ONSStateoftheScienceLectureship:

IllnessUncertaintyinAdultCancerPatients

ContentDescription:
Inhispresentation,DonaldBailey,PhD,RN,will
synthesizetheresearchliteratureonillnessuncertainty
inthecancerexperience,categorizethesedataby
cancercarecontinuumphase,andsuggestdirections
forfutureresearchandtheuseofresearchtoadvance
practiceinoncologynursing.
BaileyisanassociateprofessoratDukeUniversity,
SchoolofNursing.HavingreceivedhisPhDfromthe
UniversityofNorthCarolinaatChapelHill,hisworkis
publishedinvariouspublicationsincludingTheDaily
Reflector,TheNewsandObserver,EmoryNursing
Magazine,andCarolinaNursingMagazine.
Coordinator/Speaker:
DonaldBailey,PHDRN
AssistantProfessor
DukeUniversitySchoolofNursing
Durham,NC
chip.bailey@duke.edu
Full Disclosure:
Nothing to Disclose

Illness Uncertainty
in Adult Cancer Patients
Donald E Bailey Jr Ph D R N Donald E. Bailey Jr., Ph.D., R.N.
Associate Professor
Duke University School of Nursing
Durham, NC
Purpose / Objectives Purpose / Objectives
Synthesize the research literature on illness uncertainty
in the cancer experience
C t i t di b ti h Categorize studies by cancer care continuum phase
Suggest possible directions for future research and
the use of research to advance oncology nursing practice
The inability to determine the meaning
of illness-related events
The cognitive state created when a person
cannot adequately structure or categorize
Uncertainty Uncertainty: : Definition Definition
cannot adequately structure or categorize
illness-related events due to a lack of sufficient cues
Occurs in a situation where the decision maker
is unable to assign definite value to objects or events
and/or is unable to predict outcomes
Mishel,1988
Illness uncertainty has been identified as
the main source of psychosocial distress
in potentially life-threatening illness. It affects:
Significance of Uncertainty Significance of Uncertainty
Persons with cancer
Uncertainty is associated with:
Long-term cancer survivors
Families of persons with cancer
across the care continuum
Anxiety, Depression, Sexual dysfunction, Insomnia, Fatigue
Poorer quality of life (QOL)
Mishels (1988, 1990) uncertainty theories
provide a framework for understanding
individual responses to the experience of cancer,
and can be used to:
Significance of Uncertainty Significance of Uncertainty
Sensitize oncology nurses to the prevalence of uncertainty
and its associated distress
Facilitate development and testing of nursing interventions
Guide advancements in oncology nursing practice
ConsequencesofUncertainty ConsequencesofUncertainty
Heightened anxiety and tension
Less optimism and hope
f Tension in family relationships, work, recreation
Weakened sense of mastery and control
Heightened sense of threat and danger
Original Model of
Perceived Uncertainty in Illness
(+)
Coping Coping
Mobilizing & Mobilizing &
Affect Control Affect Control
Strategies Strategies
Danger Danger
(Mishel, 1988)
Stimuli Stimuli
Frame Frame
Structure Structure
Providers Providers
Cognitive Cognitive
Capacities Capacities
(+)
()
Inference Inference
Illusion Illusion
Coping Coping
Buffering Buffering
Strategies Strategies
Opportunity Opportunity
Uncertainty Uncertainty
Adjustment Adjustment
(+)
()
(+) A
p
p
r
a
i
s
a
l
A
p
p
r
a
i
s
a
l
Theoretical Theoretical Framework Framework
Mishels Reconceptualized
Uncertainty in Illness Theory (1990)
proposed that individual growth and
self-organization are appropriate endpoints
for continual uncertainty associated with
chronic conditions

