Being entrusted to complete patient care–related tasks is a critical step in the development of trainees’ clinical competence.1 In response to recent public concerns about the safety of the medical training system, there have been calls for increased supervision of medical trainees.2–5 Vygotsky theorized that developmental gains are maximized when learners are functioning just beyond a skill that has been fully mastered, which he refers to as the zone of proximal development.6 When translated to clinical training, this theory suggests that a trainee’s potential will be fully realized only when he or she is performing with the appropriate degree of supervision for the task.1,5 However, greater supervision can potentially hamper a trainee’s skill development and readiness to function without supervision when training is completed.7–12 Complicating this situation are the tensions that often exist between the trainee’s desired amount of supervision and the attending physician’s desire to be involved in decision making, with trainees typically preferring less supervision than supervisors provide.13–15 Given the importance of finding the appropriate level of supervision for trainees to develop clinical skills while still ensuring safe patient care,5,16,17 it is essential that we understand the process by which entrustment decisions are made.
Previous work has identified factors that influence entrustment decisions related to the trainee, supervisor, situation, task, and relationship between the trainee and his or her supervisor.15,18–20 Although the trainee is a key stakeholder in this decision, many of these factors are beyond the trainee’s control. However, a trainee’s trustworthiness is within his or her control.18 Kennedy and colleagues have described 4 foundational dimensions of trustworthiness: (1) knowledge and skill, (2) conscientiousness, (3) truthfulness, and (4) discernment of limitations.19 In addition to demonstrating trustworthiness, the literature suggests that trainees can accelerate trust development by demonstrating enthusiasm, appropriate confidence, and self-awareness; conversely, trust development is impeded when trainees are perceived as arrogant or too quick to make decisions.18,20 Beyond this initial work, the specific, effective behaviors that trainees exhibit to demonstrate trustworthiness and encourage entrustment have not been described.
Gaining a better understanding of the trainee actions that foster entrustment is important to both trainees seeking to increase their own independence in clinical care to match their competence and supervising physicians seeking to appropriately assess their trainees’ entrustability. This knowledge is particularly relevant given how many medical education programs around the world use entrustable professional activities as a trainee-assessment framework.20–26 To address this gap in understanding, we investigated pediatric resident and attending physician perceptions of self-directed actions and skills that trainees can use to promote entrustment by supervisors in the inpatient setting.
Method
Study design and setting
Using grounded theory methodology, we convened focus groups to explore resident and attending physician perceptions of trustworthiness and entrustment from May to December 2018. We chose to build upon the trustworthiness framework developed by Kennedy and colleagues,19 as the generation of new theory in grounded theory study does not need to occur in isolation, and we sought to integrate our findings with existing theory.27 We recruited participants at Boston Children’s Hospital, a tertiary care free-standing children’s hospital, and Boston Medical Center, an academic medical center, both located in Boston, Massachusetts. Pediatric residents were enrolled in the Boston Combined Residency Program, a program in which they practiced at both Boston Children’s Hospital and Boston Medical Center during their residency.
Study context and definitions
Pediatric residency programs in the United States are 3 years long. We categorized our resident participants based on their postgraduate year (PGY-1, PGY-2, or PGY-3). PGY-1s are often referred to as “interns,” and PGY-2s and PGY-3s are often referred to as “supervising residents” as they take on the role of supervising the PGY-1s. Attending physicians are general pediatricians and pediatric subspecialists who have completed their training and supervise interns and residents. Here, we use the term “supervisor” to refer to both attending physicians and supervising residents.
Participant sampling
To ensure that there would be diverse perspectives in the focus groups, we purposively sampled attending physicians who frequently supervised residents on inpatient wards, represented both institutions, and represented both hospitalists and other subspecialists. Frequent supervision was defined in 1 of 2 ways. First, we compiled a list of attending physicians who were assigned to complete 10 or more resident evaluations from inpatient services during the previous academic year. Second, we supplemented this list with attending physicians who were identified as frequently on inpatient services that used team evaluations, and thus would be missed by examining only individual evaluations. An initial email was sent to this group of 51 attending physicians. A follow-up email was sent to a smaller, targeted group to allow us to fulfill our purposive sample criteria as listed above.
