Antecedents and Outcomes of Uncertainty in Older Adults With Cancer: A Scoping Review of the Literature

Uncertainty is defined as a “period of anticipation prior to confrontation with a potentially harmful event” (Monat, Averill, & Lazarus, 1972, p. 237) and is a common experience in cancer (Applebaum et al., 2014; Gil et al., 2006; Maher & De Vries, 2011). The unknown etiology and unpredictable future of cancer can prompt a sense of sustained uncertainty lingering throughout the cancer journey (Mishel, 1981; Wright, Afari, & Zautra, 2009). Lack of ability to define and classify illness-related events (Mishel, 1988) and predict treatment outcomes can provoke an apprehensive feeling of uncertainty (Penrod, 2001) that can adversely affect patients’ psychosocial well-being (Ferrans, 1994; Gotay & Muraoka, 1998; Henderson, 1997). The cancer survivorship literature frequently locates uncertainty within the stress and coping model and suggests that uncertainty surrounding cancer can impair coping and adaptation through intensifying negative effects of stress and paralyzing anticipatory coping mechanisms (Lazarus & Folkman, 1984; Mishel, Hostetter, King, & Graham, 1984; Wonghongkul, Moore, Musil, Schneider, & Deimling, 2000). Higher levels of uncertainty have been shown to be associated with poorer quality of life (QOL), greater levels of emotional distress, higher levels of anxiety and depression, and more relationship issues with family members (Braden, 1990; Christman, 1990; Mast, 1995; Mishel, 1984).

Because cancer is primarily a disease of older adults (Hurria et al., 2014), a need exists for a better understanding of potential influences of uncertainty on adjustment outcomes in older adult cancer survivors. To date, no review has been conducted. Therefore, the objective of this review is to provide an overview of existing literature on uncertainty in older adults with cancer. The overall aim is to develop a better understanding of the role of uncertainty in coping and adaptation to facilitate the development of age-specific interventions. Current gaps in the existing body of knowledge will be identified to inform future research studies. The research question for this review is the following: What are uncertainty antecedents and outcomes in older adults with cancer?

Methods

A scoping review was conducted using the methodologic framework developed by Arksey and O’Malley (2005) and later refined by Levac, Colquhoun, and O’Brien (2010) and Daudt, van Mossel, and Scott (2013), in which a systematic review appeared ineffective because of a dearth of intervention studies of high methodologic quality. A scoping methodology is a systematic approach to guide a comprehensive search of existing evidence on a particular topic, summarize and synthesize findings, identify knowledge gaps, and inform future studies (Arksey & O’Malley, 2005; Colquhoun et al., 2014). The six steps of a scoping review are the following: (a) identifying the research question; (b) identifying relevant studies; (c) selecting studies; (d) extracting and charting data; (e) collating, summarizing, and reporting results; and (f) optional consulting with stakeholders (Arksey & O’Malley, 2005). Employing this framework, published research was analyzed to delineate the breadth, depth, and nature of evidence on the concept of uncertainty in older adults with cancer and identify the areas for future research inquiries. The sixth step, consulting with stakeholders, was omitted because the results of the review did not specify any particular theme germane to stakeholders necessitating consultation.

Identifying Relevant Studies and Search Strategy

Four electronic databases were searched using appropriate search terms as advised by a librarian. Medical Subject Headings (MeSH) terms and free text words were used for the search concepts of neoplasms, uncertainty, and aging. The three terms were combined with a Boolean “AND.” The search was limited to the English language. Articles in MEDLINE®, PsycINFO®, Scopus, and CINAHL® were searched from inception to December 2015. The search was not limited by publication year because the review was the first one in this area, and the objective was to identify the extent of the existing evidence, highlight well-established findings, and identify the gaps in the body of knowledge. Reference lists were verified for potential studies. A two-phase process was employed to select eligible articles. First, titles and abstracts were reviewed to detect relevant articles. Second, full texts of selected citations were reviewed to identify articles meeting inclusion criteria. Review of the abstracts and full-text manuscripts and data abstraction were conducted by one person.

