A revised model of uncertainty in complex healthcare settings: A scoping review

Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

HIGHLIGHTS

The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.

Navigating Uncertainty in Clinical Practice: A Structured Approach

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.

Exploring factors associated with healthcare professionals' subjective perceptions of complex issues in primary care in Japan: a self-administered survey study on confidence, satisfaction and burden levels

OBJECTIVE

The aim of this study was to explore factors associated with healthcare professionals' subjective perceptions of complex issues in primary care settings in Japan.

DESIGN

Cross-sectional survey conducted through a self-administered web-based questionnaire.

SETTING

Japan, from June to October 2020.

PARTICIPANTS

Healthcare professionals recruited via an email list from the Japan Primary Care Association.

MEASURES

The questionnaire assessed subjective perception of satisfaction, confidence and burden regarding complex issues using a 100 mm Visual Analogue Scale (VAS). Explanatory variables included the Japanese version of the Self-assessment Scale of Interprofessional Competency (JASSIC), basic demographic information, administrative experience and an organisational climate scale. This scale comprised the 'Plan, Do, See' (PDS) factor for management and the 'Do' factor in a leader-centred direction for those working under compulsion. Factors associated with subjective perceptions were analysed using binomial logistic regression analysis and Bonferroni analysis (p<0.017).

RESULTS

Data from 593 participants (average age of 41.2 years, including 133 nurses, 128 physicians and 120 social workers) were analysed. Median (quartile) VAS scores for satisfaction, confidence and burden were 50 (36-70), 52 (40-70) and 50 (30-66), respectively. Higher satisfaction group was significantly associated with PDS factor, Do factor and JASSIC Score. Greater confidence group associated with older age, male, Do factor, administrative experience and JASSIC Score. No factors were significantly associated with the higher perceived burden.

CONCLUSION

These findings reveal that interprofessional competency self-assessment influence perceptions of complex issues among healthcare professionals. Moreover, satisfaction with complex issues might be enhanced by a manageable organisational climate, while confidence might be influenced by personal attributes.

Exploring homecare leaders' risk perception and the link to resilience and adaptive capacity: a multiple case study

BACKGROUND

Home-based healthcare is considered crucial for the sustainability of healthcare systems worldwide. In the homecare context, however, adverse events may occur due to error-prone medication management processes and prevalent healthcare-associated infections, falls, and pressure ulcers. When dealing with risks in any form, it is fundamental for leaders to build a shared situational awareness of what is going on and what is at stake to achieve a good outcome. The overall aim of this study was to gain empirical knowledge of leaders' risk perception and adaptive capacity in homecare services.

METHODS

The study applied a multiple case study research design. We investigated risk perception, leadership, sensemaking, and decision-making in the homecare services context in three Norwegian municipalities. Twenty-three leaders were interviewed. The data material was analyzed using thematic analysis and interpreted in a resilience perspective of work-as-imagined versus work-as-done.

RESULTS

There is an increased demand on homecare services and workers' struggle to meet society's high expectations regarding homecare's responsibilities. The leaders find themselves trying to maneuver in these pressing conditions in alignment with the perceived risks. The themes emerging from analyzed data were: 'Risk and quality are conceptualized as integral to professional work', 'Perceiving and assessing risk imply discussing and consulting each other- no one can do it alone' and 'Leaders keep calm and look beyond the budget and quality measures by maneuvering within and around the system'. Different perspectives on patients' well-being revealed that the leaders have a large responsibility for organizing the healthcare soundly and adequately for each home-dwelling patient. Although the leaders did not use the term risk, discussing concerns and consulting each other was a profound part of the homecare leaders' sense of professionalism.

CONCLUSIONS

The leaders' construction of a risk picture is based on using multiple signals, such as measurable vital signs and patients' verbal and nonverbal expressions of their experience of health status. The findings imply a need for more research on how national guidelines and quality measures can be implemented better in a resilience perspective, where adaptive capacity to better align work-as-imagined and work-as-done is crucial for high quality homecare service provision.

Navigating the uncertainty: A novel taxonomy of vaccine hesitancy in the context of COVID-19

Vaccine hesitancy remains a significant and evolving public health challenge. The COVID-19 pandemic has created a unique decision context with significant uncertainty caused by the novelty of the disease being targeted, unfamiliarity with the vaccines being offered, misinformation, and strong handed government measures. In an effort to extend our understanding of vaccine hesitancy to the high uncertainty decision environment presented by COVID-19, we present a novel taxonomy of the determinants of vaccine hesitancy, based on an inductive analysis of qualitative data gathered during the COVID-19 pandemic. We report on focus group data from a purposive sample of 18 Canadians with varying sociodemographic characteristics and COVID-19 vaccination attitudes. An inductive thematic analysis of this data reveals eight core themes related to vaccine hesitancy: values, trust, social environment, personal anecdotes, environmental fluctuation, prior knowledge, perceived risk & systems of care. We explore these core themes as well as 25 sub-themes, contrasting them with previous models of vaccine hesitancy and suggesting potential strategies for public health professionals.

An untapped potential: Curiosity in medical school

BACKGROUND

There seems to be a common perception among medical educators that curiosity is untapped or even subjugated in medical education. This review aims to summarize research on curiosity across the fields of psychology, neuroscience, and education and report its potential to advance medical education.

