1. Theories of Uncertainty of Illness- Focus from Merle Mishel
Presented by:
Elizabeth Boeve, Tina Hill, Teresa Seigle, Jordan Sella, & Bridgett Weldon

2. Objectives: What is the Uncertainty of Illness?
How does it relate to health care from a provider standpoint?
Who is Merle Mishel?
Do you often use or see Mishel’s Theory in your everyday care?
Sec [19.07]

3. Objectives Cont.
The purpose of this power point is to help gain insight of the changes in health care and the relation of uncertainty of illness.
We have different practices that allow us to be excellent care providers and with this educational insight it will hopefully help in gaining more of an understanding of our patients and becoming stronger as providers.
seconds [24.89]

4. Overview of the Uncertainty of Illness Theory
Uncertainty regarding an illness decreases quality of life
Three major areas that impact uncertainty
MUIS
Interventions to decrease uncertainty, increase quality of life
Merle Mishel, a nurse with a Masters in Psychiatric Nursing and a Doctorate in Social Psychology, has an extensive clinical background working with breast and prostate cancer patients. Mishel saw that often times these patients experienced uncertainty of their illness and found that this impacted their quality of life negatively. She used research from her work in life threating illness’s and chronic diseases to develop the Uncertainty of Illness theory (Information and Resources for Nurses Worldwide, 2010). Although the theory was initially developed to be used with patients with an acute illness, in 1990 Mishel updated her theory to also include those with chronic illness.
The Uncertainty of Illness Theory focuses on the uncertainty one feels regarding illness and the way it will affect their life.
The theory is based on three major themes
1. Prior experiences to uncertainty
2. Evaluation of uncertainty
3. Coping of uncertainty
(Mishel, 1981).
Mishel created the Mishel Uncertainty in Illness Scale (MUIS) to help determine the uncertainty that one has. The scale is a set of 30 questions regarding the way one feels about their health, environment and the care they are receiving.
Mishel believes that as a healthcare provider it is a nurses responsibility to help the patient minimize or cope with the uncertainty they feel. A nurse can provide interventions that will help to reduce the uncertainty a patient feels. Interventions can also be used to help the patient manage the uncertainties. According to the theory decreasing the uncertainty will ultimately increase the quality of life one has.
[1 min 3 sec]

5. Nursing Paradigm
Person
Health
Nursing
Environment
The nursing paradigm are the four basic concepts that include person, health, environment and nursing and their relationship together.
Person – is the individual, including their personality.
Health – is how the person views their health
Environment – is the interaction of internal and external forces and how they influence the person.
Nursing – is the responsibility a nurse has to care for the person.
[35 seconds]

6. Nursing Paradigm and the Uncertainty of Illness Theory
Person
Health
Nursing
Environment
How the person views uncertainty, how they cope with it
Impacts how one manages uncertainty
The Uncertainty of Illness theory addresses all four concepts and fits into the nursing paradigm.
Person: In the uncertainty of illness theory Mishel recognized that everyone views uncertainty differently and that a person’s personality can affect the way that they manage and view uncertainty.
Health: Mishel believed that a person’s attitude toward their condition and how they view it will affect their life and that it plays a role in a person’s perception of individual health.
Environment: In the Uncertainty of Illness theory the environment can impact the way a person manages their uncertainty.
Nursing: Mishel found that communication and uncertainty go together. The better informed a person was the less anxiety they had regarding the uncertainty. It is important for the nurse to provide clear and concise information that the person can understand regarding their condition.
[1min 1 second]
Perception of own health
Communication can decrease uncertainty

7. Analysis of the Uncertainty of Illness Theory
Accuracy
Simplicity
Scope
Acceptance
Socio-Cultural Utility
In analyzing the Theory of Uncertainty in Illness five areas are looked at; accuracy, simplicity, scope, acceptance, and socio-cultural utility. In regards to accuracy there were concerns related to chronically ill patients fitting into the theory. In 1990 Mishel updated her theory to include chronically ill patients as well. Today Mishel’s theory can be applied to various disease’s such as schizophrenia, heart failure, cancer, and terminal illness(Mishel, 1999).
With simplicity the MUIS is easy to use for both patients and healthcare providers. It works under three different themes, antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty(Mishel, 1988). These themes fit into everyday practice and a nurse can be using them without even realizing it.
Looking at scope the uncertainty of illness theory can be used in all ages and different patient populations with an acute or chronic illness. Not only is the theory used with patients but it also can be used on family members(Mishel, 1999).
In regards to acceptance the theory is well accepted and used thorough out the nursing world. Research conducted has proved that the theory is correct and useful.
Socio-cultural utility is validated because the theory is widely accepted and used through out various cultures, ages, and conditions. The theory can also be used in a variety of health care settings.
[1min 31 seconds]

