Chapter 5: Educational Moderators of Uncertainty Tolerance

Uncertainty stimuli, by their nature, can create a sense of unease for learners (Hillen et al., 2017; Stephens et al., 2024). Some of the uncertainty stimuli that arise in health professions education are within the control of educators (Chapter 4), whereas other stimuli are beyond educator control (Chapter 1 ). Designing curricula that support health professions learners’ uncertainty tolerance development requires educators to consider the different uncertainty stimuli experienced by their learners, as well as the different factors that influence learners’ perceptions of and responses to uncertainty (Stephens & Lazarus, 2024). These factors are known in the uncertainty tolerance literature as moderators (Hillen et al., 2017; Stephens, Sarkar, et al., 2022a) and are described in the healthcare context in Chapter 3. This chapter describes moderators that educators should be aware of when designing and implementing curricula intended to develop health professions learners’ uncertainty tolerance and that can be applied to different teaching activities (e.g., problem-based learning, simulation, and workplace-based learning). Practical examples of how to do this are in Section 3  of this book and illustrate how the type of activity is less relevant to learners’ uncertainty tolerance development than the way in which it is designed and delivered with a consideration of educational moderators of uncertainty tolerance.

The role of moderators within health professions education can be illustrated with the analogy of learners exploring dark caves, in which the darkness represents uncertainty and moderators represent different lights, equipment, or learner attributes that can help (or hinder) their navigation through the caves. Depending on the different moderators at play, an individual learner may feel interested, adequately supported and sufficiently equipped to venture through the darkness of the unfamiliar caves or may be fearful and try to avoid uncertainty by going back to the caves’ threshold. Another helpful analogy that can be used to illustrate the role of moderators is learning to swim: if learners are thrown in the deep end of a pool without any prior lessons or supportive floats, some will learn to swim, while others will fear water for the rest of their lives. The goal in both analogies is to prepare learners for their life-long adventures in the face of inevitable future uncertainties.

An educator’s goal isn’t just to rely on a learner’s individual uncertainty tolerance but also to help them develop an uncertainty tolerance toolkit to draw upon now and in their future career. The toolkit can help learners to navigate the unknown with curiosity instead of fear, with hope instead of dread, and with acceptance of uncertainty and its management as part of healthcare professional practice (Stephens et al., 2021; Stephens et al., 2024).

Some moderators may support, while others may hinder, uncertainty tolerance development in learners (Hancock & Mattick, 2020; Lazarus et al., 2022; Stephens et al., 2021; Stephens, Sarkar, et al., 2022a). Importantly, none of the moderators discussed here should be categorised as inherently good or bad. Rather, it is important that educators consider the likely impacts of moderators on their learners’ uncertainty tolerance, particularly in relation to their stage of learning and prior experiences with managing uncertainty. For instance, being responsible for knowledge is a required professional skill but may hinder learners’ uncertainty tolerance development because of a fear of being wrong or speaking publicly (Stephens et al., 2021). Educators who are aware of this can consider the moderators in learners’ toolkits and decide which time and context is most appropriate to introduce this moderator into the learners’ journeys to becoming healthcare professionals (see Figure 5.1).

In the following section we will describe the moderators identified through research and how these relate to health professions education (Hancock & Mattick, 2020; Lazarus et al., 2022; Stephens et al., 2021; Stephens, Sarkar, et al., 2022a). Section 3 of this book uses the moderators in exemplar teaching activities across different health professions and disciplines. The Resources section has worksheets and activities, including a moderator ‘card game’, to support the consideration of these moderators and their application in your teaching activities. Links to individual cards are represented in each section below.

Learner-Sourced Moderators

Depending on learners’ prior experiences, knowledge, and stages within the learning journey, they enter educational experiences with different skills to manage uncertainty (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a). Their uncertainty tolerance toolkit could be empty, their tools could be damaged (because of prior bad experiences with uncertainty), or their toolkit could be stocked with a variety of tools. Awareness of the skillsets your learners have, based on the learner-sourced moderators described below, can help you more effectively select the moderators you can control (e.g., educator-sourced moderators).

