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Advances in Nursing Science Vol. 38, No. 1, pp. 55–67 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
The Health Change Trajectory Model An Integrated Model of Health Change Deborah Christensen, BSN, RN Health and illness fluctuate across a person’s life span, and various theories have been developed to address the unique perceptions and situations that accompany these fluctuations. An innovative model of health change resulted from a synthesis of the major concepts from 2 such theories: Mishel’s uncertainty in illness theory and the Corbin and Strauss chronic illness trajectory framework. The proposed integrated model, the Health Change Trajectory Model, provides original conceptual definitions that operationalize trajectory framework in the context of changes in health. The use of a health trajectory perspective extends applications of the model to a wide range of health changes that result in uncertainty and ambiguity. Key words: concept synthesis, Corbin, health, health change, illness, Mishel, nursing, Strauss, trajectory, uncertainty
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HANGES in a person’s health—from the onset of fatigue to a chronic illness or a life-threatening disease—result in unique perceptions of uncertainty. When viewed in the context of health, questions causing doubt or uncertainty will vary from “How long will my head hurt?” to “Am I going to survive?” Because nurses care for persons at diverse points along their health trajectory, an understanding of the lived experience of uncertainty and
Author Affiliation: Loyola University Chicago, Chicago, Illinois. This work is supported by 125362-GSCNP-13-348-01SCN from the American Cancer Society. Special thanks to Nola J. Pender, PhD, for her encouragement and confidence that this work had potential and merit to the nursing community. It is not often that a student finds a mentor of such caliber and dedication. The author has disclosed that he (she) has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Deborah Christensen, BSN, RN, 1155 W. Bloomington Dr. S. #5, St. George, UT 84790 ([email protected]). DOI: 10.1097/ANS.0000000000000061
its effects on health and well-being is essential to quality care. Mishel’s uncertainty in illness theory and the Corbin and Strauss chronic illness trajectory framework are 2 empirically tested theories addressing health experiences and related transitions. However, both theories were conceptualized within an illness framework. With global emphasis on the promotion of health and prevention of illness, reframing the phenomena of uncertainty and trajectory in the context of health appears timely. Persons deal with diverse changes in health throughout the life span. With an aging population, these changes are often chronic in nature and persist over time. Nurses are the key health care providers who assist persons in understanding and coping with health changes. To provide nurses with a model to address uncertainty at various points in the health trajectory and plan appropriate interventions, a concept synthesis was performed to integrate and reframe the 2 theories. In this article, I present a new integrated model, the Health Change Trajectory Model, and offer suggestions for application of the model in nursing research, education, and practice. 55
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HISTORICAL DEVELOPMENT Earnest study of theory requires an understanding of the influences and research methods used by the theorists. Glaser and Strauss1 propose that the adequacy of a theory and the process used to create it are tightly interwoven. In addition, multiple perspectives of a theory are useful in understanding and evaluating how the theory can be used in research and applied in practice. As medical advances continue and life expectancy increases, theories related to changes in health and disability adjustments must evolve. Integrating the Corbin and Strauss trajectory framework with uncertainty in illness results in such a theory with application to diverse experiences of health change.
OVERVIEW AND EVOLUTION OF THEORIES Merle Mishel’s curiosity around uncertainty, which she initially deemed ambiguity, began with an experience she had with her father after he was diagnosed with colon cancer. She describes visiting with her father in the hospital shortly after his diagnosis and being puzzled when he asked to have his ears cleaned. After contemplating his request, she determined that the ambiguity around his diagnosis caused him to focus on something that he was certain of such as feeling the difference from before and after his ears were cleaned.2 Thus began Mishel’s journey into the concepts and antecedents around uncertainty in illness. Intellectually, Mishel’s background was in nursing and social psychology; these 2 factors shaped her perceptions and conceptualizations of the uncertainty of illness theory. The original theory, published in 1988, was inductively constructed from grounded theory framework. Other theories and scholars that Mishel used to shape her theory were as follows: information processing, Warburton (1979); personality research, Bandar (1962); and coping and stress, Lazarus and
Folkman (1984). Critical social theory and chaos theory influenced the reconceptualization of Mishel’s theory in 1992. Since its inception, the uncertainty of illness theory has been used in research design; as a result, evidencebased nursing interventions have been developed and put into practice. This is an example of the reciprocal nature of theory and practice—practice and theory. During her graduate studies at San Jose State University, Juliet Corbin, also a nurse, was greatly influenced by Anslem Strauss and grounded theory. Corbin enrolled at the University of California San Francisco to pursue doctoral studies where she studied and later worked with Strauss and other renowned scholars and theorists.3 Corbin’s experience as a nurse immersed in sociology research provided the foundation for developing a framework for observing illness across a continuum. During the time Corbin worked with Strauss, they inductively conceptualized and subsequently tested trajectory framework using qualitative research methods.4
UNCERTAINTY IN ILLNESS THEORY Mishel5(p256) describes uncertainty as: “The inability to determine the meaning of illness related events; this occurs in situations where the decision-maker is unable to assign definite value to objects and events or is unable to accurately predict outcomes because sufficient cues are lacking.” Mishel’s original theory was constructed around 4 categories: (1) antecedents that contribute to the perception of uncertainty, (2) uncertainty appraised as neutral, a threat, or an opportunity, (3) problem-focused and emotionfocused coping, and (4) adaptation.5,6 Illness severity, historical assumptions around an illness or disease, information or lack of information provided by health care professionals, and personal beliefs all affect a person’s perception of uncertainty.7 Mishel and Clayton7 further proposed that until a person assigns meaning to the experience, uncertainty is fundamentally neutral. Inference
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An Integrated Model of Health Change and illusion are appraisal processes used to confer meaning to uncertainty; consequently, inferred meanings, based on historical experiences around a situation, can elicit appraisal as an opportunity or danger. Once uncertainty is appraised as a threat, people mobilize resources to subdue the associated stress. Interestingly, when uncertainty is seen as an opportunity, efforts are made to maintain uncertainty. For example, when a prognosis is grim, uncertainty can inspire hope and lead to improved coping. Initially, Mishel5(p258) ascertained that uncertainty as opportunity was reserved for situations with a negative trajectory; she states: “When the alternative is negative, uncertainty becomes the preferred state.” Problem-focused and emotionfocused coping strategies that people use to mitigate uncertainty are also described in the theory. Seeking social support and emphasizing the positive are seen as problemfocused coping behaviors whereas cognitive avoidance, distraction, and wishful thinking are characteristic of emotion-focused coping methods.8 Mishel originally envisioned adaptation as being the final step in a linear view of stress→coping→adaptation. Ultimately, adaptation was viewed as the desired outcome of effective coping strategies.9
RECONCEPTUALIZATION OF UNCERTAINTY IN ILLNESS THEORY Mishel began to question the relevance of the original theory when studied in the context of chronic illness. Cultural views of uncertainty also prompted Mishel to reconceptualize the theory. From a critical social theory perspective, Mishel5 noted that Western society holds a rational or mechanistic view of the world where accuracy is valued and uncertainty feared. McCormick10(p129) further expounds on this concept: “During a state of certainty, the future is taken for granted, but in an uncertain situation the future becomes a central focus, clouded in doubt, as a person strives to see clearly what was never clear to begin with.” Conversely, a probabilis-
