疾病不确定感

疾病不确定感

UncertaintyinIllnessYoucannotbecertainaboutuncertainty.课程目标1.理解疾病不确定感的概念2.掌握疾病不确定感的来源3.掌握疾病不确定感在不同患者的表现形式4.了解Mishel疾病不确定感理论及测量方式5.通过文献，熟悉疾病不确定感的相关因素及干预措施6.通过影片欣赏，提炼出相关概念，并指出其与照顾患者的关系7.总结过往案例中，涉及处理患者不确定感的护理措施（星期五）疾病不确定感概念Budner(1962)最早提出：不确定感是一个人对某一件事或某一情景因缺乏信息，而无法给予恰当的分类或组织时产生的一种认知。后Mishel将其发展为theoryofuncertaintyinillnessMishel’s

Backgound1961withaBachelorsofArtsfromBostonUniversityGraduate1966withMasterofScienceinpsychiatricnursingfromUniversityofCaliforniaGraduate1976,1980withMastersofArts,DoctorateinsocialpsychologyfromClaremontGraduateschool,ClaremontCaliforniaDuringMishel’sdissertationresearchshedevelopedtheMishelUncertaintyinIllnessscale(MUIS)MishelandothershavedoneresearchusinghertheoryandtoolintheareasofBreastCancer,ProstateCancer,HeadandNeckCancer,andTraumaticInjuryPurposeofTheoryMeasurethedegreetowhichanindividualisexperiencinguncertaintyduringillnessoranacuteinjurywhenthepossibilityofrecurrenceandextensionexist.Theillnesscausesuncertaintythatspreadsintotheindividual’slifeandbreaksdowntheindividual’spointofviewandreality.Slowlyanewpointofviewisformed.Uncertaintyisthedrivingforceandisacceptedasreality.Nowtheindividualmayseethatmanyoptionsarepossibleasopposedtoonlyacauseandeffectparadigm.Nursesareanimportantpartofthisprocess.(Mishel,1999).疾病不确定感概念Uncertainty(Mishel,1988)isdefinedastheinabilitytodeterminethemeaningofillness-relatedevents,occurringwhenthedecisionmakerisunabletoassigndefinitevaluetoobjectsorevents,orisunabletopredictoutcomesaccurately.

Mishel

认为，疾病不确定感的概念模式是来源并应用于护理实践的，所以将其定义为：疾病不确定感是缺乏判定与疾病有关的事物的能力，是一种认知状态，伴随着与疾病有关的症状、诊断、治疗、预后而来，个体应对不确定感的关键在于采取适当的策略适应整个疾病过程。疾病不确定感模式(一)前置因子：产生不确定感的原因，包括刺激构架认知能力与构架的提供者(二)评价或认知过程：使用推论或幻想來评价不确定感为机会还是危险负向危机：多采取负向应对行为，如敏感，逃避，否认，焦虑，抑郁正向挑战：多采取正向应对行为，如调试，接受，寻求信息，改变行为，遵医行为好，适应角色，寻求社会或者宗教支持(三)采取应对策略以减低或维持不确定感(四)有效的应对已达适应疾病不确定感理论UntreatedUncertaintycanleadtofearofillness.Thismaybecharacterizedbyseveralmanifestations.Fearofrecurrencelossofcontrolofone’slifeemotionaldistressuseofinappropriatecopingmechanismslikeavoidancearealleffectsofuncertainty.Theseconditionsifnotaddressedwillleadtotheinabilityofthepatienttoformcognitivestructuresforillnessrelatedevents,poordecisionmaking,poorpsychologicaladjustment,andpossibleposttraumaticstresslikeresponses.疾病不确定感理论Uncertaintywasfoundtocomprisethreemainthemes:uncertaintybecauseof

limitedorlackofinformation,uncertaintyconcerningthecourseandtreatmentchoicesrelatedtothedisease,anduncertaintyrelatedtoeverydaylifeandcopingwiththedisease

(Shaha,Cox,Talman,&Kelly,2008).疾病不确定感理论Withuncertainty,thepatientcannotformacognitivestructureforillness-relatedeventsresultinginpoorerdecision-making,poorerpsychosocialadjustment,lowerqualityoflifeandpost-traumaticstress-likeresponses(Christman,etal,1988;Fuemmeler,Mullins,&Marx,2001).疾病不确定感理论Mishel&Braden（1988）在不确定感理论中提出：不确定感受到症状的形态，事件的熟悉度，事件的一致性，教育程度，社会支持，权威及认知能力的影响疾病不确定感理论ConceptDefinitionsinRelationshiptoUncertaintyinIllnessAmbiguity:Inthecontextofdiseasethenatureofit’sprogression,symptoms,onset,anddurationarecauseforuncertainty.Unknown:Inthecontextofselfrelatedtotheideaofthefuture,makinglong/shorttermlifeplans.Lackofinformation:Amajorsourceofuncertaintyforpatientsislackofinformationrelatedtotreatments,hospitalsystems,andillnessrelatedevents.疾病不确定感理论ConceptDefinitionsinRelationshiptoUncertaintyinIllnessSocialSupport:Influencesuncertaintybyassistingtheindividualtointerpretthemeaningofevents.ProbabilisticThinking:Abeliefinaconditionalworldinwhichtheexpectationofcontinualcertaintyandpredictabilityisabandoned.NewViewOfLife:Theformulationofanewsenseoforder,resultingfromtheintegrationofcontinualuncertaintyintoone’sself-structure,inwhichuncertaintyisacceptedasthenaturalrhythmoflife.(M.

