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

Figures & data

Figure 1. Walker & Avant’s approach to concept analysis by eight steps.

Table I. Description of the included 26 articles.

Author Year Journal	Design/objective	Findings	Conclusion
Armstrong, 2003Oncol Nurs Forum	Concept analysis of symptom experience	Various individual factors interact to produce symptoms in individuals, and the occurrence of symptoms can influence functional health status.	Symptoms experience is the perception of the frequency, intensity, distress, and meaning of symptoms as they are produced and expressed. Symptoms are multiplicative in nature and may act as catalysts for the occurrence of other symptoms. Antecedents to the symptoms experience include demographic, disease, and individual factors. Consequences include the impact on mood state, psychological status, functional status, quality of life, disease progression, and survival.
American Thoracic Society/European Respiratory Society (ATS/ERS) 2006 Am J Respir Crit Care Med	Statement of pulmonary rehabilitation (description of symptoms, outcomes, measurement)	Provides a definition of Pulmonary rehabilitation. Patients with COPD often suffer from exercise intolerance, dyspnea, fatigue, anxiety, depression, poor motivation, cardiac ischemia, musculoskeletal problems, osteoporosis, nutritional problems, being underweight or overweight, urine incontinence, decreased quality of life, sexual problems, concentration/memory/cognitive dysfunction, social isolation, feelings of guilt, and sleep disorders. Outcomes that are important, such as control of symptoms, the ability to perform daily activities, exercise performance, and improved quality of life. Several COPD-specific instruments are available to measure the effectiveness of symptom-reducing actions.	The evidence for improvement in exercise endurance, dyspnoea, functional capacity, and quality of life is stronger for rehabilitation than for almost any other therapy in COPD, and documentation of its favourable effect on health care utilization is increasing. The success of pulmonary rehabilitation stems from its favourable influence on systemic effects and comorbidities associated with chronic lung disease.
Dodd et al., 2001 J Adv Nurs	Concept model of symptom management	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 symptom management model continues to evolve as a framework for understanding symptoms, designing, and testing management strategies and for evaluating outcomes.
Erdley, 2005 Comput Inform Nurs	Concept development of nursing information	Information is the function of the communication process between interacting persons, whether verbal or written. Time has an impact on its value. Communication, context, form, and value describe information. Nursing information is unique to each individual, and so a variety of forms will exist. Through communication, nurses become aware of their ability to provide support, heighten awareness, and provide anticipatory guidance to those in their care. Nursing information emerges as a multidimensional concept influenced by context and by individual perceptions and understanding.	Nursing information emerged as a multidimensional concept influenced by context and individual perceptions and understanding. Technologies like computers and computer networks are tools used by nurses and other healthcare practitioners that assist with patient care and information management.
Franek, 2013 Ont Health Techno Assess Ser	Systematic review of self-management support	Support in self-management is commonly used as a structured way of helping patients learn to better manage their chronic disease.	The Stanford Chronic Disease Self-Management Program (CDSMP) led to short-term improvements across a number of health status measures (including some measures of health-related quality of life), healthy behaviours, and self-efficacy compared to usual care. There was no evidence to suggest that the CDSMP improved health care utilization.
Fu et al., 2004 Oncol Nurs Forum	Concept analysis of symptom management	Symptom management is a dynamic and multidimensional process in which patients intentionally and purposefully act on and interact with the perception (or previous perception) of the symptoms in order to initiate activities or direct others to perform activities to relieve or decrease distress from a symptom, and to prevent its occurrence.	The essential attributes of symptom management are subjectivity, experientiality, intentionality, multidimensionality, dynamic process, and positive and negative outcomes.
Haworth & Dluhy, 2001 J Adv Nurs	Concept model of holistic symptom management	The patient and the nurse require varying amounts of time to allow for the revelation, initial understanding, clarification, and interpretation of the symptom experience. The relationship between nurse and patient takes time to form, and is shaped by the degree of mutuality and trust. Both parties must have respect and accountability. Effective symptom management is dependent on the nurse hearing and attending to the lifeworld of the client.	Attending to key areas of influence in the interaction process facilitates the achievement of desired outcomes in symptom management: accurate diagnosis, symptom relief, and agreement on a course of action. The dominance of chronic illness in health care, and the centrality of the symptom experience underscores the value of sensitizing nurses to these issues.
Henly et al., 2003 Nurs Res	The concept of time in symptom experiences.	Symptom experiences in time (SET) theory conceives the symptom experience as a flow process that explicitly incorporates temporal dimensions. Four dimensions of time are recognized: clock-calendar; biologic-social, perceived; and transcendent time. The four temporal dimensions are placed against a backdrop of ‘meaning-in-time’ that brings forth the potential for transformation in a symptom experience. Increasing sophistication in design, measurement, and data analysis is required to test and evaluate SET theory-based propositions. Symptom management involves the transformation of unpleasant sensations to action or non-action via decisions about seriousness, unpleasantness, explicability, and treatability.	The SET theory extends previous work by incorporating multiple temporal dimensions that reflect the human experience of health and illness manifested in the expression and management of symptoms.
