Complete Medical Theories Disc (WALDEN)

Describe one biomedical theory or model frequently used in health care and provide your rational for how it relates to improved patient outcomes.

Describe one biomedical theory or model that is utilized in your specific practice area. Provide at least two examples related to its application

Erin Christine Shankel, DNP, RN, FNP-BC and
Linda G. Wofford, DNP, RN, CPNP
Abstract: Symptom Management Theory, developed by faculty at the University of California,
San Francisco, is a middle-range nursing theory which explains the interaction between symptom
experience, symptom management strategies, and outcomes. Successful integration of the model into
the emerging field of telemonitoring has the potential to improve outcomes and lower costs associated
with the management of chronic diseases. Modifications to the model related to communication,
feedback, and adherence may make it more suitable for this application.
Key Words: chronic disease, nursing theory, symptom management theory, symptom assessment,
telemedicine
Symptom Management Theory as a Clinical
Practice Model for Symptom Telemonitoring in
Chronic Disease
A
s chronic disease and life expectancy continue
to increase simultaneously, management of
chronic conditions will become increasingly
burdensome in terms of both manpower and financial
costs. Now more than ever, creative strategies for the
management of chronic diseases are needed. The field
of telemedicine is growing rapidly, and clinical practice
models must evolve to guide and support development
of chronic disease management initiatives. The aim
of this article is to discuss the potential of Symptom
Management Theory (SMT) (Humphreys et al., 2014)
to improve outcomes and lower costs associated with
the management of chronic diseases.
The financial burden of chronic disease is staggering. Currently, the percentage of U.S. dollars spent on
chronic conditions is about 75% among the general
population (Harris & Wallace, 2012) and is closer to
95% among those over age 65 (Centers for Disease
Control and Prevention, 2013) Among older adults,
the percentage who report having one or more chronic
diseases rose more than 5% between 1998 and 2008,
and that trend will likely continue (Dall et al., 2013).
Furthermore, by 2050 the number of Americans over
65 is expected to more than double to 89 million,
compared to 40.5 million in 2010 (Dall et al., 2013).
This growing population of older and sicker patients
is projected to lead to a 25% increase in health care
Burden of Chronic Disease
expenditures by 2030 (Centers for Disease Control
The prevalence of chronic diseases such as osteoar- and Prevention, 2013).
thritis, asthma, chronic obstructive pulmonary disease
The U.S. is ill-equipped to handle the financial
[COPD], heart disease, hypertension, depression, and burden of increasing medical costs, but the healthcare
diabetes is on the rise. Approximately half of all Ameri- field also lacks the manpower (Dall et al., 2013). Lowcans have been diagnosed with at least one chronic
er-cost methods of preventing and managing chronic
disease, and one in four has multiple chronic diseases
conditions can be found in lower-acuity settings, such
(Ward, Schiller, & Goodman, 2014). The reason for
as primary care. However, fewer and fewer physicians
this rapid increase is multifactorial. On one hand, poor are choosing to go into primary care, and even increaslifestyle choices abound. On the other hand, advances ing numbers of other clinicians (such as nurse practiin medicine are contributing to greater life expectantioners [NPs] and physician assistants [PAs]) cannot
cies, giving genetic predispositions for disease more
make up the gap. In the U.S. only 35% of physicians
time to come to fruition.
are primary care providers (PCPs), compared to 50%
in other industrialized countries (Bodenheimer, et al.,
The Journal of Theory Construction & Testing
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2009). Of note, most of these countries with higher
percentages of PCPs have better outcomes, lower costs,
and better access to care than what is seen in the U.S.
Bodenheimer et al. (2009) suggest that there are
three ways that increased demand for low cost, lowacuity management of chronic diseases can be met:
specialty care, primary care, or multidisciplinary
teams. Their extensive research examined differences in
the way chronic diseases are managed in specialty and
primary care settings. In the first scenario, specialists
are uniquely equipped to manage individual conditions, but they are more likely than generalists to order
expensive diagnostic tests unnecessarily (Bellinger et
al., 2010). There are also well-documented disparities
in access to specialty care, especially among those living in rural areas and/or with low incomes (Bellinger
et al., 2010). If number of PCPs continue to dwindle,
many patients may be forced to seek routine care in
specialty settings, thereby promoting a steeper increase
in medical expenditures and health disparities.
Reliance on specialists alone would reduce coordination of care and emphasis on health promotion typically found in primary care (Bellinger et al.,
2010). The second scenario, in which primary care fills
the gap, is more ideal but, as previously mentioned,
current workforce trends do not suggest this will be
feasible. The third scenario would use a multidisciplinary team – made up of physicians, NPs, PAs,
registered nurses, pharmacists, and community health
workers – to address the needs of patients with chronic
conditions. According to Friedman et al. (2014), this
option has potential to ease disease burden, improve
outcomes, and reduce costs, but successful implementation will require significant changes to the current
health care system. For instance, one of the most
weighty barriers to implementation of team-based
care is reforming deeply held beliefs about traditional
physician role and identity. Changes required to convert the traditional healthcare system to a team-based
system are meritorious, but they will take time.
