1. An Exploration of Merle Mishel’s Uncertainty in Illness Theory
Nursing Theory:
An Exploration of Merle Mishel’s Uncertainty in Illness Theory
Hello, my name is Brandi Miller. My classmates, Marcie Chenette, Mariah Lab, Tamara Putney, and I, invite you to join us as we explore Merle Mishel’s uncertainty in illness theory. This presentation was created as part of the Ferris State University Master of Science in Nursing program.
Mishel’s original 1988 theory proposed that managing uncertainty is necessary to adapt during illness. She developed a framework to describe how individuals process the events surrounding illness. In 1990, Mishel updated her theory to better apply to chronically ill patients. Since the original conception of the uncertainty in illness theory, Mishel and other researchers have conducted several studies that support and apply the theory’s constructs.
[51 sec]
UNC School of Nursing, 2014
Ferris State University
NURS 501 Introduction to Advanced Nursing Roles
Marcie Chenette, Mariah Lab, Brandi Miller, & Tamara Putney
Bailey & Stewart, 2010

2. Objectives
Provide an overview of Mishel’s theory of uncertainty in illness
Discuss the metaparadigm concepts
Analyze the theory
Use a research example to apply theory
Explore the usefulness of the theory
The purpose of this presentation is to explore the usefulness of Merle Mishel’s uncertainty in illness theory as it relates to the world, patients, and nursing practice.
An overview of the original and reconceptualized theories will be presented.
The nursing metaparadigm concepts will be discussed, which will lead into an abbreviated analysis of this theory using the criteria of accuracy, simplicity, scope, acceptance, and sociocultural utility.
A research example will be reviewed that ties the context of this theoretical framework to real life nursing problems.
Lastly, this presentation will explore how the uncertainty in illness theory can be used in practice and will link Carper’s four patterns of knowing to the theoretical framework.
By the end of this presentation, viewers will have an improved understanding about the importance of this theory that will help them apply it in practice.
[57 sec]
Carper, 1978
Dudley-Brown, 1997
Singleterry, 2014

3. Theory Overview Original 1988 Theory
Mishel began her work in 1981 when she developed a 30-item scale to measure uncertainty, a key concept in her original 1988 theory. In formulating the original theory, Mishel recognized that a person’s stimuli frame could reduce uncertainty in illness. The stimuli frame is composed of the symptom pattern, event familiarity, and event congruence (or the consistency between expected and experienced events). In addition, she proposed that a person’s stimuli frame could be enhanced by his or her cognitive capacities and structure providers. Structure providers include credible authorities like doctors and nurses, and also social supports. These concepts are grouped together as the antecedents of uncertainty.
Uncertainty occurs when individuals are unable to determine the meaning of illness-related events. Individuals appraise uncertainty as either a danger or an opportunity using inference and illusion. Inference is the process of evaluating a situation based on past experiences. Whereas, illusion is the process of constructing positive beliefs.
When a person appraises uncertainty as dangerous, he or she copes by reducing the uncertainty and managing the emotions caused by it. Conversely, when a person appraises uncertainty as an opportunity, he or she uses coping strategies aimed at maintaining the uncertainty. Based on Mishel’s original theory, people only view uncertainty as an opportunity when the alternative is facing the certainty of a poor outcome. Using appropriate coping strategies, individuals adapt to their illness.
[1 min 38 sec]
Bailey & Stewart, 2010
Mishel, 1981
Mishel, 1988

4. Theory Overview Reconceptualized 1990 Theory
Research completed after publication of Mishel’s original theory supported its application to acutely ill patients, but did not support the theory’s application to chronically ill patients or those facing recurrence of a disease in remission. These patients initially viewed uncertainty as dangerous, but over time came to accept it as an opportunity. This conflicted with Mishel’s original theory, which proposed that only individuals faced with the certainty of poor outcomes would view uncertainty as an opportunity.
Therefore, Mishel updated her work in 1990 to accommodate the response over time of chronically ill patients and those facing disease recurrence. Recognizing the cultural bias inherent in her original work, she abandoned the Western mechanistic assumption that adaptation is the single desired outcome and that uncertainty in illness is a linear trajectory.
The new model proposed that under conditions of chronic uncertainty, people move away from evaluating uncertainty as dangerous and adopt a new world view that accepts uncertainty as part of life. The reconceptualized model also introduced the concept of probabilistic thinking, or the ability to consider multiple ways of accomplishing goals. When people with chronic illnesses or disease remission accept uncertainty as part of life, they perceive it as an opportunity to grow and change.
[1 min 32 sec]
Bailey & Stewart, 2010
Mishel, 1990

