Select A Concept Analysis From The Assigned Readings And Explain How The Findings Apply To Advanced Nursing Practice.

C L I N I C A L S T U D Y

Validation of the Mishel’s uncertainty in illness scale-brain tumor form (MUIS-BT)

Lin Lin • Alvina A. Acquaye • Elizabeth Vera-Bolanos •

Jennifer E. Cahill • Mark R. Gilbert •

Terri S. Armstrong

Received: 4 May 2012 / Accepted: 3 September 2012 / Published online: 11 September 2012

� Springer Science+Business Media, LLC. 2012

Abstract The Mishel uncertainty in illness scale (MUIS)

has been used extensively with other solid tumors throughout

the continuum of illness. Interventions to manage uncer-

tainty have been shown to improve mood and symptoms.

Patients with primary brain tumors (PBT) face uncertainty

related to diagnosis, prognosis, symptoms and response.

Modifying the MUIS to depict uncertainty in PBT patients

will help define this issue and allow for interventions to

improve quality of life. Initially, 15 experts reviewed the

content validity of the MUIS-brain tumor form (MUIS-BT).

Patients diagnosed with PBT then participated in the study to

test validity and reliability. Data was collected at one point in

time. Six out of 33 items in the original MUIS were modified

to better describe PBT patients’ uncertainty. 32 of the 186

patients in the second-stage of the study were newly diag-

nosed with PBT, 85 were on treatment, and 69 were fol-

lowed-up without active treatment. The validity of the

MUIS-BT was demonstrated by its correlations with mood

states (P \ 0.01) and symptom severity (P \ 0.01) and interference (P \ 0.01). The MUIS-BT measures four con- structs: ambiguity/inconsistency, unpredictability of disease

prognosis, unpredictability of symptoms and other triggers,

and complexity. Cronbach’s alphas of the four subscales

were 0.90, 0.77, 0.75 and 0.65, respectively. The 33-item

MUIS-BT demonstrated adequate select measures of valid-

ity and reliability in PBT patients. Based on this initial val-

idation and significant correlations with symptom distress

and mood states, further understanding of uncertainty and

evaluation of measures to help manage patients’ uncertainty

can be evaluated which in turn may improve coping and

quality of life.

Keywords Brain tumors � Quality of life � Self-report instruments � Symptoms � Uncertainty

Introduction

Primary brain tumors (PBTs) such as gliomas are a heter-

ogenous group of neoplasms associated with significant

morbidity and mortality. Glioblastoma multiforme (GBM)

is the most common and aggressive malignant glioma, and

treatment includes surgical resection, combined radiation

and temozolomide chemotherapy and then with monthly

cycles of temozolomide for up to one year [1, 2]. Once

initial treatment is completed, patients then undergo peri-

odic clinical follow-up with MRI to evaluate disease status.

At the time of recurrence, repeat tumor resection or che-

motherapy may be prescribed. Typically for recurrent

tumors, treatment is continued again until tumor progresses

or clinical symptoms mandate a change in therapeutic

approach.

Uncertainty, a person’s lack of ability to determine the

meaning of illness-related events [3], pervades the illness

trajectory of PBTs. Nearly all patients have disease pro-

gression at some point either during or after completing

L. Lin � J. E. Cahill � T. S. Armstrong Department of Family Health, School of Nursing,

The University of Texas Health Science Center at Houston,

6901 Bertner Ave., Houston, TX 77030, USA

L. Lin (&) Department of Family Health, School of Nursing,

The University of Texas Health Science Center at Houston,

6901 Bertner Ave., Room 795, Houston, TX 77030, USA

e-mail: lin.lin@uth.tmc.edu

A. A. Acquaye � E. Vera-Bolanos � M. R. Gilbert � T. S. Armstrong

Department of Neuro-Oncology, The University of Texas M.D.

Anderson Cancer Center, Houston, TX, USA

123

J Neurooncol (2012) 110:293–300

DOI 10.1007/s11060-012-0971-8

 

 

initial therapy. Median survival is less than 15 months for

those with GBM [4]. However, with concurrent temozol-

omide and radiation therapy followed by adjuvant tem-

ozolomide, about 10 % can control disease for 5 years or

longer [5]. For those with low grade gliomas, survival is

also measured in years, with the potential for malignant

transformation. Currently, there is no confirmable way to

predict based on clinical, tumor, or imaging characteristics

the clinical course or prognosis for PBT patients.