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tic worldview maintains that certainty is impossible and that uncertainty is a natural state of being.5 At the time she reconceptualized the theory, Mishel considered herself a beginning Buddhist; this is reflected in her quest to reconceptualize the theory to encompass a more global view of uncertainty appraisal.2 Mishel2 maintains that both the original and reconceptualized models are relevant to nursing and other disciplines when studying the effects of uncertainty. The linear model— stress→coping→adaptation—is seen in small degrees early in an illness process and is best addressed in the original theory whereas outcomes of ongoing uncertainty are reflected in the reconceptualized model of uncertainty in illness. Over time, uncertainty appraisal evolves and adaptation is no longer an endpoint but a step in a dynamic process. The Mishel Uncertainty in Illness Scale11 measures the concept of uncertainty appraisal and has been used empirically to study nursing interventions designed to assess, implement, and evaluate outcomes from specific nursing interventions. In addition to having been used in research, the uncertainty in illness theory has been used in nursing education and practice.9
CHRONIC ILLNESS TRAJECTORY FRAMEWORK As stated by Corbin and Strauss,12(p156) “the trajectory framework is a conceptual model built around the idea that chronic conditions have a course that varies and changes over time.” The term trajectory is metaphorically used to signify the course of an illness or disease and the interplay of various forces (medical, psychosocial, cultural) in shaping outcomes.13 Basically, trajectory framework gives structure to the lived experience of illness through conceptualization of specific phases along a continuum. These phases are pretrajectory, trajectory onset, stable, unstable, acute, crisis, comeback, downward, and dying. Like Mishel, Corbin and Strauss noted that the illness process is not linear; although
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interventions aimed at managing ill effects can shape an illness, it remains a dynamic and unpredictable process. UPDATED CHRONIC ILLNESS TRAJECTORY FRAMEWORK Several factors prompted Corbin’s update of the trajectory framework and include (1) a paradigm shift toward health promotion and wellness, (2) an increase in people living with chronic illness, (3) health care cost considerations, and (4) new nursing roles including those of case managers.4 Significantly, in redefining trajectory framework, Corbin4 emphasized that the shaping of an illness course by its various participants (individuals, families, health care providers, resource agencies, communities, organizations, institutions) must be acknowledged. Trajectory scheme refers to shaping the overall course of the illness, controlling acute symptoms, and handling disabilities that may arise because of the illness.12 There are many factors that influence and shape the trajectory scheme including availability of resources, social support, knowledge and information, financial considerations, and employment issues. In addition, personal perceptions and experiences, motivation and self-efficacy, beliefs, and relationships also affect trajectory management.12 Trajectory framework is a skeleton of sorts from which nurses can derive operational definitions and observe outcomes in each area of the nursing paradigm and in each phase of the trajectory framework. Although the Corbin and Strauss model was not designed to address acute illness, the framework is applicable to any change in health when viewed as a tool to determine phase-specific nursing interventions. Corbin12 directly asserts the relevance of trajectory framework to the nursing paradigm. Specifically, the chronic illness focus of the model is applicable to the 4 nursing metaconcepts—person, health, environment, and nursing. She further implies that the theory gives direction to nursing practice, teaching, research, and policy.12
In an analysis and evaluation of the trajectory framework, Cooley14 reminds the reader that operational definitions are needed to observe the concepts empirically. Although she does not specifically address uncertainty, Corbin4,12 does focus on illness management. In an answer on how to operationalize trajectory framework, Corbin4 identifies 5 problemsolving steps that parallel the nursing process: (1) identify problems and trajectory phase, (2) prioritize problems, (3) define appropriate plan of action, (4) implement a plan, and (5) follow-through with and evaluate the intervention. In the updated model of trajectory framework, Corbin defines management goals specific to each trajectory phase. MAJOR CONCEPTS AND RELATIONSHIPS Concepts and definitions from the uncertainty in illness theory and trajectory framework are summarized in the first column of Figure 1. These concepts and definitions have been synthesized to provide an integrated view of uncertainty resulting from a health change within a trajectory framework. The concept synthesis establishes a theoretical basis from which uncertainty or other health-related concepts can be recognized and addressed within trajectory framework. A health-related concept is a variable that along with uncertainty can fluctuate across the health change trajectory (HCT). Examples are quality of life, hope, or anxiety. Several health-related concepts may need to be addressed together in nursing interventions to alleviate overall uncertainty and optimize the health change trajectory. Fundamentally, uncertainty does not always happen as a result of illness; rather, any change in a person’s health can hold some degree of uncertainty. Likewise, use of trajectory phases solely from an illness perspective does not capture the subset of people who do not consider themselves ill. Years after development of the chronic illness trajectory, Corbin15(p257) began to question the relationship of a chronic condition, illness, and health asking: “How do persons experience illness
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An Integrated Model of Health Change
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Figure 1. Concept synthesis.
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differently from having a condition or from health?” In the proposed integrated model, a change in health replaces the concept of illness within trajectory framework. As most human beings will experience some change in health, the use of a health change trajectory perspective broadens the scope of clinical situations in which the model could be used. Operational definitions of the HCT model will provide structure for empirical research and application to nursing education and practice. PROPOSED INTEGRATED MODEL Fararo and Skvoretz16 suggest that integration or synthesis of theories and principles leads to a more comprehensive and unified model. Similarly, Glanz17(p20) states: “A growing body of evidence suggests that interventions developed with an explicit theoretical foundation or foundations are more effective that those lacking a theoretical base and that some strategies that combine multiple theories and concepts have larger effects.” By integrating uncertainty in illness and trajectory framework, concepts from both theories are merged and new operational definitions created. These definitions provide a more comprehensive view of how uncertainty or other health-related concepts can be acted upon by structure providers (defined as resources available to assist the person in the interpretation of the stimulus frame) at specified points along the HCT. In the HCT, health is defined as a state of structural, physiological, and psychological balance allowing optimal performance of intrinsically valued activities of daily life. By using the HCT model, phase-specific interventions can be initiated and measured. Although not explicitly identified, subphases exist along a trajectory and are experienced as daily fluctuations in health.4 CONCEPT SYNTHESIS AND NEW MODEL DEVELOPMENT After reviewing the concepts and definitions within their respective contexts,
analogous concepts were paired and their interpreted meanings integrated into synergistic statements that resulted in the further development of unique terminology and operational definitions for the HCT model. The concept synthesis shaped the following assumptions regarding a health change trajectory: • A change in health, especially when life-threatening or when representing a chronic condition, is complex and unpredictable. • Each person’s health change trajectory is as unique as his or her perception of a health change in each trajectory phase. • Experience and the meaning given to the experience define the self; therefore, the perception of the self is altered to some degree when experiencing a change in health. • Inferred meanings based on historical experience around a change in health result in a subjective appraisal of the situation and a plan to manage symptoms and disabilities. • Trajectory phases are structured around the presence or absence of symptoms. If any phase of the trajectory is revisited, coping skills around the situation will be affected by previous experience and pattern recognition. • How the self is affected by a change in health directly correlates with a person’s cognitive ability to assign meaning to the experience. • The biopsychosocial aspects of a person change through the process of adaptation. An adaptive response (AR) to a change in health can lead to a perceptual shift (PS). Likewise, a shift in perception can contribute to an AR. It should be noted that application of the HCT model is limited to persons capable of constructing a cognitive schema or representation of their perceived health change at some level of complexity. Thus, the model can be used to understand health changes and the related cognitions and emotions experienced by both older children and adults.
