Weighing Entrustment Decisions with Patient Care during Residency Training

Bridging the Gap: Using Consensus to Explore Entrustment Decisions and Feedback Receptivity in Competency-Based Emergency Medicine Residency Programs Through the Construction of a Q-Sample Incorporating a Delphi Technique

Background

Recent changes in medical education calls for a shift toward student-centered learning. Therefore, it is imperative that clinical educators transparently assess the work-readiness of their medical residents through entrustment-based supervision decisions toward independent practice. Similarly, it is critical that medical residents are vocal about the quality of supervision and feedback they receive. This study aimed to explore the factors that influence entrustment-based supervision decisions and feedback receptivity by establishing a general consensus among Taiwanese clinical educators and medical residents regarding entrustment decisions and feedback uptake, respectively.

Methods

In Q-methodology studies, a set of opinion statement (i.e., the Q-sample) is generated to represent the phenomenon of interest. To explore the factors that influence entrustment-based supervision decisions and feedback receptivity, a Q-sample was developed using a four-step approach: (1) literature search using electronic databases, such as PubMed and Google Scholar, and interviews with emergency clinical educators and medical residents to generate opinion statements, (2) thematic analysis and grouping using The Model of Trust, the Ready, Wiling, and Able model, and the theory of self-regulated learning, (3) translation, and (4) application of a Delphi technique, including two expert panels comprised of clinical educators and medical residents, to establish a consensus of the statements and validation for a subsequent Q-study.

Results

A total of 585 and 1,039 statements from the literature search and interviews were extracted to populate the sample of statements (i.e., the concourse) regarding entrustment-based supervision decisions for clinical educators and feedback receptivity emergency medicine residents, respectively. Two expert panels were invited to participate in a Delphi Technique, comprised of 11 clinical educators and 13 medical residents. After two-rounds of a Delphi technique, the panel of clinical educators agreed on 54 statements on factors that influence entrustment-based supervision decisions and were categorized into five themes defined by the Model of Trust. Similarly, a total of 60 statements on the factors that influence feedback receptivity were retained by the panel of medical residents and were categorized into five themes defined by the Ready, Willing, and Able model and the theory of self-regulated learning.

Conclusion

Though not exhaustive, the key factors agreed upon by clinical educators and medical residents reflect the characteristics of entrustment-based supervision decisions and feedback receptivity across specialties. This study provides insight on an often overlooked issue of the paths to teaching and learning in competency-based residency training programs. Additionally, incorporation of the Delphi technique further adds to the existing literature and puts emphasis as an important tool that can be used in medical education to rigorously validate Q-statements and develop Q-samples in various specialties.

Working Definitions of "Critical Portions": Results from Qualitative Interviews with 51 Academic Surgeons

OBJECTIVE

Identify the considerations academic surgeons use when determining which portions of a procedure are "critical" and necessitate their presence.

BACKGROUND

Teaching physicians are required to be present for the "critical portion" of surgical procedures, but the definition of what constitutes a critical portion remains elusive. Current guidelines defer to surgeons' expert judgment in identifying critical portion(s) of a procedure; little is known about what concepts surgeons apply when deciding what parts of a procedure are critical.

METHODS

Qualitative analysis of interviews with 51 practicing surgeons from a range of specialties regarding their working definition of critical portions.

RESULTS

Surgeons identified 4 common themes that they use in practice to define the critical portions of procedures: portions that require their first-hand observation of events, those involving challenging anatomy or structures that cannot be repaired if injured, and portions where an error would result in severe consequences for the patient. Surgeons also recognized contextual factors regarding the patient, trainee, surgeon, and team that might alter determinations for individual cases.

CONCLUSIONS

Although critical portion definitions are largely treated as subjective, surgeons across multiple specialties identified consistent themes defining "critical portions", suggesting that setting a minimum standard for criticality is feasible for specific procedures. Surgeons also recognized contextual factors that support the need for case-specific judgement beyond minimum standard. This framework of procedure features and contextual factors may be used as a guide for surgeons making day-to-day decisions and in future work to formally define critical portions for a given procedure.

Patient Perceptions of Trust in Trainees During Delivery of Surgical Care: A Thematic Analysis

OBJECTIVE

Trust is an essential element of an effective physician-patient relationship. There is limited literature examining trust between trainees and patients in the surgical setting. The goal of this study was to investigate how otolaryngology patients perceive trust in trainees during delivery of surgical care.

DESIGN

We extracted trainee-specific data from a larger, qualitative interview study examining trust in the surgeon-patient relationship. We then used realist thematic analysis to explore preoperative otolaryngology patients' perceptions of trust in trainees during delivery of surgical care.

SETTING

Department of Otolaryngology-Head and Neck Surgery at Michigan Medicine in Ann Arbor, MI, a tertiary academic medical center.

