532 UNIT IV Nursing Theories Analysis
n Autonomy: Alvin’s desires should be given
CASE STUDY
Alvin, 66 years of age, has been in the hospital for priority over his family members’ desires.
12 weeks with multiple trauma following a motor n Freedom: Not to honor Alvin’s wishes is a
vehicle accident. His condition worsens each day,
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
discussed with his family his desire not to be kept family members are in conflict with objective
alive in the event he was ill or injured and recovery reality. Only the patient’s feelings are consid-
was not possible. The health care team tells his ered in ethical decisions.
family that, despite aggressive treatment, many of n Self-assertion: It is not justifiable to substitute
Alvin’s body systems are failing. Even if Alvin sur- family members’ values for the patient’s.
vives, there is no hope that he will be able to live n Beneficence: The patient’s goals cannot be
without a ventilator because of extensive lung obtained by aggressive treatment; however,
damage. The team suggests supportive care for aggressive treatment may well cause the patient
Alvin and a do-not-resuscitate order. Most of further harm.
the family members express the desire to ensure n Fidelity: The health care professional’s agree-
Alvin’s comfort. Two family members believe ment with Alvin was to act as his agent in
Alvin will survive and recover. They refuse the pursuing goals that are possible to attain.
team’s suggestion and demand that Alvin receive
every available treatment to keep him alive.
CRITICAL THINKING ACTIVITIES 3. Johnny, 7 years of age, is a psychiatric inpatient
with a diagnosis of trichomania (hair pulling).
Using the Husted model, analyze the following ethical His parents are very concerned about stopping his
situations from an ethical perspective. destructive behavior and have developed a series
1. Christina, 46 years of age, has been in the hospital for of punishments for incidents of hair pulling.
Johnny has been seen pulling his hair out several
2 weeks following a traumatic injury. Her condition times during the day. His parents arrive and ask
was very grave, but she is beginning to show signs of how many times Johnny pulled his hair. What
recovery. The health care team suggests that a blood should the nurse say?
transfusion will provide the necessary support to
continue her improvement. Christina and her family 4. Eugene, 47 years of age, has several chronic
practice a religious faith that does not permit blood illnesses. Despite education and support, he
transfusions. Christina’s husband and religious leader declines to adhere to prescribed health care
insist that she not be given the transfusion regardless practices. Mark, a home health care nurse,
of the consequences. When the visitors leave, has been seeing Eugene for several months and
Christina tells the nurse that she would like to receive has made no progress in helping Eugene to
the transfusion, but only if it could be kept secret improve his health. While discussing the situa-
from her family. What should the nurse do? tion, Eugene tells Mark that he has no inten-
2 . Angela, 34 years of age, is dying of lung cancer. tion of changing any of his behaviors. Is Mark
Despite counseling and support, she is very justified in asking the physician to discontinue
frightened. When her death is imminent, she home health visits?
screams over and over, “Don’t let me die! Don’t let
me die!” Despite all efforts, Angela succumbs be- 5. Agnes is a nurse on a busy medical nursing unit.
fore her husband arrives. He asks, “How was she? Mr. Brown frequently asks Agnes to interrupt her
Was she afraid?” What should the nurse say?
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 & Husted’s Theory website at: http://www.
nursing.duq.edu/faculty/husted/details.html
n Husted, G. L., & Husted, J. H. (2008). Ethical deci-
sion making in nursing and healthcare: The sympho-
nological approach (4th ed.). New York: Springer.
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VUNIT
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
27C H A P T E R
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).
Credentials and Background 1962, graduating with distinction from the University
of the Theorist of New Mexico, Albuquerque. She went on to earn
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-
lastic Standing. She returned to school in 1960 after After receiving her Ph.D., Mercer moved to
working as a staff nurse, head nurse, and instructor in California and accepted the position of Assistant
the areas of pediatrics, obstetrics, and contagious dis- Professor in the Department of Family Health Care
eases. She completed a bachelor’s degree in nursing in Nursing at the University of California, San Francisco.
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
to full professor in 1983. She remained in that role CHAPTER 27 Ramona T. Mercer 539
until her retirement in 1987. Currently, Dr. Mercer Parents at Risk, published in 1990, also received an
is Professor Emeritus in Family Health Nursing at American Journal of Nursing Book of the Year Award.
the University of California, San Francisco (Mercer, Parents at Risk (1990) focused on strategies for facili-
curriculum vitae, 2002). tating early parent-infant interactions and promoting
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-
search, Southern Regional Board, for doctoral study. In Since her first publication in 1968, Mercer has
1982, she received the Maternal Child Health Nurse of written numerous articles for both nursing and non-
the Year Award from the National Foundation of the nursing journals. She published several online courses
March of Dimes and American Nurses Association, for Nurseweek during the 1990s and through early
Division of Maternal Child Health Practice. She 2000, including “Adolescent Sexuality and Child-
was presented with the Fourth Annual Helen Nahm bearing,” “Transitions to Parenthood,” and “Helping
Lecturer Award at the University of California, San Parents When the Unexpected Occurs.”
Francisco School of Nursing, in 1984. Mercer’s research
awards include the American Society for Psychopro- Mercer maintained membership in several profes-
phylaxis in Obstetrics (ASPO)/Lamaze National Re- sional organizations, including the American Nurses
search Award in 1987; the Distinguished Research Association and the American Academy of Nursing,
Lectureship Award, Western Institute of Nursing, and was an active member on many national commit-
Western Society for Research in Nursing in 1988; and tees. From 1983 to 1990, she was Associate Editor of
the American Nurses Foundation’s Distinguished Con- Health Care for Women International. Mercer served
tribution to Nursing Science Award in 1990 (Mercer, on the review panel for Nursing Research and Western
curriculum vitae, 2002). Mercer has authored numerous Journal of Nursing Research and on the editorial board
articles, editorials, and commentaries. In addition, she of the Journal of Adolescent Health Care, and she
has published six books and six book chapters. was on the executive advisory board of Nurseweek.
She also served as a reviewer for numerous grant pro-
In early research efforts, Mercer focused on the posals. Additionally, she was actively involved with
behaviors and needs of breastfeeding mothers, moth- regional, national, and international scientific and
ers with postpartum illness, mothers bearing infants professional meetings and workshops (Mercer, cur-
with defects, and teenage mothers. Her first book, riculum vitae, 2002). She was honored as a Living
Nursing Care for Parents at Risk (1977), received an Legend by the American Academy of Nursing during
American Journal of Nursing Book of the Year Award the Annual Meeting and Conference in Carlsbad,
in 1978. Her study of teenage mothers over the California, in November 2003. Mercer was honored
first year of motherhood resulted in the 1979 book, by the University of New Mexico in 2004, receiving
Perspectives on Adolescent Health Care, which also the first College of Nursing Distinguished Alumni
received an American Journal of Nursing Book of the Award. In 2005, she was recognized as among the
Year Award in 1980. Preceding research led Mercer to most outstanding alumni and faculty, and her name
study family relationships, antepartal stress as related appears on the Wall of Fame at the University of
to familial relationships and the maternal role, and California, San Francisco.
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
from Teens to Forties (1986a). Mercer’s fifth book, Mercer’s Theory of Maternal Role Attainment was
based on her extensive research on the topic beginning
540 UNIT V Middle Range Nursing Theories contributed. In addition, Mercer’s work was influ-
in the late 1960s. Mercer’s professor and mentor, Reva enced by von Bertalanffy’s (1968) general system
Rubin at the University of Pittsburgh, was a major theory. Her model of maternal role attainment de-
stimulus for both research and theory development. picted in Figure 27–1 uses Bronfenbrenner’s (1979)
Rubin (1977, 1984) was well known for her work in concepts of nested circles as a means of portraying
defining and describing maternal role attainment as a interactional environmental influences on the mater-
process of binding-in, or being attached to, the child nal role. The complexity of her research interest
and achieving a maternal role identity or seeing one- led Mercer to rely on several theoretical sources to
self in the role and having a sense of comfort about it. identify and study variables that affect maternal role
Mercer’s framework and study variables reflect many attainment. Although much of her work involved
of Rubin’s concepts. testing and extending Rubin’s theories, she has consis-
tently looked to the research of others in the develop-
In addition to Rubin’s work, Mercer based her ment and expansion of her theory.
research on both role and developmental theories.
She relied heavily on an interactionist approach to Use of Empirical Evidence
role theory, using Mead’s (1934) theory on role enact-
ment and Turner’s (1978) theory on the core self. Mercer selected both maternal and infant variables
In addition, Thornton and Nardi’s (1975) role acquisi- for her studies on the basis of her review of the litera-
tion process helped shape Mercer’s theory, as did ture and findings of researchers in several disciplines.
the work of Burr, Leigh, Day, and Constantine (1979).
Werner’s (1957) developmental process theories also
Macrosystem
Mesosystem
Microsystem
Mother-father relationship
Mother Child
Empathy—sensitivity to cues Temperament
Self-esteem/self-concept Ability to give cues
Parenting received as child Appearance
Maturity/flexibility Characteristics
Attitudes Responsiveness
Pregnancy/birth experience Health
Health/depression/anxiety
Role conflict/strain
Stress
Day c Child's Outcome
Maternal Role/Identity Cognitive/mental
Competence/confidence in role
Gratification/satisfaction development
Attachment to child Behavior/attachment
Health
Social competence
arSeocial support g
chool
Family functionin S
TransmPitaterednct'usltwuorarkl csoenttsinisgtesncies
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 Child-Rearing Attitudes
Maternal Role Attainment Child-rearing attitudes are maternal attitudes or beliefs
Maternal role attainment is an interactional and about child rearing (Mercer, 1986a).
developmental process occurring over time in which
the mother becomes attached to her infant, acquires Health Status
competence in the caretaking tasks involved in the Health status is defined as “The mother’s and father’s
role, and expresses pleasure and gratification in the perception of their prior health, current health,
role (Mercer, 1986a). “The movement to the personal health outlook, resistance-susceptibility to illness,
state in which the mother experiences a sense of health worry concern, sickness orientation, and
harmony, confidence, and competence in how she rejection of the sick role” (Mercer, May, Ferketich,
performs the role is the end point of maternal role et al., 1986, p. 342).
attainment—maternal identity” (Mercer, 1981, p. 74).
Anxiety
Maternal Identity Mercer and colleagues (1986) describe anxiety as “a
Maternal identity is defined as having an internalized trait in which there is specific proneness to perceive
view of the self as a mother (Mercer, 1995). stressful situations as dangerous or threatening, and
as a situation-specific state” (p. 342).
Perception of Birth Experience
A woman’s perception of her performance during Depression
labor and birth is her perception of the birth experi- According to Mercer and colleagues (1986), depres-
ence (Mercer, 1990). sion is “having a group of depressive symptoms
and in particular the affective component of the
Self-Esteem depressed mood” (p. 342).
Mercer, May, Ferketich, and DeJoseph (1986) describe
self-esteem as “an individual’s perception of how others Role Strain–Role Conflict
view oneself and self-acceptance of the perceptions” Role strain is the conflict and difficulty felt by the
(p. 341). woman in fulfilling the maternal role obligation
(Mercer, 1985a).
Self-Concept (Self-Regard)
Mercer (1986a) outlines self-concept, or self-regard, Gratification-Satisfaction
as “The overall perception of self that includes self- Mercer (1985b) describes gratification as “the
satisfaction, self-acceptance, self-esteem, and congru- satisfaction, enjoyment, reward, or pleasure that
ence or discrepancy between self and ideal self ” (p. 18). a woman experiences in interacting with her
infant, and in fulfilling the usual tasks inherent
Flexibility in mothering.”
Roles are not rigidly fixed; therefore, who fills the
roles is not important (Mercer, 1990). “Flexibility of Attachment
childrearing attitudes increases with increased de- Attachment is a component of the parental role and
velopment . . . Older mothers have the potential to identity. It is viewed as a process in which an endur-
respond less rigidly to their infants and to view each ing affectional and emotional commitment to an
situation in respect to the unique nuances” (Mercer, individual is formed (Mercer, 1990).
1986a, p. 43; 1990, p. 12).