Reconceptualized Reconceptualized
Uncertainty in Illness Theory Uncertainty in Illness Theory
Is an expansion of the original theory
Applies to the constant ncertaint fo nd in chronic illness Applies to the constant uncertainty found in chronic illness
Applies to:
Chronic illnesses with remissions and exacerbations
Illnesses with possible recurrence and extension
Reconceptualization Reconceptualization
Focus of the theory is not on management of uncertainty,
but instead on the integration of uncertainty into life
and the development of a new value system.
Reconceptualized theory of uncertainty in illness
is based on:
Principles of chaos theory (which explains irregular behavior
or disorder in complex systems)
Qualitative studies of chronically ill patients (MS, lupus)
Reconceptualization Reconceptualization
The person with chronic illness is considered to be
a complex system with irregular behavior.
In a complex system with irregular behavior In a complex system with irregular behavior,
random changes can create instability in the system.
Fluctuations can feed back on themselves,
creating stronger fluctuations.
Reconceptualized Uncertainty Model Reconceptualized Uncertainty Model
StimuliFrame StimuliFrame
SymptomPattern SymptomPattern
EventFamiliarity EventFamiliarity
EventCongruency EventCongruency
Uncertainty Opportunity
( )
()
StructureProviders StructureProviders
HealthCareProviders HealthCareProviders
SocialSupport SocialSupport
Education Education
PriorLifeExperience PriorLifeExperience
Cognitive Cognitive
Capacities Capacities
(+)
(+)
()
Methods & Data Sources Methods & Data Sources
Computerized search of literature published in English
between 1981 and 2011
Databases included: Search terms included:
PubMed / Medline
CINAHL
Uncertainty
C CINAHL
PsycINFO
Web of Science
Cancer
Mishel
Seeking: Applications of Mishels Uncertainty in Illness theory
and/or use of MUIS scales in studies of adults with cancer
across the continuum of cancer care
Limited to research on adults
Research Questions Research Questions
To what extent has illness uncertainty been studied across
Scope of survey:
Illness uncertainty in patients, survivors, and their families
and uncertainty associated with screening for cancer
the phases of the cancer care continuum?
How have studies of illness uncertainty been distributed
across cancer sites?
How has illness uncertainty been assessed in adult oncology patients?
What are the primary themes related to uncertainty across
the cancer care continuum?
NewYorkTimes (June1,2004):
Significance of Uncertainty Significance of Uncertainty
in Cancer Survivorship in Cancer Survivorship
Fundamental issue for cancer survivors is uncertainty Fundamental issue for cancer survivors is uncertainty.
Is it gone or will it come back?
Its the not knowing.
Its living with uncertainty the critical issue.
Cancer Care Trajectory Cancer Care Trajectory
Start
Here
Treatment with
IntenttoCure
CancerFree
Survival
Recurrence/ Recurrence/
SecondCancer SecondCancer
Managed
Chronic or
Intermittent
Disease
SurvivorshipCare
Lateeffects management
andsurveillancefor recurrence
andsecondcancers
Palliative care is provided throughout the cancer care trajectory. (IOM, 2005)
Palliative
Treatment
Diagnosis and Diagnosis and
Staging Staging
Death Death
Treatment Treatment
Failure Failure
Realities of Cancer Survivorship Realities of Cancer Survivorship
Estimated Number of
Persons Alive in U.S.
Diagnosed with Cancer
on January 1, 2007
Breast
Melanoma
Lung
Other
22%
7%
3%
15%
By site of cancer
11.7 million survivors
Prostate
Colorectal Gynecologic
Hematologic
Urinary Tract
19%
10%
9%
8%
7%
Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, Ruhl J, Howlader N, Tatalovich Z, Cho H, Mariotto A,
Eisner MP, Lewis DR, Cronin K, Chen HS, Feuer EJ, Stinchcomb DG, Edwards BK (eds).
SEER Cancer Statistics Review, 1975-2007, National Cancer Institute. Bethesda, MD. http://seer.cancer.gov/csr/1975_2007
Based on November 2009 SEER data submission, posted to the SEER web site, 2010.
Cancer Survivors by Age Group Cancer Survivors by Age Group
Estimated Number of Persons Alive in U.S. Diagnosed with Cancer on Jan. 1, 2007
30%
40%
50%
f

T
o
t
a
l
Total number
of persons:
11.7 million
5.6
Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W, Ruhl J, Howlader N, Tatalovich Z, Cho H, Mariotto A,
Eisner MP, Lewis DR, Cronin K, Chen HS, Feuer EJ, Stinchcomb DG, Edwards BK (eds).
SEER Cancer Statistics Review, 1975-2007, National Cancer Institute. Bethesda, MD. http://seer.cancer.gov/csr/1975_2007
Based on November 2009 SEER data submission, posted to the SEER web site, 2010.
Age (yr)
0%
10%
20%
0-19 20-29 30-39 40-49 50-59 60-69 70+
%

o
f
2.7
2.7
0.9
0.4
0.2
0.1
Prevention Screening Diagnosis Treatment Survivorship End-of-Life
Tobacco control Cancer
screening
Oncology
consultations
Chemotherapy Long-term
follow up &
Palliation
Phases of the Cancer Care Continuum Phases of the Cancer Care Continuum
Diet
Physical activity
Sun exposure
Virus exposure
Alcohol use
Chemoprevention
screening
Awareness
of cancer
signs &
symptoms
consultations
Tumor
staging
Patient
counseling
& decision
making
Surgery
Radiation
therapy
Adjuvant
therapy
Symptom
management
Psychosocial
care
follow-up &
surveillance
Late-effects
management
Rehabilitation
Coping
Health
promotion
Spiritual
issues
Hospice
Source: Hewitt, M., Greenfield, S., & Stovall, E. (2005).
From Cancer Patient to Cancer Survivor: Lost in Transition. Washington DC: National Academies Press p. 24, Box 2-2.
The 6 communication functions can help improve survival and QOL
in each phase of the cancer care continuum
Image not available
Adapted from Epstein RM, Street RL Jr. (2007 ) Patient-centered communication in cancer care:
Promoting healing and reducing suffering. Bethesda, MD: National Cancer Institute. Fig 4.1, p. 68.
Imagenotavailable.
6 Functions of Patient/Family Clinician
Communication in Cancer Settings
Fostering healing relationships
Exchanging information
Responding to emotions
Managing uncertainty
Making decisions
Enabling patient self-management
Source: Epstein RM, Street RL Jr (2007).
Patient-centered communication in cancer care: Promoting healing and reducing suffering.
Bethesda, MD: National Cancer Institute. Table 4.1, p. 67.
78 published research studies:
Findings Findings
Type of Study
Quantitative studies
Qualitative studies
Mixed methods studies
Study Design
Cross-sectional design
Longitudinal design
%
85%
12%
4%
n
66
9
3
%
65%
35%
n
51
27
Supporting literature
Specific literature reviews
Additional literature:
Nations represented: 9 Uncertainty Intervention?
Yes
No
%
26%
74%
n
20
58
13
2
Prevention Screening Diagnosis Treatment Survivorship End-of-Life
Summary: Research Studies of Uncertainty
in the Phases of the Cancer Continuum
4 studies 0 studies
2 Quant.
6 studies
6 Quant.
32 studies 35 studies 1 study
Type Type Type Type Type
31 Quant. 27 Quant. 0 Quant.
2 Qual.
3 Breast / Gyn
1 Gyn
0 Qual.
4 Breast
1 Gyn
1 Prostate
8 Breast
1 Colon
10 Gyn
1 Hematologic
12 Prostate
2 Mixed
27 Breast
1 Colon
1 Liver
1 Lung
5 Mixed
1 Prostate
Site Site Site Site Site
1 Qual. 5 Qual.
3 Mixed
1 Qual.
4 X-sec
0 Long.
3 X-sec
3 Long.
19 X-sec
13 Long.
24 X-sec
11 Long.
1 X-sec
0 Long.
Published Studies of Uncertainty in Adults with Cancer
By Year
5
6
7
8
l
i
c
a
t
i
o
n
s
Includes uncertainty in patients, survivors, and their families
and uncertainty associated with screening for cancer
0
1
2
3
4
5
N
u
m
b
e
r

