Merle Mishel`s Uncertainty in Illness Theory
Merle Mishel`s Uncertainty in Illness Theory
Uncertainty in Illness
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
As nurses, we must recognize that
there are many possible states of
health. Bringing people to their
optimal state of health is the goal.
It is imperative to foster adaption and
promote, maintain and restore
optimum health for our patients.
Body, Mind and Soul
Exploring and harnessing the power of body, mind
and soul is imperative to teach one to cope.
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
As nurses, our goal is to
guide the patient to a
place of certainty in
light of uncertainty.
We must facilitate new life…
It is crucial to never assume the
only person needing help is the
This uncertainty can exist in any
individual that is affected by the
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).
University of California, MS Nursing
Boston University, BS Nursing
Claremont Graduate School, MA Psychology
Claremont Graduate School, Ph.D. Psychology
Her dissertation began as the Perceived Ambiguity in Illness
Scale, but was later renamed the Mishel Uncertainty of Illness
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
Mishel had a personal experience with
uncertainty through her father,
who suffered with colon cancer (Smith & Liehr,
Mishel anguished in the fact that “….his body
was swollen in some places and emaciated in
“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
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).
Uncertainty in Context
Mishel 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 Theory
The Theory of Uncertainty in Illness
The 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.
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.
Four Global Concepts
This model perfectly describes the four global concepts:
Human Being, Environment, Health and Nursing
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
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
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
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.
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.
For More Information
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,
Please read the following case study. Using the information you
have learned about this theory, answer the questions at the end of
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:
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
What do you think patients need with diagnosis such as this?
How would you gauge the amount of support that a patient requires to meet
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
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-SecondEdition
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.