532 UNIT IV Nursing Theories
CASE STUDY Analysis
Alvin, 66 years of age, has been in the hospital for n Autonomy: Alvin’s desires should be given
12 weeks with multiple trauma following a motor priority over his family members’ desires.
vehicle accident. His condition worsens each day, n Freedom: Not to honor Alvin’s wishes is a
and his prognosis is very grave. He is not alert, but violation of his freedom.
he grimaces and withdraws from stimulation. n Objectivity: The subjective feelings of two
Prior to his injury, Alvin signed a living will and family members are in conflict with objective
discussed with his family his desire not to be kept reality. Only the patient’s feelings are consid-
alive in the event he was ill or injured and recovery ered in ethical decisions.
was not possible. The health care team tells his n Self-assertion: It is not justifiable to substitute
family that, despite aggressive treatment, many of family members’ values for the patient’s.
Alvin’s body systems are failing. Even if Alvin sur- n Beneficence: The patient’s goals cannot be
vives, there is no hope that he will be able to live obtained by aggressive treatment; however,
without a ventilator because of extensive lung aggressive treatment may well cause the patient
damage. The team suggests supportive care for further harm.
Alvin and a do-not-resuscitate order. Most of n Fidelity: The health care professional’s agree-
the family members express the desire to ensure ment with Alvin was to act as his agent in
Alvin’s comfort. Two family members believe pursuing goals that are possible to attain.
Alvin will survive and recover. They refuse the
team’s suggestion and demand that Alvin receive
every available treatment to keep him alive.
CRITICAL THINKING ACTIVITIES
Using the Husted model, analyze the following ethical 3. Johnny, 7 years of age, is a psychiatric inpatient
situations from an ethical perspective. with a diagnosis of trichomania (hair pulling).
1. Christina, 46 years of age, has been in the hospital for His parents are very concerned about stopping his
2 weeks following a traumatic injury. Her condition destructive behavior and have developed a series
was very grave, but she is beginning to show signs of of punishments for incidents of hair pulling.
recovery. The health care team suggests that a blood Johnny has been seen pulling his hair out several
transfusion will provide the necessary support to times during the day. His parents arrive and ask
continue her improvement. Christina and her family how many times Johnny pulled his hair. What
practice a religious faith that does not permit blood should the nurse say?
transfusions. Christina’s husband and religious leader 4. Eugene, 47 years of age, has several chronic
insist that she not be given the transfusion regardless illnesses. Despite education and support, he
of the consequences. When the visitors leave, declines to adhere to prescribed health care
Christina tells the nurse that she would like to receive practices. Mark, a home health care nurse,
the transfusion, but only if it could be kept secret has been seeing Eugene for several months and
from her family. What should the nurse do? has made no progress in helping Eugene to
2. Angela, 34 years of age, is dying of lung cancer. improve his health. While discussing the situa-
Despite counseling and support, she is very tion, Eugene tells Mark that he has no inten-
frightened. When her death is imminent, she tion of changing any of his behaviors. Is Mark
screams over and over, “Don’t let me die! Don’t let justified in asking the physician to discontinue
me die!” Despite all efforts, Angela succumbs be- home health visits?
fore her husband arrives. He asks, “How was she? 5. Agnes is a nurse on a busy medical nursing unit.
Was she afraid?” What should the nurse say? Mr. Brown frequently asks Agnes to interrupt her
CHAPTER 26 Gladys L. Husted and James H. Husted 533
work to answer questions and perform nonemer- vagrancy, but he has never been violent with
gent tasks for him. Agnes’s other patients com- himself or others. He states he enjoys his “vaca-
plain of neglect. What should Agnes do, and how tions” because his medicine makes his life seem
can she justify her actions? boring, dull, and difficult. Burt’s family calls the
6. Burt, 34 years of age, has a diagnosis of manic director of the group home and insists that Burt
depression. He lives in a group home with several be required to take his medicine each morning
others like himself. Several times a year, Burt under supervision. What should the director say,
stops taking his medication and disappears for and how could he justify various courses of
weeks at a time. Occasionally Burt is arrested for action?
POINTS FOR FURTHER STUDY
n Husted, G. L., & Husted, J. H. (2008). Ethical deci- n Husted & Husted’s Theory website at: http://www.
sion making in nursing and healthcare: The sympho- nursing.duq.edu/faculty/husted/details.html
nological approach (4th ed.). New York: Springer.
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V
UNIT
Middle Range Nursing Theories
n Middle range theories are the least abstract and contain the details of practice
application.
n Middle range theories develop evidence for nursing practice outcomes.
n Middle range theories include characteristics of nursing practice and/or nursing
situations.
n Middle range theories are theoretical evidence of applicability and outcome.
n The nursing situation details that make middle range theories recognizable
as such are:
l The situation or health condition of the client/patient
l Client/patient population or age-group
l Location or area of practice (e.g., community)
l Action of the nurse or intervention
l The client/patient outcome anticipated
27
CHAP TER
Ramona T. Mercer
1929 to present
Maternal Role Attainment—
Becoming a Mother
Molly Meighan
“The process of becoming a mother requires extensive psychological, social, and physical work.
A woman experiences heightened vulnerability and faces tremendous challenges as she
makes this transition. Nurses have an extraordinary opportunity to help women learn,
gain confidence, and experience growth as they assume the mother identity”
(Mercer, 2006, p. 649).
1962, graduating with distinction from the University
Credentials and Background of New Mexico, Albuquerque. She went on to earn
of the Theorist a master’s degree in maternal-child nursing from
Ramona T. Mercer began her nursing career in 1950, Emory University in 1964 and completed a Ph.D.
when she received her diploma from St. Margaret’s in maternity nursing at the University of Pittsburgh
School of Nursing in Montgomery, Alabama. She in 1973.
graduated with the L.L. Hill Award for Highest Scho- After receiving her Ph.D., Mercer moved to
lastic Standing. She returned to school in 1960 after California and accepted the position of Assistant
working as a staff nurse, head nurse, and instructor in Professor in the Department of Family Health Care
the areas of pediatrics, obstetrics, and contagious dis- Nursing at the University of California, San Francisco.
eases. She completed a bachelor’s degree in nursing in She was promoted to associate professor in 1977 and
Photo credit: Marie Cox, M&M Studios, San Francisco, CA.
Previous authors: Mary M. (Molly) Meighan, Alberta M. Bee, Denise Legge, and Stephanie Oetting.
538
CHAPTER 27 Ramona T. Mercer 539
to full professor in 1983. She remained in that role Parents at Risk, published in 1990, also received an
until her retirement in 1987. Currently, Dr. Mercer American Journal of Nursing Book of the Year Award.
is Professor Emeritus in Family Health Nursing at Parents at Risk (1990) focused on strategies for facili-
the University of California, San Francisco (Mercer, tating early parent-infant interactions and promoting
curriculum vitae, 2002). parental competence in relation to specific risk situa-
Mercer received awards throughout her career. In tions. Mercer’s sixth book, Becoming a Mother: Research
1963, while working and pursuing studies in nursing, on Maternal Identity from Rubin to the Present, was
she received the Department of Health, Education, and published by Springer Publishing Company of New
Welfare Public Health Service Nurse Trainee Award at York in 1995. This book contains a more complete
Emory University and was inducted into Sigma Theta description of Mercer’s Theory of Maternal Role At-
Tau. She received this award again during her years tainment and her framework for studying variables
at the University of Pittsburgh. She also received the that impact the maternal role.
Bixler Scholarship for Nursing Education and Re- Since her first publication in 1968, Mercer has
search, Southern Regional Board, for doctoral study. In written numerous articles for both nursing and non-
1982, she received the Maternal Child Health Nurse of nursing journals. She published several online courses
the Year Award from the National Foundation of the for Nurseweek during the 1990s and through early
March of Dimes and American Nurses Association, 2000, including “Adolescent Sexuality and Child-
Division of Maternal Child Health Practice. She bearing,” “Transitions to Parenthood,” and “Helping
was presented with the Fourth Annual Helen Nahm Parents When the Unexpected Occurs.”
Lecturer Award at the University of California, San Mercer maintained membership in several profes-
Francisco School of Nursing, in 1984. Mercer’s research sional organizations, including the American Nurses
awards include the American Society for Psychopro- Association and the American Academy of Nursing,
phylaxis in Obstetrics (ASPO)/Lamaze National Re- and was an active member on many national commit-
search Award in 1987; the Distinguished Research tees. From 1983 to 1990, she was Associate Editor of
Lectureship Award, Western Institute of Nursing, Health Care for Women International. Mercer served
Western Society for Research in Nursing in 1988; and on the review panel for Nursing Research and Western
the American Nurses Foundation’s Distinguished Con- Journal of Nursing Research and on the editorial board
tribution to Nursing Science Award in 1990 (Mercer, of the Journal of Adolescent Health Care, and she
curriculum vitae, 2002). Mercer has authored numerous was on the executive advisory board of Nurseweek.
articles, editorials, and commentaries. In addition, she She also served as a reviewer for numerous grant pro-
has published six books and six book chapters. posals. Additionally, she was actively involved with
In early research efforts, Mercer focused on the regional, national, and international scientific and
behaviors and needs of breastfeeding mothers, moth- professional meetings and workshops (Mercer, cur-
ers with postpartum illness, mothers bearing infants riculum vitae, 2002). She was honored as a Living
with defects, and teenage mothers. Her first book, Legend by the American Academy of Nursing during
Nursing Care for Parents at Risk (1977), received an the Annual Meeting and Conference in Carlsbad,
American Journal of Nursing Book of the Year Award California, in November 2003. Mercer was honored
in 1978. Her study of teenage mothers over the by the University of New Mexico in 2004, receiving
first year of motherhood resulted in the 1979 book, the first College of Nursing Distinguished Alumni
Perspectives on Adolescent Health Care, which also Award. In 2005, she was recognized as among the
received an American Journal of Nursing Book of the most outstanding alumni and faculty, and her name
Year Award in 1980. Preceding research led Mercer to appears on the Wall of Fame at the University of
study family relationships, antepartal stress as related California, San Francisco.
to familial relationships and the maternal role, and
mothers of various ages. In 1986, Mercer’s research on
three age groups of mothers was drawn together in Theoretical Sources
her third book, First-Time Motherhood: Experiences Mercer’s Theory of Maternal Role Attainment was
from Teens to Forties (1986a). Mercer’s fifth book, based on her extensive research on the topic beginning
540 UNIT V Middle Range Nursing Theories
in the late 1960s. Mercer’s professor and mentor, Reva contributed. In addition, Mercer’s work was influ-
Rubin at the University of Pittsburgh, was a major enced by von Bertalanffy’s (1968) general system
stimulus for both research and theory development. theory. Her model of maternal role attainment de-
Rubin (1977, 1984) was well known for her work in picted in Figure 27–1 uses Bronfenbrenner’s (1979)
defining and describing maternal role attainment as a concepts of nested circles as a means of portraying
process of binding-in, or being attached to, the child interactional environmental influences on the mater-
and achieving a maternal role identity or seeing one- nal role. The complexity of her research interest
self in the role and having a sense of comfort about it. led Mercer to rely on several theoretical sources to
Mercer’s framework and study variables reflect many identify and study variables that affect maternal role
of Rubin’s concepts. attainment. Although much of her work involved
In addition to Rubin’s work, Mercer based her testing and extending Rubin’s theories, she has consis-
research on both role and developmental theories. tently looked to the research of others in the develop-
She relied heavily on an interactionist approach to ment and expansion of her theory.
role theory, using Mead’s (1934) theory on role enact-
ment and Turner’s (1978) theory on the core self.
In addition, Thornton and Nardi’s (1975) role acquisi- Use of Empirical Evidence
tion process helped shape Mercer’s theory, as did Mercer selected both maternal and infant variables
the work of Burr, Leigh, Day, and Constantine (1979). for her studies on the basis of her review of the litera-
Werner’s (1957) developmental process theories also ture and findings of researchers in several disciplines.
Macrosystem
Mesosystem
Microsystem
Mother-father relationship
Mother
Empathy—sensitivity to cues
Self-esteem/self-concept Child
Parenting received as child Temperament
Maturity/flexibility Ability to give cues
Attitudes Appearance
Pregnancy/birth experience Characteristics
Health/depression/anxiety Responsiveness
Role conflict/strain Health Stress
Maternal Role/Identity Child's Outcome
Competence/confidence in role Cognitive/mental
Gratification/satisfaction development
Attachment to child Behavior/attachment
Health
Social competence School
Family functioning
Day care
Social support
Parent's work settings
Transmitted cultural consistencies
FIGURE 27-1 Model of Maternal Role Attainment. (Modified from Mercer, R. T. [1991]. Maternal role:
Models and consequences. Paper presented at the International Research Conference sponsored by
the Council of Nurse Researchers and the American Nurses Association, Los Angeles, CA. Copyright
Ramona T. Mercer, 1991. NOTE: This figure has been modified based on personal communication with
R. T. Mercer [January 4, 2003]. The word exosystem was replaced with mesosystem to be more consistent
with Bronfenbrenner’s [1979] model on which it is based.)
CHAPTER 27 Ramona T. Mercer 541
MAJOR CONCEPTS & DEFINITIONS
Maternal Role Attainment Child-Rearing Attitudes
Maternal role attainment is an interactional and Child-rearing attitudes are maternal attitudes or beliefs
developmental process occurring over time in which about child rearing (Mercer, 1986a).
the mother becomes attached to her infant, acquires
competence in the caretaking tasks involved in the Health Status
role, and expresses pleasure and gratification in the Health status is defined as “The mother’s and father’s
role (Mercer, 1986a). “The movement to the personal perception of their prior health, current health,
state in which the mother experiences a sense of health outlook, resistance-susceptibility to illness,
harmony, confidence, and competence in how she health worry concern, sickness orientation, and
performs the role is the end point of maternal role rejection of the sick role” (Mercer, May, Ferketich,
attainment—maternal identity” (Mercer, 1981, p. 74). et al., 1986, p. 342).
Maternal Identity Anxiety
Maternal identity is defined as having an internalized Mercer and colleagues (1986) describe anxiety as “a
view of the self as a mother (Mercer, 1995). trait in which there is specific proneness to perceive
stressful situations as dangerous or threatening, and
Perception of Birth Experience as a situation-specific state” (p. 342).
