Symptom Experience of Adult Hospitalized Medical-Surgical Patients

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1 Vol. 28 No. 5 November 2004 Journal of Pain and Symptom Management 451 Original Article Symptom Experience of Adult Hospitalized Medical-Surgical Patients Alison E. Kris, RN, PhD and Marylin J. Dodd, RN, PhD, FAAN Department of Physiological Nursing, University of California at San Francisco, San Francisco, California, USA Abstract The purpose of this study is to describe the symptom experience of adult patients hospitalized in medical/surgical units, to examine the relationship between demographic characteristics and symptom experience, and to explore the relationship between symptom severity and symptom distress. Utilizing the Memorial Symptom Assessment Scale (MSAS), patients (n 334) were asked to convey the presence or absence of each of 31 symptoms, the severity of the symptoms, and the degree to which the symptoms distressed or bothered them. Higher levels of symptom distress were found in women and in those who were unpartnered. The average number of symptoms reported per patient was 9.31 (SD 5.15), with a mean symptom distress rating of 1.8 (SD 0.84) and a mean symptom severity rating of 1.65 (SD 0.83) on a 1-5 scale. The correlation between reports of symptom severity and symptom distress varied greatly by symptom, ranging from r 0.37 to r This is the first study to examine the symptom prevalence, severity, and distress of hospitalized medical/surgical patients. The large sample size allowed for the detection of demographic differences in the reporting of symptom distress, and advances the current knowledge in the area. J Pain Symptom Manage 2004;28: U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Hospitalized adults, symptoms, symptom distress, Memorial Symptom Assessment Scale, MSAS Introduction High levels of symptom distress have been associated with diminished quality of life, 1 and decreased satisfaction with inpatient care. 2 Furthermore, patients who experience higher levels of symptom distress during their hospital stay are more likely to require home care following discharge, 3 resulting in increased costs to Address reprint requests to: Alison E. Kris, RN, PhD, 1095 Farmington Avenue, West Hartford, CT 06107, USA. Accepted for publication: January 26, U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. the health care system. While higher levels of symptom distress have been associated with shortened survival times in cancer patients, 4 nursing interventions targeted at the palliation of symptom distress have been shown to increase survival times 3 and improve quality of life. Although previous research has suggested that pain management in acute care hospitals is inadequate, 5,6 the prevalence, severity and distress from the multiplicity of symptoms experienced by patients hospitalized on medical-surgical units has not been previously evaluated. This paper a) describes the symptom experience of adult medical-surgical patients, b) examines the relationship between demographic characteristics /04/$ see front matter doi: /j.jpainsymman

2 452 Kris and Dodd Vol. 28 No. 5 November 2004 and symptom experience, and c) explores the relationship between symptom severity and symptom distress. The University of California San Francisco Symptom Management Model provides a framework for understanding the relationship between aspects of the symptom experience, symptom management strategies and symptom outcomes. 7 Previous research examining the relationships within this model, including the relationships between symptom distress and a variety of demographic characteristics (e.g., age, gender and marital status) has yielded conflicting results. McCorkle, Cooley and Shea 8 found that age was not a significant predictor of symptom distress score (n 683, P 0.32). However, Degner and Sloan 9 found that older patients experienced less symptom distress than younger patients, although the correlation was weak (n 434, r 0.11, P 0.026). Tishelman et al. 10 found that age did not have a significant impact on the total symptom distress score except in an appetite/nausea subscale, which older patients reported less distress than did younger patients (n 45, P 0.05). In addition to age, other patient characteristics have been tested. McCorkle, Cooley and Shea. 8 reported significant differences among various demographic groups. This overview of four studies found