Appendices
Appendix 1.1
Transcript to Video 1.1
If you were to ask me, ‘What is a spider bite kit?’ eight years ago, I wouldn’t have had a clue. You can hear from my accent that I actually wasn’t raised here.
I arrived in Australia in May 2016, or the year of winters, as I like to call it, with just my partner and a few suitcases. Everything was unfamiliar. People tried to reassure me that the move would be easy because I speak English. Soon after arriving, I realised just how uncertain the world could be: I didn’t know what a spider bite kit was; I kept turning on the windshield, I mean windscreen, wipers instead of the turn signal. People kept talking about ‘long blacks’ in the ‘arvo’ and a bushfire season. I was lost, to say the least.
While some days felt daunting, I loved the opportunities to be able to be curious. I was open and vulnerable when feeling confused in conversation, and I asked lots of questions. In fact, I actually said to a close friend recently how much I missed those days of realising nearly every day that I was learning something new. While at times the uncertainties did bring anxiety, fear, and concern – especially around topics related to where I live or survival kind of topics – there were many times that there was almost a joy in the uncertainty.
Uncertainty doesn’t just cling to us expats, though; it turns out uncertainty is a feature of all workplaces and of life. As the saying goes, ‘The only certainty is uncertainty’. We can’t predict the future, and the complexities of human nature mean that we will literally not ever know it all.
My name is Michelle Lazarus, and my team researches something that we all experience: uncertainty. We look at how we perceive and respond to unknowns, complexities, and ambiguities. If you name a career, I can tell you where uncertainty creeps in.
Let’s think about healthcare. While the media portrayals suggest that we know everything in healthcare, and all diagnoses come in 30 minutes, everyone involved with healthcare experiences and manages uncertainty. There are biomedical uncertainties: Is the chest pain reflux? Or is it heart attack? And there are psychosocial ones: How much does the patient need to know? How much do I want to know as a patient? Who am I within the healthcare team? What’s my role in the healthcare system?
Another field filled with uncertainty is business and economics. Those terms conjure up images of hard facts and numbers, statistics, and certainty. But how and when the numbers are used, which ones are relevant, and what they even mean when they’re ‘crunched’ is filled with uncertainty. Economic models, for instance: they are all about future planning, but they rely on data from the past. How much of these historic numbers apply to the context today?
When I mention the word science, what do you picture? The field of research is literally predicated on unknowns. After all, we wouldn’t be studying it if it was known. What questions to ask, though? What information is relevant to your current study? What methods to use, how to interpret the data, and then even how to communicate the result and how it’s heard by the world is all filled with uncertainty. The example often used is that of a hurricane or cyclone. We understand the principles of how these weather patterns work. But if you were to ask me or a weather person to give you an exact path on an exact day of the cyclone, they probably can’t.
If you are, or have ever been, a student, formally or informally, like I was when I moved to Australia, you would know that learning and teaching is also filled with uncertainty. Teachers can’t be sure about what their students knew before they come into the classroom and what they’re taking away from what they’re teaching today. And these unknowns are just ‘scratching the surface’, as they say. What I realised is that uncertainty for students, or myself as a learner, they’re never ending. Not only are we unsure of the knowledge (that’s why we’re here: to learn), but we’re also unfamiliar with where to park, how to learn, who to go to for help. We have a general lack of awareness about the entire context in which the learning is taking place. The questions we have when we’re learning are endless.
There’s a key theme underpinning every single one of these scenarios that I’ve explained, and that’s humans. Our unpredictable thoughts, behaviours, and actions, our autonomy and agency: all contribute to the spark igniting the flames of uncertainty. When we think about it in these terms, we wouldn’t want to eliminate our autonomy and freedom by eliminating the uncertainty. We want to, instead, see the uncertainty, acknowledge the uncertainty, and then adaptively and effectively manage it. This is known as our uncertainty tolerance. And we can see that it becomes a critical skill in the workplace and in life.
