Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review

Abstract

Objective: To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed.

Background: Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence.

Methods: A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included.

Results: Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role.

Conclusions: This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.

Keywords: Surgical training; intraoperative teaching; operating room guidance; resident entrusted autonomy.