that women report higher levels of symptom distress than men, with women scoring an average of 27.4 (S.D 7.9), and men reporting an average of 26.0 (S.D 7.6; n 670; P 0.02) on the Symptom Distress Scale (SDS). This finding is consistent with that of Degner and Sloan, 9 who, in a sample of 82 lung cancer patients, found that women report more distress than men (n 434, P 0.041). Tishelman et al. 10 did not find a significant contribution of gender to the level of symptom distress. In fact, her sample of 46 heterogeneous cancer patients (35 women and 11 men) showed that the women actually had a lower mean symptom distress score (SDS), although this difference was not statistically significant. Holmes 11 was unable to find any effect of gender on symptom distress in a sample of 120 newly-diagnosed cancer patients utilizing a modified symptom distress scale. Vogl et al., utilizing the Memorial Symptom Assessment Scale (MSAS), found no differences between men and women in the distress subscale in a group of 504 AIDS outpatients. 12 However, in this sample, men reported higher levels of distress from pain, cough, nausea, feeling bloated, feeling irritable, dry mouth and changes in appearance, whereas women found diarrhea and lack of sexual interest significantly more distressing. Gift and Shepard 13 utilized the MSAS in a group of 104 outpatients with chronic obstructive pulmonary disease. In this study, women had more physical symptoms (M 1.94, SD 0.60) than men (M 1.65, SD 0.53) (P 0.02),and reported thesesymptoms to be, on average, more distressing than did men (women s mean 1.7, men s mean 1.4, P 0.05). However, there were no differences between men and women on the psychological symptom subscale. McCorkle et al. 8 reported that patients who had a partner reported greater symptom distress than those without partners (M 27.6, SD 7.8) and (M 25.6, SD 7.6), respectively (P ), a finding that was contradicted elsewhere. 10 In addition to the relationship of demographic characteristics to symptom scores, the relationships between the components of the symptom experience are not well understood. While it has been asserted that symptom distress and symptom severity are different concepts requiring different measures, this relationship has rarely been reported. Methods Sample and Procedures Data were collected as part of a larger study to examine the relationship between nurse staffing levels and patient symptom experience. 17 Data collection took place on 64 medical-surgical units in 21 acute care hospitals throughout the state of California. The sample of patients included all eligible patients who were admitted to a medical-surgical unit of the hospital with a length of stay between 2 to 7 days at the time of data collection. In addition, patients were required to be over 18 years of age, alert and oriented, and able to communicate in either English or Spanish. A 100% sample of all of the patients meeting these criteria was selected from daily census sheets in consultation with the supervising nurse of the unit. Patients were asked to complete the MSAS and report the presence or absence of each symptom, how severe the symptom was (1 slight, 4 very severe) and how much the symptom

3 Vol. 28 No. 5 November 2004 Medical-Surgical Patients Symptom Experience 453 distressed or bothered them (0 not at all, 5 very much). Patients unable to complete the interview in English were interviewed in Spanish by a Spanish-speaking research assistant. Of a total of 470 patients consenting to be in the study, 334 were able to complete the MSAS. Patients unable to complete the MSAS tended to have a greater number of admission diagnoses and a slightly longer length of stay at the time of the interview, although these differences were not statistically significant. Patients able to complete the MSAS were younger than those who could not (P 0.01). The proportions of men and women were similar in both groups. While the reasons for attrition were not systematically assessed, it was the perception of the interviewers that the length of the scale contributed to attrition in this acutely ill patient population. Measures The MSAS is preferable to other measures of the symptom experience in that it is the most complete scale available, measuring the frequency, intensity and distress of 31 different symptoms. The validity and reliability of this instrument has been tested in a population of cancer patients, both inpatient and outpatient from a VA cancer treatment center in New Jersey. Cronbach s alpha coefficients for the MSAS-SF (MSAS-Short Form) subscales range from 0.76 to 0.87, with test-retest correlation coefficients of at one day in a group of hospitalized cancer patients. In addition, this instrument has demonstrated convergent validity with performance status, inpatient status andextentofdisease. 