Running head: Uncertainty

Uncertainty

April Blackmon

Auburn University/Auburn Montgomery

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Abstract

This paper explores several published articles that report how uncertainty can play a role in one’s

life. Decision-making anxiety can hinder or help the nurse that is caring for the patient suffering

from illness. Current or recurrent illness can impact a patients’ quality of life. Uncertainty is

unique in that no two people will experience the same feelings associated with that uncertainty.

Nurses also experience uncertainty in bedside practice. Fear, doubt, lack of education all

contribute to uncertainty. One goal of this concept analysis to examine how patients’ with illness

experience uncertainties. Another goal for this analysis is to look closely into how uncertainty

affects nurses and how the nurse is able to over-come self-doubt. Dealing with death and acute

events in life-threatening matters only adds to the stress of decision-making for nurses.

Figure 1:1 (p. 20) illustrates how the topics listed throughout this concept analysis are related and

how it helps the reader make connections between the topics.

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Uncertainty

Uncertainty can be defined as the state of being uncertain, not knowing the “for sure”

answer, lack of education or knowing that something is inevitable. Uncertainty can occur in

nursing, psychology, economics, sociology, and for the physician. Each area in which being

uncertain can occur has a different experience with the meaning of uncertainty (Ratner, 2011).

This concept analysis will discuss uncertainty and how it can affect many aspects of one’s life.

Concept

Uncertainty is a dynamic state in which there is a perception of being unable to assign

probabilities for outcomes that prompts a discomforting, uneasy sensation that may be affected

through cognitive, emotive or behavioral reactions (Penrod, 2007). Uncertainty as it relates to

illness is the inability to determine the illness, how to measure the value of events and how to

assess outcomes (Padilla, Mishel, Grant, 1992). This uncertainty in illness can occur not only to

the patient but to the nurse and other healthcare providers as well. Uncertainty is a phenomenon

that is difficult for people to deal with since there is an inherent desire to always know the

answer. Uncertainty as a concept is unique for every person in that learning it is not experienced

the same by each person.

Review of the Literature

This concept analysis is about uncertainty. Walker and Avant (2011) suggest using

dictionaries, thesauruses, colleagues and all available literature to support the topic. The concept

of uncertainty in nursing links making hard decisions with having added stress and anxiety

placed upon the nurses shoulders. In psychology, uncertainty is dealing with the daily struggles

of properly caring for people with mental illness. There are a vast variety of uncertainties in

many disciplines. For this paper’s purposes, two disciplines will be focused on, nursing and

psychology.

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Definitions

Uncertainty is the state of not knowing, being uncertain on any one topic, uneducated on

a topic, or having doubt. Patients facing uncertainty may either have an illness with an uncertain

trajectory or may live with the constant possibility that a previous illness could reoccur. Padilla

et al. (1992) found that the longer chronically ill persons lived with continual uncertainty, the

more positively they evaluated the uncertainty. These patients had better critical thinking which,

in turn, opens new doors to new alternatives in adjusting and changing with the nature of their

illness (Padilla et al., 1992).

Uncertainty in nursing.

The nursing definition for uncertainty is the inability to determine the meaning of illness

related events, assign definite values to objects and events, and/or accurately predict outcomes

(Padilla et al., 1992).Uncertainty in nursing is an unavoidable task. Nurses, along with other

healthcare providers must make decisions on the patient’s behalf under pressure. This decision-

making process causes a great deal of anxiety with uncertainty if one is making the right

decision. The nurse is left with the feeling of “what if,” “what if” I had done something

differently or made a different decision, would the outcomes have been better? Unfortunately,

even when right decisions are made, the patient does not always survive. According to Fawcett

(2000), when adult nurses are learning one will enter a dwelling with uncertainty phase. The

dwelling on the uncertainty phase in nursing is spent learning information that seems obscure

and irrelevant (Fawcett, 2000). Only after this phase in nursing can the nurse then understand

unity of thought and think more critically. Uncertainty can create worry for many nurses;

however, nurses are able to develop strategies to manage these concerns (Alaszawski & Coxon,

2009).

