Trusted to Learn: a Qualitative Study of Clerkship Students’ Perspectives on Trust in the Clinical Learning Environment
- 86 Downloads
Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners’ and supervisors’ level. Research has focused on resident trainees; questions exist about how medical students experience entrustment.
This study examines how clerkship students perceive supervisors’ trust in them and its impact on their learning.
Qualitative study using individual semi-structured interviews.
Clerkship medical students at the University of California, San Francisco.
We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis.
Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students’ motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy.
As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.
KEY WORDSqualitative research medical education-entrustment medical education-undergraduate medical education-clinical skills training
Miscellaneous department funds were used to support study costs, including transcription services, gift card purchases, and printing fees.
Compliance with Ethical Standards
The UCSF Institutional Review Board deemed this study exempt.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Trust. In: Merriam-Webster Online. Available at: https://www.merriam-webster.com/dictionary/trust. Accessed October 17, 2018.
- 2.Baldwin DWC, Daugherty SR, Ryan PM. How Residents View Their Clinical Supervision: A Reanalysis of Classic National Survey Data. J Grad Med Educ. 2010;2(1):37–45.Google Scholar
- 3.Busari JO, Weggelaar NM, Knottnerus AC, Greidanus P-M, Scherpbier AJJA. How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting. Med Educ. 2005;39(7):696–703.Google Scholar
- 4.Babbott S. Commentary: Watching Closely at a Distance: Key Tensions in Supervising Resident Physicians: Acad Med. 2010;85(9):1399–1400.Google Scholar
- 5.Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When Do Supervising Physicians Decide to Entrust Residents With Unsupervised Tasks? Acad Med. 2010;85(9):1408–1417.Google Scholar
- 6.Hauer KE, ten Cate O, Boscardin C, Irby DM, Iobst W, O’Sullivan PS. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv Health Sci Educ Theory Pract. 2014;19:435–456.Google Scholar
- 7.Hauer KE, Oza SK, Kogan JR, et al. How clinical supervisors develop trust in their trainees: a qualitative study. Med Educ. 2015;49(8):783–795.Google Scholar
- 8.Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency (Updated). Available at: https://icollaborative.aamc.org/resource/887. Accessed 17 Oct 2018.
- 9.Sheu L, Kogan JR, Hauer KE. How Supervisor Experience Influences Trust, Supervision, and Trainee Learning: A Qualitative Study. Acad Med. 2017;92(9):1320–1327.Google Scholar
- 10.Biondi EA, Varade WS, Garfunkel LC, et al. Discordance Between Resident and Faculty Perceptions of Resident Autonomy: Can Self-Determination Theory Help Interpret Differences and Guide Strategies for Bridging the Divide? Acad Med. 2015;90(4):462–471.Google Scholar
- 11.Sheu L, Burke C, Masters D, O’Sullivan PS. Understanding Clerkship Student Roles in the Context of 21st-Century Healthcare Systems and Curricular Reform. Teach Learn Med. 2018 [Epub ahead of print].Google Scholar
- 12.Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students’ workplace learning. Med Educ. 2007;41(1):84–91.Google Scholar
- 13.Billett S. Learning in the Workplace: Strategies for Effective Practice. Crows Nest, Australia: Allen & Unwin; 2001.Google Scholar
- 14.Bandura A. Social cognitive theory of self-regulation. Organ Behav Hum Decis Process. 1991;50(2):248–287.Google Scholar
- 15.Hauer KE, Hirsh D, Ma I, et al. The role of role: learning in longitudinal integrated and traditional block clerkships: The effects of role in clerkships. Med Educ. 2012;46(7):698–710.Google Scholar
- 16.O’Brien BC, Hirsh D, Krupat E, et al. Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships. Med Teach. 2016;38(3):297–305.Google Scholar