o
f

P
u
b
Year
Uncertainty in Adults with Cancer:
Number of Studies by Cancer Site
Hematologic
HPV
Liver
Lung
Mixed
6%
Breast
Prostate
Colon
Gynecologic
53%
17%
16%
3%
Total: 78
publications
Mishel Mishel Uncertainty in Illness Scales for Adults Uncertainty in Illness Scales for Adults
Mishel Uncertainty in Illness Scale (original): MUISA
(also identified as MUIS)
For use with: Adults hospitalized with acute illness,
and receiving medical intervention
Initial publication: 1981
Further development: 1982, 1986, 1989;
Multiple versions, variable number of items
Mishel Uncertainty in Illness ScaleCommunity: MUISC
For use with: Adults chronically ill but not hospitalized,
and not receiving medical intervention;
or, family members of chronically ill adults
Initial publication: 1986
Further development: 1989; multiple versions, variable number of items
Mishel Uncertainty in Illness ScaleSurvivor: MUISS
For use with: Cancer survivors
Initial publication: 1996
Mishel Uncertainty in Illness Scales for Adults
Mishel Uncertainty in Illness Scale (MUIS) has been translated into:
Cross-Cultural Research
English-language Mishel Uncertainty in Illness Scales used in:
U.S. 51 studies
Canada 3 studies
U.S. / Ireland comparison 1 study
Arabic
Chinese (MUIS: 5 studies in Taiwan; 1 in Hong Kong)
German
Greek
Hebrew
Korean (MUIS: 1 study)
Swedish
Thai (MUIS-C: 1 study)
Alternative Methods of Assessing Uncertainty Alternative Methods of Assessing Uncertainty
Includes n=15 studies which:
Used instruments other than MUIS, or
Addressed uncertainty with qualitative methods only
Study locations:
U.S. 7 studies
Canada 3 studies
U.S. / Ireland comparison 1 study
U.K. 1 study
Germany 1 study
Netherlands 2 studies
Study locations:
Published Studies Using MUIS to Measure Uncertainty
in Phases of the Cancer Control Continuum
Prevention Screening Diagnosis Treatment Survivorship End of Life
None
Other
measures: 4
MUIS: 5
MUIS-C: 1
MUIS: 11
MUIS-C: 9
MUIS-S: 6
Other: 1
MUIS: 24
MUIS-C: 6
Other: 2 Other: 3
None: 2
MUIS
not used
None: 6
MUIS
not used
MUIS
not used
Comparative Research on Illness Uncertainty
in Population Subgroups
Male vs. Female
Race / Ethnicity (in U.S.)
Patient & Family Member
Af i A i Whit
3
9
8
Subgroups Number of Studies
Age Groups
African American, White
Hispanic, White
African American, Hispanic, White
Patients aged >50 yr vs. <50 yr
Clinical Status
Cancer vs. no cancer
8
2
2
3
2
Pain vs no pain 1
Uncertainty Management Intervention Studies
Screening
By Cancer Care Continuum Phase
1
Phase of
Continuum
Number of
Intervention Studies
Diagnosis
Treatment
Survivorship
End of Life Care
2
10
7
0
Total 20
Uncertainty Management Intervention
4 components:
Patient-provider communication
Increased knowledge of cancer
Problem solving
Cognitive reframing
Themes
Uncertainty and Distress (Anxiety, Depression)
Uncertainty and Quality of Life
Uncertainty and Transition
Uncertainty and Personal Growth
Uncertainty and Educational / Informational Needs
Summary of Findings
Screening
Diagnosis
By Phases of the Cancer Care Continuum
g
Treatment
Survivorship
End of Life Care
Overall Impact of
Uncertainty Management Interventions
Uncertainty is reduced most often in interventions
addressing women
Uncertainty management strategies are improved Uncertainty management strategies are improved
across all of the interventions
Interventions addressing the stimuli frame antecedent
are most often successful
Transferring these findings to practice
Ethical & Policy Implications
Patients need care by nurses who are sensitive to
illness-related uncertainty and who can help them
acquire information, cognitive strategies, and skills
to deal with that uncertainty.
Interventions could be provided during routine care
across the cancer trajectory if policies were changed
to reimburse oncology and primary care nurses
for their time.
Translation to Practice
Little is known about what can be done
as part of routine clinical care to lower the burden
of cancer-related illness uncertainty.
Improved knowledge and understanding of uncertainty
theory will allow further development of interventions
and their translation to practice
Where Does the Theory Stand Now?
Uncertainty theory refers to a cognitive state
and the interventions address cognition
with consistent successful results
Need more uncertainty management intervention studies Need more uncertainty management intervention studies
with cross-cultural and minority cancer populations
to further test and expand the theory.
Need to move successful uncertainty management
interventions into practice
Future Research
Further studies of uncertainty are needed in the areas
of genetic information, prevention and screening for
primary cancer, and end of life. These 3 areas are ripe
for inter-professional research teams to advance the
science of oncology care.
Link findings on cortisol changes in breast cancer survivors
(e.g., Porter et al., 2003) to measurements of illness uncertainty
in the same population.
Research combining measures of uncertainty with
assessment of physiological variables in adult populations
with (or at risk for) cancer.
Life is uncertain. Life is uncertain.
Eat dessert first Eat dessert first Eat dessert first. Eat dessert first.
The End The End
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