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The existence of uncertainty in one area of illness often feeds back on itself and can

generate more uncertainty towards other illness-related events (Walker & Avant, 2011). The

patient facing illness can lose their stability in other aspects of his or her life when this occurs.

Patient’s quality of life will be affected in the physical and psychological limitations of their

ability to cope successfully. Padilla et al. (1992) found a significant relationship between social

support and uncertainty; indicating that as social support increases the uncertainty decreases.

Both uncertainty in illness and problems with coping skills will lead to added distress for the

patient and their families (Padilla et al., 1992).Families must find a way to create the appropriate

amount of uncertainty and certainty to maintain coping skills and minimize stress.

Uncertainty in psychology.

Psychology explains uncertainty as the condition of being uncertain, having doubt or

actually existing. Uncertainty in mental health practices can create anxiety and is guarded against

because it can be seen as an inevitable outcome to poor practice (Franks, 2004). The feeling of

uncertainty for many healthcare professionals is a reality; struggling to understand, make sense

of and care for patients with complex behavioral and emotional problems. Current trends in the

mental health field are related to promoting certainty in the form of standardizing and regulating

practices (Franks, 2004). According to Taylor (1983), cognitive adaptation can occur when

threatening events arise. Cognitive adaptation is the means by which human beings bounce back

from threatening or stressful events. Emotions and the pyschophysiological correlates are

thought to play an important role in decision-making under pressure (Studer & Clark, 2011).

Successful adaptation depends, in a large part, on the ability to withstand and modify illusions

that shield not only the present threats but also against further threats (Taylor, 1983). If the

uncertainty remains, it can dismantle the existing cognitive structures that can give meaning to

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everyday events (Walker & Avant, 2011). This loss of meaning can throw the person with a

mental illness into a state of confusion and disorganization (Walker & Avant, 2011).

Aim of the Analysis

Uncertainty plays a significant role in explaining various outcomes for the chronically

ill. When individuals are faced with illness it can be devastating to comprehend all the changes

and decisions that go along with disease. This writer is interested in Mishel’s Uncertainty in

Illness Theory to see how individuals adapt to illness and how this affects their quality of life.

Uncertainty is an important topic due to the simple fact that it can cause so much anxiety in one’s

life. Nursing is also a career in which one faces uncertainty. This writer would like to more

closely examine how nurses experience uncertainty when making decisions for others and how

he or she overcomes self-doubt. Dealing with death and acute life-threatening events only adds

to the stress of decision-making.

Analysis of the Concept

Uncertainty has many different meanings and ideas that can be relevant in several

different professions and in life itself. Uncertainty can occur to anyone at any time throughout

the lifespan. It can occur when illness strikes or when faced with the anxiety of making tough

decisions.

Process of Analysis

Walker and Avant (2011) suggest that when choosing a topic for analysis to follow these

eight steps: “1. Select a topic. 2. Determine the aims or purposes of the analysis. 3. Identify all

uses of the concept that one can discover. 4. Determine the defining attributes. 5. Identify a

model case. 6. Identify borderline, related, contrary, invented and illegitimate cases. 7. Identify

antecedents and consequences. 8. Define empirical referents”. This writer will use these eight

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steps to help guide the analysis of uncertainty and all results found. Uncertainty is an important

concept; it can include uncertainty in nursing, illness, psychology, economics, and sociology.

The “aims or purposes of the analysis helps center concentration on exactly what the writer

intends to make of the results” (Walker & Avant, 2011). This writer is interested in finding out

why uncertainty causes so much stress on an individual.

The defining attributes of the concept are the “guts” of the analysis (Walker & Avant,

2011). It is not uncommon for the attributes to appear numerous times in different topics related

to the concept (Walker & Avant, 2011). Model cases can be from real life experiences, found in

research or made up by the writer. Borderline cases are examples that include most defining

attributes but not all of them. Related cases are comparable to the concept but differ from them

when examined more closely (Walker & Avant, 2011). Contrary, invented and illegitimate cases

are all examples of what the concept is not and they do not contain all attributes.

