Twelve tips for developing healthcare learners’ uncertainty tolerance

Abstract

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.

Keywords:

• Uncertainty tolerance
• tolerance of ambiguity
• curriculum
• pedagogy

Introduction

Uncertainty is ubiquitous within healthcare, and may arise at any point along the continuum of patient care (Han et al. 2011). Rather than memorising facts and responding to single best answer multiple-choice questions, healthcare professionals will instead practice in a workplace characterised by shades of grey. Differences in how individuals perceive and respond to such uncertainty is termed their uncertainty tolerance (Hillen et al. 2017).

A large body of healthcare research examines associations between practitioner and/or learner uncertainty tolerance with healthcare related outcomes (Strout et al. 2018; Hancock and Mattick 2020). Links are identified between lower uncertainty tolerance and adverse outcomes (Strout et al. 2018), including reduced practitioner/learner wellbeing (Hancock and Mattick 2020), less favourable attitudes toward person-centred care (Geller et al. 2010; Wayne et al. 2011), and increased healthcare resource utilisation (Allman et al. 1985; Forrest et al. 2006). Accordingly, there are growing calls for health professions learners to develop effective uncertainty tolerance (Luther and Crandall 2011; Simpkin and Schwartzstein 2016; Lazarus and Brand 2020; Patel et al. 2022), with effective management of uncertainty now considered a graduate attribute by many health professional training programs. For example, in medicine the Royal College of Psychiatrists in the UK and the Royal Australian College of General Practitioners both list managing uncertainty as core or high-level competencies required of trainees (Royal Australasian College of General Practitioners 2022; Royal College of Psychiatrists 2022), and in allied health, the World Physiotherapy education framework describes that physiotherapists need ‘to develop strategies to manage ambiguity, uncertainty, change, and stress’ (World Physiotherapy 2021). Despite recognition that healthcare learners need to develop uncertainty tolerance during training, a gap remains in equipping educators with the tools to support learners’ development of this critical attribute. Accordingly, the twelve tips that follow translate contemporary research into practical ways that health professions learners, educators and institutions can foster uncertainty tolerance.

In the authors’ experience, the uncertainty tolerance construct and what it means to ‘tolerate’ uncertainty, are both frequently misunderstood. Misconceptions appear to stem, in part, from varied construct definitions, the preponderance of synonymous constructs within the literature (e.g. tolerance of ambiguity, uncertainty orientation, stress from uncertainty etc.), as well as conflation with other constructs such as risk (Tubbs et al. 2006; Hillen et al. 2017). Seeking to unify the field, Hillen et al. (2017) proposed the following definition for uncertainty tolerance: ‘the set of negative and positive psychological responses - cognitive, emotional and behavioural - provoked by the conscious awareness of ignorance about particular aspects of the world’.

Subsequent to this definition, other researchers further refined the understanding of what it means to be ‘tolerant’ of uncertainty, but not without continued debate. For example, ‘doubt’ and ‘worry’ have been conceptualised as ‘negative’ or ‘intolerant’ responses to uncertainty (Gerrity et al. 1990; Hillen et al. 2017). However, others have described the benefit of experiencing some stress in the face of uncertainty, as this can help healthcare providers recognise a need for support (Ilgen et al. 2020). Another example of similar discourse relates to ‘information seeking’, which has been described as a positive response (e.g. to build evidence supporting a differential diagnosis) by some (Hillen et al. 2017), while other work identified this behavioural response as maladaptive in the context of students continuing to seek a definitive answer in the face of unresolvable uncertainty (Stephens et al. 2021).

Longitudinal qualitative research with medical students identified that although students typically describe emotional responses to uncertainty in terms of a stress response, descriptions of their thoughts and behaviours shift from doubt and avoidance, to acceptance of uncertainty and engagement with learning despite uncertainty over time (Stephens et al. 2021, Stephens, Sarkar et al. 2023). Furthermore, methodologically diverse research has identified a variety of factors or ‘moderators’ that appear to influence students’ responses to uncertainty (Strout et al. 2018; Hancock and Mattick 2020; Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a). Together these findings suggest that rather than uncertainty tolerance being an entirely static trait, it is changeable over time and across contexts.

