Perceptions of Ad Hoc Entrustment, the Need for Supervision, and Coping Strategies in Clinical Residents: A Qualitative Study

Abstract

Purpose

Negotiating the balance between clinical residents’ roles as health care practitioners and learners is a struggle in postgraduate medical education. Although ad hoc entrustment has been studied in this context, little is known about residents’ perceptions of ad hoc over- and underentrustment, the need for supervision, and their coping strategies. Therefore, this study explored residents’ perspectives concerning these topics.

Method

The authors conducted semistructured, in-depth interviews with 12 purposively sampled residents in the graduate medical educational phase of residency who were involved in geriatric psychiatry rotations from different training sites and settings in Switzerland. The interviews were conducted between January and March 2022. Researchers used a thematic analysis to explore and interpret the data within a constructivist research paradigm.

Results

Four overarching themes were identified: ad hoc and default entrustment in the workplace, perceptions of supervision, applied coping strategies to over- and underentrustment, and suggestions for improvement. Residents described entrustment decisions in the workplace as a default, often covert process and as an explicit, ad hoc delegation of clinical tasks. Perceived optimal supervision entailed sufficient time, frequency, and availability of the supervision, supervisors referring to scientific evidence in their reasoning, trustworthiness, and a psychologically safe learning environment. Residents described suboptimal supervision as lacking appropriate feedback timing, having little or nonexistent time in general, using an ambivalent communication style, and clinical decision-making by the supervisor that is not explicit. Residents applied instrumental, appraisal-focused, and emotion-focused coping strategies. Their suggestions for improvement included instructional design of the workplace-based curriculum, supervision, teaching content, and contextual factors.

Conclusions

Within postgraduate training, addressing the organizational and contextual factors of entrustment and resident supervision is essential. Default entrustment decisions need to be explored and explicitly addressed to prevent overentrustment, meet residents’ need for supervision, and effectively coach residents to maintain their well-being.

Many health care systems depend on health care staff in training.¹ This dependency creates tension for clinical residents who are expected to work as fully functioning health care practitioners and as learners with diverse educational needs.² This dual role can negatively influence residents’ well-being and increase the risk of burnout.³ A conflict between the needs of the institution and the learner can potentially affect the general supervisory culture of residents and ad hoc entrustment decisions in the workplace.⁴ However, in contrast to increasing research on supervisors’ perspectives of ad hoc entrustment, less is known about the perspective of residents.

Ad hoc entrustment decisions involve a supervisor assigning a clinical task to a resident.⁵ Task assignments come with a corresponding level of supervision (e.g., direct vs indirect).^6,7 Hauer et al⁸ provided an overview of factors influencing supervisors’ ad hoc entrustment decisions in the clinical workplace (propensity to trust, residents’ competence and attitude, the supervisor–resident relationship, task complexity, and workplace context). The ability of residents to demonstrate their skills in the workplace,^9,10 along with factors such as resources and staffing,^11,12 resident workload,^13–15 and workplace culture,^16,17 is recognized as a contextual influencer of ad hoc entrustment decisions. Although the immediate clinical context has been a topic of research, the broader organizational aspects that may influence entrustment decisions remain underexplored.⁴

If clinical need determines ad hoc entrustment, it could lead to over- or underentrustment in competency-based medical education.^8,18 Underentrustment suggests that residents are not trusted enough with specific tasks,¹⁸ leading to the seniorization of clinical activities that systematically deprive residents of learning opportunities. In contrast, systematic overentrustment occurs when residents are trusted too much, which could lead to patient safety issues or resident burnout.^18,19 Although the coping styles of physicians to manage stress and the implications for physician well-being have been studied,^20–24 little is known about the coping strategies of clinical residents for perceived ad hoc over- or underentrustment and inadequate supervision. Therefore, we aimed to explore residents’ perceptions of supervision, ad hoc entrustment, and their coping strategies in the context of their need for supervision. We addressed the following research questions: What are the perceptions of residents in different clinical teaching settings in terms of supervision and ad hoc entrustment? How do residents manage their needs (including unmet needs) for the supervision of clinical tasks? What are residents’ suggestions for improvement?

Method

We conducted a qualitative study using semistructured, in-depth interviews within a 1constructivist research paradigm and used thematic analysis^25,26 to explore and interpret the data. We followed a 6-step framework, including familiarizing with data, generating initial codes, searching for and reviewing themes, defining and naming themes, and producing the report.^25,27 Informed consent was given twice by the interviewees; written consent was provided before the interviews and oral consent at the beginning of interviews. Data were anonymized before analysis.