A fourth option may exist. Telemonitoring, a field
in which technology is used to provide remote health
care, could allow specialists, primary care providers,
and multidisciplinary teams to more efficiently manage symptoms of chronic disease. Because collaborative management of chronic diseases places much of
the onus on patients to perform adequate self-care
between visits (Estes, 2008), remote communication
with providers is sometimes necessary. For example,
a patient who has asthma might see his NP every six
months for routine evaluation, but within that interval
he will likely experience recurring and remitting respiratory symptoms related to many factors, including
oral health (Estes, 2010). Telemonitoring can provide
a method by which patients’ self-care strategies are
guided by interactive communication with providers,
allowing patients like this one to receive immediate
input about appropriate management options.
The Journal of Theory Construction & Testing
Telemedicine and Telemonitoring of Chronic Diseases
Telemonitoring is a subset of telemedicine. Telemedicine is defined as “the use of medical information exchanged from one site to another via electronic
communications to improve a patient’s clinical health
status” (American Telemedicine Association, n.d.). The
field is relatively new and much has yet to be discovered, but emerging research shows great potential. A
2015 review of literature (American Telemedicine Association, 2015) shows that high quality, cost-effective
care can be delivered through telemedicine while also
achieving high rates of patient satisfaction.
While telemedicine is a term that can broadly be
used to describe any sort of direct patient care (including diagnosis, treatment, or consultation) that occurs
via technology for patients at a distance, telemonitoring is understood more narrowly as using telecommunication technologies to remotely monitor data about
patient status (Pare, Jaana, & Sicotte, 2007). Both
objective and subjective data can be telemonitored.
Objective data, like blood glucose readings, vital signs,
and weight, are easily measured by patients from home
and transmitted via phone, SMS messages, Smartphone applications, or computer. Similarly, subjective symptoms can be tracked and transmitted from
patients to health care providers.
Because symptoms are the most common reason
patients seek healthcare (Lee & Miaskowski, n.d.), an
acceptable alternative method of managing symptoms
might eliminate the need for some of these costly
visits. Telemonitoring could potentially provide guided
self-management of symptoms, thereby reducing unnecessary resource utilization. The full implications of
symptom telemonitoring are not yet known, but so far
it appears that “remote patient monitoring that tracks
vital signs of patients with chronic diseases is offering more-frequent contact between the patient and
the primary care provider, providing earlier detection
of potential problems, and allowing real-time alerts,
resulting in a proactive, affordable option for bestpractice health care” (Schwartz & Britton, 2011, p.
216).
Telemonitoring has the potential to offer patients
a more active and immediate role in managing their
health. When a patient experiences symptoms—for
example, wheezing—telemonitoring permits him to
share those symptoms with his provider in real time.
The role of the provider is to suggest symptom management strategies (e.g., a nebulizer treatment), and
the role of the patient is to then implement the recommended strategies as he sees fit. Continued telemonitoring can help providers evaluate ongoing symptom
status outcomes, such as reductions in coughing or
wheezing. These steps – communication of a symptom
experience, recommendation of symptom management strategies, and evaluation of outcomes – make
up the three conceptual domains of SMT. This pro-
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cess of experiencing and reporting symptoms, seeking
management, and evaluating outcomes is familiar, as it
frequently happens in traditional face-to-face patient
encounters. Telemonitoring, however, changes the timing and context of these steps, and may alter the way
SMT is understood.
Overview of SMT
Most published telemonitoring interventions do
not use any documented behavioral change theories,
clinical guidelines, or assessment tools to inform their
design (Al-Durra, Torio, & Cafazzo, 2015). Many articles that do include theoretical frameworks use theories such as the Transtheoretical Model, which focus on
patient motivation and behavior (Battaglia, Benson,
Cook, & Prochazka, 2013; Finkelstein & Cha, 2009;
Tabak, et al., 2012). While these articles are helpful in
understanding the diffusion and adoption of telemonitoring systems, there is a paucity of clinical practice
models and theoretical frameworks addressing adherence and communication with telemonitoring. SMT
(Dodd et al., 2001; Humphreys et al., 2008; Humphreys et al., 2014) may be useful in filling this gap.