Hutchinson & Wilson, 1998 Sch Inq Nurs Pract	The Theory of Unpleasant Symptoms	The caregiver and the social and environmental context, called situational factors are of importance in the theory.	When symptoms are examined in their entirety, and nursing interventions take the interactive nature of symptoms, influencing factors and symptom consequences/performance outcomes into consideration, interventions should be client specific and, therefore, more effective.
Jolly et al., 2016 Int J Chron Obstruct Pulmon Dis	Systematic review and meta-analysis of Self-management of health care behaviours	Self-management interventions had a minimal effect on hospital admission rates. Multicomponent interventions improved. HRQoL Exercise was an effective individual component. Self-management interventions involve collaboration between healthcare professional and patient, so the patient acquires and demonstrates the knowledge and skills required to manage their medical regimens, change their health behaviour, improve control over their disease, and improve their condition.	While many self-management interventions increased HRQoL, little effect was seen on hospital admissions.
Jonkman et al., 2016 Patient Educ Couns	Systematic review and meta-regression analysis of components of self-management interventions that improve HRQoL	A self-management intervention includes several components: stimulation of symptom monitoring, education in problem solving skills regarding acute exacerbations or symptoms, resource utilization, enhancement of medication adherence, physical activity, dietary intake, and smoking cessation. Self-management interventions showed great diversity in mode, content, intensity, and duration. Although self-management interventions overall improved HRQoL at 6 and 12 months, meta-regression showed counterintuitive negative effects of standardized training of interventionists and peer interaction on HRQoL at 6 months.	Self-management interventions improve HRQoL at 6 and 12 months, but interventions evaluated are highly heterogeneous. No components were identified that favourably affected HRQoL. Standardized training and peer interaction negatively influenced HRQoL, but the underlying mechanism remains unclear.
Kim et al., 2005 Cancer Nurs	Concept analysis of symptom clusters	A symptom cluster is defined as consisting of two or more symptoms that are related to each other and that occur together. Symptom clusters are composed of stable groups of symptoms, are relatively independent of other clusters, and may reveal specific underlying dimensions of symptoms. Relationships among symptoms within a cluster should be stronger than relationships among symptoms across different clusters. Symptoms in a cluster may or may not share the same aetiology. Symptom should be broadened to include both subjective (self-reported) symptoms and objective (observed) signs.	Team members promote self-management and have strategies to reduce even those symptoms that occur together (i.e., symptom clusters).
Larson, 1994 Image J Nurs Sch	A model for symptom management	Symptom management is a challenging experience for patients, families, and health care professionals. The model, focus on symptom experience, management strategies, and outcomes.	The model is applicable to practice and research, and is currently being used in a variety of studies and settings.
Lenz et al., 1995 ANS Adv Nurs Sci	Theory development of unpleasant symptoms	Unpleasant symptoms are illness-related rather than treatment-related, and there may be relationships between them. Physiological, psychological, and situational factors affect the patient’s performance, including functional status, cognitive functions, and physical performance.	A sustained substantive example is provided by the beginning development of a theory of unpleasant symptoms.
Lenz et al., 1997 ANS Adv Nurs Sci	The middle-range theory of unpleasant symptoms	Symptoms can occur alone or in isolation from one another, but if multiple symptoms occur simultaneously they are likely to catalyse each other and further worsen the overall experience. Several dimensions are common across symptoms and clinical populations: intensity (strength and severity); timing (duration and frequency of occurrence); level of distress perceived (degree of discomfort or bothersomeness); and quality. People differ in their ability to discern symptoms.	Revisions have resulted in a more accurate representation of the complexity and interactive nature of the symptom experience. Examples are provided to demonstrate the implications of the revised theory for measurement and research, and its application in practice.
Parker et al., 2005 J Nurs Scholarsh	Review of Symptom interactions	The team members use observable action to recognize, alleviate, or eliminate symptoms. The nurse promotes self-management and has strategies to reduce symptoms.	These results indicate the need for further work and theory development in this area. The symptom interactional framework is a beginning conceptual perspective designed to facilitate this work. Implications for interdisciplinary translational research designed to optimize symptom management are discussed.
Piredda, 2004 International Nursing Perspectives	Concept analysis of patient education	Communication and dialogue are needed in patient education. The process is patient-centered, and needs interaction, time, partnership, and the patient’s readiness and willingness.	Patient education is a planned process of activities designed to enable people to improve knowledge, to acquire skills, and to facilitate voluntary adaptation of behaviours in order to restore, maintain, and improve health.
