Uncertainty in illness theory (uit)

Ace your studies with our custom writing services! We've got your back for top grades and timely submissions, so you can say goodbye to the stress. Trust us to get you there!


Order a Similar Paper Order a Different Paper

Describe how the Uncertainty in Illness Theory (UIT) and Reconceptualized Uncertainty in Illness Theory (RUIT) correspond with caring in the human health experience. Provide examples from practice where you have witnessed uncertainty in patients with an acute health situation and uncertainty arising with a chronic health situation. **Please be sure to post your original post by Wednesday and both peer response posts by Sunday of the same week by end of day (11:59pm EST). **All weekly posts must include at least 2 scholarly sources as citations.

49

CHAPTER 4
Theories of Uncertainty in Illness

Margaret F. Clayton, Marleah Dean, and Merle Mishel

In this chapter, theories of uncertainty in illness are described. The original
uncertainty in illness theory (UIT) was developed by Mishel to address uncer-
tainty during the diagnostic and treatment phases of an illness or an illness
with a determined downward trajectory (Mishel, 1988). Subsequently a recon-
ceptualized uncertainty in illness theory (RUIT) was developed by Mishel to
address the experience of living with continuous uncertainty in either a chronic
illness requiring ongoing management or an illness with a possibility of recur-
rence (Mishel, 1990). Since development of the original theory, the concept of
uncertainty has been used in many disciplines including nursing, medicine,
and health communication with slightly differing defi nitions, extensions, and
applications. Companion instruments to measure uncertainty in illness have
been translated into many languages and used extensively (Mishel 1983a,
1997c).

The UIT proposes that uncertainty exists in illness situations, which are
ambiguous, complex, and unpredictable. Uncertainty is defi ned as the inabil-
ity to determine the meaning of illness-related events. It is a cognitive state
created when the individual cannot adequately structure or categorize an
illness event because of insuffi cient cues (Mishel, 1988). The theory explains
how patients cognitively structure a schema for the subjective interpretation
of uncertainty with treatments and outcomes. It is composed of three major
themes: (a) antecedents of uncertainty, (b) appraisal of uncertainty, and (c)
coping with uncertainty. Uncertainty and cognitive schema are the major con-
cepts of the theory.

The RUIT retains the defi nition of uncertainty and major themes, as in the
UIT, but adds the concepts of self-organization and probabilistic thinking. The
RUIT addresses the process that occurs when a person lives with unremitting
uncertainty found in chronic illness or in illness with a potential for recur-
rence. The desired outcome from the RUIT is a growth to a new value system,
whereas the outcome of the UIT is a return to the previous level of adaptation
or functioning (Mishel, 1990).

Copyright Springer Publishing Company. All Rights Reserved.
From: Middle Range Theory for Nursing, Fourth Edition
DOI: 10.1891/9780826159922.0004

50 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

■ PURPOSE OF THE THEORIES AND HOW THEY WERE DEVELOPED

The purpose of each theory is to describe and explain uncertainty as a basis
for practice and research. The UIT applies to the prediagnostic, diagnostic, and
treatment phases of acute and chronic illnesses. The RUIT applies to enduring
uncertainty in chronic illness or illness with the possibility of recurrence that
requires self-management. The theories focus on the ill individual and on the
family or parent of an ill individual. The use of theory within groups or com-
munities is not consistent.

The fi nding that uncertainty was reported to be common among people
experiencing illness or receiving medical treatment led to the creation of the
UIT (Mishel, 1988). Although the concept was cited in the literature, there was
no substantive exploration of how uncertainty developed and was resolved. It
was a personal experience with Mishel’s ill father that catalyzed the concept
for her as she relays in earlier editions of this chapter and to me (Clayton).
During my dissertation studies with Dr. Mishel as dissertation chair (Mishel
& Clayton, 2003, 2008), Mishel’s father was dying from colon cancer. His body
was swollen and emaciated. He did not understand what was happening, so
he focused on whatever he could control to provide some degree of predict-
ability. The effort he spent on achieving understanding crystallized the signifi –
cance of his uncertainty.

Developing the UIT included a synthesis of the research on uncertainty,
cognitive processing, and managing threatening events. The UIT was revised
from the original measurement model published in 1981, to the RUIT pub-
lished in 1988. During Mishel’s doctoral study, she focused on the develop-
ment and testing of a measure of uncertainty. At that time she was infl uenced
by the literature on stress and coping that discussed uncertainty as one type of
stressful event (Lazarus, 1974) and by the work of Norton (1975), who identi-
fi ed eight dimensions of uncertainty. His work—along with that of Moos and
Tsu (1977)—formed a framework leading to the development of the Mishel
Uncertainty in Illness Scale (Mishel, 1997c).

Mishel’s early ideas were further infl uenced by Bower (1978) and Shalit
(1977), who described uncertainty as a complex cognitive stressor, and by
Budner (1962), who described ambiguous, novel, or complex stimuli as sources
of uncertainty. The ideas of these cognitive psychologists infl uenced Mishel’s
view of uncertainty as a cognitive state rather than as an emotional response.
This distinction directed ongoing theory development. Uncertainty as a stressor
or threat was based on the work of both Shalit (1977) and Lazarus (1974). The
descriptions of coping as a primary appraisal of uncertainty and response to
uncertainty as a secondary appraisal were adapted from the work of Lazarus
(1974). The original 33-item Uncertainty in Illness Scale (Mishel, 1981) incorpo-
rated the work of these primary sources to conceptualize uncertainty in illness.
Other population-specifi c forms have been developed, for example a 23-item
version for community dwelling adults (Mishel, 1997c, 1997b), a 22-item version

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  51

for cancer survivors (Mishel, 1997c), a 22-item version for children and adoles-
cents (the USK, Uncertainty Scale for Kids; Stewart, Lynn, & Mishel, 2010), and
a version for use with parents of hospitalized children (Mishel, 1983b). More
recently, a 5-item short form for use with adults has been developed and vali-
dated (Hagen et al., 2015).

When the Uncertainty in Illness Scale was published, a body of fi ndings on
uncertainty quickly emerged in the nursing literature (Mishel, 1983a, 1984;
Mishel & Braden, 1987, 1988; Mishel & Murdaugh, 1987; Mishel, Hostetter,
King, & Graham, 1984). Research fi ndings on uncertainty substantiated the
antecedents of the theory. The stimuli frame variable, composed of familiar-
ity of events and congruence of events, was formed from research on uncer-
tainty in illness and research in cognitive psychology. Symptom pattern was
developed from qualitative studies (Mishel & Murdaugh, 1987) describing the
importance of consistency of symptoms to form a pattern. The antecedent of
cognitive capacities was based on cognitive psychology (Mandler, 1979), and
practice knowledge about instructing patients when cognitive processing abili-
ties were compromised. The fi nal antecedent of structure providers was devel-
oped from research on uncertainty in illness.

The appraisal section of the theory was developed using sources from the
original 1981 model and based on clinical data and discussions with col-
leagues. Personality variables were thought to be important in the evaluation
of uncertainty, and clinical data indicated that uncertainty could be a pre-
ferred state under specifi c circumstances. This led to inclusion of inference
and illusion as two phases of appraisal (Mishel & Braden, 1987; Mishel &
Murdaugh, 1987).

The RUIT was developed through discussion with colleagues, qualitative
data from chronically ill individuals, and an awareness of the limitations of the
UIT. The UIT was linear and explained uncertainty in the acute and treatment
phases of illness, but did not address life changes over time expressed by per-
sons with chronic illness. Qualitative interviews with chronically ill individu-
als revealed continuous uncertainty and a new view of life that incorporated
uncertainty. From the perspective of Critical Social Theory (Allen, 1985), the
patient’s desire for certainty may refl ect the goals of control and predictability
that form the sociohistorical values of Western society (Mishel, 1990). Clinical
data revealed that those who chose to incorporate uncertainty into their lives
were living a value system on the edge of mainstream ideas. To explain the
clinical data, a framework that conceptualized uncertainty as a preferred state
was initiated using the process of theory derivation described by Walker and
Avant (1989). Chaos was chosen as the parent theory to reconceptualize uncer-
tainty. Chaos theory emphasizes disorder, instability, diversity, disequilibrium,
and restructuring as the healthy variability of a system (Prigogine & Stengers,
1984). The reconceptualized theory included ideas of disorganization and
reformulation of a new stability to explain how a person with enduring uncer-
tainty emerges with a new view of life.

52 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Drawing from chaos theory (Prigogine & Stengers, 1984), uncertainty is
viewed as a force that spreads from illness to other areas of a person’s life
and competes with the person’s previous mode of functioning. As uncertain
areas of life increase, pattern disruption occurs, and uncertainty feeds back
on itself and generates more uncertainty. When uncertainty persists, its inten-
sity exceeds a person’s level of tolerance. There is a sense of disorganization
that promotes personal instability. With a high level of disorganization comes
a loss of a sense of coherence (Antonovsky, 1987). A system in disorganization
begins to reorganize at an imperceptible level that represents a gradual transi-
tion from a perspective of life oriented to predictability and control to a new
view of life in which multiple contingencies are preferable.

■ CONCEPTS OF THE THEORIES

Uncertainty is the central theoretical concept, defi ned as the inability to deter-
mine the meaning of illness-related events inclusive of inability to assign
defi nite value and/or to accurately predict outcomes (Mishel, 1988). Another
concept central to the uncertainty theory is cognitive schema, which is defi ned
as the person’s subjective interpretation of illness-related events (see Figure 4.1).
The UIT is organized around three major themes related to the concepts: (a)
antecedents of uncertainty, (b) appraisal of uncertainty, and (c) coping with
uncertainty.

Stimuli frame
Symptom pattern
Event familiarity
Event congruency

Cognitive
capacities

Structure
providers

Credible authority
Social support
Education

Adaptation

Coping:
Buffering
strategies

Uncertainty
Inference
Illusion

A
pp

ra
is

al

(+)

Coping
mobilizing
strategies

Affect-
control
strategies

(+)

Danger

Opportunity

(−)

(−)

(+)
(+)

FIGURE 4.1 Perceived uncertainty in illness.
Source: Reprinted with permission from Mishel, M. H. (1988). Uncertainty in illness. The Journal of Nursing

Scholarship, 20(4), 225–232.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  53

The ideas included in the antecedent theme of the theory include stimuli
frame, cognitive capacity, and structure providers. Stimuli frame is defi ned as
the form, composition, and structure of the stimuli that the person perceives.
The stimuli frame has three components: symptom pattern, event familiarity,
and event congruence. Symptom pattern refers to the degree to which symp-
toms are present with suffi cient consistency to be perceived as having a pat-
tern or confi guration. Event familiarity is the degree to which the situation
is habitual, repetitive, or contains recognized cues. Event congruence refers
to the consistency between the expected and the experienced illness-related
events. Cognitive capacity and structure providers infl uence the three compo-
nents of the stimuli frame. Cognitive capacity is the information-processing
ability of the individual.

Structure providers are the resources available to assist the person in the
interpretation of the stimuli frame. Structure providers include education,
social support, and credible authority.

The second major theme in the UIT is appraisal of uncertainty, which is
defi ned as the process of placing a value on the uncertain event or situation.
There are two components of appraisal: inference or illusion. Inference refers to
the evaluation of uncertainty using related examples and is built on personal-
ity dispositions, general experience, knowledge, and contextual cues. Illusion
refers to the construction of beliefs formed from uncertainty that have a posi-
tive outlook. The result of appraisal is the valuing of uncertainty as a danger
or an opportunity.

The third theme in the UIT is coping with uncertainty and includes danger,
opportunity, coping, and adaptation. Danger is the possibility of a harmful
outcome. Opportunity is the possibility of a positive outcome. Coping with a
danger appraisal is defi ned as activities directed toward reducing uncertainty
and managing the emotion generated by a danger appraisal. Coping with
an opportunity appraisal is defi ned as activities directed toward maintain-
ing uncertainty. Adaptation is defi ned as biopsychosocial behavior occurring
within the person’s individually defi ned range of usual behavior.

The RUIT includes the antecedent theme in the UIT and adds the two con-
cepts of self-organization and probabilistic thinking. Self-organization is the
reformulation of a new sense of order, resulting from the integration of con-
tinuous uncertainty into one’s self-structure in which uncertainty is accepted
as the natural rhythm of life. Probabilistic thinking is a belief in a conditional
world in which the expectation of certainty and predictability is abandoned.
The RUIT proposes four factors that infl uence the formation of a new life
perspective: prior life experience, physiological status, social resources, and
healthcare providers. In the process of reorganization, the person reevaluates
uncertainty by gradual approximations, from an aversive experience to one
of opportunity. Thus, uncertainty becomes the foundation for a new sense
of order and is accepted as the natural rhythm of life. There is an ability to
focus on multiple alternatives, choices, and possibilities; reevaluate what is

54 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

important in life; consider variation in personal investment; and appreciate the
impermanence and fragility of life. The theory also identifi es conditions under
which the new ability is maintained or blocked.

The concepts of both theories tie clearly to nursing, and other healthcare-
related disciplines by describing and explaining human responses to illness
situations. Uncertainty crosses all phases of illness from prediagnosis symp-
tomatology to diagnosis, treatment, treatment residuals, recovery, potential
recurrence, and exacerbation. Thus, the theories are pertinent to the health
experience for all age groups. Uncertainty is experienced by ill persons but
also caregivers and parents of ill children. Moreover, the theories incorporate
a consideration of the healthcare environment as a component of the stimuli
frame and the broader support network. Nursing care is represented under the
concept of structure providers. Because an important part of nursing involves
explaining and providing information, it follows that nursing actions are inter-
ventions to help patients manage uncertainty. The outcomes of both theories
are directly related to health. The health outcome is to regain personal control,
as in adaptation (UIT) or consciousness expansion (RUIT).

■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODELS

As seen in Figure 4.1, the UIT is displayed as a linear model with no feedback
loops. According to this model, uncertainty is the result of antecedents. The
major path to uncertainty is through the stimuli frame variables. Cognitive
capacities infl uence stimuli frame variables. If the person has a compromised
cognitive capacity due to fever, infection, pain, or mind-altering medication,
the clarity and defi nition of the stimuli frame variables are likely to be reduced,
resulting in uncertainty. In such a situation, it is assumed that stimuli frame
variables are clear, patterned, and distinct, and only become less so because
of limitations in cognitive capacity. However, when cognitive capacity is ade-
quate, stimuli frame variables may still lack a symptom pattern or be unfamiliar
and incongruent due to lack of information, complex information, informa-
tion overload, or confl icting information. The structure provider variables then
come into play to alter the stimuli frame variables by interpreting, providing
meaning, and explaining. These actions serve to structure the stimuli frame,
thereby reducing or preventing uncertainty. Structure providers may also
directly impact uncertainty. The healthcare provider can offer explanations or
use other approaches that directly reduce uncertainty. Similarly, uncertainty
can be reduced by one’s level of education and resultant knowledge. Social
support networks also infl uence the stimuli frame by providing information
from similar others, providing examples, and offering supportive information.

Uncertainty is viewed as a neutral state and is not associated with emotions
until evaluated. During the evaluation of uncertainty, inference and illusion
come into play. Inference and illusion are based on beliefs and personality

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  55

dispositions that infl uence whether uncertainty is appraised as a danger or as
an opportunity. Because uncertainty renders a situation amorphous and ill-
defi ned, positively oriented illusions can be generated from uncertainty, lead-
ing to an appraisal of uncertainty as an opportunity. Uncertainty appraised as
an opportunity implies a positive outcome, and buffering coping strategies are
used to maintain it. In contrast, beliefs and personality dispositions can result
in uncertainty appraised as danger. Uncertainty evaluated as danger implies
harm. Problem-focused coping strategies are employed to reduce it. If prob-
lem-focused coping cannot be used, then emotional coping strategies are used
to respond to the uncertainty. If the coping strategies are effective, adaptation
occurs. Diffi culty in adapting indicates inability to manipulate uncertainty in
the desired direction.

In contrast to the more linear nature of the UIT, the RUIT (Figure 4.2) rep-
resents the process of moving from uncertainty appraised as danger to uncer-
tainty appraised as an opportunity and resource for a new view of life. As
noted earlier in this chapter, the reconceptualized theory builds on the original
theory at the appraisal portion. The RUIT describes enduring uncertainty that
is initially viewed as danger due to its invasion into broader areas of life result-
ing in instability. The jagged line within the arrow represents both the invasion
of uncertainty and the growing instability. The patterned circular portion of the
line represents the repatterning and reorganization resulting in a revised view
of uncertainty. The bottom arrow indicates that this is a process that evolves
over time.

■ USE OF THE UNCERTAINTY THEORIES

Beginning with the publication of the Uncertainty in Illness Scale (Mishel,
1981), there has been extensive research into uncertainty in both acute and
chronic illnesses. The research on uncertainty includes studies in nurs-
ing and other disciplines. Several comprehensive reviews of research have

OpportunityUncertainty

Time

Danger

FIGURE 4.2 Uncertainty in chronic illness.
Source: Reprinted with permission from Bailey, D. E., & Stewart, J. L. (2001). Mishel’s theory of uncertainty in
illness. In A. M. Mariner-Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (5th ed., pp. 560–583).
St. Louis, MO: Mosby.

56 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

summarized and critiqued the current state of the knowledge on uncertainty
in illness (Bailey & Stewart, 2001; Barron, 2000; Dean & Street, 2015; Mast, 1995;
McCormick, 2002; Mishel, 1997b, 1999; Neville, 2003; Shaha, Cox, Talman, &
Kelly, 2008; Stewart & Mishel, 2000). Other authors have attempted to develop
an expanded defi nition of uncertainty (Penrod, 2001) or have critiqued the
current work based on a misunderstanding of the reconceptualized uncer-
tainty theory (Parry, 2003).

Although some studies focus on components of the UIT or RUIT, more recent
studies have used uncertainty as the conceptual framework for the study and
directly tested major sections of the UIT, elaborated on the UIT, or elaborated
on selected antecedents and outcomes adding richness to the theory (Clayton,
Mishel, M. H., & Belyea 2006; Dimillo et al., 2013; Farren, 2010; Hebdon, Foli, &
McComb, 2015; Jurgens, 2006; Kang, 2005, 2006, 2011; Kang, Daly, & Kim, 2004;
Kim, Lee, & Lee, 2012; Lin, Yeh, & Mishel, 2010; McCormick, Naimark, & Tate,
2006; Sammarco, 2001; Sammarco & Konency, 2010; Santacroce, 2003; Stewart,
Mishel, Lynn, & Terhorst, 2010; Wonghongkul, Dechaprom, Phumivichuvate,
& Losawatkul, 2006). Mishel’s Uncertainty in Illness Scale—Community Form
has demonstrated validity and reliability for measuring uncertainty in men
undergoing active surveillance for early-stage prostate cancer (Bailey et al.,
2011) and ethnically diverse female breast cancer survivors (Hagen et al., 2015;
Liao, Chen, Chen, & Chen, 2008; Sammarco & Konecny, 2010). The theory has
also been used as the basis for revising the Parent’s Perception of Uncertainty
Scale (Santacroce, 2001). In a study by Kang et al. (2004), researchers operation-
alized and tested the antecedents of social support and education as structure
providers along with the stimuli frame variable of symptom pattern on uncer-
tainty in patients with atrial fi brillation. Symptom severity was the strongest
predictor of uncertainty, whereas the structure provider variables of education
and social support reduced uncertainty. An unusual grounded theory study
explored children’s perception of uncertainty during treatment for cancer, cit-
ing the uncertainty theory as the sensitizing theory (Stewart, 2003). A study in
children and adolescents with cancer used the uncertainty theory to guide a
conceptual model that served as the study framework; a strong relationship
was found between children’s uncertainty and psychological distress (Stewart,
Mishel, Lynn, & Terhorst, 2010).

The uncertainty theory has grown through research studies in the areas of
credible authority and social support as the theory has been used by investi-
gators in nursing and health communication (Brashers et al., 2003; Brashers,
Neidig, & Goldsmith, 2004; Clayton et al., 2006; Miller, 2014; Middleton,
LaVoie, & Brown, 2012). For example, Brashers, a health communication
scholar (colleague of Mishel and a member of Clayton’s dissertation commit-
tee), expanded Mishel’s work into the fi eld of health communication, devel-
oping the Uncertainty Management Theory, which was heavily infl uenced by
Mishel’s theoretical conceptualization of uncertainty. This expanded uncer-
tainty theory has been used in HIV populations, noting that management

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  57

of uncertainty may preserve hope (Brashers et al., 2000). Brashers’s work is
important as it illustrates how theoretical development can bridge disciplines,
in this case nursing and health communication, contributing to team and
interdisciplinary science. Clayton’s work in nursing science also addresses
the role of structure providers evaluating the contribution of patient–provider
communication (contribution of structure providers as a credible authority)
as a way to infl uence the appraisal of uncertainty among breast cancer survi-
vors (Clayton & Dudley, 2009; Clayton, Mishel, & Belyea, 2006). Many stud-
ies have focused on the antecedents of stimuli frame and structure providers.
For instance, three aspects of illness have been found to cause uncertainty: (a)
severity of illness, (b) erratic nature of symptoms, and (c) ambiguity of symp-
toms. Severity of illness and ambiguity of symptoms correspond to the stimuli
frame component of symptom pattern, whereas the erratic nature of symptoms
corresponds to the stimuli component of event congruence.

Studies that focus on severity of illness and uncertainty are classifi ed as
those that address the theoretical link between symptom pattern and uncer-
tainty. Severity of illness refers to symptoms with such intensity that they do
not clearly refl ect a discernable, understandable pattern. Several studies have
shown that severity of illness is a predictor of uncertainty, although the indica-
tors of severity of illness have varied across studies (Mishel, 1997b). Among
patients in the acute or treatment phase of illnesses such as cardiovascular dis-
ease (Christman et al., 1988), cancer (Galloway & Graydon, 1996; Hilton, 1994),
fi bromyalgia (Johnson, Zautra, & Davis, 2006), and severe pediatric illness and
cancer (Tomlinson, Kirschbaum, Harbaugh, & Anderson, 1996; Santacroce,
2002), severity of illness was positively associated with uncertainty in patients
and/or family members. Thus, according to the UIT, the nature of the severity
presents diffi culty delineating a symptom pattern about the extent of the dis-
ease, resulting in uncertainty.

Stimuli Frame: Symptom Pattern

Studies that address the process of identifying symptoms of a disease or condi-
tion and reaching a diagnosis are classifi ed as addressing symptom pattern. The
process of receiving a diagnosis requires that a symptom pattern exists and can
be labeled as an illness or a condition. In the UIT, absence of the symptom pat-
tern is associated with uncertainty. Uncertainty levels have been reported to be
highest in those without a diagnosis and undergoing diagnostic examinations
(Hilton, 1993; Mishel, 1981). In studies where patients’ symptoms are not clearly
distinguishable from those of other comorbid conditions, or where symptoms
of recurrence can be confused with signs of aging or other natural processes
and not recognizable as signs of disease, such as in lupus, breast cancer, and
cardiac disease, symptoms are associated with uncertainty (Hilton, 1988; Mishel
& Murdaugh, 1987; Nelson, 1996; Winters, 1999). In a study of long-term breast
cancer survivors, it was not the symptoms that elicited uncertainty but events

58 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

that triggered thoughts of recurrence or the meaning of physical symptoms from
long-term treatment side effects (Gil et al., 2004). High levels of symptoms such
as pain are associated with uncertainty when one does not know how to man-
age the symptoms (Johnson et al., 2006). Additionally, fatigue, insomnia, and
affect changes were associated with elevated cancer-related uncertainty among
young breast cancer survivors (Hall, Mishel, & Germino, 2014). Researchers
investigating Korean breast cancer survivors’ uncertainty across the trajectory
of their treatment found women undergoing treatment experienced higher
levels of uncertainty than after treatment, and the majority of the symptoms
women experienced during radiation and chemotherapy treatment were cor-
related with uncertainty (Kim, Lee, & Lee, 2012). Other research has focused on
understanding the ambiguity of symptom experience associated with preterm
labor (Weiss, Saks, & Harris, 2002). Even previous experience with preterm
labor did not reduce the ambiguity associated with this condition.