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An Integrated Model of Health Change For the purpose of describing the relationships within the HCT model, the synthesized concepts were given operational definitions and a relational diagram was developed (Figure 2). Clearly defined concepts must accompany any credible theory or combination of theories because a theory is testable only to the degree that concepts are linked to operational definitions that provide logic and measurability to the theory.9 A health change trajectory is defined as a path or course of structural, physiological, and psychological balance including individual perceptions of health and the actions
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taken by self and others to manage, reduce, or eliminate a change in health. A change in health is a perceived deviation from a recent state of structural, physiological, and psychological balance. Essentially, a change in health is a subjective interpretation that may or may not have a physiological correlate. Mishel and Clayton7 describe event familiarity, event congruency, symptom pattern, and symptom severity as components of the stimuli frame that shape a cognitive interpretation or schema of the illness experience. Likewise, Corbin4 states that all aspects of the self (biography) are involved in constructing a
Figure 2. Health change trajectory relational diagram.
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perception of how an illness must be managed across trajectory phases and through the life course. Integrating these concepts into a concise definition was necessary to diagram the relationships within the HCT. Consequently, health change management is used to define the psychological, physiological, and situational factors that influence the perception, management, and subsequent outcomes related to a change in health. Cognitive schema and trajectory scheme are synthesized into health change appraisal and defined as inferred meanings on the basis of historical experience around a change in health. The change in health results in a subjective appraisal of the situation and a plan to manage symptoms and disabilities. Defining the ability of a person to appraise a health change and assign meaning to the experience results in the term cognitive meaning assignment. A structure provider working beside an individual to facilitate management of a health change is termed a health change management partner. The results from extensive testing of the uncertainty in illness theory reveal that structure providers, namely, nurses, have a strong effect on reducing uncertainty in a variety of populations who are dealing with health changes.18 Educating patients and their families is a key function of a nurse’s role. Clear communication of pertinent information relating to what a person may experience during diagnostic tests, medical procedures, and treatment with medications provides contextual cues and can reduce uncertainty and promote understanding.18 When uncertainty is managed (with or without the assistance of others), the self may experience a biopsychosocial change; this change is considered an adaptive response. In addition, a perceptual shift is an adaptive alteration in the way a health change is viewed over time. Research indicates that shifts in perception generally occur when a health change is long-lasting, unpredictable, or disabling to some degree.18 Within the HCT, even small changes in awareness are recog-
nized as leading to an adaptive response and ultimately to a perceptual shift or vice versa. The integrated concepts provide operational definitions for reflection and testing within the HCT. A health-related concept is a variable that is measurable and relates to any aspect of a health change. Concepts classified as continuous are measurable to some degree and are expressed in measures along a continuum.9
HEALTH CHANGE TRAJECTORY RELATIONAL DIAGRAM The integral component of the HCT is the person experiencing a change in health and his or her ability to assign meaning to the experience. A change in health can happen within any of the 9 phases of the trajectory framework; therefore, the relational diagram depicts this dynamic relationship by centering the person experiencing the health change within all trajectory phases. The AR, PS, and CMA are subjective interpretations of a health change; each concept is interrelated and affects a person’s ongoing subjective appraisal of a change in health (HCA). Importantly, a shift in perception can happen at any point in the HCT and is not viewed as an endpoint; rather, a PS and/or AR influence HCA continuously throughout a person’s lifetime and health change experiences. As previously stated, human perceptions are highly variable; therefore, positive or negative relationships are not consistently depicted in the relational diagram. However, it is highly probable that an AR is a positive event (as opposed to a maladaptive response) and a PS is likely to exert a positive influence on a person’s appraisal of a change in health. In addition, an individual’s perception of a change in health may or may not be accompanied by a physiological or structural change in health; nevertheless, based on a person’s CMA and his or her previous experience related to the change in health, an HCA is formed and interventions by self and others are initiated in an effort to manage the perceived health
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An Integrated Model of Health Change change (HCM). The potential to ignore a change in health also exists and is based on individual perceptions and the meaning given the situation. The relationship of HCA and HCM depicts the interaction between various factors relating to a change in health: (a) the psychological factors that influence perception and subsequent appraisal, (b) the physiological and situational factors that affect management, and (c) the resulting consequences of management interventions. Recall that HCM is a synthesis of 2 major concepts (in bold) and their corresponding subconcepts: stimuli frame, symptom pattern, event familiarity, and event congruence (uncertainty in illness theory); and trajectory projection, trajectory phasing, biography, and reciprocal impact (trajectory framework). The interaction depicted by the dotted line in the relational diagram notates the significance of positive or negative influence of the HCMP on a person’s HCA. The dotted line also signifies the importance of ongoing assessment and communication on the part of the HCMP. Although nurses and other structure providers can positively or negatively influence perceptions and management of a health change, as defined, an HCMP engages with the patient and his or her family to develop the best possible outcomes. To be sure, due to the variability in human perceptions, not all interactions will be regarded as positive; however, clear intention on the part of the HCMP combined with sensitivity to cognitive capabilities and cultural diversity are likely to promote positive perceptions and outcomes.
IMPLICATIONS FOR NURSING RESEARCH The strength of integrating both theories into the HCT model is the synthesis of complementary concepts and the creation of new operational definitions that capture results of the synthesis. The psychometric challenge is to develop tools that accurately measure the integrated concepts. For example, exist-
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ing measures of component concepts (uncertainty and trajectory) may be combined, in whole or in part, to create a measure of the integrated concept (health change trajectory), or a totally new measure of the latter concept may be needed. Qualitative research using focus groups or patient panels provides rich data to inform construction of measurement tools for the key HCT concepts.19 Thus, initial research efforts should be focused on designing reliable and valid measures of the integrated concepts. A next step is to test the proposed relationships in the HCT model to determine whether they are consistent with patient reports of the health change experience. Researchers have used the Mishel Uncertainty in Illness Scale to observe, quantify, and develop interventions to manage uncertainty related to chronic illness.20-25 Using the HCT model, researchers can identify what antecedents of uncertainty may be the most prevalent at specific trajectory phases of health change and develop appropriate and targeted interventions. Because of variability in uncertainty appraisal, Mishel5 advocates for further research into how and when uncertainty is appraised as opportunity. Given the ability of people to see opportunity in uncertainty, researchers may ask, “What phase or phases of the health change trajectory are most likely to contain uncertainty appraised as an opportunity?” For these phases, nursing interventions directed at promoting uncertainty will likely be more appropriate than those directed at minimizing uncertainty. To promote ARs, the desired outcomes of interventions in various trajectory phases must be better understood.10 Numerous studies involving trajectory framework have been conducted.26-32 Henly et al33 proposed that use of a health trajectory perspective extends the use of the nursing metaparadigm in longitudinal research by incorporating health changes over time. Henly et al32(pS5) further emphasize: Understanding the course and causes of change in health over time allows anticipation of those
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at greatest risk for adverse trajectories and events, enhances understanding of factors that influence change in health over time, and permits examination of the effects of interventions on the trajectory, including identification of for whom and at what point in the trajectory interventions are the most effective.
Outcomes research is critical in each trajectory phase to determine the structure of interventions that result in an AR and related PS. The work by Stephenson and Berry34 in identifying measures of spirituality and uncertainty at the end of life is an example of using an identified trajectory phase to explore the lived experience. Additional research is needed to help identify patient perceptions that occur most frequently within each phase of trajectory framework. With an increased understanding of health change appraisal and how coping skills can be enhanced through nursing interventions, people dealing with health changes can be empowered to meet the challenges or opportunities that a health change presents.
