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European Journal of Oncology Nursing 18 (2014) 52e57

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European Journal of Oncology Nursing


journal homepage: www.elsevier.com/locate/ejon

Psychometric properties of the Persian version of the Mishel’s


Uncertainty in Illness Scale in Patients with Cancer
Moosa Sajjadi a, b, Maryam Rassouli a, c, *, Abbas Abbaszadeh d, Hamid Alavi Majd e,
Kazem Zendehdel f
a
Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b
Gonabad University of Medical Sciences, Gonabad, Iran
c
Pediatric Nursing Department, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Vali-e Asr Street, Niyayesh Cross, Tehran, Iran
d
Department of Nursing, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
e
Department of Biostatistics, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
f
Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran

a b s t r a c t
Keywords: Purpose: Uncertainty is a major component in the illness experiences which extraordinarily can affect
Uncertainty in illness the psychological adjustment and the illness outcomes. Uncertainty in illness is defined as inability to
MUIS-A
define the illness-related events to the illness or disability in predicting the illness outcomes. The present
Psychometrics
Cancer
study aimed to translate the Persian version of Uncertainty in Illness Scale (MUIS-A) and to investigate its
Confirmatory factor analysis psychometric properties on patients with cancer.
Method: In this methodological study, validation of the Persian version of MUIS-A was performed in Iran
on 420 cancer patients attending two major hospitals in Tehran, Iran. The scale was translated into
Persian and back translated into English and revised according to editorial comments of the scale de-
signers. Then, content and face validity, construct validity, internal consistency reliability and stability of
the Persian version were measured. Data were analyzed using SPSS version 16 and LISREL 8.5.
Results: Mean of the participants MUIS-A score was 90.1 (16.8). Confirmatory factor analysis confirmed
validity of the whole instrument and its four subscales. The consistency of the instrument with a three-
week interval was r ¼ 0.91. Cronbach’s alpha was 0.89 for the whole scale of 32 MUIS-A items and
a ¼ 0.58e0.86 for its four factors.
Conclusions: The Persian version of the MUIS-A has good psychometric properties. It can be used to
assess uncertainty in illness in Iranian patients with cancer.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction the patient cannot determine the value of events or cannot accu-
rately predict the disease outcome due to the lack of sufficient cues”
Uncertainty is a natural part in the illness experience and can (Mishel, 1988).
occur at all stages of disease including diagnosis, treatment and Uncertainty occurs when the individuals cannot form a cogni-
prognosis of the disease. Uncertainty in illness occurs when the tive framework for understanding their status and interpreting
patient is unable to determine the meaning of illness-related illness related events (Bailey et al., 2011; Mishel, 1990, 2013).
events; therefore, it is considered a major cause of psychological Therefore, in most cases, it is accepted as a major stressor that most
stress to the patients (Mishel, 1997a, 2013), that can leave major people seek to reduce and to learn methods to cope with (Neville,
impacts on the psychological adaptation and outcomes of the dis- 2003). Chronic diseases are a long term and intense source of
ease (Neville, 2003). Uncertainty in illness is defined as the psychological stress that influences all aspects of patients’ life and
“inability to determine the meaning of illness-related events when reduces their daily activities and quality of life (Flemme et al.,
2005). Furthermore, various studies have been conducted on
chronic patients such as patients with cardiovascular diseases,
* Corresponding author. Pediatric Nursing Department, Nursing & Midwifery
dialysis, hepatitis, liver transplantation, AIDS and Alzheimer’s
School, Shahid Beheshti University of Medical Sciences, Vali-e Asr Street, Niyayesh
Cross, Tehran, Iran. Tel.: þ98 21 88655372; fax: þ98 21 88202521. whose results indicate that uncertainty exists in these patients and
E-mail address: Rassouli.m@gmail.com (M. Rassouli). can lead to reduction in quality of life and the ability to cope with