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
Infant cues are infant behaviors that elicit a response Four areas of social support are as follows:
from the mother (R. T. Mercer, personal communi- 1. Emotional support: “Feeling loved, cared for,
cation, September 3, 2003).
trusted, and understood” (Mercer, 1986a, p. 14)
Family 2. Informational support: “Helping the individual
Mercer and colleagues (1986) define family as “a dy-
namic system that includes subsystems—individuals help herself by providing information that is use-
(mother, father, fetus/infant) and dyads (mother- ful in dealing with the problem and/or situation”
father, mother-fetus/infant, and father-fetus/infant) (Mercer, 1986a, p. 14)
within the overall family system” (p. 339). 3. Physical support: A direct kind of help (Mercer,
Hackley, & Bostrom, 1984)
Family Functioning 4. Appraisal support: “A support that tells the role
Family functioning is the individual’s view of the taker how she is performing in the role; it enables
activities and relationships between the family and the individual to evaluate herself in relationship
its subsystems and broader social units (Mercer & to others’ performance in the role” (Mercer,
Ferketich, 1995). 1986a, p. 14)
Father or Intimate Partner Mother-Father Relationship
The father or intimate partner contributes to the pro- The mother-father relationship is the perception of
cess of maternal role attainment in a way that can- the mate relationship that includes intended and
not be duplicated by any other person (R. T. Mercer, actual values, goals, and agreements between the
two (Mercer, 1986b). The maternal attachment to
the infant develops within the emotional field of the
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
studying the paternal response to parenthood. Her CHAPTER 27 Ramona T. Mercer 543
research required numerous instruments to measure
the variables of interest. • Maternal identity develops concurrently with
maternal attachment, and each depends on the
Mercer has studied the influence of these variables other (Mercer, 1995; Rubin, 1977).
on parental attachment and competence over several
intervals, including the immediate postpartum period Nursing
and 1 month, 4 months, 8 months, and 1 year follow- Mercer (1995) stated that “Nurses are the health pro-
ing birth (Mercer & Ferketich, 1990a, 1990b). In addi- fessionals having the most sustained and intense inter-
tion, she has included adolescents, older mothers, ill action with women in the maternity cycle” (p. xii).
mothers, mothers dealing with congenital defects, Nurses are responsible for promoting the health of
families experiencing antepartal stress, parents at high families and children; nurses are pioneers in develop-
risk, mothers who had cesarean deliveries, and fathers ing and sharing assessment strategies for these patients,
in her research (Mercer, 1989; Mercer & Ferketich, she explained. Her definition of nursing provided in
1994, 1995; Mercer, Ferketich, & DeJoseph, 1993). As a personal communication is as follows:
a recent step, she compared her findings and the basis
for her original theory with current research. As a Nursing is a dynamic profession with three major
result, Mercer (2004) has proposed that the term foci: health promotion and prevention of illness,
maternal role attainment be replaced with becoming a providing care for those who need professional
mother, because this more accurately describes the assistance to achieve their optimal level of health
continued evolvement of the role across the woman’s and functioning, and research to enhance the
life span. In addition, she proposed using more recent knowledge base for providing excellent nursing
nursing research findings to describe the stages and care. Nurses provide health care for individuals,
process of becoming a mother. families, and communities. Following assessment
of the client’s situation and environment, the
Major Assumptions nurse identifies goals with the client, provides
assistance to the client through teaching, support-
For maternal role attainment, Mercer (1981, 1986a, ing, providing care the client is unable to provide
1995) stated the following assumptions: for self, and interfacing with the environment
• A relatively stable core self, acquired through life- and the client
long socialization, determines how a mother defines (R. Mercer, personal communication,
and perceives events; her perceptions of her infant’s March 21, 2004).
and others’ responses to her mothering, with her life
situation, are the real world to which she responds In her writing, Mercer (1995) refers to the impor-
(Mercer, 1986a). tance of nursing care. In Becoming a Mother: Research
• In addition to the mother’s socialization, her devel- on Maternal Identity from Rubin to the Present, Mercer
opmental level and innate personality characteristics does not specifically mention nursing care, however
also influence her behavioral responses (Mercer, she emphasizes that the kind of help or care a woman
1986a). receives during pregnancy and the first year following
• The mother’s role partner, her infant, will reflect birth can have long-term effects for her and her child.
the mother’s competence in the mothering role Nurses in maternal-child settings play a sizable role
through growth and development (Mercer, 1986a). in providing both care and information during this
• The infant is considered an active partner in the period.
maternal role-taking process, affecting and being
affected by the role enactment (Mercer, 1981). Person
• The father’s or mother’s intimate partner contributes Mercer (1985a) does not specifically define person,
to role attainment in a way that cannot be duplicated but refers to the self or core self. She views the self
by any other supportive person (Mercer, 1995). as separate from the roles that are played. Through
maternal individuation, a woman may regain her own
personhood as she extrapolates herself from the
544 UNIT V Middle Range Nursing Theories Theoretical Assertions
mother-infant dyad (Mercer, 1985b). The core self Mercer’s original Theory and Model of Maternal Role
evolves from a cultural context and determines how Attainment were introduced in 1991 during a sympo-
situations are defined and shaped (Mercer, 1985a). sium at the International Research Conference spon-
The concepts of self-esteem and self-confidence are sored by the Council of Nursing Research and American
important in attainment of the maternal role. The Nurses Association in Los Angeles, California (Mercer,
mother as a separate person interacts with her infant 1995). It was refined and presented more clearly in her
and with the father or her significant other. She is 1995 book, Becoming a Mother: Research on Maternal
both influential and is influenced by both of them Identity from Rubin to the Present (see Figure 27–1).
(Mercer, 1995).
Health Mercer’s (2004) more recent revision of her theory
In her theory, Mercer defines health status as the has focused on the woman’s transition in becoming a
mother’s and father’s perception of their prior mother. Motherhood involves an extensive change in
health, current health, health outlook, resistance- a woman’s life that requires her ongoing development.
susceptibility to illness, health worry or concern, According to Mercer, becoming a mother is more
sickness orientation, and rejection of the sick role. extensive than just assuming a role. It is unending
Health status of the newborn is the extent of disease and continuously evolving. Therefore, she proposed
present and infant health status by parental rating that the term maternal role attainment be retired.
of overall health (Mercer, 1986b). The health status She based that recommendation on the published
of a family is affected negatively by antepartum research of Walker, Crain, and Thompson (1986a,
stress (Mercer, Ferketich, DeJoseph, May, & Sollid, 1986b), Koniak-Griffin (1993), and McBride and
1988; Mercer, May, Ferketich, & DeJoseph, 1986). Shore (2001), who had examined the process of moth-
Health status is an important indirect influence ering and raised questions about the appropriateness
on satisfaction with relationships in childbearing of maternal role attainment as an end point in the
families. Health is also viewed as a desired outcome process.
for the child. It is influenced by both maternal and
infant variables. Mercer (1995) stresses the impor- Maternal Role Attainment: Mercer’s
tance of health care during the childbearing and Original Model
childrearing processes. Mercer’s Model of Maternal Role Attainment was
Environment placed within Bronfenbrenner’s (1979) nested circles
Mercer conceptualized the environment from Bron- of the microsystem, mesosystem, and macrosystem (see
fenbrenner’s definition of the ecological environment Figure 27–1). The original model proposed by Mercer
and based her earliest model in Figure 27–1 on it was altered in 2000, changing the term exosystem,
(Mercer, 1995; R. Mercer, personal communication, originally found in the second circle, and replacing it
June 24, 2000). This model illustrates the ecological with the term mesosystem. Mercer (personal commu-
interacting environments in which maternal role nication, January 4, 2003) explained that this change
attainment develops. During personal communication made the model more consistent with Bronfenbrenner’s
on January 4, 2003, Mercer explained, “Development terminology, as follows:
of a role/person cannot be considered apart from 1 . The microsystem is the immediate environment in
the environment; there is a mutual accommodation
between the developing person and the changing which maternal role attainment occurs. It includes
properties of the immediate settings, relationships factors such as family functioning, mother-father
between the settings, and the larger contexts in which relationships, social support, economic status,
the settings are embedded.” Stresses and social sup- family values, and stressors. The variables con-
port within the environment influence both maternal tained within this immediate environment interact
and paternal role attainment and the developing with one or more of the other variables in affecting
child. the transition to motherhood. The infant as an
individual is embedded within the family system.
The family is viewed as a semi-closed system main-
taining boundaries and control over interchange
between the family system and other social systems CHAPTER 27 Ramona T. Mercer 545
(Mercer, 1990). system (Mercer, 1995). National laws regarding
The microsystem is the most influential on mater- women and children and health priorities that
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-
Father enced by social support, stress, family functioning,
or and also by the relationship between mother and
father or significant other.
intimate partner Traits and behaviors of both the mother and the
infant may influence maternal role identity and child
Mother Infant outcome. Maternal traits and behaviors included in
a a Mercer’s model are empathy, sensitivity to infant cues,
cb bc self-esteem and self-concept, parenting received as a
d d child, maturity and flexibility, attitudes, pregnancy and
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,
general characteristics, responsiveness, and health.
a mother: Research on maternal identity from Rubin to the pres- Examples of the infant’s developmental responses that
ent. New York: Springer; used by permission.)
546 UNIT V Middle Range Nursing Theories to retire the term maternal role attainment because
“it implies a static situation rather than fluctuating pro-
interact with the mother’s developing maternal iden- cess” (p. 79). Finally, in a synthesis of nine qualitative
tity, depicted as a through d in Figure 27–2, include studies, Nelson (2003) described continued growth and
the following: transformation in women as they become mothers.
a. Eye contact with the mother as she talks to her or Mercer (2004) acknowledged that new challenges in
motherhood require making new connections to regain
him, grasp reflex confidence in the self and proposed replacing the term
b. Smile reflex and quieting behavior in response to maternal role attainment with becoming a mother.
the mother’s care Qualitative studies have identified stages of mater-
c. Consistent interactive behaviors with the mother nal role attainment using the descriptive terms of
d. Eliciting responses from the mother; increasingly participants. A compilation of the results of several
of these studies has led Mercer (2004, 2006) to the
more mobile following proposed changes in the names of stages
According to Mercer (1995): leading to maternal role identity:
• Commitment and preparation (pregnancy)
The personal role identity stage is reached when • Acquaintance, practice, and physical restoration
the mother has integrated the role into her self
system with a congruence of self and other roles; (first 2 weeks)
she is secure in her identity as mother, is emo- • Approaching normalization (second week to
tionally committed to her infant, and feels a
sense of harmony, satisfaction, and competence 4 months)
in the role (p. 14). • Integration of maternal identity (approximately
Using Burke and Tully’s (1977) work, Mercer 4 months)
(1995) stated that a role identity has internal and These stages parallel the original stages in Mercer’s
external components: the identity is the internalized theory, but they embrace the maternal experience
view of self (recognized maternal identity), and role is more completely and use terminology derived from
the external, behavioral component. new mothers’ descriptions of their experiences.
Theory building, according to Mercer (personal
Becoming a Mother: A Revised Model communication, September 3, 2003), is a continual
Mercer has continued to use both her own research process as research provides evidence for clarifying
and the research of others as building blocks for her concepts, additions, and deletions. Although many of
theory. In 2003, she began reexamining the Theory of the more recent studies support the findings of both
Maternal Role Attainment, proposing that the term Rubin and Mercer, Mercer (2004) recognized the evi-
becoming a mother more accurately reflects the pro- dence for needed changes in her original theory for
cess based on recent research. According to Mercer greater clarity and consistency. It is with this insight that
(2004), the concept of role attainment suggests an end she proposed retiring the term maternal role attain-
point rather than an ongoing process and may not ment. Mercer (2004) acknowledges that becoming a
address the continued expansion of the self as a mother, which connotes continued growth in mother-
mother. Mercer’s conclusions are based largely on ing, is more descriptive of the process, which is much
current nursing research about the cognitive and larger than a role. Although some roles may be termi-
behavioral dimensions of women becoming mothers. nated, motherhood is a lifelong commitment.
Walker, Crain, and Thompson’s (1986a, 1986b) ques- Mercer has continued to use Bronfenbrenner’s
tions about maternal role attainment as a continuing concept of interacting nested ecological environ-
process contributed to Mercer’s reexamination of her ments. However, she renamed them to reflect the
theory. Koniak-Griffin (1993) also questioned the living environments: family and friends, community,
behavioral and cognitive dimensions of maternal and society at large (Figure 27–3). This model places
role attainment. Hartrick (1997) reported in her study the interactions between mother, infant, and father
that mothers of children from 3 to 16 years of at the center of the interacting, living environments
age undergo a continual process of self-definition. (R. Mercer, personal communication, September 3,
McBride and Shore (2001) in their research on mothers
and grandmothers suggested that there may be a need
CHAPTER 27 Ramona T. Mercer 547
Society at large
Community
Family and friends
Father
or intimate
partner
d c b a Mother Infant a bcd
FIGURE 27-3 B ecoming 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 Logical Form
come from laws affecting woman and children, evolving
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 first year of motherhood and in her theory. De-
The newest model (Figure 27–4) shows interacting ductive logic is demonstrated in Mercer’s use of works
environments that affect the process of becoming a from other researchers and disciplines. Role and
mother. The model was developed in 2006 based on a developmental theories and the work of Rubin on
review of the nursing research about the effectiveness or maternal role attainment provided a base for the
interventions aimed at fostering the process of becom- original framework. Mercer also used inductive logic
ing a mother. This model depicts the complex issues in the development of her Theory of Maternal Role
that have the potential to either facilitate or inhibit the
548 UNIT V Middle Range Nursing Theories
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F
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BAM
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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
Practice settings.
