Merle Mishel’s

Uncertainty in Illness Theory

The following NURS 324 Powerpoint presentation will explore Merle Mishel’s nursing theory. Our group consists of four members: Meagan Dyer, Patricia Priest, Sharon Lumbert and Tamara Putney. We selected Merle Mishel because we were not familiar with her theory. We want to expand our knowledge of nursing theorists, and since we all work in some form of critical care, we knew we could apply this theory, in some form, to our everyday practice.

Overview

As nurses, we must recognize that there are many possible

states of health. Bringing people to their optimal state of health is

the goal.

Optimal Health

It is imperative to foster adaption and promote, maintain and

restore optimum health for our patients.

Exploring and harnessing the power of body, mind and soul is imperative to teach one to

cope.

Body, Mind and Soul

For when faced with uncertainty in life, weakness and fear becomes all consuming as it attempts to prevail over “living” itself.

When uncertainty is due to illness, there

is a way to help. There is a way to

empower the patient to understand the

fear, gain clarity and find direction…

As nurses, our goal is to guide the patient

to a place of certainty in light of

uncertainty.We must facilitate new life…

Empower

It is crucial to never assume the only person needing help

is the patient…

This uncertainty can exist in any individual that is affected

by the illness…

Crucial

http://nursing.unc.edu/muic/Mishelbio.html

1961 Boston University, BS Nursing

1991 University of North Carolina at Chapel Hill, School of Nursing

1994- Awarded Kenan Professor, University of North Carolina at Chapel Hill, School of Nursing

1966 University of California, MS Nursing

1976 Claremont Graduate School, MA Psychology

1980 Claremont Graduate School, Ph.D. PsychologyHer dissertation began as the Perceived Ambiguity in Illness Scale, but was later renamed the Mishel Uncertainty of Illness Scale (MUIS-A)

Merle Helaine Mishel Mishel has gained recognition for her research in psychosocial responses of the chronically or terminally ill patient. She strives to improve the outcomes and care of patients during times of uncertainty, keeping in mind the overburdened healthcare system and the individualized needs of the patient (Mishel, 2011)..

Mishel had a personal experience with uncertainty through her father,

who suffered with colon cancer (Smith & Liehr, 2008) .

Mishel anguished in the fact that “….his body was swollen in some places and

emaciated in others” (p.56).

“He didn’t understand what was happening to him to cause these diverse physiological responses, so he focused on

whatever he could control to provide some degree of predictability for

himself”(p.56).

Theory Influence

Merle Mishel’s focus on uncertainty did not begin until she entered doctoral study in

psychology.

It was at that point, she focused her dissertation on the development and testing of a measure of uncertainty (Smith & Liehr,

2008).

Focus

Uncertainty in ContextMishel is the first nursing theorist to apply uncertainty in the health and illness context (Tomey & Alligood, 2010).

When researching uncertainty she drew from previous research in the information-processing models done by Warburton in 1979 and personality research by Budner in 1962 (2010).

Merle Mishel’s Two Part TheoryThe Theory of Uncertainty in Illness

andThe Re-conceptualized Theory of Uncertainty in

Illness

“The theories focus on the individual in the context of illness or a treatable condition, and on the family or parent of an ill individual” (Smith and Liehr, p.56).

The Re-conceptualized Theory of Uncertainty in Illness was developed through a “need to rethink the theory for

application with the chronically ill. The Re-conceptualized Theory includes ideas of disorganization and reformulation

of a new stability to explain how a person with enduring uncertainty emerges with a new view of life” (p.58).

This theory is generally applied after the patient is assessed using the original theory, especially in the face

of chronic or terminal illness.

Uncertainty Defined

Mishel defines uncertainty 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, or is

unable to predict outcomes accurately” (Mishel, 1981).

This model is very applicable to all aspects of nursing and

healthcare, because there is uncertainty in any health care

problem or diagnosis.

This model perfectly describes the four global concepts: Human Being, Environment, Health and Nursing

Four Global Concepts

1. Human Being: Focuses on the human experiences in coping with illness. This theory is patient and family oriented. Mishel believes that human experiences with uncertainty in illness happen gradually and affects self and interpersonal relationships.

2. Environment: This theory is primarily used in the hospital setting, but can and has been adjusted to many other environments.