We sent an initial email inviting all residents in the Boston Combined Residency Program who were not in a combined training program with another specialty (n = 117) to participate, and we purposively selected participants to construct focus groups with representation from all 3 PGYs of training. A follow-up email was sent to participants from underrepresented years.
Data collection
We conducted focus groups because we believed the idea sharing and comparison of experiences that could occur in that setting would enrich the conversation. To ensure that participants felt comfortable sharing and expressing their ideas, we scheduled attending physicians to participate in focus groups at the hospital site at which they worked. Similarly, we grouped PGY-2s and PGY-3s—those with supervisory experience—into separate focus groups from PGY-1s—those without supervisory experience.
The focus groups were led by 2 physician investigators who had been trained in facilitating focus groups (K.H., A.S.W.). We obtained informed consent from all participants. To ensure that residents felt comfortable expressing their opinions candidly, we intentionally selected an investigator (K.H.) to lead the resident focus groups who did not otherwise have direct contact with residents. A different investigator was also present at each focus group to observe participants’ nonverbal reactions. We developed a focus group guide (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A970) that was informed by the existing literature on the components of entrustment decisions and provided definitions of trustworthiness, entrustment, and autonomy to establish a shared understanding among the investigators and focus group participants and facilitate building upon existing theory.1,19,27
We asked participants about past experiences with entrustment and actions or behaviors that they felt demonstrated trustworthiness. Our aim was to explore previously defined domains of trustworthiness and to identify traits and behaviors that help or hinder the progression from trustworthiness to entrustment.
To ensure that the questions in the focus group guide were clear and would elicit rich discussions relevant to the study aims, we piloted them with a group of attending physicians who had graduated from residency the previous year. Focus groups were recorded, transcribed by a professional transcription service, and deidentified before analysis. Refreshments were provided to focus group participants. The hospitals’ institutional review boards deemed this protocol exempt from review.
Data analysis
The primary coding team comprised 3 investigators (E.W.P., B.D.H., and A.S.W.) trained in qualitative research who were medical educators and inpatient physicians supervising residents for at least 8 weeks per year.
Consistent with grounded theory methodology,27 data collection and analysis occurred iteratively, with adaptations made to the focus group guide to expand on ideas and themes that emerged during the group discussions. Investigators independently reviewed the first 3 transcripts to generate initial codes using line-by-line coding. The investigators met to develop and refine a coding framework, then reanalyzed the data and the remaining transcripts using this coding framework. The larger group of investigators met periodically to discuss theme development and inform the emerging theory. Resident and attending physician transcripts were combined and analyzed iteratively until theoretical sufficiency was achieved. The investigators discussed disagreements until consensus was reached.
The trustworthiness of the results was enhanced by the triangulation of data sources and sites (residents and attending physicians were included and focus groups were conducted at 2 hospitals), coding by 3 independent investigators, and frequent debriefing with the investigator team.28 We used qualitative analysis software (Dedoose Version 8.0.35, SocioCultural Research Consultants LLC, Los Angeles, California) to facilitate data management and analysis.
Results
Twelve residents participated in 3 focus groups, and 18 attending physicians participated in 3 focus groups (see Table 1 for the demographic characteristics of participants). Quotations are attributed by attending physician (AP) or resident (R) focus group number, followed by participant number; for example, participant 3 in attending physician group 2 is represented by AP2-3. R1 corresponds to the PGY-1 focus group, and R2 and R3 were mixed PGY-2 and PGY-3 focus groups.
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Table 1: Demographic Characteristics of Resident and Attending Physician Focus Group Participants in a Study of Behaviors That Promote Entrustment, Boston Children’s Hospital and Boston Medical Center, 2018
Active demonstration of trustworthiness
Participants described various actions and behaviors they felt demonstrated trustworthiness. We categorized these actions using previously established domains of trustworthiness.19 These domains and strategies for residents to demonstrate the domains to supervisors are presented in Table 2.