These contemporary findings also suggest that conceptualisations of the UT construct which focus on emotional responses may inappropriately consider an individual to be ‘intolerant’ of uncertainty when they are thinking and acting to adaptively manage uncertainty despite, or even in recognition of, the stress they feel (Stephens et al. 2023). Accordingly, the field of uncertainty tolerance research is moving toward a more nuanced understanding of what it means to be uncertainty ‘tolerant’, progressing from one that was (ironically) more black and white, to one that accounts for context when considering whether a set of responses (i.e. cognitions, emotions and behaviours) are adaptive or maladaptive when responding to uncertainty (Stephens et al. 2023).

For the tips that follow, uncertainty tolerance is defined as adaptively responding to and effectively managing uncertainty within a specified context, and thus as a state that is changeable. Each tip synthesises research findings across the field, alongside the authors’ practical experiences implementing curricula designed to promote learner uncertainty tolerance. Research findings will be drawn from studies of medical students (Stephens et al. 2021; Patel et al. 2022; Stephens et al. 2022b, 2022a, Stephens et al. 2023), other healthcare populations (Moffett et al. 2021), and educators working in a range of disciplines (Lazarus 2021; Lazarus, Gouda-Vossos, et al. 2022; Lazarus, Truong et al. 2022; Truong et al. 2022). Such research is diverse in methodology, including longitudinal qualitative (Nevalainen et al. 2010; Stephens et al. 2021; Stephens et al. 2022b, 2022a, Stephens et al. 2023), cross-sectional qualitative (Ilgen et al. 2020; Scott et al. 2020; Lazarus, Gouda-Vossos, et al. 2022), mixed methods (Gowda et al. 2018), quantitative scale-based (Geller et al. 2010; Wayne et al. 2011; Caulfield et al. 2014; Hancock et al. 2015; Geller et al. 2021), scoping reviews (Moffett et al. 2021; Patel et al. 2022), systematic reviews (Strout et al. 2018; Hancock and Mattick 2020; Stephens, Lazarus et al. 2023), and meta-analysis (Stephens et al. 2022).

Together, these tips (summarised in Table 1) should inspire and empower health professions education stakeholders to implement these evidence-based approaches designed to build learner uncertainty tolerance.

Table 1. Twelve tips for supporting healthcare learners’ uncertainty tolerance development are described, alongside suggestions for how these tips may be implemented in practice.

Tip	Implementation Suggestions
Tips for Learners
Tip 1: Understand that uncertainty is inherent to healthcare learning and practice	Consider the reasons underlying uncertainty, e.g. knowledge gaps versus gaps in the body of medical evidence Question the ‘certain’ nature of ‘facts’ by exploring the underlying evidence and identifying where uncertainty is present
Tip 2: Identify factors that influence your uncertainty tolerance	Develop adaptive expertise by gaining a breadth of clinical experience and building conceptual knowledge Collaborate with peers to explore effective and diverse approaches to managing uncertainty
Tip 3: Identify your purposes for managing uncertainty	Identify responsibilities, motivations and values for managing the uncertainty in healthcare practice (e.g. learning to care for patients) Utilise identified purposes to provide a sense of certainty that informs how to manage uncertainty
Tip 4: Critically reflect on uncertain experiences	Use a framework, such as “What? So what? Now what?” to help structure the reflective process Focus on was learnt through uncertain experiences, and how this informs responses to future uncertain scenarios
Tips for Educators and Supervisors Tips
Tip 5: Signpost uncertainty within curricula	Introduce uncertainty relevant to the learner’s stage Highlight research gaps and patient factors that may influence the application of knowledge
Tip 6: Role model uncertainty tolerance	Describe personal experiences of uncertainty similar to those experienced by the learner, and how these were managed Be reassured that expressions of vulnerability can aid learners to appreciate the role of uncertainty tolerance in clinical practice
Tip 7: Support learners across uncertain thresholds	Acknowledge the extent of uncertainty experienced by students at thresholds within curriculum, including uncertainties that may not directly related to intended learning outcomes Reduce extraneous uncertainty through placement orientations and frequent communication
Tip 8: Challenge learners to build their uncertainty tolerance over time	Ask learners to individually communicate knowns and unknowns Increase the authenticity of the educational settings in which uncertainty is experienced (e.g. classroom, followed by simulation, then clinical placements)
Educational Intuitions and Systems Tips
Tip 9: Acknowledge and incorporate uncertainty in assessment strategies	Adopt principles of authentic assessment (e.g. reflective of the uncertainty tolerance required of a health professions graduate) Reward process and reasoning in addition to final ‘answers’
Tip 10: Support near-peer teaching	Train near-peer tutors about pedagogy and uncertainty tolerance Create near-peer mentoring programs that encourage role modelling of uncertainty tolerance
Tip 11: Build institutional uncertainty tolerance	Create a local community of practice focussed on uncertainty tolerance teaching approaches Consider how institutional policies can support educators to introduce uncertainty tolerance teaching approaches, and provide flexibility in policies where possible
Tip 12: Horizontally and vertically integrate approaches to developing uncertainty tolerance	Map existing curricula for sources and moderators of uncertainty Include uncertainty tolerance as a course/degree learning outcome

