Safety to Stumble: Enhancing Resident Demonstration of Clinical Reasoning through Participatory Research

Clinical reasoning (CR) is a core competency in residency training, but its demonstration in the workplace is often influenced by interpersonal and contextual factors. This study aimed to explore resident perspectives on CR demonstration and co-develop best practices to support its visibility in clinical learning environments.

We conducted a group level assessment (GLA), a participatory, qualitative research method, with residents from a large academic institution. Over two GLA sessions (n = 28), residents generated and synthesized key barriers and facilitators to CR demonstration. In a third action planning session (n=37), participants designed strategies to promote CR demonstration.

Residents emphasized that psychological safety is a prerequisite for CR demonstration. Unlike more observable competencies (e.g., communication), CR can be hidden, making it uniquely sensitive to perceptions of judgment. Participants described how team dynamics, faculty behaviors, and the structure of family-centered rounds (FCR) affect CR expression. They proposed practices to enhance CR visibility, including resident-led team goals, observable "microskills" aligned with developmental level, and adaptations to FCR to create space for protected reasoning. Participants further developed strategies supervisors can use to cultivate resident CR expression.

Promoting CR demonstration in residency requires deliberate attention to psychological safety, transparent expectations, and a shared understanding of what CR looks like in practice. A resident-informed approach can guide local adaptations and support broader efforts to make CR more visible, teachable, and assessable in clinical learning environments.