Screening
Baty,B.J.,Dudley,W.N.,Musters,A.,&Kinney,A.Y.(2006).UncertaintyinBRCA1cancersusceptibility
testing.AmericanJournalofMedicalGeneticsPartCSeminarsinMedicalGenetics,142C(4),241250.doi:
10.1002/ajmg.c.30112
Frost,C.J.,Venne,V.,Cunningham,D.,&GerritsenMcKane,R.(2004).Decisionmakingwithuncertain
information:learningfromwomeninahighriskbreastcancerclinic.JournalofGeneticCounseling,13(3),
221236.doi:10.1023/B:JOGC.0000027958.02383.a9
MacDonald,D.J.,Sarna,L.,Weitzel,J.N.,&Ferrell,B.(2010).Women'sperceptionsofthepersonalandfamily
impactofgeneticcancerriskassessment:focusgroupfindings.JournalofGeneticCounseling,19(2),148
160.doi:10.1007/s1089700992673
Rosen,N.O.,Knauper,B.,Page,G.,DiDio,P.,Morrison,E.,Mayrand,M.H.,...Rosberger,Z.(2009).Brief
researchreport:uncertaintyinducingandreassuringfactsaboutHPV:adescriptivestudyofFrench
Canadianwomen.HealthCareforWomenInternational,30(10),892902.doi:
10.1080/07399330903066434

Diagnosis
Deane,K.A.,&Degner,L.F.(1998).Informationneeds,uncertainty,andanxietyinwomenwhohadabreast
biopsywithbenignoutcome.CancerNursing,21(2),117126.
Liao,M.N.,Chen,M.F.,Chen,S.C.,&Chen,P.L.(2008).Uncertaintyandanxietyduringthediagnosticperiod
forwomenwithsuspectedbreastcancer.CancerNursing,31(4),274283.
Liu,L.N.,Li,C.Y.,Tang,S.T.,Huang,C.S.,&Chiou,A.F.(2006).Roleofcontinuingsupportivecaresin
increasingsocialsupportandreducingperceiveduncertaintyamongwomenwithnewlydiagnosedbreast
cancerinTaiwan.CancerNursing,29(4),273282.
Mishel,M.H.,Germino,B.B.,Lin,L.,Pruthi,R.S.,Wallen,E.M.,Crandell,J.,&Blyler,D.(2009).Managing
uncertaintyabouttreatmentdecisionmakinginearlystageprostatecancer:arandomizedclinicaltrial.
PatientEducationandCounseling,77(3),349359.doi:10.1016/j.pec.2009.09.009
Mishel,M.H.,Hostetter,T.,King,B.,&Graham,V.(1984).Predictorsofpsychosocialadjustmentinpatients
newlydiagnosedwithgynecologicalcancer.CancerNursing,7(4),291299.
Northouse,L.L.,Jeffs,M.,CracchioloCaraway,A.,Lampman,L.,&Dorris,G.(1995).Emotionaldistress
reportedbywomenandhusbandspriortoabreastbiopsy.NursingResearch,44(4),196201.

Treatment
TreatmentBreastCancer
Hughes,K.K.(1993).Psychosocialandfunctionalstatusofbreastcancerpatients.Theinfluenceofdiagnosis
andtreatmentchoice.CancerNursing,16(3),222229.
Jo,K.H.,&Son,B.K.(2004).[Therelationshipofuncertainty,hopeandqualityoflifeinpatientswithbreast
cancer].[InChinese.]TaehanKanhoHakhoeChi,34(7),11841193.
Kennedy,F.,Harcourt,D.,&Rumsey,N.(2008).Thechallengeofbeingdiagnosedandtreatedforductal
carcinomainsitu(DCIS).EuropeanJournalofOncologyNursing,12(2),103111.doi:
10.1016/j.ejon.2007.09.007
McHenry,J.,Allen,C.,Mishel,M.H.,&Braden,C.J.(1993).Uncertaintymanagementforwomenreceiving
treatmentforbreastcancer.InS.G.Funk,E.M.Tornquist,M.T.Champagne&R.A.Wiese(Eds.),Key
aspectsofcaringforthechronicallyill:Hospitalandhome.(pp.170177).NewYork:SpringerPublishing
Company.
Northouse,L.L.,Dorris,G.,&CharronMoore,C.(1995).Factorsaffectingcouples'adjustmenttorecurrent
breastcancer.SocialScienceandMedicine,41(1),6976.
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

