INTRODUCTION

Uncertainty refers to the inability to define the meaning of situations related with diseases, personal or environmental situations; and it is recognized as a threat of psychological stress^(1,2). In addition, it is characterized by the perception of individuals on the ambiguous meaning of the symptoms and other experiences related with a pathology. The complexity of this event is hidden and the terms used to explain it when it occurs suddenly or surprisingly of what its future will hold in terms of function, recurrence, and survival⁽³⁾.

Likewise, it is affirmed that the world is more sensitive to any situation from the environment, that is, to that uncertainty; thereby, it must be faced according to each situation or event⁽⁴⁾. It also has an important impact on the diagnosis, management, and rehabilitation of patients with chronic noncommunicable diseases (CNCD), which provokes a level of uncertainty that can affect the management and control of the entity ⁽⁵⁾. Currently, it has been studied and is considered a type of provoking thought or type of stress, which when not being sure of what to do, the mind knows there is a problem or danger where the individual must be more alert and encourages the individual to think, given that it is a new situation and it is when the state of uncertainty emerges ⁽³⁾.

Diagnostic exams are tests to determine the state of health of a patient who may or may not have a disease; in addition to establishing differential diagnoses, evaluating the severity of a pathology, and setting up treatments and possible prognostic results⁽⁶⁾. Undergoing an endoscopy or colonoscopy, although minimally invasive procedures, can cause fear and uncertainty in those on whom these will be conducted; this translates into feelings of distress and fear on said moment; inducing patients to think of multiple complications and limitations for their lives ⁽⁽⁴⁾. It is important to highlight that by taking an endoscopy or colonoscopy, one seeks to prevent or detect in time gastric and colorectal cancer, which are part of CNCD; with these entities being the cause of 71% of deaths globally, mostly of premature cause ⁽⁷⁾.

The nursing discipline has carried out studies to measure uncertainty in individuals with CNCD, but few studies have been conducted with the adaptation and validation instrument provided by Mishel’s Uncertainty in Disease Scale in diagnostic procedures. Hence, as theoretical support for this research, there is Merle Mishel’s theory that guides nursing professionals to identify the patient’s level of uncertainty upon undergoing endoscopic exams, which permits planning subsequent care interventions that contribute to patients and their families to generate positive coping strategies to manage to adapt to the results exposed and counteract the disease uncertainty ^(1,8).

It is important to define the dimensions described in Merle Mishel’s Uncertainty in Disease Scale, such as Ambiguity that refers to the state of the disease, Inconsistency or lack of information about the state of health, Unpredictability related with the course of the disease, and Complexity that refers to the lack of clarity in the information received ⁽⁹⁾. It is an input that guides the practice and interventions ⁽¹⁰⁾ prior to taking endoscopic exams to contribute in nursing care.

When performing endoscopic procedures, the nursing staff plays an important role in preparing the patient, as well as generating an environment of trust and communication (patient-health professional) to provide comprehensive care, diminish possible complications and emotional conditions generated by the procedure and, thus, provide quality in care ⁽¹¹⁾; herein, it is important to determine uncertainty levels in individuals prior to undergoing endoscopy or colonoscopy procedures in Health Service Provider Institutions (IPS, for the term in Spanish) to establish a scientific baseline to enhance nursing care in endoscopic services.

MATERIALS AND METHODS

Study with quantitative approach of descriptive, cross-sectional type, with non-probabilistic convenience sampling. The study universe was made up by individuals who are prior to taking an endoscopy and colonoscopy from Health Service Provider Institutions in Villavicencio, Colombia; the population comprised individuals programmed for an endoscopy or colonoscopy procedure in an IPS and who were from different municipalities from the Department of Meta in Colombia, with a 12-month chronogram of activities and procedures to conduct the research.