Table 2: Resident Domains of Trustworthiness
19 With Selected Strategies to Actively Demonstrate Those Domains to Supervisors, Suggested by Resident and Attending Physician Focus Group Participants in a Study of Behaviors That Promote Entrustment, Boston Children’s Hospital and Boston Medical Center, 2018
Modifiers of the pathway from trustworthiness to entrustment
Themes emerged regarding modifiers that accelerate or detract from residents being entrusted with a patient care activity. We categorized these modifiers into 4 areas: (1) self-management, (2) relationships, (3) self-advocacy, and (4) patient-centeredness.
Self-management.
A trainee’s outward projection of self in the work environment was identified as an important modifier in the decision to entrust him or her with patient care. The participants described emotional intelligence, stress management, confidence, and response to feedback as self-management skills.
Emotional intelligence. Participants felt that a trainee’s ability to “read the room” (AP2-4)—which may involve sensing the emotional tone of the room, a supervisor’s preferences, or a parent’s level of understanding of the situation—was an important factor in entrustment decisions. This skill included having the self-awareness to know how one is being perceived and the ability to adapt one’s approach to each situation. Eye contact was recognized as an important demonstration of interpersonal communication skills.
Stress management. Participants described a resident’s ability to manage stress as a quality that can either lead to or detract from entrustment. Participants perceived that those who were able to manage their stress while continuing to communicate clearly and professionally in high-pressure situations were more likely to be entrusted with further care. Conversely, those who stopped communicating clearly or who became negative in their communication in high-stress situations were less likely to be entrusted with further tasks:
The difference between a junior learner who even under stress can communicate with you what they’re thinking and what they’re doing, what their next steps are, versus somebody who, when they’re stressed and overwhelmed, just totally shuts down and doesn’t say anything and either does a whole bunch of things on their own and doesn’t tell you, or does nothing and sits there and tries to wait it out … can help you determine when it’s okay to trust that person or not. (R2-5)
Confidence. Participants felt that communicating with confidence accelerated the process of being entrusted: “You have to speak with some degree of confidence…. If you ask things in the form of a question rather than stating your opinion, I think you may not get as much autonomy.” (R3-2).
Participants perceived confidence to be especially important during stressful situations. However, when trainees demonstrated confidence without the competence to justify it—especially when coupled with a tendency to undercommunicate—this behavior was felt to greatly detract from the likelihood that a supervisor would entrust them with further responsibility:
And those are probably the people I watch the most closely—the people who are superconfident and also don’t have the appropriate proportional competence for it…. The most trouble, as far as errors reaching patients, have been with folks like that. (R3-1)
Response to feedback. Seeking feedback from supervisors often and responding to feedback with positive behavioral changes were cited as behaviors that accelerated entrustment:
I want people to come up to me and say, “What do you want to hear and how am I doing?” Because when they’re seeking your feedback it shows that they’re trying to get better and they’re trying to become entrustable, right? (AP1-6)
Relationships.
Participants felt that a trainee’s ability to build meaningful relationships and collaborate with members of a multidisciplinary team influenced the likelihood that he or she would be entrusted with responsibilities related to patient care and communication.
Relationship with supervisor. Time spent and previous interactions with a supervisor were recognized as important drivers of entrustment. In the absence of a longitudinal relationship with a supervisor, clear communication that created a dynamic of collaboration and friendship accelerated the process. For example, a trainee who felt comfortable sharing his or her thoughts and motives was felt to be more likely to gain entrustment than someone who remained quiet.
Relationship with physician team members. Participants felt that collaborating with and seeking the opinions of others, including peers and more junior residents, were important to gaining entrustment. One attending physician expressed that she would entrust a trainee who knew how to use his or her resources:
Sometimes the better intensivist is the person that doesn’t make the decision but can get all the smart people to the table and synthesizes a decision based on what the smart people say, and I think that as a resident it’s very similar just in a different level of training. (AP3-1)
In addition, if the trainee’s assessment of a patient was different from that of another provider, the trainee’s ability to negotiate that tension was perceived to be an important skill. Likewise, trainees who built a hierarchy among providers discouraged entrustment. Supervisors felt more willing to trust “team players” who collaborated with all members of the team as equals.