A woman’s perception of her performance during
labor and birth is her perception of the birth experi- Depression
ence (Mercer, 1990). According to Mercer and colleagues (1986), depres-
sion is “having a group of depressive symptoms
Self-Esteem and in particular the affective component of the
Mercer, May, Ferketich, and DeJoseph (1986) describe depressed mood” (p. 342).
self-esteem as “an individual’s perception of how others
view oneself and self-acceptance of the perceptions” Role Strain–Role Conflict
(p. 341). Role strain is the conflict and difficulty felt by the
woman in fulfilling the maternal role obligation
Self-Concept (Self-Regard) (Mercer, 1985a).
Mercer (1986a) outlines self-concept, or self-regard,
as “The overall perception of self that includes self- Gratification-Satisfaction
satisfaction, self-acceptance, self-esteem, and congru- Mercer (1985b) describes gratification as “the
ence or discrepancy between self and ideal self” (p. 18). satisfaction, enjoyment, reward, or pleasure that
a woman experiences in interacting with her
Flexibility infant, and in fulfilling the usual tasks inherent
Roles are not rigidly fixed; therefore, who fills the in mothering.”
roles is not important (Mercer, 1990). “Flexibility of
childrearing attitudes increases with increased de- Attachment
velopment . . . Older mothers have the potential to Attachment is a component of the parental role and
respond less rigidly to their infants and to view each identity. It is viewed as a process in which an endur-
situation in respect to the unique nuances” (Mercer, ing affectional and emotional commitment to an
1986a, p. 43; 1990, p. 12). individual is formed (Mercer, 1990).
Continued
542 UNIT V Middle Range Nursing Theories
MAJOR CONCEPTS & DEFINITIONS—cont’d
Infant Temperament personal communication, January 4, 2003). The
An easy versus a difficult temperament is related to father’s interactions help diffuse tension and facili-
whether the infant sends hard-to-read cues, leading tate maternal role attainment (Donley, 1993; Mercer,
to feelings of incompetence and frustration in the 1995).
mother (Mercer, 1986a).
Stress
Infant Health Status Stress is made up of positively and negatively per-
Infant health status is illness causing maternal-infant ceived life events and environmental variables
separation, interfering with the attachment process (Mercer, 1990).
(Mercer, 1986a).
Social Support
Infant Characteristics According to Mercer and colleagues (1986), social
Characteristics include infant temperament, appear- support is “the amount of help actually received, sat-
ance, and health status (Mercer, 1981). isfaction with that help, and the persons (network)
providing that help” (p. 341).
Infant Cues Four areas of social support are as follows:
Infant cues are infant behaviors that elicit a response 1. Emotional support: “Feeling loved, cared for,
from the mother (R. T. Mercer, personal communi- trusted, and understood” (Mercer, 1986a, p. 14)
cation, September 3, 2003). 2. Informational support: “Helping the individual
help herself by providing information that is use-
Family ful in dealing with the problem and/or situation”
Mercer and colleagues (1986) define family as “a dy- (Mercer, 1986a, p. 14)
namic system that includes subsystems—individuals 3. Physical support: A direct kind of help (Mercer,
(mother, father, fetus/infant) and dyads (mother- Hackley, & Bostrom, 1984)
father, mother-fetus/infant, and father-fetus/infant) 4. Appraisal support: “A support that tells the role
within the overall family system” (p. 339). taker how she is performing in the role; it enables
the individual to evaluate herself in relationship
Family Functioning to others’ performance in the role” (Mercer,
Family functioning is the individual’s view of the 1986a, p. 14)
activities and relationships between the family and
its subsystems and broader social units (Mercer & Mother-Father Relationship
Ferketich, 1995). The mother-father relationship is the perception of
the mate relationship that includes intended and
Father or Intimate Partner actual values, goals, and agreements between the
The father or intimate partner contributes to the pro- two (Mercer, 1986b). The maternal attachment to
cess of maternal role attainment in a way that can- the infant develops within the emotional field of the
not be duplicated by any other person (R. T. Mercer, parent’s relationship (Donley, 1993; Mercer, 1995).
She found that many factors may have a direct or child-rearing attitudes, and health. She included the
indirect influence on the maternal role, adding to infant variables of temperament, appearance, respon-
the complexity of her studies. Maternal factors in siveness, health status, and ability to give cues. Mercer
Mercer’s research included age at first birth, birth ex- (1995) and Ferketich and Mercer (1995a, 1995b,
perience, early separation from the infant, social 1995c) also noted the importance of the father’s role
stress, social support, personality traits, self-concept, and applied many of Mercer’s previous findings in
CHAPTER 27 Ramona T. Mercer 543
studying the paternal response to parenthood. Her • Maternal identity develops concurrently with
research required numerous instruments to measure maternal attachment, and each depends on the
the variables of interest. other (Mercer, 1995; Rubin, 1977).
Mercer has studied the influence of these variables
on parental attachment and competence over several Nursing
intervals, including the immediate postpartum period Mercer (1995) stated that “Nurses are the health pro-
and 1 month, 4 months, 8 months, and 1 year follow- fessionals having the most sustained and intense inter-
ing birth (Mercer & Ferketich, 1990a, 1990b). In addi- action with women in the maternity cycle” (p. xii).
tion, she has included adolescents, older mothers, ill Nurses are responsible for promoting the health of
mothers, mothers dealing with congenital defects, families and children; nurses are pioneers in develop-
families experiencing antepartal stress, parents at high ing and sharing assessment strategies for these patients,
risk, mothers who had cesarean deliveries, and fathers she explained. Her definition of nursing provided in
in her research (Mercer, 1989; Mercer & Ferketich, a personal communication is as follows:
1994, 1995; Mercer, Ferketich, & DeJoseph, 1993). As Nursing is a dynamic profession with three major
a recent step, she compared her findings and the basis foci: health promotion and prevention of illness,
for her original theory with current research. As a providing care for those who need professional
result, Mercer (2004) has proposed that the term assistance to achieve their optimal level of health
maternal role attainment be replaced with becoming a and functioning, and research to enhance the
mother, because this more accurately describes the knowledge base for providing excellent nursing
continued evolvement of the role across the woman’s care. Nurses provide health care for individuals,
life span. In addition, she proposed using more recent families, and communities. Following assessment
nursing research findings to describe the stages and of the client’s situation and environment, the
process of becoming a mother.
nurse identifies goals with the client, provides
assistance to the client through teaching, support-
Major Assumptions ing, providing care the client is unable to provide
For maternal role attainment, Mercer (1981, 1986a, for self, and interfacing with the environment
and the client
1995) stated the following assumptions: (R. Mercer, personal communication,
• A relatively stable core self, acquired through life- March 21, 2004).
long socialization, determines how a mother defines
and perceives events; her perceptions of her infant’s In her writing, Mercer (1995) refers to the impor-
and others’ responses to her mothering, with her life tance of nursing care. In Becoming a Mother: Research
situation, are the real world to which she responds on Maternal Identity from Rubin to the Present, Mercer
(Mercer, 1986a). does not specifically mention nursing care, however
• In addition to the mother’s socialization, her devel- she emphasizes that the kind of help or care a woman
opmental level and innate personality characteristics receives during pregnancy and the first year following
also influence her behavioral responses (Mercer, birth can have long-term effects for her and her child.
1986a). Nurses in maternal-child settings play a sizable role
• The mother’s role partner, her infant, will reflect in providing both care and information during this
the mother’s competence in the mothering role period.
through growth and development (Mercer, 1986a).
• The infant is considered an active partner in the Person
maternal role-taking process, affecting and being Mercer (1985a) does not specifically define person,
affected by the role enactment (Mercer, 1981). but refers to the self or core self. She views the self
• The father’s or mother’s intimate partner contributes as separate from the roles that are played. Through
to role attainment in a way that cannot be duplicated maternal individuation, a woman may regain her own
by any other supportive person (Mercer, 1995). personhood as she extrapolates herself from the
544 UNIT V Middle Range Nursing Theories
mother-infant dyad (Mercer, 1985b). The core self Theoretical Assertions
evolves from a cultural context and determines how Mercer’s original Theory and Model of Maternal Role
situations are defined and shaped (Mercer, 1985a). Attainment were introduced in 1991 during a sympo-
The concepts of self-esteem and self-confidence are sium at the International Research Conference spon-
important in attainment of the maternal role. The sored by the Council of Nursing Research and American
mother as a separate person interacts with her infant Nurses Association in Los Angeles, California (Mercer,
and with the father or her significant other. She is 1995). It was refined and presented more clearly in her
both influential and is influenced by both of them 1995 book, Becoming a Mother: Research on Maternal
(Mercer, 1995). Identity from Rubin to the Present (see Figure 27–1).
Mercer’s (2004) more recent revision of her theory
Health has focused on the woman’s transition in becoming a
In her theory, Mercer defines health status as the mother. Motherhood involves an extensive change in
mother’s and father’s perception of their prior a woman’s life that requires her ongoing development.
health, current health, health outlook, resistance- According to Mercer, becoming a mother is more
susceptibility to illness, health worry or concern, extensive than just assuming a role. It is unending
sickness orientation, and rejection of the sick role. and continuously evolving. Therefore, she proposed
Health status of the newborn is the extent of disease that the term maternal role attainment be retired.
present and infant health status by parental rating She based that recommendation on the published
of overall health (Mercer, 1986b). The health status research of Walker, Crain, and Thompson (1986a,
of a family is affected negatively by antepartum 1986b), Koniak-Griffin (1993), and McBride and
stress (Mercer, Ferketich, DeJoseph, May, & Sollid, Shore (2001), who had examined the process of moth-
1988; Mercer, May, Ferketich, & DeJoseph, 1986). ering and raised questions about the appropriateness
Health status is an important indirect influence of maternal role attainment as an end point in the
on satisfaction with relationships in childbearing process.
families. Health is also viewed as a desired outcome
for the child. It is influenced by both maternal and Maternal Role Attainment: Mercer’s
infant variables. Mercer (1995) stresses the impor- Original Model
tance of health care during the childbearing and Mercer’s Model of Maternal Role Attainment was
childrearing processes. placed within Bronfenbrenner’s (1979) nested circles
of the microsystem, mesosystem, and macrosystem (see
Environment Figure 27–1). The original model proposed by Mercer
Mercer conceptualized the environment from Bron- was altered in 2000, changing the term exosystem,
fenbrenner’s definition of the ecological environment originally found in the second circle, and replacing it
and based her earliest model in Figure 27–1 on it with the term mesosystem. Mercer (personal commu-
(Mercer, 1995; R. Mercer, personal communication, nication, January 4, 2003) explained that this change
June 24, 2000). This model illustrates the ecological made the model more consistent with Bronfenbrenner’s
interacting environments in which maternal role terminology, as follows:
attainment develops. During personal communication 1. The microsystem is the immediate environment in
on January 4, 2003, Mercer explained, “Development which maternal role attainment occurs. It includes
of a role/person cannot be considered apart from factors such as family functioning, mother-father
the environment; there is a mutual accommodation relationships, social support, economic status,
between the developing person and the changing family values, and stressors. The variables con-
properties of the immediate settings, relationships tained within this immediate environment interact
between the settings, and the larger contexts in which with one or more of the other variables in affecting
the settings are embedded.” Stresses and social sup- the transition to motherhood. The infant as an
port within the environment influence both maternal individual is embedded within the family system.
and paternal role attainment and the developing The family is viewed as a semi-closed system main-
child. taining boundaries and control over interchange
CHAPTER 27 Ramona T. Mercer 545
between the family system and other social systems system (Mercer, 1995). National laws regarding
(Mercer, 1990). women and children and health priorities that
The microsystem is the most influential on mater- influence maternal role attainment are within the
nal role attainment (Mercer, 1995; R. Mercer, macrosystem.
personal communication, January 4, 2003). In Maternal role attainment is a process that follows four
1995, Mercer expanded her earlier concepts stages of role acquisition; these stages have been
and model to emphasize the importance of the adapted from Thornton and Nardi’s 1975 research.
father in role attainment, stating that he helps The following stages are indicated in Figure 27–2
“diffuse tension developing within the mother- as the layers a through d:
infant dyad” (p. 15). Maternal role attainment is a. Anticipatory: The anticipatory stage begins during
achieved through the interactions of father, pregnancy and includes the initial social and psy-
mother, and infant. Figure 27–2, first intro- chological adjustments to pregnancy. The mother
duced in Mercer’s (1995) sixth book, Becoming learns the expectations of the role, fantasizes about
a Mother: Research on Maternal Identity from the role, relates to the fetus in utero, and begins to
Rubin to the Present, depicts this interaction. role-play.
The layers a through d represent the stages of b. Formal: The formal stage begins with the birth of
maternal role attainment from anticipatory to the infant and includes learning and taking on
personal (role identity) and the infant’s growth the role of mother. Role behaviors are guided by
and developmental stages (Mercer, 1995). formal, consensual expectations of others in the
2. The mesosystem encompasses, influences, and inter- mother’s social system.
acts with persons in the microsystem. Mesosystem c. Informal: The informal stage begins as the mother
interactions may influence what happens to the develops unique ways of dealing with the role not
developing maternal role and the child. The meso- conveyed by the social system. The woman makes
system includes day care, school, work setting, places her new role fit within her existing lifestyle based
of worship, and other entities within the immediate on past experiences and future goals.
community. d. Personal: The personal or role-identity stage occurs
3. The macrosystem refers to the general prototypes as the woman internalizes her role. The mother
existing in a particular culture or transmitted cul- experiences a sense of harmony, confidence, and
tural consistencies. The macrosystem includes the competence in the way she performs the role, and
social, political, and cultural influences on the the maternal role is achieved.
other two systems. The health care environment Stages of role attainment overlap and are altered
and the current health care system policies that as the infant grows and develops. A maternal role
affect maternal role attainment originate in this identity may be achieved in a month, or it can take
several months (Mercer, 1995). The stages are influ-
enced by social support, stress, family functioning,
Father and also by the relationship between mother and
or father or significant other.
intimate partner
Traits and behaviors of both the mother and the
infant may influence maternal role identity and child
outcome. Maternal traits and behaviors included in
Mother Infant Mercer’s model are empathy, sensitivity to infant cues,
a self-esteem and self-concept, parenting received as a
b a
c b child, maturity and flexibility, attitudes, pregnancy and
d c d birth experience, health, depression, and role conflict.