Think of the start of the global pandemic. How did you respond? Curious, competent, appropriate grocery shopping? Acknowledgement, ambivalence, continuing with normal activities? Or anxious, vulnerable, and panic-buying toilet paper? This question illustrates the current conceptual model of uncertainty tolerance. Importantly, your answer isn’t a value judgement. There’s no right or wrong here. And your answer likely changed depending on your unique circumstances. Uncertainty tolerance is a psychological construct with a stimulus – in this case, an entirely novel virus, which we perceive and respond to across the way we think, the way we feel, and the way we act. There are factors that are termed moderators, which can influence how we perceive or respond to this uncertainty. In my case, when it came to COVID, I had family overseas who were vulnerable in a country where the pandemic was raging. This caused me to feel a little less tolerant of the uncertainty.
There’s some research that suggests that our natural response to uncertainty is to perceive it as a threat, something negative to avoid. However, the same research suggests that uncertainty actually can provide an advantage. We tend to experience joy and hope for longer periods when faced with uncertainty. And the unknown can actually help us learn and retain knowledge better. It is the uncertainty which is the seed for opportunity, creativity, and hope.
Our research, and others’ research, had a very important finding. We aren’t born with a static amount of uncertainty tolerance. It’s something that we can change and adapt through the way we think, feel, and act. In fact, I thought this work was so important that I put together a book with Monash Publishing titled The Uncertainty Effect: How to Survive and Thrive through the Unexpected, which describes some of the different ways we can perceive and respond to this uncertainty. Additionally, we have a wide variety of publicly available research that you can read through, and I encourage you to explore.
In the face of uncertainties, the antidote isn’t certainty. In fact, certainty in its truest form is rarely possible. When we pretend that the uncertainty doesn’t exist, or we create endless checklists to try and control the uncertainty, or we engage in doom-scrolling to try to gather and outcompete the uncertainty with knowledge, we aren’t removing the uncertainty; we’re only ineffectively responding to it. This means that the uncertainty is still there, but we aren’t well prepared to face it, which can result in burnout, difficulty problem solving, disengagement, and a need for increased oversight, because we’ve become basically paralysed in the uncertainty.
There are actions we can take to help adaptively respond to uncertainty, including transparency about when and how uncertainty is present in a given situation. We can communicate what we know and what we don’t know but how we’re going to find out. We can engage in critical reflection, where we consider our thoughts, feelings, and current responses to the uncertainty as well as plan for our responses to future similar uncertainty. There are many more options we have in responding to uncertainty that show adaptive responses. Even sharing our experiences of uncertainty with those that we trust can be invaluable. We can learn we aren’t alone, and we can learn from others.
When we adaptively respond to uncertainty, there’s evidence that we are more satisfied in our jobs, more creative in our solutions. We’re able to be more judicious and thoughtful in our actions, and we can make more decisions independently.
Margaret Drabble, the writer, once said, ‘When nothing is sure, everything is possible’. By drawing on our uncertainty tolerance, by adaptively responding to and seeing the uncertainty instead of fearing and hiding from it, we’re able to see all of these possibilities.
Appendix 1.2
Transcript to Video 1.2
Hello! My name is Georgina Stephens. I’m a medical doctor, anatomy educator, and health professions education researcher. I research how medical students and doctors experience and manage uncertainty. Although building and applying knowledge and evidence is a large part of the role of a health professional, managing uncertainty is now considered an important skill for health professions learners and graduates to develop.
When I reflect on my own experience as a medical student, I don’t think I really had any idea just how much of a role uncertainty would play in my career. As an early years student, I believed that if I studied hard enough, I would acquire enough knowledge to vanquish most of the uncertainty I faced. However, my beliefs about uncertainty changed significantly as I commenced clinical placements.
On the wards, there was very little I observed that seemed to reflect my textbook learning. Instead, I began to appreciate the uncertain reality of medical practice and that absolutely certain or correct approaches to patient care were almost the exception, as knowledge was applied relative to a particular patient and context. I also became increasingly aware of the gaps in the evidence base for medical practice and how this created grey areas in how to most effectively care for patients. Although I continued to learn certain ‘facts’ to pass my exams, these often seemed disconnected from my learning for the daily practice of medicine with its inherent uncertainties.