The erratic nature of symptom onset and disease progression is a major ante-
cedent of uncertainty in chronic illness (Mishel, 1999). Symptoms that occur
unpredictably fi t the description of the stimuli frame component of event
incongruence because there is no congruity between the cue and the outcome.
The timing and nature of symptom onset, duration, intensity, and location are
unforeseeable, characterized by periods of stability, erratic fl ares of exacerba-
tion, or unpredictable recurrence resulting in uncertainty (Brown & Powell-
Cope, 1991; Mast, 1998; Mishel & Braden, 1988; Sexton, Calcasola, Bottomley, &
Funk, 1999). For example, research has demonstrated the association between
uncertainty and physical symptoms of breast cancer survivors, demonstrating
that unpredictable physical symptoms that come and go, such as fatigue and
arm problems, can create uncertainty about breast cancer recurrence (Clayton
et al., 2006; Wonghongkul et al., 2006). Similarly, diffi culty being aware of phys-
ical symptoms and determining their meaning in acute heart failure patients
has also been found to be related to greater uncertainty (Jurgens, 2006). Among
parents of ill children, unpredictable trajectories with few markers of illness are
positively associated with uncertainty (Cohen, 1993b). Diffi culty in determin-
ing cause of illness has been found to be associated with uncertainty (Cohen,
1993a; Sharkey, 1995; Turner, Tomlinson, & Harbaugh, 1990). Recent work on
patients with endometriosis found that because no cure exists and treatment
effectiveness varies, patients experience uncertainty surrounding the relation-
ship of diagnosis to treatment outcomes (Lemaire, 2004). In young adults with
asthma, uncertainty has been proposed to occur due to episode severity and/
or frequency, which is not contingent upon the person’s attempt to manage the
illness (Mullins, Chaney, Balderson, & Hommel, 2000).

Stimuli Frame: Event Familiarity

Studies that focus on the healthcare or home environment for treatment of
illness fi t under the stimuli frame component of event familiarity. Although

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  59

fewer studies have addressed this component of stimuli frame, the studies that
have been conducted support that unfamiliarity with healthcare environment,
organization, and expectations is associated with uncertainty. Healthcare envi-
ronments characterized by novelty and confusion where the rules and routines
are unknown and equipment and treatments are unfamiliar are associated
with uncertainty (Horner, 1997; Stewart & Mishel, 2000; Turner et al., 1990). A
synthesis and critique of the healthcare environment and uncertainty theories,
including UIT, across disciplines can be found in the work of Han, Klein, and
Arora (2011).

Structure Providers: Social Support

In the UIT, social support from friends, family, and those with similar experi-
ences are proposed to reduce uncertainty directly and indirectly by infl uencing
the stimuli frame. Those with similar experience have been found to infl uence
the stimuli frame by providing information about illness-related events and
symptom pattern (Van Riper & Selder, 1989; White & Frasure-Smith, 1995).
There are a number of studies that support the role of social support in reduc-
ing uncertainty among parents of ill children, adult and adolescent patients,
and their care providers (Bennett, 1993; Davis, 1990; Mishel & Braden, 1987;
Neville, 1998; Tomlinson et al., 1996). For example, research with Taiwanese
older cancer patients identifi ed family members and healthcare providers as
key sources of social support where family members such as spouses provided
emotional support and healthcare providers offered information support (Lien,
Lin, Kuo, & Chen, 2009).

However, when the illness is stigmatized, the questionable acceptance
by others limits the use of social support to manage uncertainty (Brown &
Powell-Cope, 1991; Weitz, 1989). Social interaction also may not always be sup-
portive. Unsupportive interactions serve to heighten uncertainty (Wineman,
1990). The dual impact of social support has also been investigated in men
with HIV/AIDS. Brashers et al. (2004) reported that other individuals help
HIV patients manage uncertainty by providing instrumental support, facilitat-
ing skill development, giving acceptance or validation, allowing ventilation,
and encouraging a perspective shift. They also report that there are problems
associated with social support and uncertainty management including a lack
of coordination in managing uncertainty, the addition of relational uncertainty,
and the burden of caregiver uncertainty. Other investigators have found that
family members experience high levels of uncertainty, which may impair their
ability to provide support for the patient (Brown & Powell-Cope, 1991; Mishel
& Murdaugh, 1987; Wineman, O’Brien, Nealon, & Kaskel, 1993). In a study of
uncertainty in African American and White family members of men with local-
ized prostate cancer, uncertainty was associated with family members feeling
less positive about treatments and patient recovery, feeling more psychological
distress, and engaging in less active problem solving (Germino et al., 1998).

60 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

These fi ndings bring into question the ability of family members to be sup-
portive of the patient when family members are trying to deal with their own
uncertainties. Among younger breast cancer survivors, both social support
and uncertainty together explained 27% of the variance in quality of life, with
higher levels of social support functioning to reduce uncertainty (Sammarco,
2001). Current research supports the theoretical relationship between social
support and uncertainty and provides information on factors that infl uence
effective social support.

Structure Providers: Credible Authority

Credible authority refers to healthcare providers who are seen as credible
information givers by the patient or family member. As experts, healthcare
providers have been proposed to reduce uncertainty by providing informa-
tion and promoting confi dence in their clinical judgment and performance.
Trust and confi dence in the healthcare provider’s ability to make a diagnosis,
to control the illness, and to provide adequate treatment has been reported to
be related to less uncertainty across a variety of acute and chronic illnesses
(Mishel & Braden, 1988; Santacroce, 2000). On the other hand, patients’ lack
of confi dence in the provider’s abilities increases uncertainty (Becker, Janson-
Bjerklie, Benner, Slobin, & Ferdetich, 1993; Smeltzer, 1994). Uncertainty has
also been found to increase when patients report that they are not receiving
adequate information from healthcare providers (Galloway & Graydon, 1996;
Hilton, 1988; Nyhlin, 1990; Small & Graydon, 1993; Weems & Patterson, 1989).

Appraisal of Uncertainty

According to the UIT, appraisal of uncertainty involves personality disposi-
tions, attitudes, and beliefs, which infl uence whether uncertainty is appraised
as a danger or an opportunity. There is support for the impact of uncertainty
on reducing personality dispositions such as optimism, sense of coherence,
and level of resourcefulness (Christman, 1990; Hilton, 1989; Mishel et al.,
1984). Certain dispositions such as generalized negative outcome expectan-
cies interact with uncertainty to predict psychological distress (Mullins et al.,
1995). However, selected cognitive and personality factors have been reported
to mediate the relationship between uncertainty and danger or opportunity.
Mediators that decrease the impact of uncertainty on danger and adjustment
include higher enabling skill, self-effi cacy, mastery, hope, challenge, and existen-
tial well-being (Braden, Mishel, Longman, & Burns, 1998; Landis, 1996; Mishel,
Padilla, Grant, & Sorenson, 1991; Mishel & Sorenson, 1991; Wonghongkul et al.,
2006; Wonghongkul, Moore, Musil, Schneider, & Deimling, 2000). Some studies
where appraisals were found to be positive are of populations that are a num-
ber of years posttreatment. Others have reported that positive appraisals of
uncertainty can be found along with negative appraisals, enabling both to exist
simultaneously. This has been reported for patients awaiting coronary artery

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  61

bypass surgery where uncertainty can be seen as a source for hope (McCormick
et al., 2006). However, work by Kang (2006) with a sample of patients with
atrial fi brillation reported that appraisal of uncertainty as an opportunity had
a negative relationship with depression, and appraisal of uncertainty as a dan-
ger was positively associated with depression. As uncertainty increased, so did
the danger appraisal, which was related to a decrease in mental health (Kang,
2005).

Coping With Uncertainty

Numerous investigators who have studied the management of uncertainty
have found that higher uncertainty is associated with danger and resultant
emotion-focused coping strategies such as wishful thinking, avoidance, and
fatalism (Christman, 1990; Hilton, 1989; Mishel & Sorenson, 1991; Mishel et al.,
1991; Redeker, 1992; Webster & Christman, 1988). Severe symptoms such as
high levels of pain in interaction with uncertainty have been reported to reduce
one’s ability to cope with symptoms (Johnson et al., 2006). Others report more
varied coping strategies for managing uncertainty including cognitive strate-
gies such as downward comparison, constructing a personal scenario for the
illness, use of faith or religion, and identifying markers and triggers (Baier,
1995; Mishel & Murdaugh, 1987; Wiener & Dodd, 1993). Mishel (1993) offered a
review of major uncertainty management methods; however, there is little evi-
dence for the use of any of these coping strategies mediating the relationship
between uncertainty and emotional distress (Mast, 1998; Mishel & Sorenson,
1991; Mishel et al., 1991). Although there has not been much study of the role
of hopefulness in managing uncertainty, fi ndings from a study of participation
in a clinical drug trial revealed that uncertainty was related to a decrease in
hope during time in the trial. Those with more uncertainty and less hopeful-
ness reported more negative moods (Wineman, Schwetz, Zeller, & Cyphert,
2003). Research with Thai patients being treated for head and neck cancer used
the UIT as a framework to study factors that contribute to quality of life as a
way to address coping approaches for this population. Findings indicated that
symptom experience had a positive impact on uncertainty and uncertainty had
a negative impact on quality of life (Detprapon, Sirapo-ngam, Sitthimongkol,
Mishel, & Vorapongsathorn, 2009), leading the authors to suggest that coping
with symptoms and uncertainty is critical to optimizing quality of life. In the
area of uncertainty in children, Stewart (2003) reported that children empha-
sized the routine and ordinariness of their lives despite their cancer diagnosis
and treatment as a way of coping.

Uncertainty and Adjustment

According to the UIT, adjustment refers to returning to the individual’s level
of pre-illness functioning. However, most of the research has interpreted this
as emotional stability or quality of life. Few studies have tested the complete

62 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

outcome portion of the theory, including uncertainty, appraisal, coping strate-
gies, and adjustment. Most studies examine the relationship between uncer-
tainty and an outcome and relate these fi ndings to the theory. The fi ndings
from these studies have consistently shown positive relationships between
uncertainty and negative emotional outcomes (Bennett, 1993; Mast, 1998;
Mishel, 1984; Mullins et al., 2001; Sanders-Dewey, Mullins, & Chaney, 2001;
Small & Graydon, 1993; Taylor-Piliae & Molassiotis, 2001; Wineman, Schwetz,
Goodkin, & Rudick, 1996). Further evidence for the signifi cant effect of uncer-
tainty on depression was reported by Mullins et al. (2000) in young adults with
asthma. The effect of uncertainty on depression was at its maximum under
conditions of increased illness severity. Uncertainty has also been related to
poorer psychosocial adjustment in the areas of less life satisfaction (Hilton,
1994), negative attitudes toward healthcare, family relationships, recreation
and employment (Mishel et al., 1984; Mishel & Braden, 1987), less satisfac-
tion with healthcare services (Green & Murton, 1996), poor decision mak-
ing (Mishel, 1999; Politi & Street, 2011), and poorer quality of life (D. Carroll,
Hamilton, & McGovern, 1999; Padilla, Mishel, & Grant, 1992). Santacroce
(2003) identifi ed the linkage between uncertainty and negative outcomes in
her literature review on parental uncertainty and posttraumatic stress in seri-
ous childhood illness.

There has been extensive study of uncertainty in illness based on the UIT,
and most of the research supports components of the theory. Overall, the UIT
has been very useful in guiding research with a variety of clinical populations
and caregivers.

■ RESEARCH USING THE RUIT

Less attention has been given to the study of the RUIT, possibly due to dif-
fi culty in studying a process that evolves over time. Support for the RUIT has
been found in qualitative studies that favor a transition through uncertainty
to a new orientation toward life with acceptance of uncertainty as a part of
life (Mishel, 1999). The samples for these studies included long-term diabetic
patients (Nyhlin, 1990), chronically ill men (Charmaz, 1994), HIV patients
(Brashers et al., 2003; Katz, 1996), persons with schizophrenia (Baier, 1995),
spouses of heart transplant patients (Mishel & Murdaugh, 1987), family care-
givers of AIDS patients (Brown & Powell-Cope, 1991), breast cancer survivors
(Mishel et al., 2005; Nelson, 1996; Pelusi, 1997), women who are genetically pre-
disposed to hereditary breast and ovarian cancer but have not been diagnosed
(DiMillo et al., 2013), adolescent survivors of childhood cancer (Parry, 2003),
and women recovering from cardiac disease (Fleury, Kimbrell, & Kruszewski,
1995). For example, Bailey, Wallace, and Mishel (2007), using the RUIT as an
organizing framework, interviewed men who were undergoing watchful

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  63

waiting during their treatment for prostate cancer. Although the fi ndings were
not totally supportive of the RUIT, men did express that they had generated
options, created opportunities for themselves, and remained hopeful of a posi-
tive outcome. Parry’s (2003) study of childhood cancer survivors suggests that
uncertainty can be a catalyst for growth, for a greater appreciation for life, and
for greater awareness of life purpose. However, in another study of survivors
of childhood cancer, fi ndings showed that uncertainty mediated the relation-
ship between posttraumatic stress disorder and health promotion behaviors,
indicating that uncertainty exists over time and reduces health promotion
activities (Santacroce & Lee, 2006).

Results supporting the RUIT seem to differ by subject population and meth-
odology, where more qualitative studies—compared with quantitative stud-
ies—support the RUIT. The transition through uncertainty toward a new view
of life was framed differently by each investigator and included themes such
as a revised life perspective, new ways of being in the world, growth through
uncertainty, new levels of self-organization, new goals for living, devaluat-
ing what is worthwhile, redefi ning what is normal, and building new dreams
(Bailey & Stewart, 2001). All the investigators described the gradual acceptance
of uncertainty and the restructuring of reality as major components of the pro-
cess, both of which are consistent with the RUIT.

Recently, the RUIT scale has been adapted to examine uncertainty among
breast cancer patients and survivors (Farren, 2010; Hagen et al., 2015; Hall et
al., 2014) including Korean breast cancer survivors (Kim, Lee, & Lee, 2012),
Taiwanese breast cancer patients (Liao et al., 2008), and Taiwanese parents of
children with cancer (Lin et al., 2010). The scale addresses growth through
uncertainty toward a new view of life and was developed to address the
discrepancy noted earlier between qualitative and quantitative approaches
to study the RUIT. Initial use of the scale was reported by Mast (1998). The
Growth Through Uncertainty Scale (GTUS) has been used in a few clinical
investigations. In an intervention study guided by the RUIT, baseline analysis
of the data included use of the GTUS. The analysis was to identify variables
that would predict either negative mood state or personal growth (GTUS) in
older African American and White long-term breast cancer survivors. Of the
variables found to be signifi cant predictors, negative cognitive state, which
included uncertainty, was a signifi cant predictor of both outcomes. The overall
fi ndings were supportive of the RUIT because cognitive reappraisal, defi ned as
the tendency to address concerns from a positive point of view, predicted 40%
of the variance in personal growth (GTUS; Porter et al., 2006). Also, in fi ndings
from this intervention study, at 10 months and 20 months postintervention,
older long-term African American breast cancer survivors in the treatment
group maintained or increased scores on the GTUS over time, while scores for
subjects in the control group declined over time (Gil, Mishel, Belyea, Germino,
Porter, & Clayton, 2006; Mishel et al., 2005).

64 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

■ INTERVENTIONS TO MANAGE UNCERTAINTY

An uncertainty management intervention has been developed and tested in
four clinical trials for breast cancer patients and patients with localized or
advanced prostate cancer (Braden et al., 1998; Mishel, 1997a; Mitchell, Courtney,
& Coyer, 2003; Mishel et al., 2002). The intervention was structured to follow
the UIT and was delivered by weekly phone calls to cancer patients. All studies
included equal numbers of White and minority samples. The intervention was
effective in teaching patients skills to manage uncertainty including improve-
ments in problem solving, cognitive reframing, treatment-related side effects,
and patient–provider communication. Improvement was also found in the
ability to manage the uncertainty related to side effects from cancer treatment.
Religious participation and education were found to be moderators of the treat-
ment outcomes of cancer knowledge and patient–provider communication in
the intervention trial for men with localized prostate cancer. Education was
a covariate in the study of older women during treatment for breast cancer.
Using the UIT and RUIT as frameworks for study of an intervention for older
long-term African American and White breast cancer survivors, a self-deliv-
ered uncertainty management intervention with nurse assistance was tested
and results indicated that the intervention at 10-month and 20-month follow-
up produced signifi cant differences in experimental and control groups in cog-
nitive reframing, cancer knowledge, patient–provider communication, and a
variety of coping skills. The most important results were the improvement in
the treatment groups’ pursuit of further information along with declines in
uncertainty and stable effects in personal growth over time (Gil et al., 2006;
Mishel et al., 2005).

Further intervention work based on the UIT and the RUIT has been expanded
to prostate cancer. Bailey, Mishel, Belyea, Stewart, and Mohler (2004) tested an
intervention for men selecting watchful waiting for prostate cancer, fi nding it
assisted the men in cognitively reframing and thus effectively managing their
uncertainty. Specifi cally, the results from this clinical trial showed that men in
the intervention improved on the GTUS on the subscale of living life in a new
light and believing that their future would be improved. In another study with
the same population, a pilot study with nine participants (Kazer, Baily, Sanda,
Colberg, & Kelly, 2011) supported use of an Internet intervention to improve
quality of life while uncertainty remained consistent. Additionally, Mishel et
al. (2009) developed and tested a decision-making uncertainty management
intervention for recently diagnosed prostate cancer patients. They found the
intervention improved patients’ knowledge, communication skills, problem
solving, and resource management. In similar work, Song and colleagues used
the UIT to guide a study evaluating a decision aid designed to improve infor-
mation giving and questions asking during prostate cancer treatment consulta-
tions (Song et al., 2016). Findings showed that enhanced communication with
providers empowered men and their family members.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  65

In a study of an intervention program that incorporated uncertainty reduc-
tion for women with recurrent breast cancer and their family members, fac-
tual information about cancer recurrence and treatments encouraged assertive
approaches with healthcare providers; participants focused on learning to live
with uncertainty in preference to negative certainty (Northouse et al., 2002). An
intervention trial for newly diagnosed breast cancer patients in Taiwan used
the UIT framework and provided information to questions raised by patients.
This continual supportive care was given at four points during treatment. The
fi ndings indicated that support was increased and uncertainty was decreased
1 month after surgery and 4 months after diagnosis (Liu, Li, Tang, Huang, &
Chiou, 2006). Other intervention studies included uncertainty as a variable but
did not use either the UIT or RUIT as a framework for the study or interven-
tion (Kreulen & Braden, 2004; McCain et al., 2003; Taylor-Piliae & Chair, 2002).
The number of intervention studies using one of the uncertainty theories or
including interventions to address uncertainty is continually increasing in the
literature.

■ USE OF THE THEORIES IN NURSING PRACTICE

Nurses are included in the UIT as part of the antecedent variable of struc-
ture providers. The clinical literature supports delivery of information as the
major method to help patients manage uncertainty. Nurses provide informa-
tion that helps patients develop meaning from the illness experience by pro-
viding structure to the stimuli frame. When considering the RUIT, nurses help
patients manage chronic uncertainty by assisting with patients’ reappraisal
of uncertainty from stressful to hopeful in addition to providing relevant
information.

Understanding the sources of patient uncertainty can help nurses plan for
effective information giving and may greatly assist nurses to help patients
manage or reduce their uncertainty. In one of the few articles to address the
environmental component of the stimuli frame, Sharkey (1995) discussed how
family coping could be enhanced by home care nurses normalizing health-
care into the familiar routines of families caring for a terminally ill child at
home. Among cardiac patients, White and Frasure-Smith (1995) suggested that
nurses promote the use of patient-solicited social support to manage uncer-
tainty in percutaneous transluminal coronary angioplasty (PTCA) patients.
These researchers suggested that the benefi t from the social support received
by PTCA patients was due to direct requests tailored to specifi c needs ver-
sus unsolicited social support due to simply being ill. In addition, information
from nurses about the potential long-term success of this procedure might help
reduce the higher uncertainty found in PTCA patients 3 months after surgery.
Among breast cancer survivors, Gil et al. (2004, 2005) suggested that nurses can
help women identify their personal triggers of uncertainty about recurrence

66 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

and then teach coping skills such as breathing relaxation, pleasant imagery,
calming self-talk, and distraction to help survivors manage their uncertainty.

The RUIT has also been used to inform clinical practice and help nurses
understand sources of patient uncertainty. An example of how mental health
nurses can assist patients by understanding sources of uncertainty is found
in research by Brashers et al. (2003) describing the medical, social, and per-
sonal forms of uncertainty for persons living with HIV/AIDS. Further, this
research suggests nurses should be aware that subgroups of the population
such as women, drug users, gay and lesbian persons, transgender persons, and
parents can experience different sources of uncertainty based on social stigma,
role and/or identity confusion, and lack of familiarity with the medical system.
Other research using the RUIT indicates that childhood cancer survivors often
have late emerging side effects that impact quality of life and the experience of
uncertainty similar to other long-term cancer survivors (Lee, 2006; Santacroce
& Lee, 2006). These studies suggest that childhood cancer survivors who lack
effective coping and uncertainty management skills may be unable to reap-
praise uncertainty and are at risk for the development of posttraumatic stress
symptoms (PTSS) as a way of avoiding uncertainty when life demands become
excessive (Lee, 2006). Health professionals who are aware of the increased risk
of PTSS created by an inability to reappraise uncertainty can offer develop-
mentally appropriate information, thereby clarifying the ambiguity of future
survivorship and helping childhood cancer survivors manage the continual
uncertainty in their lives (Santacroce & Lee, 2006).

Recognizing uncertainty and then providing contextual cues to reduce ambi-
guity and increase understanding is one approach that nurses can use when
communicating with patients to decrease uncertainty. Contextual cues pro-
vide explanations of what patients will see, hear, and feel during procedures
and tests, as well as what signs and symptoms they will experience at vari-
ous points in their illness trajectory. Providing information and explanations
about treatments and medications has been proposed to be the most impor-
tant and frequent approach to reducing patient uncertainty (Mishel et al., 2002;
Wineman et al., 1996). Galloway and Graydon (1996), who based their fi ndings
on recently discharged colon cancer patients, noted that nurses could provide
information to alleviate the uncertainty of being discharged to the home envi-
ronment. Correspondingly, Mitchell, Courtney, and Coyer (2003) found that
nurses provide benefi cial contextual cues and information to both families and
patients on transfer from the intensive care unit to a general hospital fl oor.
Families of patients who received clear information were more able to make
decisions for patients, reported less anxiety, and were better able to provide
emotional and physical patient support. Other effective methods for reduc-
ing patient uncertainty can include encouraging communication with patients
who have successfully managed their uncertainties. Weems and Patterson
(1989) suggest sharing the uncertainties of waiting for a renal transplant with
someone who has already received a transplant, or sharing uncertainties of

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  67

how to live with chronic obstructive pulmonary disease with someone who is
successfully managing this chronic disease (Small & Graydon, 1993). This type
of communication provides information to patients for structuring the stimuli
and also functions as a source of social support.

