Trainees' perceptions of patient safety practices: recounting failures of supervision

'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.

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.

The Relationship Between the Learning and Patient Safety Climates of Clinical Departments and Residents' Patient Safety Behaviors

PURPOSE

Improving residents' patient safety behavior should be a priority in graduate medical education to ensure the safety of current and future patients. Supportive learning and patient safety climates may foster this behavior. This study examined the extent to which residents' self-reported patient safety behavior can be explained by the learning climate and patient safety climate of their clinical departments.

METHOD

The authors collected learning climate data from clinical departments in the Netherlands that used the web-based Dutch Residency Educational Climate Test between September 2015 and October 2016. They also gathered data on those departments' patient safety climate and on residents' self-reported patient safety behavior. They used generalized linear mixed models and multivariate general linear models to test for associations in the data.

RESULTS

In total, 1,006 residents evaluated 143 departments in 31 teaching hospitals. Departments' patient safety climate was associated with residents' overall self-reported patient safety behavior (regression coefficient [b] = 0.33; 95% confidence interval [CI] = 0.14 to 0.52). Departments' learning climate was not associated with residents' patient safety behavior (b = 0.01; 95% CI = -0.17 to 0.19), although it was with their patient safety climate (b = 0.73; 95% CI = 0.69 to 0.77).

CONCLUSIONS

Departments should focus on establishing a supportive patient safety climate to improve residents' patient safety behavior. Building a supportive learning climate might help to improve the patient safety climate and, in turn, residents' patient safety behavior.

The effects of power, leadership and psychological safety on resident event reporting

CONTEXT

Although the reporting of adverse events is a necessary first step in identifying and addressing lapses in patient safety, such events are under-reported, especially by frontline providers such as resident physicians.

OBJECTIVES

This study describes and tests relationships between power distance and leader inclusiveness on psychological safety and the willingness of residents to report adverse events.

METHODS

A total of 106 resident physicians from the departments of neurosurgery, orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching hospital were asked to complete a survey on psychological safety, perceived power distance, leader inclusiveness and intention to report adverse events.

RESULTS

Perceived power distance (β = -0.26, standard error [SE] 0.06, 95% confidence interval [CI] -0.37 to 0.15; p < 0.001) and leader inclusiveness (β = 0.51; SE 0.07, 95% CI 0.38-0.65; p < 0.001) both significantly predicted psychological safety, which, in turn, significantly predicted intention to report adverse events (β = 0.34; SE 0.08, 95% CI 0.18-0.49; p < 0.001). Psychological safety significantly mediated the direct relationship between power distance and intention to report adverse events (indirect effect: -0.09; SE 0.02, 95% CI -0.13 to 0.04; p < 0.001). Psychological safety also significantly mediated the direct relationship between leader inclusiveness and intention to report adverse events (indirect effect: 0.17; SE 0.02, 95% CI 0.08-0.27; p = 0.001).

CONCLUSIONS

Psychological safety was found to be a predictor of intention to report adverse events. Perceived power distance and leader inclusiveness both influenced the reporting of adverse events through the concept of psychological safety. Because adverse event reporting is shaped by relationships and culture external to the individual, it should be viewed as an organisational as much as a personal function. Supervisors and other leaders in health care should ensure that policies, procedures and leadership practices build psychological safety and minimise power distance between low- and high-status members in order to support greater reporting of adverse events.

Discrepancies in After-Hours Communication Attitudes between Pediatric Residents and Supervising Physicians

OBJECTIVE

To examine differences in expectations when a resident should contact a supervising physician in several hospital-based, after-hours clinical circumstances.

STUDY DESIGN

We developed 34 scenarios collectively considered the most common or serious issues encountered by on-call residents, and incorporated them into a survey of pediatric residents, fellows, and attendings. For each scenario, participants were asked whether the resident should talk to the attending/fellow immediately or delay communication until the next day. ORs comparing attendings/fellows and residents were calculated, and subgroup analyses were performed examining differences among the study populations.

RESULTS

A total of 112 participants completed the survey (91% response rate). In 17 of the 34 scenarios (50%), more attendings/fellows than residents asked for immediate communication (OR >1; P < .05). Most discrepant scenarios were in uncertain areas in which residents may feel comfortable managing the issue without supervisory input or, alternatively, fail to recognize an evolving matter or a deteriorating clinical status. In subgroup analyses, residents were homogeneous in their responses; however, responses of fellows and junior faculty differed from those of senior faculty in 7 of the 34 scenarios, with senior attendings more likely desiring immediate communication.

CONCLUSION

We found differences in expectations of when a pediatric resident should contact a supervising physician after hours not only between residents and attendings/fellows, but among attendings themselves. These differences could lead to medical errors, miscommunication, and inconsistent supervision for overnight residents.