Antecedents are events that occur prior to the event or concept. If uncertainty in illness is

the concept then an antecedent would be life prior to the illness. Consequences are the events

that happen as a result of the concept, or the outcomes (Walker & Avant, 2011). The outcomes of

uncertainty in illness would be overcoming of the illness or progression of the illness. Lastly,

defining empirical referents is the final step. The empirical referents are not a measurement tool;

they are simply the means by which one can distinguish the defining attributes of the concept

(Walker & Avant, 2011). After all steps are taken, the final result will yield a proper concept

analysis.

Critical/Defining Attributes

Determining what constitutes as defining attributes of uncertainty are the “guts” of

concept analysis (Walker & Avant, 2011). If faced with a tough decision, one must understand

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and measure all attributes of uncertainty. Attributes of uncertainty are: not knowing, doubt, fear,

lack of education or something that is inevitable. Fear, an attribute of uncertainty can cause

physical measures to become elevated. Blood pressure rises, heart rate increases, diaphoresis sets

in and this causes more distress in the person making decisions. Alaszewski & Coxon (2009)

suggest that uncertainty is growing in contemporary society; this writer would like to examine

how that threatens individual well-being. If faced with this anxiety, it could cause a person to

become more uncertain about whether or not he or she is making the right decisions. If attributes

of uncertainty continues in nurses, this could eventually lead to disparities within the nursing

field (Potter & Perry, 2006). Uncertainty has been the focus of a great deal of research over the

past decade and has consistently predicted illness-related outcomes (Wallace, 2005).

Antecedents

Antecedents are events that occur prior to the uncertainty (Walker & Avant, 2011). If

uncertainty in illness is occurring in ones’ life, then an antecedent for that person would be:

quality of life before the illness occurred. Decision-making before an acute illness may have

seemed trivial. In illness, another antecedent is the stimuli frame. This frame consists of

symptom patterns and event familiarity (Mishel & Braden, 1987). The symptom pattern relates

to the disease that the patient is experiencing. In event familiarity, the degree to which a situation

is habitual, repetitive or contains recognizable cues is fostered by time and experience in the

health care environment (Mishel & Braden, 1987).

In the nursing field, the antecedent for decision-making would be to understand all

knowledge related to that person’s specialty and how to react in acute events (Fawcett, 2000).

Another antecedent would be cognitive capacity. This is the information-processing ability of a

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person and any physiological malfunction that may impair ability (Wallace, 2005). An

individual’s physical illness symptoms and perceived dangers have been largely shown to

decrease cognitive capacity.

Empirical Referents

Mishel developed the Mishel Uncertainty in Illness Scale (MUIS) which is used to

determine levels of adaptation in relation to an illness. With this scale one can measure how the

patient perceives the illness and how they are coping with said illness. The two main processes

of this scale are inference and illusion. With the inference and illusion processes patients are

evaluating situations related to their own illness. The inference and illusion can be viewed as

positive or negative; positive meaning an opportunity and negative suggesting danger. If two

patients have the same illness and patient “A” receives treatment and recovers from the illness

then that would be viewed as an opportunity. Patient “B” could gather information on the illness

and relate it to his or her own situation. This opportunity helps the patient to gather the

information needed, have a relatable situation and make the decision to resolve the illness. This

process of inference and illusion may help the patient increase quality of life. If in the same

scenario patient “A” had not recovered from the illness that would be viewed as a threat or

danger using the inference and illusion process. Patient “B” would continue with uncertainty by

not gathering information, not having a relatable situation and not adapting or coping with the

illness. This would inflict a decrease in the patient’s quality of life. The negative inference and

illusion of not recovering from the illness would create lower quality of life and decreases coping

skills (Potter& Perry, 2006).

