Marleah Dean and Richard L. Street, Jr.

19Managing uncertainty in clinical encounters

Abstract: One of the most understudied and problematic aspects of communication skills in medical encounters is the management of uncertainty. This chapter reviews evidence related to theories of uncertainty in health and illness, different sources of uncertainty, the psychosocial effects of medical uncertainty, and communicative skills clinicians can use to assist patients 'manage' uncertainty. We then demonstrate how these communication skills can be learned and routinely applied in delivery of health care in order to improve health outcomes. We conclude with particular priorities for future research exploring uncertainty management in clinical encounters.

Keywords: managing uncertainty, communication competence, cognitive communication skills, affective communication skills, communication skill training

1Introduction

Uncertainty is inherent in all health and illness experiences (Babrow and Kline 2000). Previous research has explored uncertainty in a variety of health and illness contexts including pregnancy and breastfeeding, diabetes, HIV/AIDS, genetic diseases, and especially cancer (see, for example, Brashers et al. 2000, 2003; Dean 2014; Ellington et al. 2011; Han et al. 2011; Koerber, Brice, and Tombs 2012; Matthias and Babrow 2007; Middleton, La Voie, and Brown 2012; Miller 2014; Parrott, Peters, and Traeder 2012).

Because uncertainty is inherent, it frequently cannot be completely eliminated (Epstein and Street 2007). A newly diagnosed cancer patient may experience uncertainty about survival, which may be mitigated by engaging in treatment, but then at the end of treatment, she may worry about reoccurrence. Likewise, a person living with diabetes may experience uncertainty regarding symptoms, which may be resolved after talking with a clinician, but then worry about the disease’s impact on life expectancy and mortality (Middleton, La Voie, and Brown 2012). As such, communicative skills for managing uncertainty are essential (Babrow, Kasch, and Ford 1998). Unfortunately, managing uncertainty is one of the most understudied and problematic aspects of communication skills in medical encounters (Decker, Haase, and Bell 2007; Epstein and Street 2007; Politi and Street 2011b), and the specific strategies with which to manage uncertainty are poorly understood (Bailey et al. 2004; Mishel 1999).

The purpose of this chapter is to review the uncertainty management literature. Specifically, we present evidence related to theories of uncertainty in health and illness, different sources of uncertainty, the psychosocial effects of medical uncertainty, and communicative skills clinicians and patients can use to manage the uncertainty. We then discuss how such skills can be learned and routinely applied in health care delivery in order to improve health outcomes. Finally, we conclude with particular priorities for future research exploring uncertainty management in clinical encounters.

2Uncertainty

2.1Theories of uncertainty in health and illness

Uncertainty has been conceptualized in several different ways. Broadly, uncertainty occurs when an individual believes certain aspects of an illness (e.g., prognosis, treatment, or recovery) are inconsistent, too complex, unknown or unclear, and unpredictable or random (Mishel et al. 2005). Despite the varying definitions of uncertainty, there are three important theories that seek to explain uncertainty in the health care context – the theory of uncertainty in illness (Mishel 1988), problematic integration theory (Babrow 1992), and theory of uncertainty management (Brashers et al. 2000).

The Theory of Uncertainty in Illness (TUI) proposes that uncertainty is produced when an individual’s present experience regarding the nature of an illness lacks a complete cognitive representation. In other words, some component(s) of the illness event are missing such that an individual does not have a sufficient understanding of factors related to her health and well-being (Mishel 1988). There are three important components of this uncertainty. The first component, symptom patterns, refers to an individual’s ability to recognize symptom patterns regarding her intensity, frequency, predictability, and expected outcomes. The second component, event familiarity, is the ability to organize an illness event within the context of a time and place. Lastly, event congruence refers to an individual’s ability to comprehend the consistency between what is expected and what actually is experienced for an illness-related event.

Thus, according to TUI, when a patient is uncertain, she is not able to form cognitive representations for her illness due to little or no information, knowledge, or experience with the symptoms and/or how to manage the uncertainty (Mishel 1988; Mishel and Braden 1987). Failure to effectively manage this uncertainty can result in poor decision-making, negative psychosocial consequences, and lower quality of life (Christman et al. 1988; Mishel 1999; Wong and Bramwell 1992).

In terms of managing the uncertainty, patients need to perceive their clinicians to be credible sources for information in helping them comprehend and make meaning out of their illness and choose the best course of therapeutic action (Mishel 1990). Patients also rely on other resources for understanding and interpreting issues related to their health including the Internet, print, audio, or video materials, friends and family, and cultural and religious beliefs (Sparks and Villagran 2010). In short, the relationship between uncertainty and stress is influenced by the vagueness of events and a lack of comprehensible and coherent information (Mishel 1984).

The second theory is Problem Integration (PI) theory. This theory explains that individuals orient their lives in terms of expectations and evaluations; it seeks to understand how people seek information to manage their uncertainty when dealing with an illness (Babrow 1992, 1995, 2001). There are two main components of PI – probabilistic orientations and evaluative orientations. Probabilistic orientations are rooted in cognition and refer to the likelihood that an event or issue may occur in an individual’s lifetime. Evaluative orientations are rooted in emotions and refer to the assessment of the desirability of a possible outcome. In other words, uncertainty arises when individuals’ judgments about the likelihood of wanted or unwanted outcomes are incompatible (Babrow 2001; Sparks and Villagran 2010).