Offering comprehensive information allows the nurse to function as a cred-
ible authority, strengthening the stimuli frame by enhancing disease predict-
ability and reducing symptom ambiguity. Righter (1995) used the UIT to
describe the role of an enterostomal therapy (ET) nurse as a credible authority
for the ostomy patient. She describes the ET nurse as providing structure and
order to the experience of the new ostomy patient through clinical expertise
and experience. The ET nurse reduces the ambiguity of the ostomy experience
by providing information, counseling, and support. This facilitates ostomy
patients’ adaptation to their newly altered perception of themselves and helps
them regain a sense of control and mastery by creating order and predictability.
Other ideas on changing clinical practice to reduce patient uncertainty include
educational interventions delivered in person, by telephone, or by individual-
ized patient information packets delivered through the mail (Calvin & Lane,
1999; Mishel et al., 2002). Research by Bailey et al. (2004) found that nurses
can clarify information about treatment options that create confusion for men
who have selected watchful waiting as their treatment choice for prostate can-
cer. Nurses can answer patient questions about variations in prostate-specifi c
antigen values, thus reducing uncertainty about both disease progression and
future events. Understanding the meaning of laboratory values helped men
sort out the confusion associated with mixed messages given to them by family
who promoted aggressive treatment and urologists who promoted watchful
waiting. Mishel et al. (2002) found that prostate cancer patients immediately
postsurgery or during radiation therapy felt reassured when their questions
were answered by a nurse, resulting in reduced anxiety and uncertainty. These
men also expressed appreciation for the concern of a health professional and
subsequently reported feeling less alone in their battle with cancer.

When considering the predictability of illness trajectories, Sexton et al.
(1999) found that advanced practice nurses helped patients manage a diag-
nosis of asthma by implementing nursing actions that helped patients predict
and manage their asthma attacks. Similarly, among breast cancer survivors,
unpredictable physical symptoms such as fatigue and arm problems, which
may come and go, can create uncertainty about cancer recurrence (Clayton
et al., 2006; Wonghongkul et al., 2006). Thus, providers—including advanced
practice nurses—should try to communicate in a manner that fully explains
existing symptoms and their relationship or lack thereof to cancer recurrence
(Clayton, Dudley, & Musters, 2008).

Clinical journals are increasingly identifying patient uncertainty as an
important part of the illness experience and provide suggestions for nursing
actions to reduce patient uncertainty or facilitate a new outlook by focusing
on choices and alternatives. Suggestions for managing uncertainty in clinical

68 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

practice include work by Crigger (1996), who suggests that nurses can help
women adapt positively to multiple sclerosis by shifting the emphasis from the
management of physical disability to the management of uncertainty, thereby
helping women achieve mastery over their daily lives. Similarly, Calvin and
Lane (1999) suggested incorporating preoperative psychoeducational inter-
ventions to reduce uncertainty as part of orthopedic preadmission visits. Other
examples of using the UIT to develop and implement nursing interventions
to reduce uncertainty and regain control in clinical settings are suggested
by Allan (1990) for HIV-positive men; Sterken (1996) for fathers of pediatric
cancer patients; Northouse, Mood, Templin, Mellon, and George (2000) for
patients with colon cancer; and Sharkey (1995) for homebound pediatric oncol-
ogy patients. Ritz et al. (2000) report another nursing intervention to manage
uncertainty in clinical practice. These clinicians investigated the effect of fol-
low-up nursing care by the advanced practice nurse after discharge of newly
treated breast cancer patients. Six months after diagnosis, uncertainty was
reduced and quality of life was improved. Despite this early work and subse-
quent recommendations, uncertainty is not regularly assessed during routine
nursing practice (Shaha et al., 2008). On the basis of the antecedent variables of
UIT, Northouse et al. (2000) suggested that health professionals keep in mind
individual characteristics of patients, social environments, and methods of ill-
ness appraisal when caring for patients with colon cancer. They suggested that
nurses provide patients with a framework of expectations about the physical
and emotional illness trajectory associated with the fi rst year of managing this
diagnosis. Thus, use of the UIT can help nurses recognize groups of patients
and/or caregivers that may be at risk for increased uncertainty. For example,
Sterken (1996) found that younger fathers did not understand the information
given to them about their child’s treatment and disease patterns as well as older
fathers, illustrating how cognitive capacity infl uences uncertainty. Santacroce
(2002) found that African American parents of children newly diagnosed with
cancer experienced greater uncertainty than White parents. She posits that past
experiences with the healthcare system can impact parental uncertainty. These
studies illustrate the diffi culty as well as the potential benefi t in using demo-
graphic characteristics to identify persons at risk for heightened uncertainty.

Other investigators have explained how the theory can be applied to under-
standing a clinical situation, clinical diagnosis, or clinical practice. For exam-
ple, it is important to realize when increased uncertainty can place patients
at risk for additional illnesses, such as recognizing that uncertainty is a major
factor contributing to depression in patients with hepatitis C (Saunders &
Cookman, 2005). Some clinical areas such as women’s health and cardiovascu-
lar disease have been studied in depth. In the area of women’s health, Sorenson
(1990) discusses the concepts of symptom pattern, event familiarity and con-
gruency, cognitive capacity, structure providers, and credible authority, using
examples from normal pregnancy to help nurses relate the theory to women
who are experiencing diffi culty adapting to the uncertainties of pregnancy. For

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  69

women experiencing high-risk pregnancy, they preferred the coping strategy
of avoidance as a means for managing uncertainty and preserving their sense
of well-being (Giurgescu, Penckofer, Maurer, & Bryant, 2006). Suggestions are
made about how perinatal nurses can help women accept impending mother-
hood and utilize more effective coping mechanisms to reduce uncertainty and
improve psychological well-being. Lemaire and Lenz (1995) applied the UIT to
the condition of menopause. The stimuli frame for menopause was defi ned as
the symptoms that indicate approaching menopause, including mood swings,
hot fl ashes, dry skin, and memory changes. If women received factual informa-
tion from a source deemed credible, such as nurses and healthcare providers, it
was thought that familiarity with the event of menopause would be increased
and uncertainty about this normal life event would be decreased. Consistent
with predictions of UIT, uncertainty declined after receipt of understandable
information delivered by a credible source, allowing women to construct
meaning from the ambiguity and unpredictability of their symptoms sur-
rounding the normal process of menopause. Similarly, Lemaire (2004) suggests
that nurses who understand the uncertainty associated with the symptoms of
endometriosis are better able to care for women experiencing this condition.
Nursing actions such as providing informational material, offering referrals
to support groups, and sharing electronic resources can help women better
understand and manage the ambiguity and unpredictability of symptoms
such as cramping, nonmenstrual pain, and fatigue. Other research has focused
on understanding the ambiguity of symptoms associated with preterm labor
(Weiss et al., 2002). Weiss et al. found that women lacked familiarity with the
symptom pattern of preterm labor. They suggest that language used by women
in describing preterm labor be incorporated into educational materials avail-
able to all pregnant women to help them recognize preterm labor as differenti-
ated from term labor. They stress that every expectant woman needs education
about the cues to use in recognizing preterm labor.

In patients diagnosed with atrial fi brillation, the UIT can help nurses iden-
tify patients at risk for increased uncertainty (Kang et al., 2004). Focusing on
the antecedents of uncertainty, fi ndings showed that patients with more severe
symptoms and those with less education experienced greater uncertainty, help-
ing nurses to be more aware of which patients may be at risk. Other research
has found that those patients who receive an implantable cardioverter defi bril-
lator experience great uncertainty, never knowing when their arrhythmias may
recur and when the device may “fi re” (Flemme et al., 2005). S. L. Carroll and
Arthur (2010) studied uncertainty, optimism, and anxiety in patients receiv-
ing their fi rst implantable defi brillator. Further, hospital nurses may have little
time to prepare these patients for discharge as there is no need for further hos-
pitalization postimplantation of the device. Therefore, out-patient clinic and
offi ce nurses can provide key information and support to these patients, rec-
ognizing that the high levels of uncertainty frequently experienced by these
patients put them at risk for poorer quality of life. In another study Rydström

70 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Dalheim-Englund, Segesten, and Rasmussen (2004) note the uncertainty that
affects the whole family when a child has asthma, suggesting education for
both parents and siblings about asthma as well as the impact of asthma on fam-
ily dynamics. Further, these authors stress the importance of communicating to
families that their nurse is approachable about both disease issues and family
dynamics issues as part of holistic disease management. Similarly, for women
diagnosed with fi bromyalgia, a recent study using the UIT as a guiding frame-
work suggested that the information provided by health professionals helps
reduce patient anxiety and uncertainty (Trivino Martinez, Solano Ruiz, & Siles
Gonzalez, 2016).

Another approach to improving patient care is recognizing the importance
of professional education on uncertainty to effect change in clinical practice.
Wunderlich, Perry, Lavin, and Katz (1999) suggested that critical care nurses
would benefi t from staff development sessions on how to address the uncer-
tainty that patients experience during the process of weaning from mechani-
cal ventilation. Dombeck (1996) commented that healthcare professionals need
to increase their own tolerance for ambiguity and uncertainty to effectively
listen to clients who are experiencing ambiguity and uncertainty. Similarly,
Light (1979) noted that healthcare providers have been socialized to mini-
mize uncertainty; this socialization may make it diffi cult to effectively address
patient uncertainty until healthcare workers learn more about it (Baier, 1995).
Recognizing the importance of integrating UIT into a management strategy for
asthma patients, the American Nurses Credentialing Center’s Commission on
Accreditation offered three credit hours for successful completion of a continu-
ing education unit (CEU) quiz following the published article (Sexton et al.,
1999) about coping with uncertainty. Other CEU offerings incorporating uncer-
tainty theory have been offered following a case study on spiritual disequilib-
rium (Dombeck, 1996) and an article on weaning a patient from mechanical
ventilation (Wunderlich et al., 1999).

■ CONCLUSION

The Uncertainty in Illness theories have been used in multiple ways to inform
clinician understanding of patients, families, and illness situations. Because
uncertainty is an inherent aspect of illness-related experiences (Babrow
& Kline, 2000), it is not surprising it has evolved and moved to other disci-
plines such as the fi elds of medicine and health communication. Yet with such
adaption comes different conceptualizations of uncertainty. In this chapter,
uncertainty has been defi ned as the inability to determine the meaning of an
illness-related event (Mishel, 1988). In medicine, uncertainty is defi ned as an
individual’s subjective, perceived ignorance that encompasses sources, issues,
and loci, which infl uence actions and produce psychological responses (Han,
Klein, & Arora, 2011; Han, Klein, Lehman, et al., 2011). Furthermore, in the

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  71

health communication literature, uncertainty is seen as feeling unsure about
possible choices, decisions, and/or actions due to incomplete, inaccurate, or
complex information (Dean, & Street, 2015; Shaha et al., 2008). While different,
underlying each of these defi nitions is a lack of understanding of one’s situa-
tion due to an illness event or complex health experience.

Clinical research guided by both the original UIT (1988) and the RUIT (1990)
for those coping with both acute and chronic illnesses will continue to help
identify appropriate nursing interventions for many types of illnesses and
patients. Ultimately, the recognition of the importance of uncertainty can
change clinical practice, allowing the development of nursing interventions
that facilitate a positive patient adaptation to the illness experience.

■ REFERENCES

Allan, J. D. (1990). Focusing on living, not dying: A naturalistic study of self-care

among seropositive gay men. Holistic Nursing Practice, 4(2), 56–63.

Allen, D. G. (1985). Nursing research and social control: Alternative models of science

that emphasize understanding and emancipation. Image: Journal of Nursing
Scholarship, 17, 58–64.

Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and
stay well. San Francisco, CA: Jossey-Bass.

Babrow, A. S., & Kline, K. N. (2000). From ’reducing’ to ’coping with’ uncertainty:

Reconceptualizing the central challenge in breast self-exams. Social Science &
Medicine, 51, 1805–1816.

Baier, M. (1995). Uncertainty of illness for persons with schizophrenia. Issues in
Mental Health Nursing, 16, 201–212.

Bailey, D. E., Mishel, M. H., Belyea, M., Stewart, J. L., & Mohler, J. (2004). Uncertainty

intervention for watchful waiting in prostate cancer. Cancer Nursing, 27(5),

339–346.

Bailey, D. E., & Stewart, J. L. (2001). Mishel’s theory of uncertainty in illness. In A. M.

Mariner-Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (5th ed.,

pp. 560–583). St. Louis, MO: Mosby.

Bailey, D. E., Wallace, M., Latini, D. M., Hegarty, J., Carroll, P. R., Klein, E. A., &

Albertsen, P. C. (2011). Measuring illness uncertainty in men undergoing active

surveillance for prostate cancer. Applied Nursing Research, 24, 193–199.

Bailey, D. E., Wallace, M., & Mishel, M. H. (2007). Watching, waiting and uncertainty

in prostate cancer. Journal of Clinical Nursing, 16(4), 734–741.

Barron, C. R. (2000). Stress, uncertainty, and health. In V. H. Rice (Ed.), Handbook of
stress, coping and health: Implications for nursing research, theory, and practice (pp.

517–539). Thousand Oaks, CA: Sage.

Becker, G., Janson-Bjerklie, S., Benner, P., Slobin, K., & Ferdetich, S. (1993). The

dilemma of seeking urgent care: Asthma episodes and emergency service use.

Social Science & Medicine, 37, 305–313.

72 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Bennett, S. J. (1993). Relationships among selected antecedent variables and coping

effectiveness in postmyocardial infarction patients. Research in Nursing and Health,

16, 131–139.

Bower, G. H. (1978). The psychology of learning and motivation: Advances in research and
theory. New York, NY: Academic Press.

Braden, C. J., Mishel, M. H., Longman, A. J., & Burns, L. (1998). Self-help

intervention project: Women receiving breast cancer treatment. Cancer Practice,

6(2), 87–98.

Brashers, D. E., Neidig, J. L., & Goldsmith, D. J. (2004). Social support and the

management of uncertainty for people living with HIV. Health Communication, 16,

305–331.

Brashers, D. E., Neidig, J. L., Haas, S. M., Dobbs, L. K., Cardillo, L., & Russell, J. A.

(2000). Communication in the management of uncertainty: The case of persons

living with HIV or AIDS. Communication Monographs, 67(1), 63–84.

Brashers, D. E., Neidig, J. L., Russell, J. A., Cardillo, L. W., Haas, S. M., Dobbs, L. K.,

. . . Nemeth, S. (2003). The medical, personal, and social causes of uncertainty in

HIV illness. Issues in Mental Health Nursing, 24(5), 497–522.

Brown, M. A., & Powell-Cope, G. M. (1991). AIDS family caregiving: Transitions

through uncertainty. Nursing Research, 40, 337–345.

Budner, S. (1962). Intolerance of ambiguity as a personality variable. Journal of
Personality, 30, 29–50.

Calvin, R., & Lane, P. (1999). Perioperative uncertainty and state anxiety of

orthopaedic surgical patients. Orthopedic Nursing, 18(6), 61–66.

Carroll, D., Hamilton, G., & McGovern, B. (1999). Changes in health status and

quality of life and the impact of uncertainty in patients who survive life-

threatening arrhythmias. Heart and Lung, 28(4), 251–260.

Carroll, S. L., & Arthur, H. M. (2010). A comparative study of uncertainty, optimism

and anxiety in patients receiving their fi rst implantable defi brillator for primary

and secondary prevention of sudden cardiac death. International Journal of
Nursing Studies, 47, 836–845.

Charmaz, K. (1994). Identity dilemmas of chronically ill men. The Sociological
Quarterly, 35(2), 269–288.

Christman, N. J. (1990). Uncertainty and adjustment during radiotherapy. Nursing
Research, 39(1), 17–20.

Christman, N. J., McConnell, E. A., Pfeiffer, C., Webster, K. K., Schmitt, M., & Ries,

J. (1988). Uncertainty, coping, and distress following myocardial infarction:

Transition from home to hospital. Research in Nursing and Health, 11, 71–82.

Clayton, M. F., & Dudley, W. (2009). Patient-centered communication during

oncology follow-up visits for breast cancer survivors: content and temporal

structure. Oncology Nursing Forum, 36(2), E68–E79.

Clayton, M. F., Dudley, W. N., & Musters, A. (2008). Communication with breast

cancer survivors. Health Communication, 39, 175.

Clayton, M. F., Mishel, M. H., & Belyea, M. (2006). Testing a model of symptoms,

communication, uncertainty, and well-being, in older breast cancer survivors.

Research in Nursing and Health, 29(1), 18–39.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  73

Cohen, M. H. (1993a). Diagnostic closure and the spread of uncertainty. Issues in
Comprehensive Pediatric Nursing, 16, 135–146.

Cohen, M. H. (1993b). The unknown and the unknowable: Managing sustained

uncertainty. Western Journal of Nursing Research, 15(1), 77–96.

Crigger, N. J. (1996). Testing an uncertainty model for women with multiple sclerosis.

Advances in Nursing Science, 18(3), 37–47.

Davis, L. L. (1990). Illness uncertainty, social support, and stress in recovering

individuals and family caregivers. Applied Nursing Research, 3(2), 69–71.

Dean, M., & Street, R. L., Jr. (2015). Managing uncertainty in clinical encounters. In

A. Hannawa & B. Spitzberg (Eds.), Communication Competence (pp. 477–501).

Berlin, Germany: de Gruyter Mouton.

Detprapon, M., Sirapo-ngam, Y., Mishel, M. H., Sitthimongkol, Y., &

Vorapongsathorn, T. (2009). Testing uncertainty in illness theory to predict quality

of life among Thais with head and neck cancer. Thai Journal of Nursing Research,

13(1), 1–15. Retrieved from https://www.tci-thaijo.org/index.php/PRIJNR/

article/view/6366

Dimillo, J., Samson, A., Thériault, A., Lowry, S., Corsini, L., Verma, S., & Tomiak, E.

(2013). Living with the BRCA genetic mutation: An uncertain conclusion to an

unending process. Psychology, Health & Medicine, 18(2), 125–134.

Dombeck, M. (1996). Chaos and self-organization as a consequence of spiritual

disequilibrium. Clinical Nurse Specialist, 10(2), 69–73; quiz 74–75.

Farren, A. T. (2010). Power, uncertainty, self-transcendence, and quality of life in

breast cancer survivors. Nursing Science Quarterly, 23(1), 63–71.

Flemme, I., Edvardsson, N., Hinic, H., Jinhage, B. M., Dalman, M., & Fridlund,

B. (2005). Long-term quality of life and uncertainty in patients living with an

implantable cardioverter defi brillator. Heart & Lung, 34(6), 386–392.

Fleury, J., Kimbrell, L. C., & Kruszewski, M. A. (1995). Life after a cardiac event:

Women’s experience in healing. Heart & Lung, 24, 474–482.

Galloway, S., & Graydon, J. (1996). Uncertainty, symptom distress, and information

needs after surgery for cancer of the colon. Cancer Nursing, 19(2), 112–117.

Germino, B. B., Mishel, M. H., Belyea, M., Harris, L., Ware, A., & Mohler, J. (1998).

Uncertainty in prostate cancer, ethnic and family patterns. Cancer Practice, 6(2),

102–113.

Gil, K. M., Mishel, M. H., Belyea, M., Germino, B., Porter, L., & Clayton, M. (2006).

Benefi ts of the uncertainty management intervention for African American and

White older breast cancer survivors: 20-month outcomes. International Journal of
Behavioral Medicine, 13(4), 285–294.

Gil, K. M., Mishel, M. H., Belyea, M., Germino, B., Porter, L. S., LeNey, I. C., . . .

Stewart, J. (2004). Triggers of uncertainty about recurrence and treatment

side effects in long-term older breast African American and Caucasian cancer

survivors. Oncology Nursing Forum, 31(3), 633–639.

Gil, K. M., Mishel, M. H., Germino, B., Porter, L. S., Carlton-LaNey, I., & Belyea, M.

(2005). Uncertainty management intervention for older African American and

Caucasian long-term breast cancer survivors. Journal of Psychosocial Oncology,

23(2–3), 3–21.

74 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Giurgescu, C., Penckofer, S., Maurer, M. C., & Bryant, F. B. (2006). Impact of

uncertainty, social support, and prenatal coping on the psychological well-being

of high-risk pregnant women. Nursing Research, 55(5), 356–365.

Green, J., & Murton, F. (1996). Diagnosis of Duchenne muscular dystrophy: Parents’

experiences and satisfaction. Child: Care, Health & Development, 22, 113–128.

Hagen, K. B., Aas, T., Lode, K., Gjerde, J., Lien, E., Kvaløy, J. T., . . . Lind, R. (2015).

Illness uncertainty in breast cancer patients: Validation of the 5-item short form

of the Mishel Uncertainty in Illness Scale. European Journal of Oncology Nursing,

19(2), 113–119.

Han, P. K. J., Klein, W. M. P., & Arora, N. K. (2011). Varieties of uncertainty in health

care: A conceptual taxonomy. Medical Decision Making, 31(6), 828–838.

Han, P. K. J., Klein, W. M. P., Lehman, T., Killam, B., Massett, H., & Freedman,

A. N. (2011). Communication of uncertainty regarding individualized cancer

risk estimates: Effects and infl uential factors. Medical Decision Making, 31(6),

354–366.

Hall, D. L., Mishel, M. H., & Germino, B. B. (2014). Living with cancer-related

uncertainty: Associations with fatigue, insomnia, and affect in younger breast

cancer survivors. Support Care Cancer Supportive Care in Cancer, 22(9), 2489–2495.

Hebdon, M., Foli, K., & Mccomb, S. (2015). Survivor in the cancer context: A concept

analysis. Journal of Advanced Nursing, 71(8), 1774–1786.

Hilton, B. A. (1988). The phenomenon of uncertainty in women with breast cancer.

Issues in Mental Health Nursing, 9, 217–238.

Hilton, B. A. (1989). The relationship of uncertainty, control, commitment, and threat

of recurrence to coping strategies used by women diagnosed with breast cancer.

Journal of Behavioral Medicine, 12(1), 39–54.

Hilton, B. A. (1993). Issues, problems, and challenges for families coping with breast

cancer. Seminars in Oncology Nursing, 9(2), 88–100.

Hilton, B. A. (1994). The uncertainty stress scale: Its development and psychometric

properties. Canadian Journal of Nursing Research, 26(3), 15–30.

Horner, S. (1997). Uncertainty in mothers’ care for their ill children. Journal of
Advanced Nursing, 26, 658–663.

Johnson, L. M., Zautra, A. J., & Davis, M. C. (2006). The role of illness uncertainty on

coping with fi bromyalgia symptoms. Health Psychology, 25(6), 696–703.

Jurgens, C. Y. (2006). Somatic awareness, uncertainty, and delay in care-seeking in

acute heart failure. Research in Nursing and Health, 29(2), 74–86.

Kang, Y. (2005). Effects of uncertainty on perceived health status in patients with

atrial fi brillation. British Association of Critical Care Nurses, Nursing in Critical Care,

10(4), 184–191.

Kang, Y. (2006). Effect of uncertainty on depression in patients with newly diagnosed

atrial fi brillation. Progress in Cardiology Nursing, 21(2), 83–88.

Kang, Y. (2011). The relationships between uncertainty and its antecedents in Korean

patients with atrial fi brillation. Journal of Clinical Nursing, 20, 1880–1886.

Kang, Y., Daly, B. J., & Kim, J. S. (2004). Uncertainty and its antecedents in patients

with atrial fi brillation. Western Journal of Nursing Research, 26(7), 770–783.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  75

Katz, A. (1996). Gaining a new perspective on life as a consequence of uncertainty in

HIV infection. Journal of the Association of Nurses in AIDS Care, 7(11), 51–60.

Kazer, M. W., Bailey, D. E., Sanda, M., Colberg, J., & Kelly, K. (2011). An internet

intervention for management of uncertainty during active surveillance for

prostate cancer. Oncology Nursing Forum, 38(5), 561–568.