FIGURE 27-2 A microsystem within the evolving model of Infant traits having an impact on maternal role identity
maternal role attainment. (From Mercer, R. T. [1995]. Becoming include temperament, ability to send cues, appearance,
a mother: Research on maternal identity from Rubin to the pres- general characteristics, responsiveness, and health.
ent. New York: Springer; used by permission.) Examples of the infant’s developmental responses that
546 UNIT V Middle Range Nursing Theories
interact with the mother’s developing maternal iden- to retire the term maternal role attainment because
tity, depicted as a through d in Figure 27–2, include “it implies a static situation rather than fluctuating pro-
the following: cess” (p. 79). Finally, in a synthesis of nine qualitative
a. Eye contact with the mother as she talks to her or studies, Nelson (2003) described continued growth and
him, grasp reflex transformation in women as they become mothers.
b. Smile reflex and quieting behavior in response to Mercer (2004) acknowledged that new challenges in
the mother’s care motherhood require making new connections to regain
c. Consistent interactive behaviors with the mother confidence in the self and proposed replacing the term
d. Eliciting responses from the mother; increasingly maternal role attainment with becoming a mother.
more mobile Qualitative studies have identified stages of mater-
According to Mercer (1995): nal role attainment using the descriptive terms of
participants. A compilation of the results of several
The personal role identity stage is reached when of these studies has led Mercer (2004, 2006) to the
the mother has integrated the role into her self following proposed changes in the names of stages
system with a congruence of self and other roles; leading to maternal role identity:
she is secure in her identity as mother, is emo- • Commitment and preparation (pregnancy)
tionally committed to her infant, and feels a • Acquaintance, practice, and physical restoration
sense of harmony, satisfaction, and competence (first 2 weeks)
in the role (p. 14).
• Approaching normalization (second week to
Using Burke and Tully’s (1977) work, Mercer 4 months)
(1995) stated that a role identity has internal and • Integration of maternal identity (approximately
external components: the identity is the internalized 4 months)
view of self (recognized maternal identity), and role is These stages parallel the original stages in Mercer’s
the external, behavioral component. theory, but they embrace the maternal experience
more completely and use terminology derived from
Becoming a Mother: A Revised Model new mothers’ descriptions of their experiences.
Mercer has continued to use both her own research Theory building, according to Mercer (personal
and the research of others as building blocks for her communication, September 3, 2003), is a continual
theory. In 2003, she began reexamining the Theory of process as research provides evidence for clarifying
Maternal Role Attainment, proposing that the term concepts, additions, and deletions. Although many of
becoming a mother more accurately reflects the pro- the more recent studies support the findings of both
cess based on recent research. According to Mercer Rubin and Mercer, Mercer (2004) recognized the evi-
(2004), the concept of role attainment suggests an end dence for needed changes in her original theory for
point rather than an ongoing process and may not greater clarity and consistency. It is with this insight that
address the continued expansion of the self as a she proposed retiring the term maternal role attain-
mother. Mercer’s conclusions are based largely on ment. Mercer (2004) acknowledges that becoming a
current nursing research about the cognitive and mother, which connotes continued growth in mother-
behavioral dimensions of women becoming mothers. ing, is more descriptive of the process, which is much
Walker, Crain, and Thompson’s (1986a, 1986b) ques- larger than a role. Although some roles may be termi-
tions about maternal role attainment as a continuing nated, motherhood is a lifelong commitment.
process contributed to Mercer’s reexamination of her Mercer has continued to use Bronfenbrenner’s
theory. Koniak-Griffin (1993) also questioned the concept of interacting nested ecological environ-
behavioral and cognitive dimensions of maternal ments. However, she renamed them to reflect the
role attainment. Hartrick (1997) reported in her study living environments: family and friends, community,
that mothers of children from 3 to 16 years of and society at large (Figure 27–3). This model places
age undergo a continual process of self-definition. the interactions between mother, infant, and father
McBride and Shore (2001) in their research on mothers at the center of the interacting, living environments
and grandmothers suggested that there may be a need (R. Mercer, personal communication, September 3,
CHAPTER 27 Ramona T. Mercer 547
Society at large
Community
Family and friends
Father
or intimate
partner
a Mother Infant a
b b
c c
d d
FIGURE 27-3 Becoming a mother: A revised model. (From R. T. Mercer, personal communication,
September 3, 2003.)
2003; Mercer & Walker, 2006). Variables within the process of becoming a mother (Mercer & Walker,
family and friends environment include physical and 2006). According to Mercer and Walker (2006), the
social support, family values, cultural guidelines for model presents both environmental variables and
parenting, knowledge and skills, family functioning, maternal-infant characteristics that are important
and affirmation as a mother. The community environ- considerations for both nursing practice and future
ment includes day care, places of worship, schools, work research.
settings, health care facilities, recreational facilities, and
support groups. Within the society at large, influences
come from laws affecting woman and children, evolving Logical Form
reproductive and neonatal science, national health care Mercer used both deductive and inductive logic in
programs, various social programs, and funding for developing the theoretical framework for studying
research promoting becoming a mother. factors that influence maternal role attainment during
The newest model (Figure 27–4) shows interacting the first year of motherhood and in her theory. De-
environments that affect the process of becoming a ductive logic is demonstrated in Mercer’s use of works
mother. The model was developed in 2006 based on a from other researchers and disciplines. Role and
review of the nursing research about the effectiveness or developmental theories and the work of Rubin on
interventions aimed at fostering the process of becom- maternal role attainment provided a base for the
ing a mother. This model depicts the complex issues original framework. Mercer also used inductive logic
that have the potential to either facilitate or inhibit the in the development of her Theory of Maternal Role
548 UNIT V Middle Range Nursing Theories
Funding for PHN Health Care Childbirth/
Research
Promoting BAM
Maternal-Child Minors Abuse
Facilities
Parenting
Therapeutic Relationships
Society at Large Laws Affecting Laws Defining Infant Caregiving Instruction Classes Facilities Worship
Safety
Recreational
Community
Aid to Dependent Children WIC Mother-Infant Interaction Focused Education Places of Child Care
Social Role Preparation
Mother-Infant Attachment Promotion
F
Centers
M BAM I Services & Social Protective
Laws Affecting Childbearing Decisions Group Support
Maternal Physical Recovery
Maternal Care-of-Self Promotion Affirmation as
Continuity
Maternal Well-Being Promotion Mother
of Cultural
Customs
Family
Continuity
Support
Physical & Social
Knowledge & Skills
Family & Friends
FIGURE 27-4 Interacting environments that affect the process of becoming a mother. (From Mercer,
R. T., & Walker, L. O. (2006) Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(5), pp. 570–581.)
Attainment. Through practice and research, she ob- textbooks and have been used in practice by nurses
served adaptation to motherhood from a variety of and those in other disciplines. Both the theory and
circumstances. She noted that differences existed in the model are capable of serving as a framework for
adaptation to motherhood when maternal illness com- assessment, planning, implementing, and evaluat-
plicated the postpartum period, when a child with a ing nursing care of new mothers and their infants.
defect was born, and when a teenager became a mother. The utility of Mercer’s theory in nursing practice
These observations directed the research about those is described and illustrated by Meighan (2010) in
situations and the subsequent development of her the- Chapter 17 of the fourth edition of Nursing The-
ory. Changes to her original theory have been based on ory: Utilization & Application by Alligood. Mercer’s
more recent research and deductive reasoning coupled theory is useful to practicing nurses across many
with her belief in continually improving the clarity and maternal-child settings. Mercer (1986a, 1986b) linked
usefulness of her theory. her research findings with nursing practice at
each interval from birth through the first year, mak-
Acceptance by the Nursing Community ing her theory applicable in a variety of pediatric
settings.
Practice In addition, Mercer’s theory has been used in
Mercer’s theory is highly practice oriented. The con- organizing patient care. Concepts in the research
cepts in her theory have been cited in many obstetrical conducted by Neeson, Patterson, Mercer, and May
CHAPTER 27 Ramona T. Mercer 549
(1983), “Pregnancy Outcome for Adolescents Receiving Sank (1991) used Mercer’s theory in her doctoral
Prenatal Care by Nurse Practitioners in Extended dissertation research at the University of Texas,
Roles,” were used in setting up a clinical practice. Austin, entitled Factors in the Prenatal Period That
Clark, Rapkin, Busen, and Vasquez (2001) used Affect Parental Role Attainment During the Postpar-
Mercer’s theory to establish and test a parent educa- tum Period in Black American Mothers and Fathers.
tion curriculum for substance-abusing women in a Mercer’s Theory of Maternal Role Attainment also
residential treatment facility. Meighan and Wood served as the framework for Washington’s (1997)
(2005) used the theory of maternal role attainment dissertation, Learning Needs of Adolescent Mothers
to explore the impact of hyperemesis gravidarum When Identifying Fever and Illnesses in Infants Less
on maternal role assumption. Than Twelve Months of Age at the University of
Miami. Bacon (2001), a student at the Chicago
Education School of Professional Psychology, used Mercer’s
Mercer’s work has appeared extensively in both theory in her dissertation, Maternal Role Attain-
maternity and pediatric nursing texts. Many of the ment and Maternal Identity in Mothers of Premature
current concepts in maternal-child nursing are Infants. Dilmore (2003) based her study, A Compari-
based on Mercer’s research. Her theory and models son of Confidence Levels of Postpartum Depressed
help simplify the very complex process of becoming and Non-Depressed First Time Mothers, on Mercer’s
a parent. The Theory of Maternal Role Attainment is research.
credited with enhancing understanding and making McBride (1984) wrote the following:
Mercer’s contribution extremely valuable to nursing
education. The Theory of Maternal Role Attainment Maternal role attainment has been a fundamental
provides a framework for students as they learn to concern of nursing since the pioneering work of
plan and provide care for parents in a wide variety Mercer’s mentor, Rubin, almost two decades ago. It
of settings. The Theory of Becoming a Mother has is now becoming the research-based, theoretically
rapidly gained acceptance since its introduction in sound construct that nurse researchers have been
2004. Mercer’s theory and research have also been searching for in their analysis of the experience of
used in other disciplines as they relate to parenting new mothers (p. 72).
and maternal role attainment. It has been shown to
be helpful to students in psychology, sociology, and
education. Further Development
Mercer used her initial research as a building block
Research for other studies. In later research, she aimed at iden-
Mercer advocated the involvement of students in fac- tifying predictors of maternal-infant attachment on
ulty research. During her tenure at the University of the basis of maternal experience with childbirth and
California, San Francisco, she chaired committees maternal risk status. Mercer also examined paternal
and was a committee member for numerous graduate competence on the basis of experience with childbirth
theses and dissertations. Collaborative research with and pregnancy risk status. In another study, she de-
a graduate student and junior faculty member in 1977 veloped and tested a causal model to predict partner
and 1978 led to the development of a highly reliable, relationships in high-risk and low-risk pregnancy.
valid instrument to measure mothers’ attitudes about More work and refinement of the original model and
the labor and delivery experience. Numerous re- theory have taken place during the past few years,
searchers have requested and received permission to as described earlier. She included the importance of
use the instrument. the father in maternal role attainment, adding this to
Mercer’s work has served as a springboard for her model and theory in a section of her 1995 book,
other researchers. The theoretical framework for her Becoming a Mother: Research on Maternal Identity
correlational study exploring the differences between from Rubin to the Present.
three age groups of first-time mothers (15 to 19, 20 to In First-Time Motherhood: Experiences from Teens
29, and 30 to 42 years of age) has been tested by oth- to Forties, Mercer (1986a) presented a model of
ers, including Walker and colleagues (1986a, 1986b). the following four phases occurring in the process of
550 UNIT V Middle Range Nursing Theories
maternal role attainment during the first year of childbearing that have an impact on the transition to
motherhood: motherhood.
1. The physical recovery phase (from birth to 1 month) Mercer’s concern for the utility and applicability of
2. The achievement phase (from 2 to 4 or 5 months) her theory is evident in her continued work toward
3. The disruptions phase (from 6 to 8 months) clarity and usefulness. Revisions of her theory in 2003,
4. The reorganization phase (from after the eighth although based on nursing research, are still being
month and still in process at 1 year) tested in other studies. Mercer’s (2004) proposal of
Additionally, adaptation to the maternal role was abandoning the term maternal role attainment for
proposed to occur at three levels (biological, psycho- the term becoming a mother is argued logically, but
logical, and social), which are interacting and interde- few studies put it to use in practice or research. Al-
pendent throughout the phases. These phases and though qualitative research to describe the phases of
levels of adaptation were described briefly and were becoming a mother uses the exact words of women
applied to her research. In 2003, Mercer proposed experiencing this transition, these phases have not
additional changes to the theory (2004), which included been confirmed among women in other cultures or
abandoning the term maternal role attainment for the in different circumstances.
term becoming a mother. Changes to the model and
adoption of the following four descriptive phases to the Critique
process of becoming a mother were also proposed:
1. Commitment and preparation (pregnancy) Clarity
2. Acquaintance, practice, and physical restoration The concepts, variables, and relationships have not
(first 2 weeks) always been defined explicitly, but they were described
3. Approaching normalization (second week to and implied in Mercer’s earlier work. However, the
4 months) concepts were defined theoretically and operational-
4. Integration of maternal identity (approximately ized consistently. Work toward improving clarity is
4 months) evident. Concepts, assumptions, and goals have been
These changes were based on the research studies organized into a logical and coherent whole, so that
by other nurses and are evidence of Mercer’s contin- understanding the interrelationships among the con-
ued scrutiny and critique of her theory to improve its cepts is relatively easy. Some interchanging of terms
utility in practice and research. and labels used to identify concepts, such as adapta-
According to Mercer and Walker (2006), research tion and attainment, social support, and support net-
into specific nursing interventions that foster be- work, is potentially confusing for the reader, and
coming a mother is needed. They encourage the maternal role attainment has not been defined consis-
involvement of nursing staff, students, and faculty in tently, which can obstruct clarity. Maternal identity,
the development and testing of assessment guide- a term that Mercer defines as the final stage of role
lines and instruments to measure outcomes of nurs- attainment (personal or role identity stage) is some-
ing interventions that support maternal role identity times substituted for maternal role attainment.
and the process of becoming a mother. Mercer and According to Mercer (1995), when the maternal role
Walker also encourage further research in dealing has been attained, the mother has achieved a maternal
with mothers who face special challenges, including identity, the internalized role of mother. However,
mothers who face childbirth complications, mothers the terms attainment and role identity are sometimes
with low social and economic resources, adolescent confusing.