These experiences of uncertainty only expanded as I commenced practice. Junior doctors typically change roles every few months. With each new rotation, I’d feel an intense wave of uncertainty, and this pattern continued as I increased in seniority and took on greater responsibility for patient care. Even if I had the requisite knowledge and skills, there were some parts of my job that were just unknowable. For example, I could inform my patients of published figures about rates of adverse events for different treatments, but I couldn’t tell them if they would be among the 99 per cent who would be fine or the 1 per cent who would have a life-altering complication.
I also began to feel uncertain about my career direction, which was previously something I was very certain about. So, I decided to step away from the world of clinical medicine for a little while and took up a post teaching anatomy. It was during this role that I developed a love of teaching and became interested in researching how educators can effectively support students’ learning.
The first education research project I undertook explored how students develop their professional identity. Through interviews with students I learned that managing uncertainty was a huge part of the medical student experience and something that many struggled with. So, I delved into the literature on uncertainty and encountered the construct of uncertainty tolerance.
In particular, a colleague pointed us to a review paper from Hillen and colleagues published in 2017. They defined uncertainty tolerance as 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. The authors arrived at this definition after reviewing 18 different questionnaires or scales designed to measure whether somebody tends to respond more negatively to uncertainty, also known as uncertainty intolerance, or more positively.
I ultimately embarked on a PhD exploring how medical students experience uncertainty, and let me tell you, I had to really learn to manage uncertainty during this project. One of the major reasons for this was the many different ways in which this construct has been referred to by different researchers and disciplines over time.
Research on the general topic of uncertainty commenced in the mid-20th century with the work of Else Frenkel-Brunswik, who was a personality and social psychologist. She is acknowledged as the first researcher to describe ‘tolerance vs intolerance of ambiguity’. Ambiguity is a term that is widely used in research in this field but has been defined in different ways. It typically refers to the quality of having different possible meanings. Else Frenkel-Brunswik was researching personality and ethnic prejudice in children and teenagers. She noted that individuals who were intolerant of ambiguity tended to resort to black–white solutions and make premature judgements that they held on to even when presented with information to the contrary. In comparison, those who were tolerant of ambiguity could more easily accept the coexistence of contrasting perspectives.
Building on this research, Stanley Budner developed the seminal tolerance–intolerance of ambiguity scale, which was published in 1962. Budner describes that people who are more tolerant of ambiguity tend to perceive ambiguity as ‘desirable’ or opportune, whereas those who are intolerant of ambiguity tend to perceive ambiguous situations as ‘sources of threat’. Budner’s work seems like it set a trend for scale development that continues to the present day, with researchers still trying to create a scale which most effectively captures how people respond to ambiguity.
The term intolerance or tolerance of uncertainty was introduced relatively more recently and perhaps was initially more associated with psychological research into mental health disorders. It is unclear from my reading of the literature why uncertainty emerged as a separate term from ambiguity in this field, especially as discussions of ambiguous situations are often described in papers nominally focussed on uncertainty. As with tolerance of ambiguity, research into tolerance of uncertainty has also produced a variety of scales.
Even though some researchers prefer the term ambiguity and others uncertainty, the definitions used across the literature vary. This is why Hillen and colleagues embarked upon their review, with the aim of bringing some consistency to this important field of research. They analysed how authors defined terms relating to ambiguity, uncertainty, and tolerance and also evaluated meanings implicit within the questions asked in scales. What they found was that there were no clearly discernible differences between how terms such as tolerance of ambiguity and tolerance of uncertainty were used. So, in essence, tolerance of ambiguity and tolerance of uncertainty, as well as related terms such as stress or reactions to uncertainty, can broadly be considered synonymous. This unified definition of the construct has now served as the basis for several important reviews, including how uncertainty tolerance impacts healthcare outcomes.
My hope is that educators understand that building knowledge and developing learners’ skills for managing uncertainty go hand in hand, so that ultimately our future health professionals are better prepared for the uncertainties they will face in practice.