1462-3889/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejon.2013.09.006
M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57 53

illness (Bailey et al., 2009; Brashers et al., 2004; Flemme et al., and its Persian version has been validated among patients with
2005; Lasker et al., 2010; Madar and Bar-Tal, 2009; Mauro, 2010; cancer. The study population was all the cancer patients attending
Sodowsky, 2012). the clinics and oncology wards of Imam Khomeini Hospital (Iran’s
Cancer, as one of the chronic diseases, is the second leading cause largest cancer center) and Taleghani Hospital in Tehran. Given
of death in the West (Shaha et al., 2008). It is the third cause of death these centers accept patients from all over the country, results of
in Iran after heart diseases and car accidents. Based on the recent the study can be better generalized to the society. Convenient
statistics, the rate of cancer incidence in Iran is about 107 people in sampling was performed in order to achieve a sufficient sample
100,000 people (more than 80,000 people considering Iran’s 75- size to conduct a confirmatory factor analysis. The inclusion
million population). It is predicted that with regard to the raise of criteria were willingness to participate in research, cancer diag-
environmental pollution, increasing the elderly (aging community) nosis by the oncologist, being aware of one’s illness, being Iranian,
and population growth, coming decades will witness an increasing the ability to understand and speak Persian, the minimum age of
trend in cancer so that it becomes a principle health problem in Iran 21 years, and absence of other serious illnesses and no history of
(Rasaf et al., 2012). Today, advances in cancer diagnosis and treat- serious mental disorders (such as schizophrenia). Type and stage
ment technology has led to an increase in patients’ survival, and one of cancer and treatment type were not the inclusion criteria of this
of the important points in the care of these patients is to notice and study. Based on these criteria, eventually 420 individuals were
improve the quality of life (Stewart et al., 2010b). chosen.
From the diagnosis time to the onset of treatment, patients with
cancer suffer from high levels of emotional tension (Chen et al.,
2010). Due to the complexities of treatment and symptoms, pa- Scale translation
tients experience some levels of uncertainty about illness which
originates from problems related to the inability to perform daily In this study, translation and validation of the instrument was
activities, inadequate treatment, and concerns about the relapse of performed based on the suggested model by Wild et al. (2005).
the disease (Haisfield-Wolfe et al., 2012). Various studies have been After obtaining written permission from the original designer of the
conducted in the field of uncertainty in illness in different types of scale, the original scale was translated into Persian by two people
cancer in other countries (mainly Western countries) (Detprapon fluent in English and Persian. Then the two translations were
et al., 2013; Haisfield-Wolfe et al., 2012; Harrow et al., 2008; Kur- compared and the final version was prepared with a few modifi-
ita et al., 2013; Parker et al., 2013; Shaha et al., 2008; Sherman and cations. Then, the final translated version was given to two people
Simonton, 2010; Stewart et al., 2010a; Woodgate and Degner, fluent in both languages of English and Persian (one native English
2002). The ultimate goal of these studies is to help the patients (or speaker), who were not in contact with the first people to translate
their families) to effectively manage uncertainty so that its negative it back into English. Then, the back-translation was contrasted by a
effect on the patient’s psychological adaptation is reduced (Stewart supervisor with translations of the original scale in terms of simi-
et al., 2010b). Nurses are frequently in contact with the patient, thus larity of translations, and some minor revisions were made in
they are in the best position to reduce uncertainty in patients by statements of the Persian version. Afterward, validation process of
providing information and promoting patients’ understanding of the translated scale was performed by assessing face and content
health (Madar and Bar-Tal, 2009). validity, construct validity (using confirmatory factor analysis),
In order to conduct interventions to reduce uncertainty in patients reliability, and internal consistency.
with cancer and to measure effectiveness of these interventions, a
scale is needed to measure it. There are various scales for uncertainty Content validity
assessment in different patients and groups (Lin et al., 2012; Mishel,
1997b; Pai et al., 2007; Stewart et al., 2010a). One of the convenient In order to examine the content validity index (CVI), the
and widely used scales is Mishel Uncertainty in Illness Scale-Adult translated scale was given to ten people (a specialist in clinical
form (MUIS-A). MUIS-A is a valid and reliable scale and has been psychology, an oncologist, two psychiatric nurses, two oncology
used in several studies. This instrument contains 32 items on Likert nursing instructors, four nursing assistant professors with
scale from 1 (strongly disagree) to 5 (strongly agree) points and oc- experience in instrument development) to review that and
curs in four dimensions of ambiguity, complexity, inconsistency, and provide their correctional comments. They also investigated and
unpredictability. The instrument scores between 32 and 160, and affirmed face validity of the translated scale. Then, the scale was
earning more points shows greater uncertainty (Bailey et al., 2009; given to 10 patients with cancer to express their idea about
Mishel, 1997b). MUIS-A has a good internal consistency with Coro- simplicity of use, and understandability of words and phrases.
nbach’s alpha of 0.87 for the whole instrument, 0.86 for the subscales The Persian version was finalized without much change in its
of ambiguity (13 items), 0.81 for complexity (7 items), 0.78 for sentences.
inconsistency (7 items), and 0.65 for unpredictability (5 items). This
scale has been translated into different languages and its validity and
reliability have been studied (Mishel, 1997b). Data collection
Despite the importance of the concept of uncertainty in illness
in cancer patients, no valid and reliable tool exists in this regard in To collect the data, after choosing eligible patients and
Iran. Therefore, this study was conducted with the aim of trans- explaining the study objectives and methods, the informed consent
lation and psychometric properties of the Persian Version of was obtained from them. Next, the questionnaire including de-
“Mishel Uncertainty in Illness Scale” in cancer patients. mographics (age, sex, educational level, marital status, occupation,
place of residence, type of illness, type of treatment, time of diag-
Methods nosis) and MUIS-A scale were given to them to complete.
Completion of the questionnaire took about 20e25 min. For illit-
Procedures erate people, the questionnaire was read and patients’ answers
were marked by the researcher. Investigating validity of the MUIS-A
The present study is a methodological research (LoBiondo- construct and the model fitness was conducted by confirmatory
Wood et al., 2006) through which the MUIS-A scale is translated factor analysis (CFA) using LISREL statistical software version 8.5.
54 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57