mothers, and mothers with high-risk infants. Ac- Mercer has continued to work toward greater clar-
cording to Mercer and Walker, development and ity. She has proposed using terms derived from nurs-
testing of nursing interventions that support and ing researchers that would be understood more clearly
empower parents are warranted. They encourage by users of her theory. She has questioned the use of
research to determine how best to foster becoming a the term maternal role attainment, because it connotes
mother in culturally diverse groups, explaining that a static state rather than the continuously evolving role
each culture has customs and values attached to as a mother. Mercer has examined qualitative research
CHAPTER 27 Ramona T. Mercer 551
containing the exact words of women experiencing and the completeness of operational definitions in-
motherhood, and she favors using these words to crease the empirical precision. The theoretical frame-
describe the stages of becoming a mother. work for exploring differences among age groups of
first-time mothers lends itself well to further testing
Simplicity and is being used by others for this purpose. The con-
Despite numerous concepts and relationships, the tinued scrutiny by Mercer herself has continually
theoretical framework for maternal role attainment or improved her theory and solidified her concepts.
becoming a mother organizes a rather complex phe- Mercer’s proposed changes to improve clarity of con-
nomenon into an easily understood and useful form. cepts are based on research studies of others within
The theory is predictive in nature and readily lends the discipline of nursing.
itself as a guide for practice. Concepts are not specific
to time and place and although abstract, they are Importance
described and operationalized to the extent that The theoretical framework for maternal role attain-
meanings are not easily misinterpreted. It should be ment during the first year has proved to be useful,
noted that the research to define and support the practical, and valuable to nursing. Mercer’s work is
theoretical relationships was very complex, which used repeatedly in nursing research, practice, and
was due largely to the great number of concepts. The education. The framework is also applicable to any
process of becoming a mother is multifaceted and discipline that works with mothers and children dur-
varies considerably according to the individual and ing the first year of motherhood. McBride (1984)
to environmental influences. Mercer’s theory pro- wrote, “Dr. Mercer is the one who developed the most
vides a framework for understanding this complex, complete theoretical framework for studying one
multidimensional process. aspect of parental experience, namely, the factors that
influence the attainment of the maternal role in the
Generality first year of motherhood” (p. 72).
Mercer’s theory is derived from and is specific to Throughout her career, Mercer consistently has
parent-child nursing but has been used by other dis- linked research and practice. Applications for nursing
ciplines concerned with mothering and parenting. care or nursing interventions are addressed and provide
The theory can be generalized to all women during the bond between research and practice in her works.
pregnancy through the first year after birth, regardless As she has said, nursing research is the “bridge to excel-
of age, parity, or environment. It is among the few lence” in nursing practice (Mercer, 1984, p. 47).
theories applicable to high-risk perinatal patients and
their families. As previously mentioned, it can be
applied to a variety of pediatric settings. Mercer Summary
(1995) specified her theory for the study and predic- The Theory of Maternal Role Attainment has been
tion of parental attachment, including that of the shown to be useful in both research and practice for
pregnant woman’s partner. Therefore, it is useful for nurses, as well as other disciplines concerned with
studying and working with family members following parenting. Mercer’s continued devotion to improving
birth. Mercer’s work has broadened the range of the usefulness and clarity of her theory and model
application of previously existing theories on maternal is evident and has served well those who use her
role attainment, because her studies have spanned theory. Mercer’s use of both her own research and the
various developmental levels and situational contexts, research of others strengthens her work. Her proposal
a quality that many other studies do not share. to adopt the Theory of Becoming a Mother is based
solidly on the research process. Motherhood and
Accessibility attainment of the parenting role is a very complex,
Mercer’s work has evolved from extensive research multilevel process. Mercer’s theory and her work
efforts. The concepts, assumptions, and relationships make this process logical and understandable and
are grounded predominantly in empirical observa- provide a solid foundation for practice, education,
tions and are congruent. The degree of concreteness and research.
552 UNIT V Middle Range Nursing Theories
the nurse learns that the only living grandparents
CASE STUDY
of the baby live a great distance away. Susan will
Susan, a 19-year-old woman, delivered her first not have any family or friends to turn to when she
infant prematurely 5 days ago. Although her post- takes the baby home.
partum course has been relatively uneventful, the In this high-risk perinatal case, Mercer’s frame-
infant has had difficulty and must remain hospital- work should be useful for nursing assessment and
ized. Susan and her young husband visit the nurs- intervention to facilitate maternal role attainment.
ery every afternoon to be with the baby, but they How would you use it as a guide in planning care
ask very few questions. In talking with the couple, for Susan?
CRITICAL THINKING ACTIVITIES
1. In your own practice, consider Mercer’s Theory address current changes in health care delivery
and Model of Maternal Role Attainment as a and the impact on the family? What changes in
guide. List the ways it was useful to you in the Mercer’s model, if any, do you see that need to be
care of a new mother. addressed?
2. High-risk families often continue to experience 4. Mercer proposed changing her theory from
problems for years after the birth of a child with a Maternal Role Attainment to Becoming a
congenital problem. Can Mercer’s theory be Mother to address the evolving role of mother-
adapted to help in assessment and intervention hood. Do you agree or disagree with this
for these mothers and their families beyond the change? Is it possible that becoming a mother
first year? What areas need further research and and attaining the maternal role are both relevant
development? to the theory and nursing care of new mothers/
3. Consider the current health care environment. families in the clinical setting?
Does the model proposed by Mercer adequately
POINTS FOR FURTHER STUDY
Publications Websites
n Mercer, R.T. (2004) Becoming a mother versus n Nurses for Nurses Everywhere. (2004). Nurse
maternal role attainment. Journal of Nursing information: Ramona T. Mercer. Melbourne,
Scholarship, 36(3), 226–232. Australia, at: http://www.nurses.info/nursing_
n Mercer, R. T. (2006). Nursing support of the theory_midrange_theories_ramona_mercer.htm.
process of becoming a mother. Journal of n Nurses for Nurses Everywhere. (2004). Nurse
Obstetric, Gynecologic, and Neonatal Nursing, information: Reva Rubin. Melbourne, Australia,
35(5), 649–651. at: http://www.nurses.info/nursing_theory_
n Mercer, R. T., & Walker, L. O. (2006). A review of midrange_theories_reva_rubin.htm.
nursing interventions to foster becoming a mother. n University of New Mexico Past Distinguished
Journal of Obstetric, Gynecologic, and Neonatal Alumni Award: Ramona Mercer at: http://nursing.
Nursing, 35(5), 568–582. unm.edu/alumni-and-friends/daa-profiles/ramona-
n Meighan, M. (2010). Mercer’s maternal role the- mercer.html.
ory and nursing practice. In M. R. Alligood (Ed.), n Word press at: http://khaelashofieananta.wordpress.
Nursing theory: Utilization & application (4th ed., com/2011/11/02/nursing-theory-ramona-t-mercer/.
pp. 389–410). St. Louis: Mosby.
CHAPTER 27 Ramona T. Mercer 553
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Ferketich, S. L., & Mercer, R. T. (1995a). Paternal-infant chronically ill members. Scholarly Inquiry for Nursing
attachment of experienced and inexperienced fathers Practice: An International Journal, 3, 23–26.
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568–582. ering behavior and maternal role attainment during the
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prenatal care by nurse practitioners in extended roles. when identifying fever and illnesses in infants less than
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Maternal Child Nursing Journal, 6, 67–75. Harris (Ed.), The concept of development (pp. 125–148).
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BIBLIOGRAPHY
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Books competence for experienced and inexperienced fathers.
Mercer, R. T. (1977). Nursing care for parents at risk. Nursing Research, 44, 89–95.
Thorofare, (NJ): Charles B. Slack. Mercer, R. T. (1995). A tribute to Reva Rubin. Maternal
Mercer, R. T. (1979). Perspectives on adolescent health care. Child Nursing, 20, 184.
Philadelphia: Lippincott. Mercer, R. T. (1997). Chronically ill children: How families
Mercer, R. T. (1986). First-time motherhood: Experiences adjust. Nurseweek, 10(9), 14–15, 17.
from teens to forties. New York: Springer. Mercer, R. T. (1997). The employed mother’s challenges.
Mercer, R. T. (1990). Parents at risk. New York: Springer. Nurseweek, 10(17), 10–11, 15.
Mercer, R. T. (1995). Becoming a mother: Research on Mercer, R. T. (2000). Response to “Life-span development:
maternal identity from Rubin to the present. New York: A review of theory and practice for families with
Springer. chronically ill members.” Scholarly Inquiry for Nursing
Practice, 14(4), 375–378.
Journal Articles Mercer, R. T., & Ferketich, S. L. (1995). Experienced and
Ferketich, S. L., & Mercer, R. T. (1995). Paternal-infant inexperienced mothers’ maternal competence during
attachment of experienced and inexperienced fathers infancy. Research in Nursing Health, 18, 333–343.
during infancy. Nursing Research, 44, 31–37.
28
CHAP TER
Merle H. Mishel
1939 to present
Uncertainty in Illness Theory
Donald E. Bailey, Jr. and Janet L. Stewart
“My theory can be applied to both practice and research. It has been used to explain
clinical situations and design interventions that lead to evidence-based practice. Current
and future nurse scientists have and will continue to extend the theory to different
patient populations. This work has the potential to transform health care.
(Mishel, personal communication, May 28, 2008)”
The original scale has been used as the basis for the
Credentials and Background following three additional scales:
of the Theorist 1. A community version (MUIS-C) for chronically ill
Merle H. Mishel was born in Boston, Massachusetts. individuals who are not hospitalized or receiving
She graduated from Boston University with a B.A. in active medical care
1961 and received her M.S. in psychiatric nursing 2. A measure of parents’ perceptions of uncer-
from the University of California in 1966. Mishel tainty (PPUS) with regard to their child’s illness
completed her M.A. and Ph.D. in social psychology experience
at the Claremont Graduate School in Claremont, 3. A measure of uncertainty in spouses or other fam-
California, in 1976 and 1980, respectively. Her ily members when another member of the family
dissertation research was supported by a National is acutely ill (PPUS-FM)
Research Service Award to develop and test the Early in her professional career, Mishel practiced
Perceived Ambiguity in Illness Scale, later named as a psychiatric nurse in acute care and community
the Mishel Uncertainty in Illness Scale (MUIS-A). settings. While pursuing her doctorate, she was on
Photo Credit: Dr. Michael Belyea, University of North Carolina, Chapel Hill, NC.
The authors wish to think Dr. Merle Mishel for her review and input for this chapter.
555
556 UNIT V Middle Range Nursing Theories
faculty in the Department of Nursing at the California Fulbright Award. She has been a visiting scholar at
State University at Los Angeles, rising from assistant many institutions throughout North America, includ-
professor to full professor. She practiced as a nurse ing University of Nebraska, University of Texas at
therapist in community and private practice settings Houston, University of Tennessee at Knoxville, Uni-
from 1973 to 1979. After completing her doctorate in versity of South Carolina, University of Rochester,
social psychology, Mishel became associate professor Yale University, and McGill University. Mishel was
at the University of Arizona College of Nursing in doctoral program consultant for the University of
1981 and full professor in 1988. She was Division Cincinnati College of Nursing from 1991 to 1992 and
Head of Mental Health Nursing from 1984 to 1991. Rutgers University School of Nursing in 1993. In
While at Arizona, Mishel received numerous intra- 2004, she received the Linnea Henderson Research
mural and extramural research grants that supported Fellowship Program Award from the Kent State
the continued development of the theoretical frame- University School of Nursing. Over the last 20 years,
work of uncertainty in illness. During this period, she she has presented more than 80 invited addresses at
continued practicing as a nurse therapist with the schools of nursing throughout the United States and
heart transplant program at the University Medical Canada. With growing international interest in her
Center. She was inducted as a fellow in the American theory and measurement models, Mishel conducted
Academy of Nursing in 1990. an International Symposium on Uncertainty at
Mishel moved back east in 1991 and joined the Kyungpook National University in Daegu, South
faculty at the University of North Carolina at Chapel Korea, was a visiting scholar at Mahidol University in
Hill School of Nursing as professor, and she was Bangkok, Thailand, and delivered the keynote address
awarded the endowed Kenan Professor of Nursing for the Japanese Society of Nursing Research annual
Chair in 1994. Friends of the National Institute of convention, in Sapporo, Japan.
Nursing Research presented her with a Research Mishel is a member of many professional organiza-
Merit Award in 1997 and invited her to present her tions, including the American Academy of Nursing,
research as an exemplar of federally funded nursing Sigma Theta Tau International, the American Psycho-
intervention studies at a Congressional Breakfast logical Association, the American Nurses Association,
in 1999. She is Director of the T-32 Institutional the Society of Behavioral Medicine, the Oncology
National Research Service Award Training Grant, Nursing Society, the Southern Nursing Research Soci-
Interventions for Preventing and Managing Chronic ety, and the Society for Education and Research in
Illness that awards predoctoral and postdoctoral fel- Psychiatric Nursing. She served as a grant reviewer
lowships to nurses who are interested in developing for the National Cancer Institute, the National Center
interventions for underserved chronically ill patients. for Nursing Research, and the National Institute on
Mishel’s research program is noteworthy for being Aging, and she was a charter member of the study sec-
funded continually by the National Institutes of tion on human immunodeficiency virus (HIV) at the
Health from 1984 through 2011. Each research grant National Institute of Mental Health.
has built upon findings from prior studies to move
systematically toward theoretically derived scientifi-
cally tested nursing interventions. Currently Mishel is Theoretical Sources
co-leader of the Hillman Scholars Program designed When Mishel began her research into uncertainty,
to produce a new generation of nurse innovators with the concept had not been applied in the health and
knowledge and research skills to solve complex health illness context. Her original Uncertainty in Illness
problems and improve patient care. Theory (Mishel, 1988) drew from existing informa-
Among her many awards, Mishel received a Sigma tion-processing models (Warburton, 1979) and per-
Theta Tau International Sigma Xi Chapter Nurse sonality research (Budner, 1962) from psychology
Research Predoctoral Fellowship from 1977 to 1979 that characterized uncertainty as a cognitive state
and received the Mary Opal Wolanin Research Award resulting from insufficient cues with which to form
in 1986. In 1987, Mishel was first alternate for a a cognitive schema or internal representation of a
CHAPTER 28 Merle H. Mishel 557
situation or event. Mishel attributes the underlying supported a mechanistic view with emphasis on con-
stress-appraisal-coping-adaptation framework in the trol and predictability. She used critical social theory
original theory to the work of Lazarus and Folkman to recognize bias inherent in the original theory, an
(1984). The unique aspect of this framework was its orientation toward certainty and adaptation. Mishel
application to uncertainty as a stressor in the context incorporated tenets from chaos theory and open sys-
of illness, a particularly meaningful proposal for tems for a more accurate representation of how
nursing. chronic illness creates disequilibrium and how people
With the reconceptualization of the theory, Mishel incorporate continual uncertainty to find new mean-
(1990) recognized that the Western approach to science ing in illness.
