Review articleTolerance of uncertainty: A systematic review of health and healthcare-related outcomes
Introduction
Uncertainty is an important problem in medicine, pervading nearly every activity of healthcare, from health promotion and disease prevention, to disease treatment, to palliative and end-of-life. In all of these activities uncertainty of one type or another—e.g., diagnostic, prognostic, therapeutic—arises in the minds of patients, clinicians, and trainees, and influences their thoughts, feelings, and actions [1]. Responding to these uncertainties in an adaptive way is one of the most important challenges faced by each of these parties [[2], [3]].
The critical importance of uncertainty and people’s responses to it has long been recognized; however, it has received increasing attention over the past several years [[4], [5]]. The phenomenon of “uncertainty tolerance” (UT) and its relationship to various health and healthcare-related outcomes has become the focus of an expanding body of empirical research. Searching PubMed reveals substantial growth in published papers citing uncertainty and tolerance as key words, from less than 10 in 1980; to over 200 in 2016. UT has been defined and measured in various ways in this research; although in a recent conceptual review and analysis of the phenomenon we argued that existing understandings of UT can be subsumed by an overarching; integrative definition: the set of negative and positive psychological responses—cognitive; emotional; and behavioral—provoked by the conscious awareness of ignorance about particular aspects of the world [6]. This definition acknowledges the breadth of different potential responses to uncertainty; which can be both negative (e.g.; thoughts and feelings of vulnerability; information and decision avoidance) and positive (e.g.; thoughts and feelings of opportunity and hope; information seeking and decision-making). An individual’s “tolerance” of uncertainty is the balance between these responses; and may thus be more negative (tending towards more negatively valenced responses) or positive (tending towards more positively valenced responses). Our integrative definition also acknowledges that UT can represent either a state induced by a particular situation; (consisting of a particular pattern of cognitive; emotional; or behavioral responses to uncertainty); or a trait (consisting of an individual’s propensity towards a particular pattern of responses). We have previously put forth an integrative conceptual model of UT (Fig. 1); aimed at guiding future efforts to measure and understand its mechanisms and outcomes [6].
Many past studies of UT have treated it as a trait-level propensity or characteristic of individuals and have explored its extent among patients, health care providers, and trainees, as well as the association between UT and outcomes related to health, healthcare, and healthcare education. They have utilized a number of measures of UT and have examined several settings and populations. These studies have produced potentially important findings; however, findings have been inconsistent [[7], [8], [9], [10], [11], [12], [13]]. Existing heterogeneity in the methods and findings of past studies of UT makes it difficult to draw conclusions about its extent and influence upon health- and healthcare-related outcomes, and raises the need for a comprehensive appraisal of the state of the evidence.
To meet this need, we conducted a systematic literature review, aimed at identifying existing empirical studies of UT in healthcare, describing their quality and areas of focus, and summarizing their main findings and limitations. We aimed to be as inclusive as possible, surveying studies measuring UT in different ways and examining a broad range of outcomes related to health, healthcare, and healthcare education. Here we present the findings of this analysis and discuss implications for future research.
Section snippets
Study design
Our study protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as well as guidelines provided by the Cochrane Collaboration [[14], [15]]. The review was registered with the PROSPERO international prospective registry of systematic reviews, registration #CRD42015032449.
Search strategy
Studies were considered for inclusion if they reported original research in the English language peer-reviewed literature focused on at least one of the following
Search results and study characteristics
Database searches identified 542 non-duplicate records. After reviewing titles and abstracts, 139 articles were classified as potentially relevant; full papers were assessed against eligibility criteria, and 39 (28%) were removed from further consideration. We excluded 10 qualitative studies and 23 primary psychometric studies. The remaining 67 studies were included in the review (Fig. 2).
Included studies originated from a variety of countries and regions including the United States (66%),
Discussion
UT is thought to be an important characteristic of health care providers and patients, and this systematic review sheds light on the state of scientific research and knowledge regarding this phenomenon.
Substantial heterogeneity in the methodological quality and approach of research on UT was a primary finding. Overall, the quality of past studies and the reporting of their findings in the literature has been variable and low. Most past studies have utilized relatively small or
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Acknowledgement
The authors wish to thank Heather Kemp for her expert assistance with our literature searches.
References (89)
- et al.
Tolerance of uncertainty: conceptual analysis, integrative model, and implications for health care
Soc. Sci. Med.