Northouse,L.L.,Laten,D.,&Reddy,P.(1995).Adjustmentofwomenandtheirhusbandstorecurrentbreast
cancer.ResearchinNursingandHealth,18(6),515524.
Ritz,L.J.,Nissen,M.J.,Swenson,K.K.,Farrell,J.B.,Sperduto,P.W.,Sladek,M.L.,...Schroeder,L.M.(2000).
Effectsofadvancednursingcareonqualityoflifeandcostoutcomesofwomendiagnosedwithbreast
cancer.OncologyNursingForum,27(6),923932.
Wong,C.A.,&Bramwell,L.(1992).Uncertaintyandanxietyaftermastectomyforbreastcancer.Cancer
Nursing,15(5),363371.
TreatmentColonCancer
Galloway,S.C.,&Graydon,J.E.(1996).Uncertainty,symptomdistress,andinformationneedsaftersurgery
forcancerofthecolon.CancerNursing,19(2),112117.
TreatmentGyn.Cancers
Ismail,Z.,KwokweiSo,W.,&WaichiLi,P.(2010).PreoperativeuncertaintyandanxietyamongChinese
patientswithgynecologiccancer.OncologyNursingForum,37(1),E6774.
McCorkle,R.,Dowd,M.,Ercolano,E.,SchulmanGreen,D.,Williams,A.L.,Siefert,M.L.,...Schwartz,P.
(2009).Effectsofanursinginterventiononqualityoflifeoutcomesinpostsurgicalwomenwith
gynecologicalcancers.PsychoOncology,18(1),6270.doi:10.1002/pon.1365
McCorkle,R.,Jeon,S.,Ercolano,E.,&Schwartz,P.(2011).Healthcareutilizationinwomenafterabdominal
surgeryforovariancancer.NursingResearch,60(1),4757.doi:10.1097/NNR.0b013e3181ff77e4
Mishel,M.H.,&Braden,C.J.(1987).Uncertainty.Amediatorbetweensupportandadjustment.Western
JournalofNursingResearch,9(1),4357.
Mishel,M.H.,&Braden,C.J.(1988).Findingmeaning:antecedentsofuncertaintyinillness.NursingResearch,
37(2),98103,127.
Mishel,M.H.,Padilla,G.,Grant,M.,&Sorenson,D.S.(1991).Uncertaintyinillnesstheory:areplicationofthe
mediatingeffectsofmasteryandcoping.NursingResearch,40(4),236240.
Mishel,M.H.,&Sorenson,D.S.(1991).Uncertaintyingynecologicalcancer:atestofthemediatingfunctions
ofmasteryandcoping.NursingResearch,40(3),167171.
OtisGreen,S.,Ferrell,B.,Sun,V.,Spolum,M.,Morgan,R.,&Macdonald,D.(2008).Feasibilityofanovarian
cancerqualityoflifepsychoeducationalintervention.JournalofCancerEducation,23(4),214221.doi:
10.1080/08858190802188784
Padilla,G.V.,Mishel,M.H.,&Grant,M.M.(1992).Uncertainty,appraisalandqualityoflife.QualityofLife
Research,1(3),155165.
SchulmanGreen,D.,Ercolano,E.,Dowd,M.,Schwartz,P.,&McCorkle,R.(2008).Qualityoflifeamongwomen
aftersurgeryforovariancancer.PalliativeandSupportiveCare,6(3),239247.doi:
10.1017/s1478951508000497
TreatmentHematologicCancer
Richardson,J.L.,Marks,G.,Johnson,C.A.,Graham,J.W.,Chan,K.K.,Selser,J.N.,...Levine,A.M.(1987).
Pathmodelofmultidimensionalcompliancewithcancertherapy.HealthPsychology,6(3),183207.
TreatmentMixedCancers
Christman,N.J.(1990).Uncertaintyandadjustmentduringradiotherapy.NursingResearch,39(1),1720,47.
Lien,C.,Lin,H.,Kuo,I.,&Chen,M.(2009).Perceiveduncertainty,socialsupportandpsychologicaladjustment
inolderpatientswithcancerbeingtreatedwithsurgery.JournalofClinicalNursing,18(16),23112319.
TreatmentProstateCancer
Bailey,D.E.,Jr.,Mishel,M.H.,Belyea,M.,Stewart,J.L.,&Mohler,J.(2004).Uncertaintyinterventionfor
watchfulwaitinginprostatecancer.CancerNursing,27(5),339346.
Bailey,D.E.,Jr.,Wallace,M.,Latini,D.M.,Hegarty,J.,Carroll,P.R.,Klein,E.A.,&Albertsen,P.C.(2009).
Measuringillnessuncertaintyinmenundergoingactivesurveillanceforprostatecancer.AppliedNursing
Research.doi:10.1016/j.apnr.2009.08.001
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