Mercer’s theory is highly practice oriented. The con- In addition, Mercer’s theory has been used in
cepts in her theory have been cited in many obstetrical organizing patient care. Concepts in the research
conducted by Neeson, Patterson, Mercer, and May
(1983), “Pregnancy Outcome for Adolescents Receiving CHAPTER 27 Ramona T. Mercer 549
Prenatal Care by Nurse Practitioners in Extended
Roles,” were used in setting up a clinical practice. Sank (1991) used Mercer’s theory in her doctoral
Clark, Rapkin, Busen, and Vasquez (2001) used dissertation research at the University of Texas,
Mercer’s theory to establish and test a parent educa- Austin, entitled Factors in the Prenatal Period That
tion curriculum for substance-abusing women in a Affect Parental Role Attainment During the Postpar-
residential treatment facility. Meighan and Wood tum Period in Black American Mothers and Fathers.
(2005) used the theory of maternal role attainment Mercer’s Theory of Maternal Role Attainment also
to explore the impact of hyperemesis gravidarum served as the framework for Washington’s (1997)
on maternal role assumption. dissertation, Learning Needs of Adolescent Mothers
When Identifying Fever and Illnesses in Infants Less
Education Than Twelve Months of Age at the University of
Mercer’s work has appeared extensively in both Miami. Bacon (2001), a student at the Chicago
maternity and pediatric nursing texts. Many of the School of Professional Psychology, used Mercer’s
current concepts in maternal-child nursing are theory in her dissertation, Maternal Role Attain-
based on Mercer’s research. Her theory and models ment and Maternal Identity in Mothers of Premature
help simplify the very complex process of becoming Infants. Dilmore (2003) based her study, A Compari-
a parent. The Theory of Maternal Role Attainment is son of Confidence Levels of Postpartum Depressed
credited with enhancing understanding and making and Non-Depressed First Time Mothers, on Mercer’s
Mercer’s contribution extremely valuable to nursing research.
education. The Theory of Maternal Role Attainment
provides a framework for students as they learn to McBride (1984) wrote the following:
plan and provide care for parents in a wide variety
of settings. The Theory of Becoming a Mother has Maternal role attainment has been a fundamental
rapidly gained acceptance since its introduction in concern of nursing since the pioneering work of
2004. Mercer’s theory and research have also been Mercer’s mentor, Rubin, almost two decades ago. It
used in other disciplines as they relate to parenting is now becoming the research-based, theoretically
and maternal role attainment. It has been shown to sound construct that nurse researchers have been
be helpful to students in psychology, sociology, and searching for in their analysis of the experience of
education. new mothers (p. 72).
Research Further Development
Mercer advocated the involvement of students in fac-
ulty research. During her tenure at the University of Mercer used her initial research as a building block
California, San Francisco, she chaired committees for other studies. In later research, she aimed at iden-
and was a committee member for numerous graduate tifying predictors of maternal-infant attachment on
theses and dissertations. Collaborative research with the basis of maternal experience with childbirth and
a graduate student and junior faculty member in 1977 maternal risk status. Mercer also examined paternal
and 1978 led to the development of a highly reliable, competence on the basis of experience with childbirth
valid instrument to measure mothers’ attitudes about and pregnancy risk status. In another study, she de-
the labor and delivery experience. Numerous re- veloped and tested a causal model to predict partner
searchers have requested and received permission to relationships in high-risk and low-risk pregnancy.
use the instrument. More work and refinement of the original model and
theory have taken place during the past few years,
Mercer’s work has served as a springboard for as described earlier. She included the importance of
other researchers. The theoretical framework for her the father in maternal role attainment, adding this to
correlational study exploring the differences between her model and theory in a section of her 1995 book,
three age groups of first-time mothers (15 to 19, 20 to Becoming a Mother: Research on Maternal Identity
29, and 30 to 42 years of age) has been tested by oth- from Rubin to the Present.
ers, including Walker and colleagues (1986a, 1986b).
In First-Time Motherhood: Experiences from Teens
to Forties, Mercer (1986a) presented a model of
the following four phases occurring in the process of
550 UNIT V Middle Range Nursing Theories childbearing that have an impact on the transition to
maternal role attainment during the first year of 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
tested in other studies. Mercer’s (2004) proposal of
month and still in process at 1 year) abandoning the term maternal role attainment for
Additionally, adaptation to the maternal role was the term becoming a mother is argued logically, but
proposed to occur at three levels (biological, psycho- few studies put it to use in practice or research. Al-
logical, and social), which are interacting and interde- though qualitative research to describe the phases of
pendent throughout the phases. These phases and becoming a mother uses the exact words of women
levels of adaptation were described briefly and were experiencing this transition, these phases have not
applied to her research. In 2003, Mercer proposed been confirmed among women in other cultures or
additional changes to the theory (2004), which included in different circumstances.
abandoning the term maternal role attainment for the
term becoming a mother. Changes to the model and Critique
adoption of the following four descriptive phases to the Clarity
process of becoming a mother were also proposed:
1 . Commitment and preparation (pregnancy) The concepts, variables, and relationships have not
2 . Acquaintance, practice, and physical restoration always been defined explicitly, but they were described
(first 2 weeks) and implied in Mercer’s earlier work. However, the
3 . Approaching normalization (second week to concepts were defined theoretically and operational-
4 months) ized consistently. Work toward improving clarity is
4 . Integration of maternal identity (approximately evident. Concepts, assumptions, and goals have been
4 months) organized into a logical and coherent whole, so that
These changes were based on the research studies understanding the interrelationships among the con-
by other nurses and are evidence of Mercer’s contin- cepts is relatively easy. Some interchanging of terms
ued scrutiny and critique of her theory to improve its and labels used to identify concepts, such as adapta-
utility in practice and research. tion and attainment, social support, and support net-
According to Mercer and Walker (2006), research work, is potentially confusing for the reader, and
into specific nursing interventions that foster be- maternal role attainment has not been defined consis-
coming a mother is needed. They encourage the tently, which can obstruct clarity. Maternal identity,
involvement of nursing staff, students, and faculty in a term that Mercer defines as the final stage of role
the development and testing of assessment guide- attainment (personal or role identity stage) is some-
lines and instruments to measure outcomes of nurs- times substituted for maternal role attainment.
ing interventions that support maternal role identity According to Mercer (1995), when the maternal role
and the process of becoming a mother. Mercer and has been attained, the mother has achieved a maternal
Walker also encourage further research in dealing identity, the internalized role of mother. However,
with mothers who face special challenges, including the terms attainment and role identity are sometimes
mothers who face childbirth complications, mothers confusing.
with low social and economic resources, adolescent
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
containing the exact words of women experiencing CHAPTER 27 Ramona T. Mercer 551
motherhood, and she favors using these words to
describe the stages of becoming a mother. and the completeness of operational definitions in-
crease the empirical precision. The theoretical frame-
Simplicity work for exploring differences among age groups of
Despite numerous concepts and relationships, the first-time mothers lends itself well to further testing
theoretical framework for maternal role attainment or and is being used by others for this purpose. The con-
becoming a mother organizes a rather complex phe- tinued scrutiny by Mercer herself has continually
nomenon into an easily understood and useful form. improved her theory and solidified her concepts.
The theory is predictive in nature and readily lends Mercer’s proposed changes to improve clarity of con-
itself as a guide for practice. Concepts are not specific cepts are based on research studies of others within
to time and place and although abstract, they are the discipline of nursing.
described and operationalized to the extent that Importance
meanings are not easily misinterpreted. It should be The theoretical framework for maternal role attain-
noted that the research to define and support the ment during the first year has proved to be useful,
theoretical relationships was very complex, which practical, and valuable to nursing. Mercer’s work is
was due largely to the great number of concepts. The used repeatedly in nursing research, practice, and
process of becoming a mother is multifaceted and education. The framework is also applicable to any
varies considerably according to the individual and discipline that works with mothers and children dur-
to environmental influences. Mercer’s theory pro- ing the first year of motherhood. McBride (1984)
vides a framework for understanding this complex, wrote, “Dr. Mercer is the one who developed the most
multidimensional process. complete theoretical framework for studying one
aspect of parental experience, namely, the factors that
Generality influence the attainment of the maternal role in the
Mercer’s theory is derived from and is specific to first year of motherhood” (p. 72).
parent-child nursing but has been used by other dis-
ciplines concerned with mothering and parenting. Throughout her career, Mercer consistently has
The theory can be generalized to all women during linked research and practice. Applications for nursing
pregnancy through the first year after birth, regardless care or nursing interventions are addressed and provide
of age, parity, or environment. It is among the few the bond between research and practice in her works.
theories applicable to high-risk perinatal patients and As she has said, nursing research is the “bridge to excel-
their families. As previously mentioned, it can be lence” in nursing practice (Mercer, 1984, p. 47).
applied to a variety of pediatric settings. Mercer
(1995) specified her theory for the study and predic- Summary
tion of parental attachment, including that of the
pregnant woman’s partner. Therefore, it is useful for The Theory of Maternal Role Attainment has been
studying and working with family members following shown to be useful in both research and practice for
birth. Mercer’s work has broadened the range of nurses, as well as other disciplines concerned with
application of previously existing theories on maternal parenting. Mercer’s continued devotion to improving
role attainment, because her studies have spanned the usefulness and clarity of her theory and model
various developmental levels and situational contexts, is evident and has served well those who use her
a quality that many other studies do not share. theory. Mercer’s use of both her own research and the
research of others strengthens her work. Her proposal
Accessibility to adopt the Theory of Becoming a Mother is based
Mercer’s work has evolved from extensive research solidly on the research process. Motherhood and
efforts. The concepts, assumptions, and relationships attainment of the parenting role is a very complex,
are grounded predominantly in empirical observa- multilevel process. Mercer’s theory and her work
tions and are congruent. The degree of concreteness make this process logical and understandable and
provide a solid foundation for practice, education,
and research.
552 UNIT V Middle Range Nursing Theories the nurse learns that the only living grandparents
of the baby live a great distance away. Susan will
CASE STUDY not have any family or friends to turn to when she
Susan, a 19-year-old woman, delivered her first takes the baby home.
infant prematurely 5 days ago. Although her post- In this high-risk perinatal case, Mercer’s frame-
partum course has been relatively uneventful, the work should be useful for nursing assessment and
infant has had difficulty and must remain hospital- intervention to facilitate maternal role attainment.
ized. Susan and her young husband visit the nurs- How would you use it as a guide in planning care
ery every afternoon to be with the baby, but they for Susan?
ask very few questions. In talking with the couple,
CRITICAL THINKING ACTIVITIES address current changes in health care delivery
and the impact on the family? What changes in
1. In your own practice, consider Mercer’s Theory Mercer’s model, if any, do you see that need to be
and Model of Maternal Role Attainment as a addressed?
guide. List the ways it was useful to you in the 4 . Mercer proposed changing her theory from
care of a new mother. Maternal Role Attainment to Becoming a
Mother to address the evolving role of mother-
2 . High-risk families often continue to experience hood. Do you agree or disagree with this
problems for years after the birth of a child with a change? Is it possible that becoming a mother
congenital problem. Can Mercer’s theory be and attaining the maternal role are both relevant
adapted to help in assessment and intervention to the theory and nursing care of new mothers/
for these mothers and their families beyond the families in the clinical setting?
first year? What areas need further research and
development? Websites
n Nurses for Nurses Everywhere. (2004). Nurse
3. Consider the current health care environment.
Does the model proposed by Mercer adequately information: Ramona T. Mercer. Melbourne,
Australia, at: http://www.nurses.info/nursing_
POINTS FOR FURTHER STUDY theory_midrange_theories_ramona_mercer.htm.
n Nurses for Nurses Everywhere. (2004). Nurse
Publications information: Reva Rubin. Melbourne, Australia,
n Mercer, R.T. (2004) Becoming a mother versus at: http://www.nurses.info/nursing_theory_
midrange_theories_reva_rubin.htm.
maternal role attainment. Journal of Nursing n University of New Mexico Past Distinguished
Scholarship, 36(3), 226–232. Alumni Award: Ramona Mercer at: http://nursing.
n Mercer, R. T. (2006). Nursing support of the unm.edu/alumni-and-friends/daa-profiles/ramona-
process of becoming a mother. Journal of mercer.html.
Obstetric, Gynecologic, and Neonatal Nursing, n Word press at: http://khaelashofieananta.wordpress.
35(5), 649–651. com/2011/11/02/nursing-theory-ramona-t-mercer/.
n Mercer, R. T., & Walker, L. O. (2006). A review of
nursing interventions to foster becoming a mother.
Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 35(5), 568–582.
n Meighan, M. (2010). Mercer’s maternal role the-
ory and nursing practice. In M. R. Alligood (Ed.),
Nursing theory: Utilization & application (4th ed.,
pp. 389–410). St. Louis: Mosby.