Tips for learners

Tip 1

Understand that uncertainty is inherent to healthcare learning and practice

Humans appear to be hardwired to perceive uncertainty negatively (Anderson et al. 2019), with some suggesting this has an evolutionary basis (Pain et al. 2022). Think of the perspective of a student in a bedside tutorial with a senior clinician: Uncertainty may provoke anxiety, and be perceived as a threat to the students’ credibility in the eyes of their peers and supervisors (Hillen et al. 2017). Research shows that novice medical students tend to conceptualise knowledge in ‘certain’ terms, as discrete facts (Knight and Mattick 2006). In this view, learners may largely conceptualise uncertainty as knowledge deficits (Stephens et al. 2022b).

In healthcare practice, uncertainty extends well beyond the limits of an individual’s knowledge, and is a phenomenon experienced by even expert clinicians (Ilgen et al. 2021). Healthcare uncertainties may stem from a variety of sources, including research gaps, unpredictability of future outcomes and complexities of patient care (Han et al. 2011; Stephens et al. 2022b; Scott et al. 2023). Uncertainty may be biomedical, and/or extend to patient or healthcare system centred sources (Han et al. 2011). Knowledge in such contexts is evolving and contextual; what may be considered ‘correct’ for one patient with a particular pathology may differ for another (Knight and Mattick 2006). Uncertainty is therefore an inherent part of health professional practice.

There appear to be significant consequences stemming from uncertainty intolerance, or maladaptively managing uncertainty in healthcare (Strout et al. 2018). Research demonstrates uncertainty intolerance is related to psychological distress of practitioners, paternalistic approaches to medicine, and overuse of healthcare resources (Allman et al. 1985; Forrest et al. 2006; Wayne et al. 2011; Strout et al. 2018; Hancock and Mattick 2020). Thus, developing learners’ uncertainty tolerance, before transitioning to practice, could be pivotal for their own well-being as well as benefit the healthcare system.

For learners to develop uncertainty tolerance, they first need to understand the broader nature of uncertainty in healthcare and learning, including how to distinguish gaps in knowledge from uncertainty inherent to clinical work (Stephens et al. 2022b). One activity to facilitate understanding the nature of uncertainty in healthcare is to question the nature of any ‘facts’ learnt. Considerations might include whether there are limitations or conflicts in the evidence-base underpinning a fact, or contextual factors that influence priorities for investigation or management. Coronary artery disease (CAD) is one common example learners could explore. Research gaps remain due to the underrepresentation of women with CAD in research trials (Wenger et al. 2022), and factors such as geographic locations and patient preferences may influence management plans. Once learners begin to appreciate the ways in which uncertainty may influence practice (beyond knowledge deficits), they can begin to develop skills to adaptively manage the breadth of uncertainties they will face in healthcare practice.