The sampling was non-probabilistic through convenience, stratified, in such a way that the sample was formed according to the ease of access, the availability of the people who were part of the sample, in a quarter of the year 2022 and the fulfillment of the inclusion criteria, like: being > 18 years of age, adequate cognitive capacity, and participating voluntarily in the research. The stratification had two sampling units: first, with the IPSs from the city of Villavicencio - Meta, which conducted endoscopies and colonoscopies and second, with the individuals undergoing the endoscopy or colonoscopy during the time period established. The participants were approached before taking the diagnostic exams described, and this was done with the aid of the database of the programming of these procedures provided by the IPSs, useful data for the sociodemographic characterization. The surveys were carried out in guided manner, like: the informed consent, measurement of the cognitive capacity and the questionnaire to measure uncertainty, with an estimated time of 40 minutes, for n = 477 participants.

The information was collected through a sociodemographic characterization survey and to see the relationship with the dimensions of uncertainty. To measure uncertainty, Mishel’s uncertainty scale was applied, adapted for diagnostic procedures in Spanish version and validated in the Colombian population by Leidy Yazmin Díaz Moreno ⁽⁹⁾, who authorized use of the instrument, with Cronbach’s alpha of 0.90. It has 27 items, four dimensions: ambiguity, complexity, inconsistency, and unpredictability, with Likert-type response option from 1 to 5, with 5: Sure, 4: Almost sure, 3: Moderately sure, 2: A little sure, 1: Unsure, with a higher value meaning a higher level of uncertainty. The minimum value for each item is 1 and the maximum is 5, except for items 4, 9, 11, 12, 13, 15, 17, and 19 where the score is inverted. The uncertainty level is valued in the following manner: Low level of uncertainty: (27-54), moderate level of uncertainty: (55-81), high level of uncertainty (82-135).

A 3-month time period was established for the analysis. Bearing in mind quantitative variables, calculation of measures of central tendency, mean, dispersion by range and standard deviation, measures of position percentiles and quartiles were performed. To establish uncertainty, the Shapiro normality test was performed. For the relationship of the uncertainty variables with sociodemographic variables, the analysis of variance (ANOVA) was applied. The ethical considerations requested the informed consent; clarifying that the information was confidential without registering the participant’s identity. The provisions of Resolution 8430 of 1993 of the Colombian Ministry of Health were applied, as well as the international Helsinki declaration ⁽¹²⁾.

RESULTS

Sociodemographic variables

The study interviewed 279 women and 198 men, with a mean age of 53 years; 13% without educational level and incomplete primary; 43.61% with incomplete and complete high school; 27.46% with undergraduate and graduate studies. Nearly 68.55% manifested having a partner. In terms of occupation, 56.4% reported being employees and independent workers; 35.64% were dedicated to the household and were pensioned; and 61.645 were in economic levels one and two. Experience prior to the procedure was reported by 36.69%. Procedures were conducted for cancer control (gastrointestinal) 37.5%, gastritis 30.19%, hemorrhage of lower and upper digestive tracts and polyps 14.47%, hemorrhoids 3.77% (Table 1).

Table 1. Sociodemographic characteristics of the participants prior to undergoing an endoscopy and colonoscopy. 

Source: elaborated by the authors.

n: absolute frequency; %: Absolute frequency

Perceived uncertainty

In all, 51.5% (246) of the patients reported moderate level of uncertainty, followed by high level with 28.9% (138) and low level of uncertainty with 19.5% (93) (Table 2).

Table 2. Level of uncertainty prior to undergoing endoscopy and colonoscopy. 

Source: elaborated by the authors.

SD: Standards deviation; min: minimum value; max: maximum value.

p25: percentile 25; p50: percentile 50; P75: percentile 75.

Level of uncertainty by dimensions

The patients perceive a higher level of uncertainty in the complexity dimension (13.63%) and low level of uncertainty in the ambiguity dimension (25.37%).

In the ambiguity dimension with the question: “Do you know the steps of the exam that will be conducted”, it was found that 59.5% were a little sure and unsure and 13.8% were moderately sure. In the question: “Are you clear about what Will happen to you after the exam”, 63.3% feel between a little sure and unsure and 17% feel moderately sure, and: “do you know how to take care of yourself after the exam”, 56.2% feel between a little sure and unsure, and 18.4% feel moderately sure.

In the complexity dimension, 78.9% of the patients feel sure and almost sure with the questions “is the purpose of the exam clear” and 52.6% with “do you understand what has been explained about the exam that will be conducted”. Likewise, 86.1% “Trusts that the health staff will be there when they need it”.