METHODS

For this narrative review multiple online libraries were searched using variations of the terms curiosity and school/education/learning. Additional studies were reviewed using the reference lists of included studies, and all studies were assessed for quality and relevance.

RESULTS

This review of previous research on curiosity shows that curiosity can significantly impact characteristics relevant to medical education, particularly mental health and learning. In addition, the authors outline how curiosity is linked to other epistemic emotions such as anxiety, novelty, surprise, and uncertainty. Finally, an epistemic-emotion-framework (EEF) is proposed to help educators encourage curiosity in medical students.

CONCLUSION

By drawing from other research fields, medical educators can learn valuable lessons about the importance of curiosity and how to influence it. This review provides an overview of current research and a framework for how the potential of curiosity can be harnessed to play an important role in students' medical education.

A scoping review of self-monitoring in graduate medical education

BACKGROUND

Physicians and physicians-in-training have repeatedly demonstrated poor accuracy of global self-assessments, which are assessments removed from the context of a specific task, regardless of any intervention. Self-monitoring, an in-the-moment self-awareness of one's performance, offers a promising alternative to global self-assessment. The purpose of this scoping review is to better understand the state of self-monitoring in graduate medical education.

METHODS

We performed a scoping review following Arksey and O'Malley's six steps: identifying a research question, identifying relevant studies, selecting included studies, charting the data, collating and summarising the results and consulting experts. Our search queried Ovid Medline, Web of Science, PsychINFO, Eric and EMBASE databases from 1 January 1999 to 12 October 2022.

RESULTS

The literature search yielded 5363 unique articles. The authors identified 77 articles for inclusion. The search process helped create a framework to identify self-monitoring based on time and context dependence. More than 20 different terms were used to describe self-monitoring, and only 13 studies (17%) provided a definition for the equivalent term. Most research focused on post-performance self-judgements of a procedural skill (n = 31, 42%). Regardless of task, studies focused on self-judgement (n = 66, 86%) and measured the accuracy or impact on performance of self-monitoring (n = 41, 71%). Most self-monitoring was conducted post-task (n = 65, 84%).

CONCLUSION

Self-monitoring is a time- and context-dependent phenomenon that seems promising as a research focus to improve clinical performance of trainees in graduate medical education and beyond. The landscape of current literature on self-monitoring is sparse and heterogeneous, suffering from a lack of theoretical underpinning, inconsistent terminology and insufficiently clear definitions.

Taking or creating control: A qualitative study of uncertainty among novice nurses in ambulance care

INTRODUCTION

In emergency nursing situations, uncertainty may lead to delays, or block a decision which can have devastating consequences for a patient. The ambulance service is a complex clinical environment that often challenges the decision-making capabilities of the professionals, especially novice nurses. Novice nurses' uncertainty may also lead to unhealthy transitions and turnover. To increase the understanding of how uncertainty affects novice nurses, this study explores novice nurses' uncertainty during the first year of professional practice in the ambulance service.

METHOD

A qualitative descriptive design was applied using qualitative content analysis of thirteen individual face-to-face semi-structured deep interviews.

RESULT

From nine subcategories, three generic categories were derived: Reflections on contextual understanding, Strategies to create control, and Actions to take control. These were combined to form the main category Understanding what and dealing with how, while becoming a confident professional.

CONCLUSION

Uncertainty is exacerbated by situations that demand rapid decisions or actions. This is especially true of newcomers to a profession. Preparing novices through study programs and encouraging continuous reflection in professional practice may increase resilience and tolerance of uncertainty, as well as benefiting professional development.

Pediatricians' Communication about Medical Uncertainty: Goal-Oriented Communication and Uncertainty Management

Despite the prevalence of uncertainty in medicine, many physicians experience anxiety as a result of medical uncertainty and are reluctant to discuss uncertainty with others. When pediatricians do disclose uncertainty to parents, they are managing both the parents' and their own feelings of uncertainty. The current study applies uncertainty management theory and multiple goals theory to explore pediatricians' communication about uncertainty. We collected data using in-depth semi-structured interviews with 18 pediatricians. The results suggest that pediatricians prioritize task and relational goals with parents and task and identity goals with fellow physicians. Though, their appraisal of uncertainty influences their goal-oriented communication. The results highlight the relationship between uncertainty management theory and a multiple goals framework. These frameworks provide a valuable approach for gaining a more thorough understanding of pediatrician communication in the context of uncertainty.

Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st-century literature

RATIONALE, AIMS AND OBJECTIVES: Clinical reasoning is currently extensively studied to find out how to make proper diagnoses. Literature indicates that intolerance of uncertainty (IU) may have a strong negative impact on clinical reasoning. We summarize the various consequences of IU on clinical reasoning.

METHODS

A scoping review was conducted using relevant keywords to scientific databases (i.e., Google Scholar, Medline, PsycINFO and PBSC) from September to November 2021. Complementary research included relevant articles and articles retrieved through Google Scholar's alert system. We included articles about healthcare professionals as defined by the French Public Health Code (As defined here: https://www.vie-publique.fr/fiches/37855-categories-de-professionnels-de-sante-code-se-la-sante-publique), and articles reporting on the impact of IU or uncertainty management on clinical reasoning.