Eligible studies were quantitative, qualitative, or mixed-methods. Articles were included if the mean or median age of participants was 65 years or older (or if the results were reported for subgroups with a mean or median age of 65 years or older) and if the focus was on uncertainty in cancer. Studies that focused on psychometric evaluation of uncertainty measures and commentaries were excluded from the review because they did not contain any information to answer the review question.

Data Extraction, Analysis, and Synthesis

Extracted data included research aims; research design or analysis approach; sample size; mean age; type, stage, and duration of cancer; type and duration of treatment; uncertainty scale; and major results. Evidence tables were developed to organize quantitative and qualitative data separately. Quantitative results and qualitative findings were analyzed by descriptive numeric or thematic analyses, respectively (Levac et al., 2010). Outcomes were reported under four main categories: antecedents of uncertainty, outcomes of uncertainty, management of uncertainty, and the experience of uncertainty.

Results

The initial search yielded a total of 2,584 studies. Based on screening titles and abstracts, 1,688 studies were excluded. The most common reason for excluding articles was that the primary focus was not on uncertainty in cancer (n = 1,269). Full-text article review resulted in excluding an additional 852 studies that did not meet the inclusion criteria. A total of 44 articles were selected for data extraction and analysis (see Figure 1).

Description of Included Studies

Thirty of 44 studies used a qualitative design guided mainly by phenomenology (n = 12) or grounded theory (n = 6). Of the 44 total studies, 12 were quantitative, and 2 studies used a mixed-methods design. The majority of quantitative studies (n = 10) used a cross-sectional design with the uncertainty in illness theory (Mishel, 1988) (n = 11) as the underlying conceptual framework and the Mishel Uncertainty in Illness Scale (Mishel, 1981) (n = 10) as the uncertainty measure. Seven quantitative studies used small samples from 9–43 participants. Studies were conducted in the United States (n = 15), Sweden (n = 10), the United Kingdom (n = 7), Australia (n = 4), Canada (n = 3), Norway (n = 2), Germany (n = 1), Israel (n = 1), and Taiwan (n = 1). Studies were conducted from 1995–2015 and encompassed individuals with multiple types of cancer (n = 12), prostate cancer (n = 11), breast cancer (n = 6), gastrointestinal cancer (n = 6), lung cancer (n = 4), hematologic cancer (n= 3), head and neck cancer (n = 1), and renal cancer (n = 1).

Antecedents of Uncertainty

Six studies reported data on the antecedents of uncertainty (see Table 1). Given the nature of the antecedents, they were categorized under two subheadings: demographic and clinical.

Demographic antecedents: Age, sex, and educational levels were the demographic variables studied in relation to uncertainty. A positive correlation (when two variables move in the same direction) between age (in years) and uncertainty was reported in a cross-sectional study on predominantly Caucasian (91%) and married (60%) older adults with breast cancer (Sammarco, 2003). However, no significant difference in uncertainty levels was reported when a cohort of mixed ethnicity and mostly married (56%) older adult breast cancer survivors were compared with their younger counterparts (Sammarco, 2009). Similarly, no relationship was found between age and uncertainty in a prospective study with survivors of colon cancer (Galloway & Graydon, 1996). The relationship between sex and uncertainty was examined in only one study, and no significant relationship was reported (Galloway & Graydon, 1996). Higher levels of education were negatively correlated (when two variables move in the opposite directions) with uncertainty in men with prostate cancer undergoing watchful waiting (Wallace, 2005). However, survivors of colon cancer (male and female undertaking surgery) with higher levels of education reported significantly higher uncertainty than those with lower education (Galloway & Graydon, 1996).

