Theories, Models, and Frameworks Related to Sleep-Wake

Disturbances in the Context of Cancer

Julie L. Otte, PhD, RN and Janet S. Carpenter, PhD, RN

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Abstract
Sleep-wake disturbances in the context of cancer are increasingly being recognized as a
significant problem.1–3 Sleep has been characterized as a psychobiological event that includes
physiological, psychological, and behavioral mechanisms.4 Sleep-wake disturbances have been
defined as disruptions in nighttime sleep or wakefulness that can result in negative health
outcomes.4 In various American and Canadian samples, 18% to 90% of cancer patients and
survivors reported subjective sleep-wake disturbances.2,3,5–9 Subjectively reported sleep-wake
disturbances can include a variety of diagnosable sleep-wake problems such as insomnia, restless
leg syndrome, periodic limb movement disorder, obstructive sleep apnea, or daytime sleepiness.
Of these, insomnia (difficulty falling asleep, staying asleep, or early awakening) is commonly
reported among cancer patients and survivors.10 Sleep-wake disturbances are important to
address because, if left untreated, they can negatively effect quality of life.9,11–13
A number of descriptive and intervention studies have targeted sleep-wake disturbances in
various cancer populations,2,14,15 and there are extensive published reviews of the physiology,
measurement, and terminology of sleep-wake disturbances in cancer.10,16–19 One common
limitation noted within this literature has been the lack of conceptual clarity, in-part due to the
inconsistent use or lack of disclosure of guiding theories, models, or frameworks.17,19 To the best
of our knowledge, a review article describing the theory, models, or frameworks used to guide
research in this area has not been previously published.
The purpose of this article was to review theories, models, or frameworks applied to the problem
of sleep-wake disturbances in the context of cancer. The main goals of this review were to (1)
quantify, summarize, and compare the number of studies with and without explicitly described
theories, models, or frameworks and (2) summarize and compare the theories, models, and
frameworks that were used.
This review was important because theoretically grounded research advances science for
evidence-based nursing research. One could question whether it is more important to base
research on a theory, model, or framework or to have clear and consistent variable names,
definitions, and measurement of sleep. We argue the former. Theories, models, or frameworks
are important because they provide direction for research designs, assessment tools, and
intervention development for effective symptom management. Typically, authors list the
theories, models, or frameworks that specify interrelationships of critical attributes of concepts
related to a problem. These critical attributes then link research findings to a body of knowledge
that can be used by healthcare professionals for symptom management.20 Therefore, it is through
the use of the underlying theories, models, and frameworks that we better understand the
definitions and measurement of certain research phenomena.
In nursing, the terms theory, model, and framework are often used interchangeably. By
definition, a theory provides systematic explanations about relationships among phenomena,
whereas a concept is based on observed characteristics or behaviors such as sleep.20 A theory
generally includes relational statements that are useful for explanation, description, prediction,
control, or prescription based on definitions of the underlying concepts.21 A model is a symbolic
representation of relationships among variables or concepts.20 A framework is often the
illustration that describes the conceptual underpinnings of the research and can be based on a
theory or, more specifically, on a concept (such as sleep-wake disturbances).20,21
Go to:

Methods

Data Sources
Searches were conducted to find relevant articles. Using MEDLINE, CINAHL, PubMed, and
PsychINFO search engines (n = 4), citations from January 1, 1970, to July 31, 2008, were
reviewed. Search terms used alone and in combination included the following: sleep, wake,
disturbance, impaired sleep, insomnia, theoretical, conceptual, model, frame-work, adult,
cancer, and survivor. We identified articles that included cancer patients undergoing treatment
and cancer survivors (had completed treatment). Because these search terms resulted in more
than 500 possible publications, articles were excluded from the review if they (1) were drug
interventions, (2) focused on pediatric cancer or caregivers of cancer patients, (3) were
instrument or questionnaire validation studies, (4) focused on statistical modeling of sleep-wake
disturbances, (5) were letters to the editor or single case reports, or (6) reported sleep and wake
as an incidental finding.

Procedures
On the basis of the above, 73 studies were identified and reviewed. We quantified the number of
studies with and without an explicitly stated a theory, model, or framework to clearly define
these subsets of the studies and avoid assumptions of vague descriptions of theoretical
underpinnings. We then summarized studies based on these criteria: (1) discipline of authors; (2)
type of study; (3) sample information including (a) cancer diagnosis, (b) cancer stage, and (c)
treatment status; (4) study variables; and (5) measures of sleep-wake. We then used χ2 tests to
compare these criteria between studies with and without a theory, model, or framework.
Next, we evaluated whether sleep was a primary or secondary variable within each theory,
model, or framework. We developed a written summary of each theory, model, or framework
and identified and compared their key attributes.
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Results
Quantification, Summary, and Comparison of Studies With and Without Explicitly
Described Theories, Models, or Frameworks
Of the 73 studies, 51 (70%) did not contain a reported theory, model, or framework.3,5,7,9,11,14,22–
66
These studies were considered atheoretical because there was no explicit description of a
theory, model, or framework that had guided the study. These 51 studies are listed alphabetically
in Table 1. The remaining 22 (30%) articles included a description of a theory, model, or
framework that guided the study.1,2,6,12,15,67–82 These 22 studies are listed alphabetically in Table
2. Tables 1 and and22 provide a general summary of all studies based on our review criteria.
Table 1
Summary of Studies Without a Theory, Model, or Framework

Disciplines Type of Stage of Cancer tx Variables of Measure of

Source of Authors Study Sample Cancer Status Interest Sleep-Wake

Ancoli- Psychiatry, Descripti Breast I–IIIa Pre-tx Fatigue, sleep Pittsburgh

Israel et medicine ve cancer quality, Sleep Quality
al22 circadian rhythm Index, wrist
functional actigraph
status,
depression

