When the patient has serious illness like cancer and came to the hospital and complaining from pain, anorexia and fatigue at this time what can he is suppose to do? The answer of this question is in the definition of palliative care.

What is palliative care?

Palliative care according to (World Health Organization [WHO], 2010) it is a medical profession stand up to helps the patients and families to come over the pain and other problems like physical, psychosocial and spiritual with life-threatening illness. This can be done by the prevention and relief of suffering and early assessment and treatment of pain.

Palliative care according to (Get palliativecare.org, 2010) “is provided by a team of professionals working together with your primary doctor. It is appropriate at any point in a serious illness and can be provided at the same time as treatment that is meant to cure”. Moreover, patient in the end of life can face and experience a host of distressing symptoms such as pain, dyspnea, and delirium are reported to be among the most feared and burdensome. Also, pain can be influenced by many factors, including the patient’s prior experience with pain, meaning given to pain, emotional stresses, family, and culture influences (Mcphee & papadakis, 2009).

(Mcphee& papadakis ,2009,p.70) stated that” the common problem for patients at the end of life up to 75% of patients dying of cancer is the pain and it is what people say they fear most about dying”. Therefore, nurses must be aware about the barriers to good care ,which including the lack of knowledge about the proper selection and dosing of analgesic medication ,limited training and clinical experience with pain management, addiction which can occurs if the patient and caregivers misused the medicines (Mcphee& papadakis, 2009).

In addition, there are 20 reasons can make the palliative care difficult to the nurses (Becker, 2010). I am going to mention some reasons;

Shortage of staff.

Shortage of nursing staff is one of the reasons which can make the palliative care difficult. In my experience in the hospital where I was working the staff nurses are in limited numbers , especially in the word the staff nurse can handle 9-12 patients some of these patients are having cancers and some time one staff nurse for 6 rooms each room has 5-7 patients!. Cancers patients cannot bear the pain and the staff nurse wants to do other work like inserting intravenous fluid for diabetic patient with hypoglycemia, so how the nurse can concentrate in doing that?

Here the staff has to prioritize her work, some staff nurses finding difficulty to do that. Therefore the hospital’s administration has to find and create a policy change in response to the nursing shortage as supported by Twigg , Duffield , Thompson & Rapley (2010). In addition to that, as Abrahm(2010) stated that due to shortage of staff palliative care in oncologists, intensivists, advanced cardiac, pulmonary, renal, and hepatic diseases needs to be improved.

Lack of knowledge of some medications and symptoms control.

There were 146 surveys distributed to care providers from multiple settings. Out 135 0f 146 reported that there are several problems can make the palliative care difficult like poor pain and symptoms control, lack of education for care providers as stated by Sellick , Charles , Dagsvik , & Kelley (1996)

The availability of clear polices in dealing with death issues.

In my experience only in some hospitals we can find clear polices in dealing with death issues especially brain death , this matter can involve many elements like; patient himself if he/she recommended before death if his/her brain died the caregiver can remove the supporting equipments, family according to the religion. So the staff nurse must be a wear about many religions. In understanding of the reasons and finding solutions to make the difficulties easier to the nurses can make too much improvement in quality of life.

Quality of life can be affected by the level of education in heart failure patients. Patients with high education level often can improve more than low education level which usually reported to care givers in bad physical and functional condition as supported by Barbareschi, Sanderman, Leegte, van Veldhuisen & Jaarsma (2011).

In addition, there are two factors are related to quality of life in heart failure patients, demographic and clinical. Also physical excises one of the main elements of disease management program. (Jaarsma, Johansson, Agren , & Strömberg ,2010)

I want to stress in one point from my experience I did not see patient with heart failure has been cured totally from the disease, so I think the palliative care can play role to help this patient to enhance his quality of life.

For example, one of the patients I was taking care of him he told me I am useless now!

So for this type of patients I have to help him to move this idea from his mind, and let him to understand that the life did not end yet and we are finding developments in medical field, and give him task and encourage him to do it, after of compilation I have to enhance the feeling which he can feel it and let him to understand that he is worthfull and useful.

Since I chose the heart failure I want to mention how the staff nurse can manage the pain in this case, which include:

Pharmacologic treatment: like angiotensin-converting enzyme inhibitors, β-blockers, diuretics, and possibly aldosterone antagonists and angiotensin receptor blockers (Lewis, Heitkemper, Dirksen, O’Brien & Bucher, 2007).