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Fear, when dealing with uncertainty can be measured with physical symptoms. The

person experiencing fear will exhibit fright, increased cardiac excitation, and responses of flight

or fight for adaptive purposes. Measurement indices of fear include: enhanced startle response,

increased sweating from the skin, MRI scan displays of amygdala activation, and changes in the

autonomic nervous system (Bay & Algase, 1999). Doubt, although different from uncertainty

and fear can be experienced in the same measures. Doubt is being uncertain about something or

hesitating to believe in something. If one is undergoing hesitation, his or her speech pattern will

become guarded. The person will experience excessive breaks in the flow of normal speech.

Qualitative and quantitative methods can be used to measure these referents. Using

qualitative methods the information collected would be subjective, describe the problem an

individual is facing and contain more in-depth material (Timmerman, 1999). An opinion of how

the person is experiencing the uncertainty whether in illness or life is an excellent example of

qualitative measurements. Quantitative methods are more objective, less in depth and more

generalizable. The experiences individuals have with uncertainty would be based more on

diagnostic tests, such as, MRI or PET scan to accurately use quantitative methods for

measurement. Both of the methods can however, measure uncertainty and how it is perceived in

each individual.

Nurses must always be aware and understanding of uncertainty (Potter & Perry 2006).

Decision-making is a large part of a nurses’ duty. Making decisions under extreme pressure

when uncertain medical issues arise is a large concern for nurses and other healthcare providers.

The practical way general practitioners deal with uncertainty remains unclear (Scheider et al.

2010). One’s sense of confidence and sense of control are primary factors that can determine the

nature of the experience with uncertainty (Penrod, 2007). Each nurse or healthcare provider will

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experience and handle uncertainties differently. The consequences of these experiences are

discussed in the next section.

Consequences

“Consequences are those events or incidents that occur as a result of the occurrence of the

concept” (Walker & Avant, 2011). A consequence of uncertainty in illness would be that the

patient is able to adapt to the disease. If one views the illness as a positive the outcome for that

person is coping abilities, adaptation and increases in quality of life. On the other hand, if one

views the illness as a negative his or her outcome will be viewed as a threat or danger, the coping

skills are lacking or absent, adaptation does not take place and this will result in decreased

quality of life.

Nurses, deal with uncertainty on an almost daily basis. Nurses also experience guilt or

fault when death occurs, even if the right decisions were made and all life saving measures was

taken. The outcomes of these situations result in added stress and anxiety for the nurse. Decision-

making skills can become tainted in the nurse with high stress and anxiety over uncertainties

when caring for others. The consequence of confusion is replacing anxiety with feelings of

freedom to critically examine old ways and explore new ways in nursing (Fawcett, 2000). This

helps the nurse to think more critically in an acute event. The concept of guided clinical learning

under supervision of a more experienced nurse is by no means a new trend (Charleston &

Happell, 2005). The responsibility of teaching a new nurse adds stress and anxiety on the

decision maker. An outcome for this event creates more uncertainty for the senior nurse in

charge of the new hire. This process becomes a vicious cycle, the new nurse then learns the

concept of uncertainty in the beginning of his or her career.

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Case Illustrations

“A model case is an example of the use of the concept that demonstrates all the defining

attributes of the concept” (Walker & Avant, 2011). The model case should be one that is absolute

in the concept chosen. “The model case can be made up from life experiences, found in literature

or constructed by the writer” (Walker & Avant, 2011).

Model Case

Uncertainty in nursing is the example chosen for the model case. As a nurse, one faces

uncertainty in almost every instance of an acute event. The patient is crashing, what should one

do next? Did one check the electrolytes, does the patient have an airway, is there an ambu bag in

the room, where are the emergency drugs. Defining attributes for uncertainty in nursing are: not

knowing, doubt, fear, or lack of education. Not knowing in nursing can be the result of being

unfamiliar with the surroundings or simply not knowing why the event is occurring. Working in

a large hospital, the utilization of a pool staff is common. The nurse may have never worked on

the unit before and does not know where emergency drugs are kept or how to follow the chain

for emergency help. This increases stress and uncertainty in the nurse.

