Nursing Theory

2. Dr. Merle H. Mishel
Uncertainty in Illness Theory
Presentation
PRESENTED BY:
SUJATA MOHAPATRA.

3. Background
She Born 1939 in Boston Massachusetts
Graduate 1961 with a Bachelors of Arts from
Boston University
Graduate 1966 with Master of Science in
Psychiatric nursing from University of California
Graduate 1976,1980 with Masters of Arts,
Doctorate in social psychology from Claremont
Graduate school, Claremont California.

4. During Mishel’s dissertation research she
developed the Mishel Uncertainty in Illness
scale (MUIS).
Mishel have done research using her theory
and tool in the areas of Breast Cancer,
Prostate Cancer, Head and Neck Cancer, and
Traumatic Injury.

5. Evolution of Uncertainty in Illness
Theory
In the late 1970’s there was very little known about
the phenomena of uncertainty in illness.
“There is an absence of systemic investigation of
uncertainty as a perceptual variable influencing the
appraisal of illness related events.” (Mishel, 1981)
With the assistance from a National Research Service
Award, Mishel was able to develop the Mishel
Uncertainty in illness Scale, and the midrange theory
Uncertainty in Illness.

6. Uncertainty of Illness
"Questions about inconsistent test results,
diagnoses, which treatments to pursue and even
what foods to eat can consume a patient with worry
(Spivey, 1997, p 3).
Uncertainty is the inability to determine the
meaning of illness-related events, occurring when
the decision maker is unable to assign definite value
to objects or events, or is unable to predict
outcomes accurately (Mishel , 1988).

7. Mishel uncertainty in illness
scale

8. Theory Development
The theory of uncertainty of illness is composed of three
major themes:
1. Antecedents of uncertainty- anything that occurs prior
to the illness experience that affects the patient's
thinking such as pain, prior experiences, and
perception.
2. Appraisal of uncertainty- the process of placing a value
on the uncertain situation.
3. Coping with uncertainty- activities that are used in
dealing with the uncertainty.

10. ANTECEDENTS OF UNCERTAINTY
STIMULI FRAME
COGNITIVE CAPACITIES
STRUCTURE PROVIDERS

11. STIMULI FRAME
Stimuli frame is the characteristics of the
stimuli as perceived by the individual.
ELEMENTS
Symptom pattern
Event Familiarity
Event congruency

12. COGNITIVE CAPACITIES
Cognitive capacities is the patient's ability to
process information.
Physiological malfunctions & stress related
demands on cognitive processing will
decrease available cognitive capacity.

13. STRUCTURE PROVIDERS
Structure providers is the health care providers
or support group that can effect the patient
either negatively or positively.
ELEMENTS
Education
Social support
Credible authority

15. APPRAISAL OF UNCERTAINTY
UNCERTAINITY
DANGER
INFERENCE / ILLNESS
OPPERTUNITY

16. UNCERTAINTY
The inability to determine the meaning of
illness related events.
The cognitive state created when the person
cannot adequately structure or categorize
illness related events due to a lack of sufficient
cues or antecedents of uncertainty.

17. INFERENCE & ILLUSION
Inference: Evaluation of uncertainty by
recalling memories
Inference based on;
a) Personality disposition
b) General experience
c) Specific knowledge
d) Contextual cues
Illusion: Belief constructed

18. DANGER
Findings are that higher uncertainty is
associated with danger & poor coping
strategies .
It provokes danger threats in personnel
cognitive state.

19. OPPERTUNITY
Living with continual uncertainty during
survivorship can lead to a re-evaluation of
uncertainty.
Uncertainty can be seen as the source of new
oppertunities.

21. COPING WITH UNCERTAINTY
COPING MOBILISING STRATEGIES
ADJUSTMENT
COPING SELECTIVE STRATEGIES

22. COPING MOBILISING STRATEGIES
It involves mobilizing & affect control
strategies.
It is associated with emotion based coping
strategies.