PI theory offers several advantages to understanding uncertainty in clinical encounters. One advantage is that it provides clinicians with multiple explanations for different kinds of uncertainties that can coexist on many levels (Hines et al. 2001). For example, a cancer patient may be uncertain about what course of treatment to take. This uncertainty may exist because, on one level, the patient is overwhelmed with the amount of information provided about each possible treatment; while at the same time, she may be uncertain about whether the treatment strategy will rid her of the illness. Second, PI theory assists in understanding the relational context of uncertainty as patients and clinicians must work through the uncertainty together to achieve a shared understanding of the problem and decide on appropriate actions to take to address the problem. Third, it emphasizes the importance of communication as a resource for managing uncertainty (Babrow 1995; Sparks and Villagran 2010). In sum, PI theory asserts that communication shapes our perceptions of the world especially as it relates to problematic integrations (Babrow 2001).

The last theory is Uncertainty Management Theory (UMT). This theory speaks to communication and uncertainty management. According to Brashers and his colleagues (2000), uncertainty management means making specific choices based on the perceived threat and information. Said differently, individuals assess their uncertainty in order to determine potential harm and benefits. Such assessments are intertwined with emotions such as anxiety and worry but also hope and optimism. Individuals’ assessments and emotional responses then produce possible routes of behavior and psychological actions to manage the experienced uncertainty.

There are two main types of uncertainty management – information seeking and information avoidance (Brashers et al. 2003). Though both strategies can assist in managing uncertainty, each has their own purposes. The goal of information seeking is typically to reduce uncertainty, whereas the goal of information avoidance is to retreat from overwhelming or distressing information.

In this way, a key tenet of UMT is that uncertainty management is not equivalent to uncertainty reduction. When the threat of information is perceived high, then individuals might seek out contrary information to increase the uncertainty and ultimately reduce the threat (Brashers et al. 2000). For example, a person who may worry about having an HIV infection from unprotected sex may increase uncertainty so as to reduce the threat of testing positive for HIV/AIDS. In short, successfully managing uncertainty involves “the negotiation of identity, relationships, levels of knowledge, and physical and psychological well-being” (p. 81).

Taken together, these theoretical perspectives emphasize three important aspects of medical uncertainty. First, although uncertainty at any one point in time may be reduced and sometimes eliminated, more often it ebbs and flows over time. For instance, a cancer patient’s uncertainty about the treatment experience may be reduced when her treatment is completed; however, a different form of uncertainty emerges when she is no longer actively participating in treating the cancer and consequently worrying about future recurrence. Second, people differ in their preferences for managing uncertainty such that sometimes individuals choose to maintain or even increase their uncertainty as a management mechanism (Bylund et al. 2012). For example, a patient may know his partner has tested positive for HIV/ AIDS but decide not to be tested because he does not want to burden himself with the knowledge of having the virus. Lastly, uncertainty cannot always be eliminated and therefore must be managed communicatively (Epstein and Street 2007). Overall, patients will make various decisions to manage uncertainties in an effort to maximize their health and well-being, and clinicians must determine their patients’ preferences in order to assist them in managing those uncertainties.

2.2Sources of uncertainty

Previous research has established different sources of uncertainty. Many sources relate to the amount or quality of available information. Informational uncertainty is caused by unusable, inapplicable, or even unavailable scientific evidence (Politi, Lewis, and Frosch 2013). For example, a treatment might be relatively new and thus clinical evidence is lacking (Truog, Campbell, and Curtis 2008), and this unavailable data might cause clinicians to feel unprepared to talk about the new treatment with a patient (Brehaut et al. 2008; Davison et al. 2006). Ambiguity uncertainty is defined as uncertainty related to conflicting evidence or strength of evidence. Missing or inconsistent data, differences in study results, and conflicting clinical recommendations produce ambiguity uncertainty (Politi, Lewis, and Frosch 2013; Politi and Street 2011a, 2011b; Politi, Han, and Col 2007). In other words, these sources of uncertainty can be evoked by too little information, complicated or conflicting information, or too much information (Brashers 2001; Epstein and Street 2007; Mishel 1999; Shaha et al. 2008). Finally, there is also uncertainty related to the likelihood of future health states. Stochastic uncertainty refers to being uncertain about future outcomes or events related to an illness and/or its treatment (Politi and Street 2011a, 2011b; Politi, Lewis, and Frosch 2013). For instance, how likely it is that an individual will get cancer or that a cancer treatment will cure the disease.