Bailey,D.E.,Jr.,Wallace,M.,&Mishel,M.H.(2007).Watching,waitinganduncertaintyinprostatecancer.
JournalofClinicalNursing,16(4),734741.doi:10.1111/j.13652702.2005.01545.x
Germino,B.B.,Mishel,M.H.,Belyea,M.,Harris,L.,Ware,A.,&Mohler,J.(1998).Uncertaintyinprostate
cancer.Ethnicandfamilypatterns.CancerPractice,6(2),107113.
Hegarty,J.M.,Wallace,M.,&Comber,H.(2008).Uncertaintyandqualityoflifeamongmenundergoingactive
surveillanceforprostatecancerintheUnitedStatesandIreland.AmericanJournalofMen'sHealth,2(2),
133142.doi:10.1177/1557988307300467
Mishel,M.H.,Belyea,M.,Germino,B.B.,Stewart,J.L.,Bailey,D.E.,Jr.,Robertson,C.,&Mohler,J.(2002).
Helpingpatientswithlocalizedprostatecarcinomamanageuncertaintyandtreatmentsideeffects:nurse
deliveredpsychoeducationalinterventionoverthetelephone.Cancer,94(6),18541866.
Mishel,M.H.,Germino,B.G.,Belyea,M.,Harris,L.,Stewart,J.,Bailey,D.E.J.,...Robertson,C.(2001).
Helpingpatientswithlocalizedprostatecancer:Managingaftertreatment.InS.G.T.Funk,E.M.,J.
Leeman,M.S.Miles&J.S.Harrell(Eds.),Keyaspectsofpreventingandmanagingchronicillness,(pp.235
246).NewYork:SpringerPublishingCompany.
Mishel,M.H.,Germino,B.B.,Belyea,M.,Stewart,J.L.,Bailey,D.E.,Jr.,Mohler,J.,&Robertson,C.(2003).
Moderatorsofanuncertaintymanagementintervention:formenwithlocalizedprostatecancer.Nursing
Research,52(2),8997.
Northouse,L.L.,Mood,D.W.,Montie,J.E.,Sandler,H.M.,Forman,J.D.,Hussain,M.,...Kershaw,T.(2007).
Livingwithprostatecancer:patients'andspouses'psychosocialstatusandqualityoflife.JournalofClinical
Oncology,25(27),41714177.doi:10.1200/jco.2006.09.6503
Northouse,L.L.,Mood,D.W.,Schafenacker,A.,Montie,J.E.,Sandler,H.M.,Forman,J.D.,...Kershaw,T.
(2007).Randomizedclinicaltrialofafamilyinterventionforprostatecancerpatientsandtheirspouses.
Cancer,110(12),28092818.doi:10.1002/cncr.23114
Wallace,M.(2003).Uncertaintyandqualityoflifeofoldermenwhoundergowatchfulwaitingforprostate
cancer.OncologyNursingForum,30(2),303309.doi:10.1188/03.onf.291300
Wallace,M.(2005).Findingmoremeaning:theantecedentsofuncertaintyrevisited.JournalofClinical
Nursing,14(7),863868.doi:10.1111/j.13652702.2005.01138.x

Survivorship
SurvivorshipBreastCancer
Bogart,L.M.,&Helgeson,V.S.(2000).Socialcomparisonsamongwomenwithbreastcancer:Alongitudinal
investigation.JournalofAppliedSocialPsychology,30(3),547575.
Clayton,M.F.,Mishel,M.H.,&Belyea,M.(2006).Testingamodelofsymptoms,communication,uncertainty,
andwellbeing,inolderbreastcancersurvivors.ResearchinNursingandHealth,29(1),1839.doi:
10.1002/nur.20108
Dirksen,S.R.(2000).Predictingwellbeingamongbreastcancersurvivors.JournalofAdvancedNursing,32(4),
937943.
Dirksen,S.R.,&Erickson,J.R.(2002).WellbeinginHispanicandnonHispanicwhitesurvivorsofbreast
cancer.OncologyNursingForum,29(5),820826.doi:10.1188/02.onf.820826
Farren,A.T.(2010).Power,uncertainty,selftranscendence,andqualityoflifeinbreastcancersurvivors.
NursingScienceQuarterly,23(1),6371.doi:10.1177/0894318409353793
Gil,K.M.,Mishel,M.,Belyea,M.,Germino,B.,Germino,L.S.,Porter,L.,...Stewart,J.(2004).Triggersof
uncertaintyaboutrecurrenceandlongtermtreatmentsideeffectsinolderAfricanAmericanand
Caucasianbreastcancersurvivors.OncologyNursingForum,31(3),633639.doi:10.1188/04.onf.633639
Gil,K.M.,Mishel,M.H.,Belyea,M.,Germino,B.,Porter,L.S.,&Clayton,M.(2006).Benefitsofthe
uncertaintymanagementinterventionforAfricanAmericanandWhiteolderbreastcancersurvivors:20
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