Anderson Psychology, Descripti Mixed I–IV NR Fatigue, sleep Sleep

et al23 psychiatry, ve sample disturbance, Disturbance
medicine, of depression, Scale
public health cancer mood

Andryko Psychology, Descripti Bone NR Post–bone Fatigue, sleep Pittsburgh

wski et nursing, ve marrow marrow quality, mood, Sleep Quality
al24 medicine transpla transplanta depression Index
nt tion
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

Bardwell Psychiatry, Descripti Breast I–IIIa Active or Insomnia, Women’s

et al25 psychology, ve cancer post-tx depression, Health
medicine mood, Initiative
functional Sleep
status, physical Disturbance
health, health Scale
behaviors

Berger Nursing Descripti Breast I–II Active tx Fatigue, daytime Wrist

and Farr54 ve cancer activity actigraph
nighttime rest,
circadian
rhythms

Bower et Psychiatry, Descripti Breast 0–II Post-tx Fatigue, Medical

al55 behavioral ve cancer contributing Outcomes
medicine, factors of Study-Sleep
medicine, fatigue, Scale
psychology, depression, pain,
and menopausal
biostatistics factors, sleep,
quality of life

Broeckel Psychology Descripti Breast I–III Post-tx Fatigue, sleep, Pittsburgh

mood, Sleep Quality
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

et al26 and medicine ve cancer menopausal Index

symptoms,
depression/adjus
tment disorder

Bruera et Medicine Descripti Mixed Advanced NR Insomnia, Visual analog

al56 ve sample disease hypnotic scale of
of withdrawal, insomnia
cancer cognitive failure items

Cannici et Psychology, Intervent Mixed NR Active and Insomnia, Daily sleep

al58 psychiatry ion sample post-tx muscle questionnaire
of relaxation (sleep
cancer behaviors)

Chen et Nursing, Descripti Lung III–IV Active tx Sleep Pittsburgh

al57 medicine ve cancer disturbances, Sleep Quality
chemotherapy, Index
quality of life,
functional
performance

Cohen et Psychology, Intervent Lympho I–IV Active or Sleep quality, Pittsburgh

al27 public health, ion ma post-tx psychological Sleep Quality
medicine, adjustment,
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

biostatistics, depression, Index

religion anxiety, impact
of life event,
fatigue

Coleman Nursing, Intervent Multiple NR Active tx Exercise, sleep, Wrist

et al59 biostatistics, ion myelom fatigue, mood, actigraph,
public health, a activity, muscle sleep log,
education strength, aerobic Epworth
capacity Sleepiness
Scale

Couzi et Medicine, Descripti Breast 0–III Post-tx Menopausal 66-Item

al60 psychiatry, ve cancer symptoms, questionnaire
public health willingness to with single-
take estrogen item sleep
therapy question

Crandall Medicine, Descripti Breast 0–IIIa Post-tx Severity, bother Generic

et al7 public health ve cancer of menopausal questionnaire
symptoms— with one
sleep, hot question
flashes, regarding
urogenital, restless sleep
sexual, cancer-
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

related pain,
cognitive
functioning,
depression,
menopausal
status

Davidson Psychology, Intervent Mixed NR Post-tx Sleep Sleep diary,

et al28 medicine ion sample disturbances as wrist
of insomnia, mood, actigraph
cancer functioning

Davidson Psychology, Descripti Mixed NR Active or Sleep Sleep Survey

et al5 medicine ve sample post-tx disturbances,
of insomnia,
cancer fatigue, daytime
sleepiness,
sleep-related
breathing
problem, resdess
legs, dreaming,
napping, use of
sleep
medications
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

de Moor Behavioral Intervent Renal Metastatic Active tx Expressive Pittsburgh

et al14 medicine, ion cell writing, Sleep Quality
biostatistics, cancer psychological, Index
psychiatry, behavioral
medicine adjustment

Dirksen Nursing Intervent Breast I–III Post-tx Insomnia, Insomnia

and ion cancer cognitive Severity
Epstein, behavioral Index
2008 intervention,
quality of life

Engstrom Nursing, Descripti Mixed NR Active or Sleep Study

et al29 psychiatry ve sample post-tx disturbances, specific 82-
of mood, item sleep
cancer performance, disturbance
daytime questionnaire
functioning, , qualitative
physical interview
activity, lifestyle specific to
behaviors sleep

Espie et Psychology, Intervent Mixed NR Post-tx Insomnia, Pittsburgh

al62 medicine ion sample fatigue, Sleep Quality
of cognitive Index,
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

cancer behavioral Epworth

intervention, Sleepiness
quality of life Scale

Fernandes General Descripti Mixed Advanced Active or Fatigue, daytime Wrist

et al63 science, ve sample disease post-tx activity, sleep actigraph,
medicine of disorders, sleep diary
cancer circadian rhythm

Former et Psychology, Descripti Breast NR Pre-tx, Sleep, quality of Pittsburgh

al11 medicine ve cancer active, or life, cancer Sleep Quality
post-tx treatment Index

Haghigha Medicine, Descripti Breast I–IV Active or Fatigue, General

t et al64 public health ve cancer post-tx contributing physical
factors of symptom
fatigue questionnaire