Diet and body weight: the recommended diet for these patients is low sodium diet to reduce body edema; recording upon admission body weight can detect the body weight if increased or no (Lewis et al., 2007).

Behavioral and lifestyle management: exercise/physical activity: as stated by Benetti, Araujo, & Santos (2010) exercises can improve the quality of life for heart failure.

Therefore, the nurses must promote home and community-based care by taking the responsibility and contribute in education of patient and involve him to implement the therapeutic procedure to improve the quality of life. “Teaching the patients and family how the progression of the disease is influenced by compliance with the treatment plan” (Johnson, 2008, p.428).

One of the most important points in improving quality of life as human being in my point of view is being opened to others .By this way the person can share other’s experience which can teach him/her something can change or improve the quality of life. In addition to that some patients need spiritual support which can make the life of some patients running in smooth way as supported by Hegarty , Abernethy , Olver & Currow (2011). Also, the quality of life can enhanced by the disable patients rehabilitation. As will as, mixing patients with disabilities in right and balance way can improve the quality life as supported by (Fadyl, McPherson & Kayes, 2011).

So how the caregivers can measure the quality of life?

The relationship among patients and families with caregivers can detect the quality of life as Hasson-Ohayon, Roe, Kravetz, Levy-Frank & Meir (2011) stated in their article. And, in my opinion quality of life is not easy to measure it because different criteria. The quality of life can make the measurement is so complicated, but generally speaking the improvement of individual health can indicate in quality of life.

Conclusion:

The palliative care profession is can plays important role in professional health’s fields by helping the patients and families to understand the serious illness and how to manage and improve the quality of life .By educating the nursing staff and they must be in university level in both arts and sciences (McEwen & wills’s, 2007). As deeply supported by Henderson theory which stressing on the important of education for the nurses. In addition to that the caregiver should try their best to improve the quality of life which can lead to improve the palliative care, by understanding each individual is unique in many aspects and trying to deal differently accordingly. The hospital’s managers should understand the teamwork’s conflict and create polices to solve the shortage of nursing staff can enhance the palliative care to reach to optimal quality of patient’s life.

Above given is a case study of on lifestyle health intervention. It is main case study for the following essay. The essay can be a It shall be a critical analysis of intervention`s design, delivery and those evaluation methodologies, which were being utilized for data gathering or desired outcome measuring the specified study. for this study. A critical discussion (in the light of relevant theories) of activities during developmental phase to evaluation phase of a health intervention shall be the topic of this essay— move this line above the previous line..

For discussion, the essay is being divided into three parts. Part one highlights introduction and rationale for the choice of study. The second part explores and critically analyse the key features of the intervention`s methodology, design, and delivery by comparing it with other comparators and relevant literature. Final part covers evaluation methodologies employed to measure the desired outcomes of intervention, includes data collection for measuring outcome, process and fidelity of implementation.

Sedentary behaviour is an unhealthy lifestyle. Spending more time in front of computer, TV viewing, video games playing, also not participating in outdoor activities (playing games), inactive parents who also do not support or help their children to be active, bad weather, and lack of insufficient health education in schools and communities are not only helping factors for enhancing this sedentary behaviour but the blame also goes to those cultural environments which promote physical inactivity and excessive eating. Because of this unhealthy lifestyle obesity is growing rapidly in UK. Childhood obesity is dangerous because it tracks into adulthood. In boys and girls aged 2-10 years, obesity increased from 10% in 1995 to 17% in 2005; further 16% boys and 12% girls are overweight (HSE, 2005). Data from National Child Measurement Programme showing that in England 13% children of aged 4-5 and 14.3% children of aged 10-11 are overweight; further 9.6% children of aged 4-5 years and 18.3% children of aged 10-11 are obese. It is very clear that unhealthy lifestyle plays an important role in the development and maintenance for obesity (NCMP/2008).