SMT (Dodd et al., 2001; Humphreys et al., 2008;
Humphreys et al., 2014) was originally introduced
by the nursing faculty at University of California, San
Fransisco (UCSF) in 1994, was updated in 2001, and
again in 2008. (See Figure 1.) The model development
was a collaborative effort, incorporating the expertise
of faculty with diverse experience in managing symptoms of chronic diseases such as heart disease, diabetes,
cancer, COPD, and chronic pain. It is a deductive,
middle range theory describing three simultaneously
interactive factors within the domain of nursing care
(Humphreys et al., 2008). These three main factors are
symptom experience, symptom management strategies,
and symptom status outcomes (See Figure 1). Each of
these domains is connected to the others with bidirectional arrows, symbolizing the mutual interaction of
each factor with both of the other factors. Additionally,
a broken bidirectional arrow between symptom management strategies and outcomes labeled “adherence”
exists to show the risk of nonadherence that occurs at
this stage. The model has been described extensively
elsewhere (Humphreys et al., 2014), but this article
will briefly summarize the essential points.
The commonly acknowledged starting point of the
model is the symptom experience component. Here
the patient perceives, evaluates, and responds to symptoms. Examples could include wheezing, as used in a
previous example, or a multitude of other symptoms,
such as anxiety, headache, joint pain, or insomnia.
Figure 1. Symptom Management Model.
Reprinted from “Advancing the Science of Symptom Management,” by M. Dodd, S. Janson, N. Facione, J. Faucett, E. S.
Froelicher, J. Humphreys, K. Lee, C. Miaskowski, K. Puntillo, S. Rankin, and D. Taylor, 2001, Journal of Advanced Nursing,
33(5), 668-676. Copyright 2001 by Blackwell Science Ltd. Reprinted with permission.
The Journal of Theory Construction & Testing
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Volume 20, Number 1
Figure 2. Newcomb’s Spiral Symptom Management Model.
Environment
Person
Health
Symptom
experience
communication
Symptom
management
adherence
Outcomes
feedback
Reprinted from “Using Symptom Management Theory to Explain How Nurse Practitioners Care for Children with Asthma,”
by P. Newcomb, 2010. Journal of Theory Construction & Testing, 14(2), 40-44.
While patients’ perceptions are extremely valuable, the
meanings patients assign to their symptoms occasionally lead to ill-timed or inappropriate symptom management strategies. For instance, a person who is wheezing
may not perceive his symptoms as severe enough to
seek treatment until the wheezing is so acute that it becomes necessary to go to the emergency room. Janson
and Becker (1998) described this phenomenon in an
article showing that, among patients with asthma, two
of the most common reasons that patients delay seeking care during an acute exacerbation are the concepts
of “minimization” and “uncertainty”.
Minimization refers to under-recognition of an
asthma episode’s severity, while uncertainty refers to
a patient’s ambiguity about how to interpret a symptom’s meaning or what to do about it. Because patients
suffering from chronic condition often deal with
recurring and remitting symptoms for long stretches
of time between health care visits, patients are left to
interpret their symptoms through the lens of their own
lay knowledge and past experience. Not surprisingly,
this interpretation affects how and when they progress
to the next phase of the model, symptom management
strategies.
During the second stage of symptom management strategies, an intervention may be performed.
According to Humphreys et al. (2014), the goal of
The Journal of Theory Construction & Testing
Symptom
experience
symptom management is to “avert, delay, or minimize
the symptom experience” (p. 144). However, because
patients may delay seeking advice and treatment due
to issues like minimization or uncertainty, the invasiveness, risk, cost, and potential success of the symptom management strategy varies accordingly. Using the
example of asthma, if a patient delays seeking treatment for early signs of an exacerbation, what could
have been managed conservatively through increased
inhaled corticosteroid doses often progresses to a need
for oral corticosteroids, emergency room visits, and
hospitalizations. Authors of the model agree that more
research is needed regarding how to deal with the issue
of timeliness of patient-initiated strategies (Dodd et
al., 2001).
Dodd et al. (2001) assert that the type of intervention should be specific to the symptom and should
be guided by current evidence within the field. This
expectation is problematic in patients who have
chronic diseases because they may be using symptom
management strategies that are not evidence-based.
Patients rely on information from their health care
providers, and from family, friends, media, and the
internet (Humphreys et al., 2014), especially when
communication with providers does not occur between visits. There is increasing emphasis placed on
shifting the responsibility for chronic disease symptom
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management to the individual patient (Humphreys et
al., 2014), rightly affirming value of the patient’s own
lived experience and self-knowledge. However, aligning the patient’s experience and self-awareness with the
provider’s medical knowledge can only strengthen the
accuracy of the patient’s interpretation of his symptom experience.This partnership between patient and
provider can improve the efficacy of symptom management strategies. Multiple studies have shown that this
type of collaboration, known as “informed self-monitoring” improves health outcomes (Janson & Becker,
1998; Janson et al. 2003, 2010, 2009).
