Uncertainty in Illness Middle Range Theories In Nursing Care

Afza.Malik GDA

Uncertainty in Illness Middle Range Theories In Nursing Care

Uncertainty in Illness Middle  Range Theories,Whats is Uncertainty,Uncertainty in Illness,Management of Uncertainty,Practice Guideline,Outcomes of Theories.

Uncertainty in Illness Middle  Range Theories

    Two middle-range theories of uncertainty in illness were developed by Merle Mishel. The original uncertainty in illness theory (Mishel, 1988) addressed the diagnostic and treatment phases of illness and the re-conceptualized uncertainty in illness theory (Mishel, 1990) addressed living with continuous uncertainty, be it a chronic illness or an illness that may reoccur. Mishel refers to these theories as UIT for the uncertainty in illness theory and RUIT for the reconceptualized uncertainty in illness theory (Mishel & Clayton, 2003). The theories can be applied to the experience of ill persons, caregivers, and parents of children who are ill as well as to all age groups.

 Whats is Uncertainty

    Uncertainty is defined as "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 and/or is unable to accurately predict outcomes" (Mishel & Clayton, 2003, p. 29). They identify three major themes in the UIT. These themes are: antecedents of uncertainty, appraisal of uncertainty, and coping with un- certainty. The antecedent theme is composed of stimuli frame (symptom pattern, event familiarity, and event congruence), cognitive capacity (information processing ability), and structure providers (resources available). The appraisal of uncertainty is composed of inference (based on personality dispositions, experience, knowledge, and context), and illusion (beliefs that have a positive outlook). Coping with uncertainty is composed of danger (possibility of a harmful outcome), opportunity (possibility of a positive outcome), coping (reducing and managing uncertainty), and adaptation (usual range of biopsychosocial behavior). The proposed health outcome related to the UIT is adaptation and the regaining of personal control of one's life. Mishel's model of the UIT (Mishel & Clayton, p. 30) shows linear relationships among the themes with no feedback loops. The model depicts uncertainty resulting from antecedents with the major pathway going through the stimuli frame variables that have been influenced by cognitive capacities. The RUIT "includes the antecedent theme in the UIT and adds the two concepts of self- organization and probabilistic thinking" (Mishel & Clayton, 2003, p. 31). Mishel and Clayton describe self-organization as the structuring of a new sense of order that comes from the acceptance of uncertainty as a natural life rhythm. Probabilistic thinking is a pat-tern of thinking incorporating a conditional view of the world. The RUIT sets forward "four factors that influence the formation of a new life perspective. These are prior life experience, physiological status, social re- sources, and health care providers" (Mish- el & Clayton, p. 31). On the basis of this theory it can be concluded that a person comes to a different view of the continuous experience of uncertainty in illness that goes on through time. The health outcome of the RUIT is the expansion of consciousness. Mishel's model of the RUIT (Mishel & Clay- ton, p. 33) shows a spherical configuration over time representing repatterning and reorganization resulting in a different view of un- certainty in illness.

Uncertainty in Illness

Mishel published an Uncertainty in Illness Scale in 1981 and the scale has been frequently used to study the experience of uncertainty for persons in acute or chronic illness situations. Mishel and Clayton (2003, pp. 34-38) report research that directly supports elements of the UIT, such as symptom pat- tern, event congruence, event familiarity, so- cial support, credible authority, appraisal, coping, and adjustment to uncertainty. They note that the RUIT has less frequently been used for research and support, for the RUIT has come from qualitative studies of people with chronic illness (Mishel & Clayton, p. 38).

Management of Uncertainty

    Within the last decade, an uncertainty management intervention was evaluated in four clinical trials with persons with breast cancer and prostate cancer (Mishel & Clay- ton, 2003). The intervention was based on the UIT and implemented with weekly tele- phone calls. The intervention demonstrated effectiveness for teaching skills to manage un- certainty, teaching problem solving, improv- ing cognitive reframing, enhancing patient- provider communication, and improving the management of the side effects of cancer treatment (Mishel & Clayton).

 Practice Guideline

    Mishel and Clayton (2003) propose substantive direction for practice guided by the theories and tested in research. Use of the two theories in practice offers opportunities for nurses to understand, address, and man-age sources of uncertainty in illness for patients. Providing well thought out information directly related to uncertainty is a way of providing structure to the stimuli frame. Communication with patients experiencing uncertainty by providing contextual cues, such as what will be heard and felt during procedures, is a way to reduce ambiguity and increase understanding. Uncertainty is a human response to the illness experience that is found in the frontlines of nursing practice. These theories directly relate to the planning of care to reduce or prevent uncertainty for persons with acute or chronic illness.

Outcomes of Theories

    These theories can enhance the education of undergraduate and graduate students by bringing awareness of uncertainty in illness to routine care planning. Teaching students to apply theory in practice will give direction to their care and advance their understanding of theory-based practice.

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