This document discusses Symptom Management Theory (SMT), a nursing theory that explains the interaction between a patient's symptom experience, symptom management strategies, and outcomes. The theory has potential to improve chronic disease management using telemonitoring. Telemonitoring allows remote monitoring of patient symptoms and communication with providers, which could guide self-management according to SMT's conceptual domains of symptom experience, recommended strategies, and evaluation of outcomes. The document reviews SMT and proposes it as a framework to inform telemonitoring intervention design.

1. Complete Medical Theories Disc (WALDEN)
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

2. 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 – 31 – Volume 20, Number 1 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

3. 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- – 32 – Volume 20,
Number 1 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

4. 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 – 33 – 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

5. 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 – 34 – Volume 20,
Number 1 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

6. 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. – 35 – Volume 20, Number 1 Usefulness of SMT in the

7. 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