Hunter et Psychology, Descripti Breast No active Hormonal Menopausal Women’s

al65 medicine, ve cancer cancer tx symptoms (eg, Health
psychiatry hot flashes, Questionnair
sleep), quality of e
life,
management
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

strategies

Janz et Health Descripti Breast 0–II Post-tx Symptom European

al66 behaviors/educ ve Cancer experience post- Organization
ation, tx, quality of life for Research
medicine, of Cancer
public health Quality of
Life
Questionnair
e (EORTC
QLQ-C30)

Koopman Psychology, Descripti Breast Metastatic/lo Active or Sleep Sleep

et al30 medicine ve cancer cally post-tx disturbances, questionnaire
advanced depression, (modified
social support, version of
cortisol levels insomnia
interview)

Lamb42 Nursing Descripti Mixed Active-tx or NR Sleep, Study

ve sample supportive hospitalization, specific sleep
of care cancer diagnosis questionnaire
cancer with items,
open-ended
questions
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

Le Guen Medicine Descripti Lung Small cell Pre-tx Sleep Pittsburgh

et al45 ve cancer (limited to disturbances, Sleep Quality
extensive), daytime Index,
non–small functioning Epworth
cell (stages Sleepiness
I–IV) Scale, wrist
actigraph

Lis et al46 Public health Descripti Mixed I–IV Pre-tx or Insomnia, Insomnia
ve sample active tx patient subscale of
of satisfaction, EORTC
cancer quality of life QLQ

Malone et Pharmacy, Descripti Mixed NR Active-tx Quality of life UK Sickness

al47 medicine ve sample (work, Impact
of recreation, home Profile
cancer management,
sleep), health
status

Mao et Medicine, Descripti Mixed NR Post-tx Pain, depression, Items from

al48 biostatistics ve sample anxiety, the National
of insomnia, cancer Health
cancer survivorship, Interview
impact of
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

symptom survey
burden, age,
comorbidity

Miaskows Nursing Descripti Mixed Metastatic Active-tx Fatigue, pain, Sleep diary,
ki and ve sample sleep wrist
Lee31 of disturbance, actigraph
cancer depression

Monga et Medicine, Descripti Prostate Tlc-T2c Active-tx Neuromuscular Epworth

al49 psychology ve cancer fatigue, sleep, Sleepiness
depression, Scale
radiation tx

Okuyama Psychiatry, Descripti Breast 0–III Post-tx Fatigue, Physical

et al50 medicine ve cancer correlates of symptom
fatigue, questionnaire
depression,
coping, physical
symptoms such
as sleep

Owen et Nursing Descripti Mixed NR Active or Sleep quality Pittsburgh

al32 ve sample post-tx Sleep Quality
of
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

cancer Index

Parker et Nursing, Descripti Mixed III–IV NR Sleep-wake Polysomnogr

al53 medicine ve sample patterns, aphy
of advanced
cancer cancer,
medications

Pud et al58 Nursing, Descripti Mixed NR Active tx Fatigue, sleep General sleep
psychology ve sample disturbance, disturbance
of epression, pain, scale
cancer quality of life

Quesnel Psychology Intervent Breast I–III Post-tx Insomnia, Insomnia

et al39 ion cancer depression, Severity
state/trait Index,
anxiety, fatigue, polysomnogr
quality of life aphy

Roscoe et Psychology, Descripti Breast NR Active tx Fatigue, Wrist

al34 medicine ve cancer circadian actigraph
rhythms,
depression,
mood, type of
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

cancer treatment

Savard et Psychology Descripti Breast I–III Post-tx Insomnia, Insomnia

al3 ve cancer contributing Screening
factors of Questionnair
insomnia e, Insomnia
Interview
Schedule

Savard et Psychology Descripti Breast I–III Post-tx Insomnia, Insomnia

al33 ve cancer nocturnal hot Interview
flashes, sleep Schedule
disturbances

Savard et Psychology Intervent Breast I–III Post-tx Insomnia, Insomnia

al38 ion cancer anxiety, Interview
depression, Schedule,
fatigue, quality Insomnia
of life Severity
Index, Sleep
Diary,
polysomnogr
aphy
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

Servaes et Psychology, Descripti Breast NR Post-tx Fatigue, Groninger

al43 medicine ve cancer determinates of Sleep Quality
fatigue Scale

Schultz et Nursing, Descripti Breast NR Post-tx Menopausal Menopausal

al9 medicine ve cancer symptoms, symptom
physiological questionnaire
health effects
related to cancer
treatment,
quality of life

Shapiro et Psychology, Intervent Breast II Post-tx Sleep Sleep diary

al42 medicine/publi ion cancer disturbance,
c health mood, worry,
depression,
state/trait
anxiety, type of
cancer
treatment, sense
of coherence,
control

Silberfarb Psychiatry, Descripti Lung NR Active-tx Insomnia, sleep, Pittsburgh

Sleep Quality
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

et al51 psychology ve cancer cancer Index, sleep

log

Silberfarb Psychiatry, Descripti Mixed I–IV Post-tx Sleep Polysomnogr

et al35 psychology ve sample disturbance as aphy
of insomnia,
cancer anxiety, mood,
strength,
depression,
nausea, pain,
fatigue

Simeit et Psychology Intervent Mixed NR Post-tx Sleep Pittsburgh

al36 ion sample management, Sleep Quality
of cancer- related Index
cancer quality of life

Spelten et Medicine, Descripti Mixed NR Active and Fatigue, Pittsburgh

al41 psychology ve sample post-tx depression, Sleep Quality
of sleep, physical Index
cancer problems,
cognitive
dysfunction,
psychological
distress, return
 Disciplines Type of Stage of Cancer tx Variables of Measure of
Source of Authors Study Sample Cancer Status Interest Sleep-Wake

to work

Tatrow et Behavioral Descripti Breast NR Active tx Sleep, activity, Three-item

al37 medicine ve cancer distress, quality sleep-wake
of life, fatigue, assessment
activity

Wang et Nursing, Descripti Mixed III–IV Active tx Pain, sleep Pittsburgh

al40 medicine, ve sample disturbance Sleep Quality
biostatistics of Index
cancer

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Abbreviations: NR, not reported; tx, treatment.

