Uncertainty in Illness Middle Range Introduction to Uncertainty in Illness Middle Range Theories
The Uncertainty in Illness Middle Range Theories were developed by Merle Mishel to address the psychological and emotional experience of patients dealing with illness. Two theories emerged: the original Uncertainty in Illness Theory (UIT), introduced in 1988, and the Reconceptualized Uncertainty in Illness Theory (RUIT), presented in 1990. The UIT focuses on the diagnostic and treatment phases of illness, examining how patients cope with the uncertainty that arises during these periods. In contrast, the RUIT addresses living with continuous uncertainty, such as that experienced with chronic illnesses or conditions that have the potential to recur (Mishel & Clayton, 2003).
These theories apply to various populations, including individuals experiencing illness, caregivers, parents of ill children, and people across all age groups. They provide a framework for understanding how uncertainty affects patients’ psychological and emotional well-being and how healthcare providers can support them through these challenges.
What 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). This definition encompasses several key themes:
- Antecedents of Uncertainty: These are factors that contribute to the experience of uncertainty. They include:
- Stimuli Frame: Composed of the symptom pattern, event familiarity, and event congruence.
- Cognitive Capacity: Refers to the individual’s ability to process information.
- Structure Providers: Resources available to the individual to help manage uncertainty.
- Appraisal of Uncertainty: How an individual perceives and interprets uncertainty, which involves:
- Inference: Interpretation based on personality, past experiences, knowledge, and context.
- Illusion: Beliefs that maintain a positive outlook despite uncertainty.
- Coping with Uncertainty: Strategies for managing uncertainty, which can lead to:
- Danger: The perception of a potentially harmful outcome.
- Opportunity: The perception of a potential positive outcome.
- Coping: Methods to reduce and manage uncertainty.
- Adaptation: Achieving a usual range of biopsychosocial behavior.
The primary health outcome associated with the UIT is adaptation and the regaining of personal control over one’s life. Mishel’s model of UIT presents these themes in a linear relationship, with uncertainty arising from antecedents, influenced by cognitive capacities, and managed through coping strategies.
The Reconceptualized Uncertainty in Illness Theory (RUIT) builds upon the UIT by adding two new concepts: self-organization and probabilistic thinking. Self-organization involves structuring a new sense of order by accepting uncertainty as a natural part of life. Probabilistic thinking is a pattern of thought that incorporates a conditional view of the world (Mishel & Clayton, 2003, p. 31).
The RUIT identifies four factors that influence the formation of a new life perspective:
- Prior Life Experience
- Physiological Status
- Social Resources
- Healthcare Providers
The health outcome of the RUIT is an expansion of consciousness, where individuals develop a different perspective on living with continuous uncertainty. Mishel’s model of RUIT represents this as a spherical configuration over time, illustrating the process of repatterning and reorganization, leading to a new understanding of uncertainty in illness (Mishel & Clayton, p. 33).
Uncertainty in Illness
In 1981, Mishel developed the Uncertainty in Illness Scale, a tool frequently used to study uncertainty in both acute and chronic illness situations. The scale has been instrumental in understanding how patients perceive and cope with uncertainty. Research has supported various elements of the UIT, such as symptom patterns, event congruence, event familiarity, social support, credible authority, appraisal, coping, and adjustment to uncertainty (Mishel & Clayton, 2003, pp. 34-38).
However, the RUIT has been less frequently used in research. Most support for the RUIT comes from qualitative studies of people living with chronic illness, highlighting the evolving nature of uncertainty and how it influences patients’ long-term coping strategies (Mishel & Clayton, p. 38).
Management of Uncertainty
Over the last decade, an Uncertainty Management Intervention based on the UIT was evaluated in four clinical trials involving patients with breast and prostate cancer (Mishel & Clayton, 2003). This intervention included weekly telephone calls and demonstrated effectiveness in several areas:
- Teaching Skills to Manage Uncertainty: Helping patients recognize and address their feelings of uncertainty.
- Teaching Problem-Solving Techniques: Equipping patients with strategies to solve problems related to their illness.
- Improving Cognitive Reframing: Encouraging patients to adopt new ways of thinking about their situation.
- Enhancing Patient-Provider Communication: Facilitating more effective communication between patients and their healthcare providers.
- Managing Side Effects of Cancer Treatment: Providing strategies to cope with and minimize the side effects of treatments.
These interventions effectively reduced uncertainty, helped patients regain a sense of control, and improved overall outcomes.
Practice Guidelines
Mishel and Clayton (2003) propose several practice guidelines to help healthcare professionals manage uncertainty in patients:
- Provide Clear and Relevant Information: Directly related to the sources of uncertainty. Offering well-structured and precise information helps patients make sense of their illness and reduces ambiguity.
- Enhance Communication: With patients experiencing uncertainty by offering contextual cues about what they may see, hear, or feel during medical procedures. This approach helps reduce anxiety and increases understanding.
- Use the Theories to Guide Care Planning: Understanding the principles of UIT and RUIT can help nurses plan care to reduce or prevent uncertainty for patients with acute or chronic illnesses. These theories provide a structured approach to addressing uncertainty and enhancing patient outcomes.
Outcomes of Theories
The Uncertainty in Illness theories have several significant implications for nursing practice and education:
- Improving Nursing Practice: These theories offer a framework to understand and address uncertainty in patients, enabling nurses to provide more tailored and effective care. They guide the planning of interventions that help patients manage uncertainty, improve coping skills, and adapt to their circumstances.
- Enhancing Education: Integrating these theories into undergraduate and graduate nursing curricula can raise awareness of uncertainty in illness and encourage theory-based practice. By teaching students to apply these theories in clinical settings, educators can enhance their understanding of the impact of uncertainty and improve their ability to provide patient-centered care.
- Advancing Research: The UIT and RUIT offer a robust foundation for research into patient experiences of uncertainty and how best to manage it. Further research can build on these theories to develop new interventions and strategies to support patients and improve outcomes.
Conclusion
Mishel’s Uncertainty in Illness Middle Range Theories provide a comprehensive framework for understanding the experience of uncertainty in illness and its impact on patients’ psychological and emotional well-being. By identifying the factors contributing to uncertainty, the ways patients appraise and cope with it, and the health outcomes associated with managing uncertainty, these theories offer valuable insights for nursing practice, education, and research.
Implementing these theories in clinical practice can help healthcare providers better understand and address uncertainty, leading to improved patient outcomes and a more patient-centered approach to care. Moreover, integrating these theories into nursing education ensures that future generations of nurses are equipped to recognize and manage uncertainty in their patients, enhancing the overall quality of care.