Additionally, evaluation of response to treatment is com-

plicated, a consequence of current limitations of sensitivity of

neuroimaging. For example ‘‘pseudoprogression’’ on MRI,

consisting of increased enhancing tumor size on MRI is often

difficult to distinguish from true progression [6, 7]. Often, if

imaging changes are equivocal, treatment will be continued

and repeat imaging with MRI will be performed after several

weeks. These treatment and evaluation approaches, often

result in increased uncertainty for the patient.

Anecdotally, patients report exacerbation of symptoms

and intrusive thoughts about disease progression prior to

the MRI visit, which is similar to breast cancer survivors’

experience before the mammogram checkup [8]. Because of

the likelihood of disease progression, emotional response to

uncertainty such as anxiety may be worsened when patients

with symptoms are waiting for MRI data or if they are

undergoing clinical follow-up without imaging during

treatment. The impact of uncertainty on multidimensional

aspect of quality of life has been explored in instruments such

as the European Organization for Research and Treatment

of Cancer Quality of Life Questionnaire-C30 (EORTC

QOL-C30) [9] and the Functional Assessment of Cancer

Therapy (FACT) [10, 11]. However, the sources and triggers

of uncertainty through the illness trajectory of cancer are not

identified contextually in these instruments.

The core Mishel uncertainty in illness scale (MUIS) [12]

has been used extensively with cancer patients during the

diagnostic and treatment phases. Mishel [13] further

modified the MUIS to measure unremitting uncertainty

about life changes in chronic illness and enduring uncer-

tainty about the possibility of recurrence in long term

cancer survivors. However, patients with brain tumors

usually stay ill constantly and rarely reach cancer-free

survivorship after initial treatment [1, 5]. The illness situ-

ations remain ambiguous, complex, unpredictable, and

with unavailable and inconsistent information through the

entire disease trajectory. The nature of continuous uncer-

tainty after diagnostic and acute phases in brain tumor

patients is different from uncertainty observed in patients

with other chronic illnesses or in cancer survivors, as the

disease is not curable. Modifying the MUIS for patients

with PBTs offers an opportunity to depict illness-related

uncertainty in patients with ongoing life-threatening con-

ditions such as those cancers with small possibility of cure.

According to Mishel [14], the erratic nature of symptom

onset and disease progression is a significant antecedent of

uncertainty. Patients with PBTs may feel uncertain about

how to manage symptoms as well as worry about the

duration of symptoms and their relation to the progression

of disease. In turn, patients experiencing uncertainty may

perceive a higher symptom severity and their interference

with function. This study evaluates the validity and reli-

ability of the modified MUIS for PBT patients (MUIS-

brain tumor form). By using an adequate measurement to

evaluate patients’ cognitive state of uncertainty and its

impact on mood state, symptom severity and symptom

interference, health care providers may facilitate coping as

well as improve current symptom management protocols or

develop other targeted interventions for patients with

PBTs. Moreover, this scale may be used as an outcome

measure of clinical trials testing interventions to manage

uncertainty and its impact on symptoms, mood and quality

of life.

Methods

Participants and procedure

The original items of MUIS were generated from the

interviews with hospitalized patients [12]. Validation of the

MUIS-BT consisted of several steps. Initially, a panel of 15

experts including neurosurgeons, radiation oncologists,

neuro-oncologists, nurses, and social workers evaluated the

relevance of the items of the original MUIS. The content

validity index (CVI) was then calculated for each item to

assure all items were deemed relevant [15].

To further evaluate the feasibility, reliability, and

validity of the MUIS-BT, 186 patients participated in the

second stage of the study. Sample size was primarily based

on the ability to assess the internal consistency, with at least

5 patients per item. All participants were recruited from

M.D. Anderson Cancer Center (MDACC) Brain and Spine

Clinic. The entry criteria included the following: the patient

was (a) C18 years of age, (b) able to speak, read, and write

English, (c) confirmed diagnosis of a primary brain tumor,

and (d) without cognitive deficits such as aphasia or other

alteration in mental status, as determined by the treating

physician, that would preclude the ability to self-report

uncertainty and symptoms or provide informed consent.

A trained data collector recruited convenience samples

after screening the eligibility. Patients answered the ques-

tionnaires before being examined by the physician/nurse

practitioner or results of MRI examination or other tests are

given on the day consent is provided. All questionnaires

except clinical assessment tool were completed only by the

patient, unless changes in vision or weakness make this

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difficult. For these circumstances, the data collector read

the questions to the patient or assisted with answering the

questionnaires and used a standardized script and prompt-

ing questions to avoid bias.

