Ambiguity and uncertainty tolerance, need for cognition, and their association with stress. A study among Italian practicing physicians

Building resilience in the Improving Access to Psychological Therapy (IAPT) Psychological Wellbeing Practitioner (PWP) role: a qualitative grounded theory study

AIM

Staff retention, particularly in the Psychological Wellbeing Practitioner (PWP) workforce, has historically been challenging for Improving Access to Psychological Therapy (IAPT) services. This study sought to develop an explanatory model of the resilience-building process in PWPs working within the IAPT programme.

METHOD

A qualitative design was conducted, using a grounded theory methodology. Participants were recruited from two IAPT services in the National Health Service (NHS), which were part of the same Mental Health Trust. Ten PWPs were interviewed via videoconferencing using semi-structured interviews.

RESULTS

An explanatory model of resilience in PWPs encompassed three phases: the experience of work-related challenges, the connection with their values and the related appraisal of adversity in resilient ways, and the implementation of effective coping strategies.

CONCLUSIONS

The model highlights that PWPs develop resilience through values-based sensemaking and by proactively engaging in effective coping mechanisms. This study contributes to the current understanding of the process of resilience in PWPs. More research is needed to explore the developmental processes underlying PWPs' resilience. The implications of the findings in relation to existing conceptualisations of resilience, staff wellbeing and retention are explored. Recommendations for future research are also given.

Implementation of Evidence-Based Practice and Burnout Among Occupational Therapists: The Role of Self-Efficacy

IMPORTANCE

Implementing evidence-based practice (EBP) is essential for ensuring optimal quality care and obtaining positive outcome in treatment. Occupational therapists generally hold positive attitudes toward EBP; however, EBP is not always fully implemented.

OBJECTIVE

To explore the mediating role of self-efficacy on the relationship between implementing EBP and burnout among occupational therapists.

DESIGN

A cross sectional study.

SETTING

Data were collected through social media and WhatsApp groups using an online survey accessible through Qualtrics, a secured web-based data collection system; responses were anonymous.

PARTICIPANTS

The final sample consisted of 261 female Israeli occupational therapists (ages 24-65 yr, with 1-40 yr of clinical experience).

OUTCOMES AND MEASURES

The following questionnaires assessed EBP implementation, burnout, and self-efficacy, respectively: the EBP Implementation Scale, the Maslach Burnout Inventory, and the Occupational Therapy Self-Efficacy Questionnaire. Demographic data were also collected.

RESULTS

EBP implementation was low (0-43 points out of a maximum 72 points), moderate levels of burnout and high levels of self-efficacy were reported. Significant associations with medium effect sizes were found between EBP implementation and burnout: the higher the levels of EBP implementation, the lower the levels of burnout frequency and intensity. Moreover, self-efficacy mediated these relationships. EBP implementation was related to elevated self-efficacy, which, in turn, was associated with lower burnout.

CONCLUSIONS AND RELEVANCE

EBP implementation may serve as an important tool to limit burnout among occupational therapists by fostering their trust in their ability to handle clinical challenges. Further research is needed. Plain-Language Summary: This study explored implementing evidence-based practice (EBP) and its relationships to burnout and work-related self-efficacy among occupational therapists. The study found that self-efficacy mediated the relationships between implementing EBP and burnout. Implementing EBP was associated with higher self-efficacy, which, in turn, was associated with lower burnout among occupational therapists.

Measurement of uncertainty tolerance revisited

INTRODUCTION

Uncertainty tolerance (UT) is attracting increasing attention in medical education due to the numerous challenges associated with uncertainty in professional life. Inconsistencies in analysing the relationship between UT and moderators may arise from inadequate measurement methods. Most instruments were formulated before the most widely accepted framework was published. Our aim was to investigate the validity of an UT scale using an actual framework to corroborate with better and accurate instruments.

METHODS

A total of 1052 students were invited. Various psychometric methods were used to explore validity of the TAMSAD scale in light of actual framework. Classic exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed. Secondly, content item classification was triangulated with exploratory graph analysis (EGA), and the new EFA, CFA, and cognitive diagnostic modelling (CDM) analysis were conducted. The reliability was calculated using Cronbach's alpha and McDonald's omega.

RESULTS

A total of 694 students (65.9%) responded to the questionnaire. The reliability of the TAMSAD scale was 0.782. The initial EFA revealed no clear interpretable dimensions. The TAMSAD scale items can be classified into sources of uncertainty. The EGA has three dimensions, and the new EFA led to a 17-item TAMSAD scale with the following three dimensions: ambiguity, complexity, and probability. These dimensions lead to better adjustment fit indices in the new CFA and CDM analyses.

CONCLUSION

We found evidence that the TAMSAD scale can be considered a multidimensional scale, organised in terms of sources of uncertainty.

From Tolerance for Ambiguity to Stress and Anxiety: The Mediating Role of Need for Cognitive Closure Among Chinese University Students

Based on the Entropy Model of Uncertainty, this study examined the relationship between tolerance for ambiguity and stress and anxiety, as well as the mediating roles of overall need for cognitive closure and its dimensions in this relationship. Four hundred and eighty-eight Chinese university students were recruited online and completed the survey voluntarily and anonymously. The results of structural equation modeling revealed that tolerance for ambiguity negatively predicted students' perceived stress and anxiety. Moreover, overall need for cognitive closure, as well as its dimensions of preference for order and decisiveness played full mediating roles in this relationship. Specifically, tolerance for ambiguity negatively predicted students' overall need for cognitive closure, preference for order, preference for predictability, decisiveness, and closed-mindedness. Further, preference for order negatively predicted students' perceived stress and anxiety, while overall need for cognitive closure and decisiveness positively predicted such. However, preference for predictability and closed-mindedness were not significant predictors of perceived stress and anxiety.

The contribution of mindfulness in the association between L2 learners' engagement and burnout

There has been recently a growing interest in L2 learners' engagement as a central factor in their success. However, not all L2 learners are engaged intellectually, passionately, and behaviorally in L2 learning and this can be due to their experience of burnout in language educational settings. On the other hand, L2 learners frequently encounter heightened degrees of burnout because of emotional and behavioral disengagement. To relieve the relationship between engagement and burnout, the influential technique known as mindfulness, as a coping mechanism for enhancing engagement and reducing burnout among L2 learners, has emerged. Given this conceptual model, the purpose of this paper is to argue the mediator role of mindfulness, in light of self-determination and self-control theory, between L2 students' engagement and burnout. A few directions for future inquiries are discussed following this review.