Yet much of the current research on medical uncertainty focuses on communicating risk. Politi, Han, and Col (2007) identify the following sources of such uncertainty: 1. anticipated future risks; 2. ambiguity regarding risks’ strength or validity; 3. personal risk significance (e.g., timing); 4. complex risk information (e.g., multiplicity, instability, etc.); and 5. ignorance. Han and colleagues (2011) extended these conceptions of medical uncertainty to include the decision-making process as well as medical and organizational features of health care institutions. Uncertainty exists on a continuum from disease-centered to patient-centered. Disease-centered uncertainty focuses on scientific or data-centered issues including diagnosis, prognosis, causal explanations, and treatment recommendations (e.g., risk information, estimates of outcome probability). Practical or system-centered uncertainty relates to the structures and care processes (e.g., what care does the patient need and how does she get it). Lastly, personal or patient-centered uncertainty refers to psychosocial and existential issues and concerns related to a patient’s unique situation, and how the patient perceives and manages the uncertainty (e.g., preventive actions, spirituality) (Han et al. 2011).

In sum, medical uncertainty is caused by several factors and centers around different illness issues. Uncertainty stems from potential unknown outcomes, ambiguous symptoms, the unpredictable course of the illness, the treatment and recovery’s intensity and timing, and concerns regarding illnesses’ impact on social, cognitive, and emotional functioning (Stewart, Lynn, and Mishel 2010).

2.3Psychosocial effects of medical uncertainty

Uncertainty can be attributed to feeling unsure about the “best” course of action or choice to make in a situation (Shaha et al. 2008) due to a lack of information in the present and about the future. This feeling of being unsure and uncertainty’s unpredictability can cause several detrimental effects including, but not limited to, the following: emotional distress, anxiety, stress, and depression (Christman et al. 1988; Neville 1998; Shaha et al. 2008; Stewart, Lynn, and Mishel 2010). Said differently, incompetently managed uncertainty in clinical encounters leads to psychological and emotional distress when coping resources are lacking or inadequate to resolve uncertainty or when it is not possible to manage the negative emotions associated with uncertainty (Mishel 1988; Stewart, Lynn, and Mishel 2010).

Also, because medical decisions are often based on uncertain or unknown evidence (BMJ Clinical Evidence 2007; Peters et al. 2007), patients can have a difficult time making medical choices (Mishel 1999; Politi and Street 2011b; Wong and Bramwell 1992). It would make sense then that clinicians would explicitly discuss uncertainty, yet uncertainty is rarely discussed in clinical encounters (Politi, Han, and Col 2007). Clinicians may avoid such conversations for a variety of reasons including the following: previous medical training emphasizing certainty (Johnson et al. 1988), fear that discussing uncertainty will result in more anxiety (Babrow and Kline 2000; Brashers 2001), or personal discomfort with uncertainty due to paternalistic decision-making styles (Légaré et al. 2006).

Lastly, incompetently managed uncertainty may result in loss of control (or sense of control), low resourcefulness, and lower quality of life. For example, Dirksen (2000) found uncertainty among breast cancer survivors was a significant predictor of low resourcefulness, meaning the more uncertainty survivors experienced the less they felt in control of their circumstance and future. However, when survivors had resources (e.g., social support), they were better able to cope and manage their uncertainty. Finally, uncertainties related to illness can complicate relationships by adding a level of stress, whether with clinicians, family members, friends, or coworkers, which in turn can complicate treatment and aggravate the illness (Ford, Babrow, and Stohl 1996).

In short, medical uncertainty is evident when an individual’s information about illness is unclear, inconsistent, unpredictable, or too complex. Such uncertainty results in negative psychosocial effects including emotional distress, low quality of life, poor decisions, and loss of control. In order to manage such medical uncertainty, clinicians can engage in particular communication strategies, and communication strategies for managing uncertainty can best be described within a conceptual framework of communication competence.

3Communication competence and the management of uncertainty

3.1Communication competence as a process and as an outcome

Communication competence traditionally has been conceptualized in two main ways – as an individual outcome (e.g., competent communication) and as a process (e.g., communicating competently) (Street 2003). Communication competence as an outcome can be defined as the communicator’s success in accomplishing personal and relational goals when interacting appropriately with others (Parks 1994; Spitzberg and Cupach 1984; Street 2003; Wiemann 1977). Importantly, communicative “success” is a perception, and these perceptions can arise from many different perspectives (e.g., the patient, the clinician, an observer, etc.), all or none of which may be consistent with another (Street and de Haes 2013). For example, a clinician may believe she effectively helped a patient manage her uncertainty about a hip replacement as treatment for osteoarthritis, while the patient may feel the clinician did not listen to her preferences or concerns about other treatment options such as pain management and exercise. Furthermore, the clinician may perceive that her communication behaviors appropriately followed what is expected in a medical interaction, but the patient may perceive the clinician’s communication violated accepted norms. Lastly, a particular perspective (e.g., the patient’s, a preceptor’s) may be privileged over others (e.g., the clinician’s) depending on authority granted to the evaluator (Street 2003; Street 2013). So, in an ideal sense, competent communication from this perspective occurs when relevant stakeholders mutually perceive that relevant personal and relational goals are achieved through communication that follows the accepted normative behaviors for a medical interaction.