(2017) - et al.
Intolerance of ambiguity in students entering medical school
Soc. Sci. Med.
(1989) - et al.
Tolerance for ambiguity among medical students: implications for their selection, training and practice
Soc. Sci. Med.
(1990) - et al.
Why do people worry?
Pers. Indiv. Differ.
(1994) - et al.
The intolerance of uncertainty scale: psychometric properties of the English version
Behav. Res. Ther.
(2002) - et al.
Fearing the unknown: a short version of the intolerance of uncertainty scale
J. Anxiety Disord.
(2007) - et al.
The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain
Am. J. Emerg. Med.
(2010) - et al.
Reliance on high technology among senior medical students
Am. J. Med. Sci.
(1998) - et al.
The influence of surgeon personality factors on risk tolerance: a pilot study
J. Surg. Educ.
(2013) - et al.
Fostering patient safety competencies using multiple-patient simulation experiences
Nurs. Outlook
(2009)
The association between physician risk tolerance and imaging use in abdominal pain
Am. J. Emerg. Med.
Psychiatrists' decision making between branded and generic drugs
Eur. Neuropsychopharmacol.
Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders
Behav. Res. Ther.
Metacognitions, anxiety, and distress related to motor fluctuations in Parkinson's disease
J. Psychosom. Res.
Cognitions associated with anxiety in Meniere's disease
J. Psychosom. Res.
Beliefs and emotional reactions in patients with benign paroxysmal positional vertigo: a longitudinal study
Am. J. Otolaryngol.
The impact of intolerance of uncertainty, worry and irritability on quality of life in persons with epilepsy: irritability as mediator
Epilepsy Res.
Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus
Prim. Care Diabetes
Varieties of uncertainty in health care: a conceptual taxonomy
Med. Decis. Mak.
Tolerating uncertainty—the next medical revolution
N. Engl. J. Med.
Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering
The Silent World of Doctor and Patient
Training for uncertainty
Tolerance of uncertainty and fears of making mistakes among fifth-year medical students
Fam. Med.
Tolerance of uncertainty of medical students and practicing physicians
Med. Care
Individual differences in aversion to ambiguity regarding medical tests and treatments: association with cancer screening cognitions
Cancer Epidemiol. Biomark. Prev.
The role of distress in uptake and response to predisposition genetic testing: the BMPR2 experience
Genet. Test. Mol. Biomark.
Offering cystic fibrosis carrier screening to an HMO population: factors associated with utilization
Am. J. Hum. Genet.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
Ann. Intern. Med.
Cochrane Handbook for Systematic Reviews of Interventions
Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs, and attitudes? A systematic review
BMC Public Health
Methodological index for non-randomized studies (MINORS): development and validation of a new instrument
ANZ J. Surg.
The Newcastle-Ottawa Scale (NOS) for Assessing the Quality if Nonrandomized Studies in Meta-Analyses
Physicians’ reactions to uncertainty in patient care. A new measure and new insights
Med. Care
Intolerance of ambiguity as a personality variable
J. Pers.
Measuring physicians' tolerance for ambiguity and its relationship to their reported practices regarding genetic testing
Med. Care
Physician tolerance for uncertainty: use of liver-spleen scans to detect metastases
JAMA
Measuring the ambiguity tolerance of medical students: a cross-sectional study from the first to sixth academic years
BMC Fam. Pract.
Sex and ethnicity in surgical clerkship performance
J. Med. Educ.
Intolerance of ambiguity among family practice residents
Fam. Med.
Uncertainties and ambiguities: measuring how medical students cope
Med. Educ.
The association between intolerance of ambiguity and decline in medical students' attitudes toward the underserved
Acad. Med.
Uncertainty and ambiguity and their association with psychological distress in medical students
Acad. Psychiatry
Selection of medical specialties: preferences versus choices
J. Med. Educ.
Cited by (126)
What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care
2023, Patient Education and CounselingTaking or creating control: A qualitative study of uncertainty among novice nurses in ambulance care
2023, International Emergency NursingPatient attitudes toward clinicians’ communication of diagnostic uncertainty and its impact on patient trust
2023, SSM - Qualitative Research in HealthWhat is Effective in Massage Therapy? Well, “It Depends…”: a Qualitative Study of Experienced Orthopaedic Massage Therapists
2024, International Journal of Therapeutic Massage and Bodywork: Research, Education, and Practice