Trainees' perceptions of being allowed to fail in clinical training: A sense-making model.

INTRODUCTION: Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth. METHODS: We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes. RESULTS: Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive. DISCUSSION: Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

PURPOSE: Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS: 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS: Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS: Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.

'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.

BACKGROUND: Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training. METHODS: We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants' accounts were descriptively analysed for recurring themes. RESULTS: Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development. CONCLUSION: Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety.

Allowing failure for educational purposes in postgraduate clinical training: A narrative review.

Background: Educational domains such as pedagogy or psychology have embraced the philosophy that "allowing failure" in training and practice is essential to learn. In clinical training, however, allowing learners to fail is not explicitly discussed as a strategy, possibly due to the negative implications for patients. Therefore, we do not know whether clinical supervisors allow trainees to fail for educational purposes and, if so, how this supervisory strategy is used. Methods: To inform research on this topic, we conducted a narrative review to understand what was known about this educational strategy in postgraduate medicine. Results: Analyzing the selected literature, we found no studies directly exploring the question of clinical supervisors allowing failure as an educational strategy. However, related literature on resident errors suggested that trainees perceived their own errors to be highly instructive and that factors such as a sense of responsibility and emotional response influenced the educational impact of these errors. Conclusions: The lack of discussion in the medical education literature regarding allowing failure for learning suggests that we need research into the nature and extent of this supervisory strategy which may hold educational benefits but must be employed in a manner that upholds patient safety and safeguards trainee resilience.

Beyond catharsis: the nuanced emotion of patient storytellers in an educational role.

CONTEXT: As health care organisations seek to cultivate patient and family-centred care, patient storytelling has emerged as a valued educational resource. However, repeatedly harnessing patient perspectives to educate health care professionals may have consequences. We need robust insight into what it means to be a patient storyteller in order to ensure ethical and appropriate engagement with patients as an educational resource. METHODS: Constructivist grounded theory was used to explore the experience of patients involved in a storytelling curriculum as part of hospital staff continuing education. All 33 storytellers were invited by e-mail to participate in the study. Twenty-six storytellers responded to the invitation, and 25 could be scheduled to participate. Using theoretical sampling, semi-structured interviews were conducted and analysed in a process that was inductive, iterative and comparative. RESULTS: Participants described the central role of emotions in their storytelling experience, which varied from 1 to 25 tellings over a period of 1 month to 2 years. These emotions were shaped by the passage of time, repetition of storytelling and audience acknowledgement. However, emotion remained unpredictable and had lingering implications for storytellers' vulnerability. CONCLUSION: The multiple storytelling experiences of our participants and ongoing educational nature of their role provides unique insight into how emotions ebb and flow across tellings, how emotions can be both a surprise and a rhetorical strategy, and how emotions are influenced by audience acknowledgement. These findings contribute to an emerging conversation regarding the power and politics of selecting and using storytellers for organisational purpose. Implications include how we support patient storytellers in educational roles and how we can sustainably integrate patient storytelling into health professional education.

Time-Variable Training in Medicine: Theoretical Considerations.

The introduction of competency-based medical education has shifted thinking from a fixed-time model to one stressing attained competencies, independent of the time needed to arrive at those competencies. In this article, the authors explore theoretical and conceptual issues related to time variability in medical training, starting with the Carroll model from the 1960s that put time in the equation of learning. They discuss mastery learning, deliberate practice, and learning curves.While such behaviorist theories apply well to structured courses and highly structured training settings, learning in the clinical workplace is not well captured in such theories or in the model that Carroll proposed. Important in clinical training are self-regulation and motivation; neurocognitive perspectives of time and learning; professional identity formation; and entrustment as an objective of training-all of which may be viewed from the perspective of the time needed to complete training. The authors conclude that, in approaching time variability, the Carroll equation is too simplistic in its application to the breadth of medical training. The equation may be expanded to include variables that determine effective workplace learning, but future work will need to examine the validity of these additional factors.

Enhanced Requirements for Assessment in a Competency-Based, Time-Variable Medical Education System.

Competency-based, time-variable medical education has reshaped the perceptions and practices of teachers, curriculum designers, faculty developers, clinician educators, and program administrators. This increasingly popular approach highlights the fact that learning among different individuals varies in duration, foundation, and goal. Time variability places particular demands on the assessment data that are so necessary for making decisions about learner progress. These decisions may be formative (e.g., feedback for improvement) or summative (e.g., decisions about advancing a student). This article identifies challenges to collecting assessment data and to making assessment decisions in a time-variable system. These challenges include managing assessment data, defining and making valid assessment decisions, innovating in assessment, and modeling the considerable complexity of assessment in real-world settings and richly interconnected social systems. There are hopeful signs of creativity in assessment both from researchers and practitioners, but the transition from a traditional to a competency-based medical education system will likely continue to create much controversy and offer opportunities for originality and innovation in assessment.

Learning in Practice: A Valuation of Context in Time-Variable Medical Training.

