Merle Mishel was born in Boston Massachusetts in 1939 and much of her practice in nursing was geared towards her theory of perceived ambiguity in illness scale, later named uncertainty of illness (Bailey & Stewart, 2017). This uncertainty of illness focuses on one’s outlook of what is happening to them, whether it is a new diagnosis or a chronic illness, one’s perception is the determining factor of the expected outcome. If the perspective is not clear, there will be some uncertainty of what to expect, how to care for themselves after the illness, and the information that is given to the patient through the healthcare team needs to be concise to give the patient comfort in knowing the response time to the illness is meaningful to the care team just as much as to the patient (Bailey & Stewart, 2017). There are a plethora of things that impact one's uncertainty as well as things that help lessen uncertainty. When uncertainty creeps into one's life, they begin to become unbalanced and start to question their future. As a healthcare team, we must provide as much certainty as we are able to and let them know that even with the realm of the unknown that they still can have as much quality of life as they choose to have.
Mishel conceptualized the uncertainty of illness, in the beginning, to connect the psyche of the mind with the illness one is facing (Bailey & Stewart 2017). Mishel’s training in nursing was in the psychiatric unit, she came across a lot of uncertainty with helping her patients (Bailey & Stewart 2017). In 1990, Mishel re-structured her theory to connect much of what we see in our healthcare patient’s today which is summed up by the phrase, “See it to believe it”. People in today’s time want to know what is ahead of them, they want to see the treatment plan make them feel better, and they want to have as much certainty as they can to outweigh the uncertainty (Bailey & Stewart 2017). As we study Mishel’s theory of uncertainty of illness, we will view it in light of how ambiguity arises with COPD, heart failure, and chronic kidney disease. There are plenty of other areas in healthcare that arise many questions that leave our patients wandering, we need to provide as much certainty as possible, as they are faced with the unknown.
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Description of Nursing Theorist and Theory
Mishel’s re-structured theory adds a dimension of uncertainty, this does not mean that uncertainty is ruled out in every case, even though each illness presents with uncertainty, it allows the patient to grasp what is happening and formulate an outcome in spite of the uncertainty (Bailey & Stewart 2017). When a patient exhibits uncertainty, this will inhibit what they learn due to the fact of not being able to get a solid foundation of the value of the illness. When there's not a solid foundation, then one's mind can only wonder; this can lead to misunderstanding the diagnosis due to not enough information is provided, physicians assuming the patient already knows about the diagnosis and that will lead to even more uncertainty (Cherry, B. & Jacob, S., 2017). Although ambiguity cannot be ruled out completely, this will bring together the healthcare team working with the patient to achieve desired outcomes.
Concepts of the Theory
When applying this theory to our everyday life in our areas of nursing we need to thoroughly assess our patients and their support system. We need to see how they are adapting to being in a hospital with news of the new diagnosis, or ongoing chronic illnesses. If their outlook is of 'doom and gloom', we as a nurse should seek out the root of what makes them see it that way. Once we can determine their outlook, we need to build up a rapport with the patient while we are caring for them, this is best done by making our care client-centered and letting them know we genuinely care. When we can break through the barrier of gaining trust, we then can explore how the patient truly feels, and not just their “scripted answer”. At this point, we can collect sound objective and subjective data to help with our patient's uncertainty. Their uncertainty can stem from various aspects involving but not limited to, knowledge, resources, adaptability, support system, emotional health, and physical health (Bailey & Stewart 2017). Using Michel’s theory of uncertainty, we as a healthcare professional can breakthrough socioeconomic barriers to lessen uncertainty in illnesses, directly impacting a continuum of health for our patient, and achieving the highest level of optimum life that the patient can attain. Putting to use the concepts of Mishel’s theory, a lot of factors play a role in how the patient will react to what is happening, and we as a healthcare provider need to bring as much positive to the patient as they may only see negativity at first. Given adequate space to process what is happening, sound teaching with thorough re-assessing, this should, in turn, give the patient a new perspective.
