TOUS as a TOOL: Bedside RNs Using Theory to Improve QOL for Post-Prostatectomy Patients & their Partners

Meredith A. Ford, MSN, RN, CNE
J. Michael Leger, Ph.D., MBA, RN, CNL, NEA-BC, CNE

The Theory of Unpleasant Symptoms (TOUS) focuses on understanding how patients respond to multiple symptoms of a disease process, the commonalities among these symptoms, and how interventions might be used to alleviate more than one symptom. In this interactive model, each symptom is conceptualized to be a multi-dimensional experience that can be measured independently or in combination with other symptoms (Lenz et al., 1997). Amongst symptoms, several dimensions may be separable or related to one another, such as intensity, timing, perceived distress level, and quality. Individuals can feel the symptoms differently and describe them in various ways. With TOUS being a middle-range theory, it has the potential to guide research and provide knowledge for effective intervention (Lenz et al., 1995). As one of the authors being an oncology nurse and the daughter of a dad who has been treated for prostate cancer, we began to discuss and wonder about how TOUS can be applied at the point of care – not just for patients, but also for the effects that prostate cancer treatment has on the patient’s partner. Although patients and partners have reported relatively high satisfaction with treatment results as they relate to the physical aspects of the recovery (Ramsey et al., 2013), often the topic of partner intimacy and sexual side effects are a taboo subject.

Cancer has been shown to affect the quality of life of the family; prostate cancer has a stronger effect on the partner (Hoffman, 2019). This is why prostate cancer is sometimes referred to as a “couple’s disease” because of the effects that treatment options – the most common being a radical prostatectomy (RP) – can have on the patient and the partner (Hoffman, 2019). Post-RP patients and their partners experience physical, emotional, and psychosocial symptoms following treatment with the central theme from the literature focusing on sexuality. While one doesn’t want to necessarily think about their parents having a sexual relationship, the impact of post-RP on this area of a couple’s relationship can be an over-arching factor to their overall mental health and quality of life. According to Ross, et al. (2015), a couple’s sexual recovery post-RP is consistently related to their relationship satisfaction; but, if recovery expectations aren’t realistic, this can lead to a downward spiral in the relationship caused by psychological distress. This can further lead to a decline in the mental and physical health of the patient. The effects of the patient’s and partner’s mental health are consistently related to their relationship satisfaction; however, the partner’s mental health satisfaction predicts a more significant impact on the patient’s overall mental and physical health (Ross et al., 2015).

So, how can a nurse apply TOUS to benefit post-RP patients and their partners? First, we must all agree that nurses are at the forefront for providing care to patients AND their families, in this case the patient’s partner. Thus, the nurse will have the greatest opportunity at impacting the symptoms experienced by the couple. Research has shown us that the patient’s partner experiences psychological, physiological, and situational factors much like the patient in response to post-RP recovery. Empowered with this knowledge, the nurse can be more effective by using a holistic approach to offering treatment management for both the patient and the partner. By recognizing and addressing these side effects of RP, the nurse is able to pinpoint pertinent educational materials, preventive measures for escalating symptoms, and appropriate management strategies that will benefit both the patient and the partner. Using TOUS as a theoretical framework, both the patient’s and partner’s symptoms can be correlated to identify and implement the best interventions that address multiple symptoms the couple is experiencing.


Hoffman, K. (2019, July 23). Prostate cancer: “A couple’s disease.” Inspire.

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.

Lenz, E. R., Suppe, F., Gift, A. G., Pugh, L. C., & Miligan, R. A. (1995). Collaborative development of middle-range nursing theories: Toward a theory of unpleasant symptoms. Advances in Nursing Science, 17(3), 1-13.

Ramsey, S. D., Zeliadt, S. B., Blough, D. K., Moinpour, C. M., Hall, I. J., Smith, J. L, Ekwueme, D. U., Fedorenko, C. R., Fairweather, M. E., Koepl, L. M., Thompson, I. M., Keane, T. E., & Penson, D. F. (2013). Impact of prostate cancer on sexual relationships: A longitudinal perspective on intimate partners’ experiences. The Journal of Sexual Medicine, 10(12), 3135-3143.

Ross, K. M., Ranby, K. W., Wooldridge, J. S., Robertson, C., & Lipkus, I. M. (2015). Effects of physical and mental health on relationship satisfaction: A dyadic, longitudinal examination of couples facing prostate cancer. Psycho-Oncology, 25, 898-904.

About the contributors:

Meredith A. Ford is an Assistant Professor in the School of Nursing at the University of Texas Medical Branch at Galveston (UTMB) in the undergraduate and MSN-Nurse Educator programs. Mrs. Ford graduated from Roberts Wesleyan College in Rochester, New York with a BSN degree and an MSN in Nursing Education from UTMB. She is currently working towards achieving a Ph.D. in Nursing Science from Texas Woman’s University. She has earned the credentials of a Certified Nurse Educator.

J. (John) Michael Leger is a Professor in the School of Nursing at the University of Texas Medical Branch at Galveston (UTMB) serving as the MSN-Executive Nurse Leader Track while also teaching in the DNP and Ph.D. programs. Dr. Leger graduated from Lamar University in Beaumont, Texas with an AAS in Nursing, received his BSN from UTMB, and his MBA from Our Lady of the Lake University in San Antonio, Texas. He received his Nursing Ph.D. from UTMB in 2016. He has earned the credentials of Clinical Nurse Leader, Certified Nurse Educator, and Nurse Executive, Advanced.

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