Clinical antecedents: Time since diagnosis, stage of cancer, symptom pattern, symptom distress, and comorbidities were the clinical antecedents studied in relation to uncertainty. Time since diagnosis was identified as a significant predictor of uncertainty in a prospective study with men undergoing active surveillance for prostate cancer (Parker et al., 2015). In that study, longer time since diagnosis was associated with lower levels of uncertainty. However, two studies with participants undergoing active surveillance for either prostate cancer or small renal tumors found no significant association between time since diagnosis and uncertainty (Parker et al., 2013; Wallace, 2005). The length of hospitalization, however, was shown to be positively correlated with uncertainty in older adults with colon cancer (Galloway & Graydon, 1996). In addition, uncertainty was found to vary with cancer stage in older adult patients undergoing surgery so that a significant decrease in uncertainty was only reported by patients at stages 0 and I (Lien, Lin, Kuo, & Chen, 2009). No relationships were found between uncertainty and symptom pattern and symptom distress in two small studies with survivors of prostate or colon cancer (Galloway & Graydon, 1996; Wallace, 2005). The role of comorbidities was examined in only one cross-sectional study, and it showed that the levels of uncertainty increased significantly in the presence of coexisting health conditions (Sammarco, 2003).

Outcomes of Uncertainty

Seven studies reported data on the outcomes of uncertainty. QOL was the most commonly researched outcome (Bailey, Mishel, Belyea, Stewart, & Mohler, 2004; Kazer, Bailey, Sanda, Colberg, & Kelly, 2011; Parker et al., 2013, 2015; Sammarco, 2003, 2009; Wallace, 2003). Other studied outcomes included anxiety (Lien et al., 2009; Parker et al., 2015), depressive symptoms (Galfin & Watkins, 2012; Lien et al., 2009), intrusive thoughts and avoidance behavior (Parker et al., 2013), abstract thinking and rumination (Galfin & Watkins, 2012), and fear of cancer progression (Parker et al., 2015).

Quality of life: A significant negative association between uncertainty and QOL was reported consistently. Uncertainty was found to be significantly and negatively correlated with QOL in older adults with breast cancer, and it was the most influential variable on QOL after controlling for surgery, mastectomy, age, comorbidity, and social support (Sammarco, 2003, 2009). Comparable results were reported for patients with small renal tumors and prostate cancer undergoing watchful waiting and active surveillance (Parker et al., 2013, 2015; Wallace, 2003). Uncertainty and social support together were found to explain a significantly greater variance in QOL than either variable alone (Sammarco, 2003). To understand the process through which uncertainty affects QOL, Parker et al. (2015) conducted a mediating analysis exploring whether the relationship between uncertainty and QOL was mediated by anxiety and found no significant results.

Stress indicators: The positive associations between uncertainty and (a) intrusive thoughts and avoidance behavior and (b) fear of cancer progression were supported by two longitudinal studies (Parker et al., 2013, 2015). In addition, uncertainty was found to be significantly and positively associated with abstract thinking, anxiety, depression, frequency and duration of ruminative thinking, and distress of eccentric rumination in participants receiving palliative care (Galfin & Watkins, 2012). Greater uncertainty and abstract thinking were positively linked to psychological distress and depression induced by rumination (Galfin & Watkins, 2012). The impact of uncertainty on anxiety and depression was further supported in a prospective study of uncertainty, social support, and psychological adjustment in older adult patients with cancer undergoing surgery (Lien et al., 2009). Uncertainty was shown to be significantly and positively correlated with anxiety and depression before and after surgery (Lien et al., 2009).

Management of Uncertainty

Two intervention studies (Bailey et al., 2004; Kazer et al., 2011) reported data on the influence of uncertainty management interventions on psychological well-being and QOL. Kazer et al. (2011) conducted a pilot, pre-/post-test intervention study with nine older adults undergoing active surveillance for prostate cancer to evaluate the influence and durability of a five-week, Internet-based cognitive reframing and self-management intervention on uncertainty, self-efficacy, and QOL. The results of this study were mixed, and no effect sizes were reported (Kazer et al., 2011).

Bailey et al. (2004) examined the effect of a five-week watchful waiting intervention on cognitive reframing and uncertainty management ability in a convenience sample of 39 men with prostate cancer at stage T1 or T2 and found that those receiving the intervention had greater improvement in current and expected QOL compared to those receiving usual care (Bailey et al., 2004).