Setting

All study participants were in their graduate medical educational phase during the interviews and were involved in geriatric psychiatry rotations. In Switzerland, the residency program for specialization in psychiatry and psychotherapy requires 6 years of graduate training. The training includes 4 to 5 years of specific psychiatric training and 1 year of clinical somatic medicine. Up to 1 year can be spent in a child and adolescent psychiatry and psychotherapy rotation.

The required theoretical education (approximately 600 hours) covers psychiatric diagnosis and treatment and various psychotherapeutic models, supervised directly and indirectly across multiple psychiatric settings. The mandatory clinical rotations include general adult psychiatry, outpatient care, and geriatric psychiatry. These guidelines are based on a national residency program, which includes learning objectives for each rotation.²⁸ There is no explicit standard level of supervision per training stage; typically, clinical residents work at the discretion of the supervising attending physician. However, at training hospitals, each newly admitted patient must be evaluated by an attending physician. Residents must also complete a research project and at least 4 workplace-based assessments per year (in the form of Mini Clinical Evaluation Exercise or Direct Observation of Procedural Skills) for self-chosen clinical activities (currently not predefined entrustable professional activities [EPAs]). Finally, they must take a summative written and oral examination for board certification. The Swiss residency program in psychiatry differs from typical programs in the United States because residents must apply for each rotation individually in an open job market context and are, thus, in charge of overseeing their residency progress themselves. Swiss residency training is currently undergoing a major transformation, including the introduction of EPAs.

Participants, sampling, and recruitment

We chose a purposive sampling approach and aimed for maximum variation²⁹ across different training sites (outpatient vs inpatient, academic teaching hospitals, private vs public sectors, and different language areas) in Switzerland. We chose 4 training sites to recruit residents. For each language region (German or French), 1 university hospital and 1 public teaching hospital were chosen. After the selection of training sites, we contacted the residency program directors for the contact information of their current residents in geriatric psychiatry. After obtaining permission from the residents through the residency program directors, we received the residents’ email contact information. We invited residents who provided written informed consent and appointment options. We originally planned to recruit 16 residents (4 in each training site). However, data sufficiency was reached after 12 interviews, and recruitment was stopped. We conducted the first interview on January 7, 2022, and the last on March 28, 2022.

Data collection

Before the interviews, a semistructured interview guide was developed based on the supervision and entrustment literature^8,12,30 and a previous online survey.³¹ The interview guide was translated into French and back-translated into German to ensure the accuracy of the translation. The translated interview guide is available in Supplemental Digital Appendix 1 (at http://links.lww.com/ACADMED/B687). The interview guide was piloted with 2 residents not participating in the final study and adapted based on their input. The 2 pilot interviews were not included in the analysis of the study. We conducted and recorded interviews via Zoom, version 5.7.14 (Zoom Communications Inc., San Jose, California) and used MAXQDA, version 22.3 (VERBI Software, Berlin, Germany), to transcribe and code the interviews. We gathered demographic details of each participant at the beginning of each interview—before video recording began. These data included age, sex, place of medical school graduation, goals of the residents’ specialty and subspecialty titles, setting (inpatient or outpatient), years of work experience after medical school, and employment level.

Data analysis

Data analysis followed the 6-step approach of Braun and Clarke.²⁷ The first step included data transcribing and familiarization. S.P.L. transcribed the German recordings, and a research assistant transcribed the French recordings. Both familiarized themselves with the transcripts of both languages. In the second step, S.P.L. and the research assistant generated initial codes for all transcripts, and after 2 transcripts were compared, the codes were compared to ensure a congruent understanding of the initial coding. Codes were generated by units of meaning, which means that typically 1 to 3 consecutive sentences that matched one another in terms of content were coded as a unit of meaning. These units formed the bases for subthemes and themes. They then finalized the codes and discussed them at the end of the process. This process was regularly discussed with S.H. and S.P., who were updated about the initial codes. The third step was to search for themes. Both S.P.L. and the research assistant searched for themes, identifying frequent codes and their connections to one another. S.P.L. regularly discussed the themes and progress with S.H. and S.P., and with their input, the first subthemes were identified at this stage of the analysis.²⁵ In the fourth step, all transcripts were reviewed, and initial codes were grouped into themes and subthemes. The use of thematic maps supported this process.²⁷ The fifth step defined and named the themes, including selecting representative quotations. In the sixth step, the report was produced, and all authors revised the final manuscript.