3. Health: Concerned with the effects of uncertainty and coping mechanisms on illness. The evaluation tools assist patients and families to achieve a new outlook on life.

4. Nursing: Nurses are in a position to help patients and families to understand uncertainty in illness and learn a new way of life.

Managing Uncertainty in Illness Scale(MUIS)

Mishel’s theory employs the use of scales designed by Mishel to evaluate the patient and family perceptions of the situation and illness. The results of this assessment are used by the nurse to help the patient and/or family to manage the uncertainty and

develop coping mechanisms.

This, in turn will produce better decision making and improve quality of life (Mitchell & Courtney, 2004).

Although Mishel originally developed this model to be used with cancer patients, this model has a rather large view and can also

be used in other specialties of nursing.

Uncertainty in Illness can be found in any aspect of healthcare. People need to be educated about illnesses, surgeries, life-changing events because uncertainty in illness

is prevalent.

Some Examples of the widespread use of this theory:

Uncertainty in Illness Theory was used when diagnosing children with Cystic Fibrosis and parent reactions. “Uncertainty emerged as the central dimension of parents’ experience related to their infants’ equivocal diagnostics for CF” (Tluczek, 2010).

A study was done on patients receiving ICDs, implantable cardioverter defibrillators) using Merle Mishel’s Uncertainty in Illness scale (Carroll, 2010).

A journal article was published related to the spiritual well being of individuals with fibromyalgia syndrome and used a modified Uncertainty in Illness model (Anema, 2009).

Other illnesses and patient populations this theory has been applied in: Breast cancer, prostate cancer, lymphoma, diabetes, fibromyalgia, lupus, multiple sclerosis, trauma, head and neck cancer, rheumatoid arthritis, AIDS, and many more.

Broad Scope

In conclusion, the use of this theory allows nurses and caregivers to provide information and support to

patients and their loved ones that have uncertainty about the illness. It allows patients to be emotionally healthier and have more strength to fight against an illness. Also, addressing uncertainty using Mishel’s theory, identifies

and explains the stressors that manifest from a diagnosis. By addressing uncertainty, clarity is provided and

knowledge is gained. The empowerment provided to the patient or family member by the use the Mishel’s theory and assessment tools can create a new view of life and

greatly increase quality of living.

Conclusion

For More InformationScholarly Articles Bailey, D. r., Barroso, J., Muir, A., Sloane, R., Richmond, J., McHutchison, J., & Mishel, M.

(2010). Patients with chronic hepatitis C undergoing watchful waiting: exploring trajectories of illness uncertainty and fatigue. Research in Nursing & Health, 33(5), 465-473. doi: 10.1002/nur.20397

Lien, C., Chen, S., Tsai, P., Chen, K., Hsieh, Y., & Liang, Y. (2010). Effectiveness of nursing instruction in reducing uncertainty, anxiety and self-care in breast cancer women undergoing initial chemotherapy. [Chinese]. Journal of Nursing, 57(6), 51-60.

Mishel, M. (2007). Reconceptualization of the uncertainty in illness theory. Journal of Nursing Scholarship. 22(4). 256-262. doi: 10.1111/j.1547-5069.1990.tb00225.x  

Ya-Ling Lee, Bih-Shya Gau, Wen-Ming Hsu, Hsiu-Hao Chang. (2009). A model linking uncertainty, post-traumatic stress, and health behaviors in childhood cancer survivors. Oncology Nursing Forum, 36, doi: 10.1188/09.ONF.E20-E30 

Web Links http://nursing.clayton.edu/eichelberger/nursing.htm

http://nursing.unc.edu/muic/bsumm.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2570257/

http://nursing.unc.edu/muic/Mishelbio.html

Case Study

Please read the following case study. Using the information you have learned about this theory, answer the questions at the end of the study.

The original theory will be applied, then, as the patient condition progresses you will see how the consequent re-conceptualized theory can be applied (basically, rethinking or reevaluating, using the same tools) to assist the patient in developing further mechanisms of coping or adjustment to a lifetime of uncertainty.

Case Study Continued

(Original Theory of Uncertainty in Illness)

Mary was diagnosed with Stage II Ovarian cancer.

