Answer to "Trust in a learner is affected by several factors. What are these factors and how can they be incorporated in entrustment decisions?"
Entrustment decisions happen every day and in every context in health care. In training institutions, where students, resident and fellows must develop and learn to take over responsibilities for and actually are quite involved in regular health care services, entrustment decisions are made all the time. In fact, the delivery of health care in many countries relies, to a large extent, on trainees’ providing the patient care in teaching hospitals. Thus, there is no alternative to trusting learners to act in patient care. The lay public may presume that students learn and are trained until the point where they receive a diploma and only then assume health care responsibilities. But, of course, student contributions start while they are still in training, and supervision may even extend beyond attainment of their diploma or formal awarding of privileges to carry out patient care. Supervisor trust of learners happens (and must happen) continuously, but the dynamics of where and when learners are being trusted is not always clear, and is a domain of research (Kennedy et al., 2008; Sterkenburg et al., 2010; Wijnen-Meijer et al., 2013; Choo et al., 2014; Duijn et al., 2018). Hauer and colleagues (2014) analyzed the literature on trust and found five categories of factors that determine whether a decision to trust a learner is made, adding to what others had found previously (Dijksterhuis et al., 2009; Choo et al., 2014):
(a) The characteristics of the learner - their observed skill, knowledge, attitude, competencies; all the things that would 'objectively' count toward the competence related to the task (EPA) are important. Below, we will expand on the qualities of the learner a bit more.
(b) The propensity of the supervisor to grant responsibilities. Supervisors can vastly differ in this propensity (Sterkenburg et al., 2010), likely depending on their own experiences and abilities and sense of responsibility (Gingerich et al., 2018). While, usually, more experienced clinicians seem more willing to grant autonomy to trainees, a recent study suggests that it is the more thoughtful, committed, and well-prepared members of a clinical competency committee that appear less lenient with entrustment decisions (Schumacher et al., 2018).
(c) The nature of the task. Some tasks are difficult, more complex, or involve risks, and others less so. But, even with seemingly similar tasks, a patient may be more or less at risk, leading to different decisions.
(d) The context. Not only the patient and the task are critical, but also the circumstances in the environment (available help, experienced co-workers quickly available if needed). Paradoxically, when circumstances are hectic and demanding and there is little help, entrustment decisions also may be made more readily, just because the help of the trainee is badly needed.
(e) The trainee-supervisor relationship. A supervisor needs to have experience with, or know, the trainee to develop or confirm trust. This is one reason that longitudinal clerkships fit well with entrustment processes because supervisors get to know learners better (Hirsh, Holmboe and ten Cate, 2014; Englander and Ten Cate, 2016).
Trainee features enabling trust have been the subject of several studies. In a Canadian study, Kennedy et al. (2008) found trustworthiness in medical trainees to depend on more than only their ability. They described four elements: (i) Knowledge and skill (relevant knowledge and clinical skills); (ii) Discernment (awareness of the limits of his or her clinical knowledge and skill); (iii) Conscientiousness (thoroughness in data gathering and dependability in following through with assigned tasks) and (iv) Truthfulness (the absence of deception in a trainee’s interactions with the supervisor). Trust is a very general quality, and, outside medical education, particularly in the management literature, the features of a trustworthy person are well summarized by Mayer in three factors: benevolence, integrity and ability (Mayer, Davis and Schoorman, 1995; Damodaran, Shulruf and Jones, 2017; Holzhausen et al., 2017). Given these sources, a helpful framework for medical education that captures the most important specific and general features is the following (ten Cate, 2016; Chen and ten Cate, 2018):
Ability (knowledge, skills, experience)
Integrity (benevolence, truthfulness)
Reliability (conscientiousness, consistency)
Humility (recognizing limits, willingness to ask for help)
Traditional assessments typically focus primarily on how well learners demonstrate necessary knowledge and skills (ability). In contrast, assessments within the EPA framework focus on whether learners may be entrusted to safely perform patient care tasks in the clinical workplace. These four conditions must be met to allow entrustment. An explicit conversation with learners about these conditions at the beginning of health professions training may help raise awareness that EPAs assess the demonstration of more than just knowledge and skills.
ten Cate, O. (2016) ‘Entrustment as Assessment: Recognizing the Ability, the Right, and the Duty to Act’, Journal of Graduate Medical Education, 8(2), pp. 261–262. https://doi.org/10.4300/JGME-D-16-00097.1.
Chen, H. C. and ten Cate, O. (2018) ‘Assessment through Entrustable Professional Activities’, in Learning and Teaching in Clinical Contexts: A Practical Guide. 2nd edn. Chatswood: Elsevier Health Sciences.