With respect to communication competence as a process, one approach is to look at what attributes individual communicators must have in order to communicate competently. One such attribute is motivation, an individual’s desire to communicate in effective and appropriate ways. Without such motivation, a communicator may apply insufficient effort to achieve desired personal and relational goals in the interaction. Second, communicators also need the knowledge or cognitive understanding required to communicate effectively, which includes knowledge about the topic, the interlocutors, situational exigencies, and the communicative tactics that could help achieve the goals of the encounter (Greene 1984). Finally, an individual’s communicative skills refer to her ability to produce the communication behaviors effectively in real time (Greene 1984; Spitzberg and Cupach 1984).

The limitation of this approach to communication competence is that it downplays the creative and interactional aspects by which effective interaction is achieved. Communicating competently is constitutive, meaning it is collaboratively constructed during interactions. For instance, achieving a shared understanding about a health problem (e.g., treating hypertension) requires the clinician and patient to communicate with each other in a way that accomplishes that understanding (e.g., clinician gave clear explanation of risks of high blood pressure and treatment options; patient states her preferences and asks questions about what she did not understand). In other words, competent communicators do not exist in isolation, and interactants must work together to accomplish a common goal (Street and de Haes 2013). Thus, while individuals must have the individual capacity to communicate competently (sufficient motivation, knowledge, and skills), ultimately the success of the encounter is jointly achieved through the communicative exchange of the participants (Salmon and Young 2011). Thus, in this chapter, we approach competent communication with respect to managing uncertainty from a functional communication perspective – one that embraces communication competence as both process and outcomes – which is discussed next.

3.2A functional approach to communication competence

In our view, a functional approach to communication focuses on the key tasks or “work” communication must do well in order to achieve the interaction’s goals. While there could be any number of important communicative tasks in clinician– patient care, Epstein and Street (2007) identify six key functions – effective information exchange, fostering healing relationships, responding to emotions, making quality decisions, enabling patient self-management, and with respect to this chapter, managing uncertainty.

Street and de Haes (2013) have in turn proposed a theory-driven functional approach to conceptualizing communication skills as a situation-specific, goal-oriented process (see also, Hulsman 2009; Rao et al. 2010) intended to achieve immediate (e.g., shared understanding, trust, reassurance) or intermediate (e.g., commitment to treatment, self-care skills) outcomes that improve patients’ health and well-being (see, for instance, Street et al. 2009).

The functional approach to conceptualizing communication skills is in contrast to a consensus approach (see, Bachmann 2013, for an example). In a consensus approach, the most crucial medical communication elements are discussed and determined by a group of experts over time. The advantage here is the final agreed upon elements reflect a diverse number of educators’ and scholars’ expertise and experiences (Street and de Haes 2013). However, just because a clinician may be knowledgeable in competent communication skills does not mean she can enact them; furthermore, there is no guarantee for improved health outcomes due to the lack of situational and contextual factors. Table 1 provides an overview of the differences between these two approaches to communication skills.

Since functional, competent communication is situation-specific, communicative capacity is a skill set that is distinctive from communicative outcomes (Epstein and Street 2007; van den Eertwegh et al. 2013). One’s repertoire of communicative skills represent one’s cognitive and behavioral capacity to perform potentially desirable behaviors (e.g., drawn from one’s communicative “tool box”), whereas communicative competence refers to the extent to which situationally appropriate behaviors were deployed, in conjunction with those of interlocutors, to achieve the encounter’s desired goals (e.g., communicative outcomes such as mutual understanding, agreement on a course of action) (Hulsman 2009).

Tab. 1: Functional vs. Consensus Approach to communication skills.

Functional Approach to communication skills	Consensus Approach to communication skills
–Theory drives communication skills and subsequent outcomes	– Consensus provides a variety of different experts’ knowledge and experiences
–Desired tasks or goals are important to understand in order to know what communication skills to enact	–Knowledge is considered the basis for demonstrating communication skills
–Breakdown of goals and associated communication skills communication skills increases success of improving health outcomes	–Good diverse range of in repertoire but no guarantee of being able to enact them
–Skills are used based on particular circumstances and contexts	–No guarantee of improvement in health outcomes due to lack of contextual and situational factors

With the communication function managing uncertainty, Street and de Haes (2013) identify important clinician communication skills (e.g., explaining information to minimize uncertainty, talking about the uncertainty and formulating a plan to deal with it, and discussing why certain uncertainty is related to the patient’s health and/or healthcare), which are in turn associated with particular functional outcomes (e.g., less uncertainty about health and healthcare, effective management with uncertainty, and clear understanding of the reasons for uncertainty). For instance, in the context of cancer and genetics, if it is important to explore how a patient is managing the uncertainty about being informed of tests indicating a high genetic risk for breast and ovarian cancer, then the goal is accomplished whether she self-initiates a discussion of her concerns with the clinician, or whether the discussion is prompted by the clinician (e.g., “How are you managing knowing your cancer risk?”).

Thus, communicating competently necessitates specific skills that could be useful in the management of uncertainty. But it also requires the ability to assess whether the skills needed for a particular situation were deployed so that uncertainty was managed satisfactorily. We now discuss cognitive, affective, and behavioral communicative skills that for competently managing medical uncertainty.