Tip 2

Identify factors that influence your uncertainty tolerance

How one tolerates uncertainty does not occur in isolation. Rather, uncertainty tolerance may be considered a context specific state, wherein a range of factors both within an individual and in their environment influence or ‘moderate’ how one perceives and responds to uncertainty (Hillen et al. 2017; Stephens et al. 2021; Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a). By understanding the role of moderators, and which of these are within one’s locus of control, learners may be better able to understand how they can develop their own uncertainty tolerance. Key moderators that learners have agency over include knowledge and experience, interactions with peers, and a learner’s sense of purpose or motivations for managing uncertainty (see Tip 3) (Stephens et al. 2021; Stephens et al. 2022a).

Learning in health professions programs is often likened to ‘drinking from a fire hose’, in that only a small amount of overwhelming information may be learnt at any one time. Even if an individual was able to memorise ‘all’ existing knowledge, uncertainty would persist. Priorities for learning should therefore be on understanding core concepts that may be applied to uncertain scenarios, a concept known as adaptive expertise (Cutrer et al. 2017). The same applies to building clinical experience, as this may help learners better distinguish known unknowns from unknown unknowns. Learners should therefore aim to gain a breadth and depth of clinical experience, and be curious about learning from ambiguous situations (Stephens et al. 2022a).

Uncertainty is a universal human experience, so drawing on the support and experiences of others, including other learners, can be particularly helpful (Stephens et al. 2021; Stephens et al. 2022a). When interacting with peers, research suggests that learners should avoid engaging in negative aspects of social comparison (e.g. comparing oneself unfavourably to another who appears to be performing better), and instead aim to collaborate with peers to explore effective strategies for managing uncertainty practiced by others (Stephens et al. 2022a).

Tip 3

Identify your purposes for managing uncertainty

Having a sense of purpose can provide an anchor of certainty in otherwise uncertain situations (Stephens et al. 2022a). This moderator may be particularly helpful due to the wide array of uncertainties that students may encounter during clinical placements (Stephens et al. 2022b). In addition to the healthcare and learning uncertainties described in Tip 1, students may also experience substantive professional uncertainties compared to clinicians with more established careers (Stephens et al. 2022b). These include uncertainties of professional identity (i.e. who am I in the context of clinical placements and how does this influence how I relate to those around me?) and role (i.e. what are my responsibilities and their boundaries within the context of a healthcare placement?). Research has identified numerous ways students may find purpose, including by learning to become a healthcare professional, helping others (e.g. patients and/or healthcare workers) and through personal values, such as social justice interests (Stephens et al. 2022a).

Although the primary purpose of a student on placement may be to learn, knowing what (and how) to learn, and balancing learning with the competing priorities of healthcare settings can itself be a source of uncertainty (Stephens et al. 2022b). Accordingly, students should identify their values and purposes early during their degree, and be open to having multiple and/or changeable purposes that can be applied to different uncertain scenarios (Stephens et al. 2022a). In this way, a sense of purpose may be likened to a guiding light through uncertainty, which keeps one on a path aligned with their values and responsibilities.

Tip 4

Critically reflect on uncertain experiences

Reflective learning is a metacognitive process wherein a learner intentionally and critically thinks about an event or situation in order to more fully understand and learn from it (Sandars 2009). Multiple studies now support the role of reflective learning in developing learner uncertainty tolerance through both written and audio-recorded approaches (Nevalainen et al. 2010; Gowda et al. 2018; Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a; Thacker et al. 2022). These studies include reflection in the context of clinical settings (Nevalainen et al. 2010; Stephens et al. 2022a), humanities and arts-based education (Gowda et al. 2018; Lazarus, Gouda-Vossos, et al. 2022), and applied medical humanities (Thacker et al. 2022). A key reason why reflection may be valuable in developing uncertainty tolerance is linked to emotions. During a situation, uncertainty may provoke unpleasant emotions (Hillen et al. 2017; Stephens et al. 2021; Stephens et al. 2022a, Stephens et al. 2023). Reflecting on uncertainty seems to allow learners to distance themselves from such emotions, and instead focus on the learning benefits afforded by uncertain experiences (Stephens et al. 2022a). To structure a reflection on uncertainty, using a framework, such as the ‘What, so what, now what?’ approach may be helpful (General Medical Council 2020; Stephens et al. 2022a, Stephens et al. 2023). When reflecting on uncertainty specifically, learners should include a description of the uncertainty stimulus, responses across thoughts, feelings and actions, and any moderators that may have influenced the scenario (Stephens et al. 2022a, Stephens et al. 2023).

