Merle H Mishel Uncertainty in Illness Theory PDF

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UNCERTAINTY IN ILLNESS THEORY Merle H. Mishel By: Aileen D. Villareal

“My theory can be applied to both practice and research. It has been used to explain clinical situations and design interventions that lead to evidence-based practice. Current and future nurse scientists have and will continue to extend the theory to different patient populations. This work has the potential to transform health care.” (Mishel, personal communication, May 28, 2008).

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CREDENTIALS AND BACKGROUND OF THE THEORIST Merle H. Mishel • Born in Boston, Massachusetts • 1961 – Graduated from Boston, University with a B.A • 1966 – M.S. in Psychiatric Nursing from University of California • 1976 – M.A. • 1980 – Ph. D in Social Psychology at Claremont Graduate School, Claremont California • Early in her professional career – practiced as a psychiatric nurse in acute care and community settings. • 1973 -1979 practiced as nurse therapist in both community and private practice settings • 1981 - Associate Professor at University of Arizona, College of Nursing • 1988 - promoted to professor • 1984 – 1991 – Division Head of Mental Health Nursing in Arizona • 1991 – Professor in the School of Nursing, University of North Carolina at Chapel Hill • 1991 – 1992 – Doctoral Program Consultant for the University of Cincinnati, College of Nursing • 1993 – Rutgers University School of Nursing • 1977 – 1979 – Sigma Theta Tau International Sigma Xi Chapter Nurse Research Predoctoral Fellowship • 1986 – Mary Opal Wolanin Research Award • 1994 – Awarded the endowed Keanan Professor Of Nursing Chair • 1997 – National Institute of Nursing Research presented her with Research Merit Award • 2004 – Henderson Research Fellowship Program Award

Professional Organization: • • • • • • • • •

American Academy of Nursing American Psychological Association American Nurses Association Society of Behavioural Medicine Oncology Nursing Society Society for Education and Research in Psychiatric Nursing National Cancer Institute National Center for Nursing Research National Institute of Mental Health

THEORETICAL SOURCES Original Uncertainty in Illness Theory • Information Processing Models (Warburton, 1979) • Personality Research (Budner, 1962) o Characterized uncertainty as a cognitive state with which to form a cognitive schema or internal representation of a situation • Stress – appraisal coping – adaptation framework (Lazarus and Folkman, 1984) o Transaction (interaction) occurs between a person and the environment o We become stressed when demands(pressure) exceeds our resources (our ability to cope and mediate stress)

Reconceptualised Theory • • •

Critical Social Theory The bias inherent in the original theory was recognized – an orientation toward certainty and adaptation. Chaos Theory Focus on open systems – allowed for a more accurate representation of how chronic illness creates disequilibrium and how people ultimately can incorporate continual uncertainty to find new meaning in illness.

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MAJOR CONCEPTS AND DEFINITIONS • • •

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Uncertainty – 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 outcome accurately) Cognitive Schema – person’s subjective interpretation to illness, treatment, and hospitalization. Stimuli Frame – form, composition, and structure of the stimuli that a person perceives.  Symptom Pattern – degree to which symptom occur with sufficient consistency to perceived as having a pattern.  Event Familiarity – degree to which a situation is habitual.  Event Congruence – consistency between the expected outcome and the experienced in illness-related events. Structures Providers – resources available to assist the person in the interpretation of the stimuli frame  Credible Authority – degree of trust and confidence a person has in his/her healthcare providers.  Social Support- influence uncertainty by assisting the individual to interpret the meaning of events. Cognitive Capacities- Information- processing of a person. Inference- evaluation of uncertainty using related, recalled experiences Illusion- beliefs constructed out of uncertainty. Adaption- reflects bio-psychosocial behaviour occurring within person’s individually defined range of usual behaviour New View of Life- formulation of a new sense of order, resulting from the integration of continual uncertainty into one’s self- structure. Probabilistic Thinking- belief in a conditional world in which the expectation of continual certainty and predictability is abandoned.

EMPIRICAL EVIDENCE • •

Mishel’s Uncertainty in Illness Theory grew out of her dissertation research with hospitalized patients- using both qualitative and quantitative findings to generate the first conceptualization of uncertainty in the context of illness, Support for the Reconceptualised Uncertainty in Illness Theory has been found in predominantly qualitative studies of people with a variety of chronic and lifethreatening illnesses.

MAJOR ASSUMPTIONS ORIGINAL THEORY (1988) • Uncertainty is a cognitive sate; existing cognitive schema is inadequate to support interpretation of life- threatening events. • Uncertainty- an inherently neutral experience, neither desirable nor aversive until appraised as such • Adaptation represents the continuity of an individual’s bio-psychosocial behaviour and is the desired outcome for coping efforts. • Relationships among illness event are linear and unidirectional; promoting uncertainty toward adaptation.

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RECONCEPTUALIZED THEORY (1990) • • •

People typically function in far from equilibrium states. Major fluctuations in a far-from-equilibrium system enhance the system’s receptivity to change. Fluctuations result in repatterning, which is repeated at each level of the system.