8. Analysis of the Uncertainty of Illness Theory
Mishel’s Uncertainty of Illness
Theory is a well rounded
theory that can be used in
everyday practice as a
nurse.
[13.84 seconds]

9. Description of Article
Parental uncertainty greatly influenced children’s uncertainty
Uncertainty effects children
Evaluate a conceptual model of uncertainty in children with cancer
Explore relationship of uncertainty in two indicators age and expertise
This study was done to see if Mishel’s Theory of Uncertainty could be applied to children. While evaluating subjects the investigators utilized 11 scales as tools for data collection, eight for children and three for their parents. Uncertainty was found to effect children during their cancer treatment from early diagnosis to remission. Parent’s are their children’s main “structure provider’s” their higher levels of anxiety and uncertainty were felt by their children and therefore influenced their child’s levels of anxiety and uncertainty, “as it might interfere their own abilities to support their child’s interpretation of illness events.” Children whose parents tried to stick to normal routines” were able to reinforce children’s sense of the illness as familiar, patterned and congruent with expectations.” Older subjects had a higher level of uncertainty and this is hypothesized to be due to higher cognitive functioning; however, more studies are needed to analyze these findings.
[1min 13 seconds]

10. Theory Reflections Research Purpose Questions Hypothesis Methods
“The purpose was to test a conceptualized model of uncertainty in school-aged children and adolescents with cancer adapted from a well-tested theoretical model of uncertainty in adults. A secondary goal was to explore the relationship of uncertainty to two indicators of development, age and expertise”. (Stewart, Mishel, Lynn, Terhorst., 2010, p. 2 ).
Included in the hypothesis of this study were questions that could really only be answered and proven by Mishel’s Theory framework. Could the uncertainty in illness scale be applied to children, and could the hypothesis that higher child uncertainty predicts higher levels of anxiety and depressive symptoms (Stewart, Mishel, Lynn, Terhorst., 2010, p. 2).
A tool was created to asses children’s uncertainty from Mishel’s Uncertainty in Illness Scale that had been used in adults. The theory was reflected in the research by providing a framework with which to assess which a child’s uncertainty and hoped to prove that this affected their psychological and emotional well being which then affected their coping ability related to their illness.
[1 min 11 sec]

11. Differences Without Theoretical Framework
Inability to compare findings
Lack of validity
Absence of a measurement tool
Without the theoretical framework that was originally established by Merle Mishel for adults there would be no way to compare findings from the study on adults to see if the Uncertainty in Illness Scale would be able to be used on children and if the findings were valid.
Having existing previous literature regarding the effects of uncertainty in adults provided existing data on previous findings to support the theory concepts and allowed the framework to already be in place for further theory development.
Although there were other scales of measurement for the proposed antecedents of uncertainty in children used in the study there would not have been an existing tool for measurement of uncertainty that was accessible to the researchers for them to adapt for the use on children, which increased the reliability of the uncertainty in illness scale data that was collected.
[50 seconds]
Model of Perceived Uncertainty in Illness. (From Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20 (4), 226

12. Differences Without Theoretical Framework
No basis for the research
Study findings would be less meaningful
Expands current theories and knowledge
The study without the presence of a theoretical framework would have not had the ability to provide a foundation for the examination of uncertainty in illness and it would have made this studies findings less meaningful and less useful to improving nursing practice and patient care.
The theoretical framework provided guidance to the researchers in exploring the effects of uncertainty in illness in children and helped continue to guide researchers throughout the study. It also allowed the theory to be proven in another patient population. Without the framework the study would not have been as organized and the theory of uncertainties effects on individuals would not have been already tested and established.
The theory and first study of uncertainty allowed for the further exploration and broadened the use of Mishel’s theory. Without the framework in place this study could not have “Defined the concepts and proposed relationships between concepts” (Nursing Research and Theories, 2013).
[55 seconds]
Model of Perceived Uncertainty in Illness. (From Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20 (4), 226

13. Use in Personal Nursing Practice
Structure Providers
Credible Authority
Social Support
Education
Mishel’s uncertainty of illness theory is vital in our practice as we take part in all three roles of structure providers that affect the stimuli frame and the uncertainty stage. As nurses we are viewed as credible authority by the patient through the education we have received and the position we hold. We are licensed health care providers with legal capacity to provide care. We also act as social support, whether providing actual support though caring conversations or directing patients to outside resources that will assist them in coping with illness. Lastly we act as educators. As nurses we have the greatest amount of interaction with patients than other fields of health care and we educate them about the disease process, new medications, and potential treatment options. We also provide education to the patient’s support system, i.e. family when present to enable them to better cope with their uncertainty and provide a better support system to the patient.
[1 min]