monthoutcomes.InternationalJournalofBehavioralMedicine,13(4),286294.doi:
10.1207/s15327558ijbm1304_3
Gil,K.M.,Mishel,M.H.,Germino,B.,Porter,L.S.,CarltonLaNey,I.,&Belyea,M.(2005).Uncertainty
managementinterventionforolderAfricanAmericanandcaucasianlongtermbreastcancersurvivors.
JournalofPsychosocialOncology,23(23),321.
Helgeson,V.S.,Cohen,S.,Schulz,R.,&Yasko,J.(1999).Educationandpeerdiscussiongroupinterventionsand
adjustmenttobreastcancer.ArchivesofGeneralPsychiatry,56(4),340347.
Helgeson,V.S.,Cohen,S.,Schulz,R.,&Yasko,J.(2000).Groupsupportinterventionsforwomenwithbreast
cancer:Whobenefitsfromwhat?HealthPsychology,19(2),107114.doi:10.1037/02786133.19.2.107
Hilton,B.A.(1988).Thephenomenonofuncertaintyinwomenwithbreastcancer.IssuesinMentalHealth
Nursing,9(3),217238.
Hilton,B.A.(1989).Therelationshipofuncertainty,control,commitment,andthreatofrecurrencetocoping
strategiesusedbywomendiagnosedwithbreastcancer.JournalofBehavioralMedicine,12(1),3954.
Hilton,B.A.(1993).Issues,problems,andchallengesforfamiliescopingwithbreastcancer.Seminarsin
OncologyNursing,9(2),88100.\
Mast,M.E.(1998).Correlatesoffatigueinsurvivorsofbreastcancer.CancerNursing,21(2),136142.
Mast,M.E.(1998).Survivorsofbreastcancer:illnessuncertainty,positivereappraisal,andemotionaldistress.
OncologyNursingForum,25(3),555562.
Mishel,M.H.,Germino,B.B.,Gil,K.M.,Belyea,M.,Laney,I.C.,Stewart,J.,...Clayton,M.(2005).Benefits
fromanuncertaintymanagementinterventionforAfricanAmericanandCaucasianolderlongtermbreast
cancersurvivors.PsychoOncology,14(11),962978.doi:10.1002/pon.909
Nelson,J.P.(1996).Strugglingtogainmeaning:livingwiththeuncertaintyofbreastcancer.ANS.Advancesin
NursingScience,18(3),5976.
Northouse,L.L.,Templin,T.,Mood,D.,&Oberst,M.(1998).Couples'adjustmenttobreastcancerandbenign
breastdisease:alongitudinalanalysis.PsychoOncology,7(1),3748.doi:10.1002/(sici)1099
1611(199801/02)7:1<37::aidpon314>3.0.co;2#
Pelusi,J.(1997).Thelivedexperienceofsurvivingbreastcancer.OncologyNursingForum,24(8),13431353.
Porter,L.S.,Clayton,M.F.,Belyea,M.,Mishel,M.,Gil,K.M.,&Germino,B.B.(2006).Predictingnegative
moodstateandpersonalgrowthinAfricanAmericanandWhitelongtermbreastcancersurvivors.Annals
ofBehavioralMedicine,31(3),195204.doi:10.1207/s15324796abm3103_1
Sammarco,A.(2001).Perceivedsocialsupport,uncertainty,andqualityoflifeofyoungerbreastcancer
survivors.CancerNursing,24(3),212219.
Sammarco,A.(2003).Qualityoflifeamongoldersurvivorsofbreastcancer.CancerNursing,26(6),431438.
Sammarco,A.(2009).Qualityoflifeofbreastcancersurvivors:acomparativestudyofagecohorts.Cancer
Nursing,32(5),347356;quiz357348.doi:10.1097/NCC.0b013e31819e23b7
Sammarco,A.,&Konecny,L.M.(2008).Qualityoflife,socialsupport,anduncertaintyamongLatinabreast
cancersurvivors.OncologyNursingForum,35(5),844849.doi:10.1188/08.onf.844849
Sammarco,A.,&Konecny,L.M.(2010).Qualityoflife,socialsupport,anduncertaintyamongLatinaand
Caucasianbreastcancersurvivors:acomparativestudy.OncologyNursingForum,37(1),9399.doi:
10.1188/10.onf.9399
Wonghongkul,T.,Dechaprom,N.,Phumivichuvate,L.,&Losawatkul,S.(2006).Uncertaintyappraisalcoping
andqualityoflifeinbreastcancersurvivors.CancerNursing,29(3),250257.
Wonghongkul,T.,Moore,S.M.,Musil,C.,Schneider,S.,&Deimling,G.(2000).Theinfluenceofuncertaintyin
illness,stressappraisal,andhopeoncopinginsurvivorsofbreastcancer.CancerNursing,23(6),422429.
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

