NURS 715 Week 2 Theory Presentation Part I on Mishel's Uncertainty in Illness Theory Example

Not Knowing as a Clinical Problem: Mishel's Uncertainty in Illness Theory, Its Origins, Concepts and Propositions

Slide 1: A Theory Born at the Bedside

• Merle Mishel, nurse researcher
• Uncertainty in acute illness, 1988
• Our case: Mr. Reyes, absent from cardiac rehab

Speaker notes: Merle Mishel developed the Uncertainty in Illness Theory from her clinical observation that patients facing serious illness often struggled less with bad news than with not knowing what was happening to them. She published the theory in 1988 to explain how people form meaning for illness events (Mishel, 1988). Throughout this presentation, we will follow Mr. Reyes, 63, who received a stent after a heart attack, was referred to cardiac rehabilitation and never attended. When asked why, he said he did not know whether exercise was safe or what his chest twinges meant.

Slide 2: Purpose and Scope

• Explains how people interpret illness events
• Middle range: limited concepts, testable
• Applies to acute and chronic illness

Speaker notes: The theory's purpose is to explain uncertainty, which she described as the state in which a sick person cannot assign meaning to what is happening, which occurs when a person cannot assign value to events or predict outcomes because of insufficient cues (Mishel, 1988). It is a middle range theory in the sense Smith and Liehr (2014) describe: it focuses on one phenomenon, uses a limited number of concepts and can be tested. It was first framed for acute illness and later extended to chronic illness.

Slide 3: Antecedents of Uncertainty

• Stimuli frame: symptom pattern, familiarity, congruence
• Structure providers: credible authority, social support, education
• Cognitive capacity

Speaker notes: Three groups of antecedents shape uncertainty. The stimuli frame describes how the illness presents: whether symptoms form a recognizable pattern, whether the setting and events are familiar, and whether what happens matches what was expected. Structure providers are the supports that make those cues readable: a trusted clinician, support from others and education. Cognitive capacity, how much a person can take in and reason about at that moment, can be reduced by pain, fatigue or medication. For Mr. Reyes, unfamiliar chest sensations and no trusted explanation fed his uncertainty.

Slide 4: Uncertainty and Its Appraisal

• Ambiguity, complexity, inconsistent information, unpredictability
• Appraised as danger or as opportunity
• Inference and illusion shape appraisal

Speaker notes: Uncertainty itself has several forms: ambiguity about the state of illness, complexity of treatment and care, inconsistent or missing information, and unpredictability of the course. In Mishel's account, a person reads uncertainty as danger when the unknown seems likely to end badly, and as opportunity when not knowing keeps a better ending possible, as for someone whose biopsy result has not yet come back. Inference, drawing on experience and personality, and illusion, beliefs built out of uncertainty, shape that appraisal. Mr. Reyes appraised his uncertainty as danger. His father had died suddenly of a heart attack at 60, and that memory shaped his inference: any unexplained sensation in his chest meant another attack was coming.

Slide 5: Coping and Adaptation

• Danger appraisal: mobilizing and affect-control strategies
• Opportunity appraisal: buffering strategies
• Adaptation as the outcome

Speaker notes: How a person appraises uncertainty determines how they cope. When uncertainty is seen as danger, people use mobilizing strategies, such as seeking information or taking direct action, and affect-control strategies, such as faith or avoidance, to reduce the threat. When it is seen as opportunity, people use buffering strategies to maintain the uncertainty and its hope. Effective coping leads to adaptation. Mr. Reyes coped by avoidance: he stayed home. Avoidance reduced his fear in the short term, but it also removed the very experience, supervised exercise without harm, that could have given his symptoms a familiar pattern and lowered his uncertainty.

Slide 6: Key Propositions

• Less pattern and familiarity, more uncertainty
• Structure providers reduce uncertainty
• Appraisal mediates the path to coping

Speaker notes: The theory's main propositions link these concepts. Uncertainty rises when symptoms lack a clear pattern and events are unfamiliar or unexpected, and falls when credible authority, social support and education help people interpret what is happening. Appraisal sits between uncertainty and coping, so the same level of uncertainty can lead to very different behavior. Recent research is consistent with this structure. In 150 patients with coronary artery disease, uncertainty was positively correlated with perceived stress and negatively correlated with coping, within a pathway linking uncertainty to quality of life (Allahbakhshian et al., 2026).