Kim, S. H., Lee, R., & Lee, K. S. (2012). Symptoms and uncertainty in breast cancer

survivors in Korea: Differences by treatment trajectory. Journal of Clinical Nursing,

21(7–8), 1014.

Kreulen, G. L., & Braden, C. J. (2004). Model test of the relationship between self-

help promoting nursing interventions and self-care and health status outcomes.

Research in Nursing & Health, 27, 97–101.

Landis, B. J. (1996). Uncertainty, spirituality, well-being, and psychosocial adjustment

to chronic illness. Issues in Mental Health Nursing, 17, 217–231.

Lazarus, R. S. (1974). Psychological stress and coping in adaptation and illness.

International Journal of Psychiatry in Medicine, 5, 321–333.

Lee, Y. L. (2006). The relationships between uncertainty and posttraumatic stress in

survivors of childhood cancer. Journal of Nursing Research, 14(2), 133–142.

Lemaire, G. S. (2004). More than just menstrual cramps: Symptoms and uncertainty

among women with endometriosis. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 33(1), 71–79.

Lemaire, G. S., & Lenz, E. R. (1995). Perceived uncertainty about menopause in

women attending an educational program. International Journal of Nursing Studies,

32(1), 39–48.

Liao, M., Chen, M., Chen, S., & Chen, P. (2008). Uncertainty and anxiety during the

diagnostic period for women with suspected breast cancer. Cancer Nursing, 31(4),

274–283.

Lien, C., Lin, H., Kuo, I., & Chen, M. (2009). Perceived uncertainty, social support

and psychological adjustment in older patients with cancer being treated with

surgery. Journal of Clinical Nursing, 18(16), 2311–2319.

Light, D. (1979). Uncertainty and control in professional training. Journal of Health and
Social Behavior, 20, 310–322.

Lin, L., Yeh, C., & Mishel, M. H. (2010). Evaluation of a conceptual model based on

Mishel’s theories of uncertainty in illness in a sample of Taiwanese parents of

children with cancer: A cross-sectional questionnaire survey. International Journal
of Nursing Studies, 47(12), 1510–1524.

Liu, L., Li, C. Y., Tang, S., Huang, C., & Chiou, A. (2006). Role of continuing

supportive cares in increasing social support and reducing perceived uncertainty

among women with newly diagnosed breast cancer in Taiwan. Cancer Nursing,

29(4), 273–282.

Mandler, G. (1979). Thought processes, consciousness and stress. In V. Hamilton & D.

M. Warburton (Eds.), Human stress and cognition: An information processing approach

(pp. 179–201). New York, NY: Wiley.

Mast, M. E. (1995). Adult uncertainty in illness: A critical review of research. Scholarly
Inquiry for Nursing Practice, 9(1), 3–24.

76 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Mast, M. E. (1998). Survivors of breast cancer: Illness uncertainty, positive

reappraisal, and emotional distress. Oncology Nursing Forum, 25(3), 555–562.

McCain, N. L., Munjas, B. A., Munro, C. L., Elswick, R. K., Jr., Robins, J. L., Ferreira-

Gonzalez, A., . . . Cochran, K. L. (2003). Effects of stress management on PNI-based

outcomes in persons with HIV disease. Research in Nursing & Health, 26, 102–117.

McCormick, K. M. (2002). A concept analysis of uncertainty in illness. Journal of
Nursing Scholarship, 34(2), 127–131.

McCormick, K. M., Naimark, B. J., & Tate, R. B. (2006). Uncertainty, symptom

distress, anxiety, and functional status in patients awaiting coronary artery

bypass surgery. Heart & Lung, 35(1), 34–44.

Middleton, A. V., LaVoie, N. R., & Brown, L. E. (2012). Sources of uncertainty in type

2 diabetes: Explication and implications for health communication theory and

clinical practice. Health Communication, 27, 591–601.

Miller, L. E. (2014). Uncertainty management and information seeking in cancer

survivorship. Health Communication, 29(3), 233–243.

Mishel, M. H. (1981). The measurement of uncertainty in illness. Nursing Research, 30,

258–263.

Mishel, M. H. (1983a). Adjusting the fi t: Development of uncertainty scales for

specifi c clinical populations. Western Journal of Nursing Research, 5(4), 355–370.

Mishel, M. H. (1983b). Parents’ perception of uncertainty concerning their

hospitalized child. Nursing Research, 32, 324–330.

Mishel, M. H. (1984). Perceived uncertainty and stress in illness. Research in Nursing
and Health, 7, 163–171.

Mishel, M. H. (1988). Uncertainty in illness. Journal of Nursing Scholarship, 20,

225–231.

Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image:
Journal of Nursing Scholarship, 22, 256–262.

Mishel, M. H. (1993). Living with chronic illness: Living with uncertainty. In S. G.

Funk, E. M. Tornquist, M. T. Champagne, & R. A. Wiese (Eds.), Key aspects of
caring for the chronically ill: Hospital and home (pp. 46–58). New York, NY: Springer

Publishing.

Mishel, M. H. (1997a). The effi cacy of the uncertainty management intervention for older
White and African American women with breast cancer. Paper presented at the 11th

Annual Conference of the Southern Nursing Research Society, Norfolk, VA.

Mishel, M. H. (1997b). Uncertainty in acute illness. Annual Review of Nursing Research,

15, 57–80.

Mishel, M. H. (1997c). Uncertainty in illness scales manual. Chapel Hill: School of

Nursing, University of North Carolina. Retrieved from https://nursing.unc.edu/

fi les/2012/12/mishel_uncertainty_scales.pdf

Mishel, M. H. (1999). Uncertainty in chronic illness. Annual Review of Nursing
Research, 17, 269–294.

Mishel, M. H., Belyea, M., Germino, B. B., Stewart, J. L., Bailey, D. E., Robertson, C.,

& Mohler, J. (2002). Helping patients with localized prostate carcinoma manage

uncertainty and treatment side effects: Nurse-delivered psychoeducational

intervention over the telephone. Cancer, 94(6), 1854–1866.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  77

Mishel, M. H., & Braden, C. J. (1987). Uncertainty: A mediator between support and

adjustment. Western Journal of Nursing Research, 9, 43–57.

Mishel, M. H., & Braden, C. J. (1988). Finding meaning: Antecedents of uncertainty in

illness. Nursing Research, 37, 98–127.

Mishel, M. H., & Clayton, M. F. (2003). Uncertainty in illness theories. In M. J. Smith

& P. Liehr (Eds.), Middle range theory in advanced practice nursing (pp. 25–48). New

York, NY: Springer Publishing.

Mishel, M. H., & Clayton, M. F. (2008). Theories of uncertainty in illness. In M. J.

Smith & P. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 55–84).

New York, NY: Springer Publishing.

Mishel, M. H., Germino, B. B., Belyea, M., Stewart, J. L., Bailey, D. E., Mohler, J., &

Robertson, C. (2003). Moderators of an uncertainty management intervention, for

men with localized prostate cancer. Nursing Research, 52(2), 89–97.

Mishel, M. H., Germino, B. B., Gill, K. M., Belyea, M., Laney, I. C., Stewart, J., . . .

Clayton, M. (2005). Benefi ts from an uncertainty management intervention for

African-American and Caucasian older long-term breast cancer survivors. Psycho-
Oncology, 14, 962–978.

Mishel, M. H., Germino, B. B., Lin, L., Pruthi, R. S., Wallen, E. M., Crandell, J., &

Blyler, D. (2009). Managing uncertainty about treatment decision making in

early stage prostate cancer: A randomized clinical trial. Patient Education and
Counseling, 77(3), 349–359.

Mishel, M. H., Hostetter, T., King, B., & Graham, V. (1984). Predictors of psychosocial

adjustment in patients newly diagnosed with gynecological cancer. Cancer
Nursing, 7, 291–299.

Mishel, M. H., & Murdaugh, C. L. (1987). Family adjustment to heart transplantation:

Redesigning the dream. Nursing Research, 36, 332–336.

Mishel, M. H., Padilla, G., Grant, M., & Sorenson, D. S. (1991). Uncertainty in illness

theory: A replication of the mediating effects of mastery and coping. Nursing
Research, 40, 236–240.

Mishel, M. H., & Sorenson, D. S. (1991). Uncertainty in gynecological cancer: A

test of the mediating functions of mastery and coping. Nursing Research, 40,

167–171.

Mitchell, M. L., Courtney, M., & Coyer, F. (2003). Understanding uncertainty and

minimizing families’ anxiety at the time of transfer from intensive care. Nursing
& Health Sciences, 5(3), 207–217.

Moos, R., & Tsu, V. (1977). The crisis of physical illness: An overview. In R. Moos

(Ed.), Coping with physical illness (pp. 3–25). New York, NY: Plenum.

Mullins, L. L., Cheney, J. M., Balderson, B., & Hommel, K. A. (2000). The relationship

of illness uncertainty, illness intrusiveness, and asthma severity to depression in

young adults with long-standing asthma. International Journal of Rehabilitation and
Health, 5(3), 177–185.

Mullins, L. L., Cheney, J. M., Hartman, V. L., Albin, K., Miles, B., & Roberson,

S. (1995). Cognitive and affective features of postpolio syndrome: Illness

uncertainty, attributional style, and adaptation. International Journal of
Rehabilitation and Health, 1, 211–222.

78 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Mullins, L. L., Cote, M. P., Fuemmeler, B. F., Jean, V. M., Beatty, W. W., & Paul, R. H.

(2001). Illness intrusiveness, uncertainty, and distress in individuals with multiple

sclerosis. Rehabilitation Psychology, 46(2), 139–153.

Nelson, J. P. (1996). Struggling to gain meaning: Living with the uncertainty of breast

cancer. Advances in Nursing Science, 18(3), 59–76.

Neville, K. L. (1998). The relationships among uncertainty, social support, and

psychological distress in adolescents recently diagnosed with cancer. Journal of
Pediatric Oncology Nursing, 15(1), 37–46.

Neville, K. L. (2003). Uncertainty in illness: An integrative review. Orthopaedic
Nursing, 22(3), 206–214.

Northouse, L., Mood, D., Templin, T., Mellon, S., & George, T. (2000). Couples’

patterns of adjustment to colon cancer. Social Science and Medicine, 50(2),

271–284.

Northouse, L., Walker, J., Schafenacker, A., Mood, D., Mellon, S., Galvin, E., . . .

Freeman-Gibb, L. (2002). A family-based program of care for women with

recurrent breast cancer and their family members. Oncology Nursing Forum,

29(10), 1411–1419.

Norton, R. (1975). Measurement of ambiguity tolerance. Journal of Personal
Assessment, 39, 607–619.

Nyhlin, K. T. (1990). Diabetic patients facing long-term complications: Coping with

uncertainty. Journal of Advanced Nursing, 15, 1021–1029.

Padilla, G., Mishel, M., & Grant, M. (1992). Uncertainty, appraisal and quality of life.

Quality of Life Research, 1, 155–165.

Parry, C. (2003). Embracing uncertainty: An exploration of the experiences of

childhood cancer survivors. Qualitative Health Research, 13(2), 227–246.

Pelusi, J. (1997). The lived experience of surviving breast cancer. Oncology Nursing
Forum, 24(8), 1343–1353.

Penrod, J. (2001). Refi nement of the concept of uncertainty. Journal of Advanced
Nursing, 34(2), 238–245.

Politi, M., & Street Jr., R. L. (2011). Patient-centered communication during

collaborative decision-making. In T. L. Thompson, R. Parrott & J. F. Nussbaum

(Eds.), The Routledge handbook of health communication (2nd ed., pp. 399–413). New

York, NY: Routledge.

Porter, L. S., Clayton, M. F., Belyea, J., Mishel, M., Gil, K. M., & Germino, B. B. (2006).

Predicting negative mood state and personal growth in African American and

White long-term breast cancer survivors. Annals of Behavioral Medicine, 31(3),

195–204.

Prigogine, I., & Stengers, I. (1984). Order out of chaos: Man’s new dialogue with nature.
New York, NY: Bantam Books.

Redeker, N. S. (1992). The relationship between uncertainty and coping after

coronary bypass surgery. Western Journal of Nursing Research, 14, 48–68.

Righter, B. (1995). Ostomy care. Uncertainty and the role of the credible authority

during an ostomy experience. Journal of Wound and Ostomy Care Nursing, 22(2),

100–104.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  79

Ritz, L., Nissen, M., Swenson, K., Farrell, J., Sperduto, P., Sladek, M., . . . Schroeder, L.

M. (2000). Effects of advanced nursing care on quality of life and cost outcomes of

women diagnosed with breast cancer. Oncology Nursing Forum, 27(6), 923–932.

Rydström, I., Dalheim-Englund, A.-C., Segesten, K., & Rasmussen, B. H. (2004).

Relations governed by uncertainty: Part of life of families of a child with asthma.

Journal of Pediatric Nursing, 19(2), 85–94.

Sammarco, A. (2001). Perceived social support, uncertainty, and quality of life of

younger breast cancer survivors. Cancer Nursing, 24(3), 212–219.

Sammarco, A., & Konecny, L. M. (2010). Quality of life, social support and

uncertainty among Latina and Caucasian breast cancer survivors: A comparative

study. Oncology Nursing Forum, 37(1), 93–99.

Sanders-Dewey, N., Mullins, L., & Chaney, J. (2001). Coping style, perceived

uncertainty in illness, and distress in individuals with Parkinson’s disease and

their caregivers. Rehabilitation Psychology, 46(4), 363–381.

Santacroce, S. J. (2000). Support from health care providers and parental uncertainty

during the diagnosis phase of perinatally acquired HIV infection. Journal of the
Association of Nurses in AIDS Care, 11(2), 63–75.

Santacroce, S. J. (2001). Measuring parental uncertainty during the diagnosis phase of

serious illness in a child. Journal of Pediatric Nursing, 16(1), 3–12.

Santacroce, S. J. (2002). Uncertainty, anxiety, and symptoms of posttraumatic stress in

parents of children recently diagnosed with cancer. Journal of Pediatric Oncology
Nursing, 19(3), 104–111.

Santacroce, S. J. (2003). Parental uncertainty and posttraumatic stress in serious

childhood illness. Journal of Nursing Scholarship, 35(1), 45–51.

Santacroce, S. J., & Lee, Y. L. (2006). Uncertainty, posttraumatic stress, and health

behavior in young adult childhood cancer survivors. Nursing Research, 55(4),

259–266.

Saunders, J. C., & Cookman, C. A. (2005). A clarifi ed conceptual meaning of hepatitis

Crelated depression. Gastroenterology Nursing, 28(2), 123–129; quiz 120–121.

Sexton, D. L., Calcasola, S. L., Bottomley, S. R., & Funk, M. (1999). Adults’ experience

with asthma and their reported uncertainty and coping strategies. Clinical Nurse
Specialist, 13(1), 8–17.

Shaha, M., Cox, C. L., Talman, K., & Kelly, D. (2008). Uncertainty in breast, prostate,

and colorectal cancer: Implications for supportive care. Journal of Nursing
Scholarship, 40(1), 60–67.

Shalit, B. (1977). Structural ambiguity and limits to coping. Journal of Human Stress, 3,

32–45.

Sharkey, T. (1995). The effects of uncertainty in families with children who are

chronically ill. Home Healthcare Nurse, 13(4), 37–42.

Small, S. P., & Graydon, J. E. (1993). Uncertainty in hospitalized patients with chronic

obstructive pulmonary disease. International Journal of Nursing Studies, 30,

239–246.

Smeltzer, S. C. (1994). The concerns of pregnant women with multiple sclerosis.

Qualitative Health Research, 4, 497–501.

80 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Song, L., Tyler, C., Clayton, M. F., Rodgiriguez-Rassi, E., Hill, L., Bai, J., . . . Bailey,

D. E., Jr. (2016). Patient and family communication during consultation visits:

The effects of a decision aid for treatment decision-making for localized prostate

cancer. Patient Education and Counseling, 100(2), 267–275.

Sorenson, D. L. S. (1990). Uncertainty in pregnancy. NAACOG’s Clinical Issues in
Perinatal and Women’s Health Nursing, 1(3), 289–296.

Sterken, D. J. (1996). Uncertainty and coping of fathers of children with cancer.

Journal of Pediatric Oncology Nursing, 13, 81–90.

Stewart, J. L. (2003). “Getting used to it”: Children fi nding the ordinary and routine

in the uncertain context of cancer. Qualitative Health Research, 13(3), 394–407.

Stewart, J. L., Lynn, M. R., & Mishel, M. H. (2010). Psychometric evaluation of a

new instrument to measure uncertainty in children and adolescents with cancer.

Nursing Research, 59, 119–126.

Stewart, J. L., & Mishel, M. H. (2000). Uncertainty in childhood illness: A synthesis of

the parent and child literature. Scholarly Inquiry for Nursing Practice, 17, 299–319.

Stewart, J. L., Mishel, M. H., Lynn, M. R., & Terhorst, L. (2010). Test of a conceptual

model of uncertainty in children and adolescents with cancer. Research in Nursing
and Health, 33, 179–191.

Taylor-Piliae, R. E., & Chair, S. Y. (2002). The effect of nursing intervention utilizing

music theory or sensory information on Chinese patients’ anxiety prior to cardiac

catherization: A pilot study. European Journal of Cardiovascular Nursing, 1, 203–311.

Taylor-Piliae, R. E., & Molassiotis, A. (2001). An exploration of the relationships

between uncertainty, psychological distress and type of coping strategy among

Chinese men after cardiac catheterization. Journal of Advanced Nursing, 33(1),

79–88.

Tomlinson, P., Kirschbaum, M., Harbaugh, B., & Anderson, K. (1996). The infl uence

of illness severity and family resources on maternal uncertainty during critical

pediatric hospitalization. American Journal of Critical Care, 5, 140–146.

Trivino Martinez, A., Solano Ruiz, M. C., & Siles Gonzalez, J. (2016). Application of

an uncertainty model for fi bromyalgia. Atencion Primaria, 48(4), 219–225.

Turner, M., Tomlinson, P., & Harbaugh, B. (1990). Parental uncertainty in critical care

hospitalization of children. Maternal-Child Nursing Journal, 19, 45–62.

Van Riper, M., & Selder, F. E. (1989). Parental responses to birth of a child with Down

syndrome. Loss, Grief and Care: A Journal of Professional Practice, 3(3–4), 59–76.

Walker, L. O., & Avant, K. C. (1989). Strategies for theory construction in nursing.

Norwalk, CT: Appleton-Century-Crofts.

Webster, K. K., & Christman, N. J. (1988). Perceived uncertainty and coping post

myocardial infarction. Western Journal of Nursing Research, 10(4), 384–400.

Weems, J., & Patterson, E. T. (1989). Coping with uncertainty and ambivalence while

awaiting a cadaveric renal transplant. ANNA Journal, 16(1), 27–32.

Weiss, M. E., Saks, N. P., & Harris, S. (2002). Resolving the uncertainty of preterm

symptoms: Women’s experiences with the onset of preterm labor. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 31(1), 66–76.

Weitz, R. (1989). Uncertainty and the lives of persons with AIDS. Journal of Health and
Social Behavior, 30, 270–281.

4 . THEOR IES OF UNCERTA INTY IN I LLNESS  81

White, R. E., & Frasure-Smith, N. (1995). Uncertainty and psychologic stress after

coronary angioplasty and coronary bypass surgery. Heart & Lung, 24(1), 19–27.

Wiener, C. L., & Dodd, M. J. (1993). Coping amid uncertainty: An illness trajectory

perspective. Scholarly Inquiry for Nursing Practice, 7(1), 17–31.

Wineman, N. M. (1990). Adaptation to multiple sclerosis: The role of social support,

functional disability, and perceived uncertainty. Nursing Research, 39, 294–299.

Wineman, N. M., O’Brien, R. A., Nealon, N. R., & Kaskel, B. (1993). Congruence

in uncertainty between individuals with multiple sclerosis and their spouses.

Journal of Neuroscience Nursing, 25, 356–361.

Wineman, N. M., Schwetz, K. M., Goodkin, D. E., & Rudick, R. A. (1996).

Relationships among illness uncertainty, stress, coping, and emotional well-being

at entry into a clinical drug trial. Applied Nursing Research, 9(2), 53–60.

Wineman, N. M., Schwetz, K. M., Zeller, R., & Cyphert, J. (2003). Longitudinal

analysis of illness uncertainty, coping, hopefulness, and mood during

participation in a clinical drug trial. Journal of Neuroscience Nursing, 35(2), 100–106.

Winters, C. A. (1999). Heart failure: Living with uncertainty. Progress in Cardiovascular
Nursing, 14, 85–91.

Wonghongkul, T., Dechaprom, N., Phumivichuvate, L., & Losawatkul, S. (2006).

Uncertainty appraisal coping and quality of life in breast cancer survivors. Cancer
Nursing, 29(3), 250–257.

Wonghongkul, T., Moore, S., Musil, C., Schneider, S., & Deimling, G. (2000). The

infl uence of uncertainty in illness, stress appraisal, and hope on coping in

survivors of breast cancer. Cancer Nursing, 23(6), 422–429.

Wunderlich, R., Perry, A., Lavin, M., & Katz, B. (1999). Patients’ perceptions of

uncertainty and stress during weaning from mechanical ventilation. Dimensions of
Critical Care Nursing, 18(1), 8–12.

107

CHAPTER 6
Theory of Bureaucratic Caring

Marilyn A. Ray

In 1977, Leininger declared that “caring: [is] the essence and central focus of
nursing” (p. 1). From an anthropological perspective, caring is one of the old-
est and most universal expectations for human development and survival
throughout human history. Caring is claimed by archeologists (besides the evo-
lution of the brain) as paramount in human development (Ray, 1981b). Based
on a philosophical analysis related to meaningfulness and understanding, I
determined that, for nursing, caring and love are synonymous (Ray, 1981a, p.
32). Four decades ago, as a doctoral student researcher, my passion was the
study of caring within hospitals as a way of knowing caring in nursing in prac-
tice. I wanted to learn about the meaning of care and caring in the hospital
culture, and embarked on a study focusing on the meaning and action of caring.
My dissertation was a qualitative study that laid the foundation for the Theory
of Bureaucratic Caring. This chapter about the Theory of Bureaucratic Caring
includes: explication of the purpose of the theory; description of processes
undertaken to generate the middle range theory; defi nition of the theoretical
concepts; and identifi cation of uses of the theory in research and practice.

■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

The middle range Theory of Bureaucratic Caring was discovered through
description, analysis, and interpretation of the meaning of the phenomenon of
caring in the complex institutional culture of the hospital. Interview data were
analyzed from over 192 diverse healthcare professionals including nurses, phy-
sicians, and allied health personnel as well as patients. Also included were fi eld
notes or memos from participant observation of the nursing/social process in
the hospital culture. This analysis prompted deep refl ective thinking about
the meaning of the lived experience of caring and interpretation of patterns
of culture or the organizational context from which the meaning was derived.
The initial analysis led to the integration of data into a classifi cation system of
institutional caring—psychological, practical, interactional, and philosophical
(Ray, 1981b, 1984). Subsequently, substantive and formal grounded theories

Copyright Springer Publishing Company. All Rights Reserved.
From: Middle Range Theory for Nursing, Fourth Edition
DOI: 10.1891/9780826159922.0006

108 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

were discovered to articulate the fullness of the meaning of caring in the orga-
nizational context. Qualitative data illuminated a paradox, juxtaposing the
meaning of caring as humanistic, spiritual, and ethical with the bureaucratic
system as political, economic, technological, legal, educational, and social–
cultural. Through the use of Hegelian dialectical analysis of the thesis (car-
ing) and antithesis (bureaucracy), a synthesis was articulated as the Theory of
Bureaucratic Caring (Ray, 1981b, 1984, 2010a).