Relationship with interprofessionalteam members. Communication with nonphysician team members was felt to be an important step in earning entrustment. Participants believed that supervisors’ observations of interactions between trainees and nurses played a significant role in the decision to entrust a trainee with a clinical task. Good communication and rapport with nursing staff accelerated this process, whereas lack of consistent communication with nursing staff was cited as a reason that entrustment may be reversed:
Those trainees that have a good rapport with the rest of the staff and are open to input from the rest of the staff, I’m actually also much more likely to trust. Because I feel like if a nurse comes to them and says, “I’m worried about something,” or “something’s not right,” that they’re more likely to listen to that and follow through and go examine. (AP2-5)
Attending physicians also valued trainees who created positive and lasting impressions among interprofessional staff:
When the senior resident is arriving here and the other staff … has positive impressions of them it’s also really helpful. So if it’s a resident I’ve never worked with before but all the nurses are very happy that this person is back to be a supervisor, that says a lot to me about whether or not I feel like I could trust them. (AP3-2)
Relationship with the health system. Participants felt that in our complex health systems, it was much more important for trainees to know with whom to talk to get an answer or get something done than to know the answer or know how to do something themselves. This required both familiarity with available resources and the social skills to ask others to take time out of their job to help. One attending physician cited an example in which a resident was successfully able to elicit help from neonatal intensive care unit nurses to draw labs on an infant at 2:00 am by using key skills such as being articulate in explaining why their assistance was needed and being judicious in only asking for it when truly needed.
Self-advocacy.
According to participants, the progression from demonstrating trustworthiness to being entrusted with patient care can be accelerated by actions residents take to advocate for their own entrustment. These actions include showing interest and asking explicitly to be entrusted by establishing goals with a supervisor, among others.
Showing interest. Participants felt that a trainee showing genuine interest in a topic or a particular patient by being engaged during rounds helped the supervisor to realize that the trainee was thinking critically about the patient. The supervisor was then more likely to take the time to teach and entrust the trainee. One attending physician described the actions of a resident entrusted with a decision regarding a patient’s diuretic management:
[The resident] took the time to print the [cardiac catheterization] report, ask the fellow to print the patient’s heart diagram, took the time to ask me some questions that reflected that he had been thinking beyond the sign-out. (AP1-3)
Asking for entrustment. Participants identified many situations in which residents asking their supervisors for more independence or entrustment was appropriate and effective. A primary way in which this could be accomplished was through goal setting when a trainee first started working with a supervisor:
When I’m supervising a team, I’ll talk to the attending before and say basically I’m going to be attending next year, and I’ll have to make the final decision. So if you can, stop me from doing something dangerous, but otherwise let me go on if you’re okay with it, and try to let me run rounds and not speak on rounds. I’ve had a lot of attendings who’ve been really receptive to that. (R3-2)
Additionally, residents referenced ad hoc entrustment decisions in which they felt they could ask for more entrustment. These situations tended to be acute but controlled, such as during an evaluation of a sick patient:
[The supervisor said] “Shall we go get a baseline exam on this sickle cell patient who is kind of a watcher [patient who needs more frequent reevaluations]?” And I was like, “Is it cool if I just go get an exam on the sickle cell patient? I feel pretty comfortable getting it, this exam”…. I wanted to go alone and do my own exam…. And so I think sometimes just asking for autonomy [is helpful]. (R1-1)
Attending physicians thought that they were more likely to respond positively to requests for entrustment if trainees demonstrated that they had thought through and planned for the situation ahead of time:
[A resident said] “I’d like to run this family meeting, and this is the way that I would want to do it, and these are the things that I want to bring up.” And, you know, “This is the way that I would structure it.” And if they’ve really thought through all of those pieces, I think they’re much more likely to be entrusted to do it. (AP2-5)
Patient-centeredness.
