Group 6 Marylynn Adamski Patricia Miller Sharon DeWitt Koren May

Merle H. Mishel Uncertainty in Illness Theory

Merle H. Mishel Merle H. Mishel was born in Boston, MA She went to Boston college for a B. A. Received her Masters of Science degree in psychiatric nursing from University of California. Mishel completed her Masters of Arts and PhD in social phychology. Her dissertation was the development and testing of the Perceived Ambiguity in Illness Scale. It was later known as the Uncertainty in Illness scale.

Dr Mishel is known for her research on uncertainty and its management in chronic and life-threatening illness. She has a long history of working with cancer patients.

Why we like it Uncertainty in nursing can be used in all areas of nursing. It is something that all patients feel when ill or injured with mild or severe illness. People seek medical attention when they are uncertain and looking for answers It helps to assess the uncertainty people have about their situation It helps to redirect a patients cognitive abilities & help them process info in a positive adaptive way Helps to focus on inner thoughts of the patient and what we as nurses can do to help decrease uncertainty

Parent/Child Unsure how much pain my child will have. I know how long my child's illness will last I can not plan for the future because of the unpredictability of my child's illness Unsure how I will manage care after child leaves the hospital I know that they will not find anything else wrong with my child

Adult The adult scale deals with having unanswered questions. Understanding what is explained. Things I am told can have many meanings With so many staff members, who is responsible for what? Do I understand each treatment?

Dissatisfied with the traditional linear models Mishel turned to the more dynamic chaos theory to explain how prolonged uncertainty could function as a catalyst to change a person’s perspective on life and illness.

Content Mishel’s Uncertainty in Illness Theory adds to the four global concepts of human being, environment, health, and nursing. The focus of the theory is on the internal environment of the individual and psychological outcomes based on the effectiveness of coping methods. Uncertainty viewed as danger prompts coping efforts directed at reducing the uncertainty and managing the emotional distress generated by it. Uncertainty viewed as opportunity prompts coping efforts directed at maintaining the uncertainty. The theory also clearly states the healthcare provider’s role in decreasing the uncertainty adding to the global concept of nursing. Providers can decrease uncertainty directly by promoting interpretation of events and indirectly by strengthening the stimuli frame.

Clarification of Origins The concept of uncertainty is NOT unique to nursing. Mishel’s application of uncertainty as a stressor in the context of illness IS unique making her theory of Uncertainty in Illness particularly meaningful to nursing. Mishel drew from existing information-processing models and personality research in her original Uncertainty in Illness Theory developed in 1998.

Clarification of Origins The first influence on Mishel’s theory was from the psychology discipline. Uncertainty was originally conceptualized within the psychology discipline’s information-processing models as follows: Uncertainty is a cognitive state, representing the inadequacy of an existing cognitive schema to support the interpretation of illness-related events. Uncertainty is an inherently neutral experience neither desirable nor aversive until it is considered as such.

Clarification of Origins The second influence on Mishel’s original theory was traditional stress and coping models. Two assumptions that reflect the uncertainty theory’s roots in the stress and coping models are as follows: Adaptation represents the continuity of an individual’s usual bio-psychosocial behavior and is the desired outcome of coping efforts to either reduce uncertainty viewed as danger or maintain uncertainty viewed as opportunity The relationships among illness events, uncertainty, appraisal, coping, and adaptation are linear and move from situations promoting uncertainty towards adaptation. *Mishel challenged these two assumptions in her reconceptualization of the theory in 1990 as a result of contradictory findings when the theory was applied to people with chronic illnesses.

Inference and Interpretation Inferences are the steps through which reasoning proceeds in processing thoughts. Inferences into Mishel’s Theory of Uncertainty in Illness include the thoughts about the patient’s specific conditions and the impact it may have on the his or her thought pattern. To make these inferences, the nurse must examine the aspects of illness outside of the context of the disease pattern and understand that illness affect the whole person; physically, mentally, emotionally, and spiritually.

Interpretation Interpretation of the Uncertainty in Illness Theory is based on individual perceptions and processing of the theoretical assertions formulated by Mishel and will vary by individuals. The Uncertainty in Illness Theory provides an excellent framework for interpreting the patients’ needs. The theory, applied in practice, equips nurses with the knowledge and skills needed to help patients interpret their condition and ease uncertainty.

YES YES Can this theory be used in…? Obstetrics (OB) Operating Room (OR)

Uncertainty in OB Hyperemesis Health of the Baby Perceived pain during Labor Pre-eclampsia Toxemia Complications during delivery Unplanned C-section Uncertainty in OB

Uncertainty in OR Will I be strong enough for surgery Post surgical pain Will the surgery be successful Will I still be independent How long will I be out of work Who will take care of my family When can I go back to school Uncertainty in OR

Implications & Consequences Uncertainty is inherently neutral; it can be appraised as either dangerous or beneficial. In acute illness and other extremely stressful situations in which the threat to life or the integrity of the self is perceived as being great, adults tend to appraise uncertainty as dangerous. When uncertainty is appraised as a danger and coping resources in the self and the environment are sufficient, individuals tend to take action to reduce uncertainty. However, when uncertainty is appraised as a danger and coping resources are insufficient, individuals, including young people with cancer, tend to focus coping efforts on reducing awareness of whatever generates uncertainty and controlling the distressing emotions.

