Uncertainty ncre presentation 2018
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Recognizing uncertainty and responding constructively in teaching, practice, and research.
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Uncertainty ncre presentation 2018
- 1. Uncertainty Recognizing Uncertainty and Responding Constructively in Teaching, Practice, and Research Michelle Marmé Alan Bruce National Council on Rehabilitation Education, Anaheim, CA 14 March 2018 1
- 2. Alan Bruce Michelle Marmé • Scope of the issue • What is uncertainty? • Assert: our individual assumptions mask our understanding of the critical factor that UNCERTAINTY plays in peoples’ lives • Understanding how your response to uncertainties in your own life translate to your professional roles • Strategies for responding sensitively, productively, and ethically to the other • Facilitating uncertainty as growth factor 2
- 3. Uncertainty in Context: The Prequel 3
- 5. Uncertainty in Context Universal Context • Philosophical roots • Ambiguity and the Unknown • Risk and Probability • Fuzzy logic • Gamifcation theory • Heisenberg and Quantum Mechanics Specific To Practice & Research • Broadening concept of uncertainty • Understanding physical cost of dealing/not dealing with uncertainty • Exploring how it manifests behaviorally • Ways of responding more effectively in teaching and practice • Ethics and research going forward 5
- 6. Defining Uncertainty • The inability to determine the meaning of illness-related events & occurrences in situations where the decision maker is unable to assign definite values to objects, events, &/or is unable to accurately predict outcomes because sufficient cues are lacking. – Mishel (1999) • Uncertainty exists when “details of situation are ambiguous, complex, unpredictable, or probabilistic: info is unavailable or inconsistent; one feels insecure in their own state of knowledge.” – Babrow, Hines, & Kasch (2000) • Physical, Cognitive and Emotional Aspects • Western cultures value certainty, rationality, linear thinking, scientific orientations. Related to previous experiences of loss, success, risk, conflict, stress, and anxiety • Resistance to uncertainty is built into western culture • Highly idiosyncratic • Uncertainty = stress 6
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- 8. Physical Impact of Uncertainty (Stress) • All systems shift to emergency response • Heart, respiratory rate increase • Muscle tension increases • Sensations of pain decrease • Intestinal and immune systems decrease • Prolonged stress leads to systemic exhaustion • Cortisol increases, fear-based memories created, adrenals shut down… • Over-/under-responding This Photo by Unknown Author is licensed under CC BY-NC-SA 8
- 9. Psychological/Cognitive Responses to Uncertainty • Ambiguity => confusion, anger, agitation • Heightened sense of vulnerability, loss of control, fear, disorganization • Ambivalence • Aggressive behavior … passive behavior • Stress response: physiologically similar to response to physical attack • Rigidity in processing information • Rapid cycling from calm to panic • Impaired retention of information • Soliciting opinions from multiple sources • Failing to follow instructions, to attend appointments, complete assignments 9
- 10. How do you respond to uncertainty in your own life? • Specific situation, your life or that of student/client? • What are your beliefs about uncertainty? • When were they formed? • What situations contributed to forming those conclusions? • What words do you associate with “uncertainty”? • How does “uncertainty” operate in your life? 10
- 11. Implications for how we (characteristically) respond to uncertainty in our lives? • Must examine ourselves, realize the continuum of potential responses, and approach the other from a position of genuine curiosity • Sets context for our assumptions about how others do or “ought to” respond to uncertainty in their lives… 11