- 17.Sheu L, O’Sullivan PS, Aagaard EM, et al. How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study. Acad Med. 2016;91(10):1406–1415.Google Scholar
- 18.Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893–1907.Google Scholar
- 19.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2): 77–101.Google Scholar
- 20.Bowen GA. Grounded Theory and Sensitizing Concepts. Int J Qual Methods. 2006;5(3):12–23.Google Scholar
- 21.Finlay L. Negotiating the swamp: the opportunity and challenge of reflexivity in research practice. Qual Res. 2002;2(2):209–230.Google Scholar
- 22.Mariani L. Teacher Support and Teacher Challenge in Promoting Learner Autonomy. Perspectives. 1997;22:5–19.Google Scholar
- 23.van de Pol J, Volman M, Beishuizen J. Scaffolding in Teacher–Student Interaction: A Decade of Research. Educ Psychol Rev. 2010;22(3):271–296.Google Scholar
- 24.Burgis JC, Lockspeiser TM, Stumpf EC, Wilson SD. Resident Perceptions of Autonomy in a Complex Tertiary Care Environment Improve When Supervised by Hospitalists. Hosp Pediatr. 2012;2(4):228–234.Google Scholar
- 25.Schumacher DJ, Bria C, Frohna JG. The Quest Toward Unsupervised Practice: Promoting Autonomy, Not Independence. JAMA. 2013;310(24):2613.Google Scholar
- 26.Halpern SD, Detsky AS. Graded Autonomy in Medical Education — Managing Things That Go Bump in the Night. N Engl J Med. 2014;370(12):1086–1089.Google Scholar
- 27.Kennedy TJ, Regehr G, Baker GR, Lingard L. Preserving professional credibility: grounded theory study of medical trainees’ requests for clinical support. BMJ. 2009;338:b128.Google Scholar
- 28.OʼBrien B, Cooke M, Irby DM. Perceptions and Attributions of Third-Year Student Struggles in Clerkships: Do Students and Clerkship Directors Agree? Acad Med. 2007;82(10):970–978.Google Scholar
- 29.Radcliffe C, Lester H. Perceived stress during undergraduate medical training: a qualitative study. Med Educ. 2003;37(1):32–38.Google Scholar
- 30.Vygotsky LS. Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA: Harvard University Press; 1978.Google Scholar
- 31.Chen H. Early Learner Engagement in the Clinical Workplace. Utrecht University; 2015.Google Scholar
- 32.Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ Theory Pract. 2008;13(3):361–372.Google Scholar
- 33.Ten Cate O, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach. 2007;29(6):591–599.Google Scholar
- 34.Duijn CCMA, Welink LS, Mandoki M, ten Cate OTJ, Kremer WDJ, Bok HGJ. Am I ready for it? Students’ perceptions of meaningful feedback on entrustable professional activities. Perspect Med Educ. 2017;6(4):256–264.Google Scholar
- 35.Telio S, Ajjawi R, Regehr G. The “Educational Alliance” as a Framework for Reconceptualizing Feedback in Medical Education: Acad Med. 2015;90(5):609–614.Google Scholar
- 36.Liaison Committee on Medical Education. Standards, Publications, and Notification Forms. Available at: http://lcme.org/publications/. Accessed 17 Oct 2018.
- 37.Beck S, Schirlo C, Breckwoldt J. How the Start into the Clinical Elective Year Could be Improved: Qualitative Results and Recommendations from Student Interviews. GMS J Med Educ. 2018;35(1).Google Scholar
- 38.Bannister SL, Dolson MS, Lingard L, Keegan DA. Not just trust: factors influencing learners’ attempts to perform technical skills on real patients. Med Educ. 2018;52(6):605–619.Google Scholar
- 39.Han H, Roberts NK, Korte R. Learning in the Real Place: Medical Students’ Learning and Socialization in Clerkships at One Medical School. Acad Med. 2015;90(2):231.Google Scholar
- 40.Ranji SR. What Gets Measured Gets (Micro)managed. JAMA. 2014;312(16):1637–1638.Google Scholar
- 41.Sebok-Syer SS, Chahine S, Watling CJ, Goldszmidt M, Cristancho S, Lingard L. Considering the interdependence of clinical performance: implications for assessment and entrustment. Med Educ. 2018 [Epub ahead of print].Google Scholar
- 42.Rich JV. Proposing a Model of Co-Regulated Learning for Graduate Medical Education: Acad Med. 2017;92(8):1100–1104.Google Scholar