18 The Spanish version of the MSAS and consent forms were initially prepared utilizing translation software and corrected with the assistance of a Spanish speaking colleague. In addition, the translation was checked for consistency with existing Spanish symptom scales, such as the Spanish SDS. 8 The MSAS Distress Scale score reflects the mean level of distress from all symptoms present. Assessing distress only for those symptoms reported is a benefit of the MSAS in this heterogeneous inpatient population, and contrasts with other scales, such as the Symptom Distress Scale (SDS), that sum the distress from each symptom. In the SDS, patients who have diagnoses associated with high numbers of symptoms (such as AIDS) will always have high symptom distress scores, despite the fact that the relative level of distress associated with each symptom may be low. Since the medical-surgical unit patient population includes a wide variety of diagnoses, some associated with numerous symptoms, some with few, it is important that the symptom distress scale score is independent of the number of symptoms reported. Unfortunately, the length of the MSAS may lead to high levels of subject burden as it requires responses of up to 93 questions. It should be noted that although 334 patients completed the MSAS, there are many instances in which the MSAS contains missing data. As a result, throughout this section percentages are expressed as the percentage of valid responses to a given item (NVAID%). Therefore, despite the fact that the reported frequency of an item may be the same, the percentages reported may vary. Finally, the MSAS item related to disturbances in sexual activity was omitted as it did not seem to be pertinent to an acutely-ill inpatient population, and was considered to be sensitive in nature. Results The mean age of the study sample was 57.0 (n 332, SD 18.22), with a range of 18 years of age to 93 years of age. Women comprised 54.1% of the study participants. Approximately 46% percent of the study participants were partnered. The overwhelming majority of participants were English speaking (95.2%), with 3.3% of the participants completing the patient interview in Spanish. Patients reported a mean of 13.8 (SD 3.3) years of education and were covered through a variety of insurance programs, including Medicare (n 80, 24.7%) and Medi-Cal (n 26, 8.0%). Diagnostic categories were created based upon patient diagnoses using the major diagnostic categories (as captured by ICD-9 coding) associated with the patients primary admission diagnoses. Symptom Experience Symptom Prevalence. The majority of patients reported multiple symptoms. The average number of symptoms reported per patient was 9.3 (SD 5.15). The most commonly reported symptoms included pain (n 242, 74.0%) and dryness of the mouth (n 218, 66.5%). The next

4 454 Kris and Dodd Vol. 28 No. 5 November 2004 three most commonly reported symptoms appear to be somewhat interrelated: lack of energy (n 193, 58.3%), difficulty sleeping (n 181, 55.4%) and feeling drowsy (n 162, 49.7%). The least common symptoms included problems with urination (n 26, 11.7%), hair loss (n 21, 6.9%),and mouthsores(n 21,6.8%) (Table 1). Symptom Frequency. When symptoms were present, they were experienced with varying degrees of frequency ranging from 1 rarely to 4 almost constantly. The most persistent symptoms included lack of energy (M 3.09, SD 0.96), numbness (M 3.04, SD 1.05), feeling bloated (M 3.03, SD 0.98), and pain (M 3.02, SD 1.03). Symptoms experienced on a more intermittent basis included sweating (M 2.19, SD 0.90), dizziness (M 2.14, SD 0.89), nausea (M 2.13, SD 0.96) and vomiting (M 1.82, SD 0.91). Symptom Distress. The mean symptom distress rating among this sample of patients across Table 1 Frequency of Patients Who Reported Each Symptom (n 334) Symptom Frequency % of Patients Pain Dry mouth Lack of energy Difficulty sleeping Feeling drowsy Nausea Cough Worrying Lack of appetite Shortness of breath Feeling nervous Sweats Swelling of arms or legs Dizziness Itching Difficulty