‘It depends’: The complexity of allowing residents to fail from the perspective of clinical supervisors

Abstract

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.

Keywords:

• Clinical supervision
• decision-making
• intuition
• failure
• trainee learning

Acknowledgements

The authors thank the supervisors for their participation in this study.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Glossary

Allowing failure: ‘While supervising a trainee’s clinical performance, the supervisor, influenced by both intuition and a non-linear interplay of different factors, detects an imminent trainee mistake, has the opportunity to intervene but chooses not to do so, because the educational gain for the trainee is perceived to outweigh the (potential) consequences for the patient.’

Additional information

Funding

This study was supported by Department of Medicine POEM program at the Schulich School of Medicine & Dentistry, Western University.

Notes on contributors

Jennifer M. Klasen

Jennifer M. Klasen, MD, MME is a Ph.D. candidate of the School of Health Professions Education of the Maastricht University. She works as a surgical specialist in Switzerland.

Pim W. Teunissen

Pim W. Teunissen, MD, PhD is director of the School of Health Professions Education at Maastricht University. He combines this role with clinical work as a gynecologist specialized in high-care obstetrics. He is also a professor of workplace learning in healthcare at Maastricht University.

Erik W. Driessen

Erik Driessen, PhD, is a Professor at the School of Health Professions Education at Maastricht University.

Lorelei A. Lingard

Lorelei A. Lingard, PhD, is a Professor in the Department of Medicine, and Senior Scientist in the Center for Education Research & Innovation, both at the Schulich School of Medicine & Dentistry at Western University.