A Proposed Theory of Symptom Cluster Management

Jerick Batin Tabudlo


DOI: https://doi.org/10.33546/bnj.1359

Abstract


Background: Symptom cluster management is in its early stages in many chronic and debilitating illnesses. The development of a proposed theory should be an initial step in advancing this area of interest.

Objective: This article presents the development of a Proposed Theory of Symptom Cluster Management.

Methods: The concept analysis, statement synthesis, and theory synthesis by Walker and Avant were used in the development of this proposed theory. A search from July to September 2020 for published empirical and theoretical articles was conducted in scientific databases, expanded on the web, and secondary references from identified articles.

Results: The Proposed Theory of Symptom Cluster Management is both a descriptive and explanatory theory. The defining characteristics of symptom cluster management include the basic and effectiveness components. Antecedents for symptom cluster management include socio-demographic characteristics, symptom cluster characteristics, individual clinical characteristics, individual illness factors, and situational factors or symptom experience. The consequences are clustered as personal-related, health-related, social-related outcomes, and existential outcomes. Measurement tools for the antecedents and outcomes in symptom cluster management and the analytical and statistical strategies were considered. Relational statements were also identified. Theoretical assertions were advanced.

Conclusion: The Proposed Theory of Symptom Cluster Management may provide a holistic approach because it integrates both the symptom cluster and management strategies. The concepts, statements including the complete representation of the proposed theory identified in this article, may provide cues to policymakers and clinical researchers towards the development of tailored interventions and programs.


Keywords


symptom cluster; management; strategies; theory; nursing

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References


Albusoul, R. M., Berger, A. M., Gay, C. L., Janson, S. L., & Lee, K. A. (2017). Symptom clusters change over time in women receiving adjuvant chemotherapy for breast cancer. Journal of Pain and Symptom Management, 53(5), 880-886. https://doi.org/10.1016/j.jpainsymman.2016.12.332

Amro, A., Waldum, B., Dammen, T., Miaskowski, C., & Os, I. (2014). Symptom clusters in patients on dialysis and their association with quality‐of‐life outcomes. Journal of Renal Care, 40(1), 23-33. https://doi.org/10.1111/jorc.12051

Armstrong, T. S. (2003). Symptoms experience: A concept analysis. Oncology Nursing Forum, 30(4), 601-612. https://doi.org/10.1188/03.ONF.601-606

Barsevick, A. M., Whitmer, K., Nail, L. M., Beck, S. L., & Dudley, W. N. (2006). Symptom cluster research: Conceptual, design, measurement, and analysis issues. Journal of Pain and Symptom Management, 31(1), 85-95. https://doi.org/10.1016/j.jpainsymman.2005.05.015

Bay, E., & Bergman, K. (2006). Symptom experience and emotional distress after traumatic brain injury. Care Management Journals, 7(1), 3. https://doi.org/10.1891/cmaj.7.1.3

Beddhu, S., Bruns, F. J., Saul, M., Seddon, P., & Zeidel, M. L. (2000). A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. American Journal of Medicine, 108(8), 609-613. https://doi.org/10.1016/s0002-9343(00)00371-5

Bender, C. M., Engberg, S. J., Donovan, H. S., Cohen, S. M., Houze, M. P., Rosenzweig, M. Q., . . . Sereika, S. M. (2008). Symptom clusters in adults with chronic health problems and cancer as a comorbidity. Oncology Nursing Forum, 35(1), E1-E11. https://doi.org/10.1188/08.ONF.E1-E11

Bender, C. M., Ergÿn, F. S., Rosenzweig, M. Q., Cohen, S. M., & Sereika, S. M. (2005). Symptom clusters in breast cancer across 3 phases of the disease. Cancer Nursing, 28(3), 219-225. https://doi.org/10.1097/00002820-200505000-00011

Brant, J. M., Beck, S., & Miaskowski, C. (2010). Building dynamic models and theories to advance the science of symptom management research. Journal of Advanced Nursing, 66(1), 228-240. https://doi.org/10.1111/j.1365-2648.2009.05179.x