Experience of Uncertainty

Table 2 illustrates the main findings of the included qualitative studies. The findings of reviewed literature were thematically analyzed and classified under five subheadings: (a) perception of uncertainty, (b) temporal pattern of uncertainty, (c) uncertainty and treatment decision making, (d) uncertainty and emotional well-being, and (e) coping with uncertainty.

Perception of uncertainty: Uncertainty about medical conditions and the future was one of the most common concerns expressed by older adults at different stages of cancer from diagnosis to terminal phases (Arber & Spencer, 2013; Banning, Hafeez, Faisel, Hassan, & Zafar, 2009; Gardner, 2008; Grimsbø, Ruland, & Finset, 2012; Guilhot et al., 2013; Halldórsdóttir & Hamrin, 1996; Larsson, Hedelin, & Athlin, 2007; Oliffe, Davison, Pickles, & Mróz, 2009; Persson & Hallberg, 1995; Saeteren, Lindström, & Nåden, 2011; Sandeman & Wells, 2011). Uncertainty was described as being in a state in which it is hard to cope (Berterö, Vanhanen, & Appelin, 2008; Kasper, Geiger, Freiberger, & Schmidt, 2008; Kuzari, Biderman, & Cwikel, 2013; Sharf, Stelljes, & Gordon, 2005) and ranked in the moderate to high level of unmet needs (Boyes et al., 2015). A variety of phrases, such as “not sure,” “left in limbo,” “what happens now?”, “I do not know,” and “I am waiting,” were used by older adults to describe their perception of uncertainty across the cancer trajectory (Arber & Spencer, 2013; Berterö et al., 2008; Jonsson, Aus, & Berterö, 2010). Three main sources of uncertainty were not knowing (Andreassen, Randers, Näslund, Stockeld, & Mattiasson, 2006; Jonsson et al., 2010; Winterling, Wasteson, Glimelius, Sjödén, & Nordin, 2004), waiting (Berterö et al., 2008; Kuzari et al., 2013; Larsson et al., 2007), and unpredictable future (Jonsson et al., 2010; Karlsson, Friberg, Wallengren, & Öhlén, 2014; Saeteren et al., 2011). Ambiguity and complexity of cancer diagnosis and treatment were the key contributing factors to patients’ lack of ability to understand events and interpret situations (Berterö et al., 2008; Fried & Bradley, 2003; Gardner, 2008; Jonsson et al., 2010; Oliffe et al., 2009). Waiting was commonly linked to difficult situations, such as pending diagnostic test results (Larsson et al., 2007; Oliffe et al., 2009) and delay in receiving information and treatment (Kuzari et al., 2013; Mazor et al., 2013). Unpredictable future was frequently linked to the possibility of death (Gardner, 2008; Grimsbø et al., 2012; Jonsson et al., 2010; Winterling et al., 2004). Related subthemes identified in the literature are listed on Figure 2.

Temporal pattern of uncertainty: Feelings of uncertainty peaked at certain points in time, including the time of initial diagnosis (Worster & Holmes, 2008), after completing treatment (Sandeman & Wells, 2011), at periodic medical check-ups, and at follow-up visits (Oliffe et al., 2009; Pascal & Endacott, 2010).

Treatment decision making: Treatment decision making was a unique state of uncertainty predominantly experienced by older adults with prostate cancer (Bailey, Wallace, & Mishel, 2007; Denberg, Melhado, & Steiner, 2006; Oliffe et al., 2009). The main reason was the multiple therapeutic options available for localized prostate cancer in older adults with no convincing evidence to inform the choice of optimum treatment to prolong life (Bailey et al., 2007; Oliffe et al., 2009). Active treatments, either surgical or nonsurgical, could offer the potential for cure. However, these were associated with significant risks and negative consequences (Berry et al., 2003; Bill-Axelson et al., 2005; Steineck et al., 2002). Nonactive treatments (watchful waiting and active surveillance) were described as reasonable alternatives to manage indolent prostate cancer but were linked to a sense of living with untreated cancer (Hedestig, Sandman, & Widmark, 2003) and delay in treatment (Denberg et al., 2006). As such, constant uncertainty about the best possible treatment was a common experience among older adults with prostate cancer.