Acute stress selectively blunts reward anticipation but not consumption: An ERP study

Stress-induced dysfunction of reward processing is documented to be a critical factor associated with mental illness. Although many studies have attempted to clarify the relationship between stress and reward, few studies have investigated the effect of acute stress on the temporal dynamics of reward processing. The present study applied event-related potentials (ERP) to examine how acute stress differently influences reward anticipation and consumption. In this study, seventy-eight undergraduates completed a two-door reward task following a Trier Social Stress Task (TSST) or a placebo task. The TSST group showed higher cortisol levels, perceived stress, anxiety, and negative affect than the control group. For the control group, a higher magnitude of reward elicited a reduced cue-N2 but increased stimulus-preceding negativity (SPN), suggesting that controls were sensitive to reward magnitude. In contrast, these effects were absent in the stress group, suggesting that acute stress reduces sensitivity to reward magnitude during the anticipatory phase. However, the reward positivity (RewP) and P3 of both groups showed similar patterns, which suggests that acute stress has no impact on reward responsiveness during the consummatory phase. These findings suggest that acute stress selectively blunts sensitivity to reward magnitude during the anticipatory rather than the consummatory phase.

Does social rigidity predict cognitive rigidity? Profiles of socio-cognitive polarization

Recent research has proposed a relationship between rigid political ideologies and underlying 'cognitive styles'. However, there remain discrepancies in how both social and cognitive rigidity are defined and measured. Problem-solving, or the ability to generate novel ideas by exploring unusual reasoning paths and challenging rigid perspectives around us, is often used to operationalize cognitive flexibility. Thus, we hypothesized a relation between forms of social rigidity, including Socio-cognitive polarization (i.e., a factor capturing conservative political ideology, absolutism/intolerance of ambiguity, and xenophobia), bullshit receptivity (i.e., overestimating pseudo-profound statements), overclaiming (tendency to self-enhance), and cognitive rigidity (i.e., problem-solving). Our results showed differences in performance on problem-solving tasks between four latent profiles of social rigidity identified in our sample. Specifically, those low in socio-cognitive polarization, bullshit, and overclaiming (i.e., less rigid) performed the best on problem-solving. Thus, we conclude that social and cognitive rigidity may share an underlying socio-cognitive construct, wherein those who are more socially rigid are also more likely to be also cognitively rigid when processing non-social information.

Experimental study and clustering of operating staff of search systems in the sense of stress resistance

Introduction

The main goal of this study is to develop a methodology for the organization of experimental selection of operator personnel based on the analysis of their behavior under the influence of micro-stresses.

Methods

A human-machine interface model has been developed, which considers the change in the functional state of the human operator. The presented concept of the difficulty of detecting the object of attention contributed to developing a particular sequence of ordinary test images with stressor images included in it and presented models of the flow of presenting test images to the recipient.

Results

With the help of descriptive statistics, the parameters of individual box-plot diagrams were determined, and the recipient group was clustered.

Discussion

Overall, the proposed approach based on the example of the conducted grouping makes it possible to ensure the objectivity and efficiency of the professional selection of applicants for operator specialties.

Coping with academic stress: Ambiguity and uncertainty tolerance in college students

Stress is a barrier to academic success for college students and the unique resilience effects of ambiguity and uncertainty tolerance have yet to be explored. We hypothesized that tolerance of ambiguity and tolerance of uncertainty relate to academic stress differently.

We recruited 158 undergraduate participants from a medium-size public university in the Midwestern United States.

Participants completed measures of ambiguity tolerance, uncertainty tolerance, and academic stress coping strategies. Three separate regression analyses were conducted to predict approach coping, avoidance coping, and social support coping.

Results indicated that intolerance of ambiguity is a stronger predictor of approach and avoidance academic stress coping strategies compared to intolerance of uncertainty.

These findings will allow for a better understanding of the dynamics underlying coping with academic stress that will be helpful to consider in vocational as well as mental health counseling for college students.

Event-related Potentials Corresponding to Decision-making Under Uncertain Conditions

BACKGROUND

Decision-making is essential to human functioning, and resolving uncertainty is an essential part of decision-making. Impaired decision-making is present in many pathological conditions, and identifying markers of decision-making under uncertainty will provide a measure of clinical impact in future studies of therapeutic intervention for impaired decision-making.

OBJECTIVE

To describe EEG event-related potentials (ERPs) correlating with decision-making under uncertain conditions when compared with certain conditions.

METHOD

We used a novel card-matching task based on the Wisconsin Card Sorting Test to describe the neural correlates of uncertainty, as measured by EEG, in a group of 27 neurotypical individuals. We evaluated 500-ms intervals in the 2 seconds after card presentation to identify ERPs that are associated with maximal uncertainty compared with maximal certainty.

RESULTS

After correcting for multiple comparisons, we identified an ERP in the 500-1000-ms time frame (certain > uncertain, max amplitude 12.73 µV, latency 914 ms) in the left posterior inferior region of the scalp. We also found a P300-like ERP in the left frontal and parietal regions in the 0-500-ms time frame when the individuals received correct versus incorrect feedback (incorrect feedback > correct feedback, max amplitude 1.625 µV, latency 339 ms).

CONCLUSION

We identified an ERP in the 500-1000-ms time frame (certain > uncertain) that may reflect the resolution of uncertainty, as well as a P300-like ERP when feedback is presented (incorrect feedback > correct feedback). These findings can be used in future studies to improve decision-making and resolve uncertainty on the described markers.

Identifying validity evidence for uncertainty tolerance scales: A systematic review

PURPOSE

Uncertainty tolerance (UT) is increasingly valued as a medical graduate attribute and broadly measured among medical student populations. However, the validity evidence underpinning UT scale implementation has not been summarised across studies. The present work evaluates UT scale validity evidence to better inform when, why and how UT scales ought to be used and to identify remaining validity evidence gaps.

METHODS

A literature search for psychometric studies of UT scales was completed in 2022. Records were included if they implemented one of the four most cited UT scales (i.e. Physicians' Reactions to Uncertainty scale 1990 [PRU1990] or 1995 [PRU1995], Tolerance for Ambiguity [TFA] scale or Tolerance of Ambiguity in Medical Students and Doctors scale [TAMSAD]) in a population of physicians and/or medial students and presented validity evidence according to the Standards for Educational and Psychological Testing framework. Included studies were rated and analysed according to evidence for test content, response processes, internal structure, relations to other variables and consequences of testing.

RESULTS

Among the investigated scales, 'relations to other variables' and 'internal structure' were the most commonly reported forms of validity evidence. No evidence of 'response processes' or 'consequences of testing' was identified. Overall, the PRU1990 and PRU1995 demonstrated the strongest validity evidence, although evidence primarily related to physician populations.

CONCLUSIONS

None of the studied scales demonstrated evidence for all five sources of validity. Future research would benefit from assessing validity evidence for 'response processes' and 'consequences of testing' among physicians and medical students at different training/career stages to better understand UT construct conceptualisation in these populations. Until further and stronger validity evidence for UT scales is established, we caution against implementing UT scales outside of research settings (e.g. for higher stakes decision making).

