NURS 715 Week 7 Theory Guided Practice Paper Example

Afraid of His Own Heart: Uncertainty in Illness and Self-Efficacy Theories Applied to a Patient Who Never Started Cardiac Rehabilitation

The Practice Experience

Mr. Reyes was a 63-year-old maintenance supervisor admitted to our cardiac unit with an inferior myocardial infarction. He received a single stent in his right coronary artery, recovered without complications and went home on day three with a referral to the hospital's cardiac rehabilitation program. Six weeks later, as part of a follow-up project, I called patients who had not attended. Mr. Reyes answered on the second ring. He said he had meant to go, but every time he walked to his mailbox he felt "a tightness, not pain exactly," and he did not know whether it meant his stent was closing. At sixty, his father had collapsed and died at the kitchen table, and Mr. Reyes said he did not want to "die on a treadmill in front of strangers." His wife, on the extension, said she wanted him to go but could not tell him whether the tightness was dangerous. No one from the hospital had called him since discharge.

The experience raised a question that logistics could not answer. Mr. Reyes had transportation, insurance coverage and a supportive wife. He stayed home because of what was happening in his mind. Two theories help explain why.

The Nursing Theory: Mishel's Uncertainty in Illness Theory

Mishel (1988) developed her theory to explain how people interpret illness events they cannot fully understand. In her formulation, uncertainty is present whenever too few cues are available for a sick person to judge what an illness event signifies. Three antecedents shape it. The stimuli frame concerns how symptoms present: whether they form a recognizable pattern, whether events are familiar and whether experience matches expectations. Structure providers, which Mishel names as credible authority, social support and education, give the person the means to read what is happening. Cognitive capacity limits how much information a person can process. Once present, uncertainty is appraised either as danger or as opportunity, and that appraisal determines coping. Danger leads to mobilizing strategies, such as seeking information, or affect-control strategies, such as avoidance, aimed at reducing threat. Mishel (1990) later reconceptualized the theory for chronic illness, proposing that people who live with uncertainty for years may reorganize their outlook around probability and possibility, learning to carry the unknown instead of waiting for it to disappear.

The Borrowed Theory: Bandura's Self-Efficacy Theory

Bandura (1977) placed self-efficacy, an individual's confidence in carrying out the specific actions a goal demands, at the center of behavior change. In his account, those convictions decide whether someone tries a new behavior at all, how much energy they put in and how they respond when progress stalls. Four sources inform these beliefs. Mastery experiences, actually succeeding at the behavior, are the most powerful. Vicarious experiences, seeing similar others succeed, are next. Verbal persuasion from credible people can strengthen beliefs, though less durably. Finally, physiological and emotional states, such as a racing heart, are interpreted as signs of capability or vulnerability. Although Bandura's work is broad, the self-efficacy component used in nursing is a middle range theory in practice: it has a limited set of concepts, is focused on a specific phenomenon and is measured with established scales.

Applying the Theories to Mr. Reyes

Through Mishel's Lens

Every antecedent in Mishel's model is visible in Mr. Reyes's story. The tightness he felt at the mailbox lacked a pattern he could recognize, and it did not match his expectation that a stent would fix his heart, so the stimuli frame produced uncertainty. No credible authority had explained what post-stent sensations are normal, and his wife, his main support, could not interpret them either. His father's death supplied a powerful inference: an unexplained chest sensation means death is near. He appraised the uncertainty as danger and coped through avoidance, the affect-control strategy of staying away from what frightened him.

Through Bandura's Lens

Self-efficacy theory explains why that fear translated into inaction. Mr. Reyes had no mastery experience of exercising safely since the infarction; his only recent physical experiences, walks to the mailbox, ended in a frightening sensation. He had no vicarious experience, because he had never met a patient who completed rehabilitation. No credible person had told him he could exercise safely. And he interpreted his physiological state, a tightness during mild exertion, as evidence of vulnerability rather than as a normal response to deconditioning. Every source of efficacy pointed toward low confidence.

How the Theories Work Together

The two theories describe different parts of one process. Uncertainty made the meaning of his symptoms unreadable; low self-efficacy made exercise feel impossible. Recent research supports this sequence. Among patients with coronary heart disease in three Chinese hospitals, those with more uncertainty kept to rehabilitation less well, and the link ran partly through a chain from lower cardiac self-efficacy to greater fear of activity (Wu et al., 2026). In Mr. Reyes, uncertainty about what his heart was doing became doubt about what he could do, and doubt became an empty chair in the rehabilitation gym. The theories also point to complementary interventions: explaining symptoms reduces uncertainty, while supervised sessions create the mastery experiences that build confidence.

Evaluation of the Theories

Smith and Liehr (2014) propose three criteria for evaluating middle range theory. Table 1 summarizes the verdicts for both theories.

Substantive Foundation

Both theories have a strong substantive foundation. Mishel's theory grew from nursing practice and her research with hospitalized patients, and its assumptions about meaning-making are stated clearly. Its reconceptualization for chronic illness rests on a different philosophical base, which extends its scope but requires the reader to keep two sets of assumptions in view. Bandura's theory rests on a large body of experimental and applied research across many fields, giving it unusual empirical depth.