5. Metaparadigm Concepts
Person
Environment
Health
Nursing
While the metaparadigm concepts are not explicitly defined in Mishel’s theory, they can be implicitly derived.
Mishel explains that human experience is one of the most important elements of her theory, which focuses on both individuals and families. Feelings of uncertainty can cross all stages of illness, even after the acute phase is over, because the question of disease recurrence is a big factor in the level of uncertainty a person feels.
The environment is an open system that exchanges energy and matter with the person. External environment includes the person’s stimuli frame and structure providers, and internal environment encompasses his or her cognitive capacities.
Uncertainty and mechanisms of coping are imperative to the perceived health and wellbeing of the individual. Uncertainty contributes to maladaptive coping mechanisms and health problems. Utilizing a theory based tool, measurement of uncertainty can facilitate the design of effective interventions to promote coping.
The role of nursing is to accept and promote probabilistic thinking and to avoid focusing on predictability and certainty. Nurses promote consideration of alternatives that allow their patients to adjust to the changing nature of their illness and foster the notion that there are many factors that influence a patient’s response to illness.
[1 min 23 sec]
Mishel, 1990
Mishel, 1999
Mishel, 2014

6. Analysis of the Theory Accuracy Simplicity/Complexity
Applicable to nursing today
Multiple patient populations
Verified through testing
Simplicity/Complexity
Antecedents are clear
Appraisal process is complex
Coping phase is complex
Functional with tools
Dudley-Brown proposed several criteria to evaluate nursing theories. An abbreviated analysis of the uncertainty in illness theory is presented using the criteria of accuracy, simplicity, scope, acceptability, and sociocultural utility.
Accuracy describes how well the theory applies to the real world of nursing today. Nurses responsible for different types of patient populations incorporate uncertainty concepts into their plans of care. The uncertainty in illness theory has been tested and shown to be accurate in both research and clinical settings and is frequently used in nursing education as an exemplar of middle-range nursing theories.
Simplicity is based on the number of phenomena and relationships described by a theory. The uncertainty in illness theory has 11 major concepts and three themes in the original theory, and several new concepts were introduced in the reconceptualized theory. While the antecedents of uncertainty are clear and concise, both the appraisal process and coping phase are complex. However, Mishel constructed the theory to be very functional when used appropriately with the designed tools.
[1 min 16 sec]
Bailey & Stewart, 2010
Dudley-Brown, 1997
Mishel, 1999

7. Analysis of the Theory Acceptability Scope Sociocultural Utility
Middle-range theory
Broad and generalizable
Acceptability
Nursing community
Testability
Sociocultural Utility
Cultures
Demographics
Diagnoses
By definition, middle-range theories are more narrow in scope than nursing philosophies or conceptual models. This theory applies strictly to uncertainty caused by illness, and was originally used only with cancer patients. However, it is generalizable across many patient populations. Research has been conducted assessing uncertainty in illness on children and adults with all forms of acute, chronic and terminal illness.
The uncertainty in illness theory is widely accepted in the nursing community and has been used in practice, education, and research. Empirical testing carried out by Mishel and others supports the relationships among the concepts, assumptions, and variables proposed by the theory. Mishel has secured grants and funding from the National Institute of Nursing Research and the National Cancer Institute for over twenty years.
Sociocultural utility defines how well a theory includes different cultures and if it is significant to humanity. The uncertainty in illness scale and theory have been used in eight countries outside the U.S. and have been translated into 15 languages. The theory has been tested on people of varying gender, age, race, and ethnicity, and has also been applied to families. It has been used to predict uncertainty in many different diagnoses including breast and prostate cancer, cardiac disease, and schizophrenia.
[1 min 29 sec]
Bailey & Stewart, 2010
Mishel, 1999
UNC School of Nursing, 2014
Wright, Afari, & Zautra, 2009