Slide 7: Reconceptualized for Chronic Illness

• Long-term uncertainty can become a new outlook
• Probabilistic thinking replaces certainty
• Growth through uncertainty

Speaker notes: In 1990, Mishel reconceptualized the theory for chronic illness, where uncertainty may never resolve (Mishel, 1990). Drawing on chaos theory, she proposed that people living with enduring uncertainty may move toward a new, probabilistic view of life, accepting uncertainty as part of reality and even finding growth in it. For a person with coronary disease, which is chronic and unpredictable, both versions of the theory are relevant. The original theory explains why Mr. Reyes is afraid today; the reconceptualized theory explains how he might live well with heart disease for years.

Slide 8: Measuring Uncertainty

• Mishel Uncertainty in Illness Scale and its versions
• Ambiguity, complexity, information, unpredictability
• Widely used across conditions

Speaker notes: Researchers usually operationalize the theory through Mishel's own scale, along with versions adapted for community, family and child populations. Its use across conditions shows the theory's reach. In 2026 alone, it was used to study adults with systemic lupus, where uncertainty correlated with depression and anxiety (Skojec et al., 2026), and family caregivers of people after a first ischemic stroke, where psychological adaptation partly mediated the link between uncertainty and caregiving capacity (Guo et al., 2026).

Slide 9: The Theory at Work, and What Comes Next

• Uncertainty linked to lower rehab adherence
• Self-efficacy and fear as pathways
• Part II: evaluation and application

Speaker notes: For our case, the most relevant study comes from three hospitals in China, where uncertainty in illness was negatively associated with cardiac rehabilitation adherence among patients with coronary heart disease, partly through lower cardiac self-efficacy and greater fear of activity, and latent profile analysis found that a third of patients fell into a high-uncertainty group (Wu et al., 2026). Qualitative work with people receiving cancer treatment shows that patients develop their own strategies, from creative activities to celebrations with family, to cope with uncertainty (Silveira et al., 2026). In Part II, we will evaluate the theory against explicit criteria and apply it to Mr. Reyes's care.

References

Allahbakhshian, A., Sajjadi, S. L., Sarbakhsh, P., & Tabrizi, H. (2026). The pathway analysis of relationship between illness uncertainty, perceived stress, coping strategies, and quality of life in patients with coronary artery disease. PLOS ONE, 21(9), Article e0357910. https://doi.org/10.1371/journal.pone.0357910

Guo, G., Li, X., Wang, H., Lin, Y., Li, C., Zhu, H., & Zheng, D. (2026). The relationship between uncertainty in illness and caregiving capacity in primary caregivers of patients with first-time ischemic stroke: The roles of psychological adaptation and perceived social support. Frontiers in Psychology, 17, Article 1707967. https://doi.org/10.3389/fpsyg.2026.1707967

Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20(4), 225-232. https://doi.org/10.1111/j.1547-5069.1988.tb00082.x

Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image: The Journal of Nursing Scholarship, 22(4), 256-262. https://doi.org/10.1111/j.1547-5069.1990.tb00225.x

Silveira, J. M., Spagnolo, L. M. L., Rangel, R. F., Cordeiro, F. R., Schwartz, E., Oliveira, T. B., Stübe, M., & Oliveira, C. B. (2026). Care strategies for people with cancer in light of Uncertainty in Illness Theory. Revista Brasileira de Enfermagem, 79, Article e20250491. https://doi.org/10.1590/0034-7167-2025-0491

Skojec, T. A., Davidson, T. M., & Kelechi, T. J. (2026). Uncertainty in illness and psychological adjustment in patients with systemic lupus erythematosus. Lupus. Advance online publication. https://doi.org/10.1177/09612033261484790

Smith, M. J., & Liehr, P. R. (Eds.). (2014). Middle range theory for nursing (3rd ed.). Springer Publishing.

Wu, L., Xue, H., Tian, C., & Lu, Y. (2026). Associations between uncertainty in illness and cardiac rehabilitation adherence in patients with CHD: A cross-sectional chain mediation and latent profile analysis of cardiac self-efficacy and fear of activity. Frontiers in Cardiovascular Medicine, 13, Article 1846950. https://doi.org/10.3389/fcvm.2026.1846950