considered
the gold standard for measuring symptoms. However, the
provision of quality healthcare may be jeopardized when the
evaluation of a patient's symptom by the provider or a family
member does not match the perception and interpretation of
that symptom by the patient (Fagerhaugh & Strauss 1977).
For example, healthcare professionals in emergency depart-
ments often make inferences about the degree of a person's
pain based on the patient's presenting problem rather than on
a rating score provided by the patient on a 010 numeric
rating scale. Observable problems such as a dislocated
shoulder may be given more weight than nonobservable
problems such as a migraine headache. Triage nurses in an
Nursing theory and concept development or analysis
emergency department rated presenting patients' pain signi-
cantly lower than the patients rated their own pain (Puntillo
et al. 1999).
A second issue related to the symptom experience is the
difculty in separating the patients' perceptions of a symptom
from the patients' evaluations of it. There are actually very
little data to distinguish between the patients' perceptions
and evaluations of most symptoms. The ability to make this
distinction becomes important when attempting to employ an
intervention to change a symptom experience. One way of
viewing the difference between perception and evaluation is
that evaluation is a `higher order' phenomenon: a person can
perceive pain simply by recognizing the sensations, whereas
evaluation involves a higher cognitive process of attaching
meaning to the symptom.
Concept confusion occurs when the symptom or outcome
under study or modication is confused with or clouded by a
closely related but different concept/symptom. For example,
in observing critically ill nonverbal patients, the concept of
pain may be confused by the presentation of anxiety or
agitation, because the behavioural responses are similar.
These are largely measurement issues. The instruments
chosen to assess symptoms and outcomes must be carefully
tested to avoid validity problems.
The way in which family members are involved in the
symptom experience can also create concept confusion because
others are acting as intermediaries. In the case of parent and
child, it is the parents who evaluate the child's response to a
symptom and determine the intervention needed.
The symptom experience may change over time and
detection of the symptom may become more complex.
Stevens et al. (1999), have shown that the various painful
procedures experienced by premature infants prior to under-
going a heelstick alter their responses. The behavioural
expression of the response, which is most commonly assessed
by nurses, does not change or may even diminish when the
infant is exposed to repeated pain even when the infant's
physiological responses may increase (Johnston & Stevens
1996). In other words, when monitored over a period of time,
nurses may underestimate the intensity of the symptom
experienced by the infant if behavioural cues are used
exclusively.
Clearly, the model needs further elaboration to allow for
community or group needs assessments, or health-risk pro-
ling. Such assessments would include characterizing the risk
of symptom development; evaluating the values and social
processes of at-risk groups; analysing organizational factors,
such as the resources available for effecting change; and
emphasizing prevention as well as possible constraints to
intervention. Summary group characteristics such as cultural
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
Symptom management
diversity instead of individual personal factors such as
ethnicity would be important components of the model.
The model should more specically guide the assessment of
those characteristics and allow for specication of commu-
nity intervention strategies.
Symptom management strategies
The goal of symptom management is to avert or delay a
negative outcome through biomedical, professional and self-
care strategies. Management begins with assessment of the
symptom experience from the individual's perspective.
Assessment is followed by identifying the focus for interven-
tion strategies. The intervention strategies may be targeted at
one or more components of the individual's symptom
experience to achieve one or more desired outcomes. Symp-
tom management is a dynamic process, often requiring
changes in strategies over time or in response to acceptance
or lack of acceptance of the strategies devised.
The revised model (Figure 1), includes the specications
of what (the nature of the strategy), when, where, why, how
much (intervention dose), to whom (recipient of intervention)
and how (delivered). Researchers and clinicians consider
these questions as they design, develop and prescribe symp-
tom management strategies. The specications should greatly
aid in replications of intervention studies.
The nature of the intervention depends on the state of the
science for the particular symptom. For example, the use of
around-the-clock administration of opioid analgesics is a
recommended approach for the management of metastatic
bone pain. However, little information is available on how to
assist oncology patients to adhere with the therapeutic
regimen. Therefore, a more generic intervention that utilizes
an approach of providing patients with education, self-care
skills and support is currently being tested (Miaskowski et al.
19951999). In contrast, mucositis, a commonly experienced
side-effect of chemotherapy, is a collection of signs and
symptoms for which more is known. Researchers established
that patients who regularly perform systematic oral hygiene
during chemotherapy can successfully lower their incidence
of mucositis. With this knowledge, researchers can advance
the science in the eld by testing the effectiveness and added
value of different mouthwash preparations for the prevention
of mucositis (Dodd et al. 1996).
Researchers conducting longitudinal studies are often
confronted with the problem of gauging just how much
`attention' to provide the placebo group in order to minimize
attrition, while ensuring that the attention not cause an effect.
For example, in an ongoing clinical trial testing an individu-
alized home-based exercise intervention, individuals who are
673
M. Dodd et al.
randomized to the control group receive monitoring only
with weekly phone calls of the same length as the intervention
group, but no exercise prescription (Dodd et al. 19992004).
In the evolution of the research on symptom management
strategies, developers of the model have moved from targeting
only the individual (`to whom' in the model) to including
family members and `experienced' former patients as recipi-
ents of the intervention. Miaskowski et al. (19951999)
targeted cancer patients and the family members involved in
their care with a self-care intervention to relieve the patient's
pain. From observations in clinical practice, family members,
while often very helpful to the patient in managing symptoms,
sometimes are not. Of concern are the strong beliefs held by
cancer patients and their families about the best way to relieve
pain, one issue being the use of opioid analgesics. In this
ongoing study, investigators will compare pain relief in patients
with and without family members participating in their care.