Researcher characteristics and reflexivity

To enhance credibility, multiple members of the team (with different backgrounds and language skills) were involved in the process of data collection and analysis. Researchers’ backgrounds included psychology (S.P.L.), different fields of clinical medicine (S.H., M.N., S.K., and S.P.), and medical education (S.P.L., S.H., M.N., S.K., and S.P.). To mitigate potential power imbalances, the interviews were conducted by a psychologist not involved in clinical supervision and assessment. All interviews were voluntary and explicitly unconnected to any workplace-based assessment.

Results

We identified 4 main themes and 10 subthemes in our analysis. The main themes related to ad hoc and default entrustment in the workplace, perceptions of supervision, applied coping strategies to over- and underentrustment, and suggestions for improvement. An overview of these themes is given in Table 1 and in more detail in Supplemental Digital Appendixes 2 and 3 (at http://links.lww.com/ACADMED/B687). Demographic characteristics of the interviewees are provided in Supplemental Digital Appendix 4 (at http://links.lww.com/ACADMED/B687).

Table 1.

Main Themes and Subthemes From Interview Data of Swiss Clinical Residents in Geriatric Psychiatry in 2022

Main themes	Subthemes	Description
Default and ad hoc entrustment in the workplace	Organizational aspects of default entrustment	How organizational aspects of the workplace influence entrustment decisions. This can be through the organizational onboarding process that includes clinical tasks that are, by default, entrusted to residents from the beginning (e.g., admitting an inpatient with indirect supervision). An entrustment decision might also be communicated through the electronic clinical task planer (informational technology environment) as a pending task for a new resident (e.g., seeing a patient in the memory clinic).
	Ad hoc entrustment during ward rounds	How tasks are entrusted spontaneously during ward rounds.
	Factors influencing levels of supervision	This subtheme describes clinical workplace aspects that influence levels of supervision, including local social norms for self-entrustment, situational cues such as perceived complexity of the situation, and entrustment-based discussions between the resident and attending after ad hoc entrustment decisions.
Perceptions of supervision	Perceptions of optimal supervision	The circumstances under which residents consider supervision to be optimal include when the supervisor has sufficient time and availability, an adequate frequency of explicit supervision, perceived trustworthiness, and making clinical decisions explicit. Supervision should be embedded in a psychologically safe environment.
	Perceptions of suboptimal supervision	Residents perceive supervision as suboptimal when the timing of feedback is inadequate (i.e., delayed), if there is not sufficient time for supervision (or no supervision at all), if the supervisor has an ambivalent communication style, and if clinical decision-making comes from management recommendations (or is not made explicit) and is, therefore, not understandable.
	The clinical team as supervision substitute	This subtheme describes the different sources residents use for substituting clinical supervision, including other attending physicians, senior residents, psychologists, and nurses.
Applied coping strategies	Instrumental coping strategies	This theme describes how residents use different practical strategies to overcome an unavailable supervisor by planning differently, calling another supervising physician, or discussing cases with different health professionals.
	Emotion-focused coping strategies	This theme describes the emotional techniques residents use to cope with insufficient supervision.
	Appraisal-focused coping strategies	This theme describes the appraisal-focused techniques residents use to cope with unavailable supervision.
Perceived opportunities for improvement	Curriculum and supervision	Within curricular- and supervision-related factors to improve training, residents wanted a clear curriculum detailing how learning goals and teaching clinical skills during rotations build on one another and supervisors who can coach and have sufficient qualifications (i.e., at least board certification and preferably subspecialization of supervisors).
	Teaching content	Residents wanted high-quality teaching on specific clinical knowledge and skills relevant to the workplace (e.g., neurocognitive disorders for geriatric psychiatry rotations).
	Context factors	This subtheme describes how the rotation could be improved if there were sufficient attending physicians as supervisors.

Default and ad hoc entrustment in the workplace

Residents described entrustment decisions in the workplace as a default, often covert process and as an explicit, ad hoc delegation of clinical tasks (e.g., during ward rounds).

Organizational aspects of default entrustment decisions.