PARTICIPANTS

Using convenience sampling, adults 18 years or older scheduled to undergo elective otolaryngologic surgery between February and June 2019 were invited, and 12 agreed to participate in the study.

RESULTS

All participants (n = 12) self-identified as White/Caucasian with a mean age of 60 years (range, 28-82). Participants were 50% (n = 6) female and 50% (n = 6) male. Thematic analysis of participants' perspectives about trust in trainees during delivery of surgical care revealed 3 themes. Trust in trainees is conditional based on (i) level of trainee involvement; (ii) trust in the attending surgeon; and, (iii) trust in the institution.

CONCLUSION

Trust in trainees during delivery of surgical care is conditional on types of tasks trainees perform, bounded by trust in their attending surgeon, and positively influenced by institutional trust. Trainees and surgical educators must look to innovative methods to engender trust more efficiently in the clinic and immediate pre-operative setting. Such approaches can have a positive impact on patient outcomes, facilitate stronger trainee-attending interpersonal relationships, and empower surgeons to practice the professional values integral to surgical care.

Evaluation of an undergraduate nursing entrustable professional activities framework: An exploratory qualitative research

BACKGROUND

Entrustable professional activities (EPA) are mainly used in graduate medical education and professional development and have not been widely implemented in nursing undergraduate settings. Nursing EPAs were therefore developed by the Alice Lee Centre of Nursing to translate theoretical nursing competencies into clinical practice and as forms of standardized clinical assessment tools. Feedback from various stakeholders is required to further refine the framework.

OBJECTIVES

To explore the perceptions and experiences of using the new EPA framework in nursing students and hospital and university clinical instructors.

DESIGN

An exploratory qualitative study using focus group interviews.

PARTICIPANTS

Seven year-one nursing undergraduates, 12 year-two undergraduates, seven university clinical instructors, and 18 hospital clinical instructors participated in this study.

METHODS

The students formed five groups, while the clinical instructors formed seven groups, each consisting of three to four participants. Semi-structured interviews were conducted to explore stakeholders' experiences and perceptions of the EPA assessment framework. Thematic analysis was used to analyze the data.

RESULTS

Despite initial mixed reactions of confusion and relief, many students and clinical instructors commended the comprehensive and structured EPA framework and its emphasis on holistic patient-centered care. EPAs also allow flexible assessment methods, encourage critical thinking among students, and promote team-based care and peer teaching. However, the assessment using a two-dimensional matrix with multiple competencies for the EPAs, subjective assessment criteria, the lack of standardization using checklists, subjective assessment criteria, and the lack of, manpower, and time may potentially affect the accuracy of the clinical assessments. The effectiveness of the EPA framework was also dependent on the quality of feedback, students' intrinsic motivations, and learning environments. The refinement of EPAs and entrustment levels, a physical checklist, and an incorporation of EPAs into school curricula were recommended to improve practitioners' learning experiences.

CONCLUSIONS

The use of EPAs in nursing education continues to be a novel and evolving process. There remains a need for a further refinement of the EPA framework to tailor to instructors' expectations and students' capabilities.

Entrustable professional activities in health care education: a scoping review

CONTEXT

The shift in medical education from time-based learning to outcome-based learning has drawn much attention to entrustable professional activities (EPAs) as an ideal assessment framework to translate competencies into clinical practice. Given the relative novelty of EPAs, this review aims to highlight research gaps and explore and consolidate available evidence pertaining to the development and implementation of EPAs in health care.

METHOD

Arksey and O'Malley's scoping review framework was used to present the findings. The authors performed a systematic search of PubMed, Embase, CINAHL, Scopus, MedNar, OpenGrey and ProQuest Dissertation and Theses for English articles published from the inception of each database to May 2018. A manual search of the reference lists of the included studies was conducted and an expert panel was consulted. Two reviewers screened the articles for eligibility using the inclusion criteria. All authors extracted key data and analysed the data descriptively. Thematic analysis was used to categorise the results into themes.

RESULTS

Eighty articles were included in the review. All articles were published between 2010 and 2018. Three major themes and eight sub-themes were generated: (i) development of EPAs (frameworks for EPA development and implementation, identifying core or specialty-specific EPAs, and EPAs for faculty development), (ii) evaluation of EPAs and EPA entrustment factors (revised curriculum, entrustment decisions for professional activities, and feedback on implemented EPAs and the development process), and (iii) future directions and recommendations for EPAs (implementation of EPAs in undergraduate medical education and specific disciplines, and other criticisms and recommendations for EPAs).

CONCLUSIONS

Entrustable professional activities are an essential means to translate competencies into observable and measurable clinical practice. However, high-level evidence-based research on the efficacy, development and implementation of EPAs for specific target groups (i.e. undergraduates and staff) and geographical regions (i.e. Asia and Africa) is still lacking, which suggests a direction for future research.