concentrating Feeling sad Numbness Weight loss Feeling irritable Feeling bloated Vomiting Constipation Diarrhea I don t look like myself Changes in skin Food tastes Difficulty swallowing Problems with urination Hair loss Mouth sores Other all 31 symptoms was 1.8 (SD 0.84), with responses ranging from 0 not at all to 5 very much. In addition to the symptoms included on the MSAS, a small number of patients (n 18, 5.4%) reported they experienced distress from symptoms not listed on the MSAS. These symptoms included body aches and soreness (n 3, 0.9%), feeling unsteady, weak or lightheaded (n 3, 0.9%) and having dry or chapped lips (n 2, 0.6%). While these symptoms were experienced by a relatively small number of patients, interestingly, they created the highest level of distress when present. Table 2 shows that these other symptoms had a mean distress rating of 2.73 (SD 1.01), which fell between the descriptors of somewhat and quite a bit on the symptom Table 2 Frequency, Mean and Standard Deviation of Reported Distress from Each Symptom (n 334) Standard Symptom Frequency % Mean Deviation Other Pain Feeling bloated Feeling sad Constipation Vomiting Worrying Shortness of breath Difficulty sleeping Problems with urination Difficulty swallowing Nausea Numbness Lack of energy Feeling irritable Diarrhea Food tastes Feeling nervous I don t look like myself Hair loss Swelling of arms or legs Itching Cough Mouth sores Sweats Dry mouth Difficulty concentrating Changes in skin Lack of appetite Feeling drowsy Weight loss

5 Vol. 28 No. 5 November 2004 Medical-Surgical Patients Symptom Experience 455 distress scale. Additional symptoms that created moderately high levels of distress included pain (M 2.65, SD 1.28) and feeling bloated (M 2.43, SD 1.28). Symptoms that created the least amount of distress included lack of appetite (M 1.29, SD 1.37) and feeling drowsy (M 1.11, SD 1.39). There were differences in symptom distress ratings dependent upon the ICD-9 diagnostic category of the patient. Categories with higher levels of symptom distress included disorders of nutrition and metabolism (M 2.13, SD 0.53) and respiratory conditions (M 2.09, SD 0.91). Cardiovascular disorders were associated with the lowest level of symptom distress (M 1.49, SD 0.68), a finding consistent with other reports. 8 Symptom Severity. In addition to symptom distress, patients also rated the severity of each of the symptoms included in the MSAS. Symptom severity ranged from 1 slight to 4 very severe, with an average symptom severity rating of 1.65 (SD 0.83) (Table 3). Symptoms reported as being the most severe were constipation (M 2.83, SD 1.09) and pain (M 2.60, SD 0.93), corresponding to moderate to severe on the severity subscale. Patients also reported I don t look like myself high on the severity subscale (M 2.50, SD 1.28). Symptoms which ranked low in severity included cough (M 1.93, SD 1.03), difficulty concentrating, (M 1.91, SD 0.93) and mouth sores (M 1.84, SD 1.17). Interestingly, pain is the only symptom which ranked consistently high in frequency, severity and distress. Components of the Memorial Symptom Assessment Scale: The MSAS Global Distress Index, Physical Symptom Subscale, Psychological Symptom Subscale The mean MSAS Global Distress Index (MSAS-GDI) was calculated by taking the average of the frequency of four psychological symptoms (feeling sad, worrying, feeling irritable and feeling nervous) and the distress of six physical symptoms (lack of appetite, lack of energy, pain, feeling drowsy, constipation and dry mouth). The physical symptoms were given a rating of 0 if the symptom was not present, 0.8 if it was present but caused no distress, 1.6 if it was present and caused a bit of distress, Table 3 Frequency, Mean and Standard Deviation of Severity from Each Sympton (n 334) Standard Symptom Frequency % Mean Deviation Constipation Pain I don t look like myself Lack of appetite Hair loss Diarrhea Feeling bloated Lack of energy Food tastes Difficulty sleeping Problems with urination Vomiting Numbness Shortness of breath Worrying Changes in skin Swelling of arms or legs Sweats Feeling sad Dry mouth Difficulty swallowing Nausea Feeling nervous Dizziness Feeling drowsy Itching Weight loss Feeling irritable Cough Difficulty concentrating Mouth sores if the symptom was present and caused some distress, 3.2 if it was present and caused quite a bit of distress, and 4.0 if the symptom was present and caused very much distress. The psychological symptoms comprising the MSAS- GDI were rated as 0 if the symptom was not present, 1 if present and occurring rarely, 2 if present and occurring occasionally, 3 if present and occurring frequently and 4 if the symptom was present and occurred almost constantly. The mean MSAS-GDI in this patient population ranged from 0 to 3.22 with a mean of 0.98 (SD 0.66). The Cronbach s alpha for the MSAS-GDI in this population was The MSAS Physical Symptom Subscale (MSAS-PHYS) is the average distress rating associated with 12 physical symptoms comprised of the following: lack of appetite, lack of energy,