Posey, 2006 Nurs Forum	Concept exploration of symptom perception	Important aspects include the belief that an individual has about what a particular symptom means (cognitively and emotionally), the appraisal of the symptom based on past and present knowledge and experience, and the response or action of the individual based upon that meaning and appraisal. The individual is an active participant while experiencing the symptom.	Symptom perception and the related concepts have overlapping ideas but vary in meaning and in measurement. This concept analysis explored symptom perception and the related concepts and looked at each one critically in its applicability to a final working definition of symptom perception.
Powell & Gibson, 2007 The Cochrane Library	Systematic review of self-management education	The nurse clarifies the meaning of something and recommends actions with advice. Patient education is aimed at helping patients gain the motivation, skills, and confidence to control their disease, and gain both a written and a verbal form.	Optimal self-management allowing for optimization of disease control may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualized written action plans based on symptoms. Reducing the intensity of self-management education or level of clinical review may reduce its effectiveness.
Reach, 2009. Patient Educ Couns	Trans-theoretical analysis of obstacles to patient education	Considering future patients’ adherence to educational programmes and long-term therapies, it must be focusing on patients’ projects.	The very concept of prevention entails features that jeopardize the efficiency of educational programmes used for its implementation. In chronic diseases, designing programmes proposing concrete and short-term preventive measures may represent a way to overcome this obstacle. Habit may be used to reinforce connectedness which forms personal identity. Thus, taking into account this temporal dimension of educational programmes is essential.
Roman-Rodriguez et al., 2016 NPJ Prim Care Respir Med	RCT for assessment tools in symptoms	Several COPD-specific instruments are available to measure the effectiveness of educational activities such as COPD Assessment Test (CAT) and modified Medical Research Council dyspnoea scale (mMRC).	An educational intervention programme targeted on primary care physicians enhances the use of respiratory health status tools and promotes behavioural changes.
Stamler, 1996 J Holist Nurs	Concept analysis of enablement in patient education.	Patient education is one of the interventions that are formally and informally directed at enablement, and the nurse plays the role of enabler. The process is patient-centred, and needs interaction, time, and partnership.	An analysis that resulted in a definition of enablement and the identification of three components: means; abilities; and opportunities.
Teel et al., 1997 Image J Nurs Sch	Theory of symptom interpretation.	Symptom interpretation model is based on an illness representation model, knowledge structures theory, and propositions about reasoning. Individuals name and assign meaning to environmental stimuli. Based on this interpretation, behaviours are selected for symptom management.	Symptom familiarity reinforces patterns about symptom management. Symptom interpretation model enriches understanding of symptom experiences. The intra-individual perspective, is essential to successful symptom management.
Timmins, 2006 Int J Nurs Pract	Concept exploration of information need.	Information seeking is the most frequent method used to cope with a stressful event about which information is limited, and in this case communication requires professional action.	Information need emerged as a want or desire for information to be shared by professionals using appropriate communication skills. Information-seeking behaviour manifests in individuals as a response to a stimulus that is perceived as either a challenge or a threat.
Tveiten, 2005 J Nurs Manag	Concept evaluation of supervision.	Supervision can be defined as a formal, pedagogical, relational enabling process, related to professional competence. Relationship and dialogue are central aspects. Supervision is based on theory and humanistic values, has a normative, formative and restorative function. The supervisor’s competence is of great importance. Supervision has unclear boundaries with concepts such as psychotherapy, consultation, and counselling.	Supervision can be defined as a formal, pedagogical, relational enabling process with the purpose to strengthen resources, enhance assertiveness, and improve independence and coping.
Yoon et al., 2006 Int J Nurs Pract	Concept exploration of patient education.	Patient education is a planned learning activity, purposefully designed and systematically implemented. It occurs over a period of time, and enables the learner to properly understand the information provided. It is flexibly and individually implemented to fulfil the patient’s unique needs.	Successful patient education includes enhanced patient participation in health care decision-making, improved commitment to treatment, increased patient satisfaction, increased ability to cope with illness, improved quality of life in patients and their families, and decreased anxiety.

Table II. Overview of literature search in MEDLINE and CINAHL articles written in English and published between 1982 and February 2016.

Keyword	Number of hits	Included
Concept analysis	54,458
AND symptom AND nursing	111	14
AND patient education AND nursing	129	8
AND Information AND nursing	406	2
AND supervise	8	1
AND rehabilitation AND nursing	446	1

Figure 2. Symptom-reducing actions in relation to education, information, supervision, and the emotional part.

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