The logical consequence of implementing competency-based education is moving to time-variable training. Competency-based, time-variable training (CBTVT) requires an understanding of how learners interact with their learning context and how that leads to competence. In this article, the authors discuss this relationship. They first explain that the time required to achieve competence in clinical practice depends on the availability of clinical experiences that are conducive to ongoing competence development. This requires both curricular flexibility in light of the differences in individual learners' development and a balance between longitudinal placements and transitions to different environments.Along with the deliberate use of the opportunities that learning environments offer, there is value for learners in spending ample time-in-context. For instance, guided independence is possible when trainees do not progress immediately after meeting curricular learning objectives. Next, the potential implications of CBTVT can be illustrated by two learning perspectives-Sfard's acquisition and participation metaphors-which leads to the assertion that competence is both an individual characteristic and a quality that emerges from a purposeful social interaction between individuals and their context. This theory recognizes that the deliberate use of context could be used to approach learning as acquiring collective competence.Based on this relationship between learner, context, and competence, the authors propose an approach to CBTVT that recognizes that all learners will have to meet a number of standard preset learning targets in their workplace, while still having room for further context-specific competence development and personal growth within strategically organized learning environments.

What Regulatory Requirements and Existing Structures Must Change If Competency-Based, Time-Variable Training Is Introduced Into the Continuum of Medical Education in the United States?

As competency-based medical education is adopted across the training continuum, discussions regarding time-variable medical education have gained momentum, raising important issues that challenge the current regulatory environment and infrastructure of both undergraduate and graduate medical education in the United States. Implementing time-variable medical training will require recognizing, revising, and potentially reworking the multiple existing structures and regulations both internal and external to medical education that are not currently aligned with this type of system. In this article, the authors explore the impact of university financial structures, hospital infrastructures, national accrediting body standards and regulations, licensure and certification requirements, government funding, and clinical workforce models in the United States that are all intimately tied to discussions about flexible training times in undergraduate and graduate medical education. They also explore the implications of time-variable training to learners' transitions between medical school and residency, residency and fellowship, and ultimately graduate training and independent practice. Recommendations to realign existing structures to support and enhance competency-based, time-variable training across the continuum and suggestions for additional experimentation/demonstration projects to explore new training models are provided.

What's behind the scenes? Exploring the unspoken dimensions of complex and challenging surgical situations.

PURPOSE: Physicians regularly encounter challenging and/or complex situations in their practices; in training settings, they must help learners understand such challenges. Context becomes a fundamental construct when seeking to understand what makes a situation challenging and how physicians respond to it; however, the question of how physicians perceive context remains largely unexplored. If the goal is to teach trainees to deal with challenging situations, the medical education community requires an understanding of what "challenging" means for those in charge of training. METHOD: The authors relied on visual methods for this research. In 2013, they collected 40 snapshots (i.e., data sets) from a purposeful sample of five faculty surgeons through a combination of interviews, observations, and drawing sessions. The analytical process involved three phases: analysis of each drawing, a compare-and-contrast analysis of multiple drawings, and a team analysis conducted in collaboration with three participating surgeons. RESULTS: Findings demonstrate that experts perceive the challenge of surgical situations to extend beyond their procedural dimensions to include unspoken, nonprocedural dimensions-specifically, team dynamics, trust, emotions, and external pressures. CONCLUSIONS: Findings show that analysis of surgeons' drawings is an effective means of gaining insight into surgeons' perceptions. The findings refine the common belief that procedural complexity is what makes a surgery challenging for expert surgeons. Focusing exclusively on the procedure during training may put trainees at risk of missing the "big picture." Understanding the multidimensionality of medical challenges and having a language to discuss these both verbally and visually will facilitate teaching around challenging situations.

Understanding palliative care on the heart failure care team: an innovative research methodology.

CONTEXT: There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES: To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS: This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS: We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION: We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

What's so great about rehabilitation teams? An ethnographic study of interprofessional collaboration in a rehabilitation unit.

OBJECTIVE: To explore team structures, team relationships, and organizational culture constituting interprofessional collaboration (IPC) in a particular rehabilitation setting; to develop a description of IPC practice that may be translated, adapted, and operationalized in other clinical environments. DESIGN: An ethnographic study involving: Field observations: 40 hours, over 4 weeks, daily activities, 7 interprofessional meetings, 3 care planning meetings, 1 business meeting, and 3 family meetings; Individual observations: a physiotherapist, an occupational therapist, and a social worker individually observed for 45 minutes to an hour; and Interviews: 19 participants, 11 professions, 27 informal, 5 formal interviews. Data analysis consisted of an iterative process involving coding field notes for themes by 3 members of the research team by qualitative analysis software. SETTING: Single inpatient spinal cord rehabilitation care unit in a Canadian urban academic rehabilitation hospital. PARTICIPANTS: Purposive convenience sample of core team, more than 40 professionals: physiatrist, over 21 nurses, 3 physiotherapists, 3 occupational therapists, 2 social workers, chaplain, psychologist, therapeutic recreationist, program assistant, program manager, pharmacist, advanced practice leader, 6 students (1 pharmacy, 4 registered nurse, and 1 psychology), and on-site community organizations. After university and hospital ethical approvals, all staff members were recruited to participate in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Recurrent examples of IPC fit 2 dominant themes: team culture (divided into leadership, care philosophy, relationships, and the context of practice) and communication structures (both formal and informal). CONCLUSIONS: IPC practice in rehabilitation care is supported by clinical, cultural, and organizational factors. This understanding of daily IPC work may guide initiatives to promote IPC in other clinical team settings.