6 456 Kris and Dodd Vol. 28 No. 5 November 2004 pain, feeling drowsy, constipation, dry mouth, nausea, vomiting, change in taste, weight loss, feeling bloated, and dizziness. Responses to the MSAS-PHYS are weighted similarly to the MSAS- GDI. Scores on the MSAS-PHYS ranged from 0 to 3.44 with a mean of 1.01 (SD 0.71). The Cronbach s alpha for the MSAS-PHYS was The MSAS Psychological Symptom Subscale (MSAS-PSYCH) score is the average frequency rating associated with 6 psychological symptoms. Frequency ratings are calculated similarly to the MSAS-GDI. The MSAS-PSYCH scores ranged from 0 to 3.35 with an average of 0.77 (SD 0.77). The Cronbach s alpha for the MSAS-PSYCH was The Total MSAS (TMSAS) score is calculated by taking the average of the frequency, severity and distress ratings across all 32 items in the MSAS, weighted as in the MSAS-GDI. In this sample, the MSAS was modified, excluding the one item regarding problems with sexual interest or activity, such that there were 31 items included in the scale. The TMSAS scores ranged from 0 to 2.84 with a mean of 0.80 (SD 0.56). Relationship of Symptom Experience to Demographic Characteristics Mean distress scores varied based upon gender and marital status. The mean distress ratings for women (M 1.97, SD 0.80) were significantly greater than those of men (M 1.64, SD 0.85) (P 0.01). Women also scored significantly higher on the MSAS-GDI (P 0.004), MSAS-PHYS (P 0.001) and TMSAS (P 0.048). However, the differences between men and women on the MSAS-PSYCH (P 0.358) were not statistically significant. Although not statistically significant, patients who were single tended to have higher symptom distress ratings (M 1.87, SD 0.84) than those who were partnered (M 1.71, SD 0.81) (P 0.096). However, the results of the MSAS found that patients who were partnered had significantly lower levels of symptom distress than those who were not partnered. These differences are consistent across all components of the scale, including the MSAS-GDI (P 0.005), MSAS-PSYCH (P 0.009) and TMSAS (P 0.043), with the results of the MSAS-PHYS trending toward significance (P 0.058). The results of a Pearson correlation indicate no significant correlation (r 0.04, P 0.50) between the age and symptom distress ratings in this sample. Mean severity ratings also differed by gender, however, not by marital status. The mean severity ratings for women (M 1.71, SD 0.83) were higher than those of men (M 1.53, SD 0.84) (P 0.049). However, while patients who were single reported higher levels of symptom severity (M 1.67, SD 0.86) than those who were partnered (M 1.51, SD 0.82), this difference was not statistically significant (P 0.107). Interestingly, although the relationship between age and symptom distress was not significant, there was a statistically significant relationship between age and symptom severity. Patients who were older reported a lower degree of symptom severity than patients who were younger (r 0.16, P 0.004). Relationship Between Symptom Severity and Symptom Distress The ratings of symptom distress among the items in the MSAS were correlated with the ratings of symptom severity. However, the strength of this relationship is smaller than anticipated. Previous studies have reported an average correlation of r 0.67, with a range of , 19 whereas the average relationship between severity and distress among patients in this study was only r The correlations between the severity and distress components of each symptom varied significantly by symptom. There was a high degree of association between the severity and distress components of constipation (r 0.82) and shortness of breath (r 0.80), while the degree of association between severity and distress caused from lack of appetite and hair loss was less strong (r 0.40, r 0.37, respectively) (Table 4). Discussion This is the first study to utilize the MSAS to evaluate the symptom distress of patients hospitalized in general acute care hospitals. Previous research on the MSAS has been completed at a specialized cancer center, 19 at a Veterans Affairs cancer center, 20 in AIDS outpatients, 12 patients with COPD, 13 and in children with cancer. 21 Therefore, this study extends the body

