Twelve tips for developing healthcare learners' uncertainty tolerance

BACKGROUND

Uncertainty is pervasive throughout healthcare practice. Uncertainty tolerance (i.e. adaptively responding to perceived uncertainty) is considered to benefit practitioner wellbeing, encourage person-centred care, and support judicious healthcare resource utilisation. Accordingly, uncertainty tolerance development is increasingly referenced within training frameworks. Practical approaches to support healthcare learners' uncertainty tolerance development, however, are lacking.

AIMS

Drawing on findings across the literature, and the authors' educational experiences, twelve tips for promoting healthcare learners' uncertainty tolerance were developed.

RESULTS

Tips are divided into 1. Tips for Learners, 2. Tips for Educators and Supervisors, and 3. Tips for Healthcare Education Institutions and Systems. Each tip summarises relevant research findings, alongside applications to educational practice.

CONCLUSIONS

Approaches to developing uncertainty tolerance balance factors supporting learners through uncertain experiences, with introducing challenges for learners to further develop uncertainty tolerance. These tips can reassure healthcare education stakeholders that developing learner uncertainty tolerance, alongside core knowledge, is achievable.

Approaching discussions about genetics with palliative patients and their families: a qualitative exploration with genetic health professionals

Genetic information can provide clinical benefits to families of palliative patients. However, integration of genetics into mainstream medicine has not focused on palliative populations. We explored the views and experiences of genetic health professionals in addressing genetics with palliative patients, and their families. We conducted an interpretive descriptive qualitative study with genetic counsellors and clinical geneticists using interviews and focus groups. Findings were generated using reflexive thematic analysis. Three themes were identified: (1) Focusing on the benefit to the family, (2) The discomfort of addressing genetics near end-of-life and (3) "It's always on the back-burner": Challenges to getting genetics on the palliative care agenda. Participants discussed the familial benefit of genetics in palliative care alongside the challenges when patients are near end-of-life. They perceived genetics as low priority for palliative care due to misunderstandings related to the value of genetic information. Acknowledging the challenges in the palliative care context, genetic health professionals want improved service leadership and awareness of the familial benefits of palliative genetic testing. Strong leadership to support genetic health professionals in addressing these barriers is needed for the benefits of genetic information to be realised.

Tolerance for Uncertainty, Personality Traits and Specialty Choice Among Medical Students

OBJECTIVE

The objective was to explore the tolerance for uncertainty in its different aspects (risk, ambiguity and complexity) in medical students at different times of their careers, and to relate these tolerance levels with their predominant personality traits and specialty choices. A secondary objective was to build a hypothetical model aimed at explaining the potential relationships of dependency between gender, personality traits, tolerance for uncertainty and specialty choice using a structural equation modeling (SEM) analysis.

DESIGN/SETTING/PARTICIPANTS

A prospective cross-sectional study including two cohorts of second-year (n = 155) and sixth-year (n = 157) medical students was performed during 2017 at the Buenos Aires University School of Medicine. Both student cohorts completed instruments assessing tolerance for different types of uncertainty: (1) complexity (Tolerance for Ambiguity scale); (2) risk (Pearson Risk Attitude scale); and (3) ambiguity (Ambiguity Aversion in Medicine scale). Information on age, gender and specialty choice in sixth-year medical students was included, plus the Big Five Inventory-10 (BFI-10) personality test.

RESULTS

Sixth-year students showed significantly lower scores than second-year students at tolerance for complexity (p = 0.0003) and ambiguity (p = 0.008). Sixth-year students choosing a surgical specialty were associated with low tolerance for risk and ambiguity, and moderate for complexity. Conversely, students choosing a clinical specialty were related with high tolerance for risk, moderate for ambiguity, and low for complexity. Logistic regression analysis including the uncertainty questionnaires plus BFI-10 categories demonstrated that only the "neuroticism" personality trait was independently associated with a surgical specialty choice (OR: 1.31, 95%CI: 1.03-1.67). The final SEM that best represented the data showed good fit statistics: chi-square (p = 0.108), and RMSEA (p = 0.047).

CONCLUSIONS

Tolerance for uncertainty in its different dimensions was associated with personality traits and specialty choice among medical students. A SEM analysis could satisfactorily explain the hypothetical relationships of dependency between gender, personality traits, tolerance for uncertainty, and specialty choice.

Clinician distress in seriously ill patient care: A dimensional analysis

BACKGROUND

Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention.

RESEARCH PURPOSE

The purpose of this article was to investigate the nature of clinician distress.

RESEARCH DESIGN

Qualitative inductive dimensional analysis.

PARTICIPANTS AND RESEARCH CONTEXT

After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis.

ETHICAL CONSIDERATIONS

This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis.

FINDINGS

A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event.

DISCUSSION

This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed.

CONCLUSION

For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.

Tolerance for Ambiguity Among Medical Students: Patterns of Change During Medical School and Their Implications for Professional Development

PURPOSE

Tolerance for ambiguity (TFA) is important for physicians, with implications for ethical behavior and patient care. This study explores how medical students' TFA changes from matriculation to graduation and how change in empathy and openness to diversity are associated with this change.

METHOD

Data for students who took the Matriculating Student Questionnaire (MSQ) in 2013 or 2014 and the Medical School Graduation Questionnaire (GQ) in 2017 or 2018 were drawn from the Association of American Medical Colleges (n = 17,221). Both the MSQ and GQ included a validated TFA scale and a shortened version of the Interpersonal Reactivity Index; the MSQ also included an openness to diversity scale. Tercile groups were used to assess how TFA changed from the MSQ to GQ, and regression analyses were used to assess associations between change in TFA and openness to diversity and between change in TFA and change in empathy.

