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CHAPTER 28 Merle H. Mishel 561

by promoting interpretation of events, and indi- evidence from qualitative studies that suggested
rectly by strengthening the stimuli frame. that people’s responses to uncertainty changed over
• Uncertainty appraised as danger prompts coping time within the context of serious chronic illnesses.
efforts directed at reducing the uncertainty and Thus Mishel’s theory represents the bidirectional
managing the emotional arousal generated by it. process where theory informs and is informed by
• Uncertainty appraised as opportunity prompts cop- research.
ing efforts directed at maintaining the uncertainty.
• The influence of uncertainty on psychological out- Acceptance by the Nursing Community
comes is mediated by the effectiveness of coping
efforts to reduce uncertainty appraised as danger or Practice
to maintain uncertainty appraised as opportunity. Mishel’s theory describes a phenomenon experi-
• When uncertainty appraised as danger cannot enced by acute and chronically ill individuals and
be reduced effectively, coping strategies can be their families. The theory has its beginning in
employed to manage the emotional response. Mishel’s own experience with her father’s battle with
• The longer uncertainty continues in the illness cancer. During his illness, he began to focus on
context, the more unstable the individual’s previ- events that seemed unimportant to those around
ously accepted mode of functioning becomes. him. When asked why he had chosen to focus on
• Under conditions of enduring uncertainty, indi- such events, he replied that when these activities
viduals may develop a new, probabilistic perspec- were being done, he understood what was happen-
tive on life, which accepts uncertainty as a natural ing to him. Mishel believed this was her father’s way
part of life. of taking control and making sense out of an over-
• The process of integrating continual uncertainty whelming situation. She knew early in the develop-
into a new view of life can be blocked or prolonged ment of her concept and theory that nurses could
by structure providers who do not support proba- identify the phenomenon from their experiences in
bilistic thinking. caring for patients.
• Prolonged exposure to uncertainty appraised as Several nurses have moved the theory from research
danger can lead to intrusive thoughts, avoidance, to practice. Hansen and colleagues (2012) synthesized
and severe emotional distress. findings from qualitative studies to yield a typology of
patient experiences of uncertainty that guides nursing
engagement and intervention. Similarly, the theory has
Logical Form been used in recommendations for the practice of
As a middle-range theory derived from and applica- critical, medical-surgical, and enterostomal nursing
ble to clinical practice, Mishel’s Uncertainty in Illness care (Hilton, 1992; Righter, 1995; Wurzbach, 1992).
Theory is an exemplar of the multiple steps required Based on review of the database of the Managing
to develop theory with both heuristic and practical Uncertainty in Illness Scale users (Mishel, 1997b),
value. Neither purely inductive nor deductive, master’s-prepared clinicians seek to understand the
Mishel’s theoretical work initially arose from ques- experience of uncertainty in a variety of clinical set-
tioning the nature of an important clinical problem, tings and patient populations. The scale and theory
followed by systematic qualitative and quantitative are used by clinicians from 15 countries other than
inquiry and careful application of theory borrowed the United States.
from other disciplines. Since publication of the origi-
nal theory in 1988, Mishel and others have carried Education
out numerous empirical tests of the relationships The theory has been widely used by graduate students
among the major constructs in the model, applying as the theoretical framework for theses and disserta-
and largely confirming the theory in illness contexts. tions, as the topic of concept analysis, and for the
Mishel’s reconceptualization of the theory in 1990 critique of middle-range nursing theory. Mishel uses
was deductive in that it was developed from princi- the theory as an exemplar to illustrate how theory
ples of chaos theory and was confirmed by empirical guides the development of nursing interventions in