7 Vol. 28 No. 5 November 2004 Medical-Surgical Patients Symptom Experience 457 Table 4 Correlations Between Distress and Severity Scores Pearson Symptom n Correlation Constipation Shortness of breath Itching Appearance Mouth sores Feeling bloated Vomiting Difficulty sleeping Difficulty swallowing Problems with urination Worry Skin changes Pain Diarrhea Dizziness Feeling sad Dry mouth Sweating Numbness Swelling of arms or legs Cough Weight loss Nausea Nervousness Lack of energy Feeling irritable Change in food taste Feeling drowsy Lack of appetite Hair loss of literature examining the relationships between patient characteristics and patient symptom distress scores by including a more diverse patient population. The mean rating of symptom distress on the MSAS-GDI for this group (M 0.98, SD 0.66) was lower than the level of distress reported by Portenoy et al. 22 in a group of inpatients at a specialized cancer treatment center with the diagnosis of cancer (M 1.6, SD 0.9). The symptom distress in a group of inpatient cancer patients at a Veterans Affairs hospital was also lower, with a mean MSAS-GDI of 1.25 (SD 0.82). 18 As male gender has been found to be a significant predictor of lower symptom distress, the lower level of symptom distress reported in the Chang et al. 18 study is most likely reflective of the higher proportion of male participants (98%) in this study. Women in this study reported higher mean levels of symptom distress (M 1.97, SD 0.80) than men (M 1.64, SD 1.64). The difference in levels of symptom distress was statistically significant overall, and across several of the components of the MSAS. This finding supports the work of McCorkle, Cooley & Shea utilizing the SDS, 8 Degner and Sloan 9 (utilizing a 5-point Likert scale), and Gift and Shepard 13 (utilizing the MSAS). However, it is in contrast with the work of Tishelman et al. 10 and Holmes, 11 which did not find gender-related differences in levels of symptom distress using the SDS. There may be several explanations for these incongruent findings. It is possible that this study was able to find statistically significant differences in symptom distress because of the relatively large sample size and consequent power. The effect size of gender is relatively small, 0.33 based on data from this study. This effect size would require a sample size of 292 in order to have 80% power to find differences between groups at the alpha 0.05 level of significance. 23 Previous studies that were unable to find gender differences had smaller sample sizes resulting in inadequate power to detect this small relationship (Tishelman et al. 10 n 46; Holmes 11 n 120). The investigators did not observe a statistically significant relationship between age and symptom distress scores among patients in this sample. This also supports the findings of McCorkle, Cooley and Shea, 8 who did not find age to be a significant predictor of symptom distress. However, this finding contrasts that of Degner and Sloan 9 and Tishelman et al., 10 both of whom found significant relationships between age and symptom distress scores, with older patients reporting lower symptom distress. The size of the Degner and Sloan sample was large (n 434), which may account for the differential ability to find a significant relationship. However, those authors attribute the difference in symptom distress scores by age to the belief that the older patients in the study were receiving less aggressive cancer treatment, thus lessening the associated distress. In this sample, increased age was associated with decreased ability to complete the MSAS. The difference in the completion rates between those under and over 65 was statistically significant (P 0.01). Patients in this study who had a partner reported lower scores on the MSAS-PHYS, MSAS- PSYCH, MSAS-GDI and TMSAS than those without a partner. This is consistent with McCorkle, Cooley & Shea, 8 who found that patients without partners receiving home care had significantly lower levels of symptom distress than