Translation, adaptation, and validation of the Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) scale for use in Japan

BACKGROUND

Ambiguity is inherent to the medical field; hence, assessing and educating medical trainees regarding ambiguity tolerance is essential. The Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) scale-a novel instrument that assesses ambiguity tolerance in clinical settings-has been widely used for medical education research in Western countries. However, a version of this scale applicable to the intricate clinical contexts of Japan has not yet been developed. In this study, we developed the Japanese version of the TAMSAD (J-TAMSAD) scale and tested its psychometric properties.

METHODS

In this multicenter study, we collected data through a cross-sectional survey in two universities (medical students) and ten hospitals (residents) across Japan, and evaluated the structural validity, criterion-related validity, and internal consistency reliability of the J-TAMSAD scale.

RESULTS

We analyzed the data of 247 participants. The sample was randomly divided in half, with exploratory factor analysis (EFA) performed on one half and confirmatory factor analysis (CFA) on the other. EFA led to an 18-item J-TAMSAD scale comprising five factors. CFA showed acceptable fit for this five-factor model (comparative fit index = 0.900, root mean square error of approximation = 0.050, standardized root mean square residual = 0.069, goodness of fit index = 0.987). There was a positive correlation between the J-TAMSAD scale scores and total reverse scores on the Japanese version of the Short Intolerance of Uncertainty Scale (Pearson correlation coefficient 0.41). The internal consistency was found to be satisfactory (Cronbach's alpha 0.70).

CONCLUSIONS

The J-TAMSAD scale was developed, and its psychometric properties were confirmed. The instrument can be useful for assessing tolerance of ambiguity among medical trainees in Japan. With further validation, it could be used to verify the educational effectiveness of curricula that foster ambiguity tolerance in medical trainees, or even in research assessing the relationship with other variables.

Factor structure and psychometric properties of the german version chronic uncertainty scale (CU-20)

BACKGROUND

The experience of uncertainty is ubiquitous and universal across the globe. Many available tools measuring uncertainty are focused on one aspect of uncertainty, e.g., patients with life-threatening illnesses, hence a measure considering (chronic) uncertainty as an integral experience reflect ongoing uncertainties from a socio-cultural perspective is missing. Additionally, current tools do not account for an extended timeframe to measure chronic forms of uncertainty. The objective of this study is to validate a translated German version of the 20 item Chronic Uncertainty Scale (CU-20).

METHODS

The full sample comprised N = 462 participants. Most of the participants were young German citizens and the sex distribution was relatively balanced (60% females; age in average: M = 24.56; SD = 4.78). Using equally split samples, an exploratory factor analysis (EFA) evaluated the CU-20 factor structure, followed by a confirmatory factor analysis (CFA) to test the established factor structure. Measurement invariance between male and female groups was evaluated. Internal consistency of the six-factor model was shown and scale discrimination was shown against chronic stress.

RESULTS

The EFA results showed decent model fit for the five-factor structure, however based on the CFA results, the theoretically established six-factor model fits the data significantly better. Measurement invariance between male and female groups was shown to be clearly scalar invariant. Cronbach's alpha, omega and lambda all support internal consistency and reliability of CU-20.

CONCLUSIONS

The CU-20 is a valid and reliable measure of one's state of chronic uncertainty reflecting the individuals' experiences of macrosocial forms of uncertainty, compared to the existing ones. This scale is especially useful in the context of migration, refugees or during global crises. Further psychometric testing is required in more diverse samples and a deeper look into measurement invariance is recommended.

Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance

Uncertainty tolerance, individuals' perceptions/responses to uncertain stimuli, is increasingly recognized as critical to effective healthcare practice. While the Covid-19 pandemic generated collective uncertainty, healthcare-related uncertainty is omnipresent. Correspondingly, there is increasing focus on uncertainty tolerance as a health professional graduate "competency," and a concomitant interest in identifying pedagogy fostering learners' uncertainty tolerance. Despite these calls, practical guidelines for educators are lacking. There is some initial evidence that anatomy education can foster medical students' uncertainty tolerance (e.g., anatomical variation and dissection novelty), however, there remains a knowledge gap regarding robust curriculum-wide uncertainty tolerance teaching strategies. Drawing upon humanities, arts and social sciences (HASS) educators' established uncertainty tolerance pedagogies, this study sought to learn from HASS academics' experiences with, and teaching practices related to, uncertainty pedagogy using a qualitative, exploratory study design. Framework analysis was undertaken using an abductive approach, wherein researchers oscillate between inductive and deductive coding (comparing to the uncertainty tolerance conceptual model). During this analysis, the authors analyzed ~386 min of data from purposively sampled HASS academics' (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics' perceive as impacting learners' uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.

Executive Functions in Decision Making under Ambiguity and Risk in Healthy Adults: A Scoping Review Adopting the Hot and Cold Executive Functions Perspective

Decision making (DM) has a pivotal role in supporting individual autonomy and well-being. It is considered a complex ability exploiting many cognitive functions, among which executive functions (EFs) are crucial. Few studies analyzed the role played by EFs in DM in healthy adults under ambiguity and risk, which are common conditions for most decisions in daily life. This scoping review aims to analyze the relationships between two individual tasks widely used to assess DM under these conditions (Iowa Gambling Task and Game of Dice Task) and EFs. According to the organizing principle that conceptualizes hot and cold EFs, DM under such conditions mainly implies hot EFs, but the relationship with cold EFs is still unclear. Using such an approach, a comprehensive framework is provided, highlighting main findings and identifying possible gaps in the literature. The results suggest different roles played by cold EFs in DM under ambiguity and risk, according to the characteristics of the tasks. The findings can offer guidance to further studies and to design interventions to support DM in healthy adults.

Black-and-white thinking and conspiracy beliefs prevent parents from vaccinating their children against COVID-19

Understanding predictors of parents' willingness to vaccinate their children appears fundamental to promote vaccine acceptability, especially in a pandemic scenario. The present study aimed to investigate the role of conspiracy beliefs and absolutist thinking in parental attitude toward COVID-19 vaccine, and the predictive role of parents' individual differences on decisions against children's vaccination. An online survey was administered to 415 parents of children aged 5-11, at the very beginning of the vaccination targeting this population in Italy. Results showed that absolutism predicted the tendency to believe in conspiracies, associated with a negative attitude toward the COVID-19 vaccine administration to children. Moreover, mothers were less willing to vaccinate children and parents of children aged 5-7 were more hesitant, or even against vaccination, than parents of older children. Finally, the worry about consequences of COVID-19 infection on children's health facilitated vaccine adherence. These findings contribute to deepening mechanisms regarding the vaccine acceptability.