Instruments

The Mishel’s uncertainty in illness scale-brain tumor form

(MUIS-BT), the modified 33-item MUIS [12] was used to

measure uncertainty, the inability to determine the meaning

of illness-related events. MUIS-BT employs a 5-point,

Likert scale in which 1 = ‘‘strongly disagree’’ to

5 = ‘‘strongly agree.’’ After reversing scoring appropriate

items, a total score is calculated by summing up all the

items, with higher scores indicating greater perceived

uncertainty. Reports on the validity and reliability are

published [12, 16, 17].

The M. D. Anderson Symptom Inventory-Brain Tumor

Module (MDASI-BT) consists of 22 symptoms rated on an

11-point scale (0 to 10) to indicate the presence and

severity of the symptom, with 0 being ‘‘not present’’ and 10

being ‘‘as bad as you can imagine.’’ Each symptom is rated

at its worst in the last 24 h. The MDASI-BT also includes

ratings of how much symptoms interfered with different

aspects of a patient’s life in the last 24 h. The interference

items are also measured on 0–10 scales. The scale dem-

onstrates validity and reliability in patients with PBTs [18].

Mood was assessed using the Profile of Mood States-

Short Form (POMS-SF). The original 65-item profile of

mood state was developed to assess transient distinct mood

states [19]. The scale consists of six factors, tension-anxi-

ety, depression-dejection, anger-hostility, fatigue-inertia,

vigor-activity, and confusion-bewilderment. The 37-item

short form (POMS-SF) of the POMS was developed by

Shacham [20] for physically ill subjects such as patients

with cancers. The short form retained the six subscales and

the validity and six-subscale structure and internal consis-

tency have been examined [20, 21].

The Demographic Information Sheet collected study

participant gender, ethnicity, age, level of education, mar-

ital status, religious background, and employment status.

The Clinical Assessment Tool which includes informa-

tion on tumor type; disease status (newly diagnosed, on

treatment, or on follow-up without active treatment); tumor

location; tumor bi-dimensional measurement; concurrent

medications; type of visit (clinical evaluation or MRI visit);

and performance status.

Statistical analyses

We used descriptive statistics with IBM SPSS Statistics 19

to describe how patients rate uncertainty, mood, symptom

severity and interference with function. Feasibility of the

MUIS-BT was assessed in terms of the time needed to

complete the instrument and the percentage of missing

values for items.

The content validity index was calculated after the ori-

ginal items in MUIS were reviewed by 15 experts to assure

the representativeness of the scale, with results noted pre-

viously that each item measures its respective content

domain well. Criterion-related concurrent validity was

assessed by testing the correlation between uncertainty and

symptom severity and symptom interference. A multitrait–

multimethod approach was also used to valid MUIS by

examining the relationships between uncertainty and the

subscales of POMS-SF. It was anticipated that uncertainty

should have positive correlations with anger, confusion,

depression and tension subscales and negative correlation

with vigor subscale [22].

Construct validity was further examined by factor

analysis using IBM SPSS Statistics 19. Exploratory factor

analysis (EFA) was performed to reduce the information

from all the variables into significant ‘factors.’ Principal

axis factoring with an oblimin rotation, promax with

Kaiser normalization, was undertaken to evaluate the

covariance of items and to identify derived factors. Item

loadings of [0.3 were considered adequate [23]. Each item then was evaluated for the loadings on the identified fac-

tors. Finally, reliability of the MUIS-BT was determined

by calculation of internal consistency. We calculated

Cronbach’s alphas, item-total correlations, and inter-item

correlations on identified factors determined by EFA. An

a priori criterion of 0.7 was used to assess evidence of

reliability [23].

Results

Demographics

A total of 186 patients with PBTs were recruited in this

study. Participants were primarily white (80 %) males

(53 %) with a diagnosis of glioblastoma (42 %). They

ranged in age from 19 to 80 (mean = 44.2). Thirty-two

(17 %) of the 186 patients were newly diagnosed with

PBTs, 85 (46 %) were on treatment, and 69 (37 %) were

followed-up without active treatment. Only six patients

refused to participate when approached by the research

assistant. Table 1 presents the demographics and the dis-

ease-related characteristics of the patient sample.