SurvivorshipColonCancer
Northouse,L.L.,Mood,D.,Templin,T.,Mellon,S.,&George,T.(2000).Couples'patternsofadjustmentto
coloncancer.SocialScienceandMedicine,50(2),271284.
SurvivorshipLiverCancer
Lai,H.L.,Lin,S.Y.,&Yeh,S.H.(2007).[Exploringuncertainty,qualityoflifeandrelatedfactorsinpatientswith
livercancer].(InChinese.)HuLiZaZhi,54(6),4152.
SurvivorshipLungCancer
Hsu,T.H.,Lu,M.S.,Tsou,T.S.,&Lin,C.C.(2003).Therelationshipofpain,uncertainty,andhopein
Taiwaneselungcancerpatients.JournalofPainandSymptomManagement,26(3),835842.doi:
10.1016/s08853924(03)002574
SurvivorshipOtherorMixedCancers
Borgers,R.,Mullen,P.D.,Meertens,R.,Rijken,M.,Eussen,G.,Plagge,I.,...Blijham,G.H.(1993).The
informationseekingbehaviorofcanceroutpatients:adescriptionofthesituation.PatientEducationand
Counseling,22(1),3546.
Kasper,J.,Geiger,F.,Freiberger,S.,&Schmidt,A.(2008).Decisionrelateduncertaintiesperceivedbypeople
withcancermodellingthesubjectofshareddecisionmaking.PsychoOncology,17(1),4248.doi:
10.1002/pon.1190
Molleman,E.,Krabbendam,P.J.,Annyas,A.A.,Koops,H.S.,Sleijfer,D.T.,&Vermey,A.(1984).The
significanceofthedoctorpatientrelationshipincopingwithcancer.SocialScienceandMedicine,18(6),
475480.
Molleman,E.,Pruyn,J.,&vanKnippenberg,A.(1986).Socialcomparisonprocessesamongcancerpatients.
BritishJournalofSocialPsychology,25(Pt1),113.
Morgan,M.A.(2009).Cancersurvivorship:history,qualityoflifeissues,andtheevolvingmultidisciplinary
approachtoimplementationofcancersurvivorshipcareplans.OncologyNursingForum,36(4),429436.

EndofLife
Nanton,V.,Docherty,A.,Meystre,C.,&Dale,J.(2009).Findingapathway:informationanduncertaintyalong
theprostatecancerpatientjourney.BritishJournalofHealthPsychology,14(Pt3),437458.doi:
10.1348/135910708x342890

SupportingLiterature
Bailey,D.E.,&Stewart,J.(2010).Uncertaintyinillnesstheory.InM.R.Alligood&A.M.Tomey(Eds.),Nursing
theoristsandtheirwork(7thed.,pp.599617).St.Louis,MO:Mosby.
Epstein,R.M.,&Street,R.L.,Jr..(2007).Patientcenteredcommunicationincancercare:Promotinghealing
andreducingsuffering.Bethesda,MD:NationalCancerInstitute,NIHPublicationNo.076225.
Hewitt,M.,Greenfield,S.,&Stovall,E.(Eds.).(2005).Fromcancerpatienttocancersurvivor:lostintransition.
Washington,DC:NationalAcademiesPress.
Mast,M.E.(1995).Adultuncertaintyinillness:acriticalreviewofresearch.ScholarlyInquiryforNursing
Practice,9(1),324;discussion2529.
Mishel,M.H.(1983).Adjustingthefit:developmentofuncertaintyscalesforspecificclinicalpopulations.
WesternJournalofNursingResearch,5(4),355370.
Mishel,M.H.(1984).Perceiveduncertaintyandstressinillness.ResearchinNursingandHealth,7(3),163
171.
Mishel,M.H.(1988).Uncertaintyinillness.ImagetheJournalofNursingScholarship,20(4),225232.
Mishel,M.H.(1990).Reconceptualizationoftheuncertaintyinillnesstheory.ImagetheJournalofNursing
Scholarship,22(4),256262.
StateoftheScienceLiterature:IllnessUncertaintyinAdultCancerPatients

Mishel,M.H.(1993).Livingwithchronicillness:Livingwithuncertainty.InS.G.Funk,E.M.Tornquist,M.T.
Champagne&R.A.Wiese(Eds.),Keyaspectsofcaringforthechronicallyill:Hospitalandhome(pp.46
59).NewYork:SpringerPublishingCompany.
Mishel,M.H.(1997).Uncertaintyinacuteillness.AnnualReviewofNursingResearch,15,5780.
Mishel,M.H.(1999).Uncertaintyinchronicillness.AnnualReviewofNursingResearch,17,269294.
Mishel,M.H.,&Clayton,M.F.(2011,inpress)).Uncertaintyinillnesstheories.InM.J.Smith&P.Liehr(Eds.),
Middlerangetheoryinadvancedpracticenursing.NewYork:SpringerPublishing.
Porter,L.S.,Mishel,M.,Neelon,V.,Belyea,M.,Pisano,E.,&Soo,M.S.(2003).Cortisollevelsandresponsesto
mammographyscreeninginbreastcancersurvivors:apilotstudy.PsychosomaticMedicine,65(5),842
848.
Wallace,M.,Bailey,D.,Jr.,O'Rourke,M.,&Galbraith,M.(2004).Thewatchfulwaitingmanagementoptionfor
oldermenwithprostatecancer:stateofthescience.OncologyNursingForum,31(6),10571066.doi:
10.1188/04.onf.10571066
Wiener,C.L.,&Dodd,M.J.(1993).Copingamiduncertainty:anillnesstrajectoryperspective.ScholarlyInquiry
forNursingPractice,7(1),1731;discussion3315.
LiteratureReviews
Elphee,E.E.(2008).Understandingtheconceptofuncertaintyinpatientswithindolentlymphoma.Oncology
NursingForum,35(3),449454.doi:10.1188/08.onf.449454
Montgomery,M.(2010).Uncertaintyduringbreastdiagnosticevaluation:stateofthescience.Oncology
NursingForum,37(1),7783.doi:10.1188/10.onf.7783