IMPLICATIONS FOR NURSING EDUCATION Educators can use the HCT model to promote students’ in-depth understanding of the variations in a person’s response to alterations in health within and across trajectory phases. Students can learn how nurses, as HCMPs, can influence the subjective appraisal of a change in health (HCA) and subsequent management choices (HCM) of the people in their care. This is important because analyzing and acting on the factors that affect fluctuation in HCA and HCM will better prepare students to provide personalized care. By presenting exemplars of how the HCT model can be used in the clinical setting, educators can demonstrate the role of the HCMP and encourage students to listen for antecedents of uncertainty and intervene accordingly. For example, if uncertainty is founded in financial or employment difficul-
ties, interventions will be different than if uncertainty is founded in the lack of understanding about a medical procedure. Similarly, educators can use the HCT model to encourage interventions within a health rather than an illness framework. This places student emphasis on the promotion of health pretrajectory and on early interventions in the trajectory onset phase. Students can also learn how to associate the cognitive meaning of health change and related emotional responses to achieving an AR and PS. Through increased student awareness of health change as a potential opportunity for growth and the benefits of fostering this perception in persons receiving nursing care, another advantage of using the HCT model in nursing education can be realized. IMPLICATIONS FOR NURSING PRACTICE Structure providers—particularly nurses— are a vital part of uncertainty management in all phases of the health change trajectory. With a clear understanding of the various circumstances and ways a person may appraise a change in health, nurses can tailor interventions to meet an individual’s specific needs. For example, when addressing uncertainty in the acute or crisis phase, interventions are likely to be different from those provided in the stable phase. Contrary to common wisdom, during the crisis phase, there may actually be less uncertainty than when an illness is stable. This could be because during the more serious phases of illness, the management goal is to remove the life threat. Conversely, during the stable or comeback phase, perceptions of uncertainty may reveal heightened uncertainty as described by Elizabeth McKinley35(p470) at the completion of her breast cancer treatment: After my very last radiation treatment for breast cancer, I lay on a cold steel table hairless, halfdressed and astonished by the tears streaming down my face. I thought I would feel happy about finally reaching the end of treatment, but instead I was sobbing. At the time, I wasn’t sure what emotions I was feeling. Looking back, I think I cried
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Nursing intervention
Interpersonal Physiological, and psychological, situational and cultural influences influences Provide health Provide promotion culturally and wellness sensitive, education. personcentered education regarding medical condition. Offer psychosocial support and spiritual care.
Nursing assessment
Form appropriate trajectory projection and scheme.13
Prevent onset of chronic illness.13
Trajectory Onset
Management goal
Pretrajectory
Stable
Unstable Return to stability.13
Acute
Crisis
Bring illness Remove life under control threat.13 and resume normal biography and everyday activities.13 Physical disability, Effectiveness of injury, or illness health change management
Comeback Set in motion and keep going the trajectory projection and scheme.13 Adaptive response
Downward To adapt to increasing disability with each major downward turn.13 Disability adjustment
Provide health Provide Provide frequent Provide critical Provide methods Provide education on education and updates on care management of stress physiological strengthening interventions medical and ongoing reduction, and coping skills and to strengthen condition, communication disability psychosocial compliance with health change procedures, with patient’s management, support and health change appraisal in and treatments support network. and spiritual spiritual care. management. line with health in line with the support. change individual’s management current interventions. perceptions and cognitive ability.
Adherence to Coping skills health change management plan
Maintain stability of illness, biography, and everyday activities.13
Dying
Provide physical comfort and methods of stress reduction and spiritual support.
Perceptual shift
To bring peace and closure.13
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Table 1. Nursing Assessment and Interventions
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because this body had so bravely made it through 18 months of surgery, chemotherapy, and radiation. Ironically, I also cried because I would not be coming back to that familiar table where I had been comforted and encouraged. Instead of joyous, I felt lonely, abandoned and terrified. This was the rocky beginning of cancer survivorship for me.
ing interventions can be developed and refined as the model is used in nursing research and practice.
Foremost, any management intervention directed at uncertainty must acknowledge the individual’s appraisal of uncertainty as danger or opportunity, as interventions will be either to minimize or to support the person’s appraisal of a change in health. The nurse would not set out to minimize uncertainty if it were a person’s desired state, such as when uncertainty is perceived as opportunity and is used to maintain hopefulness. Robinson et al30 state that standardized nursing assessments are not necessarily needed in each trajectory phase because the emphasis on biography, everyday life activities, and illness evaluation will vary within each phase. Fluid nursing assessments that consider CMA and health change appraisal may challenge old paradigms. However, personalized care can happen only when each person’s unique perceptions are considered in the overall plan of care. Showcased in Table 1 are possible goals, assessments, and interventions that can be applied to each phase of the HCT model. Phase-specific nurs-
Both uncertainty in illness theory and trajectory framework are stand-alone theories that have proven to be useful in nursing research, education, and practice. The existence of a synergistic relationship between both theories is reflected in the integrated statements and new terminology created through the concept synthesis and development of the HCT model. Furthermore, use of the proposed operational definitions can extend the use of trajectory framework beyond the chronic illness perspective. Framing and acting upon uncertainty or other observed health-related concepts within a health change trajectory has significant application within the nursing profession. Specifically, researchers can evaluate a variety of healthrelated concepts within trajectory framework to better understand perceptions, coping methods, and nursing interventions that may be applicable in specific practice settings. Phase-specific interventions can shape the health trajectory positively and optimize selfmanagement, adaptation, and quality of life.
CONCLUSION
