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560 UNIT V Middle Range Nursing Theories

The first two reflect how uncertainty was conceptual- • Fluctuations result in repatterning, which is repeated
ized within psychology’s information-processing mod- at each level of the system.
els, as follows: In Mishel’s reconceptualized theory, neither the
1. Uncertainty is a cognitive state, representing the antecedents to uncertainty nor the process of cogni-
inadequacy of an existing cognitive schema to sup- tive appraisal of uncertainty as danger or opportunity
port the interpretation of illness-related events. change. However, uncertainty over time, associated
2. Uncertainty is an inherently neutral experience, with a serious illness, functions as a catalyst for fluc-
neither desirable nor aversive until it is appraised tuation in the system by threatening one’s preexisting
as such. cognitive model of life as predictable and controllable.
Two more assumptions reflect the uncertainty the- Because uncertainty pervades nearly every aspect of
ory’s roots in traditional stress and coping models a person’s life, its effects become concentrated and
that posit a linear stress A coping A adaptation ultimately challenge the stability of the system. In re-
relationship as follows: sponse to the confusion and disorganization created
3. Adaptation represents the continuity of an indi- by continued uncertainty, the system ultimately must
vidual’s usual biopsychosocial behavior and is the change in order to survive.
desired outcome of coping efforts to either reduce Ideally, under conditions of chronic uncertainty, a
uncertainty appraised as danger or maintain uncer- person gradually moves away from an evaluation of
tainty appraised as opportunity. uncertainty as aversive to adopt a new view of life that
4. The relationships among illness events, uncertainty, accepts uncertainty as a part of reality (Figure 28–2).
appraisal, coping, and adaptation are linear and Thus uncertainty, especially in chronic or life-threaten-
unidirectional, moving from situations promoting ing illness, can result in a new level of organization and
uncertainty toward adaptation. a new perspective on life, incorporating the growth and
Mishel challenged assumptions 3 and 4 in her change that result from uncertain experiences.
reconceptualization of the theory, published in 1990.
The reconceptualization came about as a result of
contradictory findings when the theory was applied Theoretical Assertions
to people with chronic illnesses. The original formu- Mishel asserted the following (1988, 1990):
lation of the theory held that uncertainty typically is • Uncertainty occurs when a person cannot adequately
appraised as an opportunity only in conditions that structure or categorize an illness-related event because
represent a known downward trajectory; in other of the lack of sufficient cues.
words, uncertainty is appraised as opportunity when • Uncertainty can take the form of ambiguity, com-
it is the alternative to negative certainty. Mishel and plexity, lack of or inconsistent information, or
others found that people also appraised uncertainty unpredictability.
as an opportunity in situations without a certain down- • As symptom pattern, event familiarity, and event
ward trajectory, particularly in long-term chronic ill- congruence (stimuli frame) increase, uncertainty
nesses, and that in this context people often developed decreases.
a new view of life. • Structure providers (credible authority, social sup-
It was at this time that Mishel turned to chaos port, and education) decrease uncertainty directly
theory to explain how prolonged uncertainty could
function as a catalyst to change a person’s perspective
on life and illness. Chaos theory contributed two of
the following theoretical assumptions that replace the
linear stress A coping A adaptation outcome por- Uncertainty Danger Opportunity
tion of the model as follows:
• People, as biopsychosocial systems, typically func-
tion in far-from-equilibrium states. Time
• Major fluctuations in a far-from-equilibrium system FIGURE 28-2 Reconceptualized Model of Uncertainty in
enhance the system’s receptivity to change. Chronic Illness. (Copyright Merle Mishel, 1990.)