Construct validity The best method used to evaluate the internal consistency is
Cronbach’s alpha (Polit and Beck, 2013). The Cronbach’s alpha of
CFA is a structural equation modeling technique which is used to about 0.7 is sufficient, and of >0.80 indicates high internal con-
determine the goodness of fit between a hypothesized model and sistency of the tool (Polit and Beck, 2013). The reliability was
the data obtained from study samples (Kline, 2010). Maximum measured by Pearson’s or Spearman’s correlation coefficients in
likelihood algorithm was used to evaluate the fitness of the model. testeretest on 15 patients with a three-week interval. Usually, the
There are several fit indices for deciding on the goodness of fit of time interval of 2e3 weeks is appropriate between two tests
the model and it is recommended that different indices be used (Hawthorne et al., 2011; Polit and Beck, 2013).
(Brown, 2006; Seo et al., 2004). In this study, indices of fit chi-
square, root mean error of approximation (RMSEA), goodness-of-
fit index (GFI), comparative fit index (CFI), adjusted goodness-of-fit Results
index (AGFI), and standardized root mean square residual (SRMR)
were used. One of the most used indexes is chi-square. Because this A total of 420 questionnaires were analyzed. Demographic
index is related to the sample size, ratio of chi-square to degrees of characteristics of the study sample are shown in Table 1. Content
freedom is used, where values less than 2 indicate a good fit of the validity index was measured on relevance, clarity, and simplicity of
model. Another important index is the RMSEA, where values less the translated scale as 0.98, 0.95, and 0.96, respectively.
than 0.08 are acceptable and less than 0.05 indicates good fit of the Table 2 shows mean and standard deviation of the overall scores
model. Researchers are advised to report the confidence interval of MUIS-A and its dimensions. In order to have a better comparison
(Kline, 2010; Seo et al., 2004). Another important index is SRMR, between the present scale and the original one, data of the present
whose acceptable value is 0.06 or less (Brown, 2006; Kline, 2010). study were compared to the combined multiple studies on patients
Appropriate values are >0.9 for CFI and GFI, and >0.85 AGFI with cancer (Mishel, 1997b). The results show that mean of the
(Bentler, 1990; Helsen et al., 2013). overall score of uncertainty in illness in the present study (90.1) is
greater than that of the combined sample of cancer patients pro-
posed by Mishel (79.5). Coefficient of Cronbach’s alpha was 0.89 for
Reliability the overall scale, and 0.58e0.86 for its dimensions (Table 2). The
correlation coefficient testeretest reliability for MUIS-A was 0.91
Internal consistency and reliability were measured using SPSS (p < 0.001). Correlation coefficients for subscales of ambiguity,
software version 16. Scale internal consistency was measured by complexity, inconsistency, and unpredictability were respectively
Cronbach’s alpha for the total scale and each subscale separately. 0.90, 0.74, 0.83, and 0.60.