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An Integrated Model of Health Change 9. Bailey DE, Stewart JL. Uncertainty in illness theory. In: Alligood MR, Tomey AM, eds. Nursing Theorists and Their Work. 7th ed. Maryland Heights, MO: Mosby/Elsevier; 2010:599-617. 10. McCormick K. A concept analysis of uncertainty in illness. J Nurs Scholarsh. 2002;32(2):127-131. 11. Mishel MH. The measurement of uncertainty in illness. Nurs Res. 1981;30(5):256-263. 12. Corbin JM, Strauss AL. A nursing model for chronic illness management based upon the trajectory framework. Sch Inq Nurs Pract. 1991;5(3):155174. 13. Weiner C, Dodd M. Coping amid uncertainty: an illness perspective. Sch Inq Nurs Pract. 1993;7(1): 17-31. 14. Cooley ME. Analysis and evaluation of trajectory theory of chronic illness management. Sch Inq Nurs Pract. 1999;13(2):75-95. 15. Corbin JM. The body in health and illness. Qual Health Res. 2003;13:256-267. 16. Fararo TJ, Skvoretz J. Unification research programs: integrating two structural theories. Am J Sociol. 1987;92(5):1183-1209. http://www.jstor.org/stable/ 2780000. Accessed June 20, 2013. 17. Glanz K. Social and behavioral theories. In: Behavioral and Social Science Research. Bethesda, MD: National Institute of Health Office of Behavioral and Social Science Research; 2012:1-32. http://www.esourceresearch.org/eSourceBook/ SocialandBehavioralTheories/1LearningObjectives/ tabid/724/Default.aspx. Accessed June 20, 2013. 18. Burton CR. Re-thinking stroke rehabilitation: the Corbin and Strauss chronic illness trajectory framework. J Adv Nurs. 2000;32(3):595-602. 19. Crawford MJ, Rutter D, Manley C, et al. Systematic review of involving patients in the planning and development of health care. BMJ. 2002;325(7375): 1263. 20. Bailey DE Jr, Landerman L, Barroso J, et al. Uncertainty, symptoms and quality of life in persons with chronic hepatitis C undergoing watchful waiting. Psychosomatics. 2009;50(2):136-146. doi:10.1176/appi.psy.50.2.138. 21. Bailey DE Jr, Wallace M, Latini DM, et al. Measuring illness uncertainty in men undergoing active surveillance for prostate cancer [published online ahead of print September 18, 2009]. Appl Nurs Res. 2011;24(4):193-199. doi:10.1016/j.apnr.2009.08.001. 22. Clayton MF, Mishel MH, Belyea M. Testing a model of symptoms, communication, uncertainty, and
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well-being in older breast cancer survivors. Res Nurs Health. 2006;29(1):18-39. Kim SH, Lee R, Lee KS. Symptoms and uncertainty in breast cancer survivors in Korea: differences by treatment trajectory [published online ahead of print November 15, 2011]. J Clin Nurs. 2012;21(7/8):1014-1023. doi:10.1111/j.13652702.2011.03896.x. Mauor AM. Exploring uncertainty and psychosocial adjustment after cardioverter defibrillator implantation. J Cardiovasc Nurs. 2008;23(6):527-535. doi:10.1097/01.JCN.0000338932.73963.42. Suzuki M. Quality of life, uncertainty, and perceived involvement in decision making in patients with head and neck cancer. Oncol Nurs Forum. 2012;39(6):541-548. doi:10.1188/12.ONF .541-548. Granger B, Moser D, Harrell J, Sandelowski M, Ekman I. A practical use of theory to study adherence. Prog Cardiovasc Nurs. 2007;22(3):152-158. Halcomb E, Davidson P. Using the illness trajectory framework to describe recovery from traumatic injury. Contemp Nurse. 2005;19(1-2):232-241. Hawthorne MH. Using the trajectory framework: reconceptualizing cardiac illness. Image Sch Inq Nurs Pract. 1991;5(3):185-195. Miller CM. Trajectory and empowerment theory applied to care of patients with multiple sclerosis. J Neurosci Nurs. 1993;25(6):343-348. Robinson LA, Bevil C, Arcangelo V, Reifsnyder J, Rothman N, Smeltzer S. Operationalizing the Corbin Strauss trajectory model for elderly clients with chronic illness. Res Theory Nurs Pract. 1993;7(4):253-64; discussion 265-268. Smeltzer SC. Use of the trajectory model of nursing in multiple sclerosis. Image Sch Inq Nurs Pract. 1991;5(3):219-234. Henly SJ, Wyman JF, Gaugler JE. Health trajectory research: a call to action for nursing science. Nurs Res. 2011;60(3S):S79-S82. doi:10.1097/NNR.0b013e31821cc240. Henly SJ, Wyman JF, Findorff MJ. Health and illness over time: trajectory perspective in nursing science. Nurs Res. 2011;60(3S):S5-S14. doi:10.1097/NNR.0b013e318216dfd3. Stephenson PS, Berry DM. Spirituality and uncertainty at end of life. Oncol Nurs Forum. 2014;41(1):33-39. doi:10.1188/14.ONF.33-39. McKinley ED. Under Toad day: surviving the uncertainty of cancer recurrence. Ann Intern Med. 2000;133(6):479-480.
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Advances in Nursing Science Vol. 38, No. 1, pp. 55–67 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
The Health Change Trajectory Model An Integrated Model of Health Change Deborah Christensen, BSN, RN Health and illness fluctuate across a person’s life span, and various theories have been developed to address the unique perceptions and situations that accompany these fluctuations. An innovative model of health change resulted from a synthesis of the major concepts from 2 such theories: Mishel’s uncertainty in illness theory and the Corbin and Strauss chronic illness trajectory framework. The proposed integrated model, the Health Change Trajectory Model, provides original conceptual definitions that operationalize trajectory framework in the context of changes in health. The use of a health trajectory perspective extends applications of the model to a wide range of health changes that result in uncertainty and ambiguity. Key words: concept synthesis, Corbin, health, health change, illness, Mishel, nursing, Strauss, trajectory, uncertainty
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HANGES in a person’s health—from the onset of fatigue to a chronic illness or a life-threatening disease—result in unique perceptions of uncertainty. When viewed in the context of health, questions causing doubt or uncertainty will vary from “How long will my head hurt?” to “Am I going to survive?” Because nurses care for persons at diverse points along their health trajectory, an understanding of the lived experience of uncertainty and
Author Affiliation: Loyola University Chicago, Chicago, Illinois. This work is supported by 125362-GSCNP-13-348-01SCN from the American Cancer Society. Special thanks to Nola J. Pender, PhD, for her encouragement and confidence that this work had potential and merit to the nursing community. It is not often that a student finds a mentor of such caliber and dedication. The author has disclosed that he (she) has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Deborah Christensen, BSN, RN, 1155 W. Bloomington Dr. S. #5, St. George, UT 84790 ([email protected]). DOI: 10.1097/ANS.0000000000000061
its effects on health and well-being is essential to quality care. Mishel’s uncertainty in illness theory and the Corbin and Strauss chronic illness trajectory framework are 2 empirically tested theories addressing health experiences and related transitions. However, both theories were conceptualized within an illness framework. With global emphasis on the promotion of health and prevention of illness, reframing the phenomena of uncertainty and trajectory in the context of health appears timely. Persons deal with diverse changes in health throughout the life span. With an aging population, these changes are often chronic in nature and persist over time. Nurses are the key health care providers who assist persons in understanding and coping with health changes. To provide nurses with a model to address uncertainty at various points in the health trajectory and plan appropriate interventions, a concept synthesis was performed to integrate and reframe the 2 theories. In this article, I present a new integrated model, the Health Change Trajectory Model, and offer suggestions for application of the model in nursing research, education, and practice. 55
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HISTORICAL DEVELOPMENT Earnest study of theory requires an understanding of the influences and research methods used by the theorists. Glaser and Strauss1 propose that the adequacy of a theory and the process used to create it are tightly interwoven. In addition, multiple perspectives of a theory are useful in understanding and evaluating how the theory can be used in research and applied in practice. As medical advances continue and life expectancy increases, theories related to changes in health and disability adjustments must evolve. Integrating the Corbin and Strauss trajectory framework with uncertainty in illness results in such a theory with application to diverse experiences of health change.