■ EVOLUTION OF THE THEORY OF BUREAUCRATIC CARING

Over three decades, with the research expertise of Dr. Marian Turkel and feder-
ally funded grants using research approaches that drew on our growing under-
standing of complexity sciences, testing of the Theory of Bureaucratic Caring
was ongoing. We accomplished tool development using mixed methods to
create valid and reliable professional and patient questionnaires, focusing on
economic caring. Further data collection and analysis of the meaning of caring
in organizational cultures in public, private, and military hospitals led to the
determination that the Theory of Bureaucratic Caring demanded holographic
expression with spiritual–ethical caring as the central essence. Many publications
validated the theory as a middle range theory with strong potential for guid-
ing practice and research (Coffman, 2014, 2018; Davidson, Ray, & Turkel, 2011;
Gibson, 2008; Ray, 1987a, 1987b, 1989, 1997, 1998a, 1998b, 2010a, 2010b, 2010c,
2010d, 2010e, 2011, 2013a, 2013b, 2016; Ray & Turkel, 2010, 2012, 2014, 2015; Ray,
Turkel, & Marino, 2002; Ray, Morris, & McFarland, 2013; Turkel, 2007; Turkel &
Ray, 2000, 2001, 2004).

■ CONCEPTS OF THE THEORY

Bureaucratic Caring is spiritual–ethical caring emerging in bureaucracies.
Bureaucracies are complex systems with political, legal, economic, technologi-
cal, physical, educational and social–cultural dimensions. The central concept
of the Theory of Bureaucratic Caring is spiritual–ethical caring. Spiritual–ethi-
cal caring interconnects with the dimensional concepts gleaned and interpreted
from data. Each of the concepts of the theory is briefl y defi ned.

Spiritual–Ethical Caring is defi ned as creativity, loyalty, faithfulness to spir-
itual or religious traditions and is revealed in patterns of love, compassion,
empathy, respect, and communication to facilitate moral choices for the good
of self, persons, things, and the environment.

The Social–Cultural dimension is defi ned as values, beliefs, and attitudes
regarding ethnicity, patterns of identity, or diverse social structures, such as
family and communities that impact social structures, political, economic,
legal, and technological factors in complex national or international systems.

6 . THEORY OF BUREAUCRAT IC CAR ING  109

The Physical dimension is defi ned as factors related to the physical, mental,
and emotional states of being, health/illness, healing, and dying (or peaceful
death) of patients or persons in organizational healthcare contexts.

The Educational dimension is defi ned as both formal and informal teach-
ing–learning communicating caring processes and programs to improve
the health, healing, and well-being of persons, families, communities, and
organizations.

The Political dimension is defi ned as the energy patterns and communica-
tive action associated with power, control, and authoritative behaviors, usually
of leaders, administrators, and staff. Political relates to hierarchical systems,
roles and their differentiation or stratifi cation, unions, and governmental infl u-
ences that facilitate competition and cooperation in complex organizations.

The Economic dimension is defi ned as the exchange of goods, money, ser-
vices, insurance systems, and healthcare laws, including an understanding of
caring as interpersonal resources to appreciate and manage budgets and to
maintain the fi nancial viability and fi scal management of an organization that
interfaces with the larger community or social structure.

The Technological dimension is defi ned as nonhuman resources, such as
machines and diagnostic instruments, pharmacologic agents, computers, elec-
tronic health records (EHRs), smartphones, social media in the virtual world,
and robots, and the ethical caring knowledge and skill needed to support per-
sons, families, communities, organizations, and cultures.

The Legal dimension is defi ned as factors related to responsibility and
accountability for rules, regulations, standards of practice, procedures,
informed consent, rights to privacy, professional behaviors, insurance systems
or laws, and issues that endeavor to facilitate social justice and stability in com-
plex systems.

■ RELATIONSHIP AMONG THE CONCEPTS: THE MODEL

The model of the Theory of Bureaucratic Caring (Figure 6.1) is represented
by a circle that shows the interrelationship among the central and surround-
ing concepts. The theory model is intended to be holographic in the sense
that the part and the whole are interconnected, “…everything is a whole in
one context and a part in another—each part being in the whole and the
whole being in the part” (Ray & Turkel, 2015, pp. 464–465). Spiritual–ethical
caring is central to the model and relates to and with dimensional concepts
(economic, political, legal, technological, educational, physical, social–cul-
tural) at the periphery of the circle. Data revealed that the meaning of caring
was not only spiritual and ethical but also was expressed by participants in
the research and interpreted by the researcher as contextual—the interrela-
tionship of caring with structural phenomena of complex organizations, the
bureaucracy. “Caring [spiritual–ethical caring] is a relational pattern; it is the

110 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

fl ow of nurses’ and others own experiences in the structural context of the
organization [the bureaucracy]” (Ray & Turkel, 2015, p. 464). The arrows in
the model extend outward from each of the dimensional concepts to show
that Bureaucratic Caring connects beyond the organization, to the environ-
ment or the social world or culture at large.

Bureaucracies are cultures; they are cocreated through the interactions of
people within them, each with their specifi c cultural orientations, goals, norms,
patterns of behaviors, rituals, professional practices, and languages. Spiritual–
ethical caring thus is in relationship with the dimensional concepts descrip-
tive of the organization—economic, political, technological, legal, physical,
educational, and social–cultural (Ray & Turkel, 2015). As a living system, the
bureaucratic organization manifests in different ways depending on the pro-
cesses that are valued. Bureaucratic organizations thus are “complex, dynamic,
relational, integral, informational, computational and emergent, and open to
sets of possibilities” (Ray & Turkel, 2015. p. 465). Decisions are made in net-
works of relationships that represent a simultaneous patterning of interacting
parts. The Theory of Bureaucratic Caring (Coffman, 2014, 2018; Davidson, Ray,
& Turkel, 2011; Ray & Turkel, 2015) emerges to refl ect the reality of what it
means to care for persons in an organization in the contemporary Western and
developing world.

Educational

Political

Economic

Technological

Legal
Spiritual-
ethical
caring

Social-
cultural

Physical

FIGURE 6.1 Holographic theory of bureaucratic caring.
Source: With permission from Parker, M., & Smith, M. (2015). Nursing theories and nursing practice (4th ed.).
Philadelphia, PA: F. A. Davis.

6 . THEORY OF BUREAUCRAT IC CAR ING  111

■ USE OF THE THEORY IN NURSING RESEARCH

The following presentation illuminates the diverse ways in which the Theory
of Bureaucratic Caring was tested or used to guide research. Classifi cation
systems, conceptual models, or further middle range theories emerged from
this theory-guided research. For example, a classifi cation system, called an
Institutional Caring Classifi cation System, was developed by Ray (1984). A
conceptual model of Technological Caring, called Experiential and Principle-
Based Ethics in Critical Care, was intuited from a phenomenological study
of patients and nurses in the intensive care unit (Ray, 1987b). Clarifi cation of
the ethical principles of benefi cence, justice, and autonomy emerged from this
study. A theory of Refl ective Ethics emerged from a study in a critical care step-
down unit (Ray, 1998a). Technological Caring was reinforced in the research of
Wu and colleagues on the use of virtual technologies in a study of patients with
cardiac disease comorbid with diabetes (Wu & Ray, 2016). From knowledge
on economic caring reported by Ray (1981b, 1989), Turkel (1997) discovered
Struggling to Find a Balance: A Grounded Theory of the Nurse-Patient Relationship
Within an Economic Context. Ray and Turkel conducted research from 1995 to
2004 using Grounded Theory, phenomenological methods, and other mixed
methods for the study of caring and the economics of caring in diverse public,
private, and military hospitals (Davidson, Ray, & Turkel, 2011; Ray & Turkel,
2009; 2012; Turkel & Ray, 2000, 2001). Political caring was identifi ed in a study
of reservists in the U.S. Air Force (USAF) regarding the expansion of the mili-
tary TriCare health system (Ray & Turkel, 2001; Turkel & Ray, 2003). All of
the research of Ray and Turkel led to further grounded theories: the Theory
of Relational Complexity, the Theory of Relational Caring Complexity; and a
Theory of Workplace Redevelopment (Ray, Turkel, & Marino, 2002). The eco-
nomic caring research of Ray and Turkel was enhanced by theoretical testing
and tool development to understand more fully the meaning and the statistical
signifi cance of the economics and politics of caring.

Many researchers were interested in theory-guided research and practice
using the Theory of Bureaucratic Caring. In 1997, Valentine applied the the-
ory in her study of economics and caring. Prestia (2016a) followed through
with an application of Ray’s ideas (1997) emerging from a phenomenological
study of caring in nursing administration; Prestia studied caring strategies for
living leadership presence in nursing administration. Nyberg (1990) applied
the Theory of Bureaucratic Caring to facilitate understanding, research and
development of nursing economics with nurse administrators and in the orga-
nizational culture. Eggenberger (2011) used the theory to guide a qualitative
research related to charge nurses on the front line of practice. Conroy (2013)
applied the Theory of Bureaucratic Caring in a study of the effect of the orga-
nizational culture on implementation of evidence-based practice and how
the staff assigns a value to improvements in nursing practice. The Theory of
Bureaucratic Caring was incorporated by Prestia (2016b) into her dissertation

112 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

research, a phenomenological study of chief nursing offi cers in the contin-
ued practice of nursing leadership. In the USAF Medical Service, a research
study was conducted by Potter (2015) using the Theory for Nurse-Directed
Primary Care of patients with type 2 diabetes resulting in quality improve-
ments in clinical health and healing and sizable economic outcomes. In the
Veterans Administration, Lusk (2015) conducted a mixed method study using
the Theory of Bureaucratic Caring to compare the knowledge, skills, and atti-
tudes of newly hired nursing staff before and after the implementation of a
quality and safety competency-based nursing orientation program.

Overall, the Theory of Bureaucratic Caring has provided substantive guid-
ance for researchers wishing to focus on systems of care and those who are
employed in those systems. It is a middle range theory that shifts attention to
macrosystem perspectives, linking institutional culture, while considering the
interplay of macrosystems with microsystems, like caring. The theory provides
a structure for researchers to study the meaning of caring in institutional nurs-
ing and healthcare practice.

■ USE OF THE THEORY IN NURSING PRACTICE AND EDUCATION

Nursing practice addresses the needs of patients, nurses, and administrators as
well as an understanding of the context within which nursing practice occurs.
The challenge in nursing practice is the integration of knowledge gleaned
from nursing education and experience, which should align with the philoso-
phy, vision, and values that nursing has adopted. The Magnet Recognition
Program® has been established to achieve nursing excellence by incorporat-
ing theory-guided or conceptual professional practice models to transform
nursing and healthcare (Turkel, 2004). Theory-guided practice encompasses
the why of nursing through ways in which practitioners of nursing have inte-
grated their knowledge and understanding of what makes things work—the
pedagogy, philosophy of caring, health, and social–cultural sciences to inform
the art of nursing. The philosopher Hans-Georg Gadamer remarked that we,
as human beings are always theorizing—we are meaning-making people who
are always seeking to understand—trying to make sense out of relationships
and things of this world (van Manen, 2014). The art of practice, thus “. . .
serves to foster and strengthen the embodied ontology [way of being], epis-
temology [ways of knowing], and axiology [ways of valuing what is valuable
or ethical] of thoughtful and tactful action” (van Manen, 2014, p. 15). The fol-
lowing highlights ways in which the Theory of Bureaucratic Caring is being
used to guide nursing education as well as nursing, healthcare, and organi-
zational practice.

O’Brien (2008) incorporated the core principles of the Theory of Bureaucratic
Caring in her project to orient new public health nursing consultants in a major

6 . THEORY OF BUREAUCRAT IC CAR ING  113

state public health nursing system (Personal communication, 2008). In a cor-
rectional facility for adolescents in Georgia, McCray-Stewart used the theory
to improve the care of young detainees and reduce recidivism (Personal com-
munication, 2008). In 2012, Iowa Health (three hospitals), in Des Moines, Iowa,
adopted the Theory of Bureaucratic Caring to guide interprofessional practice
(Iowa Health) and as the theoretical foundation for Magnet recognition status
to become a center of excellence.

Elevating a successful innovation of an interprofessional practice model is
focused on a commitment by leaders to all stakeholders. Leaders must be cog-
nizant of how a system can continue to form or enhance relationships with its
members in current and projected environments. A signifi cant goal of achieving
the status of a Magnet facility employs both the spread or horizontal diffusion
of an idea, such as a nursing theory or model of caring, and scale or centralized
action to implement a single system of excellence for nursing and other dis-
ciplinary practices across a whole organization (Bar-Yam, 2004; Martin, 2017;
Turkel, 2004). Collaboration of this magnitude for policy development takes
knowledge of theory, and a theory-guided effort to determine its impact on a
complex organization and multidisciplinary practice. The collaboration takes a
deep understanding of relationships and caring communication, especially in
a complex bureaucratic culture and with people who may continue to embrace
an individualized professional culture or belief system. The process of devel-
oping a model using the middle range Theory of Bureaucratic Caring in the
Iowa Health System took a commitment by nurse leaders and others to make
things work (Bar-Yam, 2004). Inspiring a collection of diverse healthcare pro-
viders from varying disciplines to undertake whole system change focused
on unifi ed healthcare is a challenge but the Iowa Health System embraced the
challenge.

Within nursing education, the Nevada State College under the leadership
of Dr. Sherrilyn Coffman (2014) from 2007 to 2014, applied, in part, the Theory
of Bureaucratic Caring for the development of a curriculum model for the
Bachelor of Science in Nursing program. In the nursing administration pro-
gram at the Capital University in Ohio, Burkett (2016) used the theory to guide
administrative course development. Johnson (2015) developed a conceptual
framework applying the Theory of Bureaucratic Caring for advanced practice
nurses as primary care providers using a new approach—making house calls
with the homebound population to meet their healthcare needs. The Theory
of Bureaucratic Caring is currently being used in nursing education at the
National University in Bogota, Colombia, and the University of Santiago in
Santiago, Chile.

The Theory of Bureaucratic Caring is being applied in primary nursing
practice by the USAF Nurse Corps to improve the care of patients with type 2
diabetes (Potter, 2015). Creation of an Interdisciplinary Professional Person-
Centered Practice Model in the USAF is in process.

114 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

■ CONCLUSION

The Theory of Bureaucratic Caring originated from qualitative research
focused on caring in a complex organizational culture. It was published fi rst
as a dissertation (Ray, 1981b) and appeared in the literature in 1989 and in
subsequent publications noted throughout this chapter (Coffman, 2014, 2018;
Ray, 2001, 2010a, 2010e; Ray & Turkel, 2010, 2012, 2014, 2015). The theory sym-
bolizes a dynamic structure of caring that was synthesized from the dialectic
of caring as humanistic, social, educational, ethical, and religious/spiritual
(elements of humanism and caring), and the antithesis of caring as economic,
political, legal, and technological (elements of bureaucracy) into a new syn-
thesis—the Theory of Bureaucratic Caring (Ray, 1989, 2010a, 2010b, 2010c,
2010d, 2010e). The interplay between and among the dimensions highlighting
spiritual–ethical caring and the bureaucratic system as holographic or emer-
gent showed that the whole is in the part and the part is in the whole; every-
thing is an unbroken whole (Bohm, 2002; Coffman, 2014). Humanistic caring
and the elements of the bureaucracy are value-added. Interactions and sym-
bolic meaning systems are formed and reproduced from the construction of
dominant values held within nursing and indeed, other professions, includ-
ing patients, and the organization. A hospital, community health, or a health-
care system is a living organization. By understanding and incorporating the
Theory of Bureaucratic Caring, nurses bring caring into being that makes a
human community and an organization edifying to our spiritual well-being
and intellectual lives.

■ REFERENCES

Bar-Yam, Y. (2004). Making things work: Solving complex problems in a complex world.

Boston, MA: NECSI, Knowledge Press.

Bohm, D. (2002). Wholeness and the implicate order. London, UK: Routledge.

Burkett, M. (2016). Nursing administration curriculum. Columbus, OH: Capital

University.

Coffman, S. (2014). Marilyn Anne Ray’s theory of bureaucratic caring. In M. Alligood

(Ed.), Nursing theorists and their work (8th ed., pp. 98–119). St. Louis, MO: Mosby/

Elsevier.

Coffman, S. (2018). Marilyn Anne Ray: Theory of bureaucratic caring. In M. Alligood

(Ed.), Nursing theorists and their work (9th ed., pp. 80–97). St. Louis, MO: Elsevier.

Conroy, C. (2013). The effect of organizational culture on the implementation and uptake
of evidence-based practice: How staff ascribe value to practice innovation. Doctor of

Nursing Practice Project. Boston, MA: Regis College.

Davidson, A., Ray, M., & Turkel, M. (Eds.). (2011). Nursing, caring and complexity
science: For human-environment well-being. New York, NY: Springer Publishing.

6 . THEORY OF BUREAUCRAT IC CAR ING  115

Eggenberger, T. (2011). Holding the frontline: The experience of being a charge nurses in an
acute care setting (Dissertation). The Christine E. Lynn College of Nursing, Florida

Atlantic University, Boca Raton, FL.

Gibson, S. (2008). Legal caring: Preventing retraumatization of abused children

through the caring nursing interview using Roach’s six Cs. International
Association for Human Caring, 12(4), 32–37.

Johnson, P. (2015). Ray’s theory of bureaucratic caring: A conceptual framework for

APRN primary care providers and the homebound population. International
Journal for Human Caring, 19(2), 41–44.

Leininger, M. (1977). The phenomenon of caring. Part V. Caring: The essence and

central focus of nursing. Nursing Research Report, 1, 2, 4.

Lusk, D. (2015). Comparing the knowledge, skills and attitudes of newly hired nursing staff
before and after implementation of a quality and safety competency-based nursing orientation
program. Doctor of Nursing Practice Project, Denver, CO: Regis University.

Martin, D. (2017). Better now: Six big ideas to improve health care for all Canadians.

Toronto, Canada: Penguin Books.

Nyberg, J. (1990). The effects of caring and economics on nursing practice. Nursing
Administration Quarterly, 20(5), 13–18.

O’Brien, K. (2008). Application of bureaucratic caring theory in public health nursing.

Director of Public Health Nursing, State of Colorado, Denver CO.

Potter, M. (2015). Using theory-guided practice to improve diabetes health outcomes in
primary care. Doctor of Nursing Practice Project. Chicago, IL: Chamberlain

University.

Prestia, A. (2016a). Existential authenticity: Caring strategies for living leadership

presence. International Journal for Human Caring, 10(1), 8–11.

Prestia, A. (2016b). Chief nursing offi cer sustainment in the continued practice of nursing
leadership: A phenomenological inquiry (Unpublished doctoral dissertation).

Retrieved from ProQuest dissertations database (UMI No. 3691821).

Ray, M. (1981a). A philosophical analysis of caring within nursing. In M. Leininger

(Ed.), Caring: An essential human need. Thorofare, NJ: Slack.

Ray, M. (1981b). A study of caring within the institutional culture. Doctor of Philosophy.

University of Utah, Salt Lake City, UT. Dissertation Abstracts International, 42(06)

(University Microfi lms No. 8127787).

Ray, M. (1984). The development of a nursing classifi cation system of caring. In M.

Leininger (Ed.), Care: The essence of nursing and health (pp. 93–112). Thorofare, NJ:

Charles B. Slack.

Ray, M. (1987a). Health care economics and human caring: Why the moral confl ict

must be resolved. Family and Community Health, 10(1), 35–43.

Ray, M. (1987b). Technological caring: A new model in critical care. Dimensions in
Critical Care, 6(3), 166–173.

Ray, M. (1989). The theory of bureaucratic caring for nursing practice in the

organizational culture. Nursing Administration Quarterly, 13(2), 31–42.

Ray, M. (1997). The ethical theory of existential authenticity: The lived experience of

the art of caring in nursing administration. Canadian Journal of Nursing Research,

29(1), 111–126.

116 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Ray, M. (1998a). A phenomenologic study of the interface of caring and technology: A

new refl ective ethics in intermediate care. Holistic Nursing Practice, 12(4), 71–79.

Ray, M. (1998b). Complexity and nursing science. Nursing Science Quarterly, 11, 91–93.

Ray, M. (2001). Marilyn Anne Ray, the theory of bureaucratic caring. In M. Parker

(Ed.), Nursing theories and nursing practice (pp. 431–431). Philadelphia, PA: F. A.

Davis.

Ray, M. (2010a). A study of caring within an institutional culture: The discovery of
the theory of bureaucratic caring. Saarbrücken, Germany: Lambert Academic

Publishing.

Ray, M. (2010b). Creating caring organizations and cultures through communitarian

ethics. World Universities Forum Journal, 3(5), 41–52.

Ray, M. (2010c). Grounded theory method for the study of transcultural nursing. In

M. Douglas & D. Pacquiao (Eds.), Core curriculum for transcultural nursing and
health care. Thousand Oaks, CA: Sage.

Ray, M. (2010d). Phenomenological-hermeneutical research method for the study of

transcultural nursing. In M. Douglas & D. Pacquiao (Eds.), Core curriculum for
transcultural nursing and health care. Thousand Oaks, CA: Sage.

Ray, M. (2010e). Transcultural caring dynamics in nursing and health care. Philadelphia,

PA: F. A. Davis.

Ray, M. (2011). Complex caring dynamics: A unifying model of nursing inquiry. In A.

Davidson, M. Ray, & M. Turkel. (Eds.), Nursing, caring, and complexity science: For
human-environment well-being (pp. 31–52). New York, NY: Springer Publishing.

Ray, M. (2013a). Caring inquiry: The esthetic process in the way of compassion. In

In M. Smith, M. Turkel, & Z. Wolf (Eds.), Caring classics in nursing (pp. 339–345).

New York, NY: Springer Publishing.

Ray, M. (2013b). The theory of bureaucratic caring. In M. Smith, M. Turkel, & Z.

Wolf (Eds.), Caring classics in nursing (pp. 309–320). New York, NY: Springer

Publishing.

Ray, M. (2016). Transcultural caring dynamics in nursing and health care (2nd ed.).

Philadelphia, PA: F. A. Davis.

Ray, M., Morris, E., & McFarland, M. (2013). Ethnonursing method of Dr. Madeleine

Leininger. In C. Beck (Ed.), The Routledge international handbook of qualitative
nursing research (pp. 213–229). New York, NY: Routledge.

Ray, M., & Turkel, M. (2001). Impact of TRICARE/managed care on total force

readiness. Military Medicine, 166(4), 281–289.

Ray, M., & Turkel, M. (2009). Relational caring questionnaires. In J. Watson (Ed.),

Assessing and measuring caring in nursing and health sciences (2nd ed. pp. 209–218).

New York, NY: Springer Publishing.

Ray, M., & Turkel, M. (2010). The theory of bureaucratic caring. In M. Parker &

M. Smith (Eds.), Nursing theory and nursing practice (3rd ed., pp. 472–494).

Philadelphia, PA: F. A. Davis.

Ray, M., & Turkel, M. (2012). A transtheoretical evolution of caring science within

complex systems. International Journal for Human Caring, 16(2), 28–49. (Includes

Patient and Professional questionnaires)

Ray, M., & Turkel. M. (2014). Caring as emancipatory nursing praxis: The theory of

Relational Caring Complexity. Advances in Nursing Science, 37(2), 137–146.

6 . THEORY OF BUREAUCRAT IC CAR ING  117

Ray, M., & Turkel, M. (2015). The theory of bureaucratic caring. In M. Smith &

M. Parker (Eds.), Nursing theory and nursing practice (4th ed., pp. 461–482).

Philadelphia, PA: F. A. Davis.

Ray, M., Turkel, M., & Marino, F. (2002). The transformative process for nursing in

workforce redevelopment. Nursing Administration Quarterly, 26(2), 1–14.