Subject Knowledge

Experience with managing uncertainty related to the discipline can be represented by learners’ subject matter proficiency, or subject knowledge. Subject knowledge should be considered in relation to where learners are in a course or program of study in general, as well as in relation to a specific part of a course taught by an individual educator (i.e., your own local classroom knowledge). The amount of time already spent learning about the topic should be considered, alongside the depth and breadth of this learning. In addition, the nature and quality of the learning experience can play a role in defining the moderators related to subject knowledge (Stephens, Sarkar, et al., 2022a). The subject knowledge theme is divided between the moderators high subject proficiency and low subject proficiency (Lazarus et al., 2022). Click through each heading below to learn more about the moderating factors.

Worldview

How a learner understands the world (which is influenced by their attitudes, values, expectations, and experiences) informs their perceptions of and responses to uncertainty (Lazarus et al., 2022). Click through each heading below to learn more about the moderating factors that fall into this theme.

Learning Goals

Learners’ perceptions of stakes and their purpose for managing educational uncertainty appear to influence their capacity for uncertainty tolerance (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a). Their uncertainty tolerance can be impacted by situational stakes or the likelihood that a bad outcome can occur related to something they are invested in (see Chapter 3), such as individual grades, ranking within a cohort, and access to future career options (e.g., postgraduate training pathways). Click through each heading below to learn more about the moderating factors that fall into this theme.

Individual Characteristics

Each learner has personality traits and life experiences that shape who they are and how they think, feel, and act. These individual characteristics appear to influence whether learners’ responses to uncertainty are either more or less adaptive (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a). Many of the characteristics are contextual; therefore, it is important for educators to consider the overall curriculum when identifying whether individual characteristics may be applicable to a learner or learning environment. Click through each heading below to learn more about the moderating factors that fall into this theme.

Educator-Sourced Moderators

Being aware of their learners’ stage of progression, prior knowledge, and experience can help educators select the moderators most appropriate for their educational activities. The contexts in which they present uncertain learning activities impact on this as well. As mentioned in Chapter 3, moderators work together (sometimes synergistically, at other times antagonistically). Educators can use educator-sourced moderators (i.e., moderators that are within their control) to develop an environment conducive to supporting learners’ development of uncertainty tolerance (Lazarus et al., 2022). Educators also need to be mindful of the educational system within which they work, as some of the educator-sourced moderators may be limited by system constraints.

Curriculum Design

Educators should consider the methods and approaches engaged when introducing educational uncertainty. Related moderators focus on the set-up of the teaching activity that serves to challenge or support learners’ adaptive responses to uncertainty (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a). Click through each heading below to learn more about the moderating factors that fall into this theme.

Assessments

This section introduces uncertainty tolerance moderators related to assessment. Key considerations include the level of structure prescribed within assessment tasks and the educators’ approach to feedback and grading (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a). As with the curriculum in general, assessment to support development of uncertainty tolerance should be considered holistically, such as in a programmatic assessment approach. The role of assessments in moderating uncertainty tolerance is discussed more extensively in Chapter 6. Click through each heading below to learn more about the moderating factors that fall into this theme.

Educator Teaching Practices

The strategies that educators use in health professions education when facilitating the learning process or delivering uncertain learning activities can help or hinder learners’ uncertainty tolerance development (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022). Click through each heading below to learn more about the moderating factors that fall into this theme.

System-Sourced Moderators

The teaching practices of individual educators to support health professions learners’ uncertainty tolerance development need to be considered within the context of the larger educational and healthcare institutions they are working and learning in. The priorities of these systems and individuals may not always be aligned, so educators need to be pragmatic in their approaches to applying theory about uncertainty tolerance teaching practices to their local context. With these limitations in mind, this section describes some of the system-sourced moderators that educators and institutional leaders may consider (Lazarus et al., 2022; Stephens, Sarkar, et al., 2022a).

Institutional Culture

Institutional culture is informed by a variety of factors and can have substantive impacts on the extent to which an institution, and those working within it, are able to engage teaching approaches that support learner uncertainty tolerance development. The development of institutional culture is complex and includes factors linked to workforce characteristics and institutional policies and procedures, moderators related to which are described below (Stephens & Lazarus, 2024). It is important to acknowledge that institutional culture is also shaped by the broader sociocultural context in which the institution is situated. Hofestede’s (2001) cultural dimensions theory (see Chapter 7) provides a helpful framework for considering this. While societal-level cultural changes are beyond the control of individual educators, click through each heading below to learn more about the moderating factors which can be addressed within institutions.