Breland, J. Y., Hundt, N. E., Barrera, T. L., Mignogna, J., Petersen, N. J., Stanley, M. A., & Cully, J. A. (2015). Identification of anxiety symptom clusters in Patients with COPD: Implications for assessment and treatment. International Journal of Behavioral Medicine, 22(5), 590-596. https://doi.org/10.1007/s12529-014-9450-2

Buysse, D. J., Reynolds Iii, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193-213. https://doi.org/10.1016/0165-1781(89)90047-4

Carpenter, J., Andrykowski, M., Wilson, J., Hall, L., Kay Rayens, M., Sachs, B., & Cunningham, L. (1998). Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale. Issues in Mental Health Nursing, 19(5), 481-494. https://doi.org/10.1080/016128498248917

Chan, C. W. H., Richardson, A., & Richardson, J. (2011). Managing symptoms in patients with advanced lung cancer during radiotherapy: Results of a psychoeducational randomized controlled trial. Journal of Pain and Symptom Management, 41(2), 347-357. https://doi.org/10.1016/j.jpainsymman.2010.04.024

Chen, M.-L., & Tseng, H.-C. (2006). Symptom clusters in cancer patients. Supportive Care in Cancer, 14(8), 825-830. https://doi.org/10.1007/s00520-006-0019-8

Cherwin, C. H. (2012). Gastrointestinal symptom representation in cancer symptom clusters: A synthesis of the literature. Oncology Nursing Forum, 39(2), 157-165. https://doi.org/10.1188/12.Onf.157-165

Cheung, W. Y., Le, L. W., & Zimmermann, C. (2009). Symptom clusters in patients with advanced cancers. Support Care Cancer, 17(9), 1223-1230. https://doi.org/10.1007/s00520-009-0577-7

Cheville, A. L., Novotny, P. J., Sloan, J. A., Basford, J. R., Wampfler, J. A., Garces, Y. I., . . . Yang, P. (2011). The value of a symptom cluster of fatigue, dyspnea, and cough in predicting clinical outcomes in lung cancer survivors. Journal of Pain and Symptom Management, 42(2), 213-221. https://doi.org/10.1016/j.jpainsymman.2010.11.005

Cleeland, C. S., Bennett, G. J., Dantzer, R., Dougherty, P. M., Dunn, A. J., Meyers, C. A., . . . Wang, X. S. (2003). Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine‐immunologic model of cancer symptoms. Cancer: Interdisciplinary International Journal of the American Cancer Society, 97(11), 2919-2925. https://doi.org/10.1002/cncr.11382

Cleeland, C. S., Mendoza, T. R., Wang, X. S., Chou, C., Harle, M. T., Morrissey, M., & Engstrom, M. C. (2000). Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer, 89(7), 1634-1646. https://doi.org/10.1002/1097-0142(20001001)89:7<1634::aid-cncr29>3.0.co;2-v

Cook, P. F., Sousa, K. H., Matthews, E. E., Meek, P. M., & Kwong, J. (2011). Patterns of change in symptom clusters with HIV disease progression. Journal of Pain and Symptom Management, 42(1), 12-23. https://doi.org/10.1016/j.jpainsymman.2010.09.021

Corwin, E. J., Berg, J. A., Armstrong, T. S., Dabbs, A. D., Lee, K. A., Meek, P., & Redeker, N. (2014). Envisioning the future in symptom science. Nursing Outlook, 62(5), 346-351. https://doi.org/10.1016/j.outlook.2014.06.006

Daut, R. L., Cleeland, C. S., & Flanery, R. C. (1983). Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain, 17(2), 197-210. https://doi.org/10.1016/0304-3959(83)90143-4

Demiralp, M., Oflaz, F., & Komurcu, S. (2010). Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. Journal of Clinical Nursing, 19(7‐8), 1073-1083. https://doi.org/10.1111/j.1365-2702.2009.03037.x

DeVon, H. A., Vuckovic, K., Ryan, C. J., Barnason, S., Zerwic, J. J., Pozehl, B., . . . Zimmerman, L. (2017). Systematic review of symptom clusters in cardiovascular disease. European Journal of Cardiovascular Nursing, 16(1), 6-17. https://doi.org/10.1177/1474515116642594

Dirksen, S. R., Belyea, M. J., Wong, W., & Epstein, D. R. (2016). Transitions in symptom cluster subgroups among men undergoing prostate cancer radiation therapy. Cancer Nursing, 39(1), 3-11. https://doi.org/10.1097/NCC.0000000000000236

Dodd, M. J., Miaskowski, C., & Paul, S. M. (2001). Symptom clusters and their effect on the functional status of patients with cancer. Oncology Nursing Forum, 28(3), 465-470.