'It's a cultural expectation...' The pressure on medical trainees to work independently in clinical practice.

CONTEXT: Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. METHODS: In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. RESULTS: Participants conceived that the pressure towards independence in clinical work originated in trainees' desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. DISCUSSION: The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger's situated learning theory suggests that giving attention to the 'independent doctor' ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.'s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.

Questioning competence: a discourse analysis of attending physicians' use of questions to assess trainee competence.

BACKGROUND: Attending physicians (APs) must constantly assess trainees' competence to act independently, to promote learning while ensuring quality of care. This study aimed to explore, through discourse analysis of case presentations, the process of competence assessment for case-specific clinical independence. METHOD: Twenty-six case presentations in emergency medicine were observed and audiorecorded. A discourse analysis was conducted, focusing on APs' use of questioning strategies. RESULTS: Questioning strategies involved clarifying questions (to ensure APs' understanding of the case), probing questions (to probe trainees' understanding of a case or their underlying knowledge), and challenging questions (to challenge presuppositions). Case-related probing questions and challenging questions were found to be linguistic features of APs' assessments of trainees' competence. CONCLUSIONS: The identification of specific linguistic features of the process of competence assessment by APs provides a framework for faculty development and future study of the function and effects of such discourse patterns.

Making sense of grounded theory in medical education.

BACKGROUND: Grounded theory is a research methodology designed to develop, through collection and analysis of data that is primarily (but not exclusively) qualitative, a well-integrated set of concepts that provide a theoretical explanation of a social phenomenon. OBJECTIVE: This paper aims to provide an introduction to key features of grounded theory methodology within the context of medical education research. OVERVIEW: In this paper we include a discussion of the origins of grounded theory, a description of key methodological processes, a comment on pitfalls encountered commonly in the application of grounded theory research, and a summary of the strengths of grounded theory methodology with illustrations from the medical education domain. DISCUSSION: The significant strengths of grounded theory that have resulted in its enduring prominence in qualitative research include its clearly articulated analytical process and its emphasis on the generation of pragmatic theory that is grounded in the data of experience. When applied properly and thoughtfully, grounded theory can address research questions of significant relevance to the domain of medical education.

Progressive independence in clinical training: a tradition worth defending?

BACKGROUND: Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning. METHOD: A computerized literature search was performed using Medline, PsycINFO, Social Sciences Citation Index, and Educational Resources Information Center. This article presents a synthetic review of relevant empirical and theoretical concepts from the domains of medicine, psychology, education, kinesiology, and sociology. RESULTS: The clinical psychology and medical education literatures provide evidence that clinical trainees act more independently as their training progresses, but have not yet evaluated the educational efficacy of providing progressive independence, or the consequences of failing to do so. The expertise and motor learning literatures provide some theoretical evidence (as yet untested in complex clinical environments) that the provision of too much guidance or feedback to trainees could be educationally detrimental in the long term. The sociology literature provides insight into the cultural values underlying the behavior of clinical teachers and trainees relating to issues of supervision and independence. CONCLUSIONS: There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.

'You learn better under the gun': intimidation and harassment in surgical education.

BACKGROUND: Medical literature has documented a high prevalence of intimidation and harassment in the educational context. However, the research has failed to adequately delineate the nature of these phenomena as well as the different ways in which diverse actors perceive the behaviours in question. METHODS: Based on qualitative methodology anchored in a social constructionism framework, how teachers (staff surgeons) and learners (surgical residents) define intimidation and harassment were documented and compared. In addition, teachers' and learners' perceptions of the impact of these behaviours on the learning environment, including their effects on the socialisation of surgeons in training, were examined. FINDINGS: Five group interviews and 22 individual interviews were conducted across 2 university departments of surgery with a total of 22 faculty and 14 resident participants. Interviewees acknowledged the existence of intimidation and harassment, while at the same time rationalising its occurrence. This paradox was encapsulated in participant descriptions using terms such as 'good intimidation'. Our examination of the data helped us to understand that participants sustained the paradox of beneficial intimidation and harassment by rationalising questionable behaviours on 3 specific dimensions, namely: whether an acceptable purpose could be attributed to the perpetrator; whether positive effects of the behaviour existed, and whether there was a perceived necessity for the behaviour. INTERPRETATIONS: Even while their dysfunctional characteristics are recognised, intimidation and harassment are often seen as functional educational tools. The cultural value currently accorded these behaviours needs to be taken into account in educational interventions designed to shift attitudes and actions in this domain.