Policies and Procedures

Educational and healthcare institutions typically have policies and procedures that influence the types of teaching activities and assessments educators can design and implement. For example, the ability to use teaching approaches that stimulate uncertainty (see Chapter 4) may be influenced by policies favouring traditional lectures, and the ability to use flexible assessments may be influenced by assessment procedures requiring structured rubrics. The content of such policies and procedures can powerfully influence whether educators are able to successfully implement curricula intended to develop learners’ uncertainty tolerance. Click through each heading below to learn more about the moderating factors that fall into this theme.

Workforce Characteristics

For educational and healthcare institutions to effectively develop the uncertainty tolerance of their learners, they should consider the nature of the workforce they engage to educate learners and the qualities of their leadership. Click through each heading below to learn more about the moderating factors that fall into this theme.

Planning Teaching Activities to Support Uncertainty Tolerance

In the Resources section, you will find useful tools to help you plan uncertainty tolerance teaching activities, including a poster with the moderator cards and their definitions, as well as a worksheet to promote consideration of moderating factors from different perspectives. As noted throughout this chapter, some moderators support learners’ adaptive responses to uncertainty and uncertainty tolerance development, while others hinder them. The key isn’t to necessarily avoid the moderators that hinder uncertainty tolerance development; rather, it is to use these moderators when learners have developed the requisite skills for managing uncertainty. In these situations, such moderators can increase the challenge in managing uncertainty. It is important to remember that moderators work together, either synergistically or antagonistically, and have multiple sources (i.e., learner, educator, and system). Selecting the best moderators for a given learning situation may require a few attempts and will likely change as the learner population changes. All readers are encouraged to create a teaching activity in support of health professions learner uncertainty tolerance development by engaging in the resources available here.

Summary

When health professions learners are given opportunities to practise responding to educational uncertainty in preparation for their future learning and careers, they are likely to experience emotional discomfort. Selecting moderators which support learners through experiences of uncertainty can assist them to develop their uncertainty tolerance toolkit for adaptively responding to the uncertainty. Supportive moderators are important to ensure learners engage with uncertainty learning activities and approach uncertainty with curiosity rather than fear. Learners who experience and engage with uncertainty tolerance teaching practices are more likely to apply skills for managing uncertainty to future uncertain experiences. Ultimately, moderating factors which impact learners’ uncertainty tolerance stem from the learners, the educators, and the educational system within which the learning takes place. As research continues, new moderators will likely be identified.

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About the authors

name: Prof Michelle Lazarus, PhD SFHEA

institution: Monash University

website: https://research.monash.edu/en/persons/michelle-lazarus

As a Professor and Director of the Centre for Human Anatomy Education and the Deputy Director for the Monash Centre for Scholarship in Health Education at Monash University, Michelle has been in the field of medical education for over a decade, leading a research program which explores how to impact learners’ uncertainty tolerance through curriculum design. She has delivered over a dozen related workshops to educators across the globe, and has developed a series of educational artefacts to support learner uncertainty tolerance development, including a pamphlet and webinar, for Education Services Australia for teachers interested in integrating uncertainty tolerance teaching practices in their classrooms. This textbook expands on these initiatives, providing a more holistic and complete source of uncertainty tolerance theory and practice – focusing specifically on health professions educators. Michelle is an award winning educator and author. Notably, she was awarded the Australian Award for University Teaching Excellence in 2021. She is the author of the “The Uncertainty Effect: How to Survive and Thrive through the Unexpected”. Her entire career is a journey into uncertainty.

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name: Dr. Georgina C. Stephens, MBBS(Hons) PhD FHEA

institution: Monash University

website: https://research.monash.edu/en/persons/georgina-stephens

As a Senior Lecturer in the Centre for Human Anatomy Education at Monash University and medical practitioner by background, Georgina has first hand experience of what it means to manage uncertainty when caring for people seeking healthcare. Dr. Stephens transitioned to a full time academic career in 2017, focussed on clinical anatomy education and health professions education research. During her doctoral studies, she explored how medical students experience uncertainty, and examined the evidence for widely used scales intended to measure the construct of uncertainty tolerance. Her doctoral research led to five peer reviewed publications on uncertainty tolerance, all published in leading health professions education journals, and several winning awards for publication excellence. Georgina is an award winning educator, including being awarded the Dean’s Award for Innovation in Education in 2023.

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