Having doubts about the event are also common. Doubt for why this is happening, and

how to correct it quickly. Doubt is being uncertain related to an event and this is a sure example

of uncertainty. Fear is activation of flight or fight, hormones are kicking in and the nurse will

show signs of increased heart rate, blood pressure and sweat gland activity. The nurse will begin

to question his or her day; did the patient complain of chest pain, what did the chest x-ray look

like, what were the lab values. Uncertainty is at full force in the period. Lack of education can

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affect nurses. Perhaps, this is a new nurse with a seemingly stable patient whom just crashed; the

nurse does not yet have the skills to think quick and acutely for decision-making.

Antecedents for this case would be the nurse knowing everything about this patient and

this unit before the acute event. Knowing how to think critically and through a sequence of prior

events to determine causes of acute events are also antecedents of this case. Consequences for

this case would be dealing with guilt or fault in the event this situation ends badly. Another

consequence would be if the patient stabilizes, the nurse can think of how he or she reacted and

how to better prepare for similar events in the future.

Attributes for the model case are not knowing, fear, doubt and uncertainty. The nurse

experiences all attributes when dealing in an acute event. The knowledge is measured by how the

nurse reacts to the situation. Fear is seen in physical symptoms, sweat, elevated heart rate and

blood pressure. Doubt is measured by how the nurse is speaking throughout the event; talking

rapidly, or stuttering in thoughts. These are all attributes of uncertainty and as Walker & Avant

(2011) state, demonstrate the concept.

Borderline Case

“Borderline cases are examples that contain most of the defining attributes of the concept

but not all of them” (Walker & Avant, 2011). These types of cases help the reader see why the

model case is so important. An example of a borderline case for uncertainty is new nurses

making decisions for patients. Caring for others is a hard enough task, but making decisions for

others regarding care can be a daunting assignment. Upon starting work at the University of

Alabama at Birmingham hospital one must endure a lengthy orientation period. This phase

consists of learning how to effectively care for others and promotes confidence in the new nurse.

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The hospital offers a professional environment to help nurses establish caring relationships with

staff, patients and their families. The nurse-to-patient ratios give the new nurse opportunities for

a beneficial and rewarding care of experiences. Nurses share the governance model that

recognizes the important contributions and leadership of nursing staff, and encourages nursing

staff involvement of decision making (UAB, 2011). This model will help ease some added

anxiety the nurse faces when making decisions for patients. This case helps clarify thinking

about the defining attributes of the concept of interest (Walker & Avant, 2011).

The attributes in the borderline case are doubt and uncertainty. This case experiences

some of the defining attributes but not all that are correlated with uncertainty. New nurses

experience doubt in if he or she have made the right decision for a lifelong career and are

uncertain in starting a new job. The measurements of these attributes are observing the new

nurse. He or she will be hesitant in their actions with patients. The new nurse will also

experience uncertainty in any interventions that he or she may provide in patient care.

Antecedents for this case are graduating from an accredited nursing school and completion of

state board exams. Consequences for this case include: outcomes of the nursing orientation

period and preceptorship.

Related Case

“Related cases are instances of concepts that can be related to the concept but does not

contain all the defining attributes” (Walker & Avant, 2011). The related case will be associated

in some way to the concept. An example of a related case for uncertainty is having doubt when

making decisions. Doubt and uncertainty are synonyms but can be thought of differently when

making decisions. Each one of us is blasted with many decision-making opportunities each and

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every day. Many factors become involved in the decision-making process; those factors can

include self-doubt. Self-doubt is the fear of making a mistake.