CHAPTER 27 Ramona T. Mercer 553
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during infancy. Nursing Research, 44, 31–37.
28C H A P T E R
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)”
Credentials and Background The original scale has been used as the basis for the
of the Theorist following three additional scales:
1 . A community version (MUIS-C) for chronically ill
Merle H. Mishel was born in Boston, Massachusetts.
She graduated from Boston University with a B.A. in individuals who are not hospitalized or receiving
1961 and received her M.S. in psychiatric nursing active medical care
from the University of California in 1966. Mishel 2 . A measure of parents’ perceptions of uncer-
completed her M.A. and Ph.D. in social psychology tainty (PPUS) with regard to their child’s illness
at the Claremont Graduate School in Claremont, experience
California, in 1976 and 1980, respectively. Her 3. A measure of uncertainty in spouses or other fam-
dissertation research was supported by a National ily members when another member of the family
Research Service Award to develop and test the is acutely ill (PPUS-FM)
Perceived Ambiguity in Illness Scale, later named Early in her professional career, Mishel practiced
the Mishel Uncertainty in Illness Scale (MUIS-A). as a psychiatric nurse in acute care and community
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 Fulbright Award. She has been a visiting scholar at
faculty in the Department of Nursing at the California many institutions throughout North America, includ-
State University at Los Angeles, rising from assistant ing University of Nebraska, University of Texas at
professor to full professor. She practiced as a nurse Houston, University of Tennessee at Knoxville, Uni-
therapist in community and private practice settings versity of South Carolina, University of Rochester,
from 1973 to 1979. After completing her doctorate in Yale University, and McGill University. Mishel was
social psychology, Mishel became associate professor doctoral program consultant for the University of
at the University of Arizona College of Nursing in Cincinnati College of Nursing from 1991 to 1992 and
1981 and full professor in 1988. She was Division Rutgers University School of Nursing in 1993. In
Head of Mental Health Nursing from 1984 to 1991. 2004, she received the Linnea Henderson Research
While at Arizona, Mishel received numerous intra- Fellowship Program Award from the Kent State
mural and extramural research grants that supported University School of Nursing. Over the last 20 years,
the continued development of the theoretical frame- she has presented more than 80 invited addresses at
work of uncertainty in illness. During this period, she schools of nursing throughout the United States and
continued practicing as a nurse therapist with the Canada. With growing international interest in her
heart transplant program at the University Medical theory and measurement models, Mishel conducted
Center. She was inducted as a fellow in the American an International Symposium on Uncertainty at
Academy of Nursing in 1990. Kyungpook National University in Daegu, South
Korea, was a visiting scholar at Mahidol University in
Mishel moved back east in 1991 and joined the Bangkok, Thailand, and delivered the keynote address
faculty at the University of North Carolina at Chapel for the Japanese Society of Nursing Research annual
Hill School of Nursing as professor, and she was convention, in Sapporo, Japan.
awarded the endowed Kenan Professor of Nursing
Chair in 1994. Friends of the National Institute of Mishel is a member of many professional organiza-
Nursing Research presented her with a Research tions, including the American Academy of Nursing,
Merit Award in 1997 and invited her to present her Sigma Theta Tau International, the American Psycho-
research as an exemplar of federally funded nursing logical Association, the American Nurses Association,
intervention studies at a Congressional Breakfast the Society of Behavioral Medicine, the Oncology
in 1999. She is Director of the T-32 Institutional Nursing Society, the Southern Nursing Research Soci-
National Research Service Award Training Grant, ety, and the Society for Education and Research in
Interventions for Preventing and Managing Chronic Psychiatric Nursing. She served as a grant reviewer
Illness that awards predoctoral and postdoctoral fel- for the National Cancer Institute, the National Center
lowships to nurses who are interested in developing for Nursing Research, and the National Institute on
interventions for underserved chronically ill patients. Aging, and she was a charter member of the study sec-
Mishel’s research program is noteworthy for being tion on human immunodeficiency virus (HIV) at the
funded continually by the National Institutes of National Institute of Mental Health.
Health from 1984 through 2011. Each research grant
has built upon findings from prior studies to move Theoretical Sources
systematically toward theoretically derived scientifi-
cally tested nursing interventions. Currently Mishel is When Mishel began her research into uncertainty,
co-leader of the Hillman Scholars Program designed the concept had not been applied in the health and
to produce a new generation of nurse innovators with illness context. Her original Uncertainty in Illness
knowledge and research skills to solve complex health Theory (Mishel, 1988) drew from existing informa-
problems and improve patient care. tion-processing models (Warburton, 1979) and per-
sonality research (Budner, 1962) from psychology
Among her many awards, Mishel received a Sigma that characterized uncertainty as a cognitive state
Theta Tau International Sigma Xi Chapter Nurse resulting from insufficient cues with which to form
Research Predoctoral Fellowship from 1977 to 1979 a cognitive schema or internal representation of a
and received the Mary Opal Wolanin Research Award
in 1986. In 1987, Mishel was first alternate for a
situation or event. Mishel attributes the underlying CHAPTER 28 Merle H. Mishel 557
stress-appraisal-coping-adaptation framework in the supported a mechanistic view with emphasis on con-
original theory to the work of Lazarus and Folkman trol and predictability. She used critical social theory
(1984). The unique aspect of this framework was its to recognize bias inherent in the original theory, an
application to uncertainty as a stressor in the context orientation toward certainty and adaptation. Mishel
of illness, a particularly meaningful proposal for incorporated tenets from chaos theory and open sys-
nursing. tems for a more accurate representation of how
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 Structure Providers
Uncertainty Structure providers are the resources available to
Uncertainty is the inability to determine the mean- assist the person in the interpretation of the stimuli
ing of illness-related events, occurring when the frame (Mishel, 1988).
decision maker is unable to assign definite value to
objects or events, or is unable to predict outcomes Credible Authority
accurately (Mishel, 1988). Credible authority is the degree of trust and confi-
dence a person has in his or her health care providers
Cognitive Schema (Mishel, 1988).
Cognitive schema is a person’s subjective interpreta-
tion of illness, treatment, and hospitalization (Mishel, Social Supports
1988). Social supports influence uncertainty by assisting the
individual to interpret the meaning of events
Stimuli Frame (Mishel, 1988).
Stimuli frame is the form, composition, and struc-
ture of the stimuli that a person perceives, which are Cognitive Capacities
then structured into a cognitive schema (Mishel, Cognitive capacities are the information-processing
1988). abilities of a person, reflecting both innate capabili-
ties and situational constraints (Mishel, 1988).
Symptom Pattern
Symptom pattern is the degree to which symptoms Inference
occur with sufficient consistency to be perceived as Inference refers to the evaluation of uncertainty
having a pattern or configuration (Mishel, 1988). using related, recalled experiences (Mishel, 1988).
Event Familiarity Illusion
Event familiarity is the degree to which a situation is Illusion refers to beliefs constructed out of uncer-
habitual or repetitive, or contains recognized cues tainty (Mishel, 1988).
(Mishel, 1988).
Adaptation
Event Congruence Adaptation reflects biopsychosocial behavior occur-
Event congruence refers to the consistency between ring within persons’ individually defined range of
the expected and the experienced in illness-related usual behavior (Mishel, 1988).
events (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).
Similarly, the ambiguous nature of illness symptoms
The Uncertainty in Illness Theory grew out of Mishel’s and the consequent difficulty in determining the sig-
dissertation research with hospitalized patients, using nificance of physical sensations have been identified
both qualitative and quantitative findings to generate as sources of uncertainty (Cohen, 1993; Hilton, 1988;
the first conceptualization of uncertainty in the context Nelson, 1996).
of illness. With the publication of Mishel’s Uncertainty
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
experience high levels of uncertainty as well, which
Most empirical studies have been focused on two may further reduce the amount of support experi-
antecedents of uncertainty, stimuli frame and structure enced by the patient (Baird & Eliasziw, 2011; Brown
providers, and the relationship between uncertainty & Powell-Cope, 1991; Hilton, 1996; Wineman, O’Brien,
and psychological outcomes. Mishel tested other ele- Nealon, et al., 1993). Uncertainty was heightened by
ments of the model, such as the mediating roles of interactions with health care providers when patients
appraisal and coping, early in her program of research and family members received unclear information,
(Mishel & Braden, 1987; Mishel, Padilla, Grant, et al., received simplistic explanations that did not fit their
1991; Mishel & Sorenson, 1991), and these elements, as experience, or perceived that care providers were not
well as cognitive capacity as an antecedent to uncer- expert or responsive enough to help them manage
tainty, generated less research attention. the intricacies of the illness (Becker, Jason-Bjerklie,
Benner, et al., 1993; Checton & Greene, 2012; Sharkey,
Several studies have shown that objective or 1995; Step & Ray, 2011).
subjective indicators of the severity of life-threat or
illness symptoms associate positively with uncertainty Numerous studies have reported the negative impact
(Baird & Eliasziw, 2011; Grootenhuis & Last, 1997; of uncertainty on psychological outcomes, characterized
Somjaivong, Thanasilp, Preechawong, et al., 2011). variously as anxiety, depression, hopelessness, psycho-
Across a sustained illness trajectory, unpredictability logical distress (Arroll, Dancey, Attree, et al., 2012; Failla,
in symptom onset, duration, and intensity has been Kuper, Nick, et al., 1996; Grootenhuis & Last, 1997; Kim
related to perceived uncertainty (Arroll, Dancey, & So, 2012; Miles, Funk, & Kasper, 1992; Mishel &
Attree, et al., 2012; Becker, Jason-Bjerklie, Benner,
Sorenson, 1991; Page, Fedele, Pai, et al., 2012; Schepp, CHAPTER 28 Merle H. Mishel 559
1991; Wineman, 1990), quality of life (Lasker, Sogolow,
Short, et al., 2011; Somjaivong Thanasilp, Preechawong, studies of people with chronic and life-threatening ill-
et al., 2011; Song, Northouse, Braun, et al., 2011), nesses. The process of formulating a new view of life is
satisfaction with family relationships (Wineman, O’Brien, described by women with breast cancer and cardiac
Nealon, et al., 1993), satisfaction with health care disease as a revised life perspective (Hilton, 1988), new
services (Green & Murton, 1996; Tai-Seale, Stults, life goals (Carter, 1993), new ways of being in the world
Zhang, et al., 2012), and family caregivers’ maintenance (Mast, 1998; Nelson, 1996), growth through uncertainty
of their own self-care activities (Brett & Davies, 1988; (Pelusi, 1997), and new levels of self-organization
O’Brien, Wineman, & Nealon, 1995). (Fleury, Kimbrell, & Kruszewski, 1995). In studies of
men with chronic illness or their caregivers, the pro-
In 1990, the original theory was expanded to in- cess is described as transformed self-identity and new
clude the idea that uncertainty may not be resolved goals for living (Brown & Powell-Cope, 1991), a more
but may become part of an individual’s reality. In this positive perspective on life (Katz, 1996), reevaluating
context, uncertainty is appraised as an opportunity what is worthwhile (Nyhlin, 1990), contemplation and
that prompts the formation of a new, probabilistic self-appraisal (Charmaz, 1995), uncertainty viewed as
view of life. To adopt this new view of life, the patient opportunity (Baier, 1995), and redefining normal and
must be able to rely on social resources and health building new dreams (Mishel & Murdaugh, 1987).
care providers who themselves accept the idea of
probabilistic thinking (Mishel, 1990). When uncer- Major Assumptions
tainty is framed as a normal part of life, it becomes a Person
positive force for multiple opportunities and resulting
positive mood states (Gelatt, 1989; Mishel, 1990). Mishel’s Uncertainty in Illness Theory is middle-
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
Stimuli frame (Ϫ) Uncertainty Danger Appraisal (ϩ)
Symptom pattern Adaptation
Event familiarity Inference
Event congruency Illusion
(ϩ) Opportunity
(ϩ)
(ϩ)
(Ϫ)
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 • Fluctuations result in repatterning, which is repeated
The first two reflect how uncertainty was conceptual- at each level of the system.
ized within psychology’s information-processing mod- In Mishel’s reconceptualized theory, neither the
els, as follows:
1. Uncertainty is a cognitive state, representing the antecedents to uncertainty nor the process of cogni-
tive appraisal of uncertainty as danger or opportunity
inadequacy of an existing cognitive schema to sup- change. However, uncertainty over time, associated
port the interpretation of illness-related events. with a serious illness, functions as a catalyst for fluc-
2. Uncertainty is an inherently neutral experience, tuation in the system by threatening one’s preexisting
neither desirable nor aversive until it is appraised cognitive model of life as predictable and controllable.
as such. Because uncertainty pervades nearly every aspect of
Two more assumptions reflect the uncertainty the- a person’s life, its effects become concentrated and
ory’s roots in traditional stress and coping models ultimately challenge the stability of the system. In re-
that posit a linear stress A coping A adaptation sponse to the confusion and disorganization created
relationship as follows: by continued uncertainty, the system ultimately must
3. Adaptation represents the continuity of an indi- change in order to survive.
vidual’s usual biopsychosocial behavior and is the
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 Theoretical Assertions
contradictory findings when the theory was applied
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
represent a known downward trajectory; in other structure or categorize an illness-related event because
words, uncertainty is appraised as opportunity when of the lack of sufficient cues.
it is the alternative to negative certainty. Mishel and • Uncertainty can take the form of ambiguity, com-
others found that people also appraised uncertainty plexity, lack of or inconsistent information, or
as an opportunity in situations without a certain down- unpredictability.
ward trajectory, particularly in long-term chronic ill- • As symptom pattern, event familiarity, and event
nesses, and that in this context people often developed congruence (stimuli frame) increase, uncertainty
a new view of life. decreases.