3.3Communication skills clinicians may utilize to assist patients manage uncertainty

In this section, we discuss communication skills clinicians can engage in to assist their patients in managing medical uncertainty. Previous research (see Camerer and Weber 1992; Han, Moser, and Klein 2006; McCormack et al. 2011; Politi, Han, and Col 2007) suggests three types of domains for managing uncertainty: 1. cognitive skills, 2. affective skills, and 3. behavioral skills. Cognitive communication skills encompass recognizing and identifying sources of uncertainty. Affective communication skills address emotional issues through acknowledgement and validation, active listening, and empathy. Behavioral communication skills include providing information, offering resources, and teaching patients self-management skills. Table 2 provides some examples of these skills as applied to clinician–patient interactions. These examples, however, should not be used as standard language but rather in a flexible manner to determine patients’ preferences.

Before discussing specific communication skills for managing uncertainty, it is important to note that the quality of the clinician–patient relationship, specifically as it relates to trust and shared understanding, is essential to assisting patients manage their uncertainty (Arora 2003; Mishel et al. 2005; Quill and Suchman 1993). Clinicians can engage in particular patient-centered communication strategies such as validating patients’ uneasiness with uncertainty, involving patients in decision-making, and clarifying values and goals in order to reduce the negative health impacts of uncertainty (Han 2013; Politi and Street 2011a, 2011b). Furthermore, clinicians must acquire some insight, either directly or indirectly, regarding patients’ preferences in order to determine how best to deal with the patients’ uncertainty both short-term and long-term (Hoff and Hermeren 2011).

Tab. 2: Communicative skills for managing uncertainty.

Domain Category	Communication skill	Sample conversation
Cognitive	Identification: Recognizing medical uncertainty, identifying the sources of the uncertainty, and confirming understanding of the uncertainty	P: I have been reviewing the material you gave me last week on HIV/AIDS, and it seems like there is some conflicting recommendations for a person in my position. I mean how am I supposed to deal with this if there’s inconsistent evidence? C: Just to clarify, it sounds like you are concerned about the conflicting information regarding prognosis. Is that correct? P: Right.
Affective	Acknowledgement and Validation: Recognizing and affirming displayed uncertainty. Empathy: The process where one shares and understands another’s emotions and thoughts.	P: I am so scared about the future. Lupus? It’s a lifelong disease. I looked online, and there are so many treatments and all have a number of side effects. Where do we start? How long do we wait to see if something works? And some treatment involves chemotherapy agents!! I’m just overwhelmed. C: Mmm (nodding). I can understand why you would be concerned about a future reoccurrence given your family’s history. P: I mean how do I live with worrying all the time? C: I know it is difficult to function daily with such a burden. Remember, I am here to support you as your clinician (gently touches the survivor’s arm with her hand). Can you think of anything I can do to help you cope with this uncertainty?
Behavioral	Information: Providing detailed, clear content in understandable ways based on preferences. Offering resources: Giving additional resources to the patient like counseling or social support groups Self-management: The ability to self-manage one’s illness through navigating the health-care system, seeking information, dealing with side effects, and finding help when needed.	P: I am so overwhelmed with all of the decisions I have to make now that we have the results from the biopsy. Do I choose to only have surgery, or do I have chemotherapy and surgery, or do I have surgery, chemotherapy, and radiation? C: I know it is a lot to handle at the moment. I can provide you with lots of information about each type of treatment option based on your biopsy results. Once you read and understand the information, then we can talk more about it, and see if you have any questions. P: That sounds like a good plan. Thank you! C: I understand that you are trying to deal with the possibility of being diagnosed with cancer in the future. There are several self-care skills you can practice to assist in reducing that uncertainty. P: OK … (a bit hesitant) C: For example, you might try journaling when it feels like your thoughts will not go away. Get it all out on paper and see it there. Once it’s out, leave it there on the page. Then try to mediate on the positive – you have NOT been diagnosed with cancer; you simply have a high risk, and there are lots of things we can do together to help make sure you never have to deal with the effects of cancer. P: I guess that makes sense … Alright, I will try the next time and see if those ideas help at all. C: There are also several support groups for people like you. I can provide you with a list, if you would like? P: Yes, that sounds good.

3.3.1.Cognitive communication skills for managing uncertainty

Cognitive communication skills for managing uncertainty include recognition and identification of uncertainty sources. These skills assist in creating shared understanding between clinicians and patients for why uncertainty exists (Mishel et al. 2005; McCormack et al. 2011). As discussed previously, sources of uncertainty may include the unknown future, unclear roles or responsibilities, complex or conflicting medical information/evidence, and personal risk (Kasper et al. 2008; Politi, Han, and Col 2007). Therefore, when patients describe medical uncertainty, clinicians should recognize and identify the sources or reasons by engaging in open-ended questions and eliciting concerns (e.g., “Why do you think you feel uncertain about the future?”) (Street 1991, 1992). Additionally, once clinicians identify the source of uncertainty, they should confirm they have a clear understanding of the patient’s uncertainty (e.g., “So you feel uncertain about your future because your mother and aunt had cancer at a young age, correct?”) (McCormack et al. 2011). See Table 2 for an example of a conversation that illustrates cognitive uncertainty management skills.

