Rationale: Progressive trainee autonomy is considered essential for clinical learning, but potentially harmful for patients. How clinical supervisors and medical trainees establish progressive levels of autonomy in acute care environments without compromising patient safety is largely unknown.
Objectives: To explore how bedside interactions among supervisors and trainees relate to trainee involvement in patient care and to clinical oversight.
Methods: We conducted a qualitative study based on constructivist grounded theory methodology. We used participant observation for our data collection. We observed the overt teaching interactions among trainees and staff physicians in the critical care units of two university-affiliated hospitals during 74 acute care episodes. Our analysis led to the elaboration of a theoretical model of clinical supervision.
Measurements and main results: A model of interactive clinical supervision is proposed on the basis of three themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different teaching interactions. Engaging in monologues and dialogues about patient care and facilitating hands-off care provision involved progressive levels of trainee involvement without risk for patients. Facilitating hands-on provision of care and providing support-in-action encouraged further trainee involvement with limited risks for patients. Providing feedback-on-action created additional learning opportunities based on trainee independent involvement in clinical activities.
Conclusions: Engaging in teaching interactions during acute care episodes allows trainees to exercise progressive autonomy and supervisors to provide adequate clinical oversight. Our model of interactive clinical supervision can inform faculty development initiatives. Learning outcomes resulting from different levels of trainee autonomy should be further explored.
Keywords: critical care; internship and residency; learning; medical education; supervision.