It was at this time that Mishel turned to chaos • Structure providers (credible authority, social sup-
theory to explain how prolonged uncertainty could port, and education) decrease uncertainty directly
function as a catalyst to change a person’s perspective
on life and illness. Chaos theory contributed two of Uncertainty Danger Opportunity
the following theoretical assumptions that replace the
linear stress A coping A adaptation outcome por- Time
tion of the model as follows:
• People, as biopsychosocial systems, typically func- FIGURE 28-2 R econceptualized Model of Uncertainty in
tion in far-from-equilibrium states. Chronic Illness. (Copyright Merle Mishel, 1990.)
• Major fluctuations in a far-from-equilibrium system
enhance the system’s receptivity to change.
by promoting interpretation of events, and indi- CHAPTER 28 Merle H. Mishel 561
rectly by strengthening the stimuli frame.
• Uncertainty appraised as danger prompts coping evidence from qualitative studies that suggested
efforts directed at reducing the uncertainty and that people’s responses to uncertainty changed over
managing the emotional arousal generated by it. time within the context of serious chronic illnesses.
• Uncertainty appraised as opportunity prompts cop- Thus Mishel’s theory represents the bidirectional
ing efforts directed at maintaining the uncertainty. process where theory informs and is informed by
• The influence of uncertainty on psychological out- research.
comes is mediated by the effectiveness of coping
efforts to reduce uncertainty appraised as danger or Acceptance by the Nursing Community
to maintain uncertainty appraised as opportunity. Practice
• When uncertainty appraised as danger cannot
be reduced effectively, coping strategies can be Mishel’s theory describes a phenomenon experi-
employed to manage the emotional response. enced by acute and chronically ill individuals and
• The longer uncertainty continues in the illness their families. The theory has its beginning in
context, the more unstable the individual’s previ- Mishel’s own experience with her father’s battle with
ously accepted mode of functioning becomes. cancer. During his illness, he began to focus on
• Under conditions of enduring uncertainty, indi- events that seemed unimportant to those around
viduals may develop a new, probabilistic perspec- him. When asked why he had chosen to focus on
tive on life, which accepts uncertainty as a natural such events, he replied that when these activities
part of life. were being done, he understood what was happen-
• The process of integrating continual uncertainty ing to him. Mishel believed this was her father’s way
into a new view of life can be blocked or prolonged of taking control and making sense out of an over-
by structure providers who do not support proba- whelming situation. She knew early in the develop-
bilistic thinking. ment of her concept and theory that nurses could
• Prolonged exposure to uncertainty appraised as identify the phenomenon from their experiences in
danger can lead to intrusive thoughts, avoidance, caring for patients.
and severe emotional distress.
Several nurses have moved the theory from research
Logical Form to practice. Hansen and colleagues (2012) synthesized
findings from qualitative studies to yield a typology of
As a middle-range theory derived from and applica- patient experiences of uncertainty that guides nursing
ble to clinical practice, Mishel’s Uncertainty in Illness engagement and intervention. Similarly, the theory has
Theory is an exemplar of the multiple steps required been used in recommendations for the practice of
to develop theory with both heuristic and practical critical, medical-surgical, and enterostomal nursing
value. Neither purely inductive nor deductive, care (Hilton, 1992; Righter, 1995; Wurzbach, 1992).
Mishel’s theoretical work initially arose from ques-
tioning the nature of an important clinical problem, Based on review of the database of the Managing
followed by systematic qualitative and quantitative Uncertainty in Illness Scale users (Mishel, 1997b),
inquiry and careful application of theory borrowed master’s-prepared clinicians seek to understand the
from other disciplines. Since publication of the origi- experience of uncertainty in a variety of clinical set-
nal theory in 1988, Mishel and others have carried tings and patient populations. The scale and theory
out numerous empirical tests of the relationships are used by clinicians from 15 countries other than
among the major constructs in the model, applying the United States.
and largely confirming the theory in illness contexts. Education
Mishel’s reconceptualization of the theory in 1990 The theory has been widely used by graduate students
was deductive in that it was developed from princi- as the theoretical framework for theses and disserta-
ples of chaos theory and was confirmed by empirical tions, as the topic of concept analysis, and for the
critique of middle-range nursing theory. Mishel uses
the theory as an exemplar to illustrate how theory
guides the development of nursing interventions in
562 UNIT V Middle Range Nursing Theories Stewart, Lynn, & Mishel, 2010; Stewart, Mishel,
Lynn, et al., 2010). Bailey uses the theory to support
her doctoral-level courses. Mishel frequently presents research in chronic hepatitis C, a new and often
school of nursing lectures, seminars, and symposia silent disease (Bailey, Barroso, Muir, et al., 2010;
nationally and internationally, sharing her empirical Bailey, Landerman, Barroso, et al., 2009), and she is
findings and the process of theory development for testing an intervention in patients awaiting liver
faculty and students. transplant and their caregivers.
Research
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, &
Further Development Mishel, 2007). In the first study of the Uncertainty
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,
Belyea, et al., 2004; Gil, Mishel, Belyea, et al., 2006; The substantial empirical evidence supporting
Gil, Mishel, Germino, et al., 2005; Mishel, Belyea, the Uncertainty in Illness theories provides a strong
Germino, et al., 2002; Mishel, Germino, Belyea, foundation to extend the theory to intervention
et al., 2003; Mishel, Germino, Lin, et al., 2009). The development and improve patient and family out-
applicability of the theory to the context of serious comes. In addition to Mishel’s own intervention stud-
childhood illness has been supported in parents of ies in patients with breast and prostate cancer, several
children with HIV infection (Santacroce, Deatrick, & researchers tested interventions to help patients man-
Ledlie, 2002) and in children undergoing treatment age uncertainty. Many were directed at reducing
for cancer (Lin, Yeh, & Mishel, 2010; Stewart, 2003; sources of uncertainty (Chair, Chou, Sit, et al., 2012;
Chiou & Chung, 2012; Faithfull, Cockle-Hearne, &
Khoo, 2011; Kazer, Bailey, Sanda, et al., 2011; Muth- CHAPTER 28 Merle H. Mishel 563
usamy, Leuthner, Gaebler-Uhing, et al., 2012; Schover, also can lead to the individual appraising the situa-
Canada, Yuan, et al., 2012). Others focused on the tion as having a positive outcome. In this situation,
provision of support (Heiney, Adams, Wells, et al., uncertainty is preferred and the individual remains
2012) and specific coping strategies (Faithfull, Cockle- hopeful.
Hearne, & Khoo, 2011) to help patients manage their
uncertainty. Coping is the third theme of the original model of
uncertainty. Coping occurs in two forms with the
Critique end result of adaptation. If uncertainty is appraised
Clarity as a danger, then coping includes direct action, vigi-
lance, and seeking information from mobilizing
Uncertainty is the primary concept of this theory and strategies, and it affects management using faith, dis-
is defined as a cognitive state in which individuals are engagement, and cognitive support. If uncertainty is
unable to determine the meaning of illness-related appraised as an opportunity, coping offers a buffer to
events (Mishel, 1988). The original theory postulates maintain the uncertainty.
that managing uncertainty is critical to adaptation
during illness and explains how individuals cogni- The original theory was reconceptualized in 1990
tively process illness-associated events and construct to incorporate the idea that chronic illness unfolds
meaning from them. The original theory’s concepts over time, possibly years, and with that, uncertainty
were organized in a linear model around the follow- is reappraised. The person is viewed as an open
ing three major themes: system exchanging energy within his or her envi-
1 . Antecedents of uncertainty ronment, and, rather than seeking to return to a
2 . Process of uncertainty appraisal stable state, chronically ill individuals may move
3 . Coping with uncertainty toward a complex world orientation, thus forming
new meaning for their lives. If uncertainty is framed
The framework is clear and easy to follow. The as a normal view of life, it becomes a positive force
antecedents of uncertainty include the stimuli for multiple opportunities with resulting positive
frame, cognitive capacities, and structure providers. mood states. To achieve this, the individual must
In the linear model, these antecedent variables have develop probabilistic thinking, which allows one
both a direct and indirect inverse relationship with to examine a variety of possibilities and consider
uncertainty. ways of achieving them as the individual envisions
a variety of responses and realizes that life changes
The second conceptual component of the model from day to day.
is appraisal. Uncertainty is seen as a neutral state,
neither positive nor negative, until it has been ap- Mishel described this process as a new view of life
praised by the individual. Appraisal of uncertainty in which uncertainty shifts from being seen as a
involves the following two processes: (1) inference danger to being viewed as an opportunity. To adopt
and (2) illusion. Inference is constructed from the this new view of life, the patient must be able to rely
individual’s personality disposition and includes on social resources and health care providers who
learned resourcefulness, mastery, and locus of con- accept probabilistic thinking. The relationship be-
trol. These characteristics contribute to an individu- tween the health care provider and the patient must
al’s confidence in the ability to handle life events. focus on recognizing continual uncertainty and
Illusion is defined as a belief constructed from teaching the patient how to use the uncertainty to
uncertainty that considers the favorable aspects of a generate different explanations for events. Hence the
situation. Based on the appraisal process, uncer- importance of structure providers, introduced in the
tainty is viewed as either a danger or an opportunity. original theory, is maintained in the reconceptual-
Uncertainty viewed as a danger results when the ized model.
individual considers the possibility of a negative
outcome. Uncertainty is viewed as an opportunity Despite the complexity and dimensionality of
primarily through the use of illusion, but inference the two models, they are presented clearly and con-
ceptualized comprehensively. Mishel published her
measurement model in 1981, her original theoretical
model in 1988, and her reconceptualized theory in
564 UNIT V Middle Range Nursing Theories development and testing of nursing interventions to
manage uncertainty.
1990, and these publications fully explicate the model Importance
for application in clinical and research contexts. Derivable consequences are determined by examining
whether a theory guides research, informs practice,
Simplicity generates new ideas, and differentiates the focus of
The two uncertainty-in-illness models contain con- nursing from other professions. Mishel’s work repre-
cepts comprising relationships that range from simple sents an exemplar of middle-range theory that in-
to complex and direct to indirect. Eleven major con- forms clinical practice in the encompassing context of
cepts are found in the three themes of the original acute and chronic illness. The theory has generated
theory, and several new concepts are introduced in the considerable empirical research with adults dealing
reconceptualized model. The antecedents of uncer- with illness or that of family members and continues
tainty are concise, and their definitions are clear and to stimulate new research directions, such as uncer-
simple. The appraisal component is complex because it tainty in ill children, in older men electing watchful
considers cognitive processes along with beliefs and waiting as treatment of choice for prostate cancer, and
values held by the individual. The coping phase of the in health care providers informing patients of treat-
theory is also complex because it is dependent on the ment choices in conditions with uncertain prognoses.
appraisal portion of the model and again involves dif- Mishel believes that by defining and conceptualizing
ferent kinds of strategies targeted toward adaptation. an important clinical problem, her work supports and
The outcome portion of the model is differentiated enriches nursing practice. The Uncertainty in Illness
into two conceptualizations of the theory, the first Theory and its reconceptualization represent frame-
relating to patients with acute illness and the second works derived from and for practice, a process essen-
representing an expansion of the model to accommo- tial to nursing as a practice discipline.
date patients with chronic illness. Although the models
can hardly be called simple, overall the concept defini- Summary
tions and relationships are well-operationalized and
easily understood. The Uncertainty in Illness Theory provides a com-
prehensive framework within which to view the ex-
Generality perience of acute and chronic illness and to organize
The theory explains how individuals construct nursing interventions to promote optimal adjustment.
