Entrustment with health care tasks: balancing trainee autonomy, supervision, and patient safety

Abstract

For entrustment with unsupervised practice, an ultimate goal of health care education, modulating trainee autonomy during training is necessary and critical. Trainees benefit from experiencing autonomy during clinical training, but patient safety necessitates restrictions. Balancing these two must be modulated by titrating supervision to an adequate intensity. The patient, trainee, and supervisor constitute a triad in the workplace that revolves around safe and effective provision of health care tasks and effective education. In forming an 'educational alliance' with the trainee, the supervisor adjusts their role, based on the trainee's needs and desires, variations in practice, patient safety considerations, and the trainee's developmental stage. Programs that capitalize on entrustable professional activities and entrustment decision-making have a deliberate focus on the conditions for entrustment of trainees with health care tasks. Entrustment decisions about trainee autonomy happen in daily clinical practice in teaching hospitals as ad hoc decisions, sometimes implicit and unarticulated, but often deliberate and negotiated in sound educational trainee-supervisor alliances. Summative entrustment decisions, made by a team and grounded in adequate assessment data, are meant to formally privilege the trainee for future task execution with increased autonomy, within the restrictions by rules and regulations. A solid summative entrustment decision process allows for defensible adjustments in responsibility and accountability, and backs supervisors in applying appropriate supervision levels. Entrustment with tasks after established readiness for autonomous performance is educationally advantageous and could have a positive impact on patient safety.