Exploring Pediatric Residents' Experiences with Decision-Making in Complex Hospital-Based Clinical Learning...

Area of Science:

• Medical Education
• Qualitative Research
• Clinical Psychology

Background:

• Traditional resident training emphasized independent decision-making, but current clinical learning environments (CLE) may diminish resident roles.
• Tensions within the CLE, arising from social, personal, and organizational factors, impact resident engagement in clinical decision-making.
• Understanding these tensions is crucial for supporting resident development in contemporary healthcare settings.

Purpose of the Study:

• To explore how pediatric residents perceive and navigate tensions within the clinical learning environment (CLE) concerning their participation in clinical decision-making.
• To identify factors contributing to resident engagement or disengagement in decision-making processes within the CLE.

Main Methods:

• Conducted semi-structured interviews with 38 second- and third-year pediatric residents across three US academic medical centers.
• Employed a constructivist paradigm and template analysis to examine narrative excerpts on tensions in hospital-based clinical decision-making.
• Presented three representative narratives to illustrate the complexity of resident experiences in the CLE.

Main Results:

• Identified three primary areas of tension: who makes decisions, when/where decisions are made, and how decisions are executed.
• Residents sometimes successfully navigated these tensions, leading to learning and growth.
• In other instances, residents reported marginalization and disengagement from decision-making processes.

Conclusions:

• Proposed a model integrating Communities of Practice and Zone of Proximal Development (ZPD) to understand resident decision-making in the CLE.
• Residents can be central, peripheral, or marginalized participants within their ZPD, impacting their learning and engagement.
• Conscious deliberation by residents, supervisors, and leaders is needed to create supportive CLE structures that foster resident decision-making skills for independent practice.