meaning from illness-related events. It is broad and The theory helps explain the stresses associated with
generalizable and can be used with individuals expe- the diagnosis and treatment of major illnesses or
riencing illness, as well as with spouses and parents chronic conditions, the processes by which individ-
of those experiencing illness-related uncertainty. uals assess and respond to the uncertainty inherent
The concept of credible authority can be applied to in an illness experience, and the importance of pro-
physicians, nurses, and other health care workers. fessional caregivers in providing information and
The theory can be applied in many areas of nursing supporting individuals in understanding and man-
practice and has been used by clinicians for acute aging uncertainty. The reconceptualized theory
and chronic illnesses such as cancer, cardiac disease, addresses the unique context of continual uncer-
and multiple sclerosis. tainty and thereby expands the original theory to
encompass the ongoing uncertain trajectory of many
Accessibility life-threatening and chronic illnesses. The original
Mishel derived both theoretical models from her theory and its reconceptualization are well expli-
program of research. Many of the concepts, as- cated, deriving support from sound theoretical
sumptions, and relationships among variables draw foundations and extensive empirical confirmation,
support from empirical investigation. The concepts and it can be applied in illness contexts to support
are well described, and their relationships are pre- evidence-based nursing practice.
cisely constructed with clear, tested operational
definitions. Theory testing has occurred in research
and clinical settings. The theory has led to the
CASE STUDY CHAPTER 28 Merle H. Mishel 565
Part 1: Original Theory her treatment plan is different from what her
Rosie, a 45-year-old mother of three, has been primary physician told her to expect (event con-
diagnosed with stage III breast cancer. A mass was gruence) and how she will manage her family life
detected in her left breast during her annual gyne- while undergoing treatment. Lily provides an
cological appointment, and she has undergone an audiotape of the treatment conference so that
extensive diagnostic workup, including mammog- Rosie’s husband (structure provider–social sup-
raphy and sentinel node biopsy. She was referred port) can hear what took place and can support
by her primary physician to a comprehensive Rosie in asking questions and understanding the
breast cancer program at a regional medical center information provided. Lily’s support for Rosie
that was 2 hours from her home. The multidisci- and her family continues throughout Rosie’s
plinary team has recommended that Rosie un- treatment course, and she periodically reassesses
dergo preoperative chemotherapy, followed by the sources of uncertainty and the strategies that
partial mastectomy and reconstructive surgery. Rosie and her family use to manage them.
Rosie’s husband has accompanied her to most of Part 2: Reconceptualized Theory
her medical encounters, but he was unable to at- Two years after her breast cancer diagnosis, Rosie
tend the final conference, where the treatment returns to the center for a follow-up appointment.
recommendations were made. Lily asks Rosie to reflect on her cancer experience.
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 During an exacerbation of her disease, she
focuses on her plans for going to law school.
1. You have been assigned to a new patient. You want One of your colleagues suggests that she may
to know about this person’s perceptions of the cur- be in denial about the severity of her illness.
rent situation, supportive relationships, and previous Use the reconceptualized Uncertainty in Illness
experiences with health and illness. What questions Theory to propose an alternative interpretation
would you ask to assess the level of uncertainty? of her perspective.
younger African American and Caucasian breast
2. You are working with a young woman who has cancer survivors. Oncology Nursing Forum, 40(1),
been living with multiple sclerosis for 6 years. 82–92.
POINTS FOR FURTHER STUDY
n Germino, B. B., Mishel, M. H. Crandell, J., Porter,
L. Blyler, D. Jenerette, C., et al. (2013). Outcomes
of an uncertainty management intervention in
566 UNIT V Middle Range Nursing Theories n Research Tested Interventions for Practice
n Mishel, M. (2008). Portraits of Excellence: (RTIP), NCI. Managing Uncertainty in Older
Long-term Breast Cancer Survivors website at:
The Nurse Theorist Series, Vol 2, Fitne, Inc., http://rtips.cancer.gov/rtips/index.do
Athens, OH.
Chair, S. Y., Chau, M. Y., Sit, J. W. H., Wong, E. M. L., &
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long-term breast cancer survivors. Annals of Behavioral
Medicine, 31(3), 195–204. Domingues, H. R. F. (2007). Illness uncertainty and
Porter, L. S., Mishel, M., Neelon, V., Belyea, M., Pisano, E., treatment motivation in type 2 diabetes patients. Revista
& Soo, M. S. (2003). Cortisol levels and responses to Latino-Americana De Enfermagem, 15(4), 575–582.
mammography screening in breast cancer survivors: A Artsanthia, J., Mawn, B. E., Chaiphibalsarisdi, P., Nityasuddhi,
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Sammarco, A. (2001). Perceived social support, uncertainty, care needs of people living in Thailand with end-stage
and quality of life of younger breast cancer survivors. renal disease: A pilot study. Journal of Hospice and Palliative
Cancer Nursing, 24(3), 212–219. Nursing, 13(6), 403–410.
Sammarco, A. (2003). Quality of life among older survivors Bailey, D. E., Jr., & Wallace, M. (2007). Critical review: Is
of breast cancer. Cancer Nursing, 26(6), 431–438. watchful waiting a viable management option for older
Sammarco, A. (2009). Quality of life of breast cancer survi- men with prostate cancer? American Journal of Men’s
vors: a comparative study of age cohorts. Cancer Nursing, Health, 1(1), 18–28.
32(5), 347–356; quiz 357–348. Bishop, M., Stenhoff, D. M., & Shepard, L. (2007). Psycho-
Sammarco, A., & Konecny, L. M. (2008). Quality of life, social adaptation and quality of life in multiple sclerosis:
social support, and uncertainty among Latina breast can- Assessment of the disability centrality model. Journal of
cer survivors. Oncology Nursing Forum, 35(5), 844–849. Rehabilitation, 73(1), 3–12.
Sammarco, A., & Konecny, L. M. (2010). Quality of life, social Brown, R. T., Fuemmeler, B., Anderson, D., Jamieson, S.,
support, and uncertainty among Latina and Caucasian Simonian, S., Hall, R. K., et al. (2007). Adjustment of
breast cancer survivors: a comparative study. Oncology children and their mothers with breast cancer. Journal of
Nursing Forum, 37(1), 93–99. Pediatric Psychology, 32(3), 297–308.
Schroeder, J. C., Bensen, J. T., Su, L. J., Mishel, M., Ivanova, A., Budych, K., Helms, T. M., & Schultz, C. (2012). How do
Smith G. J., Godley, P. A., Fontham, E. T., & Mohler, J. L. patients with rare diseases experience the medical
(2006). The North Carolina Louisiana Prostate Cancer encounter? Exploring role behavior and its impact on
Project (PCaP): Methods and design of a multidisciplinary patient-physician interaction. Health Policy, 105(2–3),
population-based cohort study of racial differences in 154–164.
prostate cancer outcomes. Prostate, 66(11), 1162–1176. Bunkers, S. S. (2007). The experience of feeling unsure for
Schulman-Green, D., Ercolano, E., Dowd, M., Schwartz, P., women at end-of-life. Nursing Science Quarterly, 20(1),
& McCorkle R. (2008). Quality of life among women 56–63.
after surgery for ovarian cancer. Palliative Supportive Carpentier, M. Y., Mullins, L. L., Wagner, J. L., Wolfe-
Care, 6(3), 239–247. Christensen, C., & Chaney, J. M. (2007). Examination of
Stewart, J. L., Lynn, M. R., & Mishel, M. H. (2005). Evaluating the cognitive diathesis-stress conceptualization of the
content validity for children’s self-report instruments using hopelessness theory of depression in children with
children as content experts. Nursing Research, 54, 414–418. chronic illness: The moderating influence of illness
Stewart, J. L., & Mishel, M. H. (2000). Uncertainty in child- uncertainty. Childrens Health Care, 36(2), 181–196.
hood illness: A synthesis of the parent and child litera- Davidson, P. M., Dracup, K., Phillips, J., Padilla, G., & Daly, J.
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Wonghongkul, T., Moore, S. M., Musil, C., Schneider, S., & framework to guide interventions for people with heart
Deimling, G. (2000). The influence of uncertainty in ill- failure. Journal of Cardiovascular Nursing, 22(1), 58–64.
ness, stress appraisal, and hope on coping in survivors of Donovan-Kicken, E., & Bute, J. J. (2008). Uncertainty of
breast cancer. Cancer Nursing, 23(6), 422–429. social network members in the case of communication—
debilitating illness or injury. Qualitative Health Research,
Secondary Sources 18(1), 5–18.
Selected Publications Citing Mishel’s Work Drageset, S., Lindstrom, T. C., Giske, T., & Underlid, K.
Amoako, E., & Skelly, A. H. (2007). Managing uncertainty (2011). Being in suspense: Women’s experiences await-
ing breast cancer surgery. Journal of Advanced Nursing,
in diabetes: an intervention for older African American 67(9), 1941–1951.
women. Ethnicity & Disease, 17(3), 515–521. Elphee, E. E. (2008). Understanding the concept of uncer-
tainty in patients with indolent lymphoma. Oncology
Nursing Forum, 35(3), 449–454.
572 UNIT V Middle Range Nursing Theories Malbasa, T., Kodish, E., & Santacroce, S. J. (2007). Adoles-
cent adherence to oral therapy for leukemia: A focus
Fedele, D. A., Ramsey, R. R., Ryan, J. L., Bonner, M. S., group study. Journal of Pediatric Oncology Nursing,
Mullins, L. L., Jarvis, J. N., et al. (2011). The association 24(3), 139–151.
of illness uncertainty to parent and youth adjustment in
juvenile rheumatic diseases: Effect of youth age. Journal Mazanec, S. R., Daly, B. J., Douglas, S., & Musil, C. (2011).
of Developmental and Behavioral Pediatrics, 32(5), Predictors of psychosocial adjustment during the post-
361–367. radiation treatment transition. Western Journal of
Nursing Research, 33(4), 540–559.
Gill, E. A., & Babrow, A. S. (2007). To hope or to know:
Coping with uncertainty and ambivalence in women’s Martens, T. Z., & Emed, J. D. (2007). The experiences and
magazine breast cancer articles. Journal of Applied Com- challenges of pregnant women coping with thrombo-
munication Research, 35(2), 133–155. philia. Journal of Obstetric Gynecologic and Neonatal
Nursing, 36(1), 55–62.
Giske, T., & Artinian, B. (2008). Patterns of ‘balancing
between hope and despair’ in the diagnostic phase: a Middleton, A. V., LaVoie, N. R., & Brown, L. E. (2012).
grounded theory study of patients on a gastroenterology Sources of uncertainty in Type 2 Diabetes: Explication
ward. Journal of Advanced Nursing 62(1), 22–31. and implications for health communication theory
and clinical practice. Health Communication, 27(6),
Giske, T., & Gjengedal, E. (2007). “Preparative waiting” and 591–601.
coping theory with patients going through gastric diag-
nosis. Journal of Advanced Nursing, 57(1), 87–94. Mullins, L. L., Wolfe-Christensen, C., Pai, A. L. H., Carpentier,
M. Y., Gillaspy, S., Cheek, J., & Page, M. (2007). The
Haugh, K. H., & Salyer, J. (2007). Needs of patients and relationship of parental overprotection, perceived child
families during the wait for a donor heart. Heart & Lung, vulnerability, and parenting stress to uncertainty in
36(5), 319–329. youth with chronic illness. Journal of Pediatric Psychol-
ogy, 32(8), 973–982.
Jordan, A. L., Eccleston, C., & Osborn, M. (2007). Being a
parent of the adolescent with complex chronic pain: An Pai, A. L. H., Mullins, L. L., Drotar, D., Burant, C., Wagner,
interpretative phenomenological analysis. European J., & Chaney, J. M. (2007). Exploratory and confirmatory
Journal of Pain, 11(1), 49–56. factor analysis of the child uncertainty in illness scale
among children with chronic illness. Journal of Pediatric
Ju, H. O., McElmurry, B. J., Park, C. G., McCreary, L., Kim, Psychology, 32(3), 288–296.
M., & Kim, E. J. (2011). Anxiety and uncertainty in
Korean mothers of children with febrile convulsion: Pelletier, J. (2012). Appraisal of uncertainty while waiting for a
Cross-sectional survey, Journal of Clinical Nursing, kidney transplant. Unpublished dissertation, East Carolina
20(9–10), 1490–1497. University, Greenville, North Carolina.
Kagan, I., & Bar-Tal, Y. (2008). The effect of preoperative Penrod, J. (2007). Living with uncertainty: Concept advance-
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576–583. Persson, E., Lindholm, E., Berndtsson, I., Lundstam, U.,
Hulten, L., & Carlsson, E. (2012). Experiences of living with
Kang, Y. (2011). The relationships between uncertainty and increased risk of developing colorectal and gynaecological
its antecedents in Korean patients with atrial fibrillation. cancer in individuals with no identified gene mutation.
Journal of Clinical Nursing, 20(13–14), 1880–1886. Scandinavian Journal of Caring Sciences, 26(1), 20–27.
Kasper, J., Geiger, F., Freiberger, S., & Schmidt, A. (2008). Pickles, T., Ruether, J. D., Weir, L., Carlson, L., & Jakulj, F.
