Identity of the Concept
The uncertainty concept in nursing, and in fact in medicine as a whole, is one that is ever present. Because medicine deals with human beings in an ever changing environment even the most mundane cases can suddenly become something entirely different. Every human being is unique, and even from minute to minute, the facts of any case are subject to change so there is really no such thing in medicine as certainty.
Therefore, the concept of uncertainty is dealt with historically in nursing by categorizing the relative uncertainty of any case. From day to day there will be a range of uncertainty of cases from minimally uncertain to totally uncertain. Over time during a nursing shift these categories will change also. For example, a newly arrived trauma patient in the emergency room upon arrival will have a gradation of total uncertainty until the initial examination and analysis of finding is done. The triage nurse will then assign a preliminary rating of urgency for treatment, delegate tasks, and note the initial prognosis which contains the relative uncertainty of the case.
The uncertainty factor in nursing is of primary importance for several reasons. It is this initial factor which drives the necessity for testing, treatment, and analysis. The uncertainty concept in medicine dictates the need for practitioners who are adept at using it to their advantage while coping with the stress it causes. No machine or artificial intelligence could possibly cope with all the possibilities this uncertainty presents in even the most average case. Yet, the skilled practitioner has already devised alternatives, even while assigning diagnostic and treatment tasks. Most members of the team will be aware of this and, having anticipated at least some of the alternatives, be ready to act as circumstances change. The need for constant research is driven also by the uncertainty concept. The more we know for certain, the lower the factor of uncertainty will be for any given case.
Isolating Questions of the Concept
Because uncertainty is always present, unless the patient the dies, the questions which define this concept concern a degree rather than its existence or non existence. On the charts it is noted as prognosis though it is generally lacking an actual percentage point of degree. Any given case could be identified with a percentage of uncertainty by checking with statistics of identical or very similar cases. (Schlitch 2004) However, during the day to day operation of any treatment center this neither practical nor useful. These degrees of uncertainty are however, often expressed in research papers by quoting statistics concerning the relative values and efficacy of various cases in given identified classes of cases. This research can then benefit those practitioners who have the time an inclination to read it.
The questions, therefore, which isolate this concept would ask for probability that any given treatment would result in a given outcome. For example, given a young healthy patient with a compound of the ulnar bone, the question would be ‘what is the probability of complete recovery given the treatment of setting this bone and applying a cast?’. In this case the number would be above 99%. It is the uncertainty factor which prevents it from being 100%. As Wilson (1963) said these questions are rarely in their pure form. However, in research statistics can be used to derive a more exact questions and answers.
The only other question found was whether or not the concept was real or perceived. Penrod (2007) gives reasons that it is actually both. The reality cannot be changed, but the perception can.
The ‘Right’ Answers
It is interesting to note while most questions do not have a single right answer, questions concerning the uncertainty concept have no right answers, because of the nature of the content. We can get closer to a right answer in research using documented statistics. However, documented statistics cannot possibly include all cases, and therefore cannot eliminate uncertainty. (Markova 2000).
The word ‘uncertainty’ is commonly defined as the inability to establish an absolute known outcome. Certainty can be applied to such things as mathematics, some scientifically proven theorems and semantically perfect philosophical phrases. However. This is only true if shared definitions are identical. Medicine is often described as an art rather than a science. It is the concept of uncertainty that is responsible for this.
Given a case of a middle aged adult who is of average weight, has never smoked, and engages in the recommended amount of physical activity for good health, one might assume that a simple appendectomy is certain to correct a sever attack of acute appendicitis, with no side effects, and an absolute probability of no recovery. However, one interesting statistic shows that.5 % of all surgeries under general anesthetic results in complications, therefore the uncertainty concept applies. There is.5% possibility of complications due to general anesthesia. When all other conditions contained in the operating room environment the uncertainty factor of this case rises.
Given the same operation for the same condition in a seventy-two old male who is a heavy smoker that uncertainty factor will rise dramatically. Just considering the complications arising from anesthesia the statistics for complications for older patients and smokers is much higher. Therefore, the team knowing that these factors are present will have created alternative actions to deal with the possibility of complications due to general anesthesia.
After considering the idea of a contrary case to illustrate the opposite of the uncertainty concept no such cases were found involving living people. Logically as long as the patient is living the outcome is uncertain. The degree of uncertainty may be for all practical purposes, an imaginary number. The only exception might be involving an action that has a 100% chance of killing the patient. In a laboratory setting it is theoretically possible to set up experiments close enough to identical to define the results as long as all described parameters are met.
In practice, medical teams consider the uncertainty factor when planning treatment. Generally, incoming heavy trauma patients are given the most common treatment for the observed conditions, because no treatment or delayed treatment is considered to have a miniscule uncertainty for survival of the patient. One common example of this is supplying blood plasma in the case of heavy bleeding. It is known that a certain amount of loss of blood will kill the patient. It is also known that providing the fluid plasma to replace the lost blood is almost certain to be safe. So, one might say that there are also certainty factors that are considered in all medical treatment. The uncertainty concept dictates that even these have some measure of uncertainty.