Donesky, D., Janson, S. L., Nguyen, H. Q., Neuhaus, J., Neilands, T. B., & Carrieri-Kohlman, V. (2011). Determinants of frequency, duration, and continuity of home walking in patients with COPD. Geriatric Nursing, 32(3), 178-187. https://doi.org/10.1016/j.gerinurse.2011.01.011

Donesky-Cuenco, D., Nguyen, H. Q., Paul, S., & Carrieri-Kohlman, V. (2009). Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: A pilot study. The Journal of Alternative and Complementary Medicine, 15(3), 225-234. https://doi.org/10.1089/acm.2008.0389

Fan, G., Filipczak, L., & Chow, E. (2007). Symptom clusters in cancer patients: A review of the literature. Current Oncology, 14(5), 173-179. https://doi.org/10.3747/co.2007.145

Gift, A. G., Jablonski, A., Stommel, M., & Given, C. W. (2004). Symptom clusters in elderly patients with lung cancer. Oncology Nursing Forum, 31(2), 202-212. https://doi.org/10.1188/04.ONF.203-212

Given, B., Given, C., Azzouz, F., & Stommel, M. (2001). Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nursing Research, 50(4), 222-232. https://doi.org/10.1097/00006199-200107000-00006

Hays, R. D., Kallich, J. D., Mapes, D. L., Coons, S. J., & Carter, W. B. (1994). Development of the kidney disease quality of life (KDQOL TM) instrument. Quality of Life Research, 3(5), 329-338. https://doi.org/10.1007/BF00451725

Henly, S. J., Kallas, K. D., Klatt, C. M., & Swenson, K. K. (2003). The notion of time in symptom experiences. Nursing Research, 52(6), 410-417. https://doi.org/10.1097/00006199-200311000-00009

Henoch, I., Ploner, A., & Tishelman, C. (2009). Increasing stringency in symptom cluster research: A methodological exploration of symptom clusters in patients with inoperable lung cancer. Oncology Nursing Forum, 36(6), E282-292. https://doi.org/10.1188/09.Onf.E283-e292

Hermens, D. F., Naismith, S. L., Chitty, K. M., Lee, R. S. C., Tickell, A., Duffy, S. L., . . . Lagopoulos, J. (2015). Cluster analysis reveals abnormal hippocampal neurometabolic profiles in young people with mood disorders. European Neuropsychopharmacology, 25(6), 836-845. https://doi.org/10.1016/j.euroneuro.2015.02.009

Holzemer, W. L., Henry, S. B., Nokes, K. M., Corless, I. B., Brown, M. A., Powell‐Cope, G. M., . . . Inouye, J. (1999). Validation of the Sign and Symptom Check‐List for persons with HIV disease (SSC‐HIV). Journal of Advanced Nursing, 30(5), 1041-1049. https://doi.org/10.1046/j.1365-2648.1999.01204.x

Holzemer, W. L., Hudson, A., Kirksey, K. M., Hamilton, M. J., & Bakken, S. (2001). The revised sign and symptom check-list for HIV (SSC-HIVrev). Journal of the Association of Nurses in AIDS Care, 12(5), 60-70. https://doi.org/10.1016/S1055-3290(06)60263-X

Humphreys, J., Janson, S., Donesky, D. A., Dracup, K., Lee, K. A., Puntillo, K., . . . Baggott, C. (2014). Theory of symptom management. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (pp. 141–164). New York: Springer Publishing Company.