Decision-related uncertainties perceived by people with (2007). Psychosocial barriers to active surveillance for the
cancer: modeling the subject of shared decision making. management of early prostate cancer and a strategy for
Psycho-Oncology, 17(1), 42–48. increased acceptance. BJU International, 100(3), 544–551.
Kosenko, K. A., Hurley, R. J., & Harvey, J. A. (2012). Sources Politi, M. C., Han, P. K. J., & Col, N. F. (2007). Communicat-
of the uncertainty experienced by women with HPV. ing the uncertainty of harms and benefits of medical
Qualitative Health Research 22(4), 534–545. interventions. Medical Decision Making, 27(5), 681–695.
Lee, Y. L., Santacroce, S. J., & Sadler, L. (2007). Predictors of Puterman, J., & Cadell, S. (2008). Timing is everything: The
healthy behaviour in long-term survivors of childhood experience of parental cancer for young adult daughters—A
cancer. Journal of Clinical Nursing, 16(11C), 285–295. pilot study. Journal of Psychosocial Oncology, 26(2),
103–121.
Lopez, R. P., & Guarino, A. J. (2011). Uncertainty and deci-
sion making for residents with dementia. Clinical Nurs- Rosen, N. O., Knauper, B., & Sammut, J. (2007). Do individ-
ing Research, 20(3), 228–240. ual differences in intolerance of uncertainty affect health
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Maher, K., & de Vries, K. (2011). An exploration of the lived
experiences of individuals with relapsed Multiple My-
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29C H A P T E R
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).
Credentials and Background focusing on the relationship between well-being and
of the Theorist spiritual perspectives on life and death in terminally
ill and well individuals.
Pamela G. Reed was born in Detroit, Michigan, where
she grew up during the 1960s. She married her hus- Reed is on the faculty at the University of Arizona
band, Gary, in 1973, and they have two daughters. College of Nursing in Tucson, where she teaches,
Reed received her baccalaureate from Wayne State conducts research, and serves in administrative roles,
University in Detroit, Michigan, in 1974 and earned including Associate Dean for Academic Affairs since
her M.S.N. in psychiatric–mental health of children January 1983. Reed has received numerous awards for
and adolescents and in nursing education in 1976. doctoral teaching in philosophy of nursing science
She began doctoral study at that institution in 1979 and practice, and for her theory development courses.
and received her Ph.D. in 1982 with a concentration Her major fields of research are spirituality, nursing
in nursing theory and research. She pioneered nurs- philosophy, and ethical dimensions of end-of-life
ing research into spirituality beginning with her dis- and palliative caregiving. She developed two widely
sertation research, directed by Joyce J. Fitzpatrick, used research instruments, the Spiritual Perspectives
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
studies, financed by intramural and extramural fund- CHAPTER 29 Pamela G. Reed 575
ing, were reported in many presentations and publi- Reed describes her theory as originating from three
cations. Her current research examines well-being sources (Reed, 2003, 2008). The first source was the
and ethical dimensions in end-of-life caregiving by conceptualization of human development (Lerner,
family caregivers and professional nurses. She has 2002) as a lifelong process that extended beyond the
published over 100 articles and book chapters, and attainment of adulthood throughout the aging and dy-
she co-edited the sixth edition of Perspectives on ing processes. This emerging belief in the ongoing
Nursing Theory with Shearer in 2012. In 2011, Reed potential for development was a paradigm shift from
and Shearer published Nursing Knowledge and Theory previously held views that both physical growth and
Innovation: Advancing the Science of Nursing Practice, mental development ended at adolescence (Reed,
promoting a philosophy and methods of practice- 1983).
based knowledge development in 2011. The second source for the theory was the early
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-
posed that asynchrony in development among physi-
Reed’s influence is evident not only in her own cal, emotional, environmental, and social dimensions
research and publications. The impact of her work is was necessary for developmental progress. Rogers’
reflected in the research of many graduate students helicy principle characterized human development as
and in the work of other scientists nationally and in- innovative and unpredictable. This principle is similar
ternationally who have applied her theory or her two to life span principles identifying development as
measurement scales in their research. Her theoretical nonlinear, continuous throughout the life span, and
ideas have been supported and extended by the many evident in variability within and across individuals
nurses she mentored. and groups. Rogers’ resonancy principle described
human development as a process of movement that,
Theoretical Sources although unpredictable, had pattern and purpose.
Life span theorists also proposed that the process of
Reed (1991a) developed her Self-Transcendence development displayed patterns of complexity and
Theory using the strategy of deductive reformula- organization. Thus knowledge gained from the non-
tion. The strategy originated with Reed’s professors, nursing life span developmental perspective was
Ann Whall and Joyce Fitzpatrick at Wayne State reformulated using an appropriate nursing concep-
University (Fitzpatrick, Whall, Johnston, et al., tual system.
1982; Shearer & Reed, 2004; Whall, 1986.). Deductive The third source for the theory was evidence from
reformulation uses knowledge from non-nursing the- clinical experience and research indicating that clinically
ory that is reformulated with a nursing conceptual depressed older persons reported fewer developmental
model in constructing middle-range theory. The non- resources to sustain their sense of well-being in the face
nursing theory sources were life span theories on adult of decreased physical and cognitive abilities than did a
social-cognitive and transpersonal development (e.g., matched group of mentally healthy older adults (Reed,
Alexander & Langner, 1990; Commons, Richards, & 1986b). In addition, development in elderly and in
Armon, 1984; Wilber, 1980, 1981, 1990). Principles “oldest-old” adults was found to be a nonlinear process
from life span theories were reformulated using the of gain and subsequent loss, a process of transforming
nursing perspective of Martha E. Rogers’ conceptual old perspectives and behaviors, and integrating new
system of unitary human beings (Rogers, 1970, 1980, views and activities (Reed, 1989, 1991b).
1990).
576 UNIT V Middle Range Nursing Theories
MAJOR CONCEPTS & DEFINITIONS may possibly be added to describe the capacities for
boundary expansion (P. Reed, personal communica-
Vulnerability tion, June 17, 2004).
Vulnerability is one’s awareness of personal mortality
(Reed, 2003). In Reed’s earlier work, the phrase Well-Being
“awareness of one’s personal mortality” was the con- Well-being is “the sense of feeling whole and healthy,
text for development or maturation in later adult- in accord with one’s own criteria for wholeness and
hood or at the end of life. The concept of vulnerability well-being” (Reed, 2003, p. 148). In her earlier work,
broadens the awareness of personal mortality situa- Reed did not explicitly define well-being but linked
tions to include life crises such as disability, chronic the concept to mental health, which was dependent
illness, childbirth, and parenting. Self-transcendence on salient issues of development within a given
was a pattern associated with advanced development phase of life (Reed, 1989, 1991b). In an article
within that context (Reed, 1991b). in Nursing Science Quarterly, Reed described the
underlying mechanisms of well-being in “Nursing:
Self-Transcendence The Ontology of the Discipline” and proposed nurs-
Self-transcendence, initially defined by Reed (1991a) ing to be “the study of the nursing processes of well-
as “expansion of self-conceptual boundaries multi- being” (Reed, 1997a, p. 76). Well-being as a nursing
dimensionally: inwardly (e.g., through introspective process is described in terms of a synthesis of two
experiences), outwardly (e.g., by reaching out to kinds of change: changes in complexity in a life (i.e.,
others), and temporally (whereby past and future the increasing frailness of advanced aging or the loss
are integrated into the present)” (p. 71), was later of a beloved spouse) tempered by changes in inte-
defined more comprehensively (Reed , 1997b) as gration (i.e., constructing meaning from such life
follows: events).
Self-transcendence refers to fluctuation of perceived Moderating-Mediating Factors
boundaries that extend the person (or self) beyond A variety of personal and contextual variables and
the immediate and constricted views of self and the their interactions may influence the process of
world. This fluctuation is pandimensional, that is, self-transcendence as it contributes to well-being.
outward (toward others and the environment), Examples are age, gender, cognitive ability, life
inward (toward greater awareness of one’s own experiences, spiritual perspectives, social environ-
beliefs, values, and dreams), and temporal (toward ment, and historical events. These variables may
integration of past and future in a way that strengthen or weaken relationships between vul-
enhances the relative present) (p. 192). nerability and self-transcendence and between
In 2003, the pattern of boundary expansion was self-transcendence and well-being (Reed, 2003).
incorporated so that self-transcendence included the Nursing activities may be based on facilitating the
capacity to expand one’s self-boundaries “transper- mediating factor of self-transcendence.
sonally (to connect with dimensions beyond the typi-
cally discernible world)” (Reed, 2003, p. 147). As self-
transcendence is pandimensional, other dimensions
Use of Empirical Evidence in theory building was conducted with older adults
(1986b, 1989, 1991b).
Self-Transcendence Theory was grounded in belief in
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
of developmental resources were measured 3 times CHAPTER 29 Pamela G. Reed 577
(6 weeks apart) with the 36-item Developmental
Resources of Later Adulthood (DRLA) scale, previ- (Reed, 1991b). In this study, self-transcendence
ously developed and tested by Reed. Healthy adults was defined as “the expansion of one’s conceptual
perceived higher levels of resources across time boundaries inwardly through introspective activi-
than did depressed adults. Scores on the Center for ties, outwardly through concerns about other’s
Epidemiological Studies Depression (CES-D) scale welfare, and temporally by integrating perceptions
(Radloff, 1977) were significantly higher in depressed of one’s past and future to enhance the present”
individuals across time than were those of the men- (Reed, 1991b, p. 5). Self-transcendence was mea-
tally healthy. Strong relationships between DRLA sured by the newly developed Self-Transcendence
scores and subsequent CES-D scores indicated that Scale (STS), derived from the previously identified
developmental resources influenced mental health transcendence factor in the original DRLA scale.
outcomes in the healthy group; the reverse relation- The STS score was correlated inversely with both
ship found in the depressed group indicated that CES-D and Langner Scale of Mental Health Symp-
depression negatively influenced developmental re- tomatology (MHS) scores. The MHS is an index of
sources in terms of the ability to explore new out- general mental health on which higher scores indi-
looks on life, to share wisdom and experience with cate impairment in mental health in nonpsychiatric
others, and to find spiritual meaning. populations (Langner, 1962). In addition, the four
patterns of self-transcendence identified by partici-
In the second study, Reed (1989) explored the pants (generativity, introjectivity, temporal integra-
degree to which key developmental resources of later tion, and body-transcendence) were congruent with
adulthood were related to mental health in 30 hospi- Reed’s definition of the concept.
talized clinically depressed older adults (mean age,
67 years). Participants completed the DRLA and In summary, Reed’s three studies provided evi-
CES-D measures and rated the importance in their dence for her theoretical idea that self-transcendence
current lives of each developmental resource re- views and behaviors were, in fact, present in older
flected in the DRLA items. An inverse correlation adults. Data indicated that such views and behaviors
was found between the level of resources and depres- were strongly related to mental health. Thus, the find-
sion. Participants also reported that the resources ings supported a conceptualization of mental health
represented by the DRLA items were highly impor- in later adulthood that went beyond preoccupation
tant in their lives. In addition, key reasons given by with physical and cognitive declines and pointed out
participants for their psychiatric hospitalization were the importance of resources that expanded self-con-
congruent with self-transcendence issues significant cept boundaries in aging.
in later adulthood (e.g., physical health concerns,
relationships with adult children, questions about life Major Assumptions
and death).
Early in her theoretical work, Reed (1986a, 1987)
During the initial DRLA instrument development proposed a process model for constructing concep-
and testing, a factor labeled transcendence accounted tual frameworks that would guide nurses and nursing
for 45.2% of the variance in DRLA scores. In the sec- education in clinical specialties. In this model, health
ond study (Reed, 1989), the 15-item transcendence was proposed as the central concept, or axis, around
factor was also more highly correlated with the CES- which nursing activity, person, and environment
D than was the entire DRLA. Therefore, a recommen- evolved. An assumption of the model was that the
dation for future research was to examine further the focus of the nursing discipline was on building and
psychometric properties of the instrument, with a engaging knowledge to promote health processes.
goal to shorten the DRLA to facilitate ease of admin- Nursing
istration in clinical settings. The role of nursing activity was to assist persons
(through interpersonal processes and therapeutic
A third study explored patterns of self-transcen- management of their environments) with the skills
dence and mental health in 55 independent-living required for promoting health and well-being.
older adults (ranging from 80 to 97 years of age)
578 UNIT V Middle Range Nursing Theories self-transcendence must be expressed like any other
developmental capacity in life for a person to realize a
Person continuing sense of wholeness and connectedness.
Persons were conceived as developing over their life This assumption is congruent with Frankl’s (1969)
span in interaction with other persons and within an and Maslow’s (1971) conceptualizations of self-
environment of changing complexity and vibrancy transcendence as an innate human characteristic that,
that could both positively and negatively contribute to when actualized, gives purpose and meaning to a
health and well-being. person’s existence.
