Perceptions of ad hoc entrustment decisions: A qualitative study of early clinical students

Pinilla, Severin; Kyrou, Alexandra; Maissen, Norina; Klöppel, Stefan; Strik, Werner; Nissen, Christoph; Huwendiek, Sören (2021). Perceptions of ad hoc entrustment decisions: A qualitative study of early clinical students. In: AMEE 2021. virtual conference, Dundee. 27. - 30. August 2021.

Introduction: Undergraduate medical education (UME) reforms have started to incorporate competencybased designs in many countries (Chen et al. 2016). Entrustable professional activities (EPAs) as observable clinical activities that trainees carry out under supervision rely on the emergence of trust between
stakeholders (Ten Cate et al. 2015). Theoretical models of trust emergence have been developed based on research in a different fields, including medicine, higher education, and psychology (Holzhausen et al. 2017). While perceptions of trust emergence have been explored from a graduate medical education (GME)
perspective, little attention has been paid to how medical students in their first clinical rotations perceive ad hoc entrustment decisions. To address this gap in the literature, we aimed to explore which factors early clinical students perceive as relevant for ad hoc entrustment decisions in clinical workplaces.
Methods: We designed a case study within a social constructivist epistemology. We classified our study subject (clerkship year as early and first full-time clinical exposure) as a key case since it was one of the first core clerkship programs to implement an EPA-based curriculum within a formative assessment program.
The purpose of the study was exploratory, with an approach based on theories of trust formation and entrustment. The units of analysis included semi-structured interviews with clerkship students and health care team members. The sample (n=28) consisted of 46% (n=13) male and 54% (n=15) female student
interviewees from German-, French-, and Italian-speaking cantons with an average age of 24 years (range:22–33) and four health care team members identified through student feedback.
Results: Medical students in their core clerkship year perceived clinical residents as critical educational gatekeepers and key facilitators of entrustment decisions. Another important theme emerged around students’ motivation, initiative, and willingness to engage with the health care team and patients. Students
actively engaged in trust formation processes with different health care team members. The entrustment decision process was perceived as multilateral and dynamic, involving all health care team members and
patients. Multiple entrusting supervisors for clerkship students, including nurses and psychologists, emerged from our interview data. They assumed an active role in negotiating entrustment decisions both with and for clerkship students, either facilitating or hindering opportunities. The entrustment decisions emerged as a result of a multifaceted supervisor network interaction.

Discussion and Conclusions: Supervising residents ability to integrate students into clinical teams seems to be a critical factor in facilitating entrustment opportunities for clinical activities. Students active management of informal supervisor networks of health care team members and these team members
willingness to assume responsibility for the students education emerged as relevant aspects for ad hoc entrustment as well. Our studys surprising finding that some health care team members seemed to assume a professional educational responsibility beyond that which was expected from them might be regarded as
in line with Solbrekkes and Englunds work on professional responsibility (Solbrekke et al. 2011, Solbrekke et al. 2014). They point out that professional responsibility includes situated judgment, trust, negotiated 452 standards, and proactivity, which differs from the professional accountability discourse that sometimes dominates curriculum design. Incorporation of these concepts into ad hoc entrustment decisions opens up new possibilities for clinical teaching of clerkship students.
References: *The presented research paper has been accepted for publication in the Journal Medical Education on December 4th 2020.
Chen, CH, et al. , P, Developing Entrustable Professional Activities for Entry into Clerkship. Acad Med. 2016;91:247-255.
Ten Cate, O, et al., Curriculum development for the workplace using Entrustable Professional Activities
(EPAs): AMEE Guide No. 99. Med Teach. 2015;37:983-1002.
Solbrekke, et al., Bringing professional responsibility back in. Studies in Higher Education. 2011;36:847-861.
Holzhausen et al., Applying occupational and organizational psychology theory to entrustment decisionmaking
about trainees in health care: a conceptual model. Perspect Med Educ. 2017;6:119-126.
Solbrekke, TD and Sugrue, C, Professional accreditation of initial teacher education programmes: Teacher
educators' strategies—Between ‘accountability’and ‘professional responsibility’? Teaching and teacher
education. 2014;37:11-20.

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