Reliability of Uncertainty Tolerance Scales Implemented Among Physicians and Medical Students: A Systematic Review and Meta-Analysis

PURPOSE

Uncertainty tolerance (UT) is a construct describing individuals' perceptions of, and responses to, uncertainty across their cognition, emotion, and behavior. Various UT scales have been designed for physician and medical student populations. However, links between UT and other variables (e.g., training stages) are inconsistent, raising concerns about scale reliability and validity. As reliability is a precondition for validity, a necessary first step in assessing UT scales' efficacy is evaluating their reliability. Accordingly, the authors conducted a meta-analysis of the reliability of UT scales designed for, and implemented among, physician and medical student populations.

METHOD

In 2020, the authors searched 4 electronic databases alongside a citation search of previously identified UT scales. They included English-language, peer-reviewed studies that implemented UT scales in physician and/or medical student populations and reported reliability evidence. A meta-analysis of studies' Cronbach's alphas evaluated aggregated internal consistency across studies; subgroup analyses evaluated UT scales by named scale, population, and item characteristics.

RESULTS

Among 4,124 records screened, 35 studies met the inclusion criteria, reporting 75 Cronbach's alphas. Four UT scales appeared in at least 3 included studies: Physicians' Reactions to Uncertainty scale 1990 (PRU1990) and 1995 (PRU1995) versions, Tolerance for Ambiguity scale (TFA), and Tolerance of Ambiguity in Medical Students and Doctors scale (TAMSAD). The scores from these scales ranged in reliability from very good (PRU1990: 0.832, PRU1995: 0.818) to respectable (TFA: 0.761, TAMSAD: 0.711). Aggregated internal consistency was significantly higher ( P < .001) among physicians (0.797) than medical students (0.711).

CONCLUSIONS

UT scales generally demonstrated respectable internal consistency when administered among physicians and medical students, yet the reliability among medical students was significantly lower. The authors caution against using UT scores for decision-making purposes (e.g., applicant selection, program evaluation), especially among medical student populations. Future research should explore the reasons underlying these observed population differences.

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents

BACKGROUND

Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education.

OBJECTIVE

Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents.

DESIGN

Qualitative analysis of CSR-based interviews with IM residents.

PARTICIPANTS

Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019.

INTERVENTION

Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty.

APPROACH

Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis.

KEY RESULTS

The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable.

CONCLUSIONS

Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

Assessing pharmacy students' baseline tolerance for ambiguity, burnout, empathy, quality of life, and stress

INTRODUCTION

Several factors may affect student wellbeing, including tolerance for ambiguity, burnout, empathy, quality of life, and stress. A better understanding of how pharmacy students score on these scales relative to other health professional students could help educators and schools address and improve student wellbeing. The study objective was to determine a baseline measure of pharmacy student tolerance for ambiguity, burnout, empathy, quality of life, and stress.

METHODS

A voluntary survey including several assessment scales (Tolerance for Ambiguity, Oldenburg Burnout Inventory, Interpersonal Reactivity Index [empathy], Quality of Life Scale, and Perceived Stress Scale) was sent by email to all pharmacy students within a standalone college of pharmacy.

RESULTS

Two hundred thirty-one pharmacy students completed all aspects of the survey. Comparing each scale with sex, female students trended higher in Interpersonal Reactivity Index and scored significantly higher on the Oldenburg Burnout Inventory (disengagement), while male students scored significantly higher for Quality of Life. Fourth-year students scored significantly higher on the Tolerance for Ambiguity scale as compared to first- and second-year students and on the Quality of Life scale as compared with third-year students. Third-year students experienced the greatest levels of burnout. Differences were also noted based on students' anticipated area of practice (empathy) and desire to work with an underserved population (empathy and stress).

CONCLUSIONS

Pharmacy students' responses to the included scales varied greatly when considering various demographic parameters. The significant differences identified are illuminating and represent potential areas for curricular improvement, student support, and further study within pharmacy school curricula.

Sustainable Leadership, Environmental Turbulence, Resilience, and Employees' Wellbeing in SMEs

Drawing on the conservation of resources theory and contingency theories of leadership, this study aims to investigate how sustainable leadership (SL) influences employees' wellbeing (WB) through employee resilience (ER) and to examine the moderating effect of environmental turbulence (ET) on the “sustainable leadership-employees' wellbeing” relationship. Data were collected from 593 employees and 373 supervisors adopting two-wave design among small and medium-sized enterprises (SMEs) in China. The authors used structural equation modeling to empirically test the hypothesized model in this study. The research shows that SL is significantly related to the employees' WB in SMEs. Regarding mediating effect, SL also indirectly influences employees' WB through ER. Moreover, the impact of SL on employees' WB becomes more prominent in the presence of lower ET. To the best of the authors' knowledge, no prior study is available about the integrated relationship of SL, ER, ET, and employee WB.

The Role of Ambiguity Tolerance and Enthusiasm on Chinese University Teachers’ Burnout

Educators face numerous vague conditions in their daily practice and they must manage students with diverse characters that lead to burnout. In addition, tolerance of ambiguity is a term used by educators as the capability to control new, complicated or insoluble situations. Moreover, educator enthusiasm and its effect on instruction was neglected. And due to the essential function that teachers’ burnout plays in the efficiency of their achievement in the scholastic cycle, the present study inspected whether the above-mentioned constructs such as teachers’ ambiguity tolerance and enthusiasm can influence their burnout on one hand and on the other hand if these constructs can predict the teachers’ burnout or not. For the objective of the study, a group of 495 female and male Chinese university teachers in 18 provinces of China were asked to fill out the three scales, namely, teacher enthusiasm, ambiguity tolerance, and burnout. The primary results of the research, achieved through running Spearman Rho, specify that there are constructive relationships between ambiguity tolerance, enthusiasm and by employing multiple regression analysis; it is revealed that both variables, namely ambiguity tolerance, enthusiasm were the predictors of teachers’ burnout, while ambiguity tolerance was a better predictor. Accordingly, based on these findings, it can be concluded that both of these factors affect teachers’ burnout in the teaching process. In addition, this study can provide additional implications for academic scholars and experts in academic settings.

"A sorely neglected field": A multisite study of self-reported humanities exposure among emergency medicine residents

BACKGROUND

The Association of American Medical Colleges has identified the humanities as fundamental to medical education across all specialties. Evidence from undergraduate medical education (UME) demonstrates the humanities' positive impacts on outcomes that could be relevant to patient care and trainee well-being in emergency medicine (EM) residency training. However, less is known about the humanities' role in graduate medical education (GME).

OBJECTIVES

The objectives were to describe EM residents' self-reported exposure to the humanities and its relationship with their empathy, tolerance of ambiguity, and patient-centeredness, and to assess their attitudes toward the humanities in GME.

METHODS

This cross-sectional survey-based study was conducted at six U.S. EM residency programs in 2018-2019. Quantitative analyses included linear regressions testing for trends between humanities exposures and outcomes, adjusted for sex, year in training, and clustering within programs; adjunct analysis of free-text responses was performed using an exploratory constructivist approach to identify themes about views on the humanities' role in medicine.