- 12. Chronic Illness & Disability Traumatic onset from gunshot wound or stabbing; insidious neurological process; childhood onset… Drawn out process of noticing, observing, recognizing symptoms; scheduling appointments… deciphering information, social cues Trauma… disbelief… grappling with the violations of the way things are supposed to be: Expectation: Medicine has answers • Time-limited, intermittent, on-going • New uncertainties overtaking earlier uncertainties • Multi-dimensional • Fluid. Appraisal of UNCERTAINTY shifts over time … • Longer person lives with on-going uncertainty, the more positively they evaluated the uncertainty. King & Mishel (1986) • Although preferred strategies for managing uncertainty shift over time. 12
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- 16. • Uncertainty Reduction Problematic Integration Theory Uncertainty Management Theory 16 Brashers (2001); Babrow, Hines, & Kasch (2000)
- 18. Circles of Influence Each person in one’s life confronting their own issues about uncertainty … In their own ways, constantly in flux, sharing inconsistent feedback with the person in the center Assessing multiple uncertainties, identifying loci of uncertainties, integrating varying perspectives Fragile new reality. Supreme significance of support systems that reflect emerging beliefs 18 Linus
- 20. Will a person’s response to uncertainty be proportional to the extent of uncertainty being experienced? Probably not. • Actual issues, while complicated, are further complicated by person’s previous experiences of –Loss of control –Fear –Threat/danger –Lack of information/resources • Listening to Prozac… “reaction sensitivity” 20
- 21. Behavioral Cues Indicative of Efforts to Deal with Uncertainty That May Not Be Working Confused, disorganized, clumsy Irritable, rigid, literal, frustrated Asks same questions, combative/complacent, lacks commitment to plan 21
- 22. Responding Constructively to Uncertainty: In Teaching, Advisement, and Clinically… • Increase personal awareness of our own projections, our world view • Face our own fears (these may be blocking our awareness and/or interactions) • Model probabilistic thinking • You, as a person, modeling world view • Identify behaviors you observe & tentatively offer potential connections… and allow time to process 22
- 23. Responding Constructively to Uncertainty: In Teaching, Advisement, and Clinically… • Break info down into meaningful chunks • Provide info verbally & in writing • Encourage people to write down information, take notes, record questions (and answers) • Provide appropriate supports for these; increasing client independence appropriately • Ensure time to check back with the individual/family to review info and answer questions, after they have reviewed info provided… 23
- 24. Ethical Limits to Decreasing Uncertainty When person just wants to know what is happening: • Simple answers, authoritatively offered (may inhibit questions, clarifications, close down communication) • Urban legend presented as fact (intimidation) • Offer declarations of “situation as it is” when you are missing key facts or limited in your understanding of the future: no jobs in that field, you’re just not cut out to be…, • Speaking outside your expertise 24
- 25. Ethical Limits to Increasing Uncertainty • Must be truthful with client • When multiple uncertainties are identified, assist person in prioritizing order with which to address, from their point of view • Providing too much information, in ways that overwhelm current coping skills does not help the person • Help all develop a more “probabilistic world view”: context of irreducible uncertainties & increasing tolerance of these • When embracing/expanding the uncertainty of their situation interferes with making time- sensitive decisions • Examples: • Person believes that ______ will help them get better… • When individual has declining cognitive skills and the family needs to make financial, care decisions… 25
- 26. Ethical Limits to Maintaining Uncertainty • When individual vacillates between needs for expanding uncertainty & restricting uncertainty, such that this inconsistency is becoming a significant stressor for them • When you are certain of the outcome and the person/others may be harmed by maintaining uncertainty of the situation • Issues of faith • Belief in non-traditional health care options interfering with life-saving actions 26
- 27. Addressing Uncertainty The Way Forward • Uncertainty as normal part of life • Assist others in recognition of its function in our lives • Encourage redefining concept along a continuum • Help colleagues/clients distinguish this from DENIAL • Longer one lives with uncertainty, the strategies for including it in our lives shifts • Explore previous strategies for handling uncertainty and help individual assess how well those are working now 27