Table 2
Summary of Studies With a Theory, Model, or Framework

Theory, Disciplin Type of Stage of Cancer Measure

Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

Berger78 Piper’s Nursing Descripti Breast I–II Active Fatigue, Wrist

Integrated ve cance tx activity/rest, actigraph
Fatigue r cancer
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

Model treatment

Berger and Piper’s Nursing Descripti Breast I-II Active Fatigue, Morin
Higginbotha Integrated ve cance tx sleep, Sleep
m79 Fatigue r activity/rest, Diary,
Model symptom wrist
distress, actigraph
health status

Berger et Piper’s Nursing Interventi Breast I–II Active Fatigue, Pittsburgh

al70 Integrated on cance tx sleep, Sleep
Fatigue r activity, Quality
Model chemotherap Index,
y, sleep Brief Sleep
hygiene History,
intervention Sleep
Hygiene
Awareness,
Practice
Scale, wrist
actigraph,
Morin
Sleep Diary
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

Berger et Piper’s Nursing Interventi Breast I–II Active Fatigue, Pittsburgh

al15 Integrated on cance or post- sleep Sleep
Fatigue r tx disturbance, Quality
Model adherence, Index,
sleep wrist
hygiene actigraph,
Morin
Sleep Diary

Berger et Piper’s Nursing Descripti Breast I–IIIa Pre-tx Fatigue, Pittsburgh

al68 Integrated ve cance sleep-wake, Sleep
Fatigue r activity-rest, Quality
Model circadian Index,
rhythms wrist
actigraph,
sleep diary

Blesch et Piper’s Nursing Descripti Breast NR Active- Fatigue, Two-item

al76 Integrated ve and tx correlates of sleep
Fatigue lung fatigue questionnai
Model cance re
r regarding
hours of
sleep
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

obtained at
home,
during
hospitalizat
ion

Carlson et Biobehaviora Medicine Descripti Breast I–IV Post-tx Sleep Pittsburgh

al, 2007 l Model of and ve cance quality, Sleep
Altered psycholo r cortisol, Quality
Dysregulatio gy melatonin, Index
n in Orcadian catecholami
Systems nes,
psychosocial
stress/factor
s

Carpenter Model of Nursing Descripti Breast 0–III Post-tx Menopause, Blatt

and Symptom and ve cance menopausal Menopausa
Andrykowsk Management behaviora r symptoms, l Index
i6 l science quality of
life

Carpenter et Theory of Nursing Descripti Breast I–III Post-tx Hot flashes, Pittsburgh
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

al2 Unpleasant ve cance sleep, Sleep

Symptoms— r fatigue, Quality
adapted depression Index

Carpenter et Psychobiolog Nursing Interventi Breast 0–III Post-tx Hot flashes, Pittsburgh
al72 ical model of on cance sleep, mood Sleep
hot flashes r Quality
Index,
wrist
actigraph

Dodd et al77 Model of Nursing Descripti Mixe Metastatic Active Symptom Quality of
Symptom and ve d and tx cluster, Life—
Management psycholo sampl nonmetast symptom Cancer
gy e of atic outcomes,
cance functional
r status, pain,
fatigue,
sleep
insufficienc
y

Dow et al12 Model of Nursing Descripti Breast 0–IV Active Quality of Quality of
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

Quality of ve cance and life, Life—

Life r post-tx physical, Cancer
psychologic
al, social,
spiritual
domains of
quality of
life

Epstein and Spielman’s Nursing Interventi Breast I–III Post-tx Cognitive- Sleep
Dirksen73 Three- Factor on cance behavioral Diary,
Model r intervention, wrist
insomnia actigraph

Hoffman et Theory of Nursing Descripti Lung I–IV Active Symptom Cancer

al81 Unpleasant and ve cance tx cluster: pain, Symptom
Symptoms psycholo r fatigue, Experience
gy insomnia Inventory

McMillan et Orem’s Self- Nursing Descripti Mixe Any stage NR Pain, sleep Memorial
al97 care Deficit ve d disturbance, Symptom
Theory of sampl depression Assessment
Nursing e of Scale
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

cance
r

Payne et al69 Neuroendocri Nursing Descripti Breast II Active Fatigue, Demograph

ne- Based and ve cance tx sleep, ic
Regulatory medicine r depressive questionnai
Fatigue symptoms, re (sleep
Model biomarkers disturbance
), Piper
Fatigue
Scale
(sleep
disturbance
item), wrist
actigraph

Payne et al80 Neuroendocri Nursing, Interventi Breast NR Post-tx Fatigue, Pittsburgh

ne- Based medicine, on cance (hormo waking Sleep
Regulatory and r nal tx) intervention, Quality
Fatigue biostatisti sleep Index
Model cs disturbances
, depressive
symptoms,
biomarkers,
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

symptom
management

Redeker et Theory of Nursing Descripti Mixe Majority Active Insomnia, Symptom

al74 Unpleasant ve d metastatic tx fatigue, Distress
Symptoms sampl anxiety, Scale
e of depression,
cance quality of
r life

Rhodes et Orem’s Self- Nursing Qualitati Mixe NR Post-tx Tiredness, Self-care

al82 care Deficit ve d weakness, interview
Theory of sampl self-care
Nursing e of
cance
r