Table 1
Demographic and clinical characteristics of patients with cancer (n ¼ 420).

Mean SD (range)

Age (year) 46.4 13.9 (21e79)


Time since diagnosis (months) 18.5 24.2 (3e168)

N %

Sex Female 217 51.7


Male 203 48.3
Marital status Single 58 13.8
Married 331 78.8
Widowed or divorced 31 7.3
Education level Illiterate 87 20.7
Primary and Guidance school 151 36
Diploma 107 25.5
University degree 75 17.9
Occupation Self-employed 76 18.1
Employee 34 8.1
Housewife 174 41.4
Unemployed 35 8.3
Other 103 24.1
Time since diagnosis (months) <6 166 39.5
6e24 163 38.8
>24 91 21.7
Type of cancer Breast 103 24.5
Colon and rectum 99 23.6
Gastric/esophagus 36 8.6
Hematologic 72 17.1
Uterus/ovarian 25 6
Prostate 5 1.2
Lung 21 5
Skin 5 1.2
Other 54 12.9
Metastasis Yes 143 36.3
No 251 63.7
Kind of treatment Chemotherapy 105 25
Chemotherapy and surgery 189 45
Chemo and radiotherapy 26 6.2
All of them 90 21.4
Other 10 2.4
M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57 55

Table 2
Scores for MUIS-A scale and its dimensions in Iranian patients with cancer and it’s comparison with Mishel’s data bank.

Ambiguity Complexity Inconsistency Unpredictability Total mean (SD) e a


mean (SD) e a mean (SD) e a mean (SD) e a mean (SD) e a

Iranian patients 41.8 (9.4)e0.86 15.1 (3.2)e0.58 18.8 (4.2)e0.71 14.4 (3.5)e0.65 90.1 (16.8)e0.89
with cancer (N ¼ 420)
Mishel’s combined data 32.3 (9.3)e0.87 16.5 (5)e0.80 14.9 (4.7)e0.80 15.8 (3.7)e0.67 79.5 (16.9)e0.90
for cancer patients (N ¼ 761)

Construct validity great importance. Despite the importance of the issue, this problem
has not been studied in Iran that can be attributed to lack of proper
To investigate construct validity and provide the most appro- tools in Iran. Therefore, this study was conducted with the aim of
priate model for the MUIS-A, confirmatory factor analysis was used. translating and validating the Persian version of the uncertainty in
To this end, full samples of cases were randomly split into two illness scale in patients with cancer. In this study, the MUIS-A scale
approximately equal groups. 200 subjects were considered as was translated into Persian and its psychometric properties and
calibration sample and 220 subjects were considered as evaluation factor structure were evaluated. When a tool is translated or used in
sample. Calibration samples were used to check the models (2 and another culture or society, it is essential to evaluate its psycho-
4 factors) and do possible revisions. Evaluation sample was used to metric properties because that may not be appropriate in the new
validate the appropriate model. Two-dimensional model of the society (Hillen et al., 2013; Michaeli Manee, 2011). In this study,
scale did not have good fit indices, but the four-dimensional model content validity, construct validity, and reliability of this tool were
had better fit indices. The chi-square, RMSEA, SRMR and AGFI assessed.
indices confirm the fit indices of the model (Table 3). By assessing Based on the findings, the Persian version of MUIS-A generally
the scale items, it was determined that the item 32 “The serious- has good reliability and validity and its dimensions’ construct is
ness of my illness has been determined” had a weak item-scale similar to that of the original one (Mishel, 1997b). In this study, it
correlation coefficient (r ¼ 0.02), therefore, item 32 was removed. has been shown that with regard to content validity index of 0.96,
According to the suggestion of modification of fit indices in the Persian version of MUIS-A has a good content validity. Polit and
confirmatory factor analysis, transferring item 8 “I do not know Beck (2013) suggest that the CVI value of 0.9 or more should be
when to expect things will be done to me” (from the ambiguity to considered as a standard for content validity of the scales (Polit and
the inconsistency) and item 28 “treatment which is being done to Beck, 2013).
me has a known probability of success” (from the complexity to the Confirmatory factor analysis of MUIS-A was conducted using a
unpredictability) improved the fit of the model. Therefore, the four- sample of 420 cancer patients. Goodness-of-fit indices indicated
dimensional model of MUIS-A with 31 items (ambiguity 12 items, that the original model (32-item and 4-dimensional) of Persian
complexity 5 items, inconsistency 8 items and unpredictability 6 version of the uncertainty in illness scale is appropriate, but for
items) is a model with the best fit indices. CFI and GFI indices are better fit indices and to enhance the fit indices some changes are
acceptable (Bentler, 1990) and other indices such as the ratio of chi- needed to be made in the original scale. In confirmatory factor
square to degree of freedom, RMSEA, AGFI and SRMR indicate a analysis, some suggestions are given by Lisrel to modify and
good fit of the model (Brown, 2006; Helsen et al., 2013; Kline, improve the model fit indices. If they are justifiable logically and
2010). theoretically, they can be applied (Kline, 2010). In the Persian
In order to further investigate validity of the construct, the version, item 32 “The seriousness of my illness has been deter-
relationship between education level and uncertainty in illness rate mined” from complexity dimension was deleted due to its low
was used. In this study, a strong inverse correlation was found correlation coefficient of item-scale.
between uncertainty and the level of education (r ¼ 0.47, In validation of the Swedish version of this scale for the cardiac
p < 0.001) in the sense that patients with higher level of education patients, it was indicated that this item has no significant corre-
had less uncertainty. lation with the overall score of the scale and complexity subscale.
Furthermore, items 10 and 22 were excluded from the Swedish
Discussion version (Hallberg and Erlandsson, 1991). Another study was con-
ducted in Iran to validate the scale of uncertainty in illness e
Uncertainty in illness is a concept that can have broad impact on family form. This scale assesses uncertainty from patients’ family’s
cancer patients and its investigation in this group of patients is of perspective. The original version of this scale has 31 items and is