RESULTS

Response rate was 54.8% (153/279). A total of 65% of respondents were male and 28.1% of respondents had a preceding humanities degree. Preceding humanities degree and current self-reported humanities exposure were positively associated with performance on empathy subscales (p = 0.02). Seventy-five percent (n = 114) of respondents agreed humanities are important in GME; free-text responses revealed perceived positive impacts of humanities on generating well-rounded clinicians and enhancing patient care.

CONCLUSIONS

Engagement with the humanities may be associated with empathy among EM residents. Although the magnitude of associations was smaller than that seen in UME, this study demonstrates resident interest in humanities and suggests that extracurricular engagement with the humanities may be insufficient to prolong positive impacts seen in UME. Further research is needed to explore how to sustain these benefits through integration or addition of the humanities in existing GME curricula.

Factors Associated with Physician Tolerance of Uncertainty: an Observational Study

BACKGROUND

Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area.

OBJECTIVE

To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout.

DESIGN

Online confidential survey.

SETTING

The Massachusetts General Physicians Organization (MGPO).

PARTICIPANTS

All 2172 clinically active faculty in the MGPO.

MAIN MEASURES

We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics.

KEY RESULTS

Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90).

CONCLUSION

At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

The impact of Stress Management and Resilience Training (SMART) on academic physicians during the implementation of a new Health Information System: An exploratory randomized controlled trial

OBJECTIVE

The Stress Management and Resilience Training (SMART) program is an evidence-based intervention designed to build resilience in physicians in clinical practice. The objective of the current study was to assess the impact of the SMART program on academic physicians' levels of resilience, subjective happiness, stress, and anxiety, and specifically during the implementation of a new hospital-wide Health Information System (HIS).

METHODS

A total of 40 physicians in a tertiary care academic hospital were randomized (allocation ratio 1:1) to either the SMART intervention or the control condition. The SMART intervention consisted of one mandatory two-hour in-person workshop and an optional 24-week online program, designed to support the materials delivered in the workshop. Outcome measures were assessed using validated scales administered online at baseline and at 3-months and 6-months follow-up.

RESULTS

After adjusting for baseline levels of each outcome, no statistically significant intervention effect was observed for resilience, subjective happiness, stress or anxiety at 3-months or 6-months follow-up. However, physicians in the intervention group demonstrated improvements in resilience, stress and anxiety at follow-up that were within the range of clinically relevant differences.

CONCLUSIONS

The findings of this exploratory study provide modest support that the SMART intervention may be beneficial for proactively addressing physician wellness during the implementation of a new HIS and that larger randomized trials are warranted.

TRIAL REGISTRATION

NCT04384861.

A Review of the Relationship Between EFL Teachers' Academic Buoyancy, Ambiguity Tolerance, and Hopelessness

Second/foreign language education has been approved emotionally tense due to its inherent challenges, adversities, complications, and ambiguities. These factors can affect various language teaching and learning domains. Hence, it is critical for EFL teachers to be buoyant and tolerant of ambiguity so that they can teach efficiently and prevent a sense of hopelessness that can damage everything. Although there are investigations on these variables in L2 contexts, their main focus has been on EFL students and teachers’ perspectives have been largely ignored. Against this shortcoming, this study aimed to review the definitions, conceptualizations, and research findings related to teachers’ academic buoyancy, ambiguity tolerance, and hopelessness. Moreover, practical implications for EFL teachers and teacher trainers are presented to increase their awareness of language teaching challenges and ways to overcome them. Finally, the study provides directions for future research.

Coping With Students' Stress and Burnout: Learners' Ambiguity of Tolerance

In the learning milieu, academic stress is deemed as the most general mental condition that learners encounter throughout their educational process, and it has been viewed as one of the most central issues not only in general education but also specifically in language learning. Likewise, burnout has been the main point in this situation. The comprehensive sources of stress and the reasons for burnout are pinpointed in the literature so realizing their association with other aspects such as coping strategies, namely tolerance of uncertainty, are at the center of attention as it may help reduce burnout and decrease the level of stress. To this end, the goal of the present study is to prove the influence of the tolerance of ambiguity in explaining the role of stress and burnout. Briefly, some implications are set forth for the educational stakeholders.

"It's okay to not know …" a qualitative exploration of faculty approaches to working with uncertainty

BACKGROUND

Whilst it is recognised that a capacity to manage uncertainty is an essential aspect of working as a healthcare professional, there is little clear guidance on how to facilitate student learning in this domain. A lack of faculty development opportunities also suggests that health professions' educators may feel ill-equipped to assist students in developing effective approaches to uncertainty. The purpose of this study was to explore a faculty development intervention designed to help educators unpack students' experiences of uncertainty, and identify attributes which may help students to manage uncertain situations.

METHODS

This qualitative study was informed by a constructivist methodological approach, where participants were encouraged to share meaning around the nature of uncertainty in health professions' education. Two 90-min faculty development sessions were held. These sessions invited participants to apply Han et al.'s taxonomy of uncertainty to role-played scenarios of student uncertainty within a focus group setting. Focus group data were collected, and examined using a two-stage, hybrid approach of deductive and inductive thematic analysis.

RESULTS

Han et al.'s taxonomy helped participants to identify multiple sources and issues of uncertainty in the role played scenarios, thus unveiling the extent of uncertainties encountered by health professions' learners. Data analysis revealed four themes overall: "Sources of uncertainty", "Issues of uncertainty", "Uncertainty attributes", and "Learning environment." Participants also contributed to a list of attributes which they considered helpful to undergraduate health professions' students in managing uncertain situations. These included an awareness of the nature of uncertainty within healthcare practice, an ability to recognise uncertainty, and adopting attitudes of adaptability, positivity, and resilience.

CONCLUSIONS

This study highlights the successful use of Han et al.'s taxonomy of uncertainty within a faculty development setting. Our findings suggest that the taxonomy is a practical and versatile tool that health professions' educators can use in shared reflections and conversations around uncertainty with students or colleagues.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

Risk-Perception Change Associated with COVID-19 Vaccine's Side Effects: The Role of Individual Differences

The COVID-19 vaccine appears to be a crucial requirement to fight the pandemic. However, a part of the population possesses negative attitudes towards the vaccine. The spread of conspiracy theories and contradictory information about the pandemic have altered the population’s perception of risk. The risk-perception of the vaccine’s side effects may be affected by individual differences. The complex relationship between risk-perception and individual differences is relevant when people have to make decisions based on ambiguous and constantly changing information, as in the early phases of the Italian vaccination campaign. The present study aimed at measuring the effect of individual differences in risk-perception associated with the COVID-19 vaccine’s side effects in a context characterized by information ambiguity. An online survey was conducted to classify a sample of Italian pro-vaccine people into cognitive/behavioral style groups. Furthermore, changes in vaccine risk-perception after inconsistent communications regarding the vaccine’s side effects were compared between groups. The results showed that “analytical” individuals did not change their perception regarding the probability of vaccine side effects but changed their perception regarding the severity of side effects; “open” and “polarized” individuals neither changed their perception regarding the probability nor of the severity of side effects, showing a different kind of information processing, which could interfere with an informed decision-making process.