Turkel, M. (1997). Struggling to fi nd balance: A grounded theory of the nurse-patient
relationship within an economic context (Doctoral dissertation). University of Miami,

Miami, FL.

Turkel, M. (2004). Magnet status: Assessing, pursuing, and achieving nursing excellence.

Marblehead, MA: HCPro.

Turkel, M. (2007). Dr. Marilyn Ray’s theory of bureaucratic caring. International
Journal for Human Caring, 11(4), 57–74.

Turkel, M., & Ray, M. (2000). Relational complexity: A theory of the nurse-patient

relationship within an economic context. Nursing Science Quarterly, 13(4), 307–313.

Turkel, M., & Ray, M. (2001). Relational complexity: From grounded theory to

instrument development and theoretical testing. Nursing Science Quarterly, 14(4),

281–287.

Turkel, M., & Ray, M. (2003). A process model for policy analysis within the context

of political caring. International Journal for Human Caring, 7(3), 17–25.

Turkel, M., & Ray, M. (2004). Creating a caring practice environment through self-

renewal. Nursing Administration Quarterly, 28(4), 249–254.

Valentine, K. (1997). Exploration of the relationship between caring and cost. Holistic
Nursing Practice, 11(4), 71–81.

van Manen, M. (2014). Phenomenology of practice: Meaning-giving methods in
phenomenological research and writing. Walnut Creek, CA: Left Coast Press.

Wu, C.-J., & Ray, M. (2016). Technological caring for complexities of patient with

cardiac disease comorbid with diabetes. International Journal for Human Caring,

21(2), 83–87.

119

CHAPTER 7
Theory of Self-Transcendence

Pamela G. Reed

A central focus of nursing is in understanding and facilitating the human
capacity for well-being in the context of diffi cult health-related experiences.
The nursing Theory of Self-Transcendence was created from a developmen-
tal perspective of human–environment processes of health. The word develop-
mental is used in the theory to emphasize inherent change processes that are
ongoing, innovative, and context-related while also acknowledging inevitable
changes that are random or decremental. Self-Transcendence Theory origi-
nated from an interest in understanding how people transcend adversity and
the relationship among psychosocial development, mental health, and well-
being. The theory is applicable to individuals across the life span regarding
challenging life experiences, with supporting empirical fi ndings from research
with those in adolescence, adulthood, aging, and end of life.

■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

According to the intermodern philosophy of nursing science (Reed, 2011), nurs-
ing theories most broadly are open systems of knowledge that incorporate var-
ious ways of knowing including empirical, ethical, and practice-based sources.
Middle range theory in particular is a structure and process for building nursing
knowledge through inquiry and practice. Knowledge from research and prac-
tice is organized into theories for creative applications with people who need
nursing care. The purpose of the middle range Theory of Self-Transcendence
is to provide a framework for inquiry and practice regarding the promotion of
well-being in the midst of diffi cult life situations. Research and practice using
Self-Transcendence Theory may generate new discoveries about the processes
by which people attain well-being.

The idea for a Theory of Self-Transcendence was infl uenced by three major
events in the history of science, the history of nursing, and my own professional
history. First, the 1970s life-span movement in developmental psychology
provided philosophical perspective and empirical evidence that the potential
for developmental change exists across the life span, beyond childhood and

Copyright Springer Publishing Company. All Rights Reserved.
From: Middle Range Theory for Nursing, Fourth Edition
DOI: 10.1891/9780826159922.0007

120 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

adolescence, into adulthood, and throughout the processes of aging and dying
(Reed, 1983). Research fi ndings indicated that developmental change was
infl uenced less by chronological age or passage of time and more by normative
and non-normative life events and the accruement of life experiences.

Second, postulations by the scholar Martha Rogers (1970) about the nature of
change in human beings provided further inspiration for development of the
theory (Reed, 1997b). Rogerian ideas were congruent with life-span principles
of development. Philosophical views include the pandimensionality of human
beings and the human potential for healing and well-being. Pandimensionality
refers in part to various dimensions, known and as yet unknown, about human
beings and their environment, and to the capacity to expand personal bound-
aries in various ways. Several nursing theories were also foundational to the
Theory of Self-Transcendence.

Third, this theory was motivated by my clinical nurse specialist practice
experiences in applying developmental theories in child and adolescent psy-
chiatric–mental healthcare. Successful approaches to fostering mental health
and well-being required in-depth understanding of patients’ biopsychoso-
cial developmental processes and the strengths they may obtain through
development.

A detailed explanation of how these elements came together in the devel-
opment of Self-Transcendence Theory is described in Reed (1991b). The pre-
dominant approach was deductive reformulation, which incorporated various
strategies of theory development from philosophical, theoretical, empirical, and
practice-based sources. The underlying assumptions, concepts, and relation-
ships among the concepts involved in the theory development are described
in the next two sections. Research and practice, presented in later sections, also
infl uence development and ongoing refi nement of the theory.

■ CONCEPTS OF THE THEORY

The concept of the Theory of Self-Transcendence derived in part from two
major assumptions. First, it is assumed that people are integral with their
environment and are pandimensional, as postulated in Rogers’s (1980, 1994)
Science of Unitary Human Beings. This suggests that human beings may be
capable of an awareness that extends beyond physical and temporal dimen-
sions (Reed, 1997a). Using current scientifi c methods, this is measurable in
reference to everyday experiences of expanding one’s boundaries by reach-
ing deeper within the self and reaching out to others, to nature, to one’s god,
or other sources of transcendence. An important point is that boundaries not
dimensions are transcended. Contrary to views of self-transcendence as mean-
ing a separation from self, others, and the environment, in this theory self-tran-
scendence refers to connections with self, others, and the environment.

7 . THEORY OF SELF -TRANSCENDENCE  121

The second assumption is that self-transcendence is a developmental imper-
ative, meaning that it is a human resource that demands expression as do other
developmental processes such as walking in toddlers, abstract reasoning in
adolescents, and grieving in those who have suffered a loss. These resources
are a part of being human and facilitate potential for well-being. As such, the
person’s participation in self-transcendence is integral to well-being, and nurs-
ing has a role in facilitating this process.

Self-Transcendence

Self-transcendence is the central concept of the theory. It refers to the capacity
to expand personal boundaries in many ways, examples of which are as fol-
lows: intrapersonally (toward greater awareness of one’s philosophy, values,
and dreams), interpersonally (to relate to others and one’s environment), tem-
porally (to integrate one’s past and future in a way that has meaning for the
present), and transpersonally (to connect with dimensions beyond the typi-
cally observable world). Self-transcendence is a characteristic of developmen-
tal maturity in terms of an enhanced awareness of the environment and an
orientation toward broadened perspectives about life. It is expressed and mea-
sured through life perspectives and behaviors that refl ect expansion of per-
sonal boundaries.

Developmental Theories

Neo-Piagetian theories about development in adulthood and later life were
infl uential in formulating the concept of self-transcendence. Beginning in
the 1970s, life-span development researchers discovered postformal patterns
of thinking in older adults that extended beyond Piaget’s formal operations,
once thought to be the fi nal stage of cognitive development. Life-span devel-
opmental theories on social–cognitive development extended Piaget’s origi-
nal theory on reasoning, which had identifi ed formal operations (abstract and
symbolic reasoning) in youth and young adulthood as the apex of cognitive
development. Researchers identifi ed postformal stages from older adults’
continued social and cognitive development well into later life beyond
the phase of formal operations, for example, Arlin’s (1975) problem-fi nd-
ing stage, Riegel’s (1976) and Basseches’s (1984) dialectic operations, and
Koplowitz’s (1984) unitary stage. Researchers found that this mature reason-
ing was more contextual, more pragmatic, more spiritual, and more tolerant
of ambiguity and paradoxes in life than was the reasoning of earlier devel-
opmental phases (e.g., Commons, Demick, & Goldberg, 1996; Sinnott, 1998,
2011). The person using this mature form of reasoning does not seek abso-
lute answers to questions in life but rather seeks meaning from perspectives
beyond the immediate situation that integrate moral, social, and historical

122 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

dimensions. A perspective of relativism from seeing multiple, sometimes
confl icting views is balanced by the ability to make a commitment to one’s
beliefs.

Self-transcendence was conceptualized in reference to these views, with
goals more in line with Erikson’s generativity and ego integrity than with
self-absorbed strivings for identity and intimacy characteristic of earlier devel-
opmental phases (Sheldon & Kasser, 2001). Self-transcendence is expressed
through various behaviors and perspectives such as sharing wisdom with oth-
ers, integrating the physical changes of aging, accepting death as a part of life,
having an interest in helping others and learning about the world, letting go of
losses, and fi nding spiritual meaning in life.

Nursing Theories

Self-transcendence is a concept relevant to nursing. Themes of self-transcen-
dence are evident in other nursing theories. For example, in Parse’s (1992, 2015)
paradigm of human becoming, cotranscending is a major theme underlying
the philosophical assumptions of her theory and “inspiring transcendence” is
an exemplary nursing practice. Newman’s (1994) theory of health as expand-
ing consciousness postulates a transcendence of time and space as one reaches
beyond illness to develop an awareness of one’s patterns, self-identity, and
higher level of consciousness. Although all of these theorists present unique
views of transcendence, they generally share the idea of expanded awareness
beyond the immediate or constricted views of oneself and the world to trans-
form life experiences into healing (Reed, 1996). More recently, developmental
psychologists studying self-transcendence suggested it is a universal concept
related to well-being in adulthood and aging, as a way of extending personal
boundaries outward to others and the community (Hofer et al., 2016).

Nursing Philosophy

Self-transcendence is also congruent with philosophical views of nursing. Sarter
(1988) identifi ed the term as one of the central themes in the philosophical
foundations of nursing. Newman’s (1992) unitary–transformative paradigm
presents human beings as embedded in an ongoing developmental process
of changing complexity and organization, a process integrally related to well-
being. Furthermore, self-transcendence is an example of Reed’s (1997a) ontol-
ogy of nursing, where nursing most basically is defi ned as a self-organizing
process inherent among human systems that is related to well-being. Maslow
(1969) is frequently cited for his concept of self-transcendence, but his con-
ceptualization diverges from nursing by his view of self-transcendence as an
elevation or a separation of self from the environment. It is an awareness of
person–environment connections when fragmentation threatens one’s well-
being (Reed, 1997b).

7 . THEORY OF SELF -TRANSCENDENCE  123

Well-Being

A second major concept of the theory is well-being. Well-being is a sense of
feeling whole and healthy, in accord with one’s own criteria for wholeness and
health. Well-being may be defi ned in many ways, depending upon the indi-
vidual or patient population. Indicators of well-being are as diverse as human
perceptions of health and wellness, for example, life satisfaction, positive self-
concept, hopefulness, happiness, morale, self-care, and sense of meaning in
life.

Self-transcendence, as a basic human pattern of development, is logically
linked with positive, health-promoting experiences and is therefore a corre-
late if not a predictor and resource for well-being. Well-being is a correlate
and outcome of self-transcendence. Theoretical analyses and empirical studies
have consistently supported this conceptualization of self-transcendence as a
contributor to well-being (Lundman et al., 2010; McCarthy, 2011; Reed, 2009;
Teixeira, 2008).

Vulnerability

Another key concept of the theory is vulnerability. Vulnerability involves
awareness of personal mortality or risk to one’s well-being. It is theorized
that self-transcendence, as a developmental capacity (and perhaps as a sur-
vival mechanism), emerges naturally in health-related experiences and life
events that confront a person with issues of mortality and immortality. Life
events that heighten one’s sense of mortality, inadequacy, or vulnerability
can—if they do not crush the individual’s inner self—motivate developmental
progress toward a renewed sense of identity and expanded self-boundaries
(Corless, Germino, & Pittman, 1994; Erikson, 1986; Frankl, 1963; Marshall,
1980). Examples of these life events include serious or chronic illness, dis-
ability, aging, parenting, child rearing, family caregiving, loss of a loved one,
career, and other life crises. Self-transcendence is evoked through such events
and may enhance well-being by transforming losses and diffi culties into
growth experiences (Reed, 1996).

■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL

The model of the Theory of Self-Transcendence is presented in Figure 7.1. Four
basic sets of relationships among the concepts are proposed by the theory. First,
there is a relationship between the experience of vulnerability and self-tran-
scendence such that increased levels of vulnerability, as brought on by health
events, for example, motivate increased levels of self-transcendence. Further,
this relationship may be moderated by personal and contextual factors, par-
ticularly at high levels of vulnerability.

124 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

A second relationship exists between self-transcendence and well-being.
This relationship is direct and positive. For example, self-transcendence
relates positively to sense of well-being and morale, and self-transcendence
relates negatively to depression as a “negative” indicator of well-being. This
relationship represents more than a coping process; it is the integration or
transcending of a current situation to move forward toward a changed life
rather than simply a return to previous perspectives and behaviors (Willis &
Grace, 2011).

Third, self-transcendence functions as a mediator between experiences of
vulnerability and well-being. Research fi ndings indicate that self-transcen-
dence is a mechanism that helps explain the relationship between vulnerabil-
ity and well-being. Self-transcendence may mediate the effects of vulnerability
on well-being, with vulnerability experienced as, for example, illness distress;
lack of optimism, hope, or power; uncertainty; death anxiety. Without self-
transcendence, vulnerability could result in diminishing rather than sustaining
well-being. Several studies discussed later provide empirical support for this
mediator hypothesis. Self-transcendence, then, may be an underlying process
that explains how well-being is possible in diffi cult or life-threatening situa-
tions that people endure.

Fourth, personal and contextual factors may also have a role in this healing
process. A wide variety of personal and contextual factors and their interac-
tions may moderate or otherwise infl uence the process of self-transcendence
as it relates to well-being. Examples of these factors are age, gender, cogni-
tive ability, health status, past signifi cant life events, personal beliefs, family

Self-Transcendence

Personal
and

Contextual Factors

Vulnerability Well-Being

FIGURE 7.1 Self-Transcendence Theory.

7 . THEORY OF SELF -TRANSCENDENCE  125

support, and sociopolitical environment. These factors can enhance or dimin-
ish the strength of the three key variables and their relationships. For example,
advanced age or education may potentiate the relationship between self-tran-
scendence and well-being. The idea that personal and contextual factors have
a role in the theory derives from Rogers’s (1980) integrality principle about the
ongoing person–environment process over the life span.

The relationships posited by Self-Transcendence Theory identify areas for
research and, with adequate empirical support, for nursing interventions to
facilitate well-being in situations of increased vulnerability. From my nursing
perspective, which focuses on understanding inherent resources that foster
human well-being, I conceptualized self-transcendence as an independent vari-
able—a contributor to and predictor of well-being outcomes—rather than as the
dependent or outcome variable. Therefore, nursing interventions that support
the person’s inner resource for self-transcendence may focus directly on facilitat-
ing self-transcendence as it mediates the relationship between vulnerability and
well-being, or as it directly relates to well-being. Interventions may also address
infl uential personal or contextual factors that directly relate to vulnerability or to
self-transcendence, or that moderate the relationships between vulnerability and
self-transcendence, and between self-transcendence and well-being (Figure 7.1).

■ USE OF THE THEORY IN NURSING RESEARCH

Research results to date indicate that self-transcendence is a resource that
accompanies serious life experiences that intensify one’s sense of vulnerability
or mortality. Self-transcendence is a process of expanding personal boundar-
ies that helps people attain some sense of well-being in the context of diffi –
cult health situations. Findings also support the theorized direct relationship
between self-transcendence and many indicators of well-being across groups
of study participants facing a wide variety of health experiences.

The Self-Transcendence Scale

The Self-Transcendence Scale (STS; Reed, 2009) has been used in much of the
research concerning the theory. However, other measures may be used—and,
in fact, qualitative approaches have been used—to study self-transcendence.
The STS is a unidimensional instrument with 15 items measured on 4-point
Likert-type scaling. It originated from a 36-item instrument, the Developmental
Resources of Later Adulthood (DRLA) scale (Reed, 1986, 1989), which measured
the level of developmentally based psychosocial resources refl ective of devel-
opmental maturity. The DRLA was constructed from an extensive review of
theoretical and empirical literatures on adult development and aging, selected
nursing conceptual models and life-span theories, and clinical practice in psy-
chiatric–mental health nursing.

126 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

The STS was developed around a self-transcendence factor that explained half
of the variance in the DRLA with good internal consistency. The STS factor con-
sisted of items describing various behaviors and perspectives by which an indi-
vidual may expand personal boundaries inward and outward, and temporally.
The STS has demonstrated reliability (internal consistency) and validity (con-
tent, construct) across studies of various populations and health experiences. It is
brief and easy to administer either as a questionnaire or in an interview format.
Many researchers and graduate students have used the instrument in studying
self-transcendence as it relates to various health experiences and outcomes.

Initial Research

The initial research used to build the Theory of Self-Transcendence focused
on older adults, both well and those hospitalized for psychiatric treatment
of depression, as a group more likely to be facing vulnerability or end-of-life
issues than younger adults. Correlational and longitudinal studies (Reed, 1986,
1989) were designed to examine the nature and signifi cance of the relation-
ship between self-transcendence and mental health outcomes, particularly an
inverse relationship between self-transcendence and depression. Quantitative
and qualitative fi ndings in a study of oldest-old adults, aged 80 to 100 years,
also produced the same results (Reed, 1991a). In addition, four conceptual clus-
ters representing different aspects of self-transcendence were generated from
a content analysis: generativity, introjectivity, temporal integration, and body
transcendence. Elders who scored high on depression refl ected weak patterns
in these four areas, particularly in body transcendence, inner-directed activi-
ties, and positive integration of present and future.

Similar results were generated later, in research by Haugan, Hannssen, and
Moksnes (2013) in a study of self-transcendence in 202 nursing home older adult
residents. Their STS results could be empirically organized into two factors, intra-
personal and interpersonal, which also included temporal and transpersonal
items, providing further support for Self-Transcendence Theory that posited
expanding personal boundaries as a correlate of well-being in later adulthood.

Basic and Practice-Based Research by Coward

Doris Coward, who as a doctoral student studied with Reed, continued research
into self-transcendence with a focus on middle-aged adults confronting their
mortality through serious illness, advanced cancer, and AIDS. Coward (1990,
1995) initially studied the lived experience of self-transcendence in women
with advanced breast cancer. Results from her phenomenological study were
consistent with fi ndings from quantitative studies. Self-transcendence per-
spectives were salient in this group, which had a heightened awareness of
personal mortality. Self-transcendence was expressed in terms of reaching out
beyond self to help others, to permit others to help them, and to accept the
present, unchangeable events in time. This research validated Reed’s (1989)

7 . THEORY OF SELF -TRANSCENDENCE  127

quantitative measure of self-transcendence. In subsequent phenomenological
research, Coward and Lewis (1993) explored self-transcendence in women and
men with AIDS. Despite increased fear and sadness at the prospect of death, all
participants indicated self-transcendence perspectives, which in turn helped
them fi nd meaning and achieve emotional well-being. Findings from a study
of 107 women with stages III and IV breast cancer, in which structural equation
modeling was used to analyze responses, indicated that self-transcendence
had a signifi cant and direct positive effect on emotional well-being by mediat-
ing the effect of illness distress on well-being (Coward, 1991).

Coward (1996) also studied healthy adults, who ranged in age from 19 to
85 years. She was interested in extending the Theory of Self-Transcendence by
examining its salience in a group of adults who were not as actively confronted
with end-of-life issues as other seriously ill populations. Self-transcendence
was again found to be a signifi cant and strong correlate of well-being indi-
cators, namely coherence, self-esteem, hope, and other variables assessing
emotional well-being. Coward concluded that while her research supported
the hypothesized relationship between self-transcendence and mental health
variables, the fi ndings from her sample of healthy adults suggested that self-
transcendence may surface at times in the life span other than end of life, as
proposed by Victor Frankl (1969). Coward’s work helped expand the scope
of the theory to other age groups where self-transcendence may be salient.
Nevertheless, her results do not necessarily dispute the idea that some aware-
ness of human mortality is integral to self-transcendence. Awareness of mor-
tality is a basic characteristic of the human condition among both healthy and
ill adults, and may emerge slowly from the accumulation of life experiences as
well as suddenly by a health crisis event.

Intervention research by Coward and Kahn (2004, 2005) focused on the expe-
riences and functions of self-transcendence in women newly diagnosed with
breast cancer. Self-transcendence practices and perspectives were particularly
effective in helping women to resolve spiritual disequilibrium often experi-
enced after diagnosis of breast cancer (Coward & Kahn, 2004). In their 2005
study, the investigators compared a traditional community cancer support
group with a Self-Transcendence Theory–based group on outcomes regarding
the experiences of self-transcendence and physical and emotional well-being.
Women in the self-transcendence treatment group were able to attain a bet-
ter sense of community with their support group. However, the most striking
fi nding was that women in both groups had self-transcendence experiences
that sustained them through the diagnosis and treatment of their illness. They
expressed themes of outward, inward, and temporal expansion of self-bound-
aries such as reaching out for support and information, fi nding inner strength
to endure, and constructing meaning out of past experiences and future hopes.
The authors interpreted this fi nding as support for Reed’s theoretical idea that
the capacity for transcending an adverse event is a universal trait that motivates
expansion of one’s conceptual boundaries in multiple and benefi cial ways.

128 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Research by Reed and Colleagues

In an attempt to examine the theory in a group of adults that was healthy and
younger than the elders typically studied, Ellermann and Reed (2001) found
evidence of self-transcendence in middle-aged adults in the forms of parenting,
self-acceptance, and spirituality as expressions of expanding self-boundaries
related to mental health. Their results indicated a strong inverse relationship
between self-transcendence and level of depression in middle-aged adults,
particularly among women.

Decker and Reed (2005) studied self-transcendence and moral reasoning
within the context of several contextual and developmental factors to bet-
ter understand end-of-life treatment preferences among older adults. Self-
transcendence was found to be signifi cantly and positively related to a higher
level of reasoning called integrated moral reasoning, which includes both the
autonomous and social domains of moral decision making. This fi nding was
expected based on life-span developmental theory on adult cognition. Self-
transcendence did not relate signifi cantly to the desired level of aggressiveness
of end-of-life treatment, although investigators argued that more research is
needed into the role of self-transcendence and end-of-life decisions. The results
help explain why reasoning about end-of-life treatment options may involve a
complex and integrated approach.

Runquist and Reed (2007) studied correlates of well-being in 61 homeless
men and women. Self-transcendence coupled with positive physical health
status were identifi ed as independent correlates of well-being, explaining a
signifi cant 60% of the variance in well-being in this sample. Self-transcendence
held the larger and more signifi cant correlation with well-being. These fi nd-
ings suggest that interventions to foster well-being among homeless persons
include those that support self-transcendence as well as physical health.

Research by Other Investigators

Other research conducted over the past 25 years has provided support for the
Theory of Self-Transcendence. In most but not all of the quantitative studies
reported here, researchers measured self-transcendence with Reed’s (2009)
STS. In the case of qualitative studies, researchers worked from a conceptu-
alization of self-transcendence congruent with Reed’s theory. Research has
focused on various populations and health events.

Chronic Physical Illness, Mental Health, and Aging

Several researchers in addition to Reed have studied self-transcendence in
older adults in reference to chronic and serious illness and mental health and
well-being. The various indicators of well-being found to be associated with
self-transcendence, are bolded in the following research descriptions.

7 . THEORY OF SELF -TRANSCENDENCE  129

Walton, Shultz, Beck, and Walls (1991) explored self-transcendence using a
58-item scale based on Peck’s (1968) developmental stages of old age. They
identifi ed a signifi cant inverse relationship between self-transcendence and
loneliness among 107 healthy older adults.