Model of Perceived Uncertainty in illness

METAPARADIGM IN NURSING • • •

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Nursing- includes the involvement of the nurse functioning with credible authoritythe role of the nurse is to provide information and logical structure to the illness related event thereby strengthening the stimuli frame. Person – any person experiencing an illness, treatment or hospitalization including their subjective interpretation of the event and the stimuli frame. Health- ultimate goal of nursing in the uncertainty in illness theory - Depicted as adaptation which would be decreased uncertainty as with an acute illness or an episode of treatment or maintaining uncertainty in the event of chronic illness. Environment- considered a neutral state of uncertainty or no meaning associated with the event. - Influenced by cognitive abilities and the presence of structure

THEORETICAL ASSERTIONS • • • • • • •

Uncertainty occurs when a person cannot adequately structure or categorize an illness- related event. Uncertainty can take the form of ambiguity, complexity, lack of inconsistent information or unpredictability. As symptom pattern, event familiarity and event congruence increase uncertainty decrease. Structure providers decrease uncertainty. Uncertainty appraised as danger prompts coping efforts directed at reducing the uncertainty and managing the emotional arousal generated by it. Uncertainty appraised as opportunity prompts coping efforts directed at maintaining the uncertainty. The influence of uncertainty on psychological outcomes is mediated by the effectiveness of coping efforts to reduce uncertainty appraised as danger.

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When uncertainty (danger) cannot b reduced effectively, coping strategies can be employed to manage emotional response. The longer uncertainty continues in the illness context, the more unstable the individual’s previously accepted mode of functioning becomes. Under conditions of enduring uncertainty, individuals may develop a new probabilistic perspective on life which accepts uncertainty as natural part of life. The process of integrating continual uncertainty into a new view of life can be blocked by structure providers who do not support probabilistic thinking. Prolonged exposure to uncertainty (danger) can lead to intrusive thoughts, avoidance, and severe emotional distress.

LOGICAL FORM  Middle range theory  Neither purely inductive nor deductive •

Arose from asking question about the nature of an important clinical problem, followed by systematic qualitative and quantitative inquiry and careful application of theoretical models borrowed from other disciplines.

ACCEPTANCE BY THE NURSING COMMUNITY PRACTICE • Mishel’s theory describes a phenomenon experienced by acute and chronically ill individuals and their families. • Hilton(1992) applied the theory in prescribing how to assess and intervene with patients experiencing uncertainty. • She further delineated how uncertainty can activate various types of coping to manage the situation, and described appropriate nursing intervention based on a thorough assessment of the patient’s uncertainty.

EDUCATION • The theory has been widely used by graduate students as the theoretical framework for their these and dissertations. • Mishel uses the theory as an exemplar of how theory guides the development of nursing intervention in her doctoral level courses.

RESEARCH • Using the Uncertainty in illness theory and scales, a large body of knowledge has been generated by researchers. • The scales and theory are used by nurse researcher as well as scientists from other disciplines to describe and explain the psychological responses of people experiencing uncertainty due to illness.

FURTHER DEVELOPMENT • • • •

The intervention has proved effective in increasing cancer knowledge, reducing symptom, and improving quality of life. Data analysis is under way for the continuation study that extended the intervention to an individual newly diagnosed with early stage cancer and their primary support persons to aid in decision making. From qualitative data supporting the reconceptualised theory, Mishel and Fleury (1994) developed the Growth Through Uncertainty Scale (GTUS) to measure the new view of life that can emerge form continual uncertainty. Plans are under way to move the theoretically derived intervention into current practice, allowing nurses responsible for different types of patient populations to incorporate uncertainty assessment and intervention into plans of care.

CRITIQUE

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CLARITY • Uncertainty is the primary concept of this theory and is defined as a cognitive state in which individuals are unable to determine the meaning of illness-related events(Mishel, 1998) • The relationship between the healthcare provider and the patient must focus on recognizing continual uncertainty and teaching the patient how to use the uncertainty to generate different explanations for events.

SIMPLICITY • The uncertainty-in-illness models contain concepts comprising relationships that range from simple to complex and direct to indirect. • The outcome portion of the models is differentiated into two conceptualizations of the theory. • 1st – relating to patients with acute illness. • 2nd – representing an expansion of the model to accommodate patients with chronic illness.

GENERALITY • The theory explains how individuals construct meaning from illness-related events. • It is broad and generalizable and can be used with individuals experiencing their own illnesses as well as with family of people experiencing illness-related uncertainty. • The theory can be applied to many areas of nursing practice and has been used by clinicians for acute and chronic illnesses.

EMPIRICAL PRECISION • The concepts are well-described and their relationships precisely constructed such that operational definitions have been written and tested both in research and clinical settings. • The theory has allowed for development and testing of nursing interventions to manage uncertainty.

DERIVABLE CONSEQUENCE • Derivable consequences are determined by examining whether a theory guides research, inform practice, and generate new ideas. • The theory generated considerable empirical research in adults dealing with their own illness or of a family member and continue to stimulate new research directions, and in healthcare providers informing patients of treatment choices in conditions with uncertain prognosis.

SUMMARY The Uncertainty in illness Theory 1. Provides a comprehensive framework within which to view the experience of acute and chronic illness and to organize nursing interventions to promote optimal adjustment. 2. The theory helps explain the stresses associated with the diagnosis and treatment of major illnesses or chronic conditions, the processes by which individuals assess and respond to the uncertainty inherent in an illness experience, and the importance of professional caregivers in providing information and supporting individuals in understanding and managing uncertainty.

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3. The reconceptualised theory addresses the unique context of continual uncertainty and thereby expands the original theory to encompass the ongoing uncertain trajectory of many life-threatening and chronic illnesses. 4. The original theory and its reconceptualization are well explicated, deriving support from sound theoretical foundations and extensive empirical confirmation, and it can be applied in illness contexts to support evidencebased nursing practice.

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