“Improving lifestyles is thought to be one of the most effective means of reducing mortality and morbidity in the developed world. However, despite decades of health promotion, there has been no significant difference to lifestyles and instead there are rising levels of inactivity and obesity” (Kathryn Thirlaway, 2008). In UK even majority of adults 37% of men and 25% of women are meeting the government target of at least thirty/30 minutes of intense physical activity for five/5 days per week but still there is a considerable public health burden due to physically inactive people. Every year more than 356,000 people are dying due to different cancers and cardiovascular diseases. Physical inactivity is not only responsible for this death toll but is one of major cause (Steven Allender et al, 2006). According to chief medical statement “physically active people can reduce up to 50% risk of having any major disease like cancer and cardiovascular diseases but they can also prolong their lives up to 20% to 30% (D.O.H, 2004). Unhealthy lifestyle has become a public health problem because of its association with major diseases. This is the reason for promoting healthy lifestyle different governments in United Kingdom have been introducing different interventions. In policy forms and in different schools and community based settings. “Healthy weight, healthy life”, child measurement programme, change 4 life, and in past “LEAP project” (Local Exercise Action Pilots), changes in schools curriculum for making physical activities and health education compulsory, providing healthy meals in schools and the most recent policy over salt usage are some of the great examples.

To tackle above mentioned catastrophe there is an acute need of intervention. According to government policy for health promotion, an evidence based strategy for promoting healthy lifestyles is underpinning with national and local health improvement policies. Any intervention that can help in preventing obesity should be given high value. Because it is well known, in the absence of any intervention 50% of obese children will become obese adults (National audit office London, 2001).

By following the health promotion principle of “enabling people to increase control over their health and its determinants, and thereby improve their health” (W.H.O 2005), many theories explain health behaviour and a change in health behaviour. Health Belief Model (HBM), Theory of Reasoned action, social learning and Transtheoretical (stages of change) Model, theory of health education are the examples. All of them are underpinning the practise of health promotion. Understanding of these theories is very essential while developing or designing health behaviour change intervention as the “theory is logical place to begin” (John kemm et al.) and theories provide bases for study design. National Institute of Health also argues that ” a theory is a systematic way of understanding events or situation” and ” needs to be applicable to broad verity of situation”, (NIH, 2005). This mean theories provide bases and a structure of knowledge can be built upon. For example theory of health belief model by focusing on individual`s perceptions of benefits and threats to his/her health further explains that a person`s attitude is determined by his/her knowledge and on that bases he/she acts. This means that, when person gain knowledge about something that influence the attitude and on that basis a change (step wise) in his/her actions occur. Therefore, theoretical understanding of change while developing intervention is also very important. For example, for this study (MAGIC) the concept of enhancing physical activity was being derived by the theory of health belief model (HBM) and by adopting health education model approach, an attempt of behaviour change among school children was being made. The MAGIC example is reflecting that for the study the theory of health belief provided a base and on that a health education model was being built. Basically, by following health promotion principal the “MAGIC” programme was being designed to promote healthy lifestyle with the help of health education.

Using scientific research as a base for developing sound practices in public health is called evidence based approach, which integrates research and practice (Liz Trinder et al. 2000). Was there any need for developing an intervention to improve physical activity among young children? Is MAGIC program evidence based? These questions can be answered by evaluating an intervention at developmental stage. For example, a literature search (systematic review and meta-analysis) for gathering the relevant evidences had been conducted for MAGIC programme. For the purpose researchers had set an inclusion and exclusion criterion for similar case studies to conduct a systematic review and that is systematic way of evidence finding. It was very important to search for those evidences which would help them in not repeating those mistakes while developing a design which had been causing failure previously. Therefore, it was very important to know what had been done so for. What kind of methods and designs had been used or what was already known about similar interventions and what needed to be done more or different. So the evidence based strategy can be adopted from different perspectives, of a researcher`s like creating hypothesis and design building which further maximise the strength of design and can even helpful in programme delivery. A logical model can be built on the bases of evidences which further can forecast the outcome of an intervention.