Illi, J., Miaskowski, C., Cooper, B., Levine, J. D., Dunn, L., West, C., . . . Baggott, C. (2012). Association between pro-and anti-inflammatory cytokine genes and a symptom cluster of pain, fatigue, sleep disturbance, and depression. Cytokine, 58(3), 437-447. https://doi.org/10.1016/j.cyto.2012.02.015

Jarden, M., Nelausen, K., Hovgaard, D., Boesen, E., & Adamsen, L. (2009). The effect of a multimodal intervention on treatment-related symptoms in patients undergoing hematopoietic stem cell transplantation: A randomized controlled trial. Journal of Pain and Symptom Management, 38(2), 174-190. https://doi.org/10.1016/j.jpainsymman.2008.09.005

Jenkins, J. B., & McCoy, T. P. (2015). Symptom clusters, functional status, and quality of life in older adults with osteoarthritis. Orthopaedic Nursing, 34(1), 36-42. https://doi.org/10.1097/NOR.0000000000000112

Jurgens, C. Y., Moser, D. K., Armola, R., Carlson, B., Sethares, K., & Riegel, B. (2009). Symptom clusters of heart failure. Research in Nursing & Health, 32(5), 551-560. https://doi.org/10.1002/nur.20343

Kelly, D. L., Dickinson, K., Hsiao, C.-P., Lukkahatai, N., Gonzalez-Marrero, V., McCabe, M., & Saligan, L. N. (2016). Biological basis for the clustering of symptoms. Seminars in Oncology Nursing, 32(4), 351-360. https://doi.org/10.1016/j.soncn.2016.08.002

Kilbourne, A. M., Justice, A. C., Rabeneck, L., Rodriguez-Barradas, M., & Weissman, S. (2001). General medical and psychiatric comorbidity among HIV-infected veterans in the post-HAART era. Journal of Clinical Epidemiology, 54(12), S22-S28. https://doi.org/10.1016/S0895-4356(01)00443-7

Killingworth, A., & Van Den Akker, O. (1996). The quality of life of renal dialysis patients: trying to find the missing measurement. International Journal of Nursing Studies, 33(1), 107-120. https://doi.org/10.1016/0020-7489(95)00040-2

Kim, H.-J., McGuire, D. B., Tulman, L., & Barsevick, A. M. (2005). Symptom clusters: Concept analysis and clinical implications for cancer nursing. Cancer Nursing, 28(4), 270-282. https://doi.org/10.1097/00002820-200507000-00005

Kim, H. J., Barsevick, A. M., Beck, S. L., & Dudley, W. (2012). Clinical subgroups of a psychoneurologic symptom cluster in women receiving treatment for breast cancer: A secondary analysis. Oncology Nursing Forum, 39(1), E20-30. https://doi.org/10.1188/12.Onf.E20-e30

Kwekkeboom, K. L., Abbott-Anderson, K., Cherwin, C., Roiland, R., Serlin, R. C., & Ward, S. E. (2012). Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. Journal of Pain and Symptom Management, 44(6), 810-822. https://doi.org/10.1016/j.jpainsymman.2011.12.281

Lee, K. A., & Gay, C. L. (2011). Can modifications to the bedroom environment improve the sleep of new parents? Two randomized controlled trials. Research in Nursing & Health, 34(1), 7-19. https://doi.org/10.1002/nur.20413

Lee, K. A., Hicks, G., & Nino-Murcia, G. (1991). Validity and reliability of a scale to assess fatigue. Psychiatry Research, 36(3), 291-298. https://doi.org/10.1016/0165-1781(91)90027-M

Lee, S. J., & Jeon, J. (2015). Relationship between symptom clusters and quality of life in patients at stages 2 to 4 chronic kidney disease in Korea. Applied Nursing Research, 28(4), e13-e19. https://doi.org/10.1016/j.apnr.2015.03.004

Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27. https://doi.org/10.1097/00012272-199703000-00003

Mendoza, T. R., Wang, X. S., Cleeland, C. S., Morrissey, M., Johnson, B. A., Wendt, J. K., & Huber, S. L. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85(5), 1186-1196. https://doi.org/10.1002/(SICI)1097-0142(19990301)85:5<1186::AID-CNCR24>3.0.CO;2-N