Rumble et Spielman’s Psycholo Descripti Lung I–IlIa, NR Insomnia, Structured

al67 Three-Factor gy, ve cance limited sleep Interview
Model psychiatr r stage small hygiene, for Sleep
y, and cell lung cancer Disorders,
medicine cancer symptoms, Sleep
mood, Hygiene
 Theory, Disciplin Type of Stage of Cancer Measure
Model, es Study Cancer tx of
or of Samp Status Variables Sleep-
Source Framework Authors le of Interest Wake

quality of Practice
life Scale,
Insomnia
Symptom
Questionna
ire, sleep
log, wrist
actigraph

Vena et al1 Adapted Nursing, Descripti Lung Advanced Active Sleep-wake Pittsburgh
Two-Process psycholo ve cance disease tx disturbances Sleep
Model of gy, and r , quality of Quality
Sleep medicine life Index,
Regulation Epworth
Sleepiness
Scale

Young- Roy Nursing, Interventi Mixe 0–IV Active Exercise Wrist

McCaughan Adaptation biostatisti on d or post- tolerance, actigraph
et al75 Model cs, sampl tx activity,
psycholo e of sleep
gy, cance patterns,
medicine r quality of
life
 Open in a separate window
Abbreviation: tx, treatment.

Comparisons between the 51 atheoretical and 22 theoretically based studies are provided
in Table 3. χ2 Tests of differences indicated that studies that included a theory, model, or
framework were significantly (1) more likely to include authors from the discipline of nursing
and (2) less likely to have included wrist actigraphy as an outcome measure.
Table 3
Comparisons Between Articles Without a Theory, Model, or Framework (n = 51) and Articles
With a Theory, Model, or Framework (n = 22)

Without With Theory,

Theory, Model, Model, or
or Framework, Framework,
n (%) n (%) Pa

Author Disciplines Included Nursing

No 38 (75) 2 (9) <.001

Yes 13 (25) 20 (91)

Types of Study

Descriptive 40 (78) 16 (73) .59

Intervention 11 (22) 6 (27)

 Without With Theory,
Theory, Model, Model, or
or Framework, Framework,
n (%) n (%) Pa

Sample: cancer diagnoses

Mixed sample 20 (39) 6 (27) .53

Breast only 23 (45) 13 (59)

Other single cancer 8 (16) 3 (14)

Sample: stage of cancer

Nonmetastatic 16 (31) 11 (50) .21

Metastatic 5 (10) 2 (9)

Both 11 (22) 6 (27)

Not reported 19 (37) 3 (14)

 Without With Theory,
Theory, Model, Model, or
or Framework, Framework,
n (%) n (%) Pa

Sample: treatment status

Pretreatment 2 (4) 1 (5) .60

Active treatment 12 (24) 9 (41)

Posttreatmentb 21 (41) 7 (32)

Mixed sample 12 (24) 3 (14)

Not reported 4 (8) 2 (9)

Pittsburgh Sleep Quality Index included

No 38 (75) 14 (64) .35

Yes 13 (25) 8 (36)

 Without With Theory,
Theory, Model, Model, or
or Framework, Framework,
n (%) n (%) Pa

Polysomnography used

No 46 (90) 22 (100) .13

Yes 5 (10) 0 (0)

Actigraphy used

No 43 (84) 12 (55) .01

Yes 8 (16) 10 (45)

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Significant differences are in bold.
a
P value based on χ2 test of differences between groups.
b
Posttreatment included subjects taking hormonal therapy.

Summary and Comparison of Theories, Models, and Frameworks

Table 4 contains a summary and comparison of theories, models, and frameworks. There were 2
nursing theories83,84 and 9 different conceptual models.67,71,72,85–93 Three conceptual models focused
on sleep-wake disturbances as a primary variable of interest. Two theories and 6 additional
models included sleep-wake disturbances as one of several variables. These 8 latter
theories/models tended to include sleep-wake disturbances as a secondary variable or as one
variable within a cluster of several symptoms (eg, pain, fatigue, and sleep-wake disturbances). A
description of each theory and model follows, starting with ones that included sleep wake
disturbances as a primary variable and concluding with those that included it as a secondary
variable.
Table 4
Summary and Comparison of Theories, Models, and Frameworks

Physiological Psychological Behavioral

SWD Model Brief Synopsis Components Components Components

Primary Biobehavioral Model SWD manifested as X X

of Altered circadian dysregulation
Dysregulation in
Circadian Systems

Primary Spielman’s Three- Predisposing, precipitating, X X X

Factor Model and perpetuating factors
interact in insomnia

Primary Adapted Two-Process Process S and process C X X X

Model of Sleep drive sleep and wakefulness
Regulation (adapted)

Secondary Model of Quality of Sleep as part of physical X X

Life well-being, 1 of 4 quality of
life domains

Secondary Model of Symptom Symptom experience, X X X

symptom management and
 Physiological Psychological Behavioral
SWD Model Brief Synopsis Components Components Components

Management symptom outcomes are

related

Secondary Neuroendocrine-Based Describes mechanisms of X X

Regulatory Fatigue wake disturbances (fatigue)
Model

Secondary Orem’s Self-care SWD potentially impact X X X

Deficit Theory of self-care abilities
Nursing

Secondary Piper’s Integrated Sleep as one of several X X X

Fatigue Model factors influencing fatigue

Secondary Psychobiological Sleep disturbances as X

model of hot flashes outcome of menopausal hot
flashes

Secondary Roy Adaptation Model Sleep as physiological mode X X

of adaptation

Secondary Theory of Unpleasant Physiological, X X X

psychological, and
 Physiological Psychological Behavioral
SWD Model Brief Synopsis Components Components Components

Symptoms—adapted situational factors influence

sleep and other symptoms
that negatively affect
performance status

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Abbreviation: SWD, sleep wake disturbances.