Structural Integrity

Bandura's theory is the more parsimonious: a single central concept, four clearly defined sources and a straightforward proposition that stronger efficacy beliefs lead to more effort and persistence. Mishel's theory has more concepts, and some, particularly inference and illusion, are difficult to distinguish in practice. Its appraisal and coping concepts follow general stress and coping theory, which strengthens their logic but means that the distinctively nursing contribution lies mainly in the antecedents. The structure is coherent but demands more of the user.

Functional Adequacy

Both theories are highly functional. Mishel's theory is measured with established scales and has been tested in cancer, cardiac, autoimmune and pediatric populations, and it points directly to interventions targeting its antecedents. Self-efficacy is also measurable, and recent evidence shows it matters for rehabilitation outcomes. In a secondary analysis of a randomized trial involving 305 psychologically distressed patients in cardiac rehabilitation, baseline exercise self-efficacy predicted physical activity three months later, and each one-point increase in self-efficacy was associated with roughly 13 additional minutes of weekly activity (Pollok et al., 2026). Theory-based programs can raise it: in a randomized trial with older coronary patients, a staged rehabilitation program designed around a health behavior model left participants more confident about exercise and less afraid of moving than those in usual care (Zheng et al., 2026).

Implications Within the Christian Worldview

A Christian worldview does not promise freedom from uncertainty. James cautions those who announce their plans for the coming year that their lives are as brief as morning mist (English Standard Version Bible, 2001/2016, James 4:13-14). Yet Scripture repeatedly answers uncertainty with trust and with community. Paul urged believers to encourage one another (English Standard Version Bible, 2001/2016, 1 Thessalonians 5:11), which is, in Bandura's terms, a call to verbal persuasion within a community of credible others. In Called to Care, nursing is a vocation directed at the whole person (Shelly & Miller, 2006), and caring for Mr. Reyes includes caring for his fear, not only his coronary artery.

These convictions shape practice in three ways. First, the nurse can act as the credible authority Mishel describes and the persuader Bandura describes, offering honest explanation and encouragement rather than generic reassurance. Second, the nurse can connect patients with others who have walked the same path, which supplies both social support and vicarious experience. A rehabilitation graduate who says, "I felt that tightness too," may persuade more than any brochure. Third, the nurse can respect a patient's faith as a resource for coping without using it to dismiss fear. If Mr. Reyes prays about his heart, that prayer can be honored alongside a clear explanation of what his symptoms mean.

Alternative Explanations Considered

Before accepting the theoretical explanation, other explanations deserve a fair hearing. Depression after a heart attack is common and can reduce motivation for rehabilitation; Mr. Reyes did not describe low mood, but he was not screened, and a screening question belongs in any follow-up call. Practical barriers such as cost, distance and work schedules also keep patients away, yet he had insurance, a car and a supervisor's flexible hours. Finally, some patients simply do not see the value of rehabilitation. Mr. Reyes did see its value; his own words framed his absence as fear. The two theories therefore explain this experience better than the alternatives, while the alternatives remain important for other patients.

Limits of This Application

The analysis rests on one experience, chosen because it was memorable, which may not make it typical, told largely through the patient's own account in a single telephone call, so it cannot show how common this pattern is. The theories were chosen after the experience, which risks fitting the explanation to the story. And neither theory addresses the organizational failure that no one called Mr. Reyes after discharge, a gap that a DNP must address through systems rather than through patient-level theory alone.

A Practice Change Built From Both Theories

The theories together suggest a simple redesign of the rehabilitation referral. Within a week of discharge, a rehabilitation nurse calls each patient to explain common post-infarction sensations and warning signs, reducing uncertainty and providing a credible authority. The patient and a family member are invited to tour the rehabilitation gym and meet a graduate of the program, supplying familiarity and vicarious experience. The first sessions are closely monitored, so patients can watch their heart rhythm stay normal while they exercise, creating mastery and reframing physiological sensations. Scoring uncertainty and exercise confidence when patients are referred and again once they have attended six sessions, and tracking attendance throughout, would test whether the change works through the mechanisms the theories predict.

Conclusion

Mr. Reyes did not stay home because he lacked information in the abstract or a ride to the hospital. He stayed home because he could not read what his heart was telling him and did not believe he could exercise safely. Mishel's theory explains the first problem and Bandura's the second, and together they point to a practical change. Both theories withstand evaluation, with strong foundations and high functional adequacy, Bandura's more parsimonious and Mishel's more distinctively nursing. Within a Christian worldview, they call the nurse to be both an honest interpreter and an encourager.

References

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

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

Pollok, V. L., Thome-Soós, F., Benninghoven, D., & Bethge, M. (2026). Influence of exercise self-efficacy on physical activity among psychologically distressed patients undergoing cardiac rehabilitation: Secondary data analysis of a randomized controlled trial. BMC Psychology, 14(1). https://doi.org/10.1186/s40359-026-04004-8

Shelly, J. A., & Miller, A. B. (2006). Called to care: A Christian worldview for nursing (2nd ed.). IVP Academic.

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

Zheng, X., Tan, Y., Wang, X., Li, Q., Li, J., Lan, X., & Zhang, S. (2026). A randomized controlled trial of staged cardiac rehabilitation based on the Health Belief Model on kinesiophobia, self-efficacy and activities of daily living in elderly patients with coronary heart disease. Frontiers in Medicine, 13, Article 1857532. https://doi.org/10.3389/fmed.2026.1857532