The Review on the Role of Ambiguity of Tolerance and Resilience on Students' Engagement

Due to the arrival of positive psychology (PP) in the development of teaching, the construct of engagement has been thrived and got a notable function in the educational arena. Alternatively, numerous individual differences, containing ambiguity of tolerance, have been taken into consideration as a result of the key role they can play in the process of learning, and thus, on different facets of the learners' engagement. Furthermore, resilience is recommended to be an alternate and effective way of engaging English as a foreign language (EFL) learners. Also, it is a significant feature of the human adaptation system in which students can efficaciously manage and tackle stressful involvements despite their troubles and disasters. Given the eminence of both ambiguity tolerance and resilience in educational settings and the fact that little attention has been given to these constructs in foreign language learning, the present review makes an effort to scrutinize the impact of ambiguity of tolerance and resilience on EFL learners' engagement. Succinctly, the fundamental roles of ambiguity tolerance and resilience in learners' engagement were confirmed, and consistent with the conclusions drawn from the present review, some suggestions are set forth concerning the implications of this paper.

Towards a medical school curriculum for uncertainty in clinical practice

Uncertainty abounds in the clinical environment. Medical students, however, are not explicitly prepared for situations of uncertainty in clinical practice, which can cause anxiety and impact well-being. To address this gap, we sought to capture how students felt in various clinical scenarios and identify programs they found helpful as they worked through uncertainty in their clerkships to better inform curriculum that prepares them to acknowledge and navigate this uncertainty. This is an observational cross-sectional study of third-year medical students surveyed at the end of core clerkships. The survey consisted of the General Self-Efficacy (GSE) Scale and Intolerance of Uncertainty Scale (IUS). Items asked students to rate preparedness, confidence, and comfort with uncertainty in clinical practice. Items on curricular programs asked students to identify training that prepared them for uncertainty in clerkships, and examined correlations with specific clinical practice uncertainty domains (CPUDs). Spearman's rank-order correlation, Chi-Square, and ANOVA were used to analyze quantitative data. Open responses were analyzed using Braun and Clarke's Framework. Response rate was 98.9% (287/290). GSE was inversely correlated with IUS (p < 0.001). GSE was positively correlated with all CPUDs (p < 0.005). IUS had an inverse correlation with all CPUDs (p < 0.005). Pedagogies with statistically-significant relationships with preparing students for uncertainty, communicating and building relationships with patients during times of uncertainty, and overall well-being included: team debriefs, role plays, case- and team-based learning, story slams, and sharing narratives with peers and faculty (p < 0.05). Qualitatively, students appreciated storytelling, role-modeling of communication strategies, debriefing, and simulations. Strategically immersing specific educational formats into formal curriculum may help cultivate skills needed to prepare students for uncertainty. Clinical debriefs, interprofessional role plays, simulations, communications skills training, instructor emotional vulnerability, storytelling, and peer-to-peer conversations may have the most impact. Further study is required to evaluate their longitudinal impact.

Benchmarking in Academic Physical Therapy: A Multicenter Trial Using the PT-GQ Survey

OBJECTIVE

Academic physical therapy has no universal metrics by which educational programs can measure outcomes, limiting their ability to benchmark to their own historical performance, to peer institutions, or to other health care professions. The PT-Graduation Questionnaire (GQ) survey, adapted from the Association of American Medical Colleges' GQ, addresses this gap by offering both inter-professional insight and fine-scale assessment of physical therapist education. This study reports the first wave of findings from an ongoing multi-site trial of the PT-GQ among diverse academic physical therapy programs, including (1) benchmarks for academic physical therapy, and (2) a comparison of the physical therapist student experience to medical education benchmarks.

METHODS

Thirty-four doctor of physical therapy (DPT) programs (13.2% nationwide sample) administered the online survey to DPT graduates during the 2019 to 2020 academic year. PT-GQ and Association of American Medical Colleges data were contrasted via Welch's unequal-variance t test and Hedges g (effect size).

RESULTS

A total of 1025 respondents participated in the study (response rate: 63.9%). The average survey duration was 31.8 minutes. Overall educational satisfaction was comparable with medicine, and respondents identified areas of curricular strength (eg, anatomy) and weakness (eg, pharmacology). DPT respondents provided higher ratings of faculty professionalism than medicine, lower rates of student mistreatment, and a lesser impact of within-program diversity on their training. One-third of respondents were less than "satisfied" with student mental health services. DPT respondents reported significantly higher exhaustion but lower disengagement than medical students, along with lower tolerance for ambiguity. Of DPT respondents who reported educational debt, one-third reported debt exceeding $150,000, the threshold above which the DPT degree loses economic power.

CONCLUSIONS

These academic benchmarks, using the PT-GQ, provided insight into physical therapist education and identified differences between physical therapist and medical student perceptions.

IMPACT

This ongoing trial will establish a comprehensive set of benchmarks to better understand academic physical therapy outcomes.

Leader Tolerance of Ambiguity: Implications for Follower Performance Outcomes in High and Low Ambiguous Work Situations

Individuals high in tolerance of ambiguity (TOA) are comfortable with, desire, and strive to manage ambiguous situations. We predicted leader TOA would be associated with better follower performance outcomes, depending on the level (Study 1) and nature (Study 2) of follower role ambiguity. Data were collected from employees (Study 1, n = 423) and managerial employees (Study 2, n = 326) who rated their leader on three facets of TOA and provided self-reports of their own performance outcomes. Positive implications of leader TOA for follower learning goal orientation and job performance (Study 1) were most pronounced when followers perceived low role ambiguity and, in the prediction of situational coping (Study 2), when ambiguous work situations were categorized as challenges (unexpected events requiring problem-solving) compared to hindrances. Findings have theoretical implications for understanding when TOA in leaders is optimal and have practical relevance for leaders seeking to adapt to the situational needs of their followers.

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.