Table 3
Confirmatory Factor analysis Fit indices for the different MUIS-A version in Iranian patients with cancer.

c2 (df), p RMSEAc (90% CI) CFId GFIe AGFIf SRMRg

MUIS-A, 2 factorsa 657.4 (349), p < 0.001 0.067 (0.059e0.074) 0.76 0.81 0.78 0.071
MUIS-A, 4 factorsa (original) 767.4 (458), p < 0.001 0.054 (0.048e0.060) 0.87 0.90 0.88 0.063
MUIS-A, 4 factorsa (modified) 660.7 (428), p < 0.001 0.047 (0.040e0.054) 0.91 0.92 0.90 0.048
MUIS-A, 4 factorsb (modified) 652.3 (428), p < 0.001 0.049 (0.044e0.054) 0.91 0.93 0.91 0.046
a
Calibration sample (N ¼ 200).
b
Validation sample (n ¼ 220).
c
Root mean error of approximation.
d
Comparative fit index.
e
Goodness-of-fit index.
g
Standardized root mean square residual.
f
Adjusted goodness-of-fit index.
56 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57

one-dimensional. In psychometric properties of this scale applied This issue itself also can be an approval of the Persian version
for 310 family members of patients hospitalized in the ICU, it was validity of this scale and its dimensions. The score of uncertainty in
shown that 5 items were not appropriate and had to be removed. illness in our study was higher. This finding can be justified by
Content and convergent validity and reliability of the Persian lower level of patients’ education and knowledge in our society.
version of the scale was confirmed in the form of a 26-item scale. The results of the present study showed that the Persian scale of
However, in this study, construct validity and subscales of this tool MUIS-A has a good internal consistency. In the present study, the
were not assessed by factor analysis (Vagharseyyedin and Vanaki, overall Cronbach’s alpha of this scale and its dimensions is close to
2011). Another study was performed by Pai et al. (2007) on the the obtained values in the combined sample of cancer patients,
psychometrics of the uncertainty scale in pediatric patients conducted using the original scale. Two dimensions of the scale
(CUIS). This scale is the adjusted form of Mishel’s Uncertainty in have an acceptable internal consistency. Lower alpha in some di-
Illness Scale-Community Form (MUIS-C). By conducting a sepa- mensions is because of its low number of items. For example, the
rate exploratory and confirmatory factor analysis on 373 children relatively low Cronbach’s alpha in complexity dimension (0.58) can
with chronic illnesses, 8 items were removed from 23 items of the be attributed to the fact that 7 items in the original scale reduced to
original instrument. The new scale with 14 items and two di- 5 items in the Persian version. Nevertheless, the obtained alpha for
mensions received very good fit for this group of patients. various aspects of this study is close to that in some studies re-
Removing item 8 “I know everything about my disease” was rec- ported by Mishel (Mishel, 1997b). The ambiguity dimension, with
ommended by the CFA, which logically would be acceptable regard to its high internal consistency and its high correlation with
because children could not understand everything about their the whole scale (p < 0.001, r ¼ 0.93), can be used alone, but it is
illness (Pai et al., 2007). Nevertheless, in our opinion, its low item- better to use the whole instrument in the study. In addition to the
total correlation coefficient in the Persian version seems to be internal consistency, results of the testeretest showed that the
more related to the sample of the study because all subjects, ac- Persian version of this scale has a good stability.
cording to the inclusion criteria, were aware of their cancer, so
almost all of them had agreeably answered this question. This Limitations
probably would be a good item for the patients in the process of