Models With Sleep-Wake Disturbances as a Primary Variable

BIOBEHAVIORAL MODEL OF ALTERED DYSREGULATION IN CIRCADIAN

SYSTEMS
The Biobehavioral Model of Altered Dysregulation in Circadian Systems proposes mechanisms
that contribute to sleep-wake disturbances manifested as circadian dysregulation.71 The model
postulates that psychological functioning (stress, depression, mood states) have direct-reciprocal
relationships with the endocrine system, autonomic nervous system, and sleep system.
Dysregulation can be attributed to one or more of these biological systems. Dysregulation can be
measured by sleep duration and sleep quality, as well as by cortisol, melatonin, and autonomic
nervous system activity. The ultimate outcome of this dysregulation is poor quality of life,
impaired well-being, poor treatment adherence, fatigue, disease progression, and poorer
survival.71 This model was included in one article.71

SPIELMAN’S THREE-FACTOR INSOMNIA MODEL

Spielman’s Three-Factor Insomnia Model proposes interactions among predisposing,
precipitating, and perpetuating factors of insomnia.94 This cognitive-behavioral model is also
known as the 3P model. The model includes both stress and behavioral factors to explain the
evolution of insomnia and describe how individual differences cause initiation of acute
disturbances in sleep that become chronic. The model proposes that people with insomnia have
predisposing factors or traits that, when combined with life stress (precipitating factors), lead to
chronic insomnia if there are maladaptive coping strategies (perpetuating factors).86 When a
person with predisposing factors of insomnia experiences one or more precipitating factors, the
result can be acute episodes of insomnia.94 Perpetuating factors are behaviors used to compensate
for the loss of sleep. This model was included in 2 articles.67,73

TWO-PROCESS MODEL OF SLEEP REGULATION

The Two-Process Model of Sleep Regulation provides an understanding of the physiological
mechanisms that drive sleep and wakefulness.88 The model has changed over time, as researchers
were able to pinpoint mechanisms or processes of sleep in relation to the 2 major sleep cycles of
non–rapid eye movement and rapid eye movement sleep. Visually, the model is a wavelike
structure that shows the relationship between 2 physiological processes of sleep regulation,
process S and process C. The homeostatic process (process S) increases during the awake state
(drives the need for sleep) and decreases during sleep (decreases the need for sleep). Process S is
considered the basic mechanism of sleep regulation. If there is a deficit of sleep, process S elicits
a compensatory increase in the duration and intensity of sleep. This produces a sleepy feeling
during wakefulness, thus driving the need or desire to correct this deficit by falling asleep. The
circadian process (process C) determines alterations of high and low sleep propensity that are
independent of prior sleeping-waking (the timing to sleep and wakefulness), which determines
the onset and end of sleep.88 Process C is directed by a clocklike mechanism that is not related to
prior levels of sleep or the wake-like process S. Process C is the mechanism that helps the body
stay asleep. It is driven by a pacemaker found in the brain called the hypothalamic
suprachiasmatic nuclei, which works in conjunction with neurotransmitters that facilitate sleep
and thermoregulatory processes. The interaction of process S and process C has been used to
predict the timing and duration of sleep, structure of sleep, and changes in daytime
wakefulness.88 This model was adapted for use in one article.1

Theories or Models With Sleep Disturbances as a Secondary or Clustered Variable

MODEL OF QUALITY OF LIFE

The Model of Quality of Life identifies 4 domains that define an individual’s quality of life.
Developed within the discipline of nursing, the model has been used to describe the quality of
life in cancer patients. The 4 domains include physical well-being (eg, sleep), psychological
well-being (eg, depression), social well-being (eg, family distress), and spiritual well-being
(hopefulness).90–92,95,96 Each domain is stated to act singly or in combination with the other
domains and ultimately impact quality of life. The specific symptoms or factors within each
quality of life domain have been further studied in various cancers such as breast cancer (see the
study of Ferrell et al90). For this model, sleep is depicted as a physical domain that could be
singly or combined with other domain factors that impact quality of life.90 This model was
included in one article.12

MODEL OF SYMPTOM MANAGEMENT

The Model of Symptom Management was a nursing model developed by nursing faculty from
the University of California San Francisco’s Center for Symptom Management.89 The conceptual
model is based on the premise that a symptom is a subjective experience of a biophysical
function, cognition, or sensation. Starting with the symptom experience, 3 inner relationships
include the perception of the symptom, the evaluation of the symptom, and the response of the
symptom, which is related back to the perception. The response then includes internal feelings,
behaviors, or thoughts related to the perceived or actual presence of a health problem. Symptom
management strategies are actions that overcome or stop the negative outcomes from the
symptoms through medical or self-care interventions such as assessment and treatment. The
outcome of the symptoms is a complex construct that includes 10 possible dimensions.89 In this
model, sleep-wake disturbances can be a symptom or an outcome. This model was included in 2
articles.6,12

NEUROENDOCRINE-BASED REGULATORY FATIGUE MODEL

The Neuroendocrine-Based Regulatory Model was developed to describe mechanisms of fatigue
in chronic illness.93 Although thought to be a multidimensional concept, the model proposes that
fatigue is strongly influenced by endocrine-based bio-chemicals such as tryptophan and
melatonin. Any stress on the endocrine system creates biological effects that serve as markers for
fatigue.93 Antecedents of fatigue are stated to be either physiological (altered circadian rhythm of
sleep/wake) or psychological (depression). The model proposes interventions that act as a
mediator to reduce the impact of the antecedents on the endocrine system and improve fatigue.
This model was used in 2 articles.69,80