Miaskowski, C., Aouizerat, B. E., Dodd, M., & Cooper, B. (2007). Conceptual issues in symptom clusters research and their implications for quality-of-life assessment in patients with cancer. Journal of the National Cancer Institute Monographs(37), 39-46. https://doi.org/10.1093/jncimonographs/lgm003

Miaskowski, C., Cooper, B. A., Paul, S. M., Dodd, M., Lee, K., Aouizerat, B. E., . . . Bank, A. (2006). Subgroups of patients with cancer with different symptom experiences and quality-of-life outcomes: A cluster analysis. Oncology Nursing Forum 33(5), E79-E89. https://doi.org/10.1188/06.ONF.E79-E89

Miaskowski, C., Dodd, M., & Lee, K. (2004). Symptom clusters: The new frontier in symptom management research. JNCI Monographs, 2004(32), 17-21. https://doi.org/10.1093/jncimonographs/lgh023

Miaskowski, C., & Lee, K. A. (1999). Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: A pilot study. Journal of Pain and Symptom Management, 17(5), 320-332. https://doi.org/10.1016/S0885-3924(99)00008-1

Moens, K., Siegert, R. J., Taylor, S., Namisango, E., Harding, R., & Impact, E. (2015). Symptom clusters in people living with HIV attending five palliative care facilities in two sub-Saharan African countries: A hierarchical cluster analysis. PLoS One, 10(5), e0126554. https://doi.org/10.1371/journal.pone.0126554

Molassiotis, A., Wengström, Y., & Kearney, N. (2010). Symptom cluster patterns during the first year after diagnosis with cancer. Journal of Pain and Symptom Management, 39(5), 847-858. https://doi.org/10.1016/j.jpainsymman.2009.09.012

Namisango, E., Harding, R., Katabira, E. T., Siegert, R. J., Powell, R. A., Atuhaire, L., . . . Taylor, S. (2015). A novel symptom cluster analysis among ambulatory HIV/AIDS patients in Uganda. AIDS Care, 27(8), 954-963. https://doi.org/10.1080/09540121.2015.1020749

Nightingale, F. (1946). Notes on nursing: What it is, and what it is not. Cambridge: Cambridge University Press.

Nosek, M., Kennedy, H. P., Beyene, Y., Taylor, D., Gilliss, C., & Lee, K. (2010). The effects of perceived stress and attitudes toward menopause and aging on symptoms of menopause. Journal of Midwifery & Women's Health, 55(4), 328-334. https://doi.org/10.1016/j.jmwh.2009.09.005

Paice, J. A. (2004). Assessment of symptom clusters in people with cancer. JNCI Monographs, 2004(32), 98-102. https://doi.org/10.1093/jncimonographs/lgh009

Park, S. K., & Larson, J. L. (2014). Symptom cluster, healthcare use and mortality in patients with severe chronic obstructive pulmonary disease. Journal of Clinical Nursing, 23(17-18), 2658-2671. https://doi.org/10.1111/jocn.12526

Portenoy, R. K., Thaler, H. T., Kornblith, A. B., Lepore, J. M., Friedlander-Klar, H., Kiyasu, E., . . . Norton, L. (1994). The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer, 30(9), 1326-1336. https://doi.org/10.1016/0959-8049(94)90182-1

Rutledge, D. M., & McGuire, C. (2004). Evidence-based symptom management. In C. H. Yarbro, M. H. Frogge, & M. Goodman (Eds.), Cancer Symptom Management (3rd ed., pp. 3-14). Sudbury: Jones & Bartlett.

Sarna, L., & Brecht, M.-L. (1997). Dimensions of symptom distress in women with advanced lung cancer: A factor analysis. Heart & Lung, 26(1), 23-30. https://doi.org/10.1016/S0147-9563(97)90006-6

Schwartz, A., & Meek, P. (1999). Additional construct validity of the Schwartz Cancer Fatigue Scale. Journal of Nursing Measurement, 7(1), 35-45.