cancer diagnosis. The present study had some limitations. First, about 21% of the
In the Persian version, item 8 of the ambiguity dimension “I do samples were illiterate, and we had to complete the questionnaire
not know when to expect things will be done to me” was trans- through interviews, which was one of the limitations of this
ferred to the inconsistency dimension. Furthermore, item 28 research. Second, it should also be noted that applying the modi-
“treatment which is being done to me has a known probability of fication indices to guide CFA analysis increases the probability of
success” was transferred from the complexity dimension to the the findings being influenced by chance.
unpredictability dimension.
Factor structure in the original scale was shown changeable in
analyses conducted by Mishel at different times, in the sense that Conclusion
some items were transferred from one factor to another (Mishel,
1997b). Findings obtained by Pai et al. (2007) showed that in the In sum, the results of the present study show that the Persian
validated scale of uncertainty in pediatric patients, some items of scale of uncertainty in illness is a scale that not only has a good
the original scale can be placed within another factor (Pai et al., validity and reliability but also its four-dimensional structure is
2007). confirmed. Therefore, it is applicable to assess uncertainty in illness
In another study that conducted the psychometric properties of in Iranian patients with cancer. Use of this scale by nurses and re-
this scale for patients with brain tumors, some items of complexity searchers can help to promote nurses’ knowledge and holistic care
and ambiguity were transferred to other factors (Lin et al., 2012). and ultimately help to improve patient care. This study will be a
Other studies also have been conducted on the validation of the cornerstone for the future studies in the area of uncertainty in
same scale whose findings showed that the scale items can be illness in other groups of patients in Iran. Regarding the cognitive
transferred from one factor to the next (Helsen et al., 2013; Hillen sense of uncertainty in illness, qualitative studies are needed to
et al., 2013). know its other possible dimensions in Iranian patients.
Transfer of these items theoretically and logically has no
obstacle and Mishel herself has integrated some of them in the Conflict of interest
two dimensional MUIS scale. Another reason may be that Iranian
patients are not able to differentiate among sense of ambiguity, The authors declare no conflicts of interest.
complexity, and unpredictability. Therefore, it is proposed a
qualitative research be conducted to infer the sense of uncer-
Acknowledgment
tainty and its dimensions among the Iranian patients with
cancer.
The present study is a research project adopted by Shahid
According to the theory of uncertainty in illness, a negative and
Beheshti University of Medical Sciences (Tehran e Iran) and a part
significant relationship should be between the education level and
of a nursing doctoral thesis. Hereby, we express our appreciation to
score of uncertainty in illness, which has been confirmed in many
Shahid Beheshti Nursing and Midwifery School officials, and also
studies (Mishel, 2013). In this study, a strong and inverse rela-
authorities and staff in wards and Iran Cancer Center of Imam
tionship was found between education level and uncertainty in
Khomeini Hospital and Tehran Taleghani Hospital. Finally, we
illness so as education level increases in them, the level of uncer-
particularly thank all the participants.
tainty decreases. Furthermore, this finding confirms the construct
validity of this scale.
Findings of the present study show that mean and standard References
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