Billard (2001) examined the role of self-transcendence in the well-being of
aging Catholic sisters for her doctoral research. Specifi cally, she combined
Reed’s (1987) Spiritual Perspective Scale with Reed’s (1991a) STS to measure
the concept of spiritual transcendence and found that spiritual transcendence,
along with selected personality and demographic factors, contributed signifi –
cantly to explaining emotional intelligence in a sample of 377 elder Catholic
sisters.

In suicide research with 35 older adults hospitalized for depression,
Buchanan, Farran, and Clark (1995) found that self-transcendence was inte-
gral to older adults coping with the changes in later life. Desire for death and
self-transcendence (as measured by the STS) were signifi cantly and inversely
related. Klaas (1998) studied self-transcendence and depression in 77 depressed
and nondepressed elders, fi nding self-transcendence was negatively correlated
with depressive feelings and positively correlated with meaning in life in these
groups. Similarly, in a study of Taiwanese older adults residing in nursing
homes, self-transcendence was negatively correlated with depressive symp-
toms (Hsu, Badger, Reed, & Jones, 2013).

The capacity to engage in activities of daily living and self-transcen-
dence was found to be signifi cantly positively related in two studies, one
with 88 chronically ill elders (Upchurch, 1999) and another with older
African Americans where Upchurch and Mueller (2005) found that self-
transcendence was signifi cantly and positively related to the ability to carry
out instrumental activities of daily living (IADLs). Self-transcendence was
interpreted as a developmental strength infl uential in explaining why some
elders continued to remain independent while others did not, regardless of
health status. Related to IADLs, investigators Upchurch and Mueller (2005)
recommended that caregivers can support older adults’ self-care capacity
by approaches that promote self-transcendence. On a similar theme, other
investigators suggest continued research into the possible relationship
between self-transcendence and medication adherence (N. F. Thomas &
Dunn, 2014).

Walker (2002) measured self-transcendence and mastery of stress in test-
ing his theory of transformative aging. He proposed that stressful events can
bring about transformative change that enables the person to deal with the
losses and challenges that accompany aging. Self-transcendence was found to
be signifi cantly and positively related to mastery of stress and signifi cantly
inversely related to stress of aging. His fi ndings have implications for engag-
ing the resource of self-transcendence to assist middle-aged and older adults in
mastering stress and existential anxiety over the aging process.

130 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Self-transcendence was found to be related to mediate and reduce stresses of
progressive diseases of multiple sclerosis and systemic lupus erythematosus,
prostate cancer, and oral cancer, respectively (H.-C. Chen 2012; Chin-A-Loy &
Fernsler, 1998; Iwamoto, Yamawaki, & Sato, 2011). Similarly, in a study of older
women living with rheumatoid arthritis, Neill (2002) found that transcendence
of self-boundaries and personal transformation represented a process of living
successfully with a chronic illness.

In a correlational study of oldest-old adults, Swedish researchers (Nygren
et al., 2005) found signifi cant, positive relationships of moderate magnitude
between self-transcendence and several mental and physical health outcomes
including resilience, sense of coherence, and purpose in life. Their results
overall indicated that oldest-old adults were capable of experiencing levels of
self-transcendence and other positive factors comparable to those in younger
adults, although this capacity may differ between men and women, indicating
the need for further research into gender differences. Several researchers have
studied inner strength as a variable very similar to self-transcendence in its
defi nition and in a way it is proposed to promote well-being in oldest-old men
and women, that is, in terms of increased resilience, purpose in life, and sense
of coherence (Lundman et al., 2010; Viglund, Jonsén, Strandberg, Lundman,
& Nygren, 2014). One major conclusion was that while oldest-old individuals
are more vulnerable to illness than are younger people, they also may have
increased inner strength to help them not only cope but fi nd joy in later life
(Moe, Hellzen, Ekker, & Enmarker, 2013).

Life-Threatening Illness in Adults

Considerable research on self-transcendence has focused on people who have
life-threatening or life-limiting illness. Results from these studies provide con-
sistent support for Self-Transcendence Theory. Examples of this research include
individuals with cancer, HIV/AIDS, and other life-threatening illnesses.

CANCER

In a phenomenological study of eight women who had completed breast cancer
therapy, Pelusi (1997) found that surviving breast cancer very much involved
self-transcendence, expressed as setting life priorities, fi nding meaning in life,
and looking within self. Similar fi ndings occurred in a study by Kinney (1996),
who reported on her own journey through breast cancer. A process of listening
to and trusting one’s inner voice facilitated transcendence. Self-transcendence
in turn was central to the reconstruction of self. Self-transcendence also was
signifi cant in adjusting to recurrence of breast cancer (Sarenmalm, Thorén-
Jönsson, Gaston-Hohansson, & Öhlén, 2009).

In its mediating role, self-transcendence alone partially mediated the rela-
tionship between optimism and the outcome of emotional well-being in a

7 . THEORY OF SELF -TRANSCENDENCE  131

group of 93 women receiving radiation treatment for breast cancer (Matthews
& Cook, 2009). Farren’s (2010) study of 104 breast cancer survivors produced
fi ndings that self-transcendence was a signifi cant mediator in two relation-
ships—between power (knowing participation) and quality of life and between
uncertainty and quality of life. Uncertainty reduces quality of life by reducing
self-transcendence. Farren used Reed’s theory to describe self-transcendence
as a profound awareness of one’s wholeness while having awareness of fl uc-
tuations in one’s human–environmental fi eld patterns.

HIV/AIDS

Self-transcendence and quality of life were studied in 46 HIV-positive adults
by Mellors, Riley, and Erlen (1997). Data analysis revealed a signifi cant mod-
erate positive relationship between self-transcendence and quality of life for
the group, particularly for those who were the most seriously ill. Similarly,
Stevens (1999) found self-transcendence and depression to be signifi cantly and
inversely related in young adults with AIDS.

Results from other research also attest to the capacity for seriously ill indi-
viduals to transcend their illness. Persons with AIDS were able to transcend the
suffering associated with their illness in a study by Mellors, Erlen, Coontz, and
Lucke (2001). The participants demonstrated three dominant patterns indica-
tive of self-transcendence: creating a meaningful life pattern, achieving a sense
of connectedness, and engaging in self-care.

A group of investigators (Ramer, Johnson, Chan, & Barrett, 2006) interested
in quality of life among persons with HIV/AIDS studied 420 mostly Hispanic,
male patients. Among the fi ndings was a signifi cant positive relationship
between self-transcendence and level of energy in the patients. In addition,
researchers found that levels of acculturation and self-transcendence were sig-
nifi cantly related, suggesting that the meaning of self-transcendence may be
infl uenced by cultural factors. Their study not only provided support for the
relevance of self-transcendence among these patients but also suggested that
acculturation may moderate the relationship between self-transcendence and
health outcome variables in people with HIV/AIDS.

OTHER LIFE-THREATENING ILLNESSES

In a study of liver transplant recipients, Wright (2003) found self-transcendence
to be positively related to quality of life and negatively related to fatigue, with
further research needed to identify potential causal direction in these relation-
ships. Bean and Wagner (2006) also studied liver transplant recipients (N =
471) with results indicating that self-transcendence becomes salient following
the experience of liver transplant and was related signifi cantly to higher qual-
ity of life and also may function as a mediator to decrease the effects of illness
distress on quality of life.

132 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

In a phenomenological study of individuals with spinal muscular atro-
phy (SMA), self-transcendence was central to living with a sense of integrity,
hope, and meaning amid the physical limitations experienced by individu-
als with these individuals (Ho, Tseng, Hsin, Chao, & Lin, 2016). Williams
(2012) conducted a phenomenological study of eight men and women who
had received a stem cell translation the previous year. Analyses showed
that self-transcendence is brought about by the intense suffering, as lived
through the physical effects of the treatment, facing death, and eventually
drawing strength from within themselves and from spiritual support. The
fi ndings suggested that effects of vulnerability on well-being were mediated
by self-transcendence.

Research on Nurses and Other Caregivers

Self-transcendence is studied as it occurs in family caregivers, nurses, and oth-
ers providing care to patients. This area of research has increased over the years
to reveal the signifi cance of self-transcendence in the well-being of caregivers.

Enyert and Burman (1999) found caregivers’ self-transcendence behaviors,
such as being with and doing for their loved one as death approached, facili-
tated personal growth and new meaning, and they were able to reach out to
help others besides their family member. Poole’s (1999) research revealed that
self-transcendence was an important phase in being a caregiver in Grounded
Theory research with 19 family caregivers in the process of being a caregiver
for frail older adults at home. Three phases of caregiving—connecting, dis-
covering self, and transcending self—were identifi ed by which the caregiver
became able to work with healthcare personnel as a partner instead of perpetu-
ating confl ict in the relationship.

Acton and Wright (2000) and Acton (2002) addressed self-transcendence
in family caregivers of adults with dementia, proposing self-transcendence
to be a relevant and potentially therapeutic experience for family caregivers.
However, when Acton (2002) conducted a naturalistic fi eld study of family
caregivers, she found that caregivers of adults with dementia had little oppor-
tunity to nurture self-transcendence and instead experienced social isolation,
ambivalence, emotional fragility, and burden of caring for their family mem-
ber. She concluded that some of these negative experiences associated with
caregiving may inhibit development of self-transcendence in caregivers and
interfere with their continued growth and well-being. Kim et al. (2011) dem-
onstrated signifi cant positive links between self-transcendence and emotional
well-being among family caregivers of chronically ill elders.

From interviews with 16 African American and White groups of great-
grandmothers, Reese and Murray (1996) identifi ed fi ve domains of self-
transcendence: connectedness, religion, being wise, values, and stories. The
authors considered great-grandparents vital in facilitating self-transcendence
and good relationships among family members.

7 . THEORY OF SELF -TRANSCENDENCE  133

As part of her study of spiritual growth in nurses, Kilpatrick (2002) studied
the relationships among self-transcendence, spiritual perspective, and spiritual
well-being in female nursing students and faculty. She found positive correla-
tions among those variables in students and faculty. Nursing students and fac-
ulty differed signifi cantly on level of self-transcendence and spiritual well-being,
suggesting that self-transcendence may increase with development. Wasner,
Longaker, Fegg, and Borasio (2005) found that spiritual care intervention train-
ing with 48 palliative care professionals increased their self-transcendence, spir-
itual well-being, and positive attitude toward work with dying patients.

McGee (2004) employed the method of interpretive phenomenology to
examine self-transcendence and its impact on nurses’ practice. Among results
from the moving stories of nurses, McGee found self-transcendence to be an
important mechanism of healing for nurses who have experienced diffi cult
and traumatic personal life experiences. Her work highlighted the role of self-
transcendence in healing the nurse and in enriching the practice of nurses for
the mutual benefi t of both patient and nurse.

Along a similar line of thinking, Hunnibell, Reed, Quinn-Griffi n, and
Fitzpatrick (2008) conducted dissertation research based on Self-Transcendence
Theory. They studied self-transcendence as related to burnout syndrome in hos-
pice and oncology nurses. Both groups of nurses face death and life-threaten-
ing illness through their work with patients. However, they hypothesized that
because of the philosophy of their healthcare setting and opportunities to pro-
cess loss, hospice nurses would demonstrate higher levels of self-transcendence
and lower levels of burnout than oncology nurses. Their fi ndings also provided
empirical support for the hypothesis and for an inverse relationship between
self-transcendence and three types of burnout. Hunnibell et al. concluded that
self-transcendence is a resource for nurses and may protect them against burnout.

Signifi cant, positive relationships between work engagement (measured as
vigor, dedication, and absorption) and self-transcendence were found by Palmer,
Quinn Griffi n, Reed, and Fitzpatrick (2010) in their study of 84 acute care staff
registered nurses. Through self-transcendence, the nurses increased self-aware-
ness and inner strength and made sense of challenging work situations.

In summary, nurses and caregivers experience vulnerability and related
health experiences through the challenges of their work as well as in their per-
sonal lives. Overall, research fi ndings provide consistent evidence of the signif-
icance of self-transcendence in the well-being of nurses and other caregivers.

■ USE OF THE THEORY IN NURSING PRACTICE

Theory-Informed Strategies for Practice

Research results indicate that a variety of strategies derived from Self-
Transcendence Theory have been successful in promoting well-being and in

134 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

diminishing negative outcomes in practice settings. The following sections
are loosely organized by various strategies of expanding personal boundaries
intrapersonally, interpersonally, and transpersonally.

INTRAPERSONAL STRATEGIES

Intrapersonal strategies may help a person expand personal boundaries
inward to clarify knowledge about self and fi nd or create meaning and pur-
pose in a diffi cult life experience. Meditation, prayer, visualization, life review,
structured reminiscence, self-refl ection, and journaling are the techniques of
self-transcendence that nurses may facilitate in patients to help them recognize
patterns of their own healing.

Nurses may use cognitive strategies to support self-transcendence in help-
ing patients integrate a diffi cult health event into their lives. Targeting infor-
mation about the illness, using positive self-talk, and engaging in meaningful
and challenging activities are techniques that can help a person integrate and
grow from the illness experience (Coward & Reed, 1996).

The personal narrative was tested in a randomized, clinical trial as an inter-
vention for enhancing self-transcendence in women with HIV, multiple scle-
rosis, and systemic lupus erythematosus (Diener, 2003). STS scores increased
signifi cantly in the intervention groups, suggesting that the intervention was
successful in helping the women address issues related to having a life-threat-
ening or life-altering illness.

McCarthy, Jiying, and Carini (2013) and McCarthy, Jiying, Bowland, Hall,
and Connelly (2015) developed and tested a “Psychoeducational Approach to
Transcendence and Health” (PATH) program to facilitate self-transcendence
in promoting well-being in older adults. Strategies that promote self-transcen-
dence may even be helpful with individuals with Alzheimer’s disease, as dem-
onstrated in a case study of a family with a family member having this disease
(Vitale, Shaffer, & Fenton, 2014).

INTERPERSONAL STRATEGIES

Interpersonal strategies for facilitating self-transcendence focus on connect-
ing the person to others through formal or informal means, ranging from face
to face or telephone to connecting on the Internet. Nurse visits, peer counsel-
ing, informal networks, and formal support groups are examples of interper-
sonal strategies that the nurse may arrange for the person (Acton & Wright,
2000). Maintaining meaningful relationships and strengthening affi liations
with civic groups or a faith community are strategies that the nurse can facil-
itate (McCormick, Holder, Wetsel, & Cawthon, 2001). A computer-mediated
self-help intervention was designed to facilitate connections among lesbian,
gay, bisexual, and transgender (LGBT) persons who shared similar interests
(DiNapoli, Garcia-Dia, Garcia-One, O’Flaherty, & Siller, 2014).

7 . THEORY OF SELF -TRANSCENDENCE  135

Support groups are often cited as an effective way to connect people facing
a diffi cult life situation. Groups that bring together people of similar health
experiences can facilitate self-transcendence by connecting the person to others
who can share the loss and exchange information and wisdom about coping
with the experience and by providing an opportunity to reach beyond the self
to help another. Joffrion and Douglas (1994) reported that nurses can facilitate
self-transcendence during bereavement by helping the person participate in
church or civic groups, develop or resume a hobby, share personal experiences
of grief with others, and support others who have experienced loss.

In a series of pre-experimental and quasi-experimental studies, Coward
(1998, 2003) developed and refi ned a series of support group sessions to facili-
tate self-transcendence. These sessions provided a variety of activities designed
to support self-transcendence in women facing breast cancer: orientation and
information sessions, sharing cancer stories, problem solving, assertive commu-
nication training, relaxation training, values clarifi cation, ongoing educational
components, constructive thinking and self-instructional training, feelings
management, and pleasant activity planning. In another quasi-experimental
study with individuals with multiple sclerosis, peer support groups facilitated
self-transcendence and physical well-being (JadidMilani, Ashktorab, Aben-
Saeedi, & AlaviMaid, 2014). Similarly, Norberg et al. (2015) suggested that self-
transcendence facilitated social contact, outdoor activities, and other functions
that can increase longevity in elders with life-limiting medical conditions.

Group psychotherapy is another intervention strategy for enhancing self-
transcendence. Young and Reed (1995) found that this intervention approach
was effective in generating a variety of outcomes for a group of elders, for
example, intrapersonally in terms of achieving self-enrichment, self-esteem,
and self-affi rmation; interpersonally in terms of bonding with and helping oth-
ers, enabling self-disclosure, and overcoming self-absorption; and temporally
in terms of gaining acceptance of one’s past and feeling empowered about the
future. A 6-week group reminiscing intervention showed an increase in self-
transcendence and a nonsignifi cant decrease in depression for women in an
assisted living facility (Stinson & Kirk, 2006). Self-transcendence and depres-
sion level were signifi cantly, inversely related in this group.

Altruistic activities facilitate self-transcendence by providing a context for
learning new things and expanding awareness about oneself and one’s world
(Coward & Reed, 1996). Altruism also enhances a person’s inner sense of worth
and purpose. McGee (2000) explained that practicing humility and providing
service to others are tools of self-transcendence that can empower individuals to
maintain a healthy lifestyle. Connections between people, whether to receive or
provide support, are key strategies for enhancing self-transcendence. Chan and
Chan (2011) tested interventions designed to expand boundaries toward others
through participation in volunteer work and social activities. These activities
promoted acceptance and fi nding meaning in spousal death by facilitating the
passing of time among bereaved Hong Kong Chinese older adults.

136 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

In a study by Willis and Griffi th (2010) of school-age boys victimized by
bullying, altruistic views and practices were found to facilitate healing. The
boys reached out to others in helping and seeking help, having an interest in
learning and engaging in fun hobbies, and feeling empathy toward others. The
authors emphasized to practitioners the importance of planning activities and
interactions that can foster self-transcendence.

Elderly nursing home residents were studied for their perceptions on what
personal qualities allowed them to rise above the diffi culties of advanced age
(Bickerstaff, Grasser, & McCabe, 2003). Results from this qualitative study
were consistent with patterns of self-transcendence identifi ed earlier by Reed
(1991a) in her study of community-dwelling oldest-old adults: generativity,
introjectivity, temporal integration, body transcendence, and one not previ-
ously identifi ed, “relationship with self/others/higher being.” Many partici-
pants exhibited more than one pattern of self-transcendence. The researchers
concluded that caregivers of older adults in long-term care facilities and at
home should look beyond custodial care to incorporate activities that build
upon the residents’ capacity for self-transcendence that can help them cope
with the losses of later life. Results from several studies support self-transcen-
dence as clinically important in nurse–patient interactions to promote mental
health among older adults in long-term care (Haugan, 2014; Haugan, Hanssen,
& Mokenes, 2013; Haugan, Rannestad, Hammervold, Garasen, & Espnes, 2013,
2014).

TRANSPERSONAL STRATEGIES

Transpersonal strategies of self-transcendence are designed to help the person
connect with a power or purpose greater than self. The nurse’s role in this pro-
cess is often one of creating an environment in which transpersonal exploration
can occur. It is worth noting here that several of the intervention strategies that
foster intrapersonal growth can also foster a sense of transpersonal connection,
such as meditation, prayer, visualization, artistic expression, and journaling.

Spiritual perspective or spiritual well-being, rather than religion per se, has
been found to relate to self-transcendence by several researchers over the years,
including Haase, Britt, Coward, Leidy, and Penn (1992), J. C. Thomas, Burton,
Quinn Griffi n, and Fitzpatrick (2010), and Sharpnack, Quinn Griffi n, Benders,
and Fitzpatrick (2010, 2011) in their two studies on the Amish community’s use
of spiritual and alternative healthcare practices to foster well-being. Religious
activities and prayer are also identifi ed as signifi cant to the well-being of per-
sons facing life crises. McGee (2000) explained the need for the nurse to pro-
vide an environment in which patients can look beyond themselves toward a
higher power for help and be inspired to help others.

Schumann (1999) found that self-transcendence enhanced well-being in ven-
tilated patients. Spiritual connections enabled patients to use temporal per-
spectives of past and future to empower themselves; they synchronized their

7 . THEORY OF SELF -TRANSCENDENCE  137

lives with the realities of being on a ventilator and anticipating extubation and
were then better able to manage this life-threatening health experience.

Artistic modalities such as art-making activities, creative bonding practice,
memorial quilt making, and watching a therapeutic music video were based on
Self-Transcendence Theory. These artistic modalities expand personal bound-
aries and facilitate transcendence, which in turn increase well-being (Burns,
Robb, & Haase, 2009; S. Chen & Walsh, 2009; Kausch & Amer, 2007; Walsh,
Radcliffe, Castillo, Kumar, & Broschard, 2007). Robb et al. (2014) used Haase’s
Resilience in Illness model to study a music video intervention with adolescents
and young adults undergoing hematopoietic stem cell transplantation. They
found this intervention facilitated self-transcendence and resilience along with
factors relevant to well-being in these young individuals.

Other researchers found that poetry writing was an expressive therapy
for facilitating self-transcendence in caregivers facing diffi cult life situations,
and subsequently leading to positive outcomes of self-affi rmation, sense of
achievement, catharsis, and acceptance among dementia caregivers (Kidd,
Zauszniewski, & Morris, 2011). However, caregivers may need pragmatic
assistance before they can engage in activities that support self-transcendence;
for example, to foster self-transcendence in family caregivers of adults with
dementia, Acton and Wright (2000) identifi ed the importance of helping
arrange for in-home assistance or day care so that the family members have the
time and energy to engage in activities that promote transpersonal awareness.

■ SUMMARY

Research fi ndings have shown that self-transcendence is integral to well-being
across a diversity of health experiences that nurses address in practice. Nursing
practices that facilitate self-transcendence result in healing outcomes during
these health events, as in, for example, diminished depression and loneliness
among depressed elders; increased hopefulness and self-care among chroni-
cally ill elders; and increased meaning in life among persons with advanced
breast cancer and other life-threatening illnesses; and increased well-being and
self-affi rmation in family and professional caregiving.

■ CONCLUSION

Adequacy of the Theory

Professional nurses are defi ned in large part by their ability to engage human
capacities for healing and well-being. Self-transcendence was presented as a
resource for well-being. It represents “both a human capacity and a human
struggle that can be facilitated by nursing” (Reed, 1996, p. 3). A goal in

138 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

developing the theory was to gain better understanding of the dynamics of
self-transcendence as it relates to health and well-being. This knowledge, in
addition to that acquired through personal and ethical knowing and practice
experience, can be used by nurses to foster well-being through strategies of
self-transcendence.

There is internal consistency among the elements within the theory—the
concepts, their defi nitions, and proposed relationships. Positive relationships
were identifi ed between vulnerability and self-transcendence and between
self-transcendence and well-being. Self-transcendence functions as a resource,
correlate, or facilitator of specifi c indicators of well-being. Self-transcendence
is often found to be a mediator between vulnerability experiences and well-
being outcomes. Self-transcendence has also been conceptualized as an out-
come or a process of well-being in its own right. Finally, in addition to the three
key concepts in the theory, research fi ndings provide evidence on the role of
various moderators in the process of self-transcendence.

The scope of Self-Transcendence Theory now reaches beyond the initial
focus on older adults to include children, adolescents, and adults of all ages
who experience vulnerability. The theory is being studied across cultures
around the world. Research fi ndings are broadening applications of the theory
to include a variety of normative life transitions and developmental events
where processes of self-transcendence have yet to be explored in depth.

The theory provides a perspective relevant to nursing practice in pro-
posing self-transcendence as a process by which human beings may sustain
well-being in times of vulnerability. That is, self-transcendence is a process
of expanding one’s boundaries to gain new insights for organizing and tack-
ling health-related events. This process has empirical support. Findings from
research consistently indicate that self-transcendence is associated with a wide
variety of well-being indicators, from successful aging and meaning in life, to
specifi c outcomes such as decreased fatigue or increased self-care activities of
daily living. In addition, the scholarship of advanced practice nurses, graduate
students, and researchers continues to build knowledge about personal, con-
textual, and cultural factors that infl uence the process of self-transcendence.