UNCERTAINTY IN ILLNESS THEORY

MIDDLE RANGE THEORY ASSIGNMENT

BY


STEPHANIE MORRIS

Background and credentials

Merle Mishel strives to enhance patient outcome and care during uncertainty by identifying uncertainties and addressing them. Mishel has a Bachelor of Science degree in nursing from Boston University and Master of Science in nursing from the University of California. She also has a Master of Arts degree in psychology and a postgraduate degree in psychology (Bailey & Stewart, 2014). Mishel had an experience with uncertainty via her father. Mishel’s father had colon cancer and his experience influenced her to develop the theory of uncertainty in illness. Mishel’s father was not able to understand what was happening to him and was unable to cope with the disease. Mishel’s father tried to control some aspects of his life while dealing with uncertainty of his disease. Mishel started focusing on uncertainty after she began her doctoral study in psychology. Her dissertation focused on the development of uncertainty measures and testing of the measures (Polit & Beck, 2008). She developed the theory of uncertainty in illness to understand how patients can deal with uncertainty caused by their illness. Mishel described the patients experience as ambiguity over uncertainty. She developed a scale to test perceived ambiguity in illness and later renamed the scale to Mishel Uncertainty in Illness Scale (MUIS) (Bailey & Stewart, 2014). Middle range nursing theories provide clear guidance for nursing practice and they are less conceptual and abstract as compared to other theories (Alligood, 2014). The uncertainty in illness theory is considered a middle range theory as it fits into the definition above. Mishel used scientific and empirical evidence to develop the theory and the MUIS tool (Bailey & Stewart, 2014).

Theoretical source and empirical evidence

Mishel used empirical and scientific evidence to develop the theory. Study findings on uncertainty were used to develop the antecedents of the uncertainty in illness theory. Research in cognitive psychology and uncertainty in diseases was useful in developing the antecedent concept. The appraisal concept was developed utilizing clinical data and discussion with friends. Clinical data showed uncertainty was a preferred state in some situations. She also used empirical evidence on stress and coping to develop the theory (Liehr & Smith, 2014).

Primary sources

Mishel used different sources to develop the theory of uncertainty in illness. She combined research in different areas including managing dangerous events, cognitive processing and uncertainty. She used studies published before on stress and coping that examined uncertainty as a stressful event. She reevaluated her previous concept and used existing models from Warburton (1979). She used various different other studies and research such as Budner’s (1962) study which analyzed a certain event as the cause of uncertainty. Mishel significantly considered the stress-coping-adaptation method of Lazarus and Folkman (1984) in her theory. (Bailey & Stewart, 2014). These theorist’s views influenced how she viewed uncertainty as a cognitive state instead of an emotional response, and helped her to examine uncertainty as a complex cognitive stressor.

Basic considerations

The main concept in the theory of uncertainty of illness is uncertainty. Uncertainity is the lack of ability to determine the meaning of events related to a disease. For instance, patients are unable to determine the outcomes correctly and assign value. Another concept is cognitive schema. Cognitive schema is an individual’s subjective interpretation of events related to the disease. There are three major themes related to the concepts identified above (Polit & Beck, 2008). They include antecedents of uncertainty, appraisal of uncertainty and coping with uncertainty. Antecedents of uncertainty refers to things that happen before the disease experience that impact the patient’s thinking. They include pain, perception and earlier experiences. Appraisal of uncertainty entails placing value on the uncertain circumstance. Coping with uncertainty refers to activities the patient uses to deal with the uncertainty (Liehr & Smith, 2014).

Mishel has discussed the metaparadigm concepts in her theory including the environment, health, nursing and person. A person is an individual who experiences uncertainty in diseases. The uncertainty affects interpersonal relationships as the body changes. The environment refers to the healthcare environment where the theory is applicable. Uncertainity caused by diseases affects a patient’s health and patients should develop coping mechanisms to cope with the uncertainty. Healthcare professionals use MUIS tool to identify areas of the disease that are causing uncertainty. Then they address the areas to help the patient develop coping mechanisms that will enhance his health. Nursing is aimed at helping patients and families comprehend uncertainty in diseases and learn new ways of life. Nurses play a critical role in helping patients understand uncertainty in diseases and cope (Liehr & Smith, 2014).

Mishel made various assumptions when developing the theory. She assumed uncertainty is a cognitive state that represents insufficiency of a current cognitive schema to support the interpretation of events related to a disease (Polit & Beck, 2008). Besides, she assumed that uncertainty was a neutral experience not harmful until it is appraised as harmful. She also assumed that individuals can cope with uncertainty in diseases and hence improve their outcome and quality of life. She also claimed that people do not function in an equilibrium state and they need time to concentrate on self. Thus, they are unable to incorporate the uncertainty into their view of life if there is not enough time (Liehr & Smith, 2014).