RESULTS

We retrieved 1853 articles, of which 8 were kept for final analysis considering our inclusion criteria. Two behaviour categories were affected by uncertainty intolerance: investigative and prescriptive behaviours. Regarding the investigation process, mismanagement of uncertainty appeared to lead to reasoning bias, potentially resulting in diagnostic errors. IU was associated with withholding information, more referrals to peers and less use of new medical interventions. Regarding prescription behaviours, IU among health professionals could lead to overprescribing unnecessary or dangerous tests. IU was also associated with more antibiotic prescriptions for conditions where antibiotics are to be used carefully.

CONCLUSION

Few studies have yet addressed the impact of IU on clinical reasoning. IU's influence is primarily observed on investigative and prescribing behaviours. More studies are needed to fully understand the impact of IU on clinical reasoning itself, and not only on practical consequences.

Mapping uncertainty in precision medicine: A systematic scoping review

RATIONALE

Although precision medicine is seen by many as one of the most promising advances in the field of medicine, it has also raised critical questions at various levels. Many of these concerns revolve around an observation described by Kimmelman and Tannock as the 'paradox of precision medicine': somewhat surprisingly, uncertainty seems to be a key characteristic of precision medicine in practice.

AIMS AND OBJECTIVE

To better understand this concept and the underlying issues, a scoping review was undertaken to search for factors stated in the literature as contributing to or being aspects of uncertainty in precision medicine.

METHODS

A systematic search of the literature was conducted in three databases (Pubmed, Web of Science, and Jstor) and complemented with a systematic hand-search. The initial search provided 1.252 items of which 51 articles for selected as eligible for further analysis. These articles were coded with MAXQDA and categorized into four main themes (a-d) of uncertainty. The main results were summarized and discussed with a view to the interrelations between different aspects and implications for precision medicine in practice.

RESULTS

The mapping of different aspects and sources of uncertainty leads to the key result that 'uncertainty' should be understood as a cluster concept. Uncertainties are identified in many different respects and situated at different levels: Most complexity-related issues (theme a) can best be understood as ontological ('world-sided') aspects of the uncertainty paradox. Conceptual (theme b) and evidence-related uncertainties (theme c) are situated on an epistemological or methodological level, addressing foundational and normative challenges related to knowledge production in precision medicine. Finally, theme (d) targets issues on the level of material precision medicine practices. These levels are helpful to understand the different dimensions of the uncertainty paradox.

CONCLUSIONS

Uncertainty may not merely be a transient effect of the novelty of the precision medicine paradigm. Rather, it should be seen as a consequence of the ontological, epistemological and practical complexity of precision medicine, implying that uncertainty will not necessarily be reduced by more research. This finding encourages further investigations to better understand the interactions among various factors and aspects of uncertainty in precision medicine and the resulting implications for research and medical practice.

General Practitioners' Experiences of Professional Uncertainties Emerging from the Introduction of Video Consultations in General Practice: A Qualitative Study

Background

Uncertainties are omnipresent in health care, but little is known about general practitioners’ (GPs) professional uncertainties concerning digital consultations. This is problematic, as many countries have undergone an extensive digital transformation.

Objective

The aim of this study was to explore the professional uncertainties that emerged among Danish GPs with the introduction of video consultations.

Methods

We conducted qualitative interviews with 15 Danish GPs during the beginning of the COVID-19 pandemic in 2020. The interviews were analyzed using an abductive approach.

Results

We identified 3 categories of uncertainty: integrity, setting, and interaction. Respectively, these 3 categories of uncertainty refer to (1) uncertainties related to how technology may impede the provision of health care; (2) uncertainties related to the potentials of video technology; and (3) uncertainties related to how the video consultation technology affects interactions with patients.

Conclusions

The uncertainties experienced by Danish GPs appear to be a typical reaction to the introduction of new technology. Embedding video consultation technology into GPs’ working routines will take time, and GPs do not necessarily feel intuitively capable of transferring their abilities, such as being good and socially present for video-mediated consultations. The heterogeneity of professional uncertainties experienced among the GPs suggests that they are the product of individual GP-technology relationships—not of the technology in itself. Consequently, we cannot expect that uncertainties can be remedied by changing or precluding new technology.

Developing an integrated multilevel model of uncertainty in health care: a qualitative systematic review and thematic synthesis

Introduction

Uncertainty is an inevitable part of healthcare and a source of confusion and challenge to decision-making. Several taxonomies of uncertainty have been developed, but mainly focus on decisions in clinical settings. Our goal was to develop a holistic model of uncertainty that can be applied to both clinical as well as public and global health scenarios.

Methods

We searched Medline, Embase, CINAHL, Scopus and Google scholar in March 2021 for literature reviews, qualitative studies and case studies related to classifications or models of uncertainty in healthcare. Empirical articles were assessed for study limitations using the Critical Appraisal Skills Programme (CASP) checklist. We synthesised the literature using a thematic analysis and developed a dynamic multilevel model of uncertainty. We sought patient input to assess relatability of the model and applied it to two case examples.