OVERVIEW AND EVOLUTION OF THEORIES Merle Mishel’s curiosity around uncertainty, which she initially deemed ambiguity, began with an experience she had with her father after he was diagnosed with colon cancer. She describes visiting with her father in the hospital shortly after his diagnosis and being puzzled when he asked to have his ears cleaned. After contemplating his request, she determined that the ambiguity around his diagnosis caused him to focus on something that he was certain of such as feeling the difference from before and after his ears were cleaned.2 Thus began Mishel’s journey into the concepts and antecedents around uncertainty in illness. Intellectually, Mishel’s background was in nursing and social psychology; these 2 factors shaped her perceptions and conceptualizations of the uncertainty of illness theory. The original theory, published in 1988, was inductively constructed from grounded theory framework. Other theories and scholars that Mishel used to shape her theory were as follows: information processing, Warburton (1979); personality research, Bandar (1962); and coping and stress, Lazarus and
Folkman (1984). Critical social theory and chaos theory influenced the reconceptualization of Mishel’s theory in 1992. Since its inception, the uncertainty of illness theory has been used in research design; as a result, evidencebased nursing interventions have been developed and put into practice. This is an example of the reciprocal nature of theory and practice—practice and theory. During her graduate studies at San Jose State University, Juliet Corbin, also a nurse, was greatly influenced by Anslem Strauss and grounded theory. Corbin enrolled at the University of California San Francisco to pursue doctoral studies where she studied and later worked with Strauss and other renowned scholars and theorists.3 Corbin’s experience as a nurse immersed in sociology research provided the foundation for developing a framework for observing illness across a continuum. During the time Corbin worked with Strauss, they inductively conceptualized and subsequently tested trajectory framework using qualitative research methods.4
UNCERTAINTY IN ILLNESS THEORY Mishel5(p256) describes uncertainty as: “The inability to determine the meaning of illness related events; this occurs in situations where the decision-maker is unable to assign definite value to objects and events or is unable to accurately predict outcomes because sufficient cues are lacking.” Mishel’s original theory was constructed around 4 categories: (1) antecedents that contribute to the perception of uncertainty, (2) uncertainty appraised as neutral, a threat, or an opportunity, (3) problem-focused and emotionfocused coping, and (4) adaptation.5,6 Illness severity, historical assumptions around an illness or disease, information or lack of information provided by health care professionals, and personal beliefs all affect a person’s perception of uncertainty.7 Mishel and Clayton7 further proposed that until a person assigns meaning to the experience, uncertainty is fundamentally neutral. Inference
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An Integrated Model of Health Change and illusion are appraisal processes used to confer meaning to uncertainty; consequently, inferred meanings, based on historical experiences around a situation, can elicit appraisal as an opportunity or danger. Once uncertainty is appraised as a threat, people mobilize resources to subdue the associated stress. Interestingly, when uncertainty is seen as an opportunity, efforts are made to maintain uncertainty. For example, when a prognosis is grim, uncertainty can inspire hope and lead to improved coping. Initially, Mishel5(p258) ascertained that uncertainty as opportunity was reserved for situations with a negative trajectory; she states: “When the alternative is negative, uncertainty becomes the preferred state.” Problem-focused and emotionfocused coping strategies that people use to mitigate uncertainty are also described in the theory. Seeking social support and emphasizing the positive are seen as problemfocused coping behaviors whereas cognitive avoidance, distraction, and wishful thinking are characteristic of emotion-focused coping methods.8 Mishel originally envisioned adaptation as being the final step in a linear view of stress→coping→adaptation. Ultimately, adaptation was viewed as the desired outcome of effective coping strategies.9
RECONCEPTUALIZATION OF UNCERTAINTY IN ILLNESS THEORY Mishel began to question the relevance of the original theory when studied in the context of chronic illness. Cultural views of uncertainty also prompted Mishel to reconceptualize the theory. From a critical social theory perspective, Mishel5 noted that Western society holds a rational or mechanistic view of the world where accuracy is valued and uncertainty feared. McCormick10(p129) further expounds on this concept: “During a state of certainty, the future is taken for granted, but in an uncertain situation the future becomes a central focus, clouded in doubt, as a person strives to see clearly what was never clear to begin with.” Conversely, a probabilis-
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tic worldview maintains that certainty is impossible and that uncertainty is a natural state of being.5 At the time she reconceptualized the theory, Mishel considered herself a beginning Buddhist; this is reflected in her quest to reconceptualize the theory to encompass a more global view of uncertainty appraisal.2 Mishel2 maintains that both the original and reconceptualized models are relevant to nursing and other disciplines when studying the effects of uncertainty. The linear model— stress→coping→adaptation—is seen in small degrees early in an illness process and is best addressed in the original theory whereas outcomes of ongoing uncertainty are reflected in the reconceptualized model of uncertainty in illness. Over time, uncertainty appraisal evolves and adaptation is no longer an endpoint but a step in a dynamic process. The Mishel Uncertainty in Illness Scale11 measures the concept of uncertainty appraisal and has been used empirically to study nursing interventions designed to assess, implement, and evaluate outcomes from specific nursing interventions. In addition to having been used in research, the uncertainty in illness theory has been used in nursing education and practice.9
CHRONIC ILLNESS TRAJECTORY FRAMEWORK As stated by Corbin and Strauss,12(p156) “the trajectory framework is a conceptual model built around the idea that chronic conditions have a course that varies and changes over time.” The term trajectory is metaphorically used to signify the course of an illness or disease and the interplay of various forces (medical, psychosocial, cultural) in shaping outcomes.13 Basically, trajectory framework gives structure to the lived experience of illness through conceptualization of specific phases along a continuum. These phases are pretrajectory, trajectory onset, stable, unstable, acute, crisis, comeback, downward, and dying. Like Mishel, Corbin and Strauss noted that the illness process is not linear; although
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interventions aimed at managing ill effects can shape an illness, it remains a dynamic and unpredictable process. UPDATED CHRONIC ILLNESS TRAJECTORY FRAMEWORK Several factors prompted Corbin’s update of the trajectory framework and include (1) a paradigm shift toward health promotion and wellness, (2) an increase in people living with chronic illness, (3) health care cost considerations, and (4) new nursing roles including those of case managers.4 Significantly, in redefining trajectory framework, Corbin4 emphasized that the shaping of an illness course by its various participants (individuals, families, health care providers, resource agencies, communities, organizations, institutions) must be acknowledged. Trajectory scheme refers to shaping the overall course of the illness, controlling acute symptoms, and handling disabilities that may arise because of the illness.12 There are many factors that influence and shape the trajectory scheme including availability of resources, social support, knowledge and information, financial considerations, and employment issues. In addition, personal perceptions and experiences, motivation and self-efficacy, beliefs, and relationships also affect trajectory management.12 Trajectory framework is a skeleton of sorts from which nurses can derive operational definitions and observe outcomes in each area of the nursing paradigm and in each phase of the trajectory framework. Although the Corbin and Strauss model was not designed to address acute illness, the framework is applicable to any change in health when viewed as a tool to determine phase-specific nursing interventions. Corbin12 directly asserts the relevance of trajectory framework to the nursing paradigm. Specifically, the chronic illness focus of the model is applicable to the 4 nursing metaconcepts—person, health, environment, and nursing. She further implies that the theory gives direction to nursing practice, teaching, research, and policy.12
In an analysis and evaluation of the trajectory framework, Cooley14 reminds the reader that operational definitions are needed to observe the concepts empirically. Although she does not specifically address uncertainty, Corbin4,12 does focus on illness management. In an answer on how to operationalize trajectory framework, Corbin4 identifies 5 problemsolving steps that parallel the nursing process: (1) identify problems and trajectory phase, (2) prioritize problems, (3) define appropriate plan of action, (4) implement a plan, and (5) follow-through with and evaluate the intervention. In the updated model of trajectory framework, Corbin defines management goals specific to each trajectory phase. MAJOR CONCEPTS AND RELATIONSHIPS Concepts and definitions from the uncertainty in illness theory and trajectory framework are summarized in the first column of Figure 1. These concepts and definitions have been synthesized to provide an integrated view of uncertainty resulting from a health change within a trajectory framework. The concept synthesis establishes a theoretical basis from which uncertainty or other health-related concepts can be recognized and addressed within trajectory framework. A health-related concept is a variable that along with uncertainty can fluctuate across the health change trajectory (HCT). Examples are quality of life, hope, or anxiety. Several health-related concepts may need to be addressed together in nursing interventions to alleviate overall uncertainty and optimize the health change trajectory. Fundamentally, uncertainty does not always happen as a result of illness; rather, any change in a person’s health can hold some degree of uncertainty. Likewise, use of trajectory phases solely from an illness perspective does not capture the subset of people who do not consider themselves ill. Years after development of the chronic illness trajectory, Corbin15(p257) began to question the relationship of a chronic condition, illness, and health asking: “How do persons experience illness
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An Integrated Model of Health Change
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Figure 1. Concept synthesis.