23. COPING BUFFERING STRATEGIES
It is the coping selective ignoring & reordering
the priorities.
The use of coping mechanisms lead to
adaptation to uncertainty of the illness. Some
buffering coping strategies are avoidance,
priority promotion, and alteration of the
stimuli.

24. ADJUSTMENT
Adaptation or Adjustment represents the
continuity of an individual’s usual bio-psychosocial
behaviour and is the desired
outcome of coping efforts to either reduce
uncertainty appraised as danger or maintain
uncertainty appraised as opportunity.

25. MAJOR ASSUMPTIONS
CLARITY SIMPLICITY
GENERALITY ACCESSIBILITY

26. CLARITY
Clarity Despite the complex nature that
uncertainty plays in a patient’s illness the
concepts of this model are presented clearly
and they are easily comprehended.
The model translates easily into clinical and
research practice.

27. Simplicity
The antecedents of uncertainty are concise
and their definitions are clear and simple.
The appraisal of uncertainty is in itself
complex, but with the use of this theory and
the MUIS tool it is made easier.
The complete model although not simple is
easily made operational.

28. Generality & Accessibility
Generality : The theory can be applied to many areas of
nursing practice and has been used by clinicians for
acute and chronic illness such as cancer, cardiac disease,
and multiple sclerosis.
Accessibility : With use of this theory it’s been shown
that uncertainty is indeed a phenomena that patients
experience, and specifies what areas of the illness may
be responsible for uncertainty. With application of this
theory a goal of increased coping mechanisms for
patient comfort is made attainable.

29. Purpose of Theory
• The uncertainty in illness theory helps measure the degree
to which an individual is experiencing uncertainty during
illness or an acute injury.
• The illness causes uncertainty that spreads into the
individual’s life and breaks down the individual’s point of
view and reality. Slowly a new point of view is formed.
• Uncertainty is the driving force and is accepted as reality.
Now the individual may see that many options are possible
as opposed to only a cause and effect paradigm.

30. Levels of Theory Development
• The Person
• The Environment
• Health
• Importance to Nursing

31. The Person
• The person experiences uncertainty gradually, beginning
as the illness insidiously invades life.
• Questioning one’s self as the body changes with
progression of illness, and how this will change their
interpersonal relationships is common in uncertainty.
• Uncertainty in Illness Theory helps to address this effect
on the patient and assist with coping mechanisms.

32. The Environment
• Using the MUIS tool clinicians can identify the areas of
illness that are causing the greatest uncertainty.
• Addressing these areas and assisting the patient to build
better coping mechanisms will improve the patient’s
health during times of illness.

33. Health
• Uncertainty in Illness has been
researched primarily in the hospital
setting. Illness effects many aspects of life
and with increased research it might
show how Uncertainty in Illness theory
can be used to help a variety of patients
in different environments.

34. Importance to Nursing
• Nurses can assist the patient by constructing a personal
scenario for the illness which includes;
• Why or how the illness began,
• How it will progress,
• How the patient can recover.
• Incorporating the uncertainty is an approach where
there is a change in the patient’s and family’s perspective
in life, away from an orientation to control and predict
toward an acceptance of unpredictability and
uncertainty as normal.

35. Application to Nursing
1. Nursing Practice using the uncertainty in
illness model.
2. Research utilizing the theory of uncertain
illness.

36. A child diagnosed with Acute
Myeloid Leukemia using
uncertainty in illness theory

38. Illness remission
Repetitive
hospitalisation
Expectations to
get cure from
cancer
Anxiety
Hopelessness
Emotional
distress
UNCERTAINITY
Altered coping
Severe
cognitive
impairment
Negative thoughts
& beliefs regarding
the disease
Search for
oppertunities to get
relevant answers
Irrelevant information
Inadequate knowledge
regarding disease
consequences
Lack of family support
Both Psychological
distress &
Psychological
benifit
Returning to the
individuals pre-illness
level of
functioning
Re-evaluation of
uncertainity

39. Uncertainty in client diagnosed with COPD

40. Effectiveness of planned interventions were in
post-cancer older women.
(Gil, Mishel, Belyea, Germino, Porter, & Clayton, 2006)
The sample included 509 recurrence-free women (360 White, 149
African-American women) The average age of the women was 64
years. All of the women were 5-9 years post-treatment for breast
cancer.
Method Women were randomly assigned to either the intervention
or usual care control condition.
The intervention was delivered during 4 weekly telephone sessions in
which survivors were guided in the use of audiotaped cognitive-behavioral
strategies and a self-help manual.