Results

We screened 4125 studies and included 15 empirical studies, 13 literature reviews and 5 case studies. We identified 77 codes and organised these into 26 descriptive and 11 analytical themes of uncertainty. The themes identified are global, public health, healthcare system, clinical, ethical, relational, personal, knowledge exchange, epistemic, aleatoric and parameter uncertainty. The themes were included in a model, which captures the macro, meso and microlevels and the inter-relatedness of uncertainty. We successfully piloted the model on one public health example and an environmental topic. The main limitations are that the research input into our model predominantly came from North America and Europe, and that we have not yet tested the model in a real-life setting.

Conclusion

We developed a model that can comprehensively capture uncertainty in public and global health scenarios. It builds on models that focus solely on clinical settings by including social and political contexts and emphasising the dynamic interplay between different areas of uncertainty.

Common needs in uncommon conditions: a qualitative study to explore the need for care in pediatric patients with rare diseases

Background

Challenges faced by children diagnosed with a rare disease or complex condition and their family members are often characterized by disease-specific complexities, such as a prolonged diagnostic process, an uncertain prognosis, and the absence of curative treatment. The psychological burden of living with a rare disease or complex condition is often understudied and may present overarching concepts that shape the general experience of having been diagnosed with a rare condition. The present study examines common needs from a comprehensive perspective combining relevant aspects from the rare disease literature in a theoretical perspective from pediatric psychology, such as a family-centred, developmental and interdisciplinary approach. An exploratory study was designed among parents from children with a rare disease or complex condition in an Integrated University Children’s Hospital in the Netherlands. Semi-structured interviews were conducted with open-ended questions based around the experience of having a child diagnosed with a rare condition, such as the psychosocial impact on the child and it’s development, the impact on the family, and how provided care was experienced.

Results

Twelve interviews were analysed with a thematic content analysis to identify common needs. Eight themes followed from the analysis and uncovered the need for (1) family-focused care, (2) coping with uncertainty, (3) empathic communication, (4) practical support, (5) information, (6) psychological support, (7) interdisciplinary care, and (8) social support.

Conclusions

The results from our study provide directions for research and health care to support young patients with a rare disease or complex condition and their families. Moreover, our results demonstrated that there are overarching concepts across different rare diseases that may be optimally supported with interdisciplinary care.

The use of cognitive task analysis in clinical and health services research — a systematic review

Background

At times, clinical case complexity and different types of uncertainty present challenges to less experienced clinicians or the naive application of clinical guidelines where this may not be appropriate. Cognitive task analysis (CTA) methods are used to elicit, document and transfer tacit knowledge about how experts make decisions.

Methods

We conducted a methodological review to describe the use of CTA methods in understanding expert clinical decision-making. We searched MEDLINE, EMBASE and PsycINFO from inception to 2019 for primary research studies which described the use of CTA methods to understand how qualified clinicians made clinical decisions in real-world clinical settings.

Results

We included 81 articles (80 unique studies) from 13 countries, published from 1993 to 2019, most commonly from surgical and critical care settings. The most common aims were to understand expert decision-making in particular clinical scenarios, using expert decision-making in the development of training programmes, understanding whether decision support tools were warranted and understanding procedural variability and error identification or reduction. Critical decision method (CDM) and CTA interviews were most frequently used, with hierarchical task analysis, task knowledge structures, think-aloud protocols and other methods less commonly used. Studies used interviews, observation, think-aloud exercises, surveys, focus groups and a range of more CTA-specific methodologies such as the systematic human error reduction and prediction approach. Researchers used CTA methods to investigate routine/typical (n = 64), challenging (n = 13) or more uncommon, rare events and anomalies (n = 3).

Conclusions

In conclusion, the elicitation of expert tacit knowledge using CTA has seen increasing use in clinical specialties working under challenging time pressures, complexity and uncertainty. CTA methods have great potential in the development, refinement, modification or adaptation of complex interventions, clinical protocols and practice guidelines.

Registration

PROSPERO ID CRD42019128418.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01002-6.

Managing Boundary Uncertainty in Diagnosing the Patients of Rural Area Using Fuzzy and Rough Set

People of rural India often suffer from acute health conditions like diarrhea, flu, lung congestion, and anemia, but they are not receiving treatment even at primary level due to scarcity of doctors and health infrastructure in remote villages. Health workers are involved in diagnosing the patients based on the symptoms and physiological signs. However, due to inadequate domain knowledge, lack of expertise, and error in measuring the health data, uncertainty creeps in the decision space, resulting many false cases in predicting the diseases. The paper proposes an uncertainty management technique using fuzzy and rough set theory to diagnose the patients with minimum false-positive and false-negative cases. We use fuzzy variables with proper semantic to represent the vagueness of input data, appearing due to measurement error. We derive initial degree of belonging of each patient in two different disease class labels (YES/NO) using the fuzzified input data. Next, we apply rough set theory to manage uncertainty in diagnosing the diseases by learning approximations of the decision boundary between the two class labels. The optimum lower and upper approximation membership functions for each disease class label have been obtained using Non-dominated Sorting Genetic Algorithm-II (NSGA-II). Finally, using the proposed disease_similarity_factor, new patients are diagnosed precisely with 98% accuracy and minimum false cases.