3.3.2.Affective communication skills for managing uncertainty

Affective communication skills seek to address the emotional side of uncertainty such as anxiety and distress (McCormack et al. 2011). Though such skills are less prominent in the uncertainty management literature, they are important because the ability to manage uncertainty relies on patients’ emotional states (Epstein and Street 2007; Han 2013).

One affective communication skill to assist individuals in dealing with the uncertainty-induced emotions is through acknowledgement and validation (Dean and Street 2014). After clinicians recognize and identify the source of uncertainty experienced, they should acknowledge the patients’ emotional concerns regarding the uncertainty. To do this, clinicians can perform techniques such as active listening (Razavi and Delvaux 1997) and continuing to ask open-ended questions, as both skills provide space for patients to elaborate their concerns and worries (Street 1991, 1992). Clinicians can actively listen by distinguishing and responding to patients’ verbal and nonverbal communication behaviors in order to understand the patients’ experience (Egan 1994). Acknowledging uncertainty validates patients’ experience of uncertainty (Politi, Han, and Col 2007), which may contribute to a sense of feeling known (e.g., feeling fears and concerns are heard and understood and being reassured that one will not be being abandoned during care) (Anderson et al. 2008; Street et al. 2009). By acknowledging and validating uncertainty, clinicians and patients can come to a shared understanding of the sources of uncertainty, and the extent to which it is reducible or irreducible (Epstein and Street 2007; McCormack et al. 2011).

Another affective communication skill is empathy. Empathy is defined as the sharing and understanding of individuals’ emotions and thoughts (Eide et al. 2011). Clinicians can be empathetic by demonstrating respect, acting as a partner, and providing supportive communication messages to the patient (Arborelius and Österberg 1995). Clinicians can also inquire about patients’ concerns, demonstrate interest and understanding for their circumstances, and build rapport (Street 1991, 1992). See Table 2 for an example of a conversation that implements affective uncertainty management skills.

3.3.3.Behavioral strategies for managing uncertainty

The last category for managing uncertainty consists of behavioral communication skills that promote information, resources, and self-management. First, prior research treats providing information as the main mechanism for managing uncertainty (Brashers et al. 2003; McCormack et al. 2011; Miller 2014; Mishel et al. 2005; Mishel 1988; Politi and Street 2007). Under situations of uncertainty, it is helpful not only to present information in clear, detailed, and understandable ways but also to clarify what is “known” versus “unknown” (e.g., risks and benefits of treatment options) (Epstein, Alper, and Quill 2004; Epstein and Street 2007; Fagerlin, Zikmund-Fisher, and Ubel 2011; McCormack et al. 2011). Moreover, information enables individuals to interpret their situation, which can then provide closure for the uncertainty (Mishel 1990). For example, Miller (2014) found cancer survivors seek information from their clinicians in order to manage their illness-related uncertainty as well as uncertainty about their care. It is important to note short-term uncertainty may often be alleviated with information, but long-term uncertainty may require teaching patients how to self-manage their uncertainty by creating time boundaries for how long the uncertainty might be tolerated (McCormack et al. 2011), which is discussed last.

A second behavioral communication skill is offering resources like counseling or social support groups because communicating with similar others in these contexts is helpful for managing uncertainty (McCormack et al. 2011; Mishel et al. 2005). For instance, Brashers and his colleagues’ (2004) study of people living with HIV/AIDS found social support from others assists in managing uncertainty in the following ways: 1. helping with information seeking and information avoiding, 2. offering instrumental support, 3. assisting skill development, 4. providing acceptance and validation, 5. creating a space for ventilation, and 6. encouraging perspective shifts.

The last behavioral communication skill is self-management. Self-management is the perceived ability to self-manage one’s illness through navigating the health-care system, seeking information, dealing with side effects, and finding help when needed (Bodenheimer, Wagner, and Grumbach 2002; Bodenheimer et al., 2002; Epstein and Street 2007) and is especially helpful for long-term uncertainty (McCormack et al. 2011). Clinicians can engage in certain skills in order to assist patients in caring for themselves (Epstein and Street 2007). Specific self-care skills for managing uncertainty include the following: creating action plans, laying out contingencies, journaling, meditating on positive images, and engaging in positive thinking and calming self-talk (Mishel et al. 2005; Fatter and Hayes 2013; Ullrich and Lutgendorf 2002; Utley and Garza 2011).

These self-care skills are helpful in managing uncertainty across illnesses. For instance, an HIV/AIDS patient and her clinician may create a timeframe to assist in digesting the multiple treatment options and then come back together to discuss the options by a certain date. A mother and her clinician may construct a plan for addressing if her child has Down syndrome. Finally, a patient who has a genetically high predisposition for developing breast and ovarian cancer may engage in self-care skills such as journaling and mediating to deal with a possible future cancer diagnosis. See Table 2 for an example of a conversation that implements behavioral uncertainty management skills.