OREM’S SELF-CARE DEFICIT THEORY OF NURSING

Orem’s Self-care Deficit Theory of Nursing was developed in 1985 and focuses on the ability of
an individual to perform self-care activities (termed self-care agency) to maintain life, health,
and well-being or the ability to care for others (termed dependent-care agency).20,84 The nursing
role within the model is to assess the individual’s ability to perform self-care through a complete
assessment of the current health state and symptoms being experienced by the individual. The
model suggests that nurses provide 3 types of care: (1) total compensatory where the nurse
provides total care when the individual cannot perform any self-care, (2) partial compensatory
where the individual and nurse share self-care activities, and (3) supportive care or educational
care where the nurse facilitates self-care through educating the individual with the tools to make
decisions or learn skills needed for total self-care.20,84 In this model, sleep-wake disturbances are
symptoms that can result from cancer treatment that potentially impact self-care. This theory was
used in 2 articles.82,97

PIPER INTEGRATED FATIGUE MODEL

The Piper Integrated Fatigue Model has been used to study fatigue in relation to sleep
disturbances in cancer patients.15 The mid-range nursing model by Piper et al proposes a variety
of factors as influencing subjective and objective manifestations of fatigue (see Piper et al85 for
the figure). Fatigue manifestations are divided into physiological, biochemical, and behavioral
components. These components include physiological muscle fatigue, changes in behavioral
work activity, and/or symptoms of depression, and they can occur in combination as fatigue
becomes a chronic problem.85 In this model, sleep-wake disturbances are one of several factors
influencing fatigue. This model was included in 6 articles.15,68,70,76,78,79

PSYCHOBIOLOGICAL HOT FLASH MODEL

This model depicts sleep disturbances as an outcome of meno-pausal hot flashes. It shows
relationships among physiological hot flashes, perceived hot flashes, and the reporting of hot
flash severity and bother, and it proposes that hot flashes contribute to a possible cluster of
symptoms that include sleep-wake disturbances, mood disturbances, and changes in affect, which
ultimately impact quality of life. This model was included in one article.72
ROY ADAPTATION MODEL
Roy Adaptation Model is a complex nursing model postulating that human beings have the
ability to adapt to changes in the environment.87 Adaptation or coping with environmental change
occurs through maintaining 4 subsystems: (1) physiologic needs, (2) self-concept, (3)
interdependence, and (4) role function. For nursing, the goal is to use this model to guide health
promotion and adaptation to illness. The model postulates that focal, contextual, or residual
stimuli can be manipulated to promote adaptation based on stage of personal development,
family development, and culture.87 Adaptation responses can be effective or ineffective
depending on the mode of adaptation. Effective adaptation responses are thought to promote
integrity of the human system.87 In this model, sleep can be conceptualized as a physiological
mode of adaptation alone or in combination with other outcomes.75 This model was included in
one article.75

THEORY OF UNPLEASANT SYMPTOMS

The Theory of Unpleasant Symptoms83 is a mid-range nursing theory that has been used to
describe sleep as it interacts with other symptoms. The theory has 3 interrelated components: (1)
symptoms that the person experiences, (2) influencing factors that cause or affect the nature of
the symptoms, and (3) consequences of the symptom experience.83 Symptoms are the main
component of the model and are measured in terms of intensity, quality, timing, and distress. The
model posits that symptoms can occur alone or simultaneously with other symptoms and
suggests that certain symptoms can catalyze other symptoms (see Figure 2 in the study of Lenz et
al83). Influencing factors are the physiological, psychological, and situational factors influenced
by the symptoms. The third component is the consequence, defined as the impact of symptoms
on an individual’s ability to perform functional or cognitive activities. Functional performance
includes activities such as physical, daily living, social, interactive, and role performance (eg,
work) activities. The interaction among the 3 major concepts of symptoms, influencing factors,
and consequences is reciprocal and can change as the symptom experience changes. This
suggests that symptoms can moderate or mediate the relationship between influencing factors
and performance.83 In this model, sleep-wake disturbances can be one of many symptoms or an
influencing factor affecting other symptoms. This model was included in 2 articles.2,74
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Discussion

Quantification, Summary, and Comparison of Studies With and Without Explicitly

Described Theories, Models, or Frameworks
The quantification of studies indicates that most research related to sleep-wake disturbances in
cancer patients and survivors could be considered atheoretical. Most published studies that were
reviewed here did not include an explicit description of a guiding theory, model, or framework.
This is a significant limitation of existing research that may inhibit clarity of (1) the conceptual
definition of sleep-wake disturbances, (2) the subsequent operationalization of sleep-wake
disturbances, and (3) identification of contributing factors and consequences of sleep-wake
disturbances.
The summary and comparison of studies indicated first that whether an article included a theory,
model, or frame-work varied by discipline. Articles authored by nurses were significantly more
likely to include an explicit description of a theory, model, or framework. It is well-known that
non-nursing disciplines often do not disclose theoretical or conceptual models unless the purpose
of the study is to further define the underlying concepts of the model. In addition, nonnursing
journals may not allow space for the description of a theory or model. Therefore, one limitation
of this review is that it is not known whether the studies were truly atheoretical or just lacking a
written description of the theory, model, or framework.
The summary and comparison of studies also indicated that theoretically based articles were
more likely to be based on subjective measurement rather than objective measures such as wrist
actigraphy or polysomnography. Theories and models would seem to be equally relevant to
subjective and objective measurement of sleep; however, exclusion of objective measures means
that these theories and models are being tested only in the context of subjective sleep. In
addition, the subjective measures that were used varied widely within both groups of studies (for
details of sleep measures, see review18). Although the Pittsburgh Sleep Quality Index was the
most commonly used measure of subjective sleep, most studies used other types of
questionnaires to measure sleep-wake disturbances. This is also reflected by the various
terminology of sleep such as sleep-wake, insomnia, sleep disturbances, restless sleep,
and tiredness. Because of these variations in terminology and measurement, it is difficult to
ascertain if sleep-wake disturbances were conceptualized similarly across studies that did not
include theories or models.
The summary and comparison of studies did not show significant differences by group in terms
of type of study (descriptive or intervention) and sample characteristics. These criteria varied
widely within both groups of studies. Varying sample characteristics may make comparisons
across studies somewhat difficult.