How do we and how should we deal with uncertainty in Endodontics?

In many clinical cases a dentist may feel certain when for example diagnosing, deciding on treatment, or assessing the prognosis—in other cases many dentists may feel a degree of doubt or uncertainty. This paper aims to explore the philosophical concept of uncertainty and its different dimensions, using the condition “persistent apical periodontitis associated with a previously root filled tooth” as an example. Acknowledging that uncertainty exists in any clinical situation can be perceived as uncomfortable, as some might regard it as a weakness. Whilst some types of uncertainty met in dental practice can be addressed and reduced, there are other types which are inevitable and must be accepted. To make sound decisions, it is pertinent that the dentist reflects on and values the consequences of uncertainty. In this paper, a conceptual model is presented by which the dentist can identify the type of uncertainty in a clinical case, making it possible to decide on a strategy on how to manage the uncertainty and its possible consequences, with the aim to support the dentist's care for their patients. The understanding that uncertainty exists and the ability to acknowledge and be comfortable with it when making decisions should be addressed throughout our professional career, and thus ought to be developed during undergraduate education. Some suggestions on how teachers could target this are given in the paper.

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.

Financial Estimation of the Uncertainty in Medicine Using Present Value of Medical Fees and a Mortality Risk Prediction Model: a Retrospective Cohort Study

This study aimed to develop a method to enable the financial estimation of each patient’s uncertainty without focusing on healthcare technology. We define financial uncertainty (FU) as the difference between an actual amount of claim (AC) and the discounted present value of the AC (DAC). DAC can be calculated based on a discounted present value calculated using a cash flow, a period of investment, and a discount rate. The present study considered these three items as AC, the length of hospital stay, and the predicted mortality rate. The mortality prediction model was built using typical data items in standard level electronic medical records such as sex, age, and disease information. The performance of the prediction model was moderate because an area under curve was approximately 85%. The empirical analysis primarily compares the FU of the top 20 diseases with the actual AC using a retrospective cohort in the University of Miyazaki Hospital. The observational period is 5 years, from April 1, 2013, to March 31, 2018. The analysis demonstrates that the proportion of FU to actual AC is higher than 20% in low-weight children, patients with leukemia, brain tumor, myeloid leukemia, or non-Hodgkin’s lymphoma. For these diseases, patients cannot avoid long hospitalization; therefore, the medical fee payment system should be designed based on uncertainty. Our method is both practical and generalizable because it uses a small number of data items that are required in standard electronic medical records. This method contributes to the decision-making processes of health policymakers.

Towards a new understanding of uncertainty in medical education

RATIONALE, AIMS, AND OBJECTIVES

Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education.

METHOD

A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty.

RESULTS

Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education.

CONCLUSION

The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.

Communicating uncertainty: contrasting the communication experiences of patients with advanced COPD and incurable lung cancer

BACKGROUND

Due to the uncertain disease trajectory and variable rate of progression in chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) are challenged in explaining what the future may hold for patients compared to those with lung cancer (LC). Support and communication of timely information can significantly improve health outcomes.

OBJECTIVE

This study sought to identify factors that impact communication and support and recommend ways to improve patients' understanding of living with life-threatening illness.

METHODS

Semi-structured interviews with patients with LC (n = 22) and advanced COPD (n = 18), their informal carers (21 LC and 18 COPD) and HCPs (n = 51). Patients were recruited from primary and secondary care in the East of England, UK, during 2010-12.

RESULTS

Directness and clarity characterized communication in LC, whereas uncertainty and limited explanations predominated in COPD. Discussions on how the disease might impact on decisions and preferences to be made in the future were less common in COPD. Information for LC patients was mainly from hospital clinicians and any information for COPD patients mainly from primary care clinicians.

CONCLUSIONS

The experience of COPD patients could be improved by professionals soon after diagnosis explaining to them the typical pattern of decline in COPD, highlighting the inherent uncertainties about when exacerbations and death may occur. This conversation should lead to planning for the different challenges that the patient and informal carer recognize as most important to them. This contrasts with the 'breaking bad news' conversation that oncologists are highly trained to deliver.

A scoping review of practice recommendations for clinicians' communication of uncertainty

BACKGROUND

Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty.

OBJECTIVE

To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters.

SEARCH STRATEGY

A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts.

INCLUSION CRITERIA

Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients.

DATA EXTRACTION

Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice.

RESULTS

Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty.

DISCUSSION AND CONCLUSIONS

A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients.

PATIENT OR PUBLIC CONTRIBUTION

Results were presented to stakeholders (physicians) to check and improve their practical applicability.

Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper

AIMS

To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.

BACKGROUND

In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.

DESIGN

Discursive paper.

FINDINGS

Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.

CONCLUSION

COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.

RELEVANCE TO CLINICAL PRACTICE

Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

Existential uncertainty in health care: A concept analysis

RATIONALE, AIMS AND OBJECTIVES

According to an influential taxonomy of varieties of uncertainty in health care, existential uncertainty is a key aspect of uncertainty for patients. Although the term "existential uncertainty" appears across a number of disciplines in the research literature, its use is diffuse and inconsistent. To date there has not been a systematic attempt to define it. The aim of this study is to generate a theoretically-informed conceptualisation of existential uncertainty within the context of an established taxonomy.