Emotional well-being: Uncertainty was commonly linked to undesirable emotions, such as persisting threat, fear and worry (Hedestig et al., 2003), powerlessness and hopelessness (Sand, Strang, & Milberg, 2008), anxiety (Berterö et al., 2008; Guilhot et al., 2013), insecurity (Arber & Spencer, 2013; Larsson et al., 2007), and vulnerability (Larsson et al., 2007). In addition, uncertainty was identified as an essential aspect of controllability (Kidd, 2014). Loss of control and uncertainty were described as concurrent unpleasant feelings across the cancer trajectory (Arber & Spencer, 2013; Halldórsdóttir & Hamrin, 1996; Kidd, 2014; Klafke, Eliott, Olver, & Wittert, 2014; Saeteren et al., 2011; Truant & Bottorff, 1999). Likewise, less engagement in self-management activities (Kidd, 2014), difficulty in defining roles and maintaining family relationships (Gardner, 2008), and trouble with planning for the future (Andreassen et al., 2006) were reported as the most important consequences of uncertainty. The perception of uncertainty in those undergoing active surveillance and watchful waiting for prostate cancer was reported to contribute to desire for surgery as a rapid treatment (Denberg et al., 2006).

Coping with uncertainty: A wide range of coping strategies were reported to deal with uncertainty and loss of control. Gaining knowledge about cancer and health (Jonsson et al., 2010), cancer-related limitations, and possible events in the future (Clayton, Butow, Arnold, & Tattersall, 2005; Worster & Holmes, 2008) was a commonly used strategy. Complementary and alternative medicine (Guilhot et al., 2013; Klafke et al., 2014; Truant & Bottorff, 1999), support groups, and palliative care (Arber & Spencer, 2013) were also used frequently to make sense of cancer-related events and situations (Gardner, 2008). Further coping strategies included denying, minimizing, or redefining the cancer; keeping undesirable feelings out of mind; avoiding information and relying on physicians for treatment decision making; living a normal life; faith and prayer (Bailey et al., 2007; Oliffe et al., 2009); planning important activities for the future; having a goal to look forward to and something meaningful ahead (Karlsson et al., 2014); and maintaining hope and optimism (Gardner, 2008).

Discussion

The results of this review show that uncertainty is a common experience among older adults with cancer. Uncertainty persists across the cancer trajectory, affects emotional well-being, and activates a range of coping strategies. The reviewed studies identified a number of demographic and clinical antecedents of uncertainty and described psychosocial outcomes of uncertainty.

Evidence on demographic and clinical antecedents of uncertainty was mixed and limited. Some studies reported a positive association between age, education levels, and uncertainty (Galloway & Graydon, 1996; Sammarco, 2003), whereas others found negative or nonsignificant relationships (Galloway & Graydon, 1996; Sammarco, 2009; Wallace, 2005). Several studies reported a significant relationship between time since diagnosis and uncertainty (Parker et al., 2015), but others found no association (Parker et al., 2013; Wallace, 2005). The conflicting results may be because of the methodologic limitations of the studies, including frequent non-probability sampling, small sample sizes, and potential bias in sample selection. In addition, several demographic and clinical factors were included in only one study. These factors included sex (Galloway & Graydon, 1996), length of hospitalization (Galloway & Graydon, 1996), stage of cancer (Lien et al., 2009), symptom pattern (Wallace, 2005), symptom distress (Galloway & Graydon, 1996), and comorbidity (Sammarco, 2003). Therefore, it is unclear which demographic and clinical variables should be taken into consideration in future research studies and planning uncertainty management interventions for older adults with cancer.