In the inconsistency dimension, 56.1% of the participants feel between moderately sure, almost sure and sure in the questions: “Do the explanations provided seem confusing”, also, 57.9% feel “They have been given different opinions about the exam procedure”; 51.7% “the results of their prior exams are confusing”, regarding the question: “Do you know your diagnosis”, 48.9% feel moderately sure, a little sure, and unsure.

In the unpredictability dimension, 52% feel unsure with the question: “Do you know how long the exam will last”, equally so, 51% feel unsure when asked “can you explain how to carry out the exam”; moreover, 67% feel sure because “they believe nothing bad will be found during their exam” (Table 4).

Table 4. Participant uncertainty prior to undergoing an endoscopy or colonoscopy, according with each dimension. 

Source: elaborated by the authors.

n: absolute frequency; %: relative frequency.

Adjusted by dimensions, taken from the original instrument.

S: sure, CS: almost sure, MS: moderately sure, PS: a little sure, I: unsure.

Questions 4, 9, 11, 12, 13, 15, 17, and 19 are evaluated inversely.

Relationship among uncertainty dimensions and sociodemographic variables

No significant difference exists between those who underwent endoscopy vs. those who underwent colonoscopy; hence, these are procedures that generate uncertainty. With respect to the question: Has this procedure been done to you before, the participants manifest less uncertainty related with those who had not undergone the procedure.

Gender has no influence on the level of uncertainty (p = 0.633), with greater schooling meaning lower uncertainty (p = 6.286). Regarding age, younger participants have lower uncertainty level (p = 0.00264), lower economic level means higher level of uncertainty (p = 0.000105). The special health insurance regime has higher level of uncertainty related with other types of health insurance (contributive or subsidized) (p = 6.147). People diagnosed with cancer have greater uncertainty levels (p = 8.738) with respect to those who do not have a defined diagnosis, but are sure and almost sure that nothing bad will be found during the exam (80%) (Table 5).

Table 5. Relationship among uncertainty dimensions and sociodemographic variables. 

P value resulting from ANOVA.

When p < 5% (0.05), no significant difference exists among the categories of the variables.

DISCUSSION

According to the results, the mean age of the participants was 53 years; similar to the study by Gómez et al., ⁽¹³⁾ where it was 52 years; different from the study by Valderrama et al.,⁽¹⁴⁾ with 39 years, another study⁽¹⁵⁾ with 68.64 years. This is why it is considered that in different age ranges, people are subjected to endoscopic exams to rule out or confirm any disease, like cancer and which, according with the literature, this entity is considered of adults and its incidence increases with age, with the highest peak between 50 and 70 years. In turn, it is important to highlight that this pathology occurs in people < 40 years of age in 2.4%⁽¹⁶⁾_. Moreover, García et al.,⁽¹⁷⁾ state that age is associated with increased incidence of both benign and malignant gastrointestinal pathology.

In this study, the participants did not reach complete primary and high school levels, where education is fundamental in health education processes; similar research indicates correlation between schooling and level of uncertainty, where greater instruction means lower level of uncertainty^{(4)) ((15)}. Also, for Johnson et al., ⁽¹⁵⁾ the degree of schooling is correlated negatively with the uncertainty level and according the Theory of Uncertainty of Disease, an inversely proportional relation exists between educational level and uncertainty, where a higher educational level means lower uncertainty⁽¹⁸⁾. The economic level that prevailed most was, strata one and two, similar to the study by Sanabria et al., ⁽¹⁹⁾ who relate low economic level with deficient health status. The study found that 68.55% of the participants were married or in common-law relationship, which decreases uncertainty due to social support ⁽⁽¹⁵⁾, an aspect not evidenced in the present study; likewise, for Merle Mishel, the social network is important to diminish uncertainty.

With respect to the variables generating the highest (50.3%) uncertainty level “Do you know the steps of the exam you will undergo?”, the participants have greater uncertainty level due to lack of clarity related with the procedure and the questions it generates; which was solved in confusing manner by the health professionals, as reported by Burbano et al.,⁽²⁰⁾ and Sajadi et al., ⁽²¹⁾.