Self-Transcendence Theory has social congruence. Self-transcendence has
emerged as a foundational process in promoting societal welfare, as a devel-
opmental imperative across the life span for a wide variety of health-related
events. As such, nursing must be there to develop the knowledge and pro-
vide the expert support that facilitates this cost-effective and holistic process of
well-being for society.

■ REFERENCES

Acton, G. J. (2002). Self-transcendent views and behaviors: Exploring growth in

caregivers of adults with dementia. Journal of Gerontological Nursing, 28(12), 22–30.

7 . THEORY OF SELF -TRANSCENDENCE  139

Acton, G. J., & Wright, K. B. (2000). Self-transcendence and family caregivers of

adults with dementia. Journal of Holistic Nursing, 18, 143–158.

Arlin, P. K. (1975). Cognitive development in adulthood: A fi fth stage? Developmental
Psychology, 11, 602–606.

Basseches, M. (1984). Dialectical thinking and adult development. Norwood, NJ: Ablex.

Bean, K. B., & Wagner, K. (2006). Self-transcendence, illness distress, and quality of

life among liver transplant recipients. Journal of Theory Construction & Testing,

10(2), 47–53.

Bickerstaff, K. A., Grasser, C. M., & McCabe, B. (2003). How elderly nursing home

residents transcend losses of later life. Holistic Nursing Practice, 17(3), 159–165.

Billard, A. (2001). The impact of spiritual transcendence on the well-being of aging Catholic
sisters (Unpublished doctoral dissertation). Loyola College, Baltimore, MD.

Buchanan, D., Farran, C., & Clark, D. (1995). Suicidal thought and self-transcendence

in older adults. Journal of Psychosocial Nursing, 33(10), 31–34.

Burns, D. S., Robb, S. L., & Haase, J. E. (2009). Exploring the feasibility of a

therapeutic music video intervention in adolescents and young adults during

stem cell transplantation. Cancer Nursing, 32(5), 8–16.

Chan, W. C., & Chan, C. L. W. (2011). Acceptance of spousal death: The factor of time

in bereaved older adults’ search for meaning. Death Studies, 35, 147–162.

Chen, H.-C. (2012). Self-transcendence, illness perception, and depression in Taiwanese men
with oral cancer (Unpublished doctoral dissertation). The University of Arizona,

Tucson, AZ. Retrieved from http://arizona.openrepository.com/arizona/

bitstream/10150/228132/3/azu_etd_12083_sip1_m.pdf

Chen, S., & Walsh, S. M. (2009). Effect of a creative-bonding intervention on

Taiwanese nursing students’ self-transcendence and attitudes toward elders.

Research in Nursing & Health, 32, 204–216.

Chin-A-Loy, S. S., & Fernsler, J. I. (1998). Self-transcendence in older men attending a

prostate cancer support group. Cancer Nursing, 21, 358–363.

Commons, M., Demick, J., & Goldberg, C. (1996). Clinical approaches to adult
development. Norwood, NJ: Ablex.

Corless, I. B., Germino, B. B., & Pittman, M. (1994). Dying, death, and bereavement:
Theoretical perspectives and other ways of knowing. Boston, MA: Jones & Bartlett.

Coward, D. D. (1990). The lived experience of self-transcendence in women with

advanced breast cancer. Nursing Science Quarterly, 3, 162–169.

Coward, D. D. (1991). Self-transcendence and emotional well-being in women with

advanced breast cancer. Oncology Nursing Forum, 18, 857–863.

Coward, D. D. (1995). Lived experience of self-transcendence in women with AIDS.

Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24, 314–318.

Coward, D. D. (1996). Self-transcendence and correlates in a healthy population.

Nursing Research, 45, 116–122.

Coward, D. D. (1998). Facilitation of self-transcendence in a breast cancer support

group. Oncology Nursing Forum, 25, 75–84.

Coward, D. D. (2003). Facilitation of self-transcendence in a breast cancer support

group: Part II. Oncology Nursing Forum, 30(2), 291–300.

Coward, D. D., & Kahn, D. L. (2004). Resolution of spiritual disequilibrium by women

newly diagnosed with breast cancer. Oncology Nursing Forum, 31(2), E1–E8.

140 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Coward, D. D., & Kahn, D. L. (2005). Transcending breast cancer: Making meaning

from diagnosis and treatment. Journal of Holistic Nursing, 23(3), 264–283.

Coward, D. D., & Lewis, F. M. (1993). The lived experience of self-transcendence in

gay men with AIDS. Oncology Nursing Forum, 20, 1363–1369.

Coward, D. D., & Reed, P. G. (1996). Self-transcendence: A resource for healing at the

end of life. Issues in Mental Health Nursing, 17, 275–288.

Decker, I. M., & Reed, P. G. (2005). Developmental and contextual correlates of elders’

anticipated end-of-life treatment decisions. Death Studies, 29, 827–846.

Diener, J. E. S. (2003). Personal narrative as an intervention to enhance self-transcendence
in women with chronic illness (Unpublished doctoral dissertation). University of

Missouri, St. Louis, MO.

DiNapoli, J. M., Garcia-Dia, M. J., Garcia-Ona, L., O’Flaherty, D., & Siller, J. (2014). A

theory-based computer mediated communication intervention to promote mental

health and reduce high-risk behaviors in the LGBT population. Applied Nursing
Research, 27(1), 91–93.

Ellermann, C. R., & Reed, P. G. (2001). Self-transcendence and depression in middle-

aged adults. Western Journal of Nursing Research, 23, 698–713.

Enyert, G., & Burman, M. E. (1999). A qualitative study of self-transcendence in

caregivers of terminally ill patients. American Journal of Hospice and Palliative Care,
16(2), 455–462.

Erikson, E. H. (1986). Vital involvement in old age. New York, NY: Norton.

Farren, A. T. (2010). Power, uncertainty, self-transcendence, and quality of life in

breast cancer survivors. Nursing Science Quarterly, 23(1), 63–71.

Frankl, V. E. (1963). Man’s search for meaning. New York, NY: Pocket Books.

Frankl, V. E. (1969). The will to meaning. New York, NY: New American Library.

Haase, J. E., Britt, T., Coward, D. D., Leidy, N. K., & Penn, P. E. (1992). Simultaneous

concept analysis of spiritual perspective, hope, acceptance and self-

transcendence. Image: Journal of Nursing Scholarship, 24, 141–147.

Haugan, G. (2014). Nurse-patient interaction as a resource for hope, meaning in life

and self-transcendence in nursing home patients. Scandinavian Journal of Caring
Sciences, 28(1), 74–88.

Haugan, G., Hannssen, B., & Moksnes, U. K. (2013). Self-transcendence, nurse-patient

interaction, and the outcome of multidimensional well-being in cognitively intact

nursing home patients. Scandinavian Journal of Caring Sciences, 27(4), 882–893.

Haugan, G. Rannestad, T., Hammervold, R., Garåsen, H., & Espnes, G. A. (2013). Self-

transcendence in cognitively intact nursing-home patients: A resource for well-

being. Journal of Advanced Nursing, 69(5), 1147–1160.

Haugan, G., Rannestad, T., Hammervold, R., Garåsen, H., & Espnes, G. A. (2014). The

relationships between self-transcendence and spiritual well-being in cognitively

intact nursing home patients. International Journal of Older People Nursing, 9, 65–78.

Ho, H.-M., Tseng, Y.-H., Hsin, Y.-M., Chou, F.-H., & Lin, W.-T. (2016). Living with

illness and self-transcendence: The lived experience of patients with spinal

muscular atrophy. Journal of Advanced Nursing, 72(11), 2695–2705.

Hofer, J., Busch, H., Au, A., Šolcová, I. P., Tavel, P., & Tsien Wong, T. (2016).

Generativity does not necessarily satisfy all your needs: Associations among

7 . THEORY OF SELF -TRANSCENDENCE  141

cultural demand for generativity, generative concern, generative action, and need

satisfaction in the elderly in four cultures. Developmental Psychology, 52(3), 509–519.

Hsu, Y. C., Badger, T., Reed, P., & Jones, E. (2013). Factors associated with depressive

symptoms in older Taiwanese adults in a long-term care community. International
Psychogeriatrics, 25(6), 1013–1021.

Hunnibell, L. S., Reed, P. G., Quinn-Griffi n, M. Q., & Fitzpatrick, J. J. (2008). Self-

transcendence and burnout in hospice and oncology nurses. Journal of Hospice and
Palliative Nursing, 10(3), 172–179.

Iwamoto, R., Yamawaki, N., & Sato, T. (2011). Increased self-transcendence in patients

with intractable diseases. Psychiatry and Clinical Neuroscience, 65, 638–647.

JadidMilani, M., Ashktorab, T., AbedSaeedi, Z., & AlayiMaid, H. (2015). The impact

of self-transcendence on physical health status promotion in multiple sclerosis

patients attending peer support groups. International Journal of Nursing Practice,
2(6), 725–732.

Joffrion, L. P., & Douglas, D. (1994). Grief resolution: Facilitating self-transcendence

in the bereaved. Journal of Psychosocial Nursing, 32(3), 13–19.

Kausch, K. D., & Amer, K. (2007). Self-transcendence and depression among AIDS

memorial quilt panel makers. Journal of Psychosocial Nursing, 45(6), 45–53.

Kidd, L. I., Zauszniewski, J. A., & Morris, D. L. (2011). Benefi ts of a poetry writing

intervention for family caregivers of elders with dementia. Issues in Mental Health
Nursing, 32, 598–604.

Kilpatrick, J. A. W. (2002). Spiritual perspective, self-transcendence, and spiritual wellbeing
in female nursing students and female nursing faculty (Unpublished doctoral

dissertation). Widener University, Wilmington, DE.

Kim, S., Reed, P. G., Hayward, R. D., Kang, Y., & Koenig, H. G. (2011). Spirituality

and psychological well-being: Testing a theory of family interdependence among

family caregivers and their elders. Research in Nursing and Health, 34, 103–115.

Kinney, C. K. (1996). Transcending breast cancer: Reconstructing one’s self. Issues in
Mental Health Nursing, 17(3), 201–216.

Klaas, D. (1998). Testing two elements of spirituality in depressed and non-depressed

elders. The International Journal of Psychiatric Nursing Research, 4, 452–462.

Koplowitz, H. (1984). A projection beyond Piaget’s formal operational stage: A

general systems stage and a unitary stage. In M. L. Commons, F. A. Richards,

& C. Armon (Eds.), Beyond formal operations: Late adolescence and adult cognitive
development (pp. 272–296). New York, NY: Praeger.

Lundman, B., Aléx, L., Jonsén, E., Norberg, A., Nygren, B., Santamäki, R., &

Strandberg, G. (2010). Inner strength—A theoretical analysis of salutogenic

concepts. International Journal of Nursing Studies, 47(2), 251–260.

Marshall, V. M. (1980). Last chapter: A sociology of aging and dying. Monterey, CA:

Brooks-Cole.

Maslow, A. H. (1969). Various meanings of transcendence. Journal of Transpersonal
Psychology, 1, 56–66.

Matthews, E. E., & Cook, P. F. (2009). Relationships among optimism, well-being,

self-transcendence, coping, and social support in women during treatment for

breast cancer. Psycho-Oncology, 18, 716–726.

142 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

McCarthy, V. L. (2011). A new look at successful aging: Exploring a mid-range

nursing theory among older adults in a low-income retirement community. The
Journal of Theory Construction & Testing, 15(1), 17–23.

McCarthy, V. L., Jiying, L., Bowland, S., Hall, L. A., & Connelly, J. (2015).

Promoting self-transcendence and well-being in community-dwelling older

adults: A pilot study of a psychoeducational intervention. Geriatric Nursing,

26(6), 431–437.

McCarthy, V. L., Jiying, L., & Carini, R. M. (2013). The role of self-transcendence:

A missing variable in the pursuit of successful aging? Research in Gerontological
Nursing, 6, 178–186.

McCormick, D. P., Holder, B., Wetsel, M. A., & Cawthon, T. W. (2001). Spirituality and

HIV disease: An integrated perspective. Journal of the Association of Nurses in AIDS
Care, 12(3), 58–65.

McGee, E. M. (2000). Alcoholics anonymous and nursing. Journal of Holistic Nursing,

18(1), 11–26.

McGee, E. M. (2004). I’m better for having known you: An exploration of self-transcendence
in nurses (Unpublished doctoral dissertation). Boston College, Boston, MA.

Mellors, M. P., Erlen, J. A., Coontz, P. D., & Lucke, K. T. (2001). Transcending the

suffering of AIDS. Journal of Community Health Nursing, 18(4), 235–246.

Mellors, M. P., Riley, T. A., & Erlen, J. A. (1997). HIV, self-transcendence, and quality

of life. Journal of the Association of Nurses in AIDS Care, 2, 59–69.

Moe, A., Hellzen, O., Ekker, K., & Enmarker, I. (2013). Inner strength in relation to

perceived physical and mental health among the oldest old people with chronic

illness. Aging & Mental Health, 17(2), 189–196.

Neill, J. (2002). Transcendence and transformation in the life patterns of women

living with rheumatoid arthritis. Advances in Nursing Science, 24(4), 27–47.

Newman, M. (1992). Prevailing paradigms in nursing. Nursing Outlook, 40, 10–13.

Newman, M. (1994). Health as expanding consciousness (2nd ed.). New York, NY:

National League for Nursing.

Norberg, A., Lundman, B., Gustafson, Y., Norberg, C., Fischer, R. S., & Lövheim, H.

(2015). Self-transcendence (ST) among very old people: Its associations to social

and medical factors and development over fi ve years. Archives of Gerontology &
Geriatrics, 61(2), 247–253.

Nygren, B., Aléx, L., Jonsén, E., Gustafson, Y., Norberg, A., & Lundman, B. (2005).

Resilience, sense of coherence, purpose in life and self-transcendence in relation

to perceived physical and mental health among the oldest old. Aging & Mental
Health, 9(4), 354–362.

Palmer, B., Quinn Griffi n, M. T., Reed, P., & Fitzpatrick, J. J. (2010). Self-transcendence

and work engagement in acute care staff registered nurses. Critical Care Nursing
Quarterly, 33(2), 138–147.

Parse, R. R. (1992). Human becoming: Parse’s theory of nursing. Nursing Science
Quarterly, 5, 35–42.

Parse, R. R. (2015). Rosemarie Rizzo Parse’s humanbecoming paradigm. In M. C.

Smith & M. E. Parker (Eds.), Nursing theories and nursing practice (4th ed., pp.

263–277). Philadelphia, PA: F. A. Davis.

7 . THEORY OF SELF -TRANSCENDENCE  143

Peck, R. C. (1968). Psychological development in the second half of life. In B. L.

Neugarten (Ed.), Middle age and aging (pp. 88–92). Chicago, IL: University of

Chicago Press.

Pelusi, J. (1997). The lived experience of surviving breast cancer. Oncology Nursing
Forum, 24(8), 1343–1353.

Poole, D. K. (1999). Partnering with a formal program: Expanding the boundaries of
family caregiving for frail older adults (Unpublished doctoral dissertation). Medical

College of Georgia, Augusta, GA.

Ramer, L., Johnson, D., Chan, L., & Barrett, M. T. (2006). The effect of HIV/AIDS

disease progression on spirituality and self-transcendence in a multi-cultural

population. Journal of Transcultural Nursing, 17(3), 280–289.

Reed, P. G. (1983). Implications of the life-span developmental framework for well-

being in adulthood and aging. Advances in Nursing Science, 6, 18–25.

Reed, P. G. (1986). Developmental resources and depression in the elderly: A

longitudinal study. Nursing Research, 35, 368–374.

Reed, P. G. (1987). Spirituality and well-being in terminally ill hospitalized adults.

Research in Nursing and Health, 10(5), 335–344.

Reed, P. G. (1989). Mental health of older adults. Western Journal of Nursing Research,

11(2), 143–163.

Reed, P. G. (1991a). Self-transcendence and mental health in oldest-old adults.

Nursing Research, 40, 7–11.

Reed, P. G. (1991b). Toward a nursing theory of self-transcendence: Deductive

reformulation using developmental theories. Advances in Nursing Science, 13(4),

64–77.

Reed, P. G. (1996). Transcendence: Formulating nursing perspectives. Nursing Science
Quarterly, 9(1), 2–4.

Reed, P. G. (1997a). Nursing: The ontology of the discipline. Nursing Science Quarterly,

10(2), 76–79.

Reed, P. G. (1997b). The place of transcendence in nursing’s science of unitary human

beings: Theory and research. In M. Madrid (Ed.), Patterns of Rogerian knowing (pp.

187–196). New York, NY: National League for Nursing.

Reed, P. G. (2009). Demystifying self-transcendence for mental health nursing

practice and research. Archives of Psychiatric Nursing, 23(5), 397–400.

Reed, P. G. (2011). The spiral path of nursing knowledge. In P. G. Reed & N. B. C.

Shearer (Eds.), Nursing knowledge and theory innovation: Advancing the science of
nursing practice (pp. 1–35). New York, NY: Springer Publishing.

Reese, C. G., & Murray, R. B. (1996). Transcendence: The meaning of great-

grandmothering. Archives of Psychiatric Nursing, 10(4), 245–251.

Riegel, K. F. (1976). The dialectics of human development. American Psychologist, 31,

631–647.

Robb, S. L., Burns, D. S., Stegenga, K. A., Haut, P. R., Monahan, P. O., Meza, J.,

. . . Haase, J. E. (2014). Randomized clinical trial of therapeutic music video

intervention for resilience outcomes in adolescents/young adults undergoing

hematopoietic stem cell transplant: A report from the Children’s Oncology

Group. Cancer, 120(6), 909–917.

144 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Rogers, M. E. (1970). Introduction to the theoretical basis of nursing. Philadelphia, PA:

F. A. Davis.

Rogers, M. E. (1980). A science of unitary man. In J. P. Riehl & C. Roy (Eds.),

Conceptual modes for nursing practice (2nd ed., pp. 329–337). New York, NY:

Appleton-Century-Crofts.

Rogers, M. E. (1994). The science of unitary human beings: Current perspectives.

Nursing Science Quarterly, 7(1), 33–35.

Runquist, J. J., & Reed, P. G. (2007). Self-transcendence and well-being in homeless

adults. Journal of Holistic Nursing, 25(1), 5–13; discussion, 14–15.

Sarenmalm, E. K., Thorén-Jönsson, A., Gaston-Hohansson, F., & Öhlén, J. (2009).

Making sense of living under the shadow of death: Adjusting to a recurrent

breast cancer illness. Qualitative Health Research, 19(8), 1116–1130.

Sarter, B. (1988). Philosophical sources of nursing theory. Nursing Science Quarterly,

1(2), 52–59.

Schumann, R. R. (1999). Intensive care patients’ perceptions of the experience of mechanical
ventilation (Unpublished doctoral dissertation). Texas Women’s University,

Denton, TX.

Sharpnack, P. A., Quinn Griffi n, M. T., Benders, A. M., & Fitzpatrick, J. J. (2010).

Spiritual and alternative healthcare practices of the Amish. Holistic Nursing
Practice, 24, 64–72.

Sharpnack, P. A., Quinn Griffi n, M. T., Benders, A. M., & Fitzpatrick, J. J. (2011). Self-

transcendence and spiritual well-being in the Amish. Journal of Holistic Nursing,

29(2), 91–97.

Sheldon, K. M., & Kasser, T. (2001). Getting older, getting better? Personal strivings

and psychological maturity across the life span. Developmental Psychology, 37,

491–501.

Sinnott, J. D. (1998). The development of logic in adulthood: Postformal thought and its
applications. New York, NY: Plenum.

Sinnott, J. D. (2011). Constructing the self in the face of aging and death: Complex

thought and learning. In C. Hoare (Ed.), Oxford handbook of adult development and
learning (2nd ed., pp. 248–264). New York, NY: Oxford University Press.

Stevens, D. D. (1999). Spirituality, self-transcendence and depression in young adults with
AIDS (Unpublished doctoral dissertation). University of Miami, Coral Gables, FL.

Stinson, C. K., & Kirk, E. (2006). Structured reminiscence: An intervention to decrease

depression and increase self-transcendence in older women. Journal of Clinical
Nursing, 15(2), 208–218.

Teixeira, M. E. (2008). Self-transcendence: A concept analysis for nursing praxis.

Holistic Nursing Practice, 22(1), 25–31.

Thomas, J. C., Burton, M., Quinn Griffi n, M. T., & Fitzpatrick, J. J. (2010). Self-

transcendence, spiritual well-being, and spiritual practices of women with breast

cancer. Journal of Holistic Nursing, 28(2), 115–122.

Thomas, N. F., & Dunn, K. S. (2014). Self-transcendence and medication adherence in

older adults with hypertension. Journal of Holistic Nursing, 32(4), 316–326.

Upchurch, S. (1999). Self-transcendence and activities of daily living: The woman

with the pink slippers. Journal of Holistic Nursing, 17, 251–266.

7 . THEORY OF SELF -TRANSCENDENCE  145

Upchurch, S., & Mueller, W. H. (2005). Spiritual infl uences on ability to engage in

self-care activities among older African Americans. International Journal of Aging
and Human Development, 60(1), 77–94.

Viglund, K., Jonsén, E., Strandberg, G., Luncman, B., & Hygren, B. (2014). Inner

strength as a mediator of the relationship between disease and self-rated health

among old people. Journal of Advanced Nursing, 70(1), 144–152.

Vitale, S. A., Shaffer, C. M., & Fenton, H. R. A. (2014). Self-transcendence in

Alzheimer’s disease: The application of theory in practice. Journal of Holistic
Nursing, 23(4), 347–355.

Walker, C. A. (2002). Transformative aging: How mature adults respond to growing

older. Journal of Theory Construction & Testing, 6(2), 109–116.

Walsh, S. M., Radcliffe, R. S., Castillo, L. C., Kumar, A. M., & Broschard, D. M. (2007).

A pilot study to test the effect of art-making classes for family caregivers of

patients with cancer. Oncology Nursing Forum, 34(1), E9–E16. doi:10.1188/07.ONF.

E9-E16

Walton, C. G., Shultz, C., Beck, C. M., & Walls, R. C. (1991). Psychological correlates

of loneliness in the older adult. Archives of Psychiatric Nursing, 5(3), 165–170.

Wasner, M., Longaker, C., Fegg, J. J., & Borasio, G. D. (2005). Effects of spiritual care

training for palliative care professionals. Palliative Medicine, 19, 99–104.

Williams, B. J. (2012). Self-transcendence in stem cell transplantation recipients: A

phenomenologic inquiry. Oncology Nursing Forum, 39(4), E41–E48. doi:10.1188/12.

ONF.E41-E48

Willis, D. G., & Grace, P. J. (2011). The applied philosopher-scientist: Intersections

among phenomenological research, nursing science, and theory as a basis for

practice aimed at facilitating boys’ healing from being bullied. Advances in
Nursing Science, 34(1), 19–28.

Willis, D. G., & Griffi th, C. A. (2010). Healing patterns revealed in middle school

boys’ experiences of being bullied using Rogers’ Science of Unitary Human

Beings. Journal of Child and Adolescent Psychiatric Nursing, 23(3), 125–132.

Wright, K. B. (2003). Quality of life, self-transcendence, illness distress, and fatigue in liver
transplant recipients (Unpublished doctoral dissertation). University of Texas at

Austin.

Young, C., & Reed, P. G. (1995). Elders’ perceptions of the effectiveness of group

psychotherapy in fostering self-transcendence. Archives of Psychiatric Nursing, 9,

338–347.

Writerbay.net

Looking for top-notch essay writing services? We've got you covered! Connect with our writing experts today. Placing your order is easy, taking less than 5 minutes. Click below to get started.


Order a Similar Paper Order a Different Paper