Summary and Comparison of Theories, Models, and Frameworks

This review revealed wide variation in the theories, models, and frameworks that are used to
study sleep-wake disturbances in cancer. Several theories or models were only used in one study.
The exceptions were Spielman’s Three-Factor Model, the Model of Symptom Management,
Orem’s Self-care Deficit Theory, Piper’s Integrated Fatigue Model, the Neuroendocrine-Based
Regulatory Fatigue Model, and the Theory of Unpleasant Symptoms. These were each used in
more than one study. In addition, when an author produced multiple works, he/she tended to
consistently use the same model. For example, Berger et al15,68–70,78,79 used the Piper’s Integrated
Fatigue Model and Payne93 used the Neuroendocrine-Based Regulatory Fatigue Model in more
than one study. On the other hand, Carpenter et al2,6,72 used 3 different models for each of the
studies reviewed. This illustrates that use of these theories may vary both within and between
investigators and hypothesis driven.
Despite variation in the theories and models used, there were some commonalities. First, the
theories and models overall are consistent with the idea that sleep disturbances are a combination
of physiological, psychological, and behavioral phenomena.71,86,88 Nine theories/models include
physiological components,71,72,84,85,88–90,93,94 eight included psychological components,71,84,85,88–
90,93,94
and six included behavioral components.83–85,88,89,94,98
In addition, the theories/models suggest that other symptoms may be a combination of
components and/or consequences of sleep-wake disturbances. For example, when the Theory of
Unpleasant Symptoms83 was applied, it included psychological and/or physical symptoms as
components of sleep-wake disturbances. When the Model of Symptom Management was
applied, the co-occurrence of sleep-wake and other symptoms was emphasized.6 The Piper
model85 included sleep-wake disturbances as a cofactor of fatigue, suggesting that fatigue might
be a consequence of sleep disturbances. Other consequences of sleep-wake disturbances included
performance status in the Lenz model and impact on wakefulness in other models.88,94
Finally, the models suggest that factors that contribute to sleep-wake disturbances are nonlinear;
can change over time; and include predisposing, precipitating, and perpetuating factors.94 Factors
that initiate sleep disturbances (ie, predisposing or precipitating factors) may be different from
those that lead to chronic sleep disturbances (ie, perpetuating factors). Thus, these models
suggest that contributing factors should be reassessed over time.
Because of the high prevalence of sleep disturbances that contribute to poor quality of life in
cancer patients, future research should focus on the development of a model or mid-range theory
that is specific to the problem of sleep-wake disturbances in cancer. Such a model should include
demographic, physiological, psychological, and behavioral factors of sleep disturbances and
resulting health-related outcomes. In particular, cancer disease and treatment-related factors and
other problems unique to this population should be included. For example, it is likely that
women with breast cancer have unique health-related problems that might lead to sleep-wake
disturbances (eg, premature menopause),65 and these should be incorporated to increase model
specificity. The model or theory should also account for symptoms as predisposing, co-
occurring, or consequential phenomena. The theory/model also needs to clearly delineate the
nonlinear nature of sleep disturbances. Finally, the model should consider the potentially broad
impact of sleep and wake disturbances on physiological, psychological, behavioral, and social
outcomes. Having a more specific conceptual model or theory for sleep-wake disturbances could
help guide research by providing a mechanism that clearly defines and measures the concepts of
sleep-wake disturbances in cancer. This would result in increased consistency among researchers
by using similar types of measurement and similar variables increasing the ability to compare
results across studies. Ultimately, a more specific model will provide researchers with a basis to
facilitate symptom management through effective theory-based descriptive and interventions for
this prominent problem in cancer.
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Conclusion
In summary, although most existing research on sleep-wake disturbances in cancer does not
include a description of a theory, model, or framework, several theories and models have been
applied to this problem in this population at least once. The reviewed theories or models
represent options that are available to guide research on sleep-wake disturbances in cancer
populations. However, no one theory, model, or framework seems to provide an accurate picture
of sleep-wake disturbances. Additional model or theory development is needed to enhance
research that can be translated into improved clinical care in this area. It is recommended that
authors should be encouraged to explicitly state the theory, model, or framework within the
manuscript if one was used to guide the research. This could be accomplished through adding
this type of reporting to publication guidelines to ensure that the readers can identify the
conceptual underpinnings of the research.
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ACKNOWLEDGMENT
The authors gratefully acknowledge Phyllis Dexter for the editorial support.
This work was supported by the following: National Institute of Nursing Research 1 F31
NR009890, American Cancer Society predoctoral fellowship (Doctoral Scholarship in Cancer
Nursing 108142), Oncology Nursing Foundation predoctoral scholarship (2004), and Walther
Cancer Institute predoctoral fellowship (2004–2008). National Cancer Institute R25 CA117865
post-doctoral fellowship.