Feasibility

The instrument is considered feasible if 90 % of patients

complete all items on the questionnaire and the question-

naire and completion is in \10 min. We only assessed this

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Table 1 Demographic and clinical characteristics

Demographic characteristics n % Clinical characteristics n %

Gender Patient group

Female 87 46.8 Newly diagnosed 32 17.2

Male 99 53.2 On treatment with MRI 64 34.4

On treatment without MRI 21 11.3

Follow-up without active treatment 69 37.1

Marital status Recurrence

Divorced, separated, widowed 19 10.2 Yes (first time) 57 30.6

Married 139 74.7 Yes (repeated) 17 9.1

Single 28 15.1 No 112 60.2

Employment status Diagnosis

Employed (part-time, full-time, homemaker) 94 52.2 Astrocytoma 44 23.8

Employed (sick leave, disability) 24 13.3 Oligodendroglioma 38 20.5

Retired 18 10.0 Oligoastrocytoma 8 4.3

Unemployed due to diagnosis of tumor 31 17.2 Ependymoma 4 2.2

Unemployed (prior to diagnosis, student) 13 7.2 Glioblastoma and gliosarcoma 81 43.8

Other 10 5.4

Hispanic Grade

Yes 172 92.5 Grade I 3 1.6

No 13 7.5 Grade II 38 20.7

Grade III 59 32.1

Grade IV 84 45.7

Ethnic background Location

Asian or Pacific Islander 11 6.4 Infratentorial 8 4.3

Black 10 5.8 Supratentorial 178 95.7

Native American or Alaskan native 3 1.7

White 149 86.1 Location (side)

Left 103 55.4

Level of education Right 78 41.9

Some high school 6 3.2 Midline 5 2.7

High school graduate 28 15.1

Some college 46 24.7 Surgery type

College graduate 53 28.5 Biopsy 52 28.1

Post-graduate/advanced degree 53 28.5 Partial resection 63 34.1

Gross total resection 70 37.8

Household income Results of MRI

$100,000 or more 59 36.0 Response 4 2.2

$50,000 to $99,999 51 31.1 Stable 116 63.0

$30,000 to $49,999 27 16.5 Progression 27 14.6

Less than $30,000 27 16.5 Newly diagnosed 37 20.2

KPS

60–100 186 100.0

B80 36 19.4

C90 150 80.6

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in patients who completed the instrument without assis-

tance. All patients who answered the questionnaire package

by themselves spent less than 10 min on MUIS-BT. Only

six of the 186 patients did not fully complete the MUIS-

BT.

Content validity

In MUIS-BT, 6 out of 33 items in the original scale were

modified to better describe PBT patients’ uncertainty based

on the suggestions from a panel of 15 experts. The modi-

fications are minimal. Examples of the changes are: from

‘‘The results of my tests are inconsistent’’ to ‘‘The results

of my tests are inconsistent or unclear’’ and from ‘‘It is

unclear how bad my pain will be’’ to ‘‘It is unclear how bad

my symptoms will be.’’ The content validity index was

calculated for each item, with 29 out of 33 items scoring

0.8 or greater, and the wording of the remaining 4 was

modified to assure relevance [15].

Criterion-related validity

The MUIS-BT was demonstrated criterion-related validity

by its significant correlations with mood state (P \ 0.01) and symptom severity (P \ 0.01) and symptom interfer- ence (P \ 0.01). Also, MUIS-BT is positively correlated to five POMS-SF subscales of negative moods (all with

P \ 0.01) and negatively correlated with vigor subscale (P \ 0.01) [24].

Exploratory factor analysis

Ambiguity, inconsistency, complexity, and unpredictability

are the four fundamental factors of uncertainty in Mishel’s

theory [3, 12]. For MUIS-BT, a four-factor structure gen-

erated by EFA covered 50 % of the variance of the scale.

However, in MUIS-BT, ambiguity and inconsistency

merged into one factor. Only four questions stayed in the

complexity subscale compared to seven in the original

MUIS. Several items belonging to ambiguity and com-

plexity subscales in the original MUIS became unpredict-

ability-related items. The four factors of the MUIS-BT

includes: ambiguity/inconsistency; unpredictability of dis-

ease prognosis; unpredictability of symptoms and other

triggers; and complexity (see Table 2).

Reliability

We examined the internal consistency of the four subscales

of the MUSI-BT by calculating the coefficient alphas.