MAJOR CONCEPTS & DEFINITIONS
Uncertainty Structure Providers
Uncertainty is the inability to determine the mean- Structure providers are the resources available to
ing of illness-related events, occurring when the assist the person in the interpretation of the stimuli
decision maker is unable to assign definite value to frame (Mishel, 1988).
objects or events, or is unable to predict outcomes
accurately (Mishel, 1988). Credible Authority
Credible authority is the degree of trust and confi-
Cognitive Schema dence a person has in his or her health care providers
Cognitive schema is a person’s subjective interpreta- (Mishel, 1988).
tion of illness, treatment, and hospitalization (Mishel,
1988). Social Supports
Social supports influence uncertainty by assisting the
Stimuli Frame individual to interpret the meaning of events
Stimuli frame is the form, composition, and struc- (Mishel, 1988).
ture of the stimuli that a person perceives, which are
then structured into a cognitive schema (Mishel, Cognitive Capacities
1988). Cognitive capacities are the information-processing
abilities of a person, reflecting both innate capabili-
Symptom Pattern ties and situational constraints (Mishel, 1988).
Symptom pattern is the degree to which symptoms
occur with sufficient consistency to be perceived as Inference
having a pattern or configuration (Mishel, 1988). Inference refers to the evaluation of uncertainty
using related, recalled experiences (Mishel, 1988).
Event Familiarity
Event familiarity is the degree to which a situation is Illusion
habitual or repetitive, or contains recognized cues Illusion refers to beliefs constructed out of uncer-
(Mishel, 1988). tainty (Mishel, 1988).
Event Congruence Adaptation
Event congruence refers to the consistency between Adaptation reflects biopsychosocial behavior occur-
the expected and the experienced in illness-related ring within persons’ individually defined range of
events (Mishel, 1988). usual behavior (Mishel, 1988).
Continued
558 UNIT V Middle Range Nursing Theories
MAJOR CONCEPTS & DEFINITIONS—cont’d
New View of Life Probabilistic Thinking
New view of life refers to the formulation of a new Probabilistic thinking refers to a belief in a condi-
sense of order, resulting from the integration of con- tional world in which the expectation of continual
tinual uncertainty into one’s self-structure, in which certainty and predictability is abandoned (Mishel,
uncertainty is accepted as the natural rhythm of life 1988).
(Mishel, 1988).
Use of Empirical Evidence et al., 1993; Kim, Lee, & Lee, 2012; Murray, 1993).
The Uncertainty in Illness Theory grew out of Mishel’s Similarly, the ambiguous nature of illness symptoms
dissertation research with hospitalized patients, using and the consequent difficulty in determining the sig-
both qualitative and quantitative findings to generate nificance of physical sensations have been identified
the first conceptualization of uncertainty in the context as sources of uncertainty (Cohen, 1993; Hilton, 1988;
of illness. With the publication of Mishel’s Uncertainty Nelson, 1996).
in Illness Scale (Mishel, 1981), extensive research Social support has been shown to have a direct
began into adults’ experiences with uncertainty related impact on uncertainty by reducing perceived com-
to chronic and life-threatening illnesses. Considerable plexity and an indirect impact through its effect on the
empirical evidence has accumulated to support Mishel’s predictability of symptom pattern (Lin, 2012; Mishel
theoretical model in adults. Several integrative reviews & Braden, 1988; Somjaivong, Thanasilp, Preechawong,
of uncertainty research have comprehensively summa- et al., 2011; Scott, Martin, Stone, et al., 2011). The
rized and critiqued the state of the science (Cahill, perception of stigma associated with some conditions,
Lobiondo-Wood, Bergstrom, et al., 2012; Hansen, particularly HIV infection (Regan-Kubinski & Sharts-
Rørtveit, Leiknes, et al., 2012; Mishel, 1997a, 1999; Hopko, 1995) and Down’s syndrome (Van Riper
Stewart & Mishel, 2000). The authors included studies & Selder, 1989), served to create uncertainty when
that directly support the elements of Mishel’s uncer- families were unsure about how others would respond
tainty model. to the diagnosis. Family members have been shown to
Most empirical studies have been focused on two experience high levels of uncertainty as well, which
antecedents of uncertainty, stimuli frame and structure may further reduce the amount of support experi-
providers, and the relationship between uncertainty enced by the patient (Baird & Eliasziw, 2011; Brown
and psychological outcomes. Mishel tested other ele- & Powell-Cope, 1991; Hilton, 1996; Wineman, O’Brien,
ments of the model, such as the mediating roles of Nealon, et al., 1993). Uncertainty was heightened by
appraisal and coping, early in her program of research interactions with health care providers when patients
(Mishel & Braden, 1987; Mishel, Padilla, Grant, et al., and family members received unclear information,
1991; Mishel & Sorenson, 1991), and these elements, as received simplistic explanations that did not fit their
well as cognitive capacity as an antecedent to uncer- experience, or perceived that care providers were not
tainty, generated less research attention. expert or responsive enough to help them manage
Several studies have shown that objective or the intricacies of the illness (Becker, Jason-Bjerklie,
subjective indicators of the severity of life-threat or Benner, et al., 1993; Checton & Greene, 2012; Sharkey,
illness symptoms associate positively with uncertainty 1995; Step & Ray, 2011).
(Baird & Eliasziw, 2011; Grootenhuis & Last, 1997; Numerous studies have reported the negative impact
Somjaivong, Thanasilp, Preechawong, et al., 2011). of uncertainty on psychological outcomes, characterized
Across a sustained illness trajectory, unpredictability variously as anxiety, depression, hopelessness, psycho-
in symptom onset, duration, and intensity has been logical distress (Arroll, Dancey, Attree, et al., 2012; Failla,
related to perceived uncertainty (Arroll, Dancey, Kuper, Nick, et al., 1996; Grootenhuis & Last, 1997; Kim
Attree, et al., 2012; Becker, Jason-Bjerklie, Benner, & So, 2012; Miles, Funk, & Kasper, 1992; Mishel &
CHAPTER 28 Merle H. Mishel 559
Sorenson, 1991; Page, Fedele, Pai, et al., 2012; Schepp, studies of people with chronic and life-threatening ill-
1991; Wineman, 1990), quality of life (Lasker, Sogolow, nesses. The process of formulating a new view of life is
Short, et al., 2011; Somjaivong Thanasilp, Preechawong, described by women with breast cancer and cardiac
et al., 2011; Song, Northouse, Braun, et al., 2011), disease as a revised life perspective (Hilton, 1988), new
satisfaction with family relationships (Wineman, O’Brien, life goals (Carter, 1993), new ways of being in the world
Nealon, et al., 1993), satisfaction with health care (Mast, 1998; Nelson, 1996), growth through uncertainty
services (Green & Murton, 1996; Tai-Seale, Stults, (Pelusi, 1997), and new levels of self-organization
Zhang, et al., 2012), and family caregivers’ maintenance (Fleury, Kimbrell, & Kruszewski, 1995). In studies of
of their own self-care activities (Brett & Davies, 1988; men with chronic illness or their caregivers, the pro-
O’Brien, Wineman, & Nealon, 1995). cess is described as transformed self-identity and new
In 1990, the original theory was expanded to in- goals for living (Brown & Powell-Cope, 1991), a more
clude the idea that uncertainty may not be resolved positive perspective on life (Katz, 1996), reevaluating
but may become part of an individual’s reality. In this what is worthwhile (Nyhlin, 1990), contemplation and
context, uncertainty is appraised as an opportunity self-appraisal (Charmaz, 1995), uncertainty viewed as
that prompts the formation of a new, probabilistic opportunity (Baier, 1995), and redefining normal and
view of life. To adopt this new view of life, the patient building new dreams (Mishel & Murdaugh, 1987).
must be able to rely on social resources and health
care providers who themselves accept the idea of Major Assumptions
probabilistic thinking (Mishel, 1990). When uncer-
tainty is framed as a normal part of life, it becomes a Person
positive force for multiple opportunities and resulting Mishel’s Uncertainty in Illness Theory is middle-
positive mood states (Gelatt, 1989; Mishel, 1990). range and focused on persons. Mishel’s original
Support for the reconceptualized Uncertainty in Ill- Uncertainty in Illness Theory, first published in 1988,
ness Theory has been found in predominantly qualitative included several major assumptions (Figure 28–1).
Coping:
Mobilizing
strategies
Affect-
control
strategies
Danger
( )
Stimuli frame
Symptom pattern ( ) Inference
Event familiarity Uncertainty Illusion Appraisal Adaptation
Event congruency
( ) Opportunity
( )
( )
( )
Cognitive Structure providers Coping:
capacities Credible authority buffering
Social support strategies
Education
FIGURE 28-1 Model of Perceived Uncertainty in Illness. (From Mishel, M. H. [1988]. Uncertainty in illness.
Image: The Journal of Nursing Scholarship, 20(4), 226.)
560 UNIT V Middle Range Nursing Theories
The first two reflect how uncertainty was conceptual- • Fluctuations result in repatterning, which is repeated
ized within psychology’s information-processing mod- at each level of the system.
els, as follows: In Mishel’s reconceptualized theory, neither the
1. Uncertainty is a cognitive state, representing the antecedents to uncertainty nor the process of cogni-
inadequacy of an existing cognitive schema to sup- tive appraisal of uncertainty as danger or opportunity
port the interpretation of illness-related events. change. However, uncertainty over time, associated
2. Uncertainty is an inherently neutral experience, with a serious illness, functions as a catalyst for fluc-
neither desirable nor aversive until it is appraised tuation in the system by threatening one’s preexisting
as such. cognitive model of life as predictable and controllable.
Two more assumptions reflect the uncertainty the- Because uncertainty pervades nearly every aspect of
ory’s roots in traditional stress and coping models a person’s life, its effects become concentrated and
that posit a linear stress A coping A adaptation ultimately challenge the stability of the system. In re-
relationship as follows: sponse to the confusion and disorganization created
3. Adaptation represents the continuity of an indi- by continued uncertainty, the system ultimately must
vidual’s usual biopsychosocial behavior and is the change in order to survive.
desired outcome of coping efforts to either reduce Ideally, under conditions of chronic uncertainty, a
uncertainty appraised as danger or maintain uncer- person gradually moves away from an evaluation of
tainty appraised as opportunity. uncertainty as aversive to adopt a new view of life that
4. The relationships among illness events, uncertainty, accepts uncertainty as a part of reality (Figure 28–2).
appraisal, coping, and adaptation are linear and Thus uncertainty, especially in chronic or life-threaten-
unidirectional, moving from situations promoting ing illness, can result in a new level of organization and
uncertainty toward adaptation. a new perspective on life, incorporating the growth and
Mishel challenged assumptions 3 and 4 in her change that result from uncertain experiences.
reconceptualization of the theory, published in 1990.
The reconceptualization came about as a result of
contradictory findings when the theory was applied Theoretical Assertions
to people with chronic illnesses. The original formu- Mishel asserted the following (1988, 1990):
lation of the theory held that uncertainty typically is • Uncertainty occurs when a person cannot adequately
appraised as an opportunity only in conditions that structure or categorize an illness-related event because
represent a known downward trajectory; in other of the lack of sufficient cues.
words, uncertainty is appraised as opportunity when • Uncertainty can take the form of ambiguity, com-
it is the alternative to negative certainty. Mishel and plexity, lack of or inconsistent information, or
others found that people also appraised uncertainty unpredictability.
as an opportunity in situations without a certain down- • As symptom pattern, event familiarity, and event
ward trajectory, particularly in long-term chronic ill- congruence (stimuli frame) increase, uncertainty
nesses, and that in this context people often developed decreases.
a new view of life. • Structure providers (credible authority, social sup-
It was at this time that Mishel turned to chaos port, and education) decrease uncertainty directly
theory to explain how prolonged uncertainty could
function as a catalyst to change a person’s perspective
on life and illness. Chaos theory contributed two of
the following theoretical assumptions that replace the
linear stress A coping A adaptation outcome por- Uncertainty Danger Opportunity
tion of the model as follows:
• People, as biopsychosocial systems, typically func-
tion in far-from-equilibrium states. Time
• Major fluctuations in a far-from-equilibrium system FIGURE 28-2 Reconceptualized Model of Uncertainty in
enhance the system’s receptivity to change. Chronic Illness. (Copyright Merle Mishel, 1990.)
CHAPTER 28 Merle H. Mishel 561
by promoting interpretation of events, and indi- evidence from qualitative studies that suggested
rectly by strengthening the stimuli frame. that people’s responses to uncertainty changed over
• Uncertainty appraised as danger prompts coping time within the context of serious chronic illnesses.
efforts directed at reducing the uncertainty and Thus Mishel’s theory represents the bidirectional
managing the emotional arousal generated by it. process where theory informs and is informed by
• Uncertainty appraised as opportunity prompts cop- research.
ing efforts directed at maintaining the uncertainty.
• The influence of uncertainty on psychological out- Acceptance by the Nursing Community
comes is mediated by the effectiveness of coping
efforts to reduce uncertainty appraised as danger or Practice
to maintain uncertainty appraised as opportunity. Mishel’s theory describes a phenomenon experi-
• When uncertainty appraised as danger cannot enced by acute and chronically ill individuals and
be reduced effectively, coping strategies can be their families. The theory has its beginning in
employed to manage the emotional response. Mishel’s own experience with her father’s battle with
• The longer uncertainty continues in the illness cancer. During his illness, he began to focus on
context, the more unstable the individual’s previ- events that seemed unimportant to those around
ously accepted mode of functioning becomes. him. When asked why he had chosen to focus on
• Under conditions of enduring uncertainty, indi- such events, he replied that when these activities
viduals may develop a new, probabilistic perspec- were being done, he understood what was happen-
tive on life, which accepts uncertainty as a natural ing to him. Mishel believed this was her father’s way
part of life. of taking control and making sense out of an over-
• The process of integrating continual uncertainty whelming situation. She knew early in the develop-
into a new view of life can be blocked or prolonged ment of her concept and theory that nurses could
by structure providers who do not support proba- identify the phenomenon from their experiences in
bilistic thinking. caring for patients.