METHOD

Existential uncertainty was subjected to a concept analysis, which drew on existing uses of the term across multiple disciplines as well as insights from uncertainty theory more broadly and from the existential therapy literature to generate a tentative definition of the concept. Antecedents, consequences, and empirical referents of existential uncertainty were also identified. A model case was described as well as a borderline case and a related case in order to illustrate and delineate the concept.

RESULTS

Existential uncertainty is conceptualised as an awareness of the undetermined but finite nature of one's own being-in-the-world, concerned primarily with identity, meaning, and choice. This awareness is fundamental and ineradicable, and manifests at different levels of consciousness.

CONCLUSION

Humans rely on identity, worldview, and a sense of meaning in life as ways of managing the ineradicable uncertainty of our being-in-the-world, and these can be challenged by a serious diagnosis. It is important that medical professionals acknowledge issues around existential uncertainty as well as issues around scientific uncertainty, and recognise when patients might be struggling with these. Further research is required to identify ways of measuring existential uncertainty and to develop appropriate interventions, but it is hoped that this conceptualisation provides a useful first step towards that goal.

Professional and Ethical Issues in United States Acute Care Physical Therapists Treating Patients With COVID-19: Stress, Walls, and Uncertainty

OBJECTIVE

To the authors' knowledge, no peer-reviewed research has explored professional and ethical issues encountered by physical therapists in treating patients with COVID-19. The purpose of this study was to explore the experiences of physical therapists regarding the professional and ethical issues they encountered during the COVID-19 pandemic.

METHODS

The current study used reflexive thematic analysis, a qualitative research design developed by Braun and Clarke, to analyze individual interviews.

RESULTS

Analysis of the coded interviews produced 6 primary themes (uncertainty, physical therapist's role, ethical dilemmas and moral distress, emotions, providing care and working conditions, and management and leadership influence) and associated subthemes.

CONCLUSION

Physical therapists reported numerous professional and ethical issues across the individual, organizational, and societal realms during the COVID-19 pandemic. This study highlights the need for education and resources to prepare physical therapists for professional and ethical issues encountered during pandemics. Specifically, there is a need to define the physical therapist's role in pandemics and prepare physical therapy personnel for dealing with ethical issues, stress, uncertainty, and organizational changes associated with pandemics. Ethical guidelines would support organizations in delineating fair processes for triage and allocation of scarce resources for acute care physical therapy during health care emergencies.

IMPACT

The COVID-19 pandemic has produced significant changes in health care and physical therapist practice. This study reports results of the first, to our knowledge, research study focusing on professional and ethical issues experienced by physical therapists in acute care during the COVID-19 pandemic. As the United States faces an unprecedented spike in COVID-19 cases and deaths, results of this study may contribute to physical therapists' preparation for and response to professional and ethical issues encountered in acute care during the pandemic.

A randomized experimental study to test the effects of discussing uncertainty during cancer genetic counseling: different strategies, different outcomes?

Uncertainty is increasingly discussed during genetic counseling due to innovative techniques, e.g., multigene panel testing. Discussions about uncertainty may impact counselees variably, depending on counselors' communication styles. Ideally, the discussion of uncertainty enables counselees to cope with uncertainty and make well-informed decisions about testing. We examined the impact of how counselors convey uncertainty and address counselees' uncertainty, and explored the role of individual characteristics. Therefore, a randomized controlled experiment using videos was conducted. Former counselees (N = 224) viewed one video depicting a genetic consultation about multigene panel testing. The extent of counselors' communication of uncertainty (comprehensive vs. the essence) and their response to counselees' uncertainty expressions (providing information vs. providing space for emotions vs. normalizing and counterbalancing uncertainty) were systematically manipulated. Individual characteristics, e.g., uncertainty tolerance, were assessed, as well as outcome variables (primary outcomes: feelings of uncertainty and information recall). No effects were found on primary outcomes. Participants were most satisfied when the essence was communicated, combined with providing information or providing space responses (p = 0.002). Comprehensive information resulted in less perceived steering toward testing (p = 0.005). Participants with lower uncertainty tolerance or higher trait anxiety were less confident about their understanding when receiving comprehensive information (p = 0.025). Participants seeking information experienced less uncertainty (p = 0.003), and trusted their counselor more (p = 0.028), when the counselor used information providing responses. In sum, the impact of discussing uncertainty primarily depends on individual characteristics. Practical guidelines should address how to tailor the discussion of uncertainty.

Towards developing a comprehensive conceptual understanding of positive hospital culture and approaches to healthcare organisational culture change in Australia

PURPOSE

The key aim of this narrative literature review, therefore, is to identify the key conceptual categories that inform the construction of positive person-centred culture within hospitals, and how these frameworks are brought to bear upon organisational culture within healthcare systems in Australia.

DESIGN/METHODOLOGY/APPROACH

This narrative review presents a thematic synthesis of literature identified through a systematic search protocol undertaken across 19 academic databases and Google Scholar as an additional search tool. Thematic qualitative analysis was performed on the research results to determine the common themes within the diverse literature presented within this study.