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differently from having a condition or from health?” In the proposed integrated model, a change in health replaces the concept of illness within trajectory framework. As most human beings will experience some change in health, the use of a health change trajectory perspective broadens the scope of clinical situations in which the model could be used. Operational definitions of the HCT model will provide structure for empirical research and application to nursing education and practice. PROPOSED INTEGRATED MODEL Fararo and Skvoretz16 suggest that integration or synthesis of theories and principles leads to a more comprehensive and unified model. Similarly, Glanz17(p20) states: “A growing body of evidence suggests that interventions developed with an explicit theoretical foundation or foundations are more effective that those lacking a theoretical base and that some strategies that combine multiple theories and concepts have larger effects.” By integrating uncertainty in illness and trajectory framework, concepts from both theories are merged and new operational definitions created. These definitions provide a more comprehensive view of how uncertainty or other health-related concepts can be acted upon by structure providers (defined as resources available to assist the person in the interpretation of the stimulus frame) at specified points along the HCT. In the HCT, health is defined as a state of structural, physiological, and psychological balance allowing optimal performance of intrinsically valued activities of daily life. By using the HCT model, phase-specific interventions can be initiated and measured. Although not explicitly identified, subphases exist along a trajectory and are experienced as daily fluctuations in health.4 CONCEPT SYNTHESIS AND NEW MODEL DEVELOPMENT After reviewing the concepts and definitions within their respective contexts,
analogous concepts were paired and their interpreted meanings integrated into synergistic statements that resulted in the further development of unique terminology and operational definitions for the HCT model. The concept synthesis shaped the following assumptions regarding a health change trajectory: • A change in health, especially when life-threatening or when representing a chronic condition, is complex and unpredictable. • Each person’s health change trajectory is as unique as his or her perception of a health change in each trajectory phase. • Experience and the meaning given to the experience define the self; therefore, the perception of the self is altered to some degree when experiencing a change in health. • Inferred meanings based on historical experience around a change in health result in a subjective appraisal of the situation and a plan to manage symptoms and disabilities. • Trajectory phases are structured around the presence or absence of symptoms. If any phase of the trajectory is revisited, coping skills around the situation will be affected by previous experience and pattern recognition. • How the self is affected by a change in health directly correlates with a person’s cognitive ability to assign meaning to the experience. • The biopsychosocial aspects of a person change through the process of adaptation. An adaptive response (AR) to a change in health can lead to a perceptual shift (PS). Likewise, a shift in perception can contribute to an AR. It should be noted that application of the HCT model is limited to persons capable of constructing a cognitive schema or representation of their perceived health change at some level of complexity. Thus, the model can be used to understand health changes and the related cognitions and emotions experienced by both older children and adults.
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An Integrated Model of Health Change For the purpose of describing the relationships within the HCT model, the synthesized concepts were given operational definitions and a relational diagram was developed (Figure 2). Clearly defined concepts must accompany any credible theory or combination of theories because a theory is testable only to the degree that concepts are linked to operational definitions that provide logic and measurability to the theory.9 A health change trajectory is defined as a path or course of structural, physiological, and psychological balance including individual perceptions of health and the actions
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taken by self and others to manage, reduce, or eliminate a change in health. A change in health is a perceived deviation from a recent state of structural, physiological, and psychological balance. Essentially, a change in health is a subjective interpretation that may or may not have a physiological correlate. Mishel and Clayton7 describe event familiarity, event congruency, symptom pattern, and symptom severity as components of the stimuli frame that shape a cognitive interpretation or schema of the illness experience. Likewise, Corbin4 states that all aspects of the self (biography) are involved in constructing a
Figure 2. Health change trajectory relational diagram.
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perception of how an illness must be managed across trajectory phases and through the life course. Integrating these concepts into a concise definition was necessary to diagram the relationships within the HCT. Consequently, health change management is used to define the psychological, physiological, and situational factors that influence the perception, management, and subsequent outcomes related to a change in health. Cognitive schema and trajectory scheme are synthesized into health change appraisal and defined as inferred meanings on the basis of historical experience around a change in health. The change in health results in a subjective appraisal of the situation and a plan to manage symptoms and disabilities. Defining the ability of a person to appraise a health change and assign meaning to the experience results in the term cognitive meaning assignment. A structure provider working beside an individual to facilitate management of a health change is termed a health change management partner. The results from extensive testing of the uncertainty in illness theory reveal that structure providers, namely, nurses, have a strong effect on reducing uncertainty in a variety of populations who are dealing with health changes.18 Educating patients and their families is a key function of a nurse’s role. Clear communication of pertinent information relating to what a person may experience during diagnostic tests, medical procedures, and treatment with medications provides contextual cues and can reduce uncertainty and promote understanding.18 When uncertainty is managed (with or without the assistance of others), the self may experience a biopsychosocial change; this change is considered an adaptive response. In addition, a perceptual shift is an adaptive alteration in the way a health change is viewed over time. Research indicates that shifts in perception generally occur when a health change is long-lasting, unpredictable, or disabling to some degree.18 Within the HCT, even small changes in awareness are recog-
nized as leading to an adaptive response and ultimately to a perceptual shift or vice versa. The integrated concepts provide operational definitions for reflection and testing within the HCT. A health-related concept is a variable that is measurable and relates to any aspect of a health change. Concepts classified as continuous are measurable to some degree and are expressed in measures along a continuum.9
HEALTH CHANGE TRAJECTORY RELATIONAL DIAGRAM The integral component of the HCT is the person experiencing a change in health and his or her ability to assign meaning to the experience. A change in health can happen within any of the 9 phases of the trajectory framework; therefore, the relational diagram depicts this dynamic relationship by centering the person experiencing the health change within all trajectory phases. The AR, PS, and CMA are subjective interpretations of a health change; each concept is interrelated and affects a person’s ongoing subjective appraisal of a change in health (HCA). Importantly, a shift in perception can happen at any point in the HCT and is not viewed as an endpoint; rather, a PS and/or AR influence HCA continuously throughout a person’s lifetime and health change experiences. As previously stated, human perceptions are highly variable; therefore, positive or negative relationships are not consistently depicted in the relational diagram. However, it is highly probable that an AR is a positive event (as opposed to a maladaptive response) and a PS is likely to exert a positive influence on a person’s appraisal of a change in health. In addition, an individual’s perception of a change in health may or may not be accompanied by a physiological or structural change in health; nevertheless, based on a person’s CMA and his or her previous experience related to the change in health, an HCA is formed and interventions by self and others are initiated in an effort to manage the perceived health
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An Integrated Model of Health Change change (HCM). The potential to ignore a change in health also exists and is based on individual perceptions and the meaning given the situation. The relationship of HCA and HCM depicts the interaction between various factors relating to a change in health: (a) the psychological factors that influence perception and subsequent appraisal, (b) the physiological and situational factors that affect management, and (c) the resulting consequences of management interventions. Recall that HCM is a synthesis of 2 major concepts (in bold) and their corresponding subconcepts: stimuli frame, symptom pattern, event familiarity, and event congruence (uncertainty in illness theory); and trajectory projection, trajectory phasing, biography, and reciprocal impact (trajectory framework). The interaction depicted by the dotted line in the relational diagram notates the significance of positive or negative influence of the HCMP on a person’s HCA. The dotted line also signifies the importance of ongoing assessment and communication on the part of the HCMP. Although nurses and other structure providers can positively or negatively influence perceptions and management of a health change, as defined, an HCMP engages with the patient and his or her family to develop the best possible outcomes. To be sure, due to the variability in human perceptions, not all interactions will be regarded as positive; however, clear intention on the part of the HCMP combined with sensitivity to cognitive capabilities and cultural diversity are likely to promote positive perceptions and outcomes.