After long considered, examination of this idea it was determined that the only borderline cases would involve unknown factors. For example, a patient known to have been exposed to a deadly biological poison in sufficient amounts for his age, weight, and health to cause death might be a borderline case if that patient had been administered the antidote to that poison elsewhere unbeknownst to the team. This patient might be considered uncertain to survive to a high degree should the hospital not have access to the antidote. Does the uncertainty concept apply in this case or not? The answer would depend upon the perspective of the questioner. This is an invented case which clarifies border line cases for this concept. Invented cases may also be created by practitioners using known criteria to apply to a currently unknown case in order to estimate its degree of uncertainty.
The social context of the uncertainty concept in medicine has historically developed methods for more accurate measurement of degree and for dealing with the social costs. That is, medical organizations have refined methods of assessing risk in order to help their practitioners to make more useful treatment programs. In addition, in recognition of the uncertainty concept these same organizations have devised ways of dealing with unexpected outcomes. Indemnity insurance for both organizations and individual practitioners is one example of dealing with the risk. The third way organizations deal with the uncertainty concept is by identifying the impact upon the social environment of the organization and of the individuals which comprise it. One example is that many organizations provide psychological counseling, stress management, and funding for upgrading skills for their members. These measures can help the medical practitioners deal with unexpected outcomes and pressure which accumulates due to the uncertainty factor. In this way the organization provides support to deal with the uncertainty concept.
Penrod (2007) found that, “One’s sense of confidence and sense of control are primary essences that determine the nature of the experience of uncertainty. The experience of living with uncertainty is dynamic, with fluctuations in the types and modes of uncertainty in response to precognitive and cognitive ways of knowing. Probabilistic paradigms preclude existential and situational modes of uncertainty for which probabilities cannot be appreciated.”
The anxiety underlying all medical treatment is a constant factor for medical practitioners. By identifying the degree of uncertainty much of this anxiety can be allayed. An interesting parallel which illustrates one possible danger in precisely identifying the degree of uncertainty is the practice of long distance drivers of making frequent changes of body position, eye focus, background noise, and speed in order to prevent highway blindness. In other words, medical teams must keep in mind that a.0125% degree of uncertainty is not equal to absolute zero. While this is insignificant in estimating a profit it can become extremely in estimating probable outcomes of medical treatment. The mistake in estimating a profit may throw future financial forecast off and result in slight disappointment or slight elation in the finance department. In the medical field such small mistakes may result in burying the patient. However for all practical results medical practitioners have learned to use the uncertainty concept to support decisions for medical treatment when there is no standard norm.
The Uncertainty Concept is also a reality for patients, and strategies should also be developed to help them and their families deal with this factor. The concept of uncertainty has been often applied to patients and families living with chronic illness. “Mishel’s (1999) early work in uncertainty began in patients with gynecologic malignancy. Her major focus has remained on patients with cancer, but the causes of uncertainty have been studied in populations of patients with rheumatoid arthritis, asthma, and AIDS….Mishel (1988) defined uncertainty as the inability to determine the meaning of illness-related events because of a lack of sufficient cues that allow patients to assign value to objects or events and accurately predict outcomes.”
The uncertainty concept in medicine underlies all treatment and drives the need for meticulous research. Because there are no palatable alternatives to creating treatment based upon the known or calculated degree of certainty for a given outcome the uncertainty concept is ever present in medical practice. The old adage as long as there is life there is hope, holds especially true in medical practice. It is the degree of hope that governs medical treatment. The concept of uncertainty is express as a prognosis, which generally does not include actual figures, but is usually in more general terms such as “there is a high degree of …” In laboratory settings and controlled research percentages are used to express the uncertainty concept.
Medical organizations and practitioners have learned to base their actions upon the known uncertainty degree. Organizations have learned to supply support for medical personal because the uncertainty concept is constant in their practice. This is known to raise stress levels and create legal and social problems. In medical practice, there is no alternative to uncertainty.
Schlitch, Thomas, 2004, Objectifying Uncertainty:History of Risk Concepts in Medicine, Topoi, Springer Netherlands, Vol. 2. Number 2, pp211-219.
Penrod, Janice, 2007, Living with uncertainty: concept advancement, Journal of Advanced Nursing, Volume 57, Number 6, pp. 658-667(10) Blackwell Publishing, Web.
Elphee , Erin Elizabeth , 2008, Understanding the concept of uncertainty in patients with indolent lymphoma, Oncology Nursing Forum, Web.
Mishel, M.H. (1988). Uncertainty in illness. Image: Journal of Nursing Scholarship, 20(4), 225-232.
Mishel, M.H. (1990). Reconceptualization of the Uncertainty in Illness Theory. Image: Journal of Nursing Scholarship, 22(4), 256-262.
Mishel, M.H. (1999). Uncertainty in chronic illness. Annual Review of Nursing Research, 17, 269-294.
Mishel, M.H., & Braden, C.J. (1987). Uncertainty. A mediator between support and adjustment. Western Journal of Nursing Research, 9(1), 43-57.
Mishel, M.H., & Braden, C.J. (1988). Finding meaning: Antecedents of uncertainty in illness. Nursing Research, 37(20), 98-103, 127.
Markova, E.V., 2000, The Concept of Uncertainty in Measurements: Pro and Con, Measurement Techniques, Vol. 43, Number 5, 2000, pp 391-393.