Reflections on experiences of uncertainty may draw on direct learning experiences, or can be stimulated through arts-based approaches such as using photographs and narratives to generate opportunities to contemplate uncertainties related to the lived experiences of others (Brand et al. 2017; Brand et al. 2023). The reflection should conclude what was learnt from the uncertainty, and how this may impact future scenarios and clinical decision-making. Providing options for learners to reflect in their preferred medium (e.g. written, audio-recorded, visual arts-based approaches, etc.) may enhance engagement (Sandars 2009). Reflection should be practised frequently, and be formative, in order to most effectively develop uncertainty tolerance (Stephens et al. 2022a).

Tips for educators and supervisors

Tip 5

Signpost uncertainty within curricula

Prior research has identified that learners may lack awareness about the ubiquity of uncertainty in healthcare (see Tip 1), and have trouble distinguishing limitations in their own knowledge from limitations in the body of medical knowledge (Fox 1957, Stephens et al. 2022). Signposting is one approach to help learners develop experience in identifying what they don’t know as individuals (i.e. known unknowns) versus what is not yet known across the body of medical knowledge (i.e. unknown unknowns). When more accepted medical knowledge is presented (e.g. in a lecture), balancing these with purposeful highlighting of the unknown ‘edges’ of the topic could prove valuable.

Extending from the example provided in Tip 1 about CAD, educators could discuss the common presenting signs and symptoms of CAD, alongside gender differences, and the lack of knowledge about presentations in people who do not identify with their gender assigned at birth. In case-based learning, instead of focussing on a singular best answer or ‘correct’ diagnosis, cases could be built to incorporate a range of likely answers or differentials, which learners need to justify as more or less likely based on available information (Stephens et al. 2021; Richmond 2022; Stephens et al. 2022b). Extending from signposting uncertainty by the educator within a teaching activity, the authors would also advocate for explicitly including adaptively managing uncertainty within learning outcomes. The key is to select, incorporate and highlight uncertainty in a manner recognising the learner’s stage (Richmond 2022; Stephens et al. 2022b). Introducing too many uncertainties too early may result in learners sinking rather than swimming in a proverbial sea of uncertainty (Lazarus, Gouda-Vossos, et al. 2022; Lazarus et al. 2023).

Tip 6

Role model uncertainty tolerance

Adaptively managing uncertainty is inter-related to attributes such as humility and vulnerability (García Ochoa and McDonald 2019; Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a). Modelling such adaptive responses to uncertainty can help both normalise the discomfort typically accompanying uncertainty, and provide examples of strategies for responding to this uncertainty in a way that builds learners’ confidence to manage existing and future uncertainty (Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a).

One effective method for role-modelling adaptive responses to uncertainty is intellectual candour (Molloy and Bearman 2019). This term describes the bounded sharing of personal experiences, typically by the one with the greatest power in a situation (in this case the educator). Consider a general medical physician who is unsure about the diagnosis of a person presenting with fatigue and unintentional loss of weight. Initial investigations have not identified a conclusive cause for the person’s presentation. To demonstrate intellectual candour to a medical student shadowing them, the physician could use phrases such as ‘I’m not sure what the diagnosis is, but this is what I’m thinking…’, or even ‘What I’m struggling with here is…, and this is what I am going to do next to address this…’ Keys to the success of intellectual candour are that the educator acknowledges the presence of uncertainty, and ‘thinks-aloud’ their approach to managing it, and thus role-models to the learner an example of how to manage uncertainty (Molloy and Bearman 2019). Acknowledging the uncertainty may be considered an expression of vulnerability, which is balanced with credibility through the ‘think-aloud’.

By balancing vulnerability with credibility, intellectual candour can help educators convey their current and/or prior challenges with managing similar and related uncertainties to what learners are working through, and practical steps for effectively moving through these uncertainties (Molloy and Bearman 2019; Stephens et al. 2022a). When educators place themselves ‘in the shoes’ of the learner, uncertainty is contextualised as a collectively shared experience independent of career stage or role.