Choo, K. J., Arora, V. M., Barach, P., Johnson, J. K., et al. (2014) ‘How do supervising physicians decide to entrust residents with unsupervised tasks? A qualitative analysis’, Journal of Hospital Medicine, 9(3), pp. 169–175. https://doi.org/10.1002/jhm.2150.
Damodaran, A., Shulruf, B. and Jones, P. (2017) ‘“Trust” versus “competency” in the workplace’, Medical Education, 51(3), pp. 338–338. https://doi.org/10.1111/medu.13203.
Dijksterhuis, M. G. K., Voorhuis, M., Teunissen, P. W., Schuwirth, L. W. T., et al. (2009) ‘Assessment of competence and progressive independence in postgraduate clinical training’, Medical Education, 43(12), pp. 1156–1165. https://doi.org/10.1111/j.1365-2923.2009.03509.x.
Duijn, C. C. M. A., Welink, L. S., Bok, H. G. J. and Ten Cate, O. T. J. (2018) ‘When to trust our learners? Clinical teachers’ perceptions of decision variables in the entrustment process’, Perspectives on Medical Education, 7(3), pp. 192–199. https://doi.org/10.1007/s40037-018-0430-0.
Englander, R. and Ten Cate, O. (2016) ‘Longitudinal integrated clerkships and entrustable professional activities: A perfect match’, in Longitudinal Integrated Clerkships (LICs)—Principles, Outcomes, Practical Tools and Future Directions. 1st edn. North Syracuse, New York: Alliance for Clinical Education / Gegensatz Press, pp. 261–269.
Gingerich, A., Daniels, V., Farrell, L., Olsen, S.-R., et al. (2018) ‘Beyond hands-on and hands-off: supervisory approaches and entrustment on the inpatient ward’, Medical Education, 52(10), pp. 1028–1040. https://doi.org/10.1111/medu.13621.
Hauer, K. E., Ten Cate, O., Boscardin, C., Irby, D. M., et al. (2014) ‘Understanding trust as an essential element of trainee supervision and learning in the workplace’, Advances in Health Sciences Education: Theory and Practice, 19(3), pp. 435–456. https://doi.org/10.1007/s10459-013-9474-4.
Hirsh, D. A., Holmboe, E. S. and ten Cate, O. (2014) ‘Time to trust: longitudinal integrated clerkships and entrustable professional activities’, Academic Medicine: Journal of the Association of American Medical Colleges, 89(2), pp. 201–204. https://doi.org/10.1097/ACM.0000000000000111.
Holzhausen, Y., Maaz, A., Cianciolo, A. T., ten Cate, O., et al. (2017) ‘Applying occupational and organizational psychology theory to entrustment decision-making about trainees in health care: a conceptual model’, Perspectives on Medical Education, 6(2), pp. 119–126. https://doi.org/10.1007/s40037-017-0336-2.
Kennedy, T. J. T., Regehr, G., Baker, G. R. and Lingard, L. (2008) ‘Point-of-care assessment of medical trainee competence for independent clinical work’, Academic Medicine: Journal of the Association of American Medical Colleges, 83(10 Suppl), pp. S89-92. https://doi.org/10.1097/ACM.0b013e318183c8b7.
Mayer, R. C., Davis, J. H. and Schoorman, F. D. (1995) ‘An Integrative Model of Organizational Trust’, Academy of Management Review, 20(3), pp. 709–734. https://doi.org/10.5465/amr.1995.9508080335.
Schumacher, D. J., King, B., Barnes, M. M., Elliott, S. P., et al. (2018) ‘Influence of Clinical Competency Committee Review Process on Summative Resident Assessment Decisions’, Journal of Graduate Medical Education, 10(4), pp. 429–437. https://doi.org/10.4300/JGME-D-17-00762.1.
Sterkenburg, A., Barach, P., Kalkman, C., Gielen, M., et al. (2010) ‘When Do Supervising Physicians Decide to Entrust Residents With Unsupervised Tasks?’, Academic Medicine, 85(9), p. 1408. https://doi.org/10.1097/ACM.0b013e3181eab0ec.
Wijnen-Meijer, M., van der Schaaf, M., Nillesen, K., Harendza, S., et al. (2013) ‘Essential facets of competence that enable trust in medical graduates: a ranking study among physician educators in two countries’, Perspectives on Medical Education, 2(5), pp. 290–297. https://doi.org/10.1007/s40037-013-0090-z.