• Prolonged exposure to uncertainty appraised as Several nurses have moved the theory from research
danger can lead to intrusive thoughts, avoidance, to practice. Hansen and colleagues (2012) synthesized
and severe emotional distress. findings from qualitative studies to yield a typology of
patient experiences of uncertainty that guides nursing
engagement and intervention. Similarly, the theory has
Logical Form been used in recommendations for the practice of
As a middle-range theory derived from and applica- critical, medical-surgical, and enterostomal nursing
ble to clinical practice, Mishel’s Uncertainty in Illness care (Hilton, 1992; Righter, 1995; Wurzbach, 1992).
Theory is an exemplar of the multiple steps required Based on review of the database of the Managing
to develop theory with both heuristic and practical Uncertainty in Illness Scale users (Mishel, 1997b),
value. Neither purely inductive nor deductive, master’s-prepared clinicians seek to understand the
Mishel’s theoretical work initially arose from ques- experience of uncertainty in a variety of clinical set-
tioning the nature of an important clinical problem, tings and patient populations. The scale and theory
followed by systematic qualitative and quantitative are used by clinicians from 15 countries other than
inquiry and careful application of theory borrowed the United States.
from other disciplines. Since publication of the origi-
nal theory in 1988, Mishel and others have carried Education
out numerous empirical tests of the relationships The theory has been widely used by graduate students
among the major constructs in the model, applying as the theoretical framework for theses and disserta-
and largely confirming the theory in illness contexts. tions, as the topic of concept analysis, and for the
Mishel’s reconceptualization of the theory in 1990 critique of middle-range nursing theory. Mishel uses
was deductive in that it was developed from princi- the theory as an exemplar to illustrate how theory
ples of chaos theory and was confirmed by empirical guides the development of nursing interventions in
562 UNIT V Middle Range Nursing Theories
her doctoral-level courses. Mishel frequently presents Stewart, Lynn, & Mishel, 2010; Stewart, Mishel,
school of nursing lectures, seminars, and symposia Lynn, et al., 2010). Bailey uses the theory to support
nationally and internationally, sharing her empirical research in chronic hepatitis C, a new and often
findings and the process of theory development for silent disease (Bailey, Barroso, Muir, et al., 2010;
faculty and students. Bailey, Landerman, Barroso, et al., 2009), and she is
testing an intervention in patients awaiting liver
Research transplant and their caregivers.
As described above, a large body of knowledge has From qualitative data supporting the reconcep-
been generated by researchers using the Uncertainty tualized theory, Mishel and Fleury (1994) devel-
in Illness Theory and scales. Mishel’s program of oped the Growth Through Uncertainty Scale
research encompassed testing the psychoeducational (GTUS) to measure the new view of life that can
nursing interventions derived from the theoretical emerge from continual uncertainty. Researchers
model in samples of adults with breast and prostate have also used the reconceptualized theory to un-
cancers. The scales and theory used by nurse derstand the uncertainty experience of long-term
researchers and scientists from other disciplines survivors of breast cancer (Mast, 1998) and indi-
describe and explain psychological responses of viduals with schizophrenia and their family mem-
people experiencing uncertainty due to illness and bers (Baier, 1995). The reconceptualized theory
test interventions to manage uncertainty in illness served as the foundation for Mishel and colleagues’
contexts. The scales have been translated into 12 lan- nursing intervention study of women younger than
guages and applied in research throughout the world. 50 years of age facing the enduring uncertainties
Mishel (1997a, 1999) reviewed research conducted inherent in surviving breast cancer. Bailey used the
on uncertainty in acute and chronic illness and theory and data from qualitative interviews with
coauthored a review of the research on uncertainty in older men who had elected watchful waiting as
childhood illness (Stewart & Mishel, 2000). Current treatment for their prostate cancer, to develop a
research on uncertainty in illness is focused on the- nursing intervention to integrate uncertainty into
ory testing. their lives, view their lives in a positive perspective,
and improve their quality of life (Bailey, Wallace, &
Mishel, 2007). In the first study of the Uncertainty
Further Development Management Intervention for Watchful Waiting,
Mishel and colleagues have used the original theory men came to see their lives in a new and positive
as the framework for seven federally funded nursing light, reported their quality of life as higher than did
intervention studies. The intervention has increased the control group, and expected it to be high in the
cancer knowledge, reduced symptom burden, and future (Bailey, Mishel, Belyea, et al., 2004). Wallace
improved quality of life in Mexican-American, (now, Kazer) and Bailey conducted a pilot test of
Caucasian, and African-American women with a web-based version of the intervention for men
breast cancer, in African-American and Caucasian with prostate cancer undergoing active surveillance
men newly diagnosed with prostate cancer, and (previously referred to as watchful waiting) (Kazer,
in those with localized, advanced, or recurrent pros- Bailey, Sanda, et al., 2011).
tate cancer and their family members (Gil, Mishel, The substantial empirical evidence supporting
Belyea, et al., 2004; Gil, Mishel, Belyea, et al., 2006; the Uncertainty in Illness theories provides a strong
Gil, Mishel, Germino, et al., 2005; Mishel, Belyea, foundation to extend the theory to intervention
Germino, et al., 2002; Mishel, Germino, Belyea, development and improve patient and family out-
et al., 2003; Mishel, Germino, Lin, et al., 2009). The comes. In addition to Mishel’s own intervention stud-
applicability of the theory to the context of serious ies in patients with breast and prostate cancer, several
childhood illness has been supported in parents of researchers tested interventions to help patients man-
children with HIV infection (Santacroce, Deatrick, & age uncertainty. Many were directed at reducing
Ledlie, 2002) and in children undergoing treatment sources of uncertainty (Chair, Chou, Sit, et al., 2012;
for cancer (Lin, Yeh, & Mishel, 2010; Stewart, 2003; Chiou & Chung, 2012; Faithfull, Cockle-Hearne, &
CHAPTER 28 Merle H. Mishel 563
Khoo, 2011; Kazer, Bailey, Sanda, et al., 2011; Muth- also can lead to the individual appraising the situa-
usamy, Leuthner, Gaebler-Uhing, et al., 2012; Schover, tion as having a positive outcome. In this situation,
Canada, Yuan, et al., 2012). Others focused on the uncertainty is preferred and the individual remains
provision of support (Heiney, Adams, Wells, et al., hopeful.
2012) and specific coping strategies (Faithfull, Cockle- Coping is the third theme of the original model of
Hearne, & Khoo, 2011) to help patients manage their uncertainty. Coping occurs in two forms with the
uncertainty. end result of adaptation. If uncertainty is appraised
as a danger, then coping includes direct action, vigi-
Critique lance, and seeking information from mobilizing
strategies, and it affects management using faith, dis-
Clarity engagement, and cognitive support. If uncertainty is
Uncertainty is the primary concept of this theory and appraised as an opportunity, coping offers a buffer to
is defined as a cognitive state in which individuals are maintain the uncertainty.
unable to determine the meaning of illness-related The original theory was reconceptualized in 1990
events (Mishel, 1988). The original theory postulates to incorporate the idea that chronic illness unfolds
that managing uncertainty is critical to adaptation over time, possibly years, and with that, uncertainty
during illness and explains how individuals cogni- is reappraised. The person is viewed as an open
tively process illness-associated events and construct system exchanging energy within his or her envi-
meaning from them. The original theory’s concepts ronment, and, rather than seeking to return to a
were organized in a linear model around the follow- stable state, chronically ill individuals may move
ing three major themes: toward a complex world orientation, thus forming
1. Antecedents of uncertainty new meaning for their lives. If uncertainty is framed
2. Process of uncertainty appraisal as a normal view of life, it becomes a positive force
3. Coping with uncertainty for multiple opportunities with resulting positive
The framework is clear and easy to follow. The mood states. To achieve this, the individual must
antecedents of uncertainty include the stimuli develop probabilistic thinking, which allows one
frame, cognitive capacities, and structure providers. to examine a variety of possibilities and consider
In the linear model, these antecedent variables have ways of achieving them as the individual envisions
both a direct and indirect inverse relationship with a variety of responses and realizes that life changes
uncertainty. from day to day.
The second conceptual component of the model Mishel described this process as a new view of life
is appraisal. Uncertainty is seen as a neutral state, in which uncertainty shifts from being seen as a
neither positive nor negative, until it has been ap- danger to being viewed as an opportunity. To adopt
praised by the individual. Appraisal of uncertainty this new view of life, the patient must be able to rely
involves the following two processes: (1) inference on social resources and health care providers who
and (2) illusion. Inference is constructed from the accept probabilistic thinking. The relationship be-
individual’s personality disposition and includes tween the health care provider and the patient must
learned resourcefulness, mastery, and locus of con- focus on recognizing continual uncertainty and
trol. These characteristics contribute to an individu- teaching the patient how to use the uncertainty to
al’s confidence in the ability to handle life events. generate different explanations for events. Hence the
Illusion is defined as a belief constructed from importance of structure providers, introduced in the
uncertainty that considers the favorable aspects of a original theory, is maintained in the reconceptual-
situation. Based on the appraisal process, uncer- ized model.
tainty is viewed as either a danger or an opportunity. Despite the complexity and dimensionality of
Uncertainty viewed as a danger results when the the two models, they are presented clearly and con-
individual considers the possibility of a negative ceptualized comprehensively. Mishel published her
outcome. Uncertainty is viewed as an opportunity measurement model in 1981, her original theoretical
primarily through the use of illusion, but inference model in 1988, and her reconceptualized theory in
564 UNIT V Middle Range Nursing Theories
1990, and these publications fully explicate the model development and testing of nursing interventions to
for application in clinical and research contexts. manage uncertainty.
Simplicity Importance
The two uncertainty-in-illness models contain con- Derivable consequences are determined by examining
cepts comprising relationships that range from simple whether a theory guides research, informs practice,
to complex and direct to indirect. Eleven major con- generates new ideas, and differentiates the focus of
cepts are found in the three themes of the original nursing from other professions. Mishel’s work repre-
theory, and several new concepts are introduced in the sents an exemplar of middle-range theory that in-
reconceptualized model. The antecedents of uncer- forms clinical practice in the encompassing context of
tainty are concise, and their definitions are clear and acute and chronic illness. The theory has generated
simple. The appraisal component is complex because it considerable empirical research with adults dealing
considers cognitive processes along with beliefs and with illness or that of family members and continues
values held by the individual. The coping phase of the to stimulate new research directions, such as uncer-
theory is also complex because it is dependent on the tainty in ill children, in older men electing watchful
appraisal portion of the model and again involves dif- waiting as treatment of choice for prostate cancer, and
ferent kinds of strategies targeted toward adaptation. in health care providers informing patients of treat-
The outcome portion of the model is differentiated ment choices in conditions with uncertain prognoses.
into two conceptualizations of the theory, the first Mishel believes that by defining and conceptualizing
relating to patients with acute illness and the second an important clinical problem, her work supports and
representing an expansion of the model to accommo- enriches nursing practice. The Uncertainty in Illness
date patients with chronic illness. Although the models Theory and its reconceptualization represent frame-
can hardly be called simple, overall the concept defini- works derived from and for practice, a process essen-
tions and relationships are well-operationalized and tial to nursing as a practice discipline.
easily understood.
Generality Summary
The theory explains how individuals construct The Uncertainty in Illness Theory provides a com-
meaning from illness-related events. It is broad and prehensive framework within which to view the ex-
generalizable and can be used with individuals expe- perience of acute and chronic illness and to organize
riencing illness, as well as with spouses and parents nursing interventions to promote optimal adjustment.
of those experiencing illness-related uncertainty. The theory helps explain the stresses associated with
The concept of credible authority can be applied to the diagnosis and treatment of major illnesses or
physicians, nurses, and other health care workers. chronic conditions, the processes by which individ-
The theory can be applied in many areas of nursing uals assess and respond to the uncertainty inherent
practice and has been used by clinicians for acute in an illness experience, and the importance of pro-
and chronic illnesses such as cancer, cardiac disease, fessional caregivers in providing information and
and multiple sclerosis. supporting individuals in understanding and man-
aging uncertainty. The reconceptualized theory
Accessibility addresses the unique context of continual uncer-
Mishel derived both theoretical models from her tainty and thereby expands the original theory to
program of research. Many of the concepts, as- encompass the ongoing uncertain trajectory of many
sumptions, and relationships among variables draw life-threatening and chronic illnesses. The original
support from empirical investigation. The concepts theory and its reconceptualization are well expli-
are well described, and their relationships are pre- cated, deriving support from sound theoretical
cisely constructed with clear, tested operational foundations and extensive empirical confirmation,
definitions. Theory testing has occurred in research and it can be applied in illness contexts to support
and clinical settings. The theory has led to the evidence-based nursing practice.
CHAPTER 28 Merle H. Mishel 565
CASE STUDY her treatment plan is different from what her
primary physician told her to expect (event con-
Part 1: Original Theory gruence) and how she will manage her family life
Rosie, a 45-year-old mother of three, has been while undergoing treatment. Lily provides an
diagnosed with stage III breast cancer. A mass was audiotape of the treatment conference so that
detected in her left breast during her annual gyne- Rosie’s husband (structure provider–social sup-
cological appointment, and she has undergone an port) can hear what took place and can support
extensive diagnostic workup, including mammog- Rosie in asking questions and understanding the
raphy and sentinel node biopsy. She was referred information provided. Lily’s support for Rosie
by her primary physician to a comprehensive and her family continues throughout Rosie’s
breast cancer program at a regional medical center treatment course, and she periodically reassesses
that was 2 hours from her home. The multidisci- the sources of uncertainty and the strategies that
plinary team has recommended that Rosie un- Rosie and her family use to manage them.
dergo preoperative chemotherapy, followed by
partial mastectomy and reconstructive surgery. Part 2: Reconceptualized Theory
Rosie’s husband has accompanied her to most of Two years after her breast cancer diagnosis, Rosie
her medical encounters, but he was unable to at- returns to the center for a follow-up appointment.
tend the final conference, where the treatment Lily asks Rosie to reflect on her cancer experience.
recommendations were made. Rosie describes the time of diagnosis and treat-
Lily, the advanced practice nurse coordinating ment as chaotic and dominated by uncertainty,
Rosie’s care (structure provider-credible author- and she wonders how she and her family got
ity), directs her interventions toward addressing through it, but she tells Lily that gradually she
the many sources of uncertainty for Rosie and came to see the cancer experience as providing
her family, including lack of information about new meaning to her life and helping her set pri-
treatment options and outcomes (event familiar- orities. She left a job she was dissatisfied with and
ity), unfamiliarity with the treatment environ- now directs her energy toward her relationships
ment (event familiarity), expectations for chemo- with her teenage children. Rosie and her husband
therapy side effects and postoperative recovery recently enjoyed a long-postponed second honey-
(symptom pattern), impact of treatment on fam- moon trip to Hawaii. She tells Lily that she now
ily relationships, and prognosis. In particular, embraces each day as an opportunity to live life
Lily addresses Rosie’s many questions about why and enrich the lives of her children.