8 458 Kris and Dodd Vol. 28 No. 5 November 2004 those who were partnered (P 0.01). Other studies have pointed to the important role family members play in delivering care to patients in institutional settings. 24,25 When patients in this study were questioned about the nursing care they had received, they reported that they did not receive help with bathing, grooming and getting dressed from the nursing staff, but instead, from their spouses. The additional support provided by a patient s partner may serve to lessen symptom distress. While standards issued by the Joint Commission on the Accreditation of Healthcare Organizations have required assessment and intervention to alleviate pain since 2001, pain management continues to be inadequate. Among the 74% (n 242) of medical-surgical patients who reported pain, more than half rated it as severe (38.9%) or very severe (16.3%). In addition, both dry mouth and constipation rank high in prevalence and severity, respectively. While medication data was not obtained as part of this study, it is thought that the high levels of these symptoms might point to what may be poor management of the side effects of the opioids often utilized for the palliation of pain. Therefore, proper symptom management needs to anticipate and control for the numerous co-existing and often intercorrelated symptoms which exist in this patient population. Future research is needed to further understand the process of symptom management on acute care units, and how these processes of care, in turn, influence symptom outcomes. Acknowledgments This paper was written with the support of the National Institutes of Health, National Institute of Nursing Research (T32 NR 07088), The John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Initiative and a research grant from Sigma Theta Tau International. AEK would also like to acknowledge the assistance of her dissertation committee, including Dr. Jean Ann Seago, Dr. Marylin Dodd and Dr. Joanne Spetz, as well as the efforts of Dana Wright, who assisted with data collection. References 1. Germino BB. Symptom distress and quality of life. Semin Oncol Nurs 1987;3(4): Kroenke K, Stump T, Clark DO, Callahan CM, McDonald CJ. Symptoms in hospitalized patients: outcome and satisfaction with care. Am J Med 1999;107(5): McCorkle R, Strumpf NE, Nuamah IF, et al. A specialized home care intervention improves survival among older post-surgical cancer patients. J Am Geriatr Soc 2000;48(12): Kukull W, McCorkle R, Driever M. Symptom distress: psychosocial variables and survival from lung cancer. J Psychosoc Oncol 1986;4: Clarke EB, French B, Bilodeau ML, et al. Pain management knowledge, attitudes and clinical practice: the impact of nurses characteristics and education. J Pain Symptom Manage 1996;11(1): Wallace KG, Reed BA, Pasero C, Olsson GL. Staff nurses perceptions of barriers to effective pain management. J Pain Symptom Manage 1995;10(3): Dodd M, Janson S, Facione N, et al. Advancing the science of symptom management. J Adv Nurs 2001;33(5): McCorkle R, Cooley M, Chea J. A user s manual for the symptom distress scale. org/sds. Accessed October 31, Degner LF, Sloan JA. Symptom distress in newly diagnosed ambulatory cancer patients and as a predictor of survival in lung cancer. J Pain Symptom Manage 1995;10(6): Tishelman C, Taube A, Sachs L. Self-reported symptom distress in cancer patients: reflections of disease, illness or sickness? Soc Sci Med 1991;33(11): Holmes S. Use of a modified symptom distress scale in assessment of the cancer patient. Int J Nurs Stud 1989;26(1): Vogl D, Rosenfeld B, Breitbart W, et al. Symptom prevalence, characteristics, and distress in AIDS outpatients. J Pain Symptom Manage 1999;18(4): Gift AG, Shepard CE. Fatigue and other symptoms in patients with chronic obstructive pulmonary disease: do women and men differ? J Obstet Gynecol Neonatal Nurs 1999;28(2): Grant M. Future directions in symptom management. Paper presented at: Symptom Management Proceedings, 1994; San Francisco, CA. 15. Johnson JE. Effects of accurate expectations about sensations on the sensory and distress components of pain. J Pers Soc Psychol 1973;27(2): Rhodes VA, Watson PM. Symptom distress the concept: past and present. Semin Oncol Nurs 1987;3(4): Kris AE. Examination of the relationhip between nurse staffing levels and patient symptom distress. [Doctoral Dissertation]San Francisco: University of California, San Francisco, 2002.

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