IMPLICATIONS FOR NURSING RESEARCH The strength of integrating both theories into the HCT model is the synthesis of complementary concepts and the creation of new operational definitions that capture results of the synthesis. The psychometric challenge is to develop tools that accurately measure the integrated concepts. For example, exist-
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ing measures of component concepts (uncertainty and trajectory) may be combined, in whole or in part, to create a measure of the integrated concept (health change trajectory), or a totally new measure of the latter concept may be needed. Qualitative research using focus groups or patient panels provides rich data to inform construction of measurement tools for the key HCT concepts.19 Thus, initial research efforts should be focused on designing reliable and valid measures of the integrated concepts. A next step is to test the proposed relationships in the HCT model to determine whether they are consistent with patient reports of the health change experience. Researchers have used the Mishel Uncertainty in Illness Scale to observe, quantify, and develop interventions to manage uncertainty related to chronic illness.20-25 Using the HCT model, researchers can identify what antecedents of uncertainty may be the most prevalent at specific trajectory phases of health change and develop appropriate and targeted interventions. Because of variability in uncertainty appraisal, Mishel5 advocates for further research into how and when uncertainty is appraised as opportunity. Given the ability of people to see opportunity in uncertainty, researchers may ask, “What phase or phases of the health change trajectory are most likely to contain uncertainty appraised as an opportunity?” For these phases, nursing interventions directed at promoting uncertainty will likely be more appropriate than those directed at minimizing uncertainty. To promote ARs, the desired outcomes of interventions in various trajectory phases must be better understood.10 Numerous studies involving trajectory framework have been conducted.26-32 Henly et al33 proposed that use of a health trajectory perspective extends the use of the nursing metaparadigm in longitudinal research by incorporating health changes over time. Henly et al32(pS5) further emphasize: Understanding the course and causes of change in health over time allows anticipation of those
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at greatest risk for adverse trajectories and events, enhances understanding of factors that influence change in health over time, and permits examination of the effects of interventions on the trajectory, including identification of for whom and at what point in the trajectory interventions are the most effective.
Outcomes research is critical in each trajectory phase to determine the structure of interventions that result in an AR and related PS. The work by Stephenson and Berry34 in identifying measures of spirituality and uncertainty at the end of life is an example of using an identified trajectory phase to explore the lived experience. Additional research is needed to help identify patient perceptions that occur most frequently within each phase of trajectory framework. With an increased understanding of health change appraisal and how coping skills can be enhanced through nursing interventions, people dealing with health changes can be empowered to meet the challenges or opportunities that a health change presents.
IMPLICATIONS FOR NURSING EDUCATION Educators can use the HCT model to promote students’ in-depth understanding of the variations in a person’s response to alterations in health within and across trajectory phases. Students can learn how nurses, as HCMPs, can influence the subjective appraisal of a change in health (HCA) and subsequent management choices (HCM) of the people in their care. This is important because analyzing and acting on the factors that affect fluctuation in HCA and HCM will better prepare students to provide personalized care. By presenting exemplars of how the HCT model can be used in the clinical setting, educators can demonstrate the role of the HCMP and encourage students to listen for antecedents of uncertainty and intervene accordingly. For example, if uncertainty is founded in financial or employment difficul-
ties, interventions will be different than if uncertainty is founded in the lack of understanding about a medical procedure. Similarly, educators can use the HCT model to encourage interventions within a health rather than an illness framework. This places student emphasis on the promotion of health pretrajectory and on early interventions in the trajectory onset phase. Students can also learn how to associate the cognitive meaning of health change and related emotional responses to achieving an AR and PS. Through increased student awareness of health change as a potential opportunity for growth and the benefits of fostering this perception in persons receiving nursing care, another advantage of using the HCT model in nursing education can be realized. IMPLICATIONS FOR NURSING PRACTICE Structure providers—particularly nurses— are a vital part of uncertainty management in all phases of the health change trajectory. With a clear understanding of the various circumstances and ways a person may appraise a change in health, nurses can tailor interventions to meet an individual’s specific needs. For example, when addressing uncertainty in the acute or crisis phase, interventions are likely to be different from those provided in the stable phase. Contrary to common wisdom, during the crisis phase, there may actually be less uncertainty than when an illness is stable. This could be because during the more serious phases of illness, the management goal is to remove the life threat. Conversely, during the stable or comeback phase, perceptions of uncertainty may reveal heightened uncertainty as described by Elizabeth McKinley35(p470) at the completion of her breast cancer treatment: After my very last radiation treatment for breast cancer, I lay on a cold steel table hairless, halfdressed and astonished by the tears streaming down my face. I thought I would feel happy about finally reaching the end of treatment, but instead I was sobbing. At the time, I wasn’t sure what emotions I was feeling. Looking back, I think I cried
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Nursing intervention
Interpersonal Physiological, and psychological, situational and cultural influences influences Provide health Provide promotion culturally and wellness sensitive, education. personcentered education regarding medical condition. Offer psychosocial support and spiritual care.
Nursing assessment
Form appropriate trajectory projection and scheme.13
Prevent onset of chronic illness.13
Trajectory Onset
Management goal
Pretrajectory
Stable
Unstable Return to stability.13
Acute
Crisis
Bring illness Remove life under control threat.13 and resume normal biography and everyday activities.13 Physical disability, Effectiveness of injury, or illness health change management
Comeback Set in motion and keep going the trajectory projection and scheme.13 Adaptive response
Downward To adapt to increasing disability with each major downward turn.13 Disability adjustment
Provide health Provide Provide frequent Provide critical Provide methods Provide education on education and updates on care management of stress physiological strengthening interventions medical and ongoing reduction, and coping skills and to strengthen condition, communication disability psychosocial compliance with health change procedures, with patient’s management, support and health change appraisal in and treatments support network. and spiritual spiritual care. management. line with health in line with the support. change individual’s management current interventions. perceptions and cognitive ability.
Adherence to Coping skills health change management plan
Maintain stability of illness, biography, and everyday activities.13
Dying
Provide physical comfort and methods of stress reduction and spiritual support.
Perceptual shift
To bring peace and closure.13
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Table 1. Nursing Assessment and Interventions
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because this body had so bravely made it through 18 months of surgery, chemotherapy, and radiation. Ironically, I also cried because I would not be coming back to that familiar table where I had been comforted and encouraged. Instead of joyous, I felt lonely, abandoned and terrified. This was the rocky beginning of cancer survivorship for me.
ing interventions can be developed and refined as the model is used in nursing research and practice.
Foremost, any management intervention directed at uncertainty must acknowledge the individual’s appraisal of uncertainty as danger or opportunity, as interventions will be either to minimize or to support the person’s appraisal of a change in health. The nurse would not set out to minimize uncertainty if it were a person’s desired state, such as when uncertainty is perceived as opportunity and is used to maintain hopefulness. Robinson et al30 state that standardized nursing assessments are not necessarily needed in each trajectory phase because the emphasis on biography, everyday life activities, and illness evaluation will vary within each phase. Fluid nursing assessments that consider CMA and health change appraisal may challenge old paradigms. However, personalized care can happen only when each person’s unique perceptions are considered in the overall plan of care. Showcased in Table 1 are possible goals, assessments, and interventions that can be applied to each phase of the HCT model. Phase-specific nurs-
Both uncertainty in illness theory and trajectory framework are stand-alone theories that have proven to be useful in nursing research, education, and practice. The existence of a synergistic relationship between both theories is reflected in the integrated statements and new terminology created through the concept synthesis and development of the HCT model. Furthermore, use of the proposed operational definitions can extend the use of trajectory framework beyond the chronic illness perspective. Framing and acting upon uncertainty or other observed health-related concepts within a health change trajectory has significant application within the nursing profession. Specifically, researchers can evaluate a variety of healthrelated concepts within trajectory framework to better understand perceptions, coping methods, and nursing interventions that may be applicable in specific practice settings. Phase-specific interventions can shape the health trajectory positively and optimize selfmanagement, adaptation, and quality of life.
CONCLUSION
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