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A detailed description of the newly revised and updated theory of unpleasant symptoms is provided. 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. A detailed exemplar describes how it guided the design of a multifaceted intervention to encourage successful breastfeeding.

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In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

This study reports results of the 2-year follow-up phase of a randomized study comparing outcomes of patients assigned to a nurse practitioner or a physician primary care practice. In the sample of 406 adults, no differences were found between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient services. Physician patients averaged more primary care visits than nurse practitioner patients. The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians.

One promising approach to strengthening theory-research and theory-practice linkages is to place greater emphasis on developing and using theories of the middle range to underpin nursing research and practice. In this article, a postpositivistic definition of middle-range theory is advanced, an argument is made for shifting nursing's theory development activities from discipline-defining grand theories to middle-range theories, and a collaborative and incremental approach to middle-range theory development is described and illustrated. A sustained substantive example is provided by the beginning development of a theory of unpleasant symptoms.

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