Alphas for the four factors were 0.90 (ambiguity or

inconsistency), 0.77 (unpredictability of disease prognosis),

0.75 (unpredictability of symptoms and other triggers), and

0.65 (complexity). Overall, these results indicate a high

level of reliability for MUIS-BT.

Discussion

Results of this study indicate that the MUIS-BT has

acceptable psychometric integrity. The instrument offers

health care providers an approach to measure the nature of

uncertainty during and after diagnostic and acute phases of

PBTs. It further provides an opportunity to evaluate the

impact of uncertainty on patients’ physical outcomes such

as symptom severity and interference as well as psycho-

logical outcomes such as moods. Also, the instrument has a

potential to be modified for measuring caregiver’s uncer-

tainty similar to the Parent Perception of Uncertainty Scale

(PPUS) measuring parents’ response to their child’s illness

and hospitalization [25].

The study is limited by its cross-sectional nature. For

this initial development and validation stage, it was

important to include a sample representative of the entire

illness trajectory. Additional analyses will be performed to

evaluate the important relationship of each factor in newly

diagnosed patients, those on therapy with and without

recurrence, and those in long term follow-up. Overall,

psychometric properties evaluated in this report were

adequate, including evidence of content, construct, and

criterion validity, as well as internal consistency. The

reliability of the complexity subscale did not meet the

a priori criterion of 0.7. However, the small number of

items in this subscale, as well as the varied treatment

approaches and time since diagnosis may have impacted

this result.

There are no existing treatment regimens that lead to an

absolute cure for PBTs. The possibility of disease pro-

gression is high after initial postoperative treatment and the

primary method of surveillance for disease progression and

evaluating treatment response is brain MRI. However,

there are several limitations to MRI evaluation, including

differences in image quality, magnet strength, and patient

positioning that make image to image comparisons difficult

[26]. Additionally, the results of MRI may show a

‘‘pseudoprogression’’ that is difficult to distinguish from

progressing tumor [6, 7]. Some therapies cause changes in

imaging characteristics that may not correlate with tumor

response or failure. Regardless of the possibility of

pseudoprogression or pseudoresponse in MRI evaluation,

uncertainty may heighten when patients are waiting for

MRI data or excluded from the discussion of the MRI

evaluation but undergoing therapy.

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Interestingly, more items in MUIS-BT belong to unpre-

dictability than in the original MUIS. The structure of the

MUIS-BT presents the reality that patients feel the cues

about the state of the illness are vague and indistinct and

the information concerning diagnosis and seriousness of the

disease are inconsistent or deficient. Even though the

Table 2 Pattern matrix of the exploratory factor analysis

Factors MUIS-BT items Factor loadings

Factor 1 Factor 2 Factor 3 Factor 4

Factor 1:

a = 0.90

Ambiguity and

inconsistency

11. The doctors say things to me that are confusing 0.846 -0.115 -0.103 0.076

22. The results of my tests are inconsistent or unclear. (1) 0.783 -0.104 0.014 0.179

14. It is hard to know if the treatments or medications I am getting are

helping me

0.740 -0.157 0.076 0.052

13. My treatment is too hard for me to figure out 0.705 0.054 -0.104 0.153

05. I do not understand what they have told me about my illness 0.685 0.047 -0.169 0.061

15. There are so many different types of staff; it is unclear who is

responsible for what. (2)

0.683 -0.120 0.059 -0.007

18. I don’t know how to manage my side effects from treatment 0.624 -0.009 0.012 0.083

19. I have been told different things about what is wrong with me 0.562 -0.039 0.093 0.036

02. I have a lot of question without answers 0.562 0.350 -0.115 -0.128

08. I do not know when to expect things (e.g. treatment, tests, etc.) will be

done to me. (1)

0.550 0.190 -0.021 0.087

01. I don’t know what is wrong with me 0.544 0.070 -0.268 0.037

29. They have not given me a specific explanation of my illness 0.504 0.061 -0.036 0.135

24. I don’t know when I will be able to care for myself 0.471 0.045 0.229 0.034

16. Because my condition keeps changing, I cannot plan for the future 0.431 0.127 0.281 -0.075

03. I am unsure if I am getting better or worse 0.423 0.310 0.181 -0.057

21. I usually know if I am going to have a good or bad day. (3) -0.324 0.303 0.266 0.133

Factor 2:

a = 0.77

Unpredictability of

disease prognosis

25. I generally know the course of my illness -0.139 0.680 0.149 0.061

07. When I have symptoms, I know what these mean about my

condition. (1,5)