Participants felt that trainees accelerated their entrustment by prioritizing patient care and demonstrating that priority by making decisions based on the best interest of the patient, taking ownership of every detail of the patient’s care, building a relationship with the patient and family, and spending time at the patient’s bedside.
Patient ownership. Participants felt they were more likely to entrust trainees who, in addition to being conscientious and detail oriented, exceeded expectations and were motivated by providing the best care for the patient:
To what extent they’re taking ownership for that patient and truly, proactively seeking to really kind of follow through on every single aspect of that patient’s care. And I think that speaks volumes, versus someone who’s more passively taking care of a patient. (AP2-3)
Relationships with patients and families. Supervisors believed that building a therapeutic alliance with a patient’s family was very important to entrusting that trainee with the care of that patient:
The intern was able to very quickly take command of the room, calm the parents down, explain to the parents what was going on, what our expectations were, and what the next 24 hours were going to be like, to the point that within the next 10 minutes they were laughing and joking and asking if that person could be their new pediatrician. (R3-3)
This supervisor felt that, for future events or parental concerns, she could send this trainee into the situation unsupervised. Moreover, participants indicated the importance of communicating in language that the families could understand, thereby allowing the establishment of a shared mental model between the trainee and the patient’s family. Demonstration of this practice by trainees during family-centered rounds led supervisors to entrust them with care outside of rounds. Participants valued trainees’ spending extra time with the patient and family to continue to build rapport and the therapeutic alliance.
Conceptual model of entrustment
We synthesized our findings into a conceptual model of a resident-driven pathway to promote entrustment (see Figure 1). For supervisors to entrust a trainee with clinical care, the trainee must actively demonstrate his or her trustworthiness so that it is apparent to the supervisor. Although a trainee’s trustworthiness is foundational to entrustment, the trainee’s relationships, self-advocacy, self-management, and patient-centeredness can either detract from or accelerate entrustment decisions.
Figure 1: Conceptual model of a resident-driven pathway from trustworthiness to entrustment, based on the findings of a qualitative study of resident behaviors that promote entrustment by supervisors, Boston Children’s Hospital and Boston Medical Center, 2018.
Discussion
In this study, residents and attending physicians described actions and behaviors that contribute to entrustment, which can be categorized in the domains of trustworthiness described by Kennedy and colleagues.19 We also determined the critical importance of a trainee’s ability to actively demonstrate his or her trustworthiness, a factor that has not been described previously. Importantly, we found that trainees can accelerate or impede their own entrustment by displaying actions and skills within the domains of self-management, relationships, self-advocacy, and patient-centeredness.
Previous studies have shown that supervisors assess the language used by trainees as a proxy for clinical competence.18,19,29,30 We likewise found that many of the actions that increased entrustment involved active demonstration of trustworthiness through verbalization of associated traits. This finding supports the literature that “think aloud” is a powerful strategy for trainees to show—and for supervisors to assess—clinical reasoning.31,32 For example, one intern may be just as knowledgeable as another intern but may be trusted less if he or she does not verbalize a patient’s illness severity and anticipated clinical trajectory to a supervisor. Our findings suggest that “think aloud” could also be used as a strategy for trainees to demonstrate discernment of limitations, thus allowing supervisors to assess their trustworthiness. For example, 2 residents may both understand their limits, yet the one who verbalizes knowledge gaps to his or her supervisor may be more likely to be trusted. Similarly, 2 residents may be equally conscientious, yet the one who is able to update his or her supervisor when tasks are completed may appear more trustworthy. Importantly, we hypothesize that many of these strategies to make characteristics of trustworthiness more explicit are teachable skills.