- 30. Research • Economics, Engineering, Decision Processing – Varying metrics effect how information perceived by listener – Risk assessment/management, shared decision making – Benefits of probabilistic perspectives in embracing uncertainty • Nursing Education Research – Assurances vs facts and stage of illness – Expanding vs restricting uncertainty – Evolution of appraisal of uncertainty over time • Communications Research – Multi-layered, interconnected, temporal – Shared decision making 30
- 31. Research • Medical Research – Physicians reluctant to disclose uncertainty. Some evidence that this can be harmful to patient/doctor relationship, depending upon how presented. Patients believed to expect doctor to offer clarity, certainties, guidance. – Traditionally, seek to reduce uncertainty, provide data, lab values, jargon. – Research encourages improving comprehensibility of info shared, ensuring that misconceptions are identified & corrected. – Report lab data as “heart-age”, life space (eg, parent of 4 year old) rather than age/gender profiles – How physicians struggle with uncertainties in competence while in training: • Limitations in knowledge • Medical controversies • Bias in care provision (age, e.g.) • Bureaucratic approvals for “untested” methods • Scientific uncertainty 31
- 32. Potential Research Areas to Consider • Definitions of “uncertainty” are fragmented. Develop unified, coherent, measurable concept, applicable across disciplines • Develop probabilistic thinking curriculum, for individuals, their support systems, rehabilitation staff • Evaluate the efficacy of this training on individual outcomes • Investigate whether the nature of uncertainty, such as conflicting information vs incomplete information, results in distinct psychological responses, outcomes • Disability specific research related to uncertainty • Family issues concerning uncertainty • Communication-related-issues-among-individual-supports related 32
- 33. CRCC in Context of ‘Embracing Uncertainty’ This presentation addresses the following areas of the CRCC Code of Practice SECTION A: THE COUNSELING RELATIONSHIP A.1. WELFARE OF THOSE SERVED A.2 RESPECTING DIVERSITY A.3 CLIENT RIGHTS: informed consent, individualized approach to communication, inability to give consent, support network involvement A.4 AVOIDING VALUE IMPOSITION A.7 GROUP WORK 33
- 34. CRCC in Context of ‘Embracing Uncertainty’ SECTION B: CONFIDENTIALITY, PRIVILEGED COMMUNICATION & PRIVACY B.1 Respecting Client Rights B.2 Exceptions: serious or foreseeable harm; contagious, life-threatening diseases B.3 Information Shared with Others B.4 Groups and Families B.7 Case Consultation SECTION C: ADVOCACY & ACCESSIBILITY C.1 Advocacy SECTION D: PROFESSIONAL RESPONSIBILITY D.1 Professional Competence D.2 Cultural Competence/Diversity D.5 Responsibility to Public & Others D.6 Scientific Bases for Interventions 34
- 35. Suggested Readings • Babrow, AS, Hines, SC, & Kasch, CR. (2000). Managing uncertainty in illness explanation: An application of problematic integration theory. In B. Whaley (Ed.), Explaining Illness: Research, Theories, & Strategies, (pp. 1-67), Hillsdale, NJ: Erlbaum. • Brashers, DE. (2001). Communication and uncertainty management. Journal of Communication, 51 (13), 477- 496. • Han, P.K.J. (2013). Conceptual, methodological, and ethical problems in communicating uncertainty in clinical evidence. Medical Care Research Reviews, 70 (10), 14S-36S. • Han, P.K.J., Klein, W.M.P, & Arora, N.K. (2012). Varieties of uncertainty in health care: A conceptual taxonomy. Medical Decision Making, 31 (6), 828-838. • Mishel, M.H. (1999). Uncertainty in chronic illness. In J.J. Fitzpatrick (ed.), Annual Review of Nursing Research, 17, pp. 269-294. NY: Springer Publishing Company. • Peters, A., McEwen, B.S., & Friston, K. (2017). Uncertainty & stress: Why it causes diseases and how it is mastered by the brain. Progress in Neurobiology, 156, 164-188. • Spiegelhalter, D.J. (2008). Understanding uncertainty. Annals of Family Medicine, 6 (3), 196-197. 35
- 36. Thank you. Alan Bruce Michelle Marmé abruce@ulsystems.com mmarme@gmail.com 36