The conflicting results with regard to the relationships between demographic (age and education) and clinical characteristics (time since diagnosis) and uncertainty in older adult cancer survivors are in line with the results of similar studies with younger adults with cancer (Jeon, Choi, Lee, & Noh, 2016; Kim, Lee, & Lee, 2012; Lin et al., 2013). Evidence suggests that the role and significance of demographic and clinical antecedents of uncertainty might vary across the cancer trajectory (Kim et al., 2012). However, the results of studies with younger cancer survivors may not be directly comparable to the findings of studies with older adults because the type and nature of stress, appraisal process, and coping efforts may change with age (Aldwin, Sutton, Chiara, & Spiro, 1996; Diehl, Coyle, & Labouvie-Vief, 1996; Molton et al., 2008; Moos, Brennan, Schutte, & Moos, 2006).

A solid understanding of antecedents of uncertainty is important because these factors may be essential in structuring a cognitive schema and decreasing uncertainty (Mishel, 1988). Therefore, studies of higher methodologic quality with populations other than Caucasian patients with breast and prostate cancers, who had been overrepresented in the reviewed studies, are warranted to develop a better understanding of the contributing role of demographic and clinical factors to uncertainty in older adults with cancer.

Despite the discrepancy in the literature regarding the antecedents of uncertainty, results on the outcomes of uncertainty were converging. A significant negative association between uncertainty and QOL was consistently supported in the reviewed studies (Parker et al., 2013, 2015; Sammarco, 2003, 2009; Wallace, 2003). In addition, the negative relationship between uncertainty and QOL has been extensively supported in studies with younger cancer populations (McCorkle et al., 2009; Sammarco & Konecny, 2008; Somjaivong, Thanasilp, Preechawong, & Sloan, 2011; Suzuki, 2012; Wonghongkul, Dechaprom, Phumivichuvate, & Losawatkul, 2006). However, it is important to note that the sample sizes of some studies with older adults were too small for the applied statistical analyses, and few studies controlled for potential confounding variables, such as comorbidities, stage of cancer, type and intent of treatment, and cancer prognosis. Therefore, it is unknown whether uncertainty is an independent factor in predicting QOL in older adult cancer survivors. Future research should address this gap and explore how and to what extent uncertainty can affect QOL.

Positive relationships between uncertainty and anxiety and depression were reported in the reviewed studies (Galfin & Watkins, 2012; Lien et al., 2009). However, these results may not be generalizable because the samples were limited to those undergoing surgery or receiving palliative care. There is a large body of evidence explaining how uncertainty can provoke anxiety and depression (Baas, De Dreu, & Nijstad, 2011; Dugas, Gagnon, Ladouceur, & Freeston, 1998; Fresco, Frankel, Mennin, Turk, & Heimberg, 2002). One explanation is that uncertainty about the occurrence or nonoccurrence of adverse events can intensify and prolong emotional reactions (Grupe & Nitschke, 2011; Nitschke et al., 2009; Wilson, Centerbar, Kermer, & Gilbert, 2005) and cause people to overestimate negative outcomes (Grupe & Nitschke, 2011). Individuals dealing with uncertain situations may tend to regain a sense of order and control through engagement in ruminative thinking characterized by repetitive, monotonous, negative, and self-focused thoughts (Baas, de Dreu, & Nijstad, 2012; Baas et al., 2011; Watkins, Moberly, & Moulds, 2008; Segerstrom, Tsao, Alden, & Craske, 2000). Ruminative thinking has been suggested as the core construct of anxiety and depression disorder (Baas et al., 2011; Fresco et al., 2002). Because of the prevalence and significance of anxiety and depression (Alici, Weiss, Holland, Nelson, & Roth, 2011; Fann, Fan, & Unützer, 2009; Weiss Wiesel et al., 2015) in older adult cancer survivors and the substantial impact of emotional distress on survival rate and QOL in this population, more research is needed to explain and clarify the association between uncertainty and emotional distress in older adults with cancer.

The reviewed intervention studies did not provide generalizable findings related to management of uncertainty because of methodologic weaknesses, small and nonrandomized samples, and lack of control groups. No randomized, controlled trials have been conducted. Consequently, little is known about the impact of uncertainty management programs on important health outcomes in older adults with cancer. This area should be targeted with intervention studies.