Assumptions of the Theory
When formulating any theory there will be a lot of different opinions due to different perspectives of the nursing field, what works in one area may not necessarily fit or work in another area. One assumption with this theory was that the present ability of the patient to make decisions and process what is happening was directly related to the uncertainty that they would experience and that past life events that brought uncertainty could not play a role in the current state of uncertainty (Bailey & Stewart 2017). Once you have faced previous trials and times of weariness of not knowing then one assumed that you could not use what you interpreted through that trial to help you through what is in front of you now. I choose to believe that one’s past struggles and fears can roll over into the current, the way you handle what was happening in the past can come to light in part of the new trial to help you cope. Another assumption is that the “not knowing” cannot be determined good or bad, the gray area so to speak is an even playing field (Bailey & Stewart 2017). Most would agree with this assumption, sometimes what you do not know won’t hurt you, although within the nursing field we are to provide evidence-based practice education that allows the patient to determine if what they are facing is good or bad. Another misconception of Mishel’s theory leads people to believe that due to the uncertainty, it would lead one to be under some sort of stress, and in the face of stress, it would make them have to change (Bailey & Stewart 2017). When anyone is faced with the unknown, we cannot assume that it will be a linear projection to get them to overcome whatever they are faced with. In terms of chronic illnesses, the patient has dealt with the illness for a while, and the result of the illness may not be a death like some. It has proven to be a process, especially with chronic illnesses, people may face ambiguity at different times but not constantly, so they must choose how to cope when presented with the unknown and that is not every day. According to Mishel, with the uncertainty not being a constant daily thing, it suggests that the person lives with what is happening to them and over time they will make choices that will keep them on the track of more peace than one of fear (Bailey & Stewart 2017).
Application of Theory to my Practice
Mishel’s theory can come into context across the various spectrum of patients along the continuum of life that are faced with an array of illnesses. In terms of heart failure, one can present with different symptoms each time due to the complexity of the cardiovascular system. The patient can get overwhelmed, which can lead to not being able to understand the connection of systems to heart failure and can give the sense of losing control to the patient. When the patient feels out of control, at times they can get depressed due to not knowing all the symptoms to look for when dealing with heart failure (Chen & Kao, 2018). During their study with patients that dealt with heart failure, not knowing what to expect at times correlated to make them feel bad and this brought on depressive symptoms, thus prolonging the healing time. (Chen & Kao, 2018). On our unit, we tend to see patients that fight with depressive states due to heart failure symptoms impeding their quality of life. In conjunction with heart failure is COPD which also has a set of symptoms that interferes with one’s life, limiting what they can do. This study correlates how COPD limits one’s interactions and social life, therefore, limiting their support system (Hoth, K. 2014). We see this almost daily on our unit, people are not able to participate in various celebrations due to a restriction of activity caused by their breathing. This can lead to ambiguity in one's life and raise questions if they will ever be able to be 'normal' again? Another thing we are faced with in our unit is chronic kidney disease. There is a lot of uncertainty with this illness, even though they may get dialysis, they are unsure how long it will sustain them because it is not a cure-all for the disease. This study shows the various options available for someone that presents with CKD, with those decisions come ambiguity that will play a role in the patient’s decision of treatment plan (Harwood, L. RN, & Clark, L. Ph.D., 2014). We see various stages of CKD, some that require dialysis whether peritoneal or hemodialysis and some that are managed by medications, diet, and exercise. With all options available there is some grey area that is in the patient's mind, will their kidneys ever get better, with proper teaching can they maintain an active lifestyle and prevent worsening of their kidneys? These questions are just a few we encounter, the mindset of the individual is one that has a lot of control with the situation at hand, if they don't have a great mindset then it will not be a great outcome, thus with a good mindset they will be able to achieve as much as they desire.
Conclusion
We all have uncertainties that we face in life, it is almost evident that at one moment in our life we will be faced with things we have not planned. As a healthcare professional, we need to keep in mind how we felt when we were faced with unknowns. We play a crucial role in educating our patients and equipping them. I believe each of us as healthcare professionals can incorporate Mishel’s theory while we are caring for our patients, knowing that they are faced with some kind of fear of the unknown, and it is our role, if the patient will allow us to do so, to help them get over the hump and know that they can overcome in light of what they are facing.
References
- Chen, T.-Y. & Kao, C-W (2018). Uncertainty and depressive symptoms as mediators of quality of life in patients with heart failure. PLose ONE pages 1-13.
- Bailey, D.E, Jr., & Stewart, J.L. (2017, February 09). Uncertainty in illness theory. Retrieved from https://nursekey.com/uncertainty-in-illness-theory/
- Hoth, K., Wamboldt, F., Ford, D., Sandhaus, R., Strange, C., Bekelman, D., & Holm, K. (2014). The social environment and illness uncertainty in chronic obstructive pulmonary disease. International society of behavioral sciences, pages 22:223-232
- Harwood, L. RN, & Clark, L., Ph.D. (2014). Dialysis modality decision making for older adults with CKD. Journal of clinical nursing: retrieved from https://onlinelibrary-wiley-com.proxy.longwood.edu/doi/full/10.1111/jocn.12582
- Cherry, B. & Jacob, S. (2017). Contemporary nursing issues, trends, and management. (7th edition). St. Louis, MO. Elsevier.
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