Entrustment Decision Making in Clinical Training

Abstract

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

Applying occupational and organizational psychology theory to entrustment decision-making about trainees in health care: a conceptual model

“…An essential part of granting trainees progressive independence is the supervisor’s decision to entrust the trainee with specific activities. These daily decisions are also referred to as ad hoc entrustment decisions [2]. …”

Using the Entrustable Professional Activities Framework in the Assessment of Procedural Skills

“…Entrustability-aligned anchors (ranging from ''no task execution'' to ''supervision may be provided to junior learners'') were then added to the rubric, as adapted from previously published tools. 23,25 Final rubrics included 6 to 10 items per procedure (see online supplemental material for a copy of the rubrics).…”

“…Although there are published reports on how to develop EPAs, [22][23][24][25][26] there is relatively little guidance on how to use them in assessment. One approach entails use of entrustability-aligned anchor scales, 27 which reflect the continuum of abilities ranging from DOI: http://dx.doi.org/10.4300/JGME-D-16-00282.1 passive observer to being able to perform an activity independently and provide supervision to others.…”

Attending Physician Remote Access of the Electronic Health Record and Implications for Resident Supervision: A Mixed Methods Study

“…24 Five major determinants of entrustment (trainee, supervisor, relationship, task, and contextual factors) have been well described, and are well aligned with the findings of our study. 25 Remote use of the EHR may further inform attending judgments regarding entrustment of autonomy to residents, particularly for ad hoc entrustment decisions. 25 Time constraints were a prominent reason influencing attending remote EHR access in several subthemes.…”

“…25 Remote use of the EHR may further inform attending judgments regarding entrustment of autonomy to residents, particularly for ad hoc entrustment decisions. 25 Time constraints were a prominent reason influencing attending remote EHR access in several subthemes. Work hour limitations have significantly affected the time spent in direct contact between supervising attendings and residents.…”