Tip 7

Support learners across uncertain thresholds

A threshold concept describes previously unknown knowledge that once understood, permanently alters the learner’s perception of the world around them (Meyer and Land 2005). They are by nature transformative yet troublesome, as they require learners to redefine their existing knowledge and beliefs in order to reach a new understanding (Jones and Hammond 2022). Threshold concepts abound in health professions education, with many predicated on the intrinsic uncertainties of healthcare practice (Jones and Hammond 2022). This may contribute to health professions learners feeling overwhelmed by ‘a whole lot of uncertainty’, particularly at key educational transitions (Stephens et al. 2022b).

To help support learners’ capacity to manage the uncertainty of threshold concepts, educators can create an environment that is psychologically safe and supportive. This may involve recognising the many sources of uncertainty experienced by learners, and reducing those extraneous to intended learning outcomes. For example, uncertainties about learning in healthcare settings can be reduced through the provision of orientation programs and frequent feedback from supervisors, which can help support learners to focus on learning about the uncertainties of healthcare practice (Stephens et al. 2022a).

Educators can also develop educational activities which draw on teamwork and diverse perspectives (Stephens et al. 2021; Lazarus, Gouda-Vossos, et al. 2022). Creating a learning team who can collectively manage uncertainty seems to lessen associated discomfort, and diverse perspectives can be harnessed to identify varied knowns that may be utilised to manage remaining unknowns (Lazarus, Gouda-Vossos, et al. 2022; Stephens et al. 2022a). Indeed, there are a variety of different ‘lights’ (i.e. moderators) that educators can ‘switch on’ to help support learners’ transition across the dark and troubling liminal space of a threshold concept and develop skills to effectively manage uncertainty (Meyer and Land 2005; Lazarus, Gouda-Vossos, et al. 2022; Lazarus, et al. 2023).

Tip 8

Challenge learners to build their uncertainty tolerance over time

Once learners cross a threshold and are beginning to develop skills to adaptively manage uncertainty, educators can actively challenge these learners’ uncertainty tolerance to a greater extent to better prepare them for real-world uncertainties and to set them up for crossing the next inevitable threshold. A straightforward way to increase the challenge posed by uncertainty is to have learners individually responsible for communicating knowledge (including relevant knowns and unknowns) in front of the class (as opposed to the supportive, team-based approaches described in Tip 7) (Stephens et al. 2021). Educators could also pepper in, with increasing frequency, the idea that there are substantive unknowns in the field of healthcare, and that the norms and averages used in foundational learning may not be applicable to individual patients. This approach differs from the bounded uncertainty shared through intellectual candour, and instead involves sharing experiences of uncertainty that are broad and sweeping (Bearman and Molloy 2017; Molloy and Bearman 2019; Lazarus, Gouda-Vossos, et al. 2022).

The learning environment may also be engaged to grade uncertainty stimuli. In order of increasing challenge, learners may be introduced to uncertainty initially through case-based learning in a classroom, followed by clinical simulation, and then clinical placements (Lazarus et al. 2023). Through these activities, educators can introduce clinical decision-making in the presence of uncertainty that considers person-centred approaches and judicious resource utilisation. For example, a case-based activity early in a course could include a short list of investigations which learners need to arrange in order of priority (Stephens et al. 2021). Later in a course, learners could be challenged through a simulation to communicate their preferred next steps without a supplied short list (Lazarus, Gouda-Vossos, et al. 2022). Hence to effectively develop learners’ uncertainty tolerance, educators should aim to balance challenges and supports of uncertainty tolerance related to students’ learning stage and prior experiences, enabling curricular spiralling (see Tip 12). As more uncertainty is purposefully integrated into the curriculum, role modelling uncertainty tolerance (see Tip 6) and critical reflection (Tip 4) also become increasingly relevant.