0.037 0.573 -0.020 0.113

12. I know how long my illness will last 0.107 0.535 0.052 -0.263

20. It is not clear what is going to happen to me. (4) 0.294 0.450 0.211 -0.215

06. The purpose of each treatment is clear to me. (5) 0.069 0.424 -0.271 0.193

04. It is unclear how bad my symptoms will be. (1,4) 0.302 0.398 0.098 -0.124

10. I understand everything explained to me. (5) 0.282 0.359 -0.103 0.244

Factor 3:

a = 0.75

Unpredictability of

symptoms and

other triggers

23. I don’t know if my treatment(s) will work. (4) 0.324 -0.081 0.606 -0.013

17. The course of my illness keeps changing. I have good and bad

days. (4)

0.474 -0.058 0.504 -0.101

27. I am certain they will not find anything else wrong with me -0.177 0.053 0.501 0.113

30. My symptoms are predictable; I know when I will feel better or

worse. (1)

-0.349 0.322 0.492 0.324

26. Because of the treatment(s), what I can do and cannot do keeps

changing. (4)

0.324 -0.109 0.491 0.033

09. My symptoms continue to change off and on. (4) 0.129 0.146 0.333 0.165

Factor 4:

a = 0.65

Complexity

31. I can depend on the medical team to be there when I need them. (1) 0.142 0.009 0.208 0.572

28. The treatment(s) I am receiving has helped other people before 0.178 -0.023 0.172 0.557

32. I know how serious my illness is 0.161 0.059 -0.021 0.507

33. The doctors and nurses use words that I can understand 0.076 -0.081 0.100 0.400

(1) These items are modified from the original MUIS; (2) This item is eliminated from the 4-factor form of the original MUIS; (3) This item

belongs to the unpredictability factor in the original MUIS; (4) These items belong to the ambiguity factor in the original MUIS; (5) These items

belong to the complexity factor in the original MUIS

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treatment protocols of PBTs are comparatively uncompli-

cated and clear, patients are full of uncertainty as a conse-

quence of the inability to make daily or future predictions

concerning symptomatology and illness outcome. An

example of items measuring unpredictability of disease

prognosis is ‘‘I know how long my illness will last,’’ and an

example of measuring unpredictability of symptoms and

other triggers is ‘‘My symptoms are predictable; I know

when I will feel better or worse.’’

The development of the MUSI-BT is the first step in a

program of research concerning managing uncertainty and

symptoms in PBT patients. The 33-item MUIS-BT has

demonstrated select measures of validity and reliability in

this population. Further validation of the instrument,

including repeated measures over time to further evaluate

instrument sensitivity to treatment status will be completed

in order to depict uncertainty throughout the disease tra-

jectory. The identified factors lend themselves to structured

evaluation of interventions related to the underlying

domains. For example, targeted symptom interventions

may impact situational uncertainty, whereas, cognitive re-

framing may impact prognostic unpredictability or

ambiguity.

For patients with PBTs, symptoms triggering the pos-

sibility of illness recurrence or progression are intrusive,

vacillate randomly, and may be uncontrollable and unpre-

dictable. Furthermore, the effects of cancer therapies result

in uncertainty about how to manage symptoms, how long

they will last, and what impact they will have on daily life.

Patients with PBTs endure unpredictable and inconsistent

symptoms, continual questions about illness recurrence or

progression, possible impact on life goals, and an unknown

future. Persistent uncertainty becomes a source of chronic

stress that can increase patients’ symptom severity and

interference with function as well as intensify negative

moods [24, 27]. Through evaluating patients’ uncertainty

and its impact on symptom distress and mood disturbance,

an uncertainty management intervention may improve the

current symptom management protocol and lessen the

psychological distress for patients with PBTs.

Acknowledgments This study is supported by the Elizabeth W. Quinn Oncology Research Award from the University of Texas

Health Science Center at Houston, School of Nursing. The authors

would like to thank the research subjects for their participation. The

authors would also like to thank the clinical experts and Dr. Mishel

for evaluating the content validity of MUIS-BT.

Funding This study is supported by the Elizabeth W. Quinn Oncology Research Award from the University of Texas Health

Science Center at Houston, School of Nursing.

Conflict of interest None.

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