Association between role conflict and ambiguity and stress among nurses in primary health care centers in Saudi Arabia during the coronavirus disease 2019 pandemic: A cross-sectional study

This study aimed to assess the association between role conflict and ambiguity among nurses in primary healthcare centers (PHCs) in Saudi Arabia and their stress levels during the coronavirus disease 2019 (COVID-19) pandemic.In this online cross-sectional study, sociodemographic and occupational characteristics, role conflict, and ambiguity of 432 nurses were assessed using the Bowling Scale for Role Conflict and Ambiguity and stress was assessed using the 10-item Perceived Stress Scale from September 27 to October 17, 2020. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for above-median stress levels of nurses with average and high (2nd and 3rd tertiles) role conflict and ambiguity compared with nurses with low role conflict and ambiguity (1st tertile).The mean (standard deviation) age of the nurses was 36.5 ± 6.6 years, and 25.9% of them were males. After adjusting for PHC type and working hours, nurses with average and high role conflict had significantly higher stress rates than those with low role conflict, with ORs (95% CIs) of 2.69 (1.62-4.46) and 6.31 (3.78-10.53), respectively. Similarly, nurses with average- and high-role ambiguity had significantly higher stress than those with low role ambiguity, with ORs (95% CIs) of 2.15 (1.30-3.55) and 7.68 (4.54-13.01), respectively. Increasing stress rates were detected across increasing categories of role conflict and ambiguity (P values for trend <.001).We found that role conflict and ambiguity were associated with stress among nurses in PHCs in Saudi Arabia during the COVID-19 pandemic.

When diversity leads to closed-mindedness: Cognitive factors explain the effects of perceived diversity

This paper makes a case for explaining diversity effects through cognitive factors as compared to demographic or other differences in backgrounds. We argue that studying perceived diversity in conjunction with diversity beliefs can explain positive and negative effects through a motivated opening or closing of the mind (Need for Cognitive Closure, NFCC). NFCC is the motivation to avoid uncertainty and ambiguity. In Study 1, we experimentally demonstrate that asking participants to think about differences among their coworkers increases their NFCC. Study 2 shows that greater uncertainty about social norms in the workplace is positively related to NFCC. Study 3 confirms the mediating role of NFCC in explaining divergent thinking attitudes in expatriates working in various multicultural cities around the world. Study 4 demonstrates that perceived diversity is positively associated with NFCC when people hold negative beliefs about diversity, whereas positive beliefs mitigate this effect. Lastly, Study 5 shows that the interaction between perceived diversity and diversity beliefs is further moderated by task type. Taken together, the present research highlights the importance of studying cognitive factors to explain diversity effects.

Examining the Association between Evidence-Based Practice and Burnout among Spanish Physical Therapists: A Cross-Sectional Study

The aim of this study was to quantify the level of burnout and competence for evidence-based practice among Spanish physical therapists and to determine if there is a relationship between these and other socio-professional factors. A cross-sectional study with 472 Spanish Physiotherapists. An electronic survey was conducted that included the Maslach Burnout Inventory, Evidence-Based Practice Questionnaire and sociodemographic data. The three subscales of the Burnout correlated with attitude and total Evidence-Based Practice Questionnaire. Attitude and practice for evidence-based practice, educational level and experience were the variables that showed the greatest influence on burnout. Burnout and the degree of evidence-based practice were identified as being discretely related. Specifically, it seems that the evidence-based practice could improve the lack of personal accomplishment, meaning that through interventions perceived as more effective and advantageous, a sense of mastery and self-efficacy is experienced.

The ubiquity of uncertainty: a scoping review on how undergraduate health professions' students engage with uncertainty

Although the evidence base around uncertainty and education has expanded in recent years, a lack of clarity around conceptual terms and a heterogeneity of study designs means that this landscape remains indistinct. This scoping review explores how undergraduate health professions' students learn to engage with uncertainty related to their academic practice. To our knowledge, this is the first scoping review which examines teaching and learning related to uncertainty across multiple health professions. The scoping review is underpinned by the five-stage framework of (Arksey and O'Malley in Scoping studies: Towards a methodological framework International Journal of Social Research Methodology 8(1) 19-32, 2005). We searched MEDLINE, Embase, PsychINFO, ISI Web of Science, and CINAHL and hand-searched selected health professions' education journals. The search strategy yielded a total of 5,017 articles, of which 97 were included in the final review. Four major themes were identified: "Learners' interactions with uncertainty"; "Factors that influence learner experiences"; "Educational outcomes"; and, "Teaching and learning approaches". Our findings highlight that uncertainty is a ubiquitous concern in health professions' education, with students experiencing different forms of uncertainty at many stages of their training. These experiences are influenced by both individual and system-related factors. Formal teaching strategies that directly support learning around uncertainty were infrequent, and included arts-based teaching, and clinical case presentations. Students also met with uncertainty indirectly through problem-based learning, clinical teaching, humanities teaching, simulation, team-based learning, small group learning, tactical games, online discussion of anatomy topics, and virtual patients. Reflection and reflective practice are also mentioned as strategies within the literature.

Physician Well-being and the Future of Health Information Technology

The issue of clinician burnout has become a growing concern in health care, with an increased emphasis on health information technology as a contributing factor. Technology-mediated stresses have arisen with the electronic health record, and we can anticipate new and different impacts from future information tools. This article discusses technology's pivotal role in physician well-being, not only in the quality of its design but also through its capacity to enable future models of care that are more manageable for physicians and more effective for patients. Three general aims along with specific efforts are proposed to benefit physician well-being in technology-mediated work.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

COVID-19 uncertainty and sleep: the roles of perceived stress and intolerance of uncertainty during the early stage of the COVID-19 outbreak

BACKGROUND

The COVID-19 pandemic brings unprecedented uncertainty and stress. This study aimed to characterize general sleep status among Chinese residents during the early stage of the outbreak and to explore the network relationship among COVID-19 uncertainty, intolerance of uncertainty, perceived stress, and sleep status.

METHODS

A cross-sectional correlational survey was conducted online. A total of 2534 Chinese residents were surveyed from 30 provinces, municipalities, autonomous regions of China and regions abroad during the period from February 7 to 14, 2020, the third week of lockdown. Final valid data from 2215 participants were analyzed. Self-report measures assessed uncertainty about COVID-19, intolerance of uncertainty, perceived stress, and general sleep status. Serial mediation analysis using the bootstrapping method and path analysis were applied to test the mediation role of intolerance of uncertainty and perceived stress in the relationship between uncertainty about COVID-19 and sleep status.

RESULTS

The total score of sleep status was 4.82 (SD = 2.72). Age, place of residence, ethnicity, marital status, infection, and quarantine status were all significantly associated with general sleep status. Approximately half of participants (47.1%) reported going to bed after 12:00 am, 23.0% took 30 min or longer to fall asleep, and 30.3% slept a total of 7 h or less. Higher uncertainty about COVID-19 was significantly positively correlated with higher intolerance of uncertainty (r = 0.506, p < 0.001). The mediation analysis found a mediating role of perceived stress in the relationship between COVID-19 uncertainty and general sleep status (β = 0.015, 95%C.I. = 0.009-0.021). However, IU was not a significant mediator of the relationship between COVID-19 uncertainty and sleep (β = 0.009, 95%C.I. = - 0.002-0.020). Moreover, results from the path analysis further showed uncertainty about COVID-19 had a weak direct effect on poor sleep (β = 0.043, p < 0.05); however, there was a robust indirect effect on poor sleep through intolerance of uncertainty and perceived stress.