Tips for healthcare education institutions and systems

Tip 9

Acknowledge and incorporate uncertainty in assessment strategies

Assessment approaches influence students’ learning behaviours (Scott 2020). High-stakes written or clinical examinations with single-best answers may communicate to students that certainty exists to a greater degree than is typical of health professions practice, as well as lead students to engage in surface learning intended to maximise short-term performance (e.g. ‘cramming’ or use of artificial intelligence chat bots for diagnosis), rather than deep learning (Scott 2020). Overly objective assessments may also dissuade students from engaging with clinical uncertainties, resulting in students potentially prioritising library or private study over placement experiences (Stephens et al. 2022a).

To help students’ motivation for learning in a manner that embraces real-world clinical uncertainty, assessments (and related learning outcomes) should explicitly address uncertainty, and include authentic and formative approaches. In other words, assessments should be reflective of the knowledge, skills and attributes practised in the clinical workplace when managing uncertainty (Schuwirth and Van der Vleuten 2011), and facilitate enhanced learning (Boud 2015). Simulated clinical assessments, such as objective structured clinical examinations (OSCEs), could be designed to incorporate uncertainty. For example, a station based on communicating uncertainty in a manner that aligns with the preferences of the simulated patient. Another authentic approach may involve long cases wherein students are required to apply their knowledge and skills to evaluate a patient, and make decisions as they would in practice (Richmond 2022). Students should be specifically asked to communicate areas of uncertainty pertaining to the case, and how they would manage these. Assessment rubrics should address processes and reasoning, rather than simply rewarding correct outcomes. Rather than one-off, end of semester assessments, multiple opportunities for in-semester assessments alongside the provision of formative feedback are likely to benefit student engagement with authentic clinical uncertainty that they encounter through placements/work-integrated learning (Stephens et al. 2022a). Other elements of an assessment strategy designed to promote uncertainty tolerance could include multi-source feedback (e.g. about communicating uncertainty to patients and clinicians) and reflective learning portfolios (see Tip 4).

Scales intended to measure uncertainty tolerance are available, including measures that ask about responses to uncertainty and ambiguity in general (Geller et al. 1993), and within the context of healthcare (Gerrity et al. 1990; Gerrity et al. 1995; Hancock et al. 2015). It is important to note that there are considerable limitations in the validity evidence for commonly used uncertainty tolerance scales, particularly within medical student populations and in relation to evidence for responses processes (i.e. whether participants understand the scale in the same way intended by scale developers), and consequences of testing (Stephens et al. 2022; Stephens, Lazarus et al. 2023). At present, uncertainty tolerance scales are not recommended for use as part of medical student assessment, and further research is required to understand how scales may be implemented within research and educational settings (Stephens et al. 2022; Stephens, Lazarus et al. 2022).

Tip 10

Support near-peer teaching

A powerful adjunct to expert educator led approaches for fostering learner uncertainty tolerance may be the use of near-peer teaching and mentoring programmes (Stephens et al. 2022a). A near-peer tutor/mentor is typically one or two academic years ahead of their tutee/mentee. Near-peer teaching programs are widely engaged within health profession education, and benefit learning due to the social and cognitive congruence between tutors and tutees (Shenoy and Petersen 2020). In prior research about medical students’ experiences of uncertainty on clinical placements, novice clinical learners described informal learning encounters with near-peers, and the benefits of learning how to manage uncertainty from someone who had recently been through similar experiences (Stephens et al. 2022a).

Thus, educational institutions should support the engagement of near-peer teaching and mentoring by providing training of near-peers in pedagogical approaches in general, and ideally approaches designed to support uncertainty tolerance. For example, near-peer mentors could be trained in the use of intellectual candour (see Tip 8) as a means of facilitating their mentees learning about uncertainty tolerance (Molloy and Bearman 2019). The engagement of near-peers may also be beneficial during key educational transitions, for example an institution could support near-peers to lead orientation sessions about adapting to the uncertainty of learning in a clinical setting.

Tip 11

Build institutional uncertainty tolerance

Teaching practices which support uncertainty tolerance need to be considered in the context of the wider educational system. The challenge for educators is balancing the tension between educational systems typically built on rewarding, acknowledging and controlling ‘certainty’ through institutional policies and regulations, with the intrinsically uncertain and unpredictable nature of teaching (Jordan et al. 2014). There is some evidence that educators attempting to work across these tensions are more likely to burnout, as the system they work within doesn’t leave room for them to adjust and adaptively manage uncertainty intrinsic in teaching generally, and associated with uncertainty tolerance teaching practices more specifically (Helsing 2007).