In summary, managing uncertainty requires competent, patient-centered communication between the clinician and patient. Cognitive, affective, and behavioral communicative skills provide particular ways in which individuals may manage medical uncertainty. Cognitive skills include recognizing and identifying uncertainty sources. Affective skills encompass acknowledging and validating emotions, listening actively, and being empathetic. Lastly, behavioral skills involve providing information, offering resources, and teaching self-management.

4How communication skills are learned and applied to health care delivery

4.1Theoretical notions of communication skills that manage uncertainty and the associated functional health outcomes

With an understanding of communication skills that clinicians can employ to assist patients in managing their medical uncertainty, we now move on to discuss theoretical notions of communication skills and the ways in which the skills can contribute to managing uncertainty in health care. As previously stated, managing uncertainty has not received much attention from a communication skills perspective despite the importance of viewing communication competence as a process and identifying communication skills in a theory-driven way (Street and de Haes 2014). Thus, we conclude by presenting an organizational framework for communication skills, their theoretical notions, and functional outcomes. See Table 3 for an overview.

The first cognitive communication skill – identifying sources of uncertainty – can be linked to the theory of uncertainty in illness (TUI) because of its emphasis on cognitive representations and the importance of overcoming event vagueness and lack of comprehensible/coherent information (Mishel 1988). The desired functional outcome of identifying uncertainty sources is that the patient understands reasons for her uncertainty and what is known versus unknown (Epstein and Street 2007). To achieve this outcome, clinicians can determine if uncertainty exists through open-ended questions, categorize expressed uncertainty into reducible and irreducible categories by checking understanding, and ultimately reiterate understanding of the uncertainty.

Within the affective domain of managing uncertainty, problematic integration theory (PIT) is helpful. PIT’s inclusion of evaluative orientations (e.g., emotional assessment of a desired possible outcome) (Babrow 2001) supports the importance of affective communication skills to manage uncertainty. First, acknowledging and validating uncertainty through supportive communication and building rapport addresses patients’ emotional distress and anxiety, which can make the patient feel her concerns are important and reassures her that she will not be abandoned during care. Engaging in active listening communicates to the patient that the clinician wants to hear and understand her situation. Lastly, empathetically responding to emotions by encouraging emotional expression and providing nonverbal and verbal reassurances helps the patient feel the clinician understands her actual thoughts and feelings.

Finally, behavioral communication skills are supported by all three theories but especially uncertainty management theory. As discussed previously, TUI, PIT, and UMT all speak to the importance of information in managing uncertainty at some level (Babrow 2001; Brashers et al. 2003; Mishel 1988). Yet UMT’s focus on information seeking and information avoidance provides a valuable theoretical basis for the provision of information as a way to manage medical uncertainty. Specifically, providing information results in knowledge gain. To assess what information is desired by patients, clinicians should determine patients’ information needs, provide information and check understanding simultaneously, and clarify any confusing or difficult information. At the same time, it is important for clinicians to respect patients who do not want additional information (e.g., avoid information) as a way to manage their uncertainty.

The behavioral communication skill offering resources is also supported by UMT. Brashers and colleagues’ (2004) research on uncertainty management and social support provides a theoretical framework for connecting patients experiencing uncertainty to additional resources like counseling and social support groups. Explaining the benefits of such resources and determining when such referrals are needed enhances the patient’s means to seek additional support and assistance outside the clinical setting (Dean and Street 2014).

Finally, though no theory directly speaks to teaching self-management skills, previous research does support self-management’s ability to assist patients in managing their uncertainty (e.g., Epstein and Street 2007; Mishel et al. 2005). Whether formulating a plan to deal with uncertainty and laying out potential contingencies to encouraging journaling, meditation, or positive thinking and self-talk, self-care skills enable the patient to take care of herself outside the clinical setting. To teach these skills, clinicians can seek patients’ preferences for clinician involvement, make partnership statements, create decision trees and timelines, review next steps, and provide evidence for personal reflection and positive imagery (Epstein and Street; Mishel et al. 2005).

4.2Teaching communication skills to manage medical uncertainty

How then can clinicians effectively teach patients to manage their uncertainty? Communication skill trainings are one answer. Although there are several strategies used in communication skill trainings, the most successful strategies are the learner-centered, practice-oriented active and interactive strategies (Berkhof et al. 2011; Libert et al. 2001; Merckaert et al. 2005). Active/interactive teaching strategies encompass not only discussing training skills but practicing them; these strategies are in contrast to passive strategies, which usually consist of lectures (Berkhof et al. 2011). There are three main active/interactive strategies that have been shown to be effective in teaching communication skills – role-play, feedback, and discussions – and these strategies can be used to teach clinicians how to manage patients’ medical uncertainty.