CRITICAL THINKING ACTIVITIES
1. You have been assigned to a new patient. You want During an exacerbation of her disease, she
to know about this person’s perceptions of the cur- focuses on her plans for going to law school.
rent situation, supportive relationships, and previous One of your colleagues suggests that she may
experiences with health and illness. What questions be in denial about the severity of her illness.
would you ask to assess the level of uncertainty? Use the reconceptualized Uncertainty in Illness
2. You are working with a young woman who has Theory to propose an alternative interpretation
been living with multiple sclerosis for 6 years. of her perspective.
POINTS FOR FURTHER STUDY
n Germino, B. B., Mishel, M. H. Crandell, J., Porter, younger African American and Caucasian breast
L. Blyler, D. Jenerette, C., et al. (2013). Outcomes cancer survivors. Oncology Nursing Forum, 40(1),
of an uncertainty management intervention in 82–92.
566 UNIT V Middle Range Nursing Theories
n Mishel, M. (2008). Portraits of Excellence: n Research Tested Interventions for Practice
The Nurse Theorist Series, Vol 2, Fitne, Inc., (RTIP), NCI. Managing Uncertainty in Older
Athens, OH. Long-term Breast Cancer Survivors website at:
http://rtips.cancer.gov/rtips/index.do
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572 UNIT V Middle Range Nursing Theories
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29
CHAP TER
Pamela G. Reed
1952 to present
Self-Transcendence Theory
Doris D. Coward
“The quest for nursing is to understand the nature of and to facilitate
nursing processes in diverse contexts of health experiences”
(Reed, 1997a, p. 77).
focusing on the relationship between well-being and
Credentials and Background spiritual perspectives on life and death in terminally
of the Theorist ill and well individuals.
Pamela G. Reed was born in Detroit, Michigan, where Reed is on the faculty at the University of Arizona
she grew up during the 1960s. She married her hus- College of Nursing in Tucson, where she teaches,
band, Gary, in 1973, and they have two daughters. conducts research, and serves in administrative roles,
Reed received her baccalaureate from Wayne State including Associate Dean for Academic Affairs since
University in Detroit, Michigan, in 1974 and earned January 1983. Reed has received numerous awards for
her M.S.N. in psychiatric–mental health of children doctoral teaching in philosophy of nursing science
and adolescents and in nursing education in 1976. and practice, and for her theory development courses.
She began doctoral study at that institution in 1979 Her major fields of research are spirituality, nursing
and received her Ph.D. in 1982 with a concentration philosophy, and ethical dimensions of end-of-life
in nursing theory and research. She pioneered nurs- and palliative caregiving. She developed two widely
ing research into spirituality beginning with her dis- used research instruments, the Spiritual Perspectives
sertation research, directed by Joyce J. Fitzpatrick, Scaleand the Self-Transcendence Scale. Her research
Photo credit: David VanGelder, Tucson, AZ.
The author expresses her appreciation to Pamela G. Reed for her mentoring over the years and particularly for her support during
the development of this chapter.
574
CHAPTER 29 Pamela G. Reed 575
studies, financed by intramural and extramural fund- Reed describes her theory as originating from three
ing, were reported in many presentations and publi- sources (Reed, 2003, 2008). The first source was the
cations. Her current research examines well-being conceptualization of human development (Lerner,
and ethical dimensions in end-of-life caregiving by 2002) as a lifelong process that extended beyond the
family caregivers and professional nurses. She has attainment of adulthood throughout the aging and dy-
published over 100 articles and book chapters, and ing processes. This emerging belief in the ongoing
she co-edited the sixth edition of Perspectives on potential for development was a paradigm shift from
Nursing Theory with Shearer in 2012. In 2011, Reed previously held views that both physical growth and
and Shearer published Nursing Knowledge and Theory mental development ended at adolescence (Reed,
Innovation: Advancing the Science of Nursing Practice, 1983).
promoting a philosophy and methods of practice- The second source for the theory was the early
based knowledge development in 2011. work of nursing theorist Martha E. Rogers (Rogers,
Reed is a fellow in the American Academy of 1970, 1980, 1990). Rogers’ three principles of homeo-
Nursing and a member of a number of professional dynamics were congruent with the key principles
organizations, including Sigma Theta Tau Interna- of the evolving Life Span Developmental Theory.
tional, the American Nurses Association, and the Rogers’ integrality principle identified development
Society of Rogerian Scholars. She serves on the edito- as a function of both human and contextual factors; it
rial review boards of numerous journals and was also identified disequilibrium between person and
Contributing Editor for a Nursing Science Quarterly environment as an important trigger of development.
column, Scholarly Dialogue. Similarly, developmental theorist Riegel (1976) pro-
Reed’s influence is evident not only in her own posed that asynchrony in development among physi-
research and publications. The impact of her work is cal, emotional, environmental, and social dimensions
reflected in the research of many graduate students was necessary for developmental progress. Rogers’
and in the work of other scientists nationally and in- helicy principle characterized human development as
ternationally who have applied her theory or her two innovative and unpredictable. This principle is similar
measurement scales in their research. Her theoretical to life span principles identifying development as
ideas have been supported and extended by the many nonlinear, continuous throughout the life span, and
nurses she mentored. evident in variability within and across individuals
and groups. Rogers’ resonancy principle described
human development as a process of movement that,
Theoretical Sources although unpredictable, had pattern and purpose.
Reed (1991a) developed her Self-Transcendence Life span theorists also proposed that the process of
Theory using the strategy of deductive reformula- development displayed patterns of complexity and
tion. The strategy originated with Reed’s professors, organization. Thus knowledge gained from the non-
Ann Whall and Joyce Fitzpatrick at Wayne State nursing life span developmental perspective was
University (Fitzpatrick, Whall, Johnston, et al., reformulated using an appropriate nursing concep-
1982; Shearer & Reed, 2004; Whall, 1986.). Deductive tual system.
reformulation uses knowledge from non-nursing the- The third source for the theory was evidence from
ory that is reformulated with a nursing conceptual clinical experience and research indicating that clinically
model in constructing middle-range theory. The non- depressed older persons reported fewer developmental
nursing theory sources were life span theories on adult resources to sustain their sense of well-being in the face
social-cognitive and transpersonal development (e.g., of decreased physical and cognitive abilities than did a
Alexander & Langner, 1990; Commons, Richards, & matched group of mentally healthy older adults (Reed,
Armon, 1984; Wilber, 1980, 1981, 1990). Principles 1986b). In addition, development in elderly and in
from life span theories were reformulated using the “oldest-old” adults was found to be a nonlinear process
nursing perspective of Martha E. Rogers’ conceptual of gain and subsequent loss, a process of transforming
system of unitary human beings (Rogers, 1970, 1980, old perspectives and behaviors, and integrating new
1990). views and activities (Reed, 1989, 1991b).
576 UNIT V Middle Range Nursing Theories
MAJOR CONCEPTS & DEFINITIONS
Vulnerability may possibly be added to describe the capacities for
Vulnerability is one’s awareness of personal mortality boundary expansion (P. Reed, personal communica-
(Reed, 2003). In Reed’s earlier work, the phrase tion, June 17, 2004).
“awareness of one’s personal mortality” was the con- Well-Being
text for development or maturation in later adult-
hood or at the end of life. The concept of vulnerability Well-being is “the sense of feeling whole and healthy,
broadens the awareness of personal mortality situa- in accord with one’s own criteria for wholeness and
tions to include life crises such as disability, chronic well-being” (Reed, 2003, p. 148). In her earlier work,
illness, childbirth, and parenting. Self-transcendence Reed did not explicitly define well-being but linked
was a pattern associated with advanced development the concept to mental health, which was dependent
within that context (Reed, 1991b). on salient issues of development within a given
phase of life (Reed, 1989, 1991b). In an article
Self-Transcendence in Nursing Science Quarterly, Reed described the
Self-transcendence, initially defined by Reed (1991a) underlying mechanisms of well-being in “Nursing:
as “expansion of self-conceptual boundaries multi- The Ontology of the Discipline” and proposed nurs-
dimensionally: inwardly (e.g., through introspective ing to be “the study of the nursing processes of well-
experiences), outwardly (e.g., by reaching out to being” (Reed, 1997a, p. 76). Well-being as a nursing
others), and temporally (whereby past and future process is described in terms of a synthesis of two
are integrated into the present)” (p. 71), was later kinds of change: changes in complexity in a life (i.e.,
defined more comprehensively (Reed , 1997b) as the increasing frailness of advanced aging or the loss
follows: of a beloved spouse) tempered by changes in inte-
Self-transcendence refers to fluctuation of perceived gration (i.e., constructing meaning from such life
events).
boundaries that extend the person (or self) beyond
the immediate and constricted views of self and the Moderating-Mediating Factors
world. This fluctuation is pandimensional, that is, A variety of personal and contextual variables and
outward (toward others and the environment), their interactions may influence the process of
inward (toward greater awareness of one’s own self-transcendence as it contributes to well-being.
beliefs, values, and dreams), and temporal (toward Examples are age, gender, cognitive ability, life
integration of past and future in a way that experiences, spiritual perspectives, social environ-
enhances the relative present) (p. 192). ment, and historical events. These variables may
In 2003, the pattern of boundary expansion was strengthen or weaken relationships between vul-
incorporated so that self-transcendence included the nerability and self-transcendence and between
capacity to expand one’s self-boundaries “transper- self-transcendence and well-being (Reed, 2003).
sonally (to connect with dimensions beyond the typi- Nursing activities may be based on facilitating the
cally discernible world)” (Reed, 2003, p. 147). As self- mediating factor of self-transcendence.
transcendence is pandimensional, other dimensions
Use of Empirical Evidence in theory building was conducted with older adults
Self-Transcendence Theory was grounded in belief in (1986b, 1989, 1991b).
the developmental nature of older adults and the ne- In the first study, Reed (1986b) examined pat-
cessity of continued development to maintain mental terns of developmental resources and depression
health and a sense of well-being during the process of over time in 28 mentally healthy and 28 clinically
aging (Reed, 1983). Therefore, Reed’s initial research depressed older adults (mean age, 67.4 years). Levels
CHAPTER 29 Pamela G. Reed 577
of developmental resources were measured 3 times (Reed, 1991b). In this study, self-transcendence
(6 weeks apart) with the 36-item Developmental was defined as “the expansion of one’s conceptual
Resources of Later Adulthood (DRLA) scale, previ- boundaries inwardly through introspective activi-
ously developed and tested by Reed. Healthy adults ties, outwardly through concerns about other’s
perceived higher levels of resources across time welfare, and temporally by integrating perceptions
than did depressed adults. Scores on the Center for of one’s past and future to enhance the present”
Epidemiological Studies Depression (CES-D) scale (Reed, 1991b, p. 5). Self-transcendence was mea-
(Radloff, 1977) were significantly higher in depressed sured by the newly developed Self-Transcendence
individuals across time than were those of the men- Scale (STS), derived from the previously identified
tally healthy. Strong relationships between DRLA transcendence factor in the original DRLA scale.
scores and subsequent CES-D scores indicated that The STS score was correlated inversely with both
developmental resources influenced mental health CES-D and Langner Scale of Mental Health Symp-
outcomes in the healthy group; the reverse relation- tomatology (MHS) scores. The MHS is an index of
ship found in the depressed group indicated that general mental health on which higher scores indi-
depression negatively influenced developmental re- cate impairment in mental health in nonpsychiatric
sources in terms of the ability to explore new out- populations (Langner, 1962). In addition, the four
looks on life, to share wisdom and experience with patterns of self-transcendence identified by partici-
others, and to find spiritual meaning. pants (generativity, introjectivity, temporal integra-
In the second study, Reed (1989) explored the tion, and body-transcendence) were congruent with
degree to which key developmental resources of later Reed’s definition of the concept.
adulthood were related to mental health in 30 hospi- In summary, Reed’s three studies provided evi-
talized clinically depressed older adults (mean age, dence for her theoretical idea that self-transcendence
67 years). Participants completed the DRLA and views and behaviors were, in fact, present in older
CES-D measures and rated the importance in their adults. Data indicated that such views and behaviors
current lives of each developmental resource re- were strongly related to mental health. Thus, the find-
flected in the DRLA items. An inverse correlation ings supported a conceptualization of mental health
was found between the level of resources and depres- in later adulthood that went beyond preoccupation
sion. Participants also reported that the resources with physical and cognitive declines and pointed out
represented by the DRLA items were highly impor- the importance of resources that expanded self-con-
tant in their lives. In addition, key reasons given by cept boundaries in aging.
participants for their psychiatric hospitalization were
congruent with self-transcendence issues significant
in later adulthood (e.g., physical health concerns, Major Assumptions
relationships with adult children, questions about life Early in her theoretical work, Reed (1986a, 1987)
and death). proposed a process model for constructing concep-
During the initial DRLA instrument development tual frameworks that would guide nurses and nursing
and testing, a factor labeled transcendence accounted education in clinical specialties. In this model, health
for 45.2% of the variance in DRLA scores. In the sec- was proposed as the central concept, or axis, around
ond study (Reed, 1989), the 15-item transcendence which nursing activity, person, and environment
factor was also more highly correlated with the CES- evolved. An assumption of the model was that the
D than was the entire DRLA. Therefore, a recommen- focus of the nursing discipline was on building and
dation for future research was to examine further the engaging knowledge to promote health processes.
psychometric properties of the instrument, with a
goal to shorten the DRLA to facilitate ease of admin- Nursing
istration in clinical settings. The role of nursing activity was to assist persons
A third study explored patterns of self-transcen- (through interpersonal processes and therapeutic
dence and mental health in 55 independent-living management of their environments) with the skills
older adults (ranging from 80 to 97 years of age) required for promoting health and well-being.