RESULTS

Mean TFA scores decreased (d = -.67) among students with the highest TFA at matriculation but increased (d = .60) among students with the lowest TFA at matriculation. Regression results showed that change in TFA was significantly and positively associated with change in empathy (beta = .05, P < .001) and that openness to diversity (as reported at matriculation) was significantly and positively associated with TFA at graduation (beta = .05, P < .001).

CONCLUSIONS

This is the first nationally representative study to suggest that medical students' TFA changes over time, but in different directions depending on TFA at matriculation. TFA over time was also associated with change in empathy and openness to diversity. Medical schools should consider strategies to assess TFA in their admissions processes and for cultivating TFA throughout the learning process.

[An exploration of factors influencing nursing practice with families experiencing perinatal loss ]

INTRODUCTION

Perinatal loss is a complex phenomenon with multiple dimensions and represents a professional challenge for nurses. There are as many different ways of coping with bereavement as there are parents, and nurses must adapt their intervention in order to adequately support grieving parents.

PURPOSE

This qualitative study explored the factors that influence nursing practice with bereaved families in a secondary obstetric care center in Quebec.

METHODS

Guba and Lincoln's fourth generation evaluation approach was used. Ten nurses participated in this qualitative study. Data collection was performed using semi-structured interviews. Validation interviews were conducted with three nurses and two gynecologists. The analysis was performed within the perspective of Watson's theory of caring.

RESULTS

A thematic analysis was performed and five themes were identified: the relational quality between the nurse and the family, personal characteristics of the nurse, the feelings expressed by nurses, the working environment, and the context in which the nursing care is provided to the family.

CONCLUSION

In light of the results, some aspects of nursing practice should be encouraged in order to assure adequate support is provided to grieving families.

Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes

BACKGROUND

Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes.

METHODS

We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme.

RESULTS

Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being.

CONCLUSIONS

Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.

Conflicts in Learning to Care for Critically Ill Newborns: "It Makes Me Question My Own Morals"

Caring for critically ill and dying patients often triggers both professional and personal growth for physician trainees. In pediatrics, the neonatal intensive care unit (NICU) is among the most distressing settings for trainees. We used longitudinal narrative writing to gain insight into how physician trainees are challenged by and make sense of repetitive, ongoing conflicts experienced as part of caring for very sick and dying babies. The study took place in a 45-bed, university-based NICU in an urban setting in the United States. From November 2009 to June 2010 we enrolled pediatric residents and neonatology fellows at the beginning of their NICU rotations. Participants were asked to engage in individual, longitudinal narrative writing about their "experience in the NICU." Thematic narrative analysis was performed. Thirty-seven physician trainees participated in the study. The mean number of narratives per trainee was 12; a total of 441 narratives were available for analysis. Conflict was the most pervasive theme in the narratives. Trainees experienced conflicts with families and conflicts with other clinicians. Trainees also described multiple conflicts of identity as members of the neonatology team, as members of the medical profession, as members of their own families, and as members of society. Physician trainees experience significant conflict and distress while learning to care for critically ill and dying infants. These conflicts often led them to question their own morals and their role in the medical profession. Physician trainees should be educated to expect various types of distress during intensive care rotations, encouraged to identify their own sources of distress, and supported in mitigating their effects.

Ambiguity tolerance of students matriculating to U.S. medical schools

PURPOSE

To examine the psychometric adequacy of a tolerance for ambiguity (TFA) scale for use with medical students. Also, to examine the relationship of TFA to a variety of demographic and personal variables in a national sample of entering U.S. medical students.

METHOD

The authors used data from the 2013 Association of American Medical Colleges Matriculating Student Questionnaire in which questions on TFA were included for the first time that year. Data from 13,867 entering medical students were analyzed to examine the psychometric properties of the TFA scale. In addition, the relationships of TFA to sex, age, perceived stress, and desire to work in an underserved area were analyzed. Finally, the relationship of TFA to specialty preference was examined.

RESULTS

The TFA scale was found to be psychometrically adequate for use in a medical student population. TFA was found to be higher in men and in older students. Lower TFA was associated with higher perceived stress levels. Students with higher TFA were more likely to express desire to work in an underserved area. Different levels of TFA may be associated with certain specialty preferences.

CONCLUSIONS

These findings support the assessment of TFA to understand how this personal characteristic may interact with the medical school experience and with specialty choice. Longitudinal work in this area will be critical to increase this understanding.

Tolerance for ambiguity: an ethics-based criterion for medical student selection

Planned changes to the MCAT exam and the premedical course requirements are intended to enable the assessment of humanistic characteristics and, thus, to select students who are more likely to become physicians who can communicate and relate with patients and engage in ethical decision making. Identifying students who possess humanistic and communication skills is an important goal, but the changes being implemented may not be sufficient to evaluate key personality traits that characterize well-rounded, thoughtful, empathic, and respectful physicians. The author argues that consideration should be given to assessing prospective students' tolerance for ambiguity as part of the admission process. Several strategies are proposed for implementing and evaluating such an assessment. Also included in this paper is an overview of the conceptual and empirical literature on tolerance for ambiguity among physicians and medical students, its impact on patient care, and the attention it is given in medical education. This evidence suggests that if medical schools admitted students who possess a high tolerance for ambiguity, quality of care in ambiguous conditions might improve, imbalances in physician supply and practice patterns might be reduced, the humility necessary for moral character formation might be enhanced, and the increasing ambiguity in medical practice might be better acknowledged and accepted.