FINDINGS

Culture change interventions in hospitals attempt to address the problem of widespread unprofessional behaviour within healthcare systems. However, diverse definitions and seemingly fragmented approaches to understanding and enacting organisational culture change present a significant hurdle in achieving cohesive and sustainable healthcare reform. This narrative literature review offers a comprehensive conceptual view of the key approaches that inform positive person-centred culture within hospital settings. In total, three primary dimensions, belonging, behaving and being, aligned against organisational goals, individual behaviours and worker as well as organisational identity were identified. Other individual and group interactional dynamics that give rise to negative organisational culture are further analysed to understand the fault lines along which existing culture change interventions are typically operationalised.

RESEARCH LIMITATIONS/IMPLICATIONS

This review is not exhaustive and is limited in its methodological scope. The central values and themes identified within the literature are integral to designing humanised healthcare systems. However, owing to the qualitative nature and contextual variability of these factors, these themes do not lend themselves to replicable quantification.

SOCIAL IMPLICATIONS

This analysis contributes to foundational research efforts towards transforming healthcare practice to be more aligned with humanised and equitable values within increasingly complex healthcare organisational settings. Designing culture change interventions that align more suitably with the values-driven categories identified in this literature review may increase the effectiveness and sustainability of these interventions and reform efforts at organisational and systemic levels.

ORIGINALITY/VALUE

This article presents a comprehensive framework to approach healthcare organisational reform through shared and equitable models of operation, management and governance rather than continuing to promote narrowly defined outcomes derived from commodified models of healthcare practice.

Engaging with Uncertainty and Complexity: A Secondary Analysis of Primary Care Responses to Intimate Partner Violence

Complex problems generate uncertainty. The number and diversity of interactions between different health professionals, perspectives, and components of the problem makes predicting an outcome impossible. In effort to reduce the uncertainty of intimate partner violence interventions, health systems have developed standardized guidelines and protocols. This paper presents a secondary analysis of 17 New Zealand primary care professional narratives on intimate partner violence as a health issue. We conducted a complexity-informed content analysis of participant narratives to explore uncertainty in greater depth. This paper describes three ways primary care professionals interact with uncertainty: reducing uncertainty, realizing inherent uncertainty, and engaging with uncertainty. We found dynamic patterns of interaction between context and the experience of uncertainty shape possible response options. Primary care professionals that probed into uncertainty generated new understanding and opportunities to respond to intimate partner violence.

The multidisciplinary team perspectives on agitation management in critical care: A qualitative study

BACKGROUND

People who are experiencing a period of critical illness frequently experience severe agitation. The presence of agitation can pose risks to the patient, family, and clinical team.

AIMS AND OBJECTIVES

To capture the views and opinions of critical care multidisciplinary teams concerning the approaches in the management of agitation, and to understand and identify the perceived risks and benefits of current management strategies.

DESIGN

A descriptive qualitative design.

METHODS

Data were gathered using semi-structured interviews with multidisciplinary teams from adult critical care units from one region in the United Kingdom.

FINDINGS

A total of 19 participants participated between February to September 2017. There were two group interviews (GIs) (n = 12, GI 1 n = 8, GI 2 n = 4) and seven one-to-one interviews, across four hospital organisations with one participant working via an agency. The mean length (± SD) of each interview, one to one or group, was 58.86 minutes (5.81 minutes). Three major themes were generated about the complex clinical decision-making required to manage an agitated patient. These themes represented: the burden of care, continuity of clinical decision-making, and uncertainty and indecision experienced by participants.

CONCLUSION

Participants described caring for an agitated patient as challenging and stressful. Staff sought clarification on what level of restrictive practice is allowed. Feelings of anxiety and stress generated by the decisions made may have an impact on staff, particularly those who are more inexperienced, which in the longer term could lead to fatigue or moral distress.

RELEVANCE TO CLINICAL PRACTICE

The study has emphasised the challenges faced by multidisciplinary teams and how decision-making may impact on individuals within the team.

Facilitating supportive care in cardiac intensive care units

PURPOSE OF REVIEW

The number of patients who die in the hospital in the Western world is high, and 20-30% of them are admitted to an ICU in the last month of life, including those in cardiac ICUs (CICUs) where invasive procedures are performed and mortality is high. Palliative consultation is provided in only a few cases. The ethical and decisional aspects associated with the advanced stages of illness are very rarely discussed.

RECENT FINDINGS

The epidemiological and clinical landscape of CICUs has changed in the last decade; the incidence of acute coronary syndromes has decreased, whereas noncardiovascular diseases, comorbidities, the patients' age and clinical and therapeutic complexity have increased. The use of advanced and invasive treatments, such as mechanical ventilation, mechanical circulatory support and renal replacement therapies, has increased. This evolution increases the possibility of developing a life-threatening clinical event.

SUMMARY

This review aimed to analyze the main epidemiological, clinical, ethical and training aspects that can facilitate the introduction of supportive/palliative care programs in the CICU to improve symptom management during the advanced/terminal stages of illness, and address such issues as advance care planning, withdrawing/withholding life-sustaining treatments, deactivation of implantable defibrillators and palliative sedation.