Health Theoretical Assertions
In the early process model, health was defined implicitly
as a life process of both positive and negative experi- There are three basic concepts in the Self-Transcendence
ences from which individuals create unique values and Theory: vulnerability, self-transcendence, and well-
environments that promote well-being. being (Reed, 2003, 2008). Vulnerability is the aware-
ness of personal mortality that arises with aging and
Environment other life phases, or during health events and life
Family, social networks, physical surroundings, and crises (Reed, 2003). The concept of vulnerability
community resources were environments that signifi- clarifies that the context within which self-transcen-
cantly contributed to health processes that nurses in- dence is realized is not only when confronting end-
fluenced through “managing therapeutic interactions of-own-life issues but also includes life crises such as
among people, objects, and [nursing] activities” disability, chronic illness, childbirth, and parenting.
(Reed, 1987, p. 26). Self-transcendence refers to the fluctuations in per-
ceived boundaries that extend persons beyond their
This metaparadigmatic approach to knowledge immediate and constricted views of self and the
development for a nursing specialty was innovative world. The fluctuations are pandimensional: outward
and foundational to Reed’s own future work with the (toward awareness of others and the environment),
concepts of spirituality and self-transcendence. Self- inward (toward greater insight into one’s own beliefs,
Transcendence Theory evolved from the perspective values, and dreams), temporal (toward integration of
that self-transcendence is one of many processes past and future in a way that enhances the relative
related to health, and the overall goal of the theory present), and transpersonal (toward awareness of
was to provide nurses with another perspective on the dimensions beyond the typically discernible world)
human capacity for well-being. (Reed, 1997b, 2003, 2008). Well-being is “feeling
whole and healthy, in accord with one’s own criteria
In her initial explication of the emerging Self- for wholeness and well-being” (Reed, 2003, p. 148).
Transcendence Theory, Reed (1991a) identified one The theory also allows for additional personal and
key assumption based on Rogers’ conceptual system. contextual variables such as age, gender, life experi-
This assumption was that persons are open systems ences, and social environment that can influence the
who impose conceptual boundaries upon themselves relationships among the three basic concepts. Interven-
to define their reality and to provide a sense of whole- tions would focus on nursing activities that facilitate
ness and connectedness within themselves and their self-transcendence.
environment. Reed (2003) reaffirmed this assumption
in a later publication, restating Rogers’ basic assump- Three major propositions of the theory were devel-
tion that “human beings are integral with their environ- oped from the three basic concepts. The first proposi-
ment” (p. 146). Self-conceptual boundaries fluctuate tion is that self-transcendence is greater in persons
in form across the life span and are associated with facing end-of-own-life issues than in persons not fac-
human health and development. Self-transcendence ing such issues. End-of-own-life issues are interpreted
was proposed as an important indicator of a person’s broadly, as they arise with life events, illness, aging, and
conceptual self-boundaries that could be assessed at other experiences that increase awareness of personal
specific times. mortality.
A second assumption identified in the later de-
scription of the theory was that self-transcendence
is a developmental imperative (Reed, 2003), that is,
The second proposition is that self-transcendence CHAPTER 29 Pamela G. Reed 579
is positively related to well-being (Reed, 1991a). 1 . Increased vulnerability is related to increased self-
Alternatively, decreased self-transcendence (as in the
inability to reach out to others or to accept friend- transcendence.
ship) is positively related to depression as an indicator 2 . Self-transcendence is positively related to well-
of decreased well-being or mental health. An impor-
tant refinement to Self-Transcendence Theory has to being and functions as a mediator between vulner-
do with the mediating effects of self-transcendence. ability and well-being.
Research results accumulated in the last decade indi- 3 . Personal and contextual factors may influence
cate that self-transcendence mediates the relationship the relationship between vulnerability and self-
between vulnerability and well-being. In other words, transcendence and between self-transcendence
self-transcendence is an underlying process or mech- and well-being.
anism that explains why people may attain well-being
when confronted with increased vulnerability. Logical Form
The key assumption about person-environmental Reed’s empirical middle-range theory was con-
process (Reed, 1991a) led the third and revised set of structed using the strategy of deductive reformulation
propositions by Reed in 2003. Personal and environ- to enhance understanding of the end-of-life phenom-
mental factors function as correlates, moderators, or enon of self-transcendence (Reed, 1991a). The logic
mediators of the relationships between vulnerability, used was primarily deduction, to ensure that the
self-transcendence, and well-being. middle-range theory was congruent with Rogerian
and life span principles. Analogical reasoning was
In summary, the 2003, updated Self-Transcendence also used to work from other theories of life span
Theory proposes the following three sets of relation- development, comparing psychology and nursing
ships (Figure 29–1): about human development and potential for well-
being in all phases of life. The key concepts of the
Self-Transcendence
Personal
and
Contextual Factors
Vulnerability Well-Being
FIGURE 29-1 M odel 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 persons with dementia (Acton & Wright, 2000) and
bereaved individuals (Joffrion & Douglas, 1994). Acton
theory are related in a clear and logical manner, while and Wright (2000) suggest arranging respite care for
allowing for creativity in the way the theory is ap- caregivers so that they have time and energy for transper-
plied, tested, and further developed. Reed’s strategy of sonal activities. Applications of creative-bonding art
constructing a nursing theory—from non-nursing activities to promote self-transcendence were used in
theories, a nursing conceptual model, research, and studies with nursing students and older adults (Chen &
clinical and personal experiences—piqued nurses’ Walsh, 2009; Walsh, Chen, Hacker, et al., 2008) and in
interest in the phenomenon of developmental matu- late-stage Alzheimer’s disease (Walsh, Lamet, Lindgren,
rity and provided impetus for further theorizing into et al., 2011). McGee (2000) suggested that recovery in
the variety of situations where awareness of personal alcoholism involves self-transcendence, facilitated by a
mortality occurs. nurse-designed environment that supports the 12 steps
and 12 traditions of Alcoholics Anonymous.
Acceptance by the Nursing Community
Education
The quest for nursing is to facilitate human well-being Self-transcendence is in the writings of nurse theorists
through what Reed calls “nursing processes,” of which who are influential in nursing education (Erickson,
self-transcendence is one example (Reed, 1997a). 2002; Erickson, Tomlin, & Swain, 1983; Newman,
Self-Transcendence Theory has been widely used in 1986; Parse, 1981; Rogers, 1970, 1980; Sarter, 1988;
practice, education, and research. Watson, 1979, 1985). These theories share a common
Practice view identifying self-transcendence as a foundational
Reed’s (1986a, 1987) process model for clinical specialty concept for the discipline. All levels of education may
education and psychiatric–mental health nursing prac- use the theory in courses to support care of the aging.
tice articulates relationships among the metaparadigm Guo, Phillips, and Reed (2010) supported the need for
constructs of health, persons and their environments, non-hospice nurses to improve their abilities and atti-
and nursing activity. Self-Transcendence Theory tudes toward older adults and their family caregivers
delineates specific concepts from Reed’s process related to end-of-life care. The art-activity with older
model: constructs of health (i.e., well-being), per- adults at community senior centers is designed to
son (i.e., self-transcendence), and environment (i.e., develop more positive attitudes in nursing students
vulnerability), and it proposes relationships among when caring for them (Chen & Walsh, 2009; Walsh,
these concepts to direct nursing activities. Reed Chen, Hacker, et al., 2008).
(1991a) and Coward and Reed (1996) have sug-
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
for nurses benefiting from self-transcendence atti-
Self-transcendence may be integral to healing in tudes and behaviors. Self-transcendence perspectives
many life situations. Nurse activities that promote the correlated with lower levels of burnout in hospice and
activities of self-reflection, altruism, hope, and faith oncology nurses (Hunnibell, Reed, Quinn-Griffin,
in vulnerable persons are associated with an increased et al., 2008) and with higher levels of work engage-
sense of well-being. Group psychotherapy (Stinson & ment in acute care nurses (Palmer, Quinn, Reed,
Kirk, 2006; Young & Reed, 1995) and breast cancer et al., 2010).
support groups (Coward, 1998, 2003; Coward & Kahn
2004; 2005) are interventions that nurse researchers Research
used to provide clients with opportunity for examin- A number of research studies provide evidence to
ing their values, for reaching out to share experience support the association between self-transcendence
with and help similar others, and for finding meaning and increased well-being in populations that typically
from their health situations. Others suggested similar are confronted with awareness of their own personal
strategies to facilitate well-being in caregivers of
mortality. The research studies related self-transcen- CHAPTER 29 Pamela G. Reed 581
dence to depression among elders (Reed, 1986b, 1989, failure (Gusick, 2008), liver transplant recipients
1991a). Other research reported similar relationships (Bean & Wagner, 2006), bullied middle-school boys
in depressed older adults (Klaas, 1998; Stinson & (Willis & Grace, 2011; Willis & Griffith, 2010), stem
Kirk, 2006; Young & Reed, 1995), middle-aged adults cell transplant recipients (Williams, 2012), and per-
(Ellermann & Reed, 2001), and individuals who lost sons with dementia (Walsh, Lamet, Lindgren, et al.,
loved ones from HIV/AIDS (Kausch & Amer, 2007). 2011). Kim and colleagues (2011) found interdepen-
Buchanan, Ferran, and Clark (1995) examined self- dence within Korean caregiver-elder dyads on self-
transcendence and suicidal thought in older adults. transcendence variables and well-being. Two other
Upchurch (1999) and Upchurch & Mueller (2005) reports examined the role of caregivers of end-of life
explored the relationship between self-transcendence older adults and reported a positive relationship be-
and activities of daily living in noninstitutionalized tween caregiver transcendence and well-being (Phillips
older adults. Two studies explored self-transcendence & Reed, 2009a, 2009b). Positive relationships among
and older adults’ perceptions of positive physical and transcendence and transformation and finding mean-
mental health (Bickerstaff, Grasser, & McCabe, 2003; ing were also described in women with chronic condi-
Nygren et al., 2005). Walton, Shultz, Beck, and Walls tions such as arthritis (Neill, 2002; Shearer, Fleury, &
(1991) identified an inverse relationship between self- Reed, 2009).
transcendence and loneliness in healthy older adults.
Decker and Reed (2005) found that integrated moral Intervention studies designed by nurses to promote
reasoning, completion of a living will, and prior expe- self-transcendence views and behavior documented
rience with a life-threatening illness were related to changes in self-transcendence and well-being. One
older adults’ desire for less aggressive treatment at the intervention, a Self-Transcendence Theory–based
end of life. support group, had a small positive effect on self-
transcendence and well-being in women with newly
A number of studies have demonstrated a positive diagnosed breast cancer (Coward, 1998, 2003; Coward
relationship among self-transcendence and well-being & Kahn, 2004). Young and Reed (1995) found that
or quality of life in persons with HIV or AIDS (Coward, group psychotherapy facilitated self-transcendence in
1994, 1995; Coward & Lewis, 1993; McCormick, a small sample of older adults. A personal narrative
Holder, Wetsel, et al., 2001; Mellors, Erlen, Coontz, intervention increased self-transcendence scores in
et al., 2001; Mellors, Riley, & Erlen, 1997; Sperry, 2011; women with HIV, multiple sclerosis, and systemic lu-
Stevens, 1999). Numerous studies have described pus erythematosus compared to women in a control
self-transcendence or related concepts in women with group (Diener, 2003). Responses of several people
breast cancer (Carpenter, Brockopp, & Andrykowski, with late-stage Alzheimer’s disease following a similar
1999; Coward, 1990, 1991; Coward & Kahn, 2004, 2005; simple art intervention evidenced self-transcendence
Farren, 2010; Kamienski, 1997; Kinney, 1996; Matthews and well-being (Walsh, Lamet, Lindgren, et al., 2011).
& Cook, 2009; Pelusi, 1997; Taylor, 2000; Thomas, A poetry-writing intervention for caregivers of older
Burton, Quinn-Griffin, et al., 2010). adults with dementia found themes of self-transcen-
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-
transcendence in caregivers of persons with dementia Reed has mentored a number of master’s and
as well as in caregivers of terminally ill patients who doctoral students in research on self-transcendence.
had died within the previous year (Enyert & Burman, Research results from these studies provide addi-
1999; Reed & Rousseau, 2007). Other populations tional empirical support for the theory and are cited
studied include healthy middle-aged adults (Coward, earlier in the chapter and listed in the bibliography.
1996), elderly men with prostate cancer (Chin-A-Loy
& Fernsler, 1998), female nursing students and faculty Further Development
(Kilpatrick, 2002), nurses (Hunnibell, Reed, Quinn-
Griffin, et al., 2008; McGee, 2004), homeless adults Reed’s initial conceptualization of self-transcendence
(Runquist & Reed, 2007), elders with chronic heart focused on later adulthood and identified the impor-
tance of personal resources that expand self-boundaries
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