The delegation of some clinical tasks to residents was embedded in organizational processes that implicitly involved entrustment decisions. Residents were informed about this type of entrustment decision through appointments via the hospital’s clinical care information technology system or through emails from administrative and other health care staff.

Some entrustment decisions were made by default at the beginning of a rotation. Residents were expected to know what their tasks were and had the responsibility for these tasks throughout their rotation without any assessment or explicit entrustment decisions: “The … head of the clinic explained to me at the beginning how things work. When there is an admission … I do it spontaneously without anyone having to tell me” (interview 9).

Ad hoc entrustment during ward rounds.

Ad hoc entrustment of clinical activities to residents was a core element of ward rounds. Tasks were spontaneously entrusted to residents once they were discussed during a patient visit. This type of ad hoc entrustment decision was integrated into the daily flow of ward rounds without making the entrustment reasoning of the supervisor explicit to the trainee:

It’s often during rounds, where a nurse explains what happened to the patient, and then I react according to the diagnosis … the head of the clinic … may also say “this patient should be monitored, this test should be done, etc.” (interview 6)

Factors influencing levels of supervision.

The level of supervision was influenced by several factors, including social norms for self-entrustment, context-related factors, and entrustment-based discussions. The social norms of the teaching hospital guided the residents in their self-entrusted levels. They observed the standards and then adapted their degree of autonomy when assuming clinical tasks.

At first, I thought I was going to make more decisions …. But gradually I observed that my colleague was not doing it herself and preferred to discuss the changes with the attending physician …. So, I started to do the same, I was not doing things by myself anymore …. So, at the beginning, I was more into action before talking. Now [the attendings] make the final decision. I ask the question and wait for the answer. (interview 9)

Ad hoc self-entrustment also depended on a case’s complexity and the resident’s confidence.

Every morning there is a colloquium [i.e., meeting of attending and residents] with the residents … [who] are … independent. But it depends on how he [the resident] feels. If he feels comfortable, he can make decisions, and if he has doubts, the attending is there to guide. (interview 7)

Supervisors also co-constructed ad hoc entrustment decisions with residents. They made their decisions through unstructured entrustment-based discussions:

The input also comes from the attending, … for example lumbar puncture, [the attending asks, e.g.] “Do you want to do that? Yes? How often have you done it?” … Then first the theoretical knowledge is repeated, then the procedure is discussed, prepared, carried out under supervision, and then even feedback [is given]. (interview 4)

Perceptions of supervision

The residents described how they perceived clinical supervision in their day-to-day work. They described aspects that they perceived as optimal, those they perceived as suboptimal, and the clinical team members in their environment who were perceived as cosupervising staff. Notably, residents described members of the clinical team other than the attending physician supervising some clinical activities and that the interdisciplinary workspace allowed for psychologists or social workers to provide supervision. These team members provided supervision not only when a resident was distressed and felt overwhelmed but sometimes as an implicit standard.

Perceptions of optimal supervision.

For residents, optimal supervision entailed sufficient time, frequency, and availability of the supervision, supervisors referring to scientific evidence in their reasoning, trustworthiness, and a psychologically safe learning environment. One resident described how understaffing and time pressure shaped supervision:

It would be to find time in the week where we sit down and go through the patients and the main issues …. That’s what we don’t really have here because we’re often alone …. You don't have time to ask all the questions and you must hurry up to be able to talk. (interview 6)

The way supervisors made clinical decisions mattered to the residents. They perceived supervision as optimal if the supervisor made clinical decisions explicit and based on evidence. For residents, it was important that they could trust their supervisors’ decisions: “I would say [optimal supervision] is when the [supervisor] makes me feel that I can trust them with [their] decisions … that they make decisions that are based on evidence” (interview 9).

For residents to perceive supervision as optimal, the context also mattered and involved aspects of a safe psychological environment: “It is supervision … where the supervisee feels comfortable bringing forward all issues … when the [resident] does not feel unfairly criticized or judged” (interview 11).

Perceptions of suboptimal supervision.