Clinical supervision and learning opportunities during simulated acute care scenarios

CONTEXT

Closer clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees' learning, but have not paid specific attention to the learning processes involved.

METHODS

We conducted a simulation-based study to explore the learning opportunities created during simulated resuscitation scenarios under different levels of supervision. Fifty-three residents completed a supervised scenario. Residents were randomised to one of three levels of supervision: telephone (distant); in-person after telephone consultation (immediately available), and in-person from the beginning of the simulation (direct). These interactions were converted into 234 pages of transcripts for analysis. We performed an inductive thematic analysis followed by a deductive analysis using situated learning theory as a theoretical framework.

RESULTS

Learning opportunities created during simulated scenarios were identified as belonging to either of two categories, incidental and engineered opportunities. The themes resulting from this framework contributed to our understanding of trainees' contributions to patient care, supervisors' influences on patient care, and trainee-supervisor interactions. All forms of supervision offered trainees incidental opportunities for practice, although the nature of these contributions could be affected by the bedside presence of supervisors. Supervisors' involvement in patient care by telephone and in person was associated with a shift of responsibility for patient care, but represented, respectively, engineered and incidental opportunities for observation. In-person supervisor-trainee interactions added value to observation and created additional opportunities for incidental feedback and engineered practice.

CONCLUSIONS

The shift of responsibility for patient care occurred during both direct and distant supervision, and did not necessarily translate into a lack of opportunities for trainee participation and practice.

"Excuse me:" teaching interns to speak up

BACKGROUND

A consistent finding in health care is that interns (junior physicians) are unwilling to "speak up" to attendings or consultants (senior physicians), which involves the related behaviors of challenging or questioning the actions of attendings, seeking guidance about one's own performance, and reporting one's errors. Training designed to encourage interns to speak up was designed, conducted, and evaluated at University Hospital Galway, an academic teaching hospital affiliated with the National University of Ireland, Galway, in January 2012-March 2012 and November 2012-January 2013.

METHOD

Training, which was based on the Crew Resource Management model, was constructed around filmed stories of attending physicians describing situations in which, when they were interns, their communication and assertiveness skills were challenged, and their reflections on what they could have done better.

RESULTS

A total of 110 interns attended the training. The feedback from participants was positive. There was a significant increase in knowledge as a result of the training, and some evidence to support a shift in attitudes in the desirable direction relating to the need to speak up to seniors. No effect of the training was found on behavior.

CONCLUSIONS

The willingness to share examples of poor performance is an important part of building a good safety culture. Listening to the stories ofattendings describing and reflecting on a situation in which they struggled is a powerful teaching method for training interns in the communication and assertiveness skills that are critical to their job. However, a sustained change in attitudes and behavior to speaking up will require a reinforcement of learning with deliberate practice to develop the skills introduced through the training program.

Teaching in the ICU

Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.

Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture

PURPOSE

Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students' perceptions of safety culture and identified curricular gaps in patient safety training.

METHOD

A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test.

RESULTS

One hundred twenty-one students (71% response rate) rated "teamwork within units" and "organizational learning" highest among the survey domains; "communication openness" and "nonpunitive response to error" were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience.

CONCLUSIONS

Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

Supervision in psychiatry: terra incognita?

PURPOSE OF REVIEW

Supervision is accepted as a part of postgraduate psychiatric training programmes (at least in the western world). However, despite its ubiquity, it is little researched. The purpose of this review was to synthesize research on supervision in psychiatry in the last 3 years (2009-2011). Given the dearth of such research, the boundary was extended to include general medicine and other mental health professions.

RECENT FINDINGS

The lack of research into supervision in psychiatry was confirmed by a comprehensive search of literature. The few articles published specific to psychiatry did, however, reflect the position of psychiatry, bridging medicine and the psychotherapies. Thus, they span from the impact of workplace-based assessments and reframing the theories of learning applicable to psychiatric training, through to the learning of psychotherapy by psychiatric trainees.The literature on supervision in general medicine is dominated by the impact of competency-based training, with its associated methods of assessment, and issues around the decision to entrust trainees with various professional activities.The psychotherapy supervision literature has been notable for two disparate themes: the centenary of psychotherapeutic supervision in 2009 prompted a number of scholars to write reflective pieces capturing advances and areas for further research; whereas the development of evidence-based clinical supervision has given rise to a considerable body of work.

SUMMARY

Research into supervision in psychiatry remains largely a terra incognita. If supervision is to continue to occupy a role as a key component of psychiatric training, research to justify that is needed urgently.

Mainstreaming risk management education into new resident and fellow orientation

INTRODUCTION

Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety.

METHODS

DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey.

RESULTS

Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution.

CONCLUSION

Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.