Information about decision making comes from the environment and from those involved

in the decision. Some information may be supportive and encouraging and some may not. This is

where self-doubt of making mistakes arises, other’s expectations of the decision and even

criticism of past mistakes. Responses, from others help to shape and develop one’s self-

perception, part of which involves decision-making abilities. If allowed, fear can interfere with a

decision, self-doubt sets in and the decision becomes that much harder to make. A self-doubting

mindset can set one up to fail. According to Walker & Avant (2011), related cases should have

names of their own; this case would be named “Self-Doubt.” This case can help the reader see

how self-doubt is related to uncertainty but does not contain the defining attributes of

uncertainty.

Attributes of the related case are experiencing doubt when making decisions. This is the

only attribute in this case. Doubt is measured in this case by how the nurse values self. Self-

doubt comes from how the nurse values him or herself and the expectations in place from others.

The nurse will be hesitant in patient care and most likely seek others’ opinions for help in

decision-making. Hesitation can be seen in speech as slow, stuttering or rapid. Antecedents of

this case are having knowledge of what the decision is regarding and how to properly proceed.

Consequences in the related case are overcoming the self-doubt or continuing with the doubt. If

the new nurse is able to overcome the self-doubt an outcome would be confidence in decision-

making skills. If the nurse is unable to overcome the self-doubt, he or she will continue to suffer

when making decisions.

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Analysis Summary

Walker & Avant (2011) suggest using eight steps to guide the analysis process. These

steps are listed above and used throughout this analysis. Uncertainty can occur in nursing,

psychology, economics, sociology, statistics and for the physician. Each area in which

uncertainty occurs has different experiences and meanings with the concept. Uncertainty is a

dynamic state in which there is a perception of being unable to assign probabilities for outcomes

that prompts a discomforting, uneasy sensation that is affected through cognitive, emotive or

behavioral reactions (Penrod, 2007). Uncertainty affects patients, nurses and other healthcare

providers. In nursing, one is responsible for making decisions on the patients’ behalf. This leaves

the nurse with the “what if” feeling, “what if” a different decision could have been made or

another outcome could have been better? Uncertainty can create added worry for many nurses;

however, nurses are able to develop strategies to help manage these concerns (Alaszawski &

Coxon, 2009).

Psychologists are faced with struggling to understand, make sense of and care for patients

with complex behavioral and emotional problems. According to Taylor, cognitive adaptation can

occur when threatening events arise (Taylor, 1983). If this uncertainty remains, it can dismantle

the existing cognitive structures that give meaning to everyday events (Walker & Avant, 2011).

When individuals are faced with illness it can be devastating to comprehend all the

changes and decisions that go along with the disease. The disease can be comprehended as a

positive or as a threat. Positive meaning that the event is viewed as an opportunity and the patient

will make the necessary changes to increase quality of life, cope appropriately and adaptation

occurs. If the event is viewed as a negative or as a threat the patient does not develop any coping

skills, adaptation does not occur and quality of life decreases.

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Implications/Application to Nursing Practice

Several uses of the results of this concept analysis have been discussed. Implications for

uncertainty in illness are inference and illusion; this is when patients are evaluating situations

related to their own illness. The process of inference and illusion may help or hinder quality of

life.

Problem-solving and decision-making are important skills for nursing and in life. One

implication for nursing practice would be better decision-making skills. Some nurses may have

moderate decision-making skills but should still focus more on improving the quality of their

decisions (Studer & Clark, 2011). Nurses that are less natural in decision-making, especially

under pressure, may be able to handle a quality assessment of an acute event but need to practice

being more decisive in acting upon that assessment (Struder & Clark, 2009).

Controlling fear is another implication for nursing. There are many factors that can create

fear in nursing. Fear is a product of subconscious reactions to certain stimuli that is internal to

oneself (UAB, 2011). When the fear level is increased, the ability to think rationally tends to

spiral downward to the point where one’s actions can become inappropriate for the situation. To

begin controlling fear, one must examine the mechanisms that cause fear. Often preparing for an

event that is fearful can help one master control over the situation. Train the mind to

acknowledge the fear and accept if for what it is, simply the mind telling the body that it is

distressed about something (UAB, 2011).

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