8. Research Article Outcomes of an uncertainty management intervention
Purpose
Intervention
Method
Findings
Conclusion and implications
Examining a research study allows one to see how Mishel’s theory can be used in practice. The name of this study is: Outcomes of an Uncertainty Management Intervention, in Younger African American and Caucasian Breast Cancer Survivors (Germino et al., 2013).
In this 2013 study, researchers reported the outcomes of an uncertainty management intervention in young breast cancer survivors.  The purpose of the study was to determine if a tailored intervention reduced uncertainty, facilitated fewer breast cancer-specific concerns, and produced more positive psychological outcomes.
Participants in the intervention group received a CD and a guidebook that provided strategies to control uncertainty and promote self-efficacy.  They also received four weekly follow-up calls to reinforce the strategies.  Participants in the control group received four weekly supportive telephone calls to control for the time researchers spent with the intervention group.
Breast cancer survivors receiving the intervention reported decreased uncertainty and improved coping.  The intervention allowed breast cancer survivors to easily access information, resources, and management strategies.  The tools can be adapted for use on a variety of electronic devices.
[1 min 23 sec]
Germino et al., 2013

9. Theory Reflection Purpose:
Appropriate interventions decrease uncertainty
Hypothesis:
Less uncertainty
Better uncertainty management
Fewer concerns
More positive psychological outcomes
Methods:
Theory derived scales
Designed to address antecedents of uncertainty
The uncertainty in illness theory was explicitly named by the breast cancer study authors as the theoretical basis for the research, and was foundational to the study purpose, hypothesis, and design. The theory provided a framework for selecting interventions to improve outcomes under conditions of uncertainty.
The purpose of the study was to show that with proper interventions there would be a decrease in uncertain feelings in patients who are experiencing cancer or remission.  According to the theory, the antecedents of uncertainty can be managed by interventions designed to facilitate a new world view where uncertainty is regarded as an opportunity.
The authors of the study hypothesized that the women who received the intervention, in comparison to women in the control group, would have less uncertainty, better uncertainty management, fewer concerns, and more positive psychological outcomes.
The uncertainty in illness theory was also integrated into the study methods.  Uncertainty was measured using scales based on the theory and interventions were designed to reduce uncertainty by addressing its antecedents.
[1 min 12 sec]
Germino et al., 2013

10. Implications of Framework
With no theoretical framework:
Uncertainty concepts would lack clarity and measurability
No existing knowledge to compare
Study less meaningful
Utilizing a theory in research allows for prediction, explanation, and, at times, control of phenomena (University of Southern California, 2013). The researchers in the breast cancer survivor study integrated the uncertainty in illness theory in all aspects of their study design (Germino et al., 2013). Key concepts from the theory were incorporated into the study purpose and hypothesis. Their research not only drew significantly from past studies, but also expanded on the knowledge generated. Variables and interventions were selected and designed to correspond with theory concepts, and the data were analyzed and interpreted within the constructs of the theoretical framework. Without the theoretical framework of Mishel’s uncertainty in illness theory, study concepts would lack clarity and there would be no mechanism to measure uncertainty. In other words there would be no link to existing knowledge, so the results of the study would be less meaningful.
[58 sec]
Germino et al., 2013
University of Southern California, 2013