H.Mishel,etal.,2002).疾病不确定感理论不确定感来源模棱两可的疾病状况复杂的治疗和照护系统疾病诊断和疾病严重程度等相关资讯的缺乏无法预测疾病的进展和预后（Mishel&Braden,1988）疾病不确定感理论不确定感表现包括：会重复，主动询问相关资讯抱怨身体症状次数增加设法延长与医护人员的接触对周遭刺激变得敏感不确定感通常伴有威胁感觉评估状况能力降低限制对危机情境控制感及无助感增加疾病不确定感理论刺激事件性质住院的次数疾病的形态所接受的检查及治疗不确定感的影响因素个人因素性别年龄教育程度人格特质成长背景生活经验信仰与价值观及个人对疾病与健康的信念疾病不确定感理论-特点Clarity:ClarityDespitethecomplexnaturethatuncertaintyplaysinapatient’sillnesstheconceptsofthismodelarepresentedclearlyandtheyareeasilycomprehended.Themodeltranslateseasilyintoclinicalandresearchpractice.Simplicity:SimplicityTheantecedentsofuncertaintyareconciseandtheirdefinitionsareclearandsimple.Theappraisalofuncertaintyisinitselfcomplex,butwiththeuseofthistheoryandtheMUIStoolitismadeeasier.Thecompletemodelalthoughnotsimpleiseasilymadeoperational.疾病不确定感理论Generality:GeneralityThetheorycanbeappliedtomanyareasofnursingpracticeandhasbeenusedbycliniciansforacuteandchronicillnesssuchascancer,cardiacdisease,andmultiplesclerosis.Accessibility:AccessibilityWithuseofthistheoryit’sbeenshownthatuncertaintyisindeedaphenomenathatpatientsexperience,andspecifieswhatareasoftheillnessmayberesponsibleforuncertainty.Withapplicationofthistheoryagoalofincreasedcopingmechanismsforpatientcomfortismadeattainable.疾病不确定感理论Uncertaintyisashiftingandenduringexperienceincancerandthefocusisonmanaginguncertainty,noteliminatingit(Mishel,etal,2002;Mishel,etal,2005).Thereareafewstudiesaboutinterventionstomanageuncertaintyeffectively.Literaturereview–Uncertainty疾病不确定感影响因素患者人口学特质疾病特点身体症状社会支持：物质支持、情绪支持、讯息支持、评价支持应对策略

陈先华等在研究中发现，急性心肌梗死病人的不确定感与逃避、听天由命、感情冲动、寻求支持4类应对方式有显著的正性关系，与面对、乐观、自我依赖3类应对方式有显著的负性关系，与掩饰应对方式没有显著性关系

Literaturereview–Uncertainty疾病不确定感与其他相关概念的研究

与生活质量的相关研究对乳癌患者的研究显示，疾病不确定感是影响患者生活质量的重要因素之一，且与生活质量呈负相关

孙玉姣等人对COPD患者疾病不确定感与生存质量的研究发现，疾病不确定感与生存质量呈负相关对肺癌患者的研究显示，疾病不确定感与生活质量中的躯体功能、情绪功能、认知功能、社会功能呈正相关，即对疾病相关知识越缺乏，越不了解，其生活质量中这四个功能越差Literaturereview–Uncertainty疾病不确定感与其他相关概念的研究与焦虑抑郁的相关研究对肺癌患者的研究显示疾病不确定感不明确性和不连贯性越高，患者焦虑抑郁水平越高与希望的研究

黄人珍等人更指出乳癌患者不确定感得分越高其希望状态越低与信息需求相关的研究孙红研究发现，对围手术期乳癌患者提供系统性的信息支持，能显著降低乳癌患者疾病不确定感。对围手术期冠脉介入患者的研究显示，提供有针对性的信息支持，能显著降低患者的焦虑和疾病不确定感水平。

Literaturereview–UncertaintyInterventionssuchaseducationself-carepromotion,anduncertaintymanagementhavebeensuggestedtohaveareducingand,therefore,positiveeffectsontheexperienceofuncertaintyinwomenwithbreastcancer.

(Wonghongkul,Moore,Musil,Schneider,&Deimling,2000),(Braden,Mishel,&Longman,1998)(Chen,Zhuang&Gao,2007).Onequasi-experimentalstudy,theexperimentalgroupwasgiveninformationalsupportaccordingtoinformationalsupportguideline．Therewassignificantlydecreasethemeanrankofuncertaintyinillnessscoresbothonthedaybeforeoperationandthedaybeforedischargeintheexperimentalgroup.

Sun,&Guo(2004)Literaturereview–UncertaintyAboveall,knowledgeandinformationaretheprimaryresourcesformanaginguncertainty.Theyenablethesurvivortointerpretthesituationandusuallybringclosuretotheuncertainty.Socialsupportisconceptualizedasoneoftheresourcesthatalleviatesuncertaintybyprovidingasolutiontotheproblemorchangingtheinterpretationoftheproblem.Oneofthebenefitsfromsocialsupportisthatithelpsthepatientreduceunpredictability

(Cohen,2004;Michael,Berkman,Colditz,Holmes,&Kawachi,2002).(Mishel,1997).Literaturereview–Uncertainty

疾病不确定感理论现已广泛地被应用在对癌症、心脏病和各种慢性疾病人群的研究中。在癌症人群中，此理论已研究了宫颈癌、肺癌、乳腺癌