Institutions can, themselves, become adaptive in the face of uncertainty by training and supporting educators’ development of uncertainty tolerance through similar actions described for learners (e.g. rewarding process, peer support through communities of practice etc.). Further strategies for developing institutional uncertainty tolerance include developing flexible guidelines that are more accepting of the unknown, drawing upon the expertise of sectors already embracing uncertainty tolerance well such as arts, humanities, and social sciences (Lazarus, Gouda-Vossos, et al. 2022; Patel et al. 2022), and removing or realigning student feedback away from ‘student comfort’ towards one that acknowledges the discomfort intrinsic in transformative learning predicated on uncertainty (Meyer and Land 2005).

Tip 12

Horizontally and vertically integrated approaches to developing uncertainty tolerance

Similar to concepts such as professionalism and inclusivity, approaches to develop learner uncertainty tolerance should not be delivered as standalone, single time point interventions (Irby and Hamstra 2016; Dogra and Carter-Pokras 2018). One-off interventions risk the perception of developing uncertainty tolerance as something able to be ‘ticked off’, when it is instead a continual process. Accordingly, approaches to support uncertainty tolerance development should not be siloed away from other components of the curriculum. Rather, strategies for developing learner uncertainty tolerance should be interwoven across disciplines and throughout the duration of a degree program (Stephens et al. 2022a). An ideal approach may be curricular spiralling (Harden 1999), where learners are iteratively asked to build on their prior learning and manage increasingly challenging uncertainties (e.g. where more is at stake) over time and with experience.

Many health professions institutions may already incorporate some approaches that benefit uncertainty tolerance within their programs, without this being a specific learning outcome (e.g. near-peer teaching and reflective learning). Health professions educational leaders are therefore encouraged to map existing curricula as it pertains to uncertainty tolerance, and specifically address uncertainty tolerance within learning objectives and assessments. Uncertainty abounds within health professions education, so there is no need to ‘reinvent the wheel’ when it comes to stimulating uncertainty in learners. The key, however, is building an education program wherein developing uncertainty tolerance is valued, and integrated both horizontally and vertically throughout the curriculum, so that learners recognize that healthcare knowledge and uncertainty tolerance are interwoven, with both necessary for effective healthcare practice.

Conclusions

Although health professions learners may crave certainty, authentic healthcare practice requires the development of skills to adaptively manage or ‘tolerate’ uncertainty. Health professions educators can play an important role in developing learners’ uncertainty tolerance. This article advocates for including uncertainty as a learning outcome in health professions programs, and provides strategies that may be actioned by educators, institutions and learners themselves to support its development. Across tips, approaches to developing uncertainty tolerance balance factors which support students through uncertain experiences, with factors that challenge learners to further develop their uncertainty tolerance. Collectively these tips should reassure healthcare education stakeholders that developing learner uncertainty tolerance is achievable and valuable.

Acknowledgments

We wish to thank the students and educators who participated in our prior studies from which many of our tips are drawn. We also acknowledge the people of the Kulin Nations as the traditional owners of the unceded lands on which we work, and respectfully recognise Elders past and present.

Disclosure statement

The authors do not have and conflicts of interest to declare.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Georgina C. Stephens

Georgina C. Stephens, MBBS (Hons), PhD, FHEA, is a Senior Lecturer in the Centre for Human Anatomy Education, Monash University, Clayton, Australia. She is a clinical anatomy educator, health professions education researcher and medical practitioner. Her research interests focus on uncertainty tolerance in the context of medical education, and ethical considerations relating to donor dissection.

Michelle D. Lazarus

Michelle D. Lazarus, PhD, SFHEA, is an Associate Professor and Director of the Centre for Human Anatomy Education, and Deputy Director of the Monash Centre for Scholarship in Heath Education at Monash University, Clayton, Australia. She has extensive experience teaching clinical anatomy. Her research interests focus on uncertainty tolerance and how this relates to education, sustainability, artificial intelligence, and cultural literacy.