Skelly, A. H., Leeman, J., Carlson, J., Soward, A. C. M., & Burns, D. (2008). Conceptual model of symptom‐focused diabetes care for African Americans. Journal of Nursing Scholarship, 40(3), 261-267. https://doi.org/10.1111/j.1547-5069.2008.00236.x

Suwanno, J., Petpichetchian, W., Riegel, B., & Issaramalai, S.-a. (2009). A model predicting health status of patients with heart failure. Journal of Cardiovascular Nursing, 24(2), 118-126. https://doi.org/10.1097/jcn.0b013e318197a75c

Taylor, S., Kuch, K., Koch, W. J., Crockett, D. J., & Passey, G. (1998). The structure of posttraumatic stress symptoms. Journal of Abnormal Psychology, 107(1), 154-160.

Thong, M. S. Y., van Dijk, S., Noordzij, M., Boeschoten, E. W., Krediet, R. T., Dekker, F. W., . . . Group, N. S. (2009). Symptom clusters in incident dialysis patients: Associations with clinical variables and quality of life. Nephrology Dialysis Transplantation, 24(1), 225-230. https://doi.org/10.1093/ndt/gfn449

Uçeyler, N., Rogausch, J. P., Toyka, K. V., & Sommer, C. (2007). Differential expression of cytokines in painful and painless neuropathies. Neurology, 69(1), 42-49. https://doi.org/10.1212/01.wnl.0000265062.92340.a5

Vincenzi, C. B., Moody, K., & Spirig, R. (2009). Development and pretesting of a set of symptom assessment tools in HIV: The HIV Symptom Experience Assessment Scale and the HIV Symptom Manageability Scale. Applied Nursing Research, 22(3), 204-210. https://doi.org/10.1016/j.apnr.2007.10.002

Voss, J. G., Portillo, C. J., Holzemer, W. L., & Dodd, M. J. (2007). Symptom cluster of fatigue and depression in HIV/AIDS. Journal of Prevention & Intervention in the Community, 33(1-2), 19-34. https://doi.org/10.1300/J005v33n01_03

Walker, L. O., & Avant, K. C. (2004). Strategies for theory construction in nursing (4th ed.). Upper Saddle River New Jersey: Pearson/Prentice Hall.

Walsh, D., & Rybicki, L. (2006). Symptom clustering in advanced cancer. Supportive Care in Cancer, 14(8), 831-836. https://doi.org/10.1007/s00520-005-0899-z

Wang, X. S., Laudico, A. V., Guo, H., Mendoza, T. R., Matsuda, M. L., Yosuico, V. D., . . . Cleeland, C. S. (2006). Filipino version of the M. D. Anderson Symptom Inventory: Validation and multisymptom measurement in cancer patients. Journal of Pain and Symptom Management, 31(6), 542-552. https://doi.org/10.1016/j.jpainsymman.2005.11.011

Wang, X. S., Wang, Y., Guo, H., Mendoza, T. R., Hao, X. S., & Cleeland, C. S. (2004). Chinese version of the M. D. Anderson Symptom Inventory: Validation and application of symptom measurement in cancer patients. Cancer, 101(8), 1890-1901. https://doi.org/10.1002/cncr.20448

Ware, J. E., Kosinski, M., & Keller, S. (1994). SF-36 physical and mental health summary scales: A user's manual. Boston, MA: Health Assessment Lab. New England Medical Center.

Wilson, I. B., & Cleary, P. D. (1995). Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. JAMA, 273(1), 59-65. https://doi.org/10.1001/jama.1995.03520250075037

Zimmerman, L., Barnason, S., Hertzog, M., Young, L., Nieveen, J., Schulz, P., & Tu, C. (2011). Gender differences in recovery outcomes after an early recovery symptom management intervention. Heart & Lung, 40(5), 429-439. https://doi.org/10.1016/j.hrtlng.2010.07.018

Zuniga, J. A., Bose, E., Park, J., Lapiz-Bluhm, M. D., & García, A. A. (2017). Diabetes changes symptoms cluster patterns in persons living with HIV. Journal of the Association of Nurses in AIDS Care, 28(6), 888-896. https://doi.org/10.1016/j.jana.2017.07.004


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