Others (Robinson et al. 1998, Whittemore et al. 2000)
have used `experienced' former patients to deliver the inter-
vention to an affected individual. In one such study, Rankin
is testing an intervention in a trial using three groups, one
comprised of elderly (>65 years) people who have had a
myocardial infarction (MI), have completed phase III cardiac
rehabilitation and have been educated as `peer advisors' to
problem solve and provide empathetic listening and social
support to others. The other two groups are a control group
and a second intervention group comprised of subjects who
receive a self-efcacy coaching intervention from cardio-
vascular advanced practice nurses. Problem solving and social
support is provided to the unpartnered elder who has had a
MI and is then released into the community with few
resources. Peer advisors have successfully intervened in
situations involving congestive heart failure, management of
physical energy demands, recurrent angina, depression and
have helped with obtaining visiting nursing services. Sharing
common experiences of recovery from MI enables the peer
advisors to develop relationships in which they assist study
participants by giving advice, alleviating fears and encour-
aging study participants to advocate for themselves within
the healthcare system.
Remaining issues and limitations: symptom
management strategies
A number of questions about symptom management remain
to be explored. For example, how is the issue of timeliness of
patient-initiated strategies dealt with? How are appropriate
and inappropriate strategies handled? Are the management
strategies effective or ineffective? Are they health-damaging?
What if there is a conict between patient and provider about
674 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
treatment choices? Who determines the dose (intensity,
duration, frequency) of the strategy?
The recipient can be an individual, the family, or the
community. Occupational and environmental health nursing,
for example, focuses care towards groups of workers or
community members rather than individuals. In the example
cited earlier, interventions involving the prevention of occu-
pational musculoskeletal pain and injury are targeted at
groups of workers facing similar job hazards. Similarly, public
health strategies focused at the group level will have the most
impact when whole neighbourhoods or other populations
may be at risk from exposure to environmental toxins.
Adherence (i.e. whether the intended recipient of the
strategy actually receives or uses the strategy prescribed) and
intervention integrity present a potentially more challenging
issue. Intervention strategies that are too demanding are
associated with increased risk for nonadherence (see Figure 1,
broken arrow between the symptom management and out-
comes dimensions).
If the intervention is applied inconsistently or not at all,
intervention integrity and the internal validity of the overall
test of the intervention are affected. Adherence is a critical
factor that affects the outcome of the intervention and is
under the control of the patient or family member who is the
target of the intervention (Turk & Rudy 1991, Sidani &
Braden 1997). However, characteristics of the health care
provider and health care system can also inuence adherence.
Outcomes
Outcomes emerge from symptom management strategies as
well as from the symptom experience. In the revised model
the outcomes dimension focuses on eight factors. A new
outcome cost includes nancial status and health services
utilization dimensions of the original model as well as receipt
of workers compensation. The costs of poorly managed
symptoms include missed professional opportunities for ad-
vancement at work, or comparable `costs' with the individ-
ual's personal life (Stommel et al. 1993, Given et al. 1994).
In the revised model there are no arrows indicating
directionality between the multidimensional indicators and
symptom status. Rather, all outcomes may be related to each
other as well as to symptom status.
The duration of symptom evaluation depends upon its
persistence, need for continued intervention and response to
treatment. When a symptom is successfully treated and
completely resolved, the model is no longer relevant. But, if
continued intervention is necessary to control recurring
symptoms, then the model continues to be applicable and
direct management and measurement of outcomes continues.
Nursing theory and concept development or analysis
Remaining issues and limitations: outcomes
A key question that has not yet been resolved is who
evaluates symptom outcomes? Is it always the patient? For
occupational and environmental health groups self care may
be considered an outcome, whereas others viewed self-care
as the ability to perform symptom management strategies. A
question for testing is: can the model embrace both of these
views and be congruent?
3 References
The model as a whole
Remaining issues and limitations: the model as a whole
A number of questions continue to be raised by UCSF
researchers involved in developing and rening this model.
For example, we are interested in studying the presentation
of several concurrent symptoms or coexistent symptoms
that may occur as a `symptom cluster.' More specically,
one symptom may receive the rst intervention or two
symptoms may be addressed simultaneously. The dynamic
nature of symptom expression means that the primary
symptom within a cluster may be subject to rapid change.
In this case, the position of the symptom in the model
might well move from foreground (priority) to background
as other symptoms become more or less distressing or more
or less severe.
In addition, the present model does not distinguish
between acute and chronic symptoms. The ramications of
acute vs. chronic symptom management need to be
explored if the model is to be comprehensive and optimally
useful.
Conclusions
The symptom management model continues to evolve as a
framework for understanding symptoms, designing and
testing management strategies and for evaluating outcomes.
The symptom management model is offered as a concep-
tualization to guide selection of management strategies in
contrast to a recently published theory of unpleasant
symptoms that focuses more on explaining the symptom
experience and how it affects function (Lenz et al. 1997).
The model is highly generalizable. The UCSF faculty
members are committed to developing symptom
management knowledge and middle range theories are
useful for this purpose. In this endeavor, dialogue with
nursing colleagues in graduate schools, clinical practice,
research and education around the globe is actively
encouraged.
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 33(5), 668676
Symptom management
Acknowledgements
The authors wish to thank the remaining members of the
Center for Symptom Management Faculty Group and the pre
and postdoctoral fellows, especially Amy Tsang, for their
discussions and insights concerning the model. This study
was funded by United States National Institutes of Health,
NIH, NINR: P30 NR03927.
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