Residents described suboptimal supervision as lacking appropriate feedback timing, having little or nonexistent time in general, using an ambivalent communication style, and clinical decision-making by the supervisor that is not explicit. Residents elaborated, saying that feedback for a potential teaching moment sometimes arrived significantly delayed:

So, supervision is less effective if it comes with a big-time delay to the teaching moment … for example … if I get my feedback on a report or clinical activity two months later … the learning effect is not very big. (interview 4)

Lack of supervision time for residents meant that only urgent and necessary topics could be discussed in meetings due to understaffing:

Well, one issue is the staffing of the senior physicians …. There have been times … there is simply no senior physician …. And then senior doctors from other wards or from somewhere else come to help out … and they often don't have so much time. Then there is … only time for the most necessary things and that is not helpful. (interview 5)

Extreme cases of suboptimal supervision were described as no supervision or residents not feeling supervised at all: “But the supervision is very very bad at the moment …. So, there is no supervision” (interview 2).

In terms of supervisors’ communication styles, residents struggled with ambivalent or unclear communication. Residents perceived supervision as suboptimal if they were unable to understand the clinical decision-making of their supervisors. It was important for them to understand why a supervisor was accepting management recommendations or making clinical decisions, and they perceived it as suboptimal if such explanations were not explicit: “When it’s not helpful is when I'm just told ‘do this’ without explaining the reason for the choice” (interview 6).

The clinical team as a supervision substitute.

In addition to the official supervisor, usually senior physicians or leading physicians, the residents had other, unofficial sources of clinical supervision, including other attending physicians, peer residents, psychologists, and nurses. Residents described that different people in the clinical team guided the clinical tasks and that the structures allowed for members of the team to provide supervision. These team members provided supervision not only when the resident was distressed and felt overwhelmed but also as part of standard practice:

Then there’s the nursing staff, with whom I often have a chat, to whom I say, “I don't know what more I can do to help this person.” As they have more experience, they have ideas and suggest things. (interview 6)

Applied coping strategies

If residents encountered situations where they felt overentrusted with clinical tasks, they described different ways of coping with their unmet need for supervision.

Instrumental coping strategies.

Specifically, they mentioned instrumental coping strategies, including planning differently, reaching out to other attending physicians, or discussing cases with different health professionals:

I think I'm lucky because I have a colleague with whom we talk a lot about clinical cases. She is a psychologist and finished her studies this summer. I [also] have [peer residents] who are much more experienced than I am, and I sometimes use them as “attendings.” If I have medical questions and my attending physician is not available, I [ask them]. (interview 6)

Emotion-focused coping strategies.

If residents perceived supervision as insufficient, they also applied emotional-coping techniques, such as emotionally withdrawing from the situation:

But of course, it upsets you inside and it also causes [a mental block] and you think about the cases, and you're horrified about what's going on …. To a certain extent I [just deal with it] and to a certain extent I also withdraw from it. (interview 2)

Appraisal-focused coping strategies.

For appraisal-focused coping, residents either changed their attitude such that they would consider their problem as not urgent or assumed that it was not their problem at all:

Yes, so it is a balancing act of feeling responsible for the patients and showing my commitment on the one hand and at the same time saying … that’s not my problem. So, I can easily distance myself from that [responsibility]. (interview 2).

Perceived opportunities for improvement

All residents had suggestions on how their postgraduate geriatric psychiatry training could be improved. Aspects that were mentioned included the instructional design of the workplace-based curriculum, supervision, teaching content, and contextual factors.

Curriculum and supervision.

In their recommendations for improvement, residents mentioned aspects of the curriculum and supervision (e.g., an explicit curriculum that determines which aspects of the specialty are taught first), supportive supervision, and making board certification mandatory for becoming a supervisor. Residents saw potential in better structuring a residency rotation and introducing an explicit curriculum that defines learning goals, the teaching of clinical skills, and when these skills are taught:

My idea is that … skills are taught one after the other, not, for example, three skills at the same time … it makes sense to first concentrate only on seeing outpatients. Once you have done that, you can move on to the next area. For example, emergency care, [then] psychotherapeutic care, [and then] home treatment … not [all] at the same time. (interview 3)

Another way to improve the rotation was described as planned, supportive supervision and better qualifications for attending physicians. However, residents also described time conflicts between patient care and supervision: “The prerequisite for [good] supervision is simply that there are attending physicians who have a specialist qualification … there are so many attending physicians who do not have [this] competence” (interview 2).

Teaching content.

Residents suggested improvements to the teaching content of workplace-based curricula. Specifically, they mentioned that didactic content should refer to the (sub)specialty, for example, neurocognitive disorders and common medical and neurologic conditions, in geriatric psychiatry rotations.

Context factors.

Residents mentioned increasing attending physician staffing to enhