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Uncertainty

in
Illness
Theory
Merle H. MIshel

Credentials and Background

Credentials and Background


Born in 1939, in Boston Massachusetts
She Graduated from Boston University with a B.A. in
1961
Received her M.S. in psychiatric nursing from the
University of California in 1966
Completed her M.A. and Ph.D. in social psychology at
the Claremont Graduate School, California in 1976 and
1980, respectively.

Her dissertation research, supported by an individual


national research service award, was the development
and testing of the perceived ambiguity in Illness scale,
later renamed the Mishel Uncertainty in Illness Scale
(MUIS-A). the original scale has been used as the basis
for the following three additional scales:
A community version (MUIS-C) for chronically ill individuals
who are not hospitalized or receiving active care.
A measure of parents perceptions of uncertainty (PPUS) with
regard to their childs illness experience.
A measure of uncertainty in spouses or other family members
when another member of the family is acutely ill (PPUS-FM)

Early in her professional career, Mishel practiced as a


psychiatric nurse in acute care and community
settings, while pursuing her doctorate, she was a
faculty in the Department of Nursing in the California
State University at Los Angeles, rising from assistant
to full professor.
She practiced as a nurse therapist in both community
and private practice settings from 1973-1979.
Upon completion of her doctorate degree in social
psychology, she relocated to the University of Arizona,
College of Nursing in 1981.

She served as division head for mental health nursing


from 1984-1991.
She received numerous intramural and extra mural
research grants that supported the the continued
development of her theoretical framework.
She was inducted as fellow in the American Academy
of Nursing in 1990
Became professor at the University of North Carolina
School of Nursing in 1991

Was awarded, Kenan Professor of Nursing Chair in


1994
Given the Research Merit Award in 1997
Recipient of Sigma Theta Tau International Sigma Xi
Chapter Nurse Research Predoctoral Fellowship from
1977 to 1979 and received the Mary Opal Wolanin
Research Award in 1986.

She is a member of American Academy of Nursing,


Sigma Theta Tau International, American Psychological
Association, American Nurses Association, Society of
Behavioral Medicine, and Oncology Nursing Society.
Served as grant reviewer for the National Cancer
Institute, National Center for Nursing Research, and
National Institute for Aging and was a charter member
of the study section on human immune deficiency
virus (HIV) at the National Institute of Mental Health.

Theoretical Sources

Theoretical Sources
When Mishel started her research into uncertainty, the
concept had not previously been applied in the health
and illness context.
Her original Uncertainty in Illness Theory (Mishel,
1988) drew from existing information-processing
models (Warburton, 1979) and personality research
(Budner, 1962) from psychology discipline, which
characterized uncertainty as a cognitive state
resulting from insufficient cues with which form a
cognitive schema or interpersonal representation of a
situation or event.
She attributes the underlying stress-appraisal-copingadaptation framework in the original theory to the

The unique aspect was her application of this


framework to uncertainty as a stressor in the context
of illness, which made the framework particularly
meaningful for nursing.
With the conceptualization of the theory, Mishel
(1990) recognized that the western approach to
science supported a mechanistic view in its emphasis
on control and predictability.

By using critical social theory, Mishel recognized the


bias inherent in the original theory, an orientation
toward certainty and adaptation. She incorporated
tenets from chaos theory, and because of its 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.

Major Concepts & Definitions

Major Concepts & Definitions


Uncertainty
The inability to determine the meaning of illnessrelated events, occurring when the decision make is
unable to assign definite value to objects or events,
or is unable to predict outcomes accurately

Cognitive Schema
Is a persons subjective interpretation of illness,
treatment, and hospitalization

Stimuli Frame
Is the form, composition, and structure of the
stimuli that a person perceives, which are then
structured into a cognitive schema

Symptom Pattern
Is the degree to which symptoms occur with
sufficient consistency to be perceived as having a
pattern or configuration

Event Familiarity
Is the degree to which a situation is habitual or
repetitive, or contains recognized cues

Event Congruence
Refers to the consistency between the expected
and the experienced in illness-related events

STRUCTURE PROVIDERS
Are the resources available to assist the person in
the interpretation of the stimuli frame

Credible Authority
Is the degree of trust and confidence a person has
in his or her healthcare providers

Social Supports
Social Supports influence uncertainty by assisting
the individual to interpret the meaning of events

COGNITIVE CAPACITIES
Are the information-processing abilities of a person,
reflecting both innate capabilities and situational
constraints

INFERENCE
Refers to the evaluation of uncertainty using
related, recalled experiences

ILLUSION
Refers to beliefs constructed out of uncertainty

ADAPTATION
Reflects biophysical behavior occurring within
persons individually defined range of usual
behavior

NEW VIEW OF LIFE


Refers to the formulation of a new sense of order,
resulting from the integration of continual
uncertainty into ones self structure, in which
uncertainty is accepted as the natural rhythm of life

PROBABILISTIC THINKING
Refers to the belief in a conditional world in which
the expectation of continual certainty and

Major Assumptions

Major Assumptions
Mishels original Uncertainty in illness theory,
first published in 1988, included several major
assumptions. The first two reflect how
uncertainty was conceptualized originally
within the psychology disciplines informationprocessing models, as follows:
Uncertainty is a cognitive state, representing the
inadequacy of an existing cognitive schema to
support interpretation of illness related events
Uncertainty is an inherently neutral experience,
neither desirable nor aversive until it is appraised
as such.

Two more assumptions reflect the uncertainty


theorys roots in traditional stress and coping
models that posit a linear stress coping
adaptation relationship as follows:
Adaptations represents the continuity of an
individuals usual biophysical behavior and is the
desired outcome of coping efforts to either reduce
uncertainty appraised as danger or maintain
uncertainty appraised as opportunity
The relationships among illness events, uncertainty,
appraisal, coping, and adaptations are linear and
unidirectional, moving from a situations promoting
uncertainty toward adaptation.

Mishel herself challenged these last two assumptions


in her reconceptualization of her theory, published in
1990.
The reconceptualization came about as a result of
contradictory findings, when the theory was applied to
people with chronic illness.
The original theory held that uncertainty, typically is
appraised as an opportunity only in conditions that
represent a known downward trajectory.
MIshel and others found that people also appraised
uncertainty as an opportunity in situations without a
certain downward trajectory, particularly, in long-term
chronic illnesses, and that in this context people often
develop a new view of life.

Mishel became dissatisfied with the traditional linear


models that informed the original theory, she turned
to the more dynamic chaos theory to explain how
prolonged uncertainty could function as a catalyst to
change a persons perspective on life and illness.
Chaos theory contributed two of the following
theoretical assumptions, which replace the linear
stress coping adaptation outcome portion of the
model as follows:

People as biophysical systems typically function in
far-from-equilibrium states
Major Fluctuations in a far-from-equilibrium system
enhance the systems receptivity to change
Fluctuations result in re-patterning, which is

Because uncertainty pervades nearly every aspect of


a persons life, its effects become concentrated and
ultimately challenge the stability of the system. In
response to the confusion and disorganization created
by continued uncertainty, the system ultimately must
change in order to survive
Ideally under conditions of chronic uncertainty, a
person gradually moves away from an evaluation of
uncertainty as aversive to adopt a new view of life
that accepts uncertainty as a part of reality. (insert
figure 28-2)
Thus uncertainty, especially in chronic or life
threatening illness, can result in a new level of
organization and a new perspective on life.
Incorporating the growth and change that can result
from uncertain experiences.

Theoretical Assertions

Theoretical Assertions

Mishel asserted the following:

1. Uncertainty occurs when a person cannot adequately structure or


categorize an illness-related event because of lack of cues
2. Uncertainty can take the form of ambiguity, complexity, lack of or
inconsistent information, or unpredictability
3. As symptom pattern event familiarity, and event congruence (stimuli
frame) increase, uncertainty decreases
4. Structure providers (Credible Authority, social support, and education)
decrease uncertainty directly by promoting interpretation of events, and
indirectly by strengthening the stimuli frame

5. Uncertainty appraised as danger prompts coping efforts directed at


reducing the uncertainty and managing the emotional arousal generated
by it
6. Uncertainty appraised as opportunity prompts coping efforts directed at
maintaining the uncertainty
7. The influence of uncertainty on psychological outcomes is mediated by
the effectiveness of coping efforts to reduce uncertainty appraised as
danger or to maintain uncertainty appraised as opportunity
8. When uncertainty appraised as danger cannot be reduced effectively,
coping strategies can be employed to manage the emotional response

9. The longer uncertainty continues in the illness context, the more


unstable the individuals previously accepted mode of functioning
becomes
10.Under conditions of enduring uncertainty, individuals may develop a
new, probabilistic, perspective on life, which accepts uncertainty as a
natural part of life
11.The process of integrating continual uncertainty into a new view of life
can be blocked or prolonged by structure providers who do not support
probabilistic thinking
12.Prolonged exposure to uncertainty appraised danger can lead to
intrusive thoughts, avoidance, and severe emotional distress.

Mishel believes the most important product of


her research program is the return of
knowledge to practice. Toward the end, plans
are under way to move the theoretically
derived intervention into current practice,
allowing nurses responsible for different types
of patient populations