She felt a small mass in her abdomen and presented to her doctor. She was scared and tried to find as much information as possible through journal articles, books, videos. She was flooded with lots of information some of which seemed very outdated. Mary was referred to a gynecologist who had a CT and blood work done which confirmed a large mass and blood levels that revealed an elevated CA of 125, which is a tumor marker for ovarian cancer (the normal range is 0-30 and Mary's was 4147).

She visited an oncologist and got a second opinion from a gynecological oncologist and found a treatment plan she was happy with. She began chemotherapy and visited community wellness center. This provided her with a support group for patients and family members and offered lectures from doctors, nurses, dietitians, and offered holistic health approaches. Mary also joined a support group of 12 people that became like family to her. She finished her chemotherapy treatments and had a repeat CT done to find she had four new tumors. She underwent a second round of chemotherapy and another "second look" surgery. This surgery resulted in majority of the biopsies being negative and some still had a few cancer cells. The next step was having radioactive isotope, P-32 injected into her abdomen to kill those cells on contact and another round of chemo.

Case Study Continued

(Re-conceptualized Theory Application)

It has been one year since Mary's last surgery and six months since her last chemo treatment. She changed career paths going from a lawyer to a substitute teacher. She experienced the loss of some friends that could not cope with the stressors that come with cancers while she gained lifetime friends that gave her much needed support. She also has permanent hearing loss due to the chemotherapy which has proved to be an adjustment. She has accepted the side effects from the cancer treatment. She also visited England, which she had been wanting to do for some time. She also went to Alaska and began to take camping trips to enjoy the beauty in nature.

Please answer the following questions:

1. If you were a part of a health team who had a patient like Mary, how would you assess her uncertainty? How could you help to lessen this uncertainty? What would be the best way to present information regarding treatment options?

2. What do you think patients need with diagnosis such as this?

3. How would you gauge the amount of support that a patient requires to meet their needs?

References

Anema, C., Johnson, M., Zeller, J., Fogg, L., & Zetterlund, J. (2009). Spiritual well-being in individuals with fibromyalgia syndrome: relationships with symptom pattern variability, uncertainty, and psychosocial adaptation. Research & Theory for Nursing Practice, 23(1), 8-22. Retrieved from EBSCOhost.

Carroll, S., & Arthur, H. (2010). A comparative study of uncertainty, optimism and anxiety in patients receiving their first implantable defibrillator for primary or secondary prevention of sudden cardiac death. International Journal of Nursing Studies, 47(7), 836-845. doi:10.1016/j.ijnurstu.2009.12.005

Mishel, M. (1981). The measurement of uncertainty in illness. Nursing Research, 30, 258-263. Retrieved from EBSCOhost.

Mishel, M. (2011). Managing uncertainty in cancer. Retrieved from http://nursing.unc.edu/muic/Mishelbio.html

Mitchell, M. L., Courtney, M. D. (2004). Reducing family members’ anxiety and uncertainty in illness around transfer from intensive care: an intervention study. Intensive and Critical Care Nursing, 20(4):pp. 223-231. Retrieved from http://eprints.qut.edu.au/1363/1/1363a.pdf

Smith, M.J., & Liehr, P. R. (2008). Middle range theory for nursing (2nd ed.) (pp. 56-58). New York: Springer Publishing Company, LLC. Retrieved from http://www.scribd.com/doc/18432523/Middle-Range-Theory-for-Nursing-Second-Edition

Tluczek, A., Chevalier McKechnie, A., & Lynam, P. (2010). When the cystic fibrosis label does not fit: a modified uncertainty theory. Qualitative Health Research, 20(2), 209-223. doi:10.1177/1049732309356285

Tomey, M.A. & Alligood, M.R. (2005). Nursing theorists and their work (7th ed.). St. Louis: Elsevier.

Additional Information

http://nursing.unc.edu/muic/index.html

http://nursing.unc.edu/muic/instruments.html

http://nursing.unc.edu/directories/search.php?x=76

http://www.nurses.info/nursing_theory_midrange_theories_merle_mishel.html

http://www.nursing.arizona.edu/scripts/ShowNursingVideoAllv1.asp?qtype=date

http://www.journalofnursingstudies.com/article/S0020-7489%2810%2900175-6/abstract

Thank You