During stage three of the model, the symptom
experience and symptom management strategies lead
to symptom status outcomes, which can then go on
to subsequently influence future symptom experience
and, in turn, symptom management strategies. Outcomes can include quality of life, self-care, morbidity
and comorbidy, mortality, functional status, emotional
status, and direct and indirect costs (Dodd et al.,
2001). For patients with chronic diseases, symptom
experiences and evidence-based symptom management
strategies may not immediately or obviously result in
improved symptom status outcomes. For example, it
may not be obvious to the hypertensive patient that
daily adherence to prescribed medication is associated
with gradual improvement in such blood pressure-related symptoms as headaches or blurred vision. Unless
strategies are employed to assist patients to make these
connections, positive symptom management strategies
producing gradual clinical improvements may not be
reinforced.
Newcomb’s Modifications to the SMT Model
Newcomb (2010) suggested an alteration to the
SMT model in which communication and feedback
were explicitly described as conceptual links between
the model components symptom experience, symptom
management strategies, and symptom status outcomes.
(See Figure 2.) Communication, positioned between
symptom experience and symptom management
strategies in the model, emphasizes the bidirectional
exchange of information between a patient’s experience
of symptoms and his attempts at symptom management, which may involve the patient’s health care provider and/or family members. For example, Newcomb
(2010) used this communication concept to explain
the unique ways children and parents collaborate first
to perceive and interpret asthma symptoms and then
to respond. However, competing demands and limited access to care can negatively impact the patient’s
likelihood of initiating communication with providers,
and unfortunatly, in an outpatient setting, unscheduled communication relies upon the patient or parents
taking initiative. The UCSF faculty who developed
the model agree that “providers must establish and
maintain good patient-provider communication if they
are to understand their patient’s symptom perception,
The Journal of Theory Construction & Testing
accept symptom experience, and implement management strategies” (Humphreys et al., 2014, p. 155).
Newcomb’s modified model makes the communication concept more explicit.
The second concept Newcomb (2010) adds to the
original SMT model is feedback. Feedback explains
how patients evaluate the efficacy of their symptom
management strategies in terms of their resulting
health outcomes. Feedback refers to the patient’s
receipt of information concerning whatever disease
process is underlying the symptoms of interest, and
this information can help the patient notice connections between the symptom experience and outcomes.
For example, if a patient with uncontrolled asthma
was prescribed a new daily controller medication and
then returned to the clinic two weeks later stating, “I
don’t think it makes much difference. I think I’m going to stop using it”, he could benefit from feedback.
Appropriate feedback might include a comparison of
a symptom survey completed during the current visit
compared to one completed two weeks ago. If self-reported scores improved during the two-week interval,
that information could inform the patient of gradual
changes in his symptom experience that he may not
have noticed on his own. Access to feedback can help
patients make informed decisions about adherence,
which can subsequently affect outcomes. When selfmanagement strategies result in improved symptom
status outcomes, the successful strategies are likely to
be repeated. As already discussed, some outcomes may
not be immediately noticeable to patients with chronic
diseases, which causes a breakdown in the SMT model
at the point of feedback.
Application of the SMT Model to Telemonitoring
Telmonitoring technologies such as electronic logs,
text messaging, and interactive SmartPhone apps can
empower patients to track their symptoms, receive
immediate feedback, and manage their chronic disease
symptoms more effectively. Because of this cyclical
process, the SMT model, which has been useful in
a multitude of other clinical settings, shows promise
within the field of telemonitoring.
The model has gained particular acceptance in
a few pockets of clinical practice such as oncology
(Baggott, Cooper, Marina, Matthay, & Miaskowski,
2012; Cherwin, 2012; Steel et al., 2010) and cardiology (DeVon, Ryan, Rankin, & Cooper, 2010; Hwang,
Ahn, & Jeong, 2012; Jurgens et al., 2009; McSweeney, Cleves, Zhao, Lefler, & Yang, 2010; Riegel et al.,
2010). Health professionals within the disciplines of
cancer and cardiac care may gradually become familiar with the theory through reading current literature
relevant to their specialty. Likewise, those blazing trails
in the field of telemonitoring must be exposed to SMT
through reading about successful applications to their
practice.
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Usefulness of SMT in the emerging field of telemonitoring has been explicitly addressed in only one
article. In 2009, SMT was used as the framework
for studying the effect of telehealth intervention on
physical activity and functioning in patients who had
recently undergone coronary artery bypass surgery
(Barnason, Zimmerman, & Schulz). The intervention was a 6-week symptom management tool that
was connected to the participants’ telephones. Participants responded to assessment questions, and received
management strategies based on their reported symptoms. In this way, the patients’ symptom perceptions
were immediately addressed by electronic symptom
telemonitoring devices), with an expectation of improving outcomes related to activity and functioning.
Comparing the telemonitoring group with the usual
care group yeilded a significant main effect (F[1,209]=
4.66, p