The uncertainty in illness schema consists of different themes related to the main concepts. The themes are antecedents of uncertainty, appraisal of uncertainty and coping with uncertainty. The antecedent theme comprises of stimuli frame, structure providers and cognitive capacity. Stimuli frame refers to the form and structure of the stimuli an individual perceives. The stimuli frame consists of symptom pattern, event knowledge and event congruence (Polit & Beck, 2008). Symptom patterns imply the extent to which symptoms have a pattern. Event familiarity is the extent to which a situation has recognized cues. Event congruence implies the consistency between the expected disease related events and the events experienced. Cognitive capacity and structure providers impact the stimuli frame. Cognitive capacity refers to a person’s ability to process information (Liehr & Smith, 2014).

Logical Form

The development of nursing theories should follow a logical process and must be in line with the underlying objectives (Polit & Beck, 2008). Concepts and sub concepts should be clearly stated and described consistently without ambiguity. The uncertainty in illness theory is well developed as the concepts are clearly presented and easily understood. After Michel reexamined her concept in 1990 the uncertainty of illness theory became deductive due to her using qualitative studies and chaos theory. These research studies lead her to change the direction of the theory. The theory now states that people’s uncertainty is always changing due to major life events and illnesses (Bailey & Stewart, 2014).

Relationship to Research, Education and Advanced Practice in Nursing

The theory of uncertainty in illness can be applied in different areas including education, nursing research and advanced nursing practice. The theory is used in advanced nursing practice to address uncertainty in different diseases and hence patient concerns regarding their diseases. This improves their outcome and quality of life. Patients learn how to cope with uncertain events by understanding the disease process. The theory can be applied in nursing research as it helps researchers understand experience of patients with chronic and terminal diseases (Polit & Beck, 2008). The uncertainty in illness theory has been used in studies that focus on uncertainty related to cancer to understand sources of uncertainty in the population how to resolve them. It also used in education to equip nursing students with knowledge and skills required to understand disease uncertainty and coping mechanisms.

Implications

The uncertainty in illness theory has implications on advanced nursing practice. The theory influences caring of patients as it permits nurses to offer information to patients and families with uncertainty about the disease. Nurses are supposed to provide support to patients and families with uncertainty about their diseases. As a result, patients become emotionally and physically healthier and have strength to cope with the disease. The empowerment offered to patients and families enables them view life differently and increases quality of life (Liehr & Smith, 2014).

The uncertainty in illness theory can be used to care for a cancer patient the theory is useful in helping a cancer patient cope with the disease and eliminating uncertainty. Cancer can lead to stress because of the uncertainty around the disease, treatment and side effects. Cancer patients are unable to understand events related to the disease and these results to uncertainty and negatively impact their health. The theory can be used to help the patient understand the disease situation and make meaning and thus participate in the plan of care. Therefore, the theory is useful in educating the patient about cancer and addressing their concerns (Liehr & Smith, 2014).

Summary

Merle H. Mishel’s theory of Uncertainty in Illness was initially focused on the person’s ability to resolve uncertainty. Although, she reevaluated and added the notion that uncertainty may never resolve, but will become part of the person’s identity and affect their perceptions and quality of life. The uncertainty in illness theory is essential in transforming patient care and experience. The theory helps patients understand uncertainty related with their illness and address the causes of uncertainty. They developing coping skills and hence are able to cope with the disease. The concepts are clear and well described. The theory can be used in nursing practice, nursing research and education as it is easy to understand and apply.

References

Alligood, M.R. (2014).

Nursing theorists and their work.

(8

^th

ed.) St. Louis, MO: Mosby Inc.

Bailey, Jr., D. E., & Stewart, J. L. (2014). Uncertainty in Illness Theory. In M. R. Alligood, Nursing Theorists and Their Work (8th ed., pp. 555-573). St. Louis, MO: Elsevier Mosby.

Liehr, P.R.., & Smith, M. J. (2014).

Middle range theory for nursing

. New York, NY: Springer

Polit, D.F. & Beck, C. T. (2008).

Nursing research.

Philadephia: Lippincott Williams and Wilkins

Appendix A: Schematic