Reconceptualization of the Uncertainty in Illness Theory

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State of the Science uncertainty and to use it as a positive force in the patient's life. In the mechanistic paradigm, uncertainty is viewed as the enemy that must be eliminated. The assumption is all aspects of the illness can be linearly determined. In this paradigm, health care providers cannot join into a partnership with the patient to use the uncertainty as a force for evolution. In the probabilistic paradigm the uncertainty is viewed as natural: uncertainty is an inherent part of reality, and life is not assumed to be determinate with precision. When family, friends and health care providers support a probabilistic view of life and of the illness, the acknowledgment of uncertainty removes a barrier to trust. The realization that uncertainty in an unescapably part of reality can motivate people to work at creating the trusting relationships and mutual support necessary in a world where no one can have a sure or final answer. Accepting uncertainty opens the door to consider multiple possibilities since nothing is certain or universal (Burszajen et al., 1981). Within this conceptualization of the process of living with uncertainty in chronic illness, there are four situations in which the reevaluation of uncertainty can be blocked or prolonged, thus threatening the viability of the dissipative structure. The first situation occurs when the patient's supportive resources do not promote a probabilistic or conditional view of life. The second situation occurs when the patient is the major caretaker of significant others and delays their psychological response to their diagnosis and treatment. The delayed response to their experience blocks them from fully activating interactions with supportive others to facilitate restructuring the evaluation of uncertainly. The third situation occurs in patients who are isolated from interaction with social resources. These patients have less opportunity to obtain assistance in structuring the new view of life to dissipate the sense of uncertainty as aversive. The fourth blocking situation occurs when the patient's health care providers maintain a persistent search for predictability and certainty. When patients are treated by health care providers who fail to acknowledge the natural existence of uncertainty, the patient maintains the view uncertainty is an anomaly that must be removed. As the process of integration and accommodation is blocked or prolonged, the behavior of the person will resemble that seen in posttraumatic stress disorders, a condition caused by exposure to catastrophic uncertainty and unpredictability. The evolution of uncertainty as being aversive continues to reverberate in the person, creating behaviors such as uncontrollable and emotionally distressing, intrusive thoughts or images connected with the aversive events, alternating with psychic numbing to shield the person from the trauma and a purposeful avoidance of situations, individuals, thoughts and feelings about the experience (Green, Grace & Lindy, 1988). This response is cyclic with clusters of symptoms fluctuating differtially over time (Green, Lindy & Grace, 1985; Green et al., 1985). Although this complex of behaviors will be demonstrated initially when uncertainty disrupts the person's life, the intensity and duration of the symptom complex will be prolonged and magnified in any of the four situations described above. Probabilistic Thinking Feedback from the health care providers promoting a probabilistic world view encourages the development of a new sense of order in the person. Current nursing practice Volume 22, Number 4, Winter 1990 involves activities that are consistent with this world view. Nursing activities with the chronically ill function currently to promote probabilistic thinking when nurses help the patient to consider multiple new ways to accomplish valued activities or consider alternatives in adjusting to the changing nature of the illness or foster the notion there are many factors influencing the patient's response to treatment. Nursing functions to facilitate the patient's evaluation of uncertainty and promote a probabilistic view of life. When we encourage patients to consider alternatives and choices as possibilities, we are teaching them to alter their thinking from mechanistic to probabilistic. This new view of uncertainty as a natural phenomena is a new view of the world in which instability and fluctuation are natural and increase the person's range of possibilities. When nurses join with patients in the use of probabilistic thinking, the energy exchange between the patient and the external resources maintains the dissipative structure. When patients become adherents of probabilistic thinking, they seem to select health care professionals who will join them in this view of the world. While this new view of uncertainty remainsat the theoretical level without empirical support, the view of uncertainty as leading to more possibilities and new patterns of contingencies is being considered not only in nursing but also in the current psychological literature on control (Strickland, 1989). The beneficial aspects of predictability and its related concept of control are being called into question (Piper & Langer, 1986). Newer theories of cognitive processing consider that to generate differentially effective responses, a certain amount of uncertainty may be essential (Piper & Langer, 1986). Creativity may require a letting go of conventional ways and creating new contingencies out of seemingly unrelated situations that are not completely predictable. Perhaps our emphasis on logical, linear thinking, which is a mechanistic world view, has inadvertently promoted inflexibility and a commitment to determinism in the chronically ill that precludes consideration of a conditional world view. The reformulization of the uncertainty theory has embraced this view. References Alien, 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. Amonovsky. A. (1987). Unraveling the mystery of health: How people manage stress and stay well. San Francisco: Jossey-Bass. Braden, C.J. (1990). Learned self-help response to chronic illness experience: A test of three alternative theories. Scholarly Inquiry for Nursing Practice, 4(1), 23-41. Brent, S. B. (1978). 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Reconceptualization of the Uncertainty in Illness Theory

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