Findings of qualitative studies showed that uncertainty was commonly experienced by older adult cancer survivors regardless of the type or stage of cancer. More importantly, uncertainty and controllability were strongly linked, with increased perception of uncertainty associated with a greater sense of loss of control. Participants described a wide range of strategies to manage uncertainty and improve the sense of controllability.

To the authors’ knowledge, this is the first review on the concept of uncertainty in older adults with cancer. The significant strength of this review lies in using a systematic approach to search multiple databases and analyze and synthesize data, and including studies of quantitative and qualitative designs. However, this review has limitations. First, the conducted search may not have been exhaustive despite employing comprehensive search strategies, including multiple databases, and consulting with a librarian. Second, as in any review, the results are limited by the methodologic quality of the included studies.

Implications for Nursing

Uncertainty about cancer diagnosis, treatment, and prognosis is a common experience in older adult cancer survivors (Arber & Spencer, 2013; Guilhot et al., 2013). Uncertainty may result in anxiety, depression, and poorer QOL in this population (Lien et al., 2009; Parker et al., 2013). Cancer-related uncertainty is related partly to lack of knowledge about the diagnostic and therapeutic procedures (Arber & Spencer, 2013) and partly to the unpredictable future of living with cancer (Grimsbø et al., 2012). Nurses are in a unique position to assess the source and extent of uncertainty in older adult cancer survivors and provide them with appropriate information, education, and support to cope with uncertainty. Similarly, nurses need to be aware of the potential role of uncertainty in provoking emotional distress and should be able to identify patients who are at higher risk for developing anxiety and depression under conditions of uncertainty. Nurses can use therapeutic communication to encourage patients to express their feelings and adopt the best strategies to deal with negative emotions. Communication techniques and strategies can help nurses establish and maintain therapeutic communication (Bramhall, 2014). Nurses can create a trusting environment by respecting patients in the context of their age and culture, applying active listening techniques, showing empathy for patients’ concerns, and explaining procedures in a way that patients can understand (Bramhall, 2014; Wooten, 2013). Likewise, nurses should target this area with intervention studies and randomized, controlled trials to examine which interventions are feasible, effective, and efficient to manage uncertainty in this population. Nurses can also play a role in enhancing QOL in older adults with cancer through designing, implementing, and evaluating uncertainty management interventions.

Conclusion

Uncertainty is a common and persistent experience in older adults with cancer that can affect their psychosocial well-being and QOL. However, existing evidence is not sufficient to develop a solid understanding about the antecedents and outcomes of uncertainty in this population. Further studies are required to identify the most essential factors contributing to uncertainty. In addition, large-scale, high-quality studies are needed to explore the mechanism underpinning the effect of uncertainty on QOL and emotional distress.

About the Author(s)

Ghodraty Jabloo is a PhD candidate and RN in the Lawrence S. Bloomberg Faculty of Nursing, and Alibhai is an associate professor in the Department of Medicine and Institute of Health Policy, Management, and Evaluation, both at the University of Toronto in Ontario, Canada; Fitch is an expert lead in person-centered care at the Canadian Partnership Against Cancer in Toronto; and Tourangeau is an associate professor and associate dean in the Lawrence S. Bloomberg Faculty of Nursing, Ayala is an instruction and faculty liaison librarian in the Gerstein Science Information Centre, and Puts is an assistant professor in the Lawrence S. Bloomberg Faculty of Nursing, all at the University of Toronto. Puts is supported by a Canadian Institutes of Health Research New Investigator Award. Ghodraty Jabloo completed the data collection. Alibhai and Puts provided statistical support. Ghodraty Jabloo, Alibhai, Tourangeau, Ayala, and Puts provided the analysis. Ghodraty Jabloo, Alibhai, Fitch, Ayala, and Puts contributed to the manuscript preparation. All authors contributed to the conceptualization and design. Ghodraty Jabloo can be reached at vida.ghodratyjabloo@mail.utoronto.ca, with copy to editor at ONFEditor@ons.org. Submitted September 2016. Accepted for publication November 30, 2016.