14. Personal Nursing Practice Continued
Appraisal
Inference or illusion
Danger
Opportunity
Coping
Mobilizing strategies, affect-control strategies
Buffering strategies
Review of Adaptation
Nurses play a role during the appraisal stage during a patient's uncertainty. We work during the appraisal stage to enable patients to value their uncertainty as an opportunity rather than a danger. We do this by working on the two components of appraisal, inference and illusion. We assess the patient’s personality dispositions, general experience, knowledge, and contextual cues to enable the patient to better evaluate their uncertainty. We also evaluate the patient’s beliefs that are formed from their uncertainty by talking with them about how they feel in order to better provide a positive outlook or “illusion”. We work to mitigate dangers that could provide for a harmful outcome through education, evaluation of support systems and increase possibilities of opportunity through the same work. We can evaluate a patient’s coping strategies by speaking with them and directing them to appropriate resources if needed such as a therapist or med-social worker. We also evaluate how the patient is adapting and can return to previous stages in order to correct unhealthy adaptation.
[1 min 18 sec]
Much of the work we provide affects the different stages of uncertainty of illness for a patient and may be done without recognizing it.

15. Correlation Between Theory and Practice
Correlation between Nursing Paradigm and Uncertainty of Illness Theory
Person
Health
Nursing
Environment
As nurses we work on all stages of the nursing paradigm to provide for the best possible outcome during uncertainty in illness. We evaluate the person’s or patient’s uncertainty by having caring conversations. Although we cannot change aspects of the person such as personality, we are able to tailor the care we provide to the individual. We also try to control aspects of health, such as treating causes of disease with assistance of other health care providers and determining how a person views their health. We also work to control internal and external forces of the person’s environment so that uncertainty is better managed. The fourth paradigm is where we as nurses provide care working to deter uncertainty where the paradigms overlap. The area in the middle is a total sum of all four concepts of the nursing paradigm and provides for an experience, this experience perceived by the person will have a direct affect on their uncertainty.
[1min 3 seconds]
Model of Perceived Uncertainty in Illness. (From Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20 (4), 226

16. Importance of Differentiating Nursing Knowledge from other Practices
Fawcett’s Nursing Paradigm
Mishel’s Uncertainty in Illness Theory
Carper (1978) Patterns of Knowing
Work such as Carper’s patterns of knowing show how nursing knowledge is unique and this also helps to explain why it is important to distinguish nursing knowledge from others. In order for the field of nursing to be considered a profession we must have a unique body of knowledge. This unique body of knowledge is developed when theories and concepts are created under a profession and in order to develop theories and concepts a foundation must be in place as a starting point. As nurses we provide care across an entire spectrum and are not focused on individual aspects of care as other professions are. By working to develop knowledge that impacts the health of a person in a physical, emotional, and spiritual manner we are essentially gate keepers to health and without a unique nursing knowledge there are aspects of care that cannot be performed.
[59.50 sec]
Total slide show time 12min 38seconds

17. References
Dudley-Brown, S.L. (1997). The evaluation of nursing theory: A method for our madness. International Journal of Nursing Studies, 34(1), 76-83
Information and Resources for Nurses Worldwide. (2010). Merle Mishel. Retrieved from
Lin, L., et al. (2012).The Journal of Neuro-Oncology.Validation of the Mishel’s uncertainty in illness scale-brain tumor form (MUIS-BT). DOI: /s
Mishel, M. (1981). The measurement of uncertainty in illness. Nursing Research, 30 (5),
Mishel, M. H. (1999). Uncertainty in chronic illness. Annual Review of Nursing Research, 17(1),
Mishel, M. H. (1988). Uncertainty in illness. Nursing Journal of Scholarship, 20 (4),
Mishel, M. H. (1988). Uncertainty in illness. IMAGE: Journal of Nursing Scholarship, 20,
Mishel, M. (2013). Theories of uncertainty in illness. Smith, Mary Jane, Liehr P. (Eds.), Middle Range Theory for Nursing (pp ). (3rd edition). Retrieved from:
Mishel. M.H. (2011). Uncertainty in illness. In J. Fitzpatrick, Encyclopedia of nursing research. New York, NY: Springer Publishing Company. Retrieved from:
Nursing theories. (2013). Nursing Research and Theories. Retrieved from Current Nursing Online
Stewart. J.L., Merle, M. H., Lynn, M. R., Terhost, L. (2010). Test of a conceptual model of uncertainty in children and adolescents with cancer. Res Nurs Healht. 33(3), doi: /nur.20374
Tourville, C., Ingalls, K. (2003) The living tree of nursing theories. Nursing Forum. 38(3) 21-36
University of Arkansas for Medical Sciences. (2013, January). Philosophy. In College of Nursing. Retrieved from