RESUMO
Objective: Lack of trust between supervisors and trainees can have harmful consequences. Trust has been examined between physicians, patients, and staff in multiple settings but has not been examined in a bidirectional manner in the pediatric emergency department (PED). Debra Meyerson in 1996 discussed the theory of swift trust, a type of trust that develops quickly between temporary groups through reliance on categories. Meyerson describes categories as groups unified by social identities such as gender or profession. We explored the applicability of swift trust in the relationship between supervisors and trainees in the PED. Methods: This multimethods study used qualitative interviews and the validated interpersonal mistrust trust measure (IMTM) to assess baseline trusting style. PED attendings from a single institution and residents from various training levels, specialties, and institutions rotating through the same PED were sampled until thematic saturation was reached. Interviews were analyzed using directed content analysis. IMTM scores were triangulated with interviewee's reported trusting styles. Results: Seventeen PED attendings and 16 residents participated. Residents and attendings emphasized different factors that influence trust. Common factors across groups included affect, the need for vulnerability, and appropriate communication. Most described reliance on certain categories (level of training, specialty, etc.) when making trusting decisions. Categories such as gender and race were noted to be unimportant when making trusting decisions about others, although some participants believed these attributes played into decisions made by others. Quantitative data from the IMTM supported qualitative conclusions regarding trusting style. Conclusions: The trusting relationship between supervisors and trainees in the PED dovetails with the swift trust theory. Common factors that influence trust reveal entry points for attendings and residents to improve trust and ultimately prevent negative patient outcomes. Future studies may examine how reliance on categories influences an individual's trust in their colleagues.
RESUMO
BACKGROUND: The entrustable professional activity (EPA) assessment framework allows supervisors to assign entrustment levels to physician trainees for specific activities. Limited opportunity for direct observation of trainees hampers entrustment decisions, in particular for infrequently performed activities. Simulation allows for direct observation, so tools to assess performance of EPAs in simulation could potentially provide additional data to complement clinical assessments. OBJECTIVE: We developed and collected validity evidence for a simulation-based tool grounded in the EPA framework. METHODS: We developed E-ASSESS (EPA Assessment for Structured Simulated Emergency ScenarioS) to assess performance in 2 EPAs among pediatric residents participating in simulation-based team training in 2017-2018. We collected validity data, applying Messick's unitary view. Three raters used E-ASSESS to assign entrustment levels based on performance in simulation. We compared those ratings to entrustment levels assigned by clinical supervisors (different from the study raters) for the same residents on a separate tool designed for clinical practice. We calculated intraclass correlation (ICC) for each tool and Pearson correlation coefficients to compare ratings between tools. RESULTS: Twenty-eight residents participated in the study. The ICC between the 3 raters for entrustment ratings on E-ASSESS ranged from 0.65 to 0.77, while ICC among raters of the clinical tool were 0.59 and 0.57. We found no significant correlations between E-ASSESS ratings and clinical practice ratings for either EPA (r = -0.35 and 0.38, P > .05). CONCLUSIONS: Assessment following an EPA framework in the simulation context may be useful to provide data points to inform entrustment decisions as part of resident assessment.