Our conceptual model shows that a trainee actively demonstrating trustworthiness is fundamental to a supervisor’s entrustment decision, but other modifiers influence this decision as well. We grouped these actions and behaviors into 4 categories: self-management, relationships, self-advocacy, and patient-centeredness. We described these as modifiers of the pathway to entrustment as they have both positive and negative valence, meaning certain actions may accelerate and others may detract from the movement toward entrustment. For example, speaking with confidence was identified as a way for trainees to signal to supervisors that they are ready for more trust and independence, but inappropriate confidence was described as an indication that closer supervision was needed. Furthermore, a trainee who was thought to have made significant effort to build a therapeutic alliance with a family and spent dedicated time at the patient’s bedside would be more likely to be entrusted to break bad news to a family, whereas another trainee who was less patient-centered would be less likely to be entrusted to have a difficult conversation with a family.
Previous studies have suggested that self-confidence, self-awareness, skill in interprofessional communication, empathy and openness toward patients, and a sense of responsibility are factors that affect a supervisor’s entrustment decision.1,18 These components were among our findings as well. Although the effect of these traits and behaviors may seem obvious to some, trainees may not intuitively recognize the influence that these behaviors have on entrustment. Furthermore, our work deepens the understanding of how supervisors perceive these traits and how displaying them may modify the pathway to entrustment for trainees. For example, we found that good communication with interprofessional team members was important, but a deeper relationship that extends to reciprocal respect for each other’s input and lasting rapport was even more effective. We also identified emergent themes that encompassed these skills and together informed the conceptual model. For example, self-confidence and self-awareness are both components of trainees’ ability to manage how their own thoughts and emotions are perceived by others, which we describe in the overarching theme of self-management. We also found that self-management includes trainees’ ability to manage how they project themselves to others in times of stress, which is vital when considering entrustment in clinical care.
Although the supervisor continues to play an important role in entrustment,18,33 the key part of our model is that trainees themselves also play a crucial, active role in entrustment decisions. As supervisors’ styles and perceptions of appropriate supervision can vary significantly,13 trainees’ educational experiences can suffer from either under- or oversupervision. A clear appraisal of trainees’ trustworthiness is essential to the decision to entrust them with patient care; trainees can facilitate an accurate assessment of trustworthiness by employing the strategies described by our study participants. They need to not only prove their trustworthiness through active demonstrations of the domains of trustworthiness but also develop and employ skills within those domains.
Some components of this model may allow a supervisor to form a more accurate assessment of a trainee’s competence (e.g., encouraging verbalization of task completion and clinical reasoning), but it is possible that other elements of this model may cloud the assessment process. For example, a trainee who is confident, has very strong interpersonal skills, and asks for entrustment may be perceived as more ready for entrustment than someone who is truly more competent but not as strong in these areas. Through a better understanding of the entrustment process as described here, supervisors can be aware of these modifiers and how they might influence their entrustment decision.
This qualitative study has some important limitations. Our findings are specific to the context of our study and may not be transferable.28 We purposively sampled attending physicians who were most involved in resident inpatient clinical education as we felt that these participants would be most interested in the topic and best able to reflect on the research questions. However, the views of our participants may differ from attending physicians who have less experience with or investment in promoting resident education. We chose to use focus groups as we felt the group dynamic would promote the generation of ideas and facilitate discussion, but it is possible that participants felt less comfortable sharing dissenting views or discussing sensitive subjects than they might have in individual interviews. Our focus groups were small, but we proceeded with data collection until theoretical sufficiency was achieved and no new themes emerged. Although we had only 2 PGY-2 participants, we felt that we adequately captured the intern and supervising resident perspectives. Lastly, the members of the research team who participated in coding were medical educators who served as attending physicians on inpatient services and therefore had their own experiences with entrustment decisions in the inpatient setting, which may have affected their interpretation of the data.
Conclusions
This study elucidates actions that residents can take to actively demonstrate their own trustworthiness, enabling them to influence the level of entrustment granted to them. Future research should focus on whether these skills and actions can be taught effectively to trainees to help them promote an appropriate level of entrustment. These modifiers could serve as competencies on which our trainees are given feedback and assessed to be as effective as possible in the clinical environment.
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