41. Nurses guided women through the intervention over the course
of four weekly 30-minute telephone calls.
Each telephone call with the patient focused on four skills-pleasant
imagery, calming self-talk, distraction, and relaxation.
The patients were given guidance through the self-help manual to
help individual to their specific needs.
How the results were measured:
• Cancer survivor knowledge scale, social support questionnaire,
and patient-provider communication were ratings used to
measure the components of uncertainty management. Coping
strategies were measured using a questionnaire with 6 subscales.
Profile of mood states measured negative mood state. The 39-
item scale, The Growth Through Uncertainty Scale) measured
positive life change or personal growth.

42. The Results:
At 10-months, the survivor intervention condition (as
compared to the control condition group) results showed
improvement in cognitive reframing, cancer knowledge of
symptoms and side effects, and other coping skills.
The 20-month outcomes showed benefits for women in the
intervention condition. These benefits were in the forms of a
decline in illness uncertainty and personal growth over the
time frame. This suggests that the intervention group
continues to benefit and has an overall improvement in
quality of life.

43. CRITIQUE
The development of this theory lacks existing scales to measure
coping mechanisms in relationship to uncertainty.
The study of coping with uncertainty could benefit from
triangulated studies (Mishel, 1999). Some of the most important
parts of this theory are the aspects to which it gives nurses insight
into the point of view of the patient.
The theory provides a framework to base deep and meaningful
assessments about uncertainty on, and then construct
interventions to assist the patient to deal with the elements of
illness that are uncertain.

45. References
BOOKS
 Alligood, M. R. & Tomey, Ann M. (2010). Nursing Theorists and Their Work (7th ed.).
Maryland Heights, Missouri: Mosby Elsevier.
 Bailey, D., Wallace, M., Mishel, M. (2005). Watching, waiting and uncertainty in prostate
cancer. Journal of Clinical Nursing, 16 (4) 734-741.
 De Graves, S. & Aranda, S. (2008). Living with hope and fear-the uncertainty of
childhood cancer after relapse. Cancer Nursing, 31 (4), 292-301
 Gil, K, Mishel, M., Belyea, M., Germino, B., Porter, L., & Clayton, M. (2006). Benefits of
the uncertainty management intervention for African American and white older breast
cancer survivors: 20 month outcomes. International Journal of Behavorial Medicine, 13
(4), 286-294.
JOURNALS
• Lee, Y., Gau, B., Hsu, W., & Chang, H. (2009). A model linking uncertainty, post-traumatic
stress, and health behaviors in childhood cancer survivors. Oncology Nursing
Forum, 36 (1), 20-30. DOI:10.1188/09.ONF.E20-E30
• Mishel, M. & Sorenson, D. (1991). Uncertainty in gynecological cancer: a test of the
mediating functions of mastery and coping. Nursing Research, 40 (3), 161-171.

46. WEBSIITES
• http://rtips.cancer.gov/rtips/. Lasted updated on 4/27//2012. Accessed
on 4/22/2014.
• Mishel, M. (1981). The measurement of uncertainty in illness. Nursing
Research, 30 (5), 258-263.
• Mishel, M. (1997). Uncertainty in acute illness. Annual Review of Nursing
Research, 15 (1), 57-80.
• Smith, Mary Jane & Liehr, Patricia R., (2003). Middle Range Theory for
Nursing. New York, NY: Springer Publishing Company, Inc.
• Spivey, A.(1997, January 27). FYI Research. UNC University Gazette.
Retrieved from http://gazette.unc.edu/archives/99jan27/file16.html.