"I Was Worried About the Patient, but I Wasn't Feeling Worried": How Physicians Judge Their Comfort in Settings of Uncertainty

PURPOSE

Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort.

METHOD

Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty.

RESULTS

Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment.

CONCLUSIONS

The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.

Resilience in the Surgical Scheduling to Support Adaptive Scheduling System

Operating Room (OR) managers frequently encounter uncertainties related to real-time scheduling, especially on the day of surgery. It is necessary to enable earlier identification of uncertainties occurring in the perioperative environment. This study aims to propose a framework for resilient surgical scheduling by identifying uncertainty factors affecting the real-time surgical scheduling through a mixed-methods study. We collected the pre- and post-surgical scheduling data for twenty days and a one-day observation data in a top-tier general university hospital in South Korea. Data were compared and analyzed for any changes related to the dimensions of uncertainty. The observations in situ of surgical scheduling were performed to confirm our findings from the quantitative data. Analysis was divided into two phases of fundamental uncertainties categorization (conceptual, technical and personal) and uncertainties leveling for effective decision-making strategies. Pre- and post-surgical scheduling data analysis showed that unconfirmed patient medical conditions and emergency cases are the main causes of frequent same-day surgery schedule changes, with derived factors that affect the scheduling pattern (time of surgery, overtime surgery, surgical procedure changes and surgery duration). The observation revealed how the OR manager controlled the unexpected events to prevent overtime surgeries. In conclusion, integrating resilience approach to identifying uncertainties and managing event changes can minimize potential risks that may compromise the surgical personnel and patients' safety, thereby promoting higher resilience in the current system. Furthermore, this strategy may improve coordination among personnel and increase surgical scheduling efficiency.

Innovations in framework synthesis as a systematic review method

Framework synthesis is one systematic review method employed to address health care practice and policy. Adapted from framework analysis methods, it has been used increasingly, using both qualitative and mixed-method systematic review methods. This article demonstrates a spectrum of approaches to framework synthesis that are dependent on the extent to which theory is tentative, emergent, refined, or established; and that stakeholder involvement may help to understand the topic's complexity where theory is more nascent. The choice of approach depends on the degree of match with existing theories and, in the absence of existing theory, the scale and heterogeneity of the literature to be managed.

Adding value to core outcome set development using multimethod systematic reviews

Trials evaluating the same interventions rarely measure or report identical outcomes. This limits the possibility of aggregating effect sizes across studies to generate high-quality evidence through systematic reviews and meta-analyses. To address this problem, core outcome sets (COS) establish agreed sets of outcomes to be used in all future trials. When developing COS, potential outcome domains are identified by systematically reviewing the outcomes of trials, and increasingly, through primary qualitative research exploring the experiences of key stakeholders, with relevant outcome domains subsequently determined through transdisciplinary consensus development. However, the primary qualitative component can be time consuming with unclear impact. We aimed to examine the potential added value of a qualitative systematic review alongside a quantitative systematic review of trial outcomes to inform COS development in neonatal care using case analysis methods. We compared the methods and findings of a scoping review of neonatal trial outcomes and a scoping review of qualitative research on parents', patients', and professional caregivers' perspectives of neonatal care. Together, these identified a wider range and greater depth of health and social outcome domains, some unique to each review, which were incorporated into the subsequent Delphi process and informed the final set of core outcome domains. Qualitative scoping reviews of participant perspectives research, used in conjunction with quantitative scoping reviews of trials, could identify more outcome domains for consideration and could provide greater depth of understanding to inform stakeholder group discussion in COS development. This is an innovation in the application of research synthesis methods.

Organisational change in hospitals: a qualitative case-study of staff perspectives

Background

Organisational change in health systems is common. Success is often tied to the actors involved, including their awareness of the change, personal engagement and ownership of it. In many health systems, one of the most common changes we are witnessing is the redevelopment of long-standing hospitals. However, we know little about how hospital staff understand and experience such potentially far-reaching organisational change. The purpose of this study is to explore the understanding and experiences of hospital staff in the early stages of organisational change, using a hospital redevelopment in Sydney, Australia as a case study.

Methods

Semi-structured interviews were conducted with 46 clinical and non-clinical staff working at a large metropolitan hospital. Hospital staff were moving into a new building, not moving, or had moved into a different building two years prior. Questions asked staff about their level of awareness of the upcoming redevelopment and their experiences in the early stage of this change. Qualitative data were analysed using thematic analysis.

Results

Some staff expressed apprehension and held negative expectations regarding the organisational change. Concerns included inadequate staffing and potential for collaboration breakdown due to new layout of workspaces. These fears were compounded by current experiences of feeling uninformed about the change, as well as feelings of being fatigued and under-staffed in the constantly changing hospital environment. Nevertheless, balancing this, many staff reported positive expectations regarding the benefits to patients of the change and the potential for staff to adapt in the face of this change.

Conclusions

The results of this study suggest that it is important to understand prospectively how actors involved make sense of organisational change, in order to potentially assuage concerns and alleviate negative expectations. Throughout the processes of organisational change, such as a hospital redevelopment, staff need to be engaged, adequately informed, trained, and to feel supported by management. The use of champions of varying professions and lead departments, may be useful to address concerns, adequately inform, and promote a sense of engagement among staff.