Case Study Susan is a 28 year old married woman who has recently been diagnosed with HIV. She was tested for HIV as part of a prenatal screening program which tests all pregnant women. This diagnosis is coming as quite a surprise to Susan. She is quickly becoming very upset. Susan is a very conservative person who does not engage in any risky behaviors such as IV drug use, and is monogamous with her husband. She does not work in a field where exposure to the virus is a high potential and has never received a blood transfusion. She is a well educated person with a good family support system. Susan concludes that her husband must be the source of her infection. The implications of this could mean that he has been unfaithful. She now must cope with the possibility of infidelity and an unstable marriage. Susan is also concerned for the welfare of her child. She is afraid that the baby will be born with HIV. She Has concerns about health insurance and finances, particularly if she cannot rely on her husband.

What kinds of questions must Susan have? What kinds of questions do you have for Susan as her nurse? What does Susan know about HIV already? What are the next steps that Susan needs to take? Are there any possibilities regarding Susan’s mode of transmission which could exclude infidelity? What resources are available to help Susan? How can you as her nurse help her to process these events and resolve the uncertainty so that she can move forward with a positive outlook? Can you help her identify positive coping mechanisms? Using the model of perceived uncertainty in illness, identify what Susan’s cognitive abilities are, what her stimuli frame is, and what structure providers she has in place.

As Susan’s nurse, you ascertain that she is a person with good cognitive capabilities. She has a good support network of extended family who are able to help her make decisions and support her as she deals with her new situation. Since she is well educated, she is able to share that she does have some background information about HIV. She is aware that there are treatments available which will slow the progression of the disease. She knows that there are treatments available which will reduce the risk of transmission to her baby. Still, she is completely unfamiliar with the events she is in store for. She doesn’t know what her treatments will involve or how often she will need to follow up with her doctors. After she confronted her husband, they were able to determine that he was indeed the source of her infection, but he maintained that he had not committed infidelity. He was able to trace the source of his infection to partners he’d had before they were married. Susan is able to move forward with her treatments with the support of her husband and family. She is optimistic that her unborn child will be disease free. You, her nurse, are able to provide her with resources such as support groups and further treatment information. You are able to answer her questions and reinforce her positive behaviors and attitudes. Susan is able to work through her uncertainty and uses positive coping mechanisms to continue to adapt to her new diagnosis.

Weblink By Sharon DeWitt http://www.nurses.info/nursing_theory_midrange_theories_merle_mishel.htm

Scholarly Article By Sharon DeWItt Ya-Ling Lee, Bih-Shya Gau, Wen- Ming Hsu, Hsiu-Hao Chang. Oncology Nursing Forum. Jan 2009 v36 i1 pE20(11).

Resources and Weblink By Koren May Journal article Wright, L.J., Afari, N., Zautra, A. (2009). The illness uncertainty concept: a review. Current Pain and Headache Reports, 13(2), 133-138. doi:10.1007/s11916-009-0232 Textbook Bailey, D.E., & Stewart, J.L. (2010). Merle H. Mishel: Uncertainty in illness theory. In M. Alligood & A Tomey (Eds.) Nursing theorists and their work (pp 599-617). Maryland Heights, MO: Mosby Elsevier. Website http://nursing.unc.edu/muic/index.html (this website contains samples of the scales developed by Mishel and several studies using Mishels theories, as well as more references available)

Resources and Web-links Scholarly Article Padilla, G. V., Mishel M. H., & Grant M. M. (1992, June). Uncertainty, appraisal, and quality of life. Quality of Life Research. 1(3), 155- 165. Web-link The following web-link provides an overview of the Theory of Uncertainty in Illness in a PowerPoint presentation format. http://www.authorstream.com/Presentation/cgannon-276275-uncertainty-illness- theory-212mishelfinalpresen-education-ppt-powerpoint/ By Patricia Miller

Resources and web -link By Marylynn Adamski Scholarly article Johnson-Wright, L., Afari, N., Zautha, A., (2009). The Illness uncertainty concept: a review. Current pain and headache report. 13(2), 133-138, DOI: 10.1007/s11916-009- 0023-z Web-link http://www.nurses.info/nursing_theory_midrange_theories_merle_mishel.htm.

By Marylynn Adamski References Bailey, D.E., Stewart, J.L. (2010). Merle H. Mishel: Uncertainty in Illness Theory. In M. Alligood, & A. Tomey, (Eds.) Nursing Theorists and Their Works (pp. 599-617). Maryland Heights: Mosby Elsevier. Mishel, M (n.d) Mid range nursing theory. Retrieved from http://www.nurses.info/nursing_theory_midrange_theories_merle_mishel.htm.