11. Implications of Framework
Framework based on nursing theory
Appropriateness
Clear conceptual definitions
Guided by propositional statements
Operational definitions provided
Study findings support framework
Nieswiadomy [pronounced ness-we-odomy] asserts in the book Foundations of Nursing Research that a theoretical or conceptual framework should be used in all studies. Using her guidelines to critique the breast cancer survivor study framework, it fares quite well. The study framework is clearly identified in the research and it is based on a middle-range nursing theory: the theory of uncertainty in illness. The study appropriately incorporated the theoretical concepts, definitions, and relationships throughout all aspects of the research design. Theoretical propositions were used to develop the research hypothesis. Using the Survivor Version of the Mishel Uncertainty in Illness Scale and the Growth through Uncertainty Scale, operational definitions were provided. The study findings were related to the uncertainty in illness theoretical framework and support the theory relationships.
[58 sec]
Germino et al., 2013
Nieswiadomy, 2012

12. Theory in Practice Operating room management
Uncertainty related to post-operative symptoms
Pre- and post-operative education can decrease uncertainty
Nursing clinical instruction
Easy to teach and widely applicable
Valuable tool for care planning
Merle Mishel’s theory is useful in practice. Here are some examples to show how the theory can be applied to our individual practices.
Patients have many reasons to be uncertain prior to surgery. Surgical nurses like Marcie must ask the right questions to ensure that patients have adequate knowledge and resources. Education begins in the physician’s office, then patients speak with a pre-anesthesia nurse. On the day of surgery, a pre-op assessment is completed, and prior to discharge, the patient is given printed discharge instructions. Education should be patient specific based on the surgery and the needs of the patient.
Merle Mishel’s theory can be applied to Mariah’s role as an adjunct nursing instructor by teaching the students how to apply this theory to their patients. This theory is a good learning tool for students to understand that the patients they encounter might all have some level of uncertainty. The students will be better prepared to converse with their patients about the illness or diagnosis once they better understand the patient’s state of mind.
[1 min 6 sec]

13. Theory in Practice Hospital telemetry unit Hospital critical care unit
Uncertainty predicts depression in female heart failure patients
Nurses can design gender-specific interventions
Hospital critical care unit
Laryngectomy patients experience fear and traumatic thoughts
Appropriate interventions can assist in coping and relaxation
I work on a telemetry unit and often care for patients with congestive heart failure and other comorbid, chronic issues. Several studies have examined how the uncertainty in illness theory can be used with these patients. Using the Mishel Uncertainty in Illness Scale, Kao and colleagues found that uncertainty was a predictor of depression in female heart failure patients. Nurses can use this information to design gender-specific interventions aimed at reducing uncertainty in this population.
Tamara works in the intensive care unit and often cares for patients recovering from a laryngectomy due to laryngeal cancer. These patients can experience traumatic thoughts and fear related to their illness. Through the use of Mishel’s assessment tools, interventions can be developed to help patients relax during or after triggering events, or with coping in everyday life.  Offering the patient the best possible resources and materials related to the illness and ensuring open lines of communication are very important.
[1 min 5 sec]
Kao et al., 2013

14. Link Between Theory & Practice
Empirics
Esthetics
Personal knowledge
Ethics
The theory of uncertainty in illness can be described using Carper’s fundamental patterns of knowing in nursing (Carper, 1978). Mishel’s work organizes nursing knowledge into a logical theory that has been empirically tested and found to be reliable.  The theory integrates abstract and systematic explanations to characterize the impact of uncertainty and suggest avenues to reduce it. Using the art of nursing, or esthetics, nurses help patients explore what uncertainty means and design unique interventions to help patients cope. Nurses develop authentic relationships with patients to facilitate the exploration and resolution of uncertainty.  They recognize that patients are constantly changing and promote probabilistic thinking to help patients internalize uncertainty as an opportunity. Nurses also help patients face moral and ethical dilemmas, such as viewing uncertainty as an opportunity when the alternative is the certainty of a downward trajectory.
[1 min 4 sec]
Carper, 1978