578 UNIT V Middle Range Nursing Theories
Person self-transcendence must be expressed like any other
Persons were conceived as developing over their life developmental capacity in life for a person to realize a
span in interaction with other persons and within an continuing sense of wholeness and connectedness.
environment of changing complexity and vibrancy This assumption is congruent with Frankl’s (1969)
that could both positively and negatively contribute to and Maslow’s (1971) conceptualizations of self-
health and well-being. transcendence as an innate human characteristic that,
when actualized, gives purpose and meaning to a
Health person’s existence.
In the early process model, health was defined implicitly
as a life process of both positive and negative experi-
ences from which individuals create unique values and Theoretical Assertions
environments that promote well-being. There are three basic concepts in the Self-Transcendence
Theory: vulnerability, self-transcendence, and well-
Environment being (Reed, 2003, 2008). Vulnerability is the aware-
Family, social networks, physical surroundings, and ness of personal mortality that arises with aging and
community resources were environments that signifi- other life phases, or during health events and life
cantly contributed to health processes that nurses in- crises (Reed, 2003). The concept of vulnerability
fluenced through “managing therapeutic interactions clarifies that the context within which self-transcen-
among people, objects, and [nursing] activities” dence is realized is not only when confronting end-
(Reed, 1987, p. 26). of-own-life issues but also includes life crises such as
This metaparadigmatic approach to knowledge disability, chronic illness, childbirth, and parenting.
development for a nursing specialty was innovative Self-transcendence refers to the fluctuations in per-
and foundational to Reed’s own future work with the ceived boundaries that extend persons beyond their
concepts of spirituality and self-transcendence. Self- immediate and constricted views of self and the
Transcendence Theory evolved from the perspective world. The fluctuations are pandimensional: outward
that self-transcendence is one of many processes (toward awareness of others and the environment),
related to health, and the overall goal of the theory inward (toward greater insight into one’s own beliefs,
was to provide nurses with another perspective on the values, and dreams), temporal (toward integration of
human capacity for well-being. past and future in a way that enhances the relative
In her initial explication of the emerging Self- present), and transpersonal (toward awareness of
Transcendence Theory, Reed (1991a) identified one dimensions beyond the typically discernible world)
key assumption based on Rogers’ conceptual system. (Reed, 1997b, 2003, 2008). Well-being is “feeling
This assumption was that persons are open systems whole and healthy, in accord with one’s own criteria
who impose conceptual boundaries upon themselves for wholeness and well-being” (Reed, 2003, p. 148).
to define their reality and to provide a sense of whole- The theory also allows for additional personal and
ness and connectedness within themselves and their contextual variables such as age, gender, life experi-
environment. Reed (2003) reaffirmed this assumption ences, and social environment that can influence the
in a later publication, restating Rogers’ basic assump- relationships among the three basic concepts. Interven-
tion that “human beings are integral with their environ- tions would focus on nursing activities that facilitate
ment” (p. 146). Self-conceptual boundaries fluctuate self-transcendence.
in form across the life span and are associated with Three major propositions of the theory were devel-
human health and development. Self-transcendence oped from the three basic concepts. The first proposi-
was proposed as an important indicator of a person’s tion is that self-transcendence is greater in persons
conceptual self-boundaries that could be assessed at facing end-of-own-life issues than in persons not fac-
specific times. ing such issues. End-of-own-life issues are interpreted
A second assumption identified in the later de- broadly, as they arise with life events, illness, aging, and
scription of the theory was that self-transcendence other experiences that increase awareness of personal
is a developmental imperative (Reed, 2003), that is, mortality.
CHAPTER 29 Pamela G. Reed 579
The second proposition is that self-transcendence 1. Increased vulnerability is related to increased self-
is positively related to well-being (Reed, 1991a). transcendence.
Alternatively, decreased self-transcendence (as in the 2. Self-transcendence is positively related to well-
inability to reach out to others or to accept friend- being and functions as a mediator between vulner-
ship) is positively related to depression as an indicator ability and well-being.
of decreased well-being or mental health. An impor- 3. Personal and contextual factors may influence
tant refinement to Self-Transcendence Theory has to the relationship between vulnerability and self-
do with the mediating effects of self-transcendence. transcendence and between self-transcendence
Research results accumulated in the last decade indi- and well-being.
cate that self-transcendence mediates the relationship
between vulnerability and well-being. In other words,
self-transcendence is an underlying process or mech- Logical Form
anism that explains why people may attain well-being Reed’s empirical middle-range theory was con-
when confronted with increased vulnerability. structed using the strategy of deductive reformulation
The key assumption about person-environmental to enhance understanding of the end-of-life phenom-
process (Reed, 1991a) led the third and revised set of enon of self-transcendence (Reed, 1991a). The logic
propositions by Reed in 2003. Personal and environ- used was primarily deduction, to ensure that the
mental factors function as correlates, moderators, or middle-range theory was congruent with Rogerian
mediators of the relationships between vulnerability, and life span principles. Analogical reasoning was
self-transcendence, and well-being. also used to work from other theories of life span
In summary, the 2003, updated Self-Transcendence development, comparing psychology and nursing
Theory proposes the following three sets of relation- about human development and potential for well-
ships (Figure 29–1): being in all phases of life. The key concepts of the
Self-Transcendence
Personal
and
Contextual Factors
Vulnerability Well-Being
FIGURE 29-1 Model of Self-Transcendence Theory. (Reed, P. G. [2008]. The theory of self-transcendence.
In M. J. Smith & P. R Liehr [Eds.], Middle range theory for nursing [2nd ed.]. New York, Springer).
580 UNIT V Middle Range Nursing Theories
theory are related in a clear and logical manner, while persons with dementia (Acton & Wright, 2000) and
allowing for creativity in the way the theory is ap- bereaved individuals (Joffrion & Douglas, 1994). Acton
plied, tested, and further developed. Reed’s strategy of and Wright (2000) suggest arranging respite care for
constructing a nursing theory—from non-nursing caregivers so that they have time and energy for transper-
theories, a nursing conceptual model, research, and sonal activities. Applications of creative-bonding art
clinical and personal experiences—piqued nurses’ activities to promote self-transcendence were used in
interest in the phenomenon of developmental matu- studies with nursing students and older adults (Chen &
rity and provided impetus for further theorizing into Walsh, 2009; Walsh, Chen, Hacker, et al., 2008) and in
the variety of situations where awareness of personal late-stage Alzheimer’s disease (Walsh, Lamet, Lindgren,
mortality occurs. et al., 2011). McGee (2000) suggested that recovery in
alcoholism involves self-transcendence, facilitated by a
nurse-designed environment that supports the 12 steps
Acceptance by the Nursing Community and 12 traditions of Alcoholics Anonymous.
The quest for nursing is to facilitate human well-being
through what Reed calls “nursing processes,” of which Education
self-transcendence is one example (Reed, 1997a). Self-transcendence is in the writings of nurse theorists
Self-Transcendence Theory has been widely used in who are influential in nursing education (Erickson,
practice, education, and research. 2002; Erickson, Tomlin, & Swain, 1983; Newman,
1986; Parse, 1981; Rogers, 1970, 1980; Sarter, 1988;
Practice Watson, 1979, 1985). These theories share a common
Reed’s (1986a, 1987) process model for clinical specialty view identifying self-transcendence as a foundational
education and psychiatric–mental health nursing prac- concept for the discipline. All levels of education may
tice articulates relationships among the metaparadigm use the theory in courses to support care of the aging.
constructs of health, persons and their environments, Guo, Phillips, and Reed (2010) supported the need for
and nursing activity. Self-Transcendence Theory non-hospice nurses to improve their abilities and atti-
delineates specific concepts from Reed’s process tudes toward older adults and their family caregivers
model: constructs of health (i.e., well-being), per- related to end-of-life care. The art-activity with older
son (i.e., self-transcendence), and environment (i.e., adults at community senior centers is designed to
vulnerability), and it proposes relationships among develop more positive attitudes in nursing students
these concepts to direct nursing activities. Reed when caring for them (Chen & Walsh, 2009; Walsh,
(1991a) and Coward and Reed (1996) have sug- Chen, Hacker, et al., 2008).
gested nursing activities that facilitate expansion of Self-transcendence is a pathway for helping the
self-conceptual boundaries—journaling, art activi- healer, or healing the healer, so that nurses learn to
ties, meditation, life review, and religious expres- maintain a healthy lifestyle as they care for others
sion, to name a few. (Conti-O’Hare, 2002). Two studies provide support
Self-transcendence may be integral to healing in for nurses benefiting from self-transcendence atti-
many life situations. Nurse activities that promote the tudes and behaviors. Self-transcendence perspectives
activities of self-reflection, altruism, hope, and faith correlated with lower levels of burnout in hospice and
in vulnerable persons are associated with an increased oncology nurses (Hunnibell, Reed, Quinn-Griffin,
sense of well-being. Group psychotherapy (Stinson & et al., 2008) and with higher levels of work engage-
Kirk, 2006; Young & Reed, 1995) and breast cancer ment in acute care nurses (Palmer, Quinn, Reed,
support groups (Coward, 1998, 2003; Coward & Kahn et al., 2010).
2004; 2005) are interventions that nurse researchers
used to provide clients with opportunity for examin- Research
ing their values, for reaching out to share experience A number of research studies provide evidence to
with and help similar others, and for finding meaning support the association between self-transcendence
from their health situations. Others suggested similar and increased well-being in populations that typically
strategies to facilitate well-being in caregivers of are confronted with awareness of their own personal
CHAPTER 29 Pamela G. Reed 581
mortality. The research studies related self-transcen- failure (Gusick, 2008), liver transplant recipients
dence to depression among elders (Reed, 1986b, 1989, (Bean & Wagner, 2006), bullied middle-school boys
1991a). Other research reported similar relationships (Willis & Grace, 2011; Willis & Griffith, 2010), stem
in depressed older adults (Klaas, 1998; Stinson & cell transplant recipients (Williams, 2012), and per-
Kirk, 2006; Young & Reed, 1995), middle-aged adults sons with dementia (Walsh, Lamet, Lindgren, et al.,
(Ellermann & Reed, 2001), and individuals who lost 2011). Kim and colleagues (2011) found interdepen-
loved ones from HIV/AIDS (Kausch & Amer, 2007). dence within Korean caregiver-elder dyads on self-
Buchanan, Ferran, and Clark (1995) examined self- transcendence variables and well-being. Two other
transcendence and suicidal thought in older adults. reports examined the role of caregivers of end-of life
Upchurch (1999) and Upchurch & Mueller (2005) older adults and reported a positive relationship be-
explored the relationship between self-transcendence tween caregiver transcendence and well-being (Phillips
and activities of daily living in noninstitutionalized & Reed, 2009a, 2009b). Positive relationships among
older adults. Two studies explored self-transcendence transcendence and transformation and finding mean-
and older adults’ perceptions of positive physical and ing were also described in women with chronic condi-
mental health (Bickerstaff, Grasser, & McCabe, 2003; tions such as arthritis (Neill, 2002; Shearer, Fleury, &
Nygren et al., 2005). Walton, Shultz, Beck, and Walls Reed, 2009).
(1991) identified an inverse relationship between self- Intervention studies designed by nurses to promote
transcendence and loneliness in healthy older adults. self-transcendence views and behavior documented
Decker and Reed (2005) found that integrated moral changes in self-transcendence and well-being. One
reasoning, completion of a living will, and prior expe- intervention, a Self-Transcendence Theory–based
rience with a life-threatening illness were related to support group, had a small positive effect on self-
older adults’ desire for less aggressive treatment at the transcendence and well-being in women with newly
end of life. diagnosed breast cancer (Coward, 1998, 2003; Coward
A number of studies have demonstrated a positive & Kahn, 2004). Young and Reed (1995) found that
relationship among self-transcendence and well-being group psychotherapy facilitated self-transcendence in
or quality of life in persons with HIV or AIDS (Coward, a small sample of older adults. A personal narrative
1994, 1995; Coward & Lewis, 1993; McCormick, intervention increased self-transcendence scores in
Holder, Wetsel, et al., 2001; Mellors, Erlen, Coontz, women with HIV, multiple sclerosis, and systemic lu-
et al., 2001; Mellors, Riley, & Erlen, 1997; Sperry, 2011; pus erythematosus compared to women in a control
Stevens, 1999). Numerous studies have described group (Diener, 2003). Responses of several people
self-transcendence or related concepts in women with with late-stage Alzheimer’s disease following a similar
breast cancer (Carpenter, Brockopp, & Andrykowski, simple art intervention evidenced self-transcendence
1999; Coward, 1990, 1991; Coward & Kahn, 2004, 2005; and well-being (Walsh, Lamet, Lindgren, et al., 2011).
Farren, 2010; Kamienski, 1997; Kinney, 1996; Matthews A poetry-writing intervention for caregivers of older
& Cook, 2009; Pelusi, 1997; Taylor, 2000; Thomas, adults with dementia found themes of self-transcen-
Burton, Quinn-Griffin, et al., 2010). dence in caregivers following the intervention (Kidd,
Acton (2003), Acton and Wright (2000), and Kidd, Zauszniewski, Morris, et al., 2011).
Zauszniewski, and Morris (2011) explored self- Reed has mentored a number of master’s and
transcendence in caregivers of persons with dementia doctoral students in research on self-transcendence.
as well as in caregivers of terminally ill patients who Research results from these studies provide addi-
had died within the previous year (Enyert & Burman, tional empirical support for the theory and are cited
1999; Reed & Rousseau, 2007). Other populations earlier in the chapter and listed in the bibliography.
studied include healthy middle-aged adults (Coward,
1996), elderly men with prostate cancer (Chin-A-Loy
& Fernsler, 1998), female nursing students and faculty Further Development
(Kilpatrick, 2002), nurses (Hunnibell, Reed, Quinn- Reed’s initial conceptualization of self-transcendence
Griffin, et al., 2008; McGee, 2004), homeless adults focused on later adulthood and identified the impor-
(Runquist & Reed, 2007), elders with chronic heart tance of personal resources that expand self-boundaries
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