CONCLUSIONS

These findings suggest that intolerance of uncertainty and perceived stress are critical factors in the relationship between COVID-19 uncertainty and sleep outcomes. Results are discussed in the context of the COVID-19 pandemic, and practical policy implications are also provided.

Understanding Contextual Factors Effects and Their Implications for Italian Physiotherapists: Findings from a National Cross-Sectional Study

An online cross-sectional survey was conducted using Google Docs software. The aim was to understand the management of contextual factors and to identify which are most relevant and which clinicians underestimate. A total of 1250 physiotherapists were chosen from the database of the Manual Therapists group mailing list (GTM-IFOMPT MO) from July to August 2020. A total of 699 responses were received that were considered valid (56%). Participants (40.83%) identified contextual factors (CFs) as "any element, even involuntary, with which the patient interacts during treatment". Physiotherapists individually chose the representation of CF with the "therapeutic relationship" (82.9%), followed by "therapeutic setting" (75.8%). This choice differed between participants belonging to different age groups. Participants favor communication strategies (76.93%). More than half (57.88%) pay attention to patient involvement during the course of care; and in response to the patients' doubts about the use of treatments with limited scientific efficacy, they suggest different medical treatments. The patient's previous clinical experience is not considered significant and does not influence the choice of treatment. Subsequently, however, the participants reported that they stimulate the patients' positive expectations of the success of the clinical outcome (45.27%). Knowledge of contextual factors in physiotherapy appears limited and very heterogeneous. Future research could increase the focus on professional development.

[Impact of an elective course in evidence-based clinical decision-making on competencies and attitudes of medical students: A pilot study]

BACKGROUND

Evidence-based medicine (EbM) as a teaching subject is increasingly taken into account in the Master Plan 2020. To date, neither theoretical requirements nor practical applications of EbM have been consistently implemented in the clinical curriculum. To fill this gap, a digital and tutor-based EbM course has been developed. The aim is to identify the student characteristics (statistical competence, Need for Cognition (NFC), work and experience patterns (AVEM), diagnostic uncertainty) of the first cohort in order to ensure successful course implementation and to prepare future doctors for their role as mediators of health literacy using EbM methods.

METHODS

The long-term study started in the summer term 2019 with 10 medical students during their clinical training. The measurements were conducted before (t0) and after course attendance (t1). Socio-demographic variables were taken at t0, the Quick Risk Test, PRU questionnaire, the NFC scale and the AVEM were collected at t0 and t1.

RESULTS

Half of the students started their doctoral thesis before attending the course. The first test results of the Quick Risk Test (t0) were between 50 % and 90 % and at t1 between 60 % and 100 %. The students showed high scores on the NFC scale (X¯=4.6, SD=0.52, Δ X¯ t0 - t1=0.1) and medium scores on the Perfectionism scale (X¯=3.8, SD=0.51, Δ X¯ t0 - t1=0.1), Resignation Tendency (X¯=3.8, SD=1.17, Δ X¯ t0 - t1=0.1) and on the scale Aggressive Problem Solving (X¯=3.9, SD=1.06, Δ X¯ t0 - t1=0.2). They achieved high levels of Anxiety Due to Diagnostic Uncertainty (X¯=4.8, SD=0.69, Δ X¯ t0 - t1=0.4) and on the scale Concern about Poor Outcomes (X¯=3.9, SD=1.54, Δ X¯ t0 - t1=0.6). The scale Restraint in Disclosing Uncertainty to Patients was more pronounced than the scale Restraint in Disclosing Errors to Physicians (X¯=3.5, SD=0.93, Δ X¯ t0 - t1=-0.3 compared to X¯=2.3, SD=1.20, Δ X¯ t0 - t1=0.1).

DISCUSSION

Statistical competence improved with course attendance, with only one student being able to correctly answer all items at t1. NFC and AVEM were strongly expressed and were not very sensitive to change in the sample. The greatest changes were observed on the scales of concern about poor results and fear of diagnostic uncertainty, both of which decreased with course participation.

CONCLUSION

In the long term, the development of a new measuring instrument to assess EbM competencies instead of the Quick Risk Test is conceivable. The longitudinal design will also enable us to make causal interpretations and to track changes in students' competence feelings, behaviour and attitudes.

An experimental philosophical bioethical study of how human rights are applied to clitorectomy on infants identified as female and as intersex

Clitorectomies performed on the genitals of infants identified as female and as intersex have been described both as similar procedures and as different procedures. The former types of surgery have been recognised more consistently as human rights abuses than the latter in recent decades. We tested social psychological explanations of why human rights are differently recognised when infants are described as 'intersex' or 'female'; 122 laypeople in the UK read one of two near-identical descriptions of clitorectomies performed on intersex or female infants and reported their agreement with 22 items about the human rights of such infants. Clitorectomies were perceived as violating human rights more by women than by men, and more so when infants were described as female than intersex. Endorsement of human rights was better predicted by several psychological variables when infants were described as female than as intersex. Less politically conservative participants, as assessed by a Right-Wing Authoritarianism measure, and participants who trusted medical authority more recognised human rights violations of female infants more than intersex infants. Results are discussed with respect to human rights efforts to protect infants from medically non-necessary genital surgery on the basis of membership in identity categories or possession of sex characteristics.

The interplay between risk and protective factors during the initial height of the COVID-19 crisis in Italy: The role of risk aversion and intolerance of ambiguity on distress

The present study aimed to test a model of relations to ascertain the determinants of distress caused by lockdown for COVID-19. It was hypothesized that the exposure to the COVID-19 increased distress directly and through the mediation of worry, health-related information seeking, and perception of the utility of the lockdown. It was also expected that higher levels of ambiguity intolerance corresponded to higher distress directly and through the mediation of worry, health information seeking behaviors, and perceived utility of the lockdown. Finally, it was expected that risk aversion positively influenced distress directly and through the increasing of worry, health-related information seeking behavior, and more positive perception of the utility of the lockdown The study was conducted in Italy during the mandatory lockdown for COVID-19 pandemic on 240 individuals (age range 18-76). Data recruitment was conducted via snowball sampling. COVID-19 exposure was positively associated with worry and health-related information seeking. Risk-aversion was positively associated with health-related information seeking and perceived utility of the lockdown to contain the spread of the virus. Worry and health-related information seeking were positively associated with distress, whereas the perceived utility of the lockdown was negatively associated with distress. Intolerance for the ambiguity was directly linked to distress with a positive sign. Findings suggest that risk aversion represents both a risk factor and a protective factor, based on what kind of variable mediates the relationship with distress, and that the intolerance to the ambiguity is a risk factor that busters distress.