15. Link Between Theory & Practice
Interactions with people are never the same
Nursing knowledge is unique
Carper’s patterns of knowing help distinguish relationships of phenomena seen in practice
State of health is in constant flux
Article shows treatments must be holistic and approached from many angles to be effective
Designing interventions for the varying actions of people is difficult.  In order to produce desired patient outcomes, the knowledge and education nurses possess must be unique. Using Carper’s (1978) patterns of knowing helps define nursing knowledge. Even though there is a clear need for a holistic team approach to patient care, the medical model of care still dominates (Fiandt, Forman, Megel, Pakieser, & Burge, 2003). Most health care professions focus on one specialty or body organ. Nursing is unique in that the profession is concerned with the person as a whole and recognizes the best way to optimize patient outcomes is to take a holistic approach. Nurses must use their unique knowledge to understand that health is in a constant state of flux.
The research done by Germino and colleagues (2013) shows that care and treatment of patients must be approached from many angles.  It demonstrates the complex relationships people share with metaparadigm systems around them.  The patients in the study responded to interventions of all kinds designed to allow them to use what was most helpful.
[1 min 1 sec]
Carper, 1978
Fiandt, Forman, Megel, Pakieser, & Burge, 2003
Germino et al., 2013

16. Conclusion Theory overview Abbreviated analysis Use in research
Use in practice
Link between unique nursing knowledge and nursing practice
Fear. Uncertainty. What does the future look like? Many people diagnosed with an illness ask questions to understand their disease, but they are fearful. Merle Mishel’s theory of uncertainty in illness allows nurses to help patients comprehend and deal with their uncertainty. It can be used to develop innovative strategies to enhance coping, reduce uncertainty, and help patients grow through their illness experience. The uncertainty in illness theory uniquely defines the metaparadigm concepts of person, environment, health, and nursing. It has been shown to be accurate and functional, and can be broadly applied to a variety of nursing practice settings. It is widely accepted by the nursing community, and has been translated across several cultures. The uncertainty in illness theory has been used in a variety of research studies, including the breast cancer survivor study profiled in this presentation. The theory is useful and demonstrates the unique link between nursing knowledge and practice.
Thank you for viewing our presentation.
[1 min 11 sec]

17. References
Bailey, D. E., Jr., & Stewart, J. L. (2010). Merle H. Mishel: Uncertainty in illness theory. In M. R. Alligood, & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed, pp ). Maryland Heights, MO: Mosby Elsevier. Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), Dudley-Brown, S. L. (1997). The evaluation of nursing theory: A method for our madness. International Journal of Nursing Studies, 1, Fiandt, K., Forman, J., Megel, M E., Pakieser, R.A., & Burge, S. (2003). Integral nursing: An emerging framework for engaging the evolution of the profession. Nursing Outlook, 51(3), Germino, B. B., Mishel, M. H., Crandell, J., Porter, L., Blyler, D., Jenerette, C., & Gil, K. M. (2013). Outcomes of an uncertainty management intervention in younger African American and Caucasian breast cancer survivors. Oncology Nursing Forum, 40, doi: /13.ONF Kao, C. W., Chen, T. Y., Cheng, S. M., Lin, W. S., Friedmann, E., & Thomas, S. A. (2013). Gender differences in the predictors of depression among patients with heart failure. European Journal of Cardiovascular Nursing, 0(0), 1-9. doi: / Mishel, M. H. (1981). The measurement of uncertainty in illness. Nursing Research, 30,
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18. References
Mishel, M. H. (1988). Uncertainty in illness. IMAGE: Journal of Nursing Scholarship, 20, Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. IMAGE: Journal of Nursing Scholarship, 22, Mishel, M. H. (1999). Uncertainty in chronic illness. Annual Review of Nursing Research, 17(1), Mishel, M. H. (2014). Theories of uncertainty in illness. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing [Kindle edition] (3rd ed.). Retrieved from Amazon.com Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Upper Saddle River, NJ: Pearson. Singleterry, L. (2014). Syllabus for NURS 501 introduction to advanced nursing roles. (Available from the Ferris State University School of Nursing, 200 Ferris Drive, Big Rapids, MI 49307) University of Southern California. (2013). Organizing your social sciences research paper: Theoretical framework. Retrieved from UNC School of Nursing. (2014). Directory: Merle Mishel, PhD, RN, FAAN. Retrieved from Wright, L. J., Afari, N., & Zautra, A. (2009). The illness uncertainty concept: A review. Current Pain and Headache Reports, 13,
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