Role-play is a teaching strategy where participants act out designated roles in order to practice communication skills (Berkhof et al. 2011). According to Rider and Keefer (2006), role-play is an effective teaching strategy for all education levels of clinicians because it emphasizes effective listening skills and provides information to patients. Role-play provides clinicians with the opportunity to practice recognizing common verbal and nonverbal communication behaviors (e.g., noticing a patient’s body tense up during a long period of silence) that signal important information and then appropriately respond with information (e.g., “It looks like you are overwhelmed with this news. What information would be helpful to know right now?”). Several studies have reported evidence for role-play’s effectiveness because it is based in active learning (e.g., Aspegren 1999; Gysels, Richardson, and Higginson 2005; Libert et al. 2001; Rao et al. 2007). For instance, Lane and Rollnick (2007) found role-play with simulated patients or colleagues improved physicians’ communication skills more than didactic strategies (e.g., lectures/presentations). In regards to managing uncertainty, role-play would be effective to teach all three uncertainty management domains and the associated communication skills but especially affective communication skills like empathy and validation of emotions.

Feedback is a strategy where physicians learn from their own communicative behaviors by receiving constructive information from skilled instructors, colleagues/peers, and sometimes standardized or real patients. Feedback should provide specific communication skill strengths and weaknesses (Brown et al. 2010). It can be oral or written and structured or unstructured. Feedback is especially effective when used in association with role-play because clinicians are able to practice and then adjust their behavior based on the provided feedback (Berkhof et al. 2011). For instance, Brown and colleagues (2010) developed a communication skills training for oncology physicians that combined role-play and feedback. First, physicians engaged in the role-play to practice communication skills associated with Epstein and Street’s (2007) six clinician–patient communication functions discussed earlier (e.g., effective information exchange, fostering healing relationships, responding to emotions, making quality decisions, enabling patient self-management, and managing uncertainty). Then, feedback was provided formally from the instructors as well as provided informally by fellow trainees. Regardless of type of health care clinician or context of care, combining these two teaching strategies would be particularly effective in instructing cognitive and affective communication skills for managing patients’ uncertainty.

Lastly, discussion encompasses conversations about communication skills among instructors/facilitators and clinicians. The purpose of discussion is to hear multiple perspectives about a particular skill in order to better perform the skill as well as discuss issues that may be more challenging or unconventional. Discussion can be used in large or small groups to talk about many different skills such as patient-centered interviewing, breaking bad news, obtaining a medical history, and with respect to this chapter, managing uncertainty. It is important to note that small group discussion has shown to be more effective than large group discussion (Gysels, Richardson, and Higginson 2005 Libert et al. 2001). Small discussion groups would be especially helpful to teach behavioral communication skills such as self-care skills.

In sum, achieving communication competence is the purpose of a communication skills training. Yet instead of just focusing on teaching clinicians specific competent communication skills, we need to teach clinicians how to achieve competent communication with their communication interactants, whether that is patients, family members, or other clinicians. A basic foundational belief that communication competence is a process rather than an outcome will assist clinicians in better performing competent skills and thus produce better health outcomes. Such belief should be emphasized throughout uncertainty management communication skill trainings.

5Conclusion

In conclusion, this chapter reviews literature on managing uncertainty in clinical encounters. Specifically, we describe theories of uncertainty in illness and health, different sources of uncertainty, and its psychosocial effects of uncertainty, as well as present communicative skills clinicians can use to manage medical uncertainty. We also discuss how communication competence skills related to managing uncertainty can be taught and routinely applied in delivery of health care in order to improve health outcomes. Finally, we conclude with main priorities for future research in this area.

Priorities for future work

Given the scarcity of research examining uncertainty management, there are several priorities for future research. First, and broadly, future research should focus on managing uncertainty (Epstein and Street 2007). Despite the advancement and application of the uncertainty management theories and research discussed in this chapter, much literature especially in the medical field still views uncertainty from a reductionist perspective (Brashers 2001). Yet it is clear, based on a variety of research in health and illness contexts, medical uncertainty cannot always be eliminated. As Brashers (2001) stated, “‘reducing uncertainty’ is not the same as ‘man-aging the effects of uncertainty’” (p. 489). Thus, more research needs to examine competent communication skills for managing uncertainty in clinical encounters.

For example, it is important for researchers to test how clinician–patient communication about uncertainty sources and uncertainty management strategies impact health outcomes. Qualitative research could investigate patients’ uncertain health experiences and strategies they find helpful in managing their uncertainty (see, Dean 2014 for an example). Then based on qualitative research, hypotheses could test how clinician–patient communication about the patient-centered communication function managing uncertainty leads to intermediate and long-term health outcomes (Epstein and Street 2007; Street et al. 2009). By testing proposed pathway models, scholars can further understand how communication impacts health outcomes.

Second, one needed area for further investigation is the connection between managing uncertainty and making collaborative decisions (Politi, Han, and Col 2007; Politi and Street 2011a). This is important because collaborative decision-making can be impeded by uncertainty. Hence, by assessing conversations between clinicians and patients regarding uncertainty and making decisions, we can continue to understand the ways in which we can assist patients in managing their medical uncertainty in order to come to a common understanding during the decision-making process (Politi and Street 2011a).

Finally, and practically, researchers need to develop communication skill trainings from a functional communication competence perspective (Street and de Haes 2013). Uncertainty management inventions should be theory-driven (e.g., based in uncertainty in illness theory, problematic integration theory, or uncertainty management theory), and doing so validates the communication skill trainings.

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