Regarding the question “Given that you do not know what will be the exam results, is it difficult to plan your future?” (46.1%), similar studies found a higher level of uncertainty (86.1%) Montalvo et al.,⁽²²⁾ report not knowing how long it will take (50.9%), which is why they cannot plan their future. Due to the foregoing, professional intervention is important for future planning, according to each case; be it short-, mid-, and long-term; and, thus, think of possible risks and gains, including health complications ⁽³⁾.

Regarding the question: “Do you believe the exam that will be conducted will be successful?” (75.1%), success can depend on the nursing intervention that should clear doubts and concerns and see the knowledge users have of the practice phenomenon to facilitate health care ⁽²³⁾. Furthermore, interacting with users, who have dimensions that must be approached holistically and, thus, patients trust that the health staff will be there when they need it (74.6%).

In taking the exams, the nursing staff plays an important role in preparing the patients; they must create an environment of trust and communication (patient-health professional) to provide comprehensive care, reduce possible complications and emotional conditions that are generated by the procedure, and provide quality care ⁽²⁴⁾. Besides, performing timely interventions according to individual needs and, thus, turn uncertainty into an opportunity in life adaptation ⁽²⁰⁾.

The present study reported moderate level of uncertainty (51.5%), similar to the study by Ozawa et al., ⁽²⁵⁾ with 56.5% and the study by Dong et al.,⁽²⁶⁾ with 52.22%; the latter generated by monthly family income, duration of the disease (28 days or more); aspects not evaluated in the present study. In the study by Muñoz et al., ⁽²⁷⁾ 62% had irregular degree of uncertainty generated by feeling unsure by not knowing the course of the disease.

The study by Bonilla⁽²⁸⁾ reports moderate level of uncertainty (38%) and it was because the participants had many questions without answers to know their pathological condition, its progress, improvement or complication. Rather, in this study, the patients understood everything explained about the exam to be conducted. Likewise, in the study by Rodríguez et al., ⁽²⁹⁾ uncertainty was present in 36.4% of the participants and was correlated with low quality of life; contrary to the present study, with moderate level of uncertainty, which was not correlated with quality of life. Endoscopic exams diagnose chronic diseases that affect the quality of life of patients due to the course, treatment, and duration of these entities ⁽²⁹⁾.

The study by Valderrama et al.,⁽¹⁴⁾ with high level of uncertainty (80.8%) generated by the information provided prior to taking the exam; given that it was understood in different ways. Thereby, lack of information about the disease with regards to treatment, possible comorbidities, and the means to prevent the comorbidities were considered sources of uncertainty for the patients⁽³⁰⁾. In this study, the participants (41.7%) stated that the results of their prior exams are confusing and they suspected that in the result something bad could be found (67%). For Hinojosa et al., ⁽⁸⁾ uncertainty is generated in the disease or during its course and on the negative experiences lived, given that they affect the family and the environment. This is where the intervention by nursing professionals must identify support networks to face the cause and for the uncertainty to be lower.

CONCLUSIONS

This study reported moderate level of uncertainty, which indicates that strategies must continue to strengthen health promotion and disease prevention in endoscopic services; bearing in mind that when subjected to endoscopy or colonoscopy, one seeks to discard or confirm a chronic disease (cancer), where scientific evidence indicates that cancer occurs in high percentage in adults and increases with age.

It was detected that low schooling and low economic level intervene in the feeling of uncertainty. For this reason, when detecting this type of patient, nursing professionals must emphasize clear language through educational processes that permit explaining about the doubts regarding the procedure and possible results; besides evaluating the knowledge of the phenomenon by the practice to facilitate the intervention and establish a scientific baseline to enhance nursing care in endoscopic services.

Therefore, with the orientation by the Merle Mishel theory, the importance of using this instrument is evidenced in the evaluation through each of the dimensions, upon detecting in detail which of them generates greater uncertainty, like the inconsistency dimension that mostly the explanations you have been given about the exam seem confusing. A fact that highlights the intervention by nursing professionals from which they can plan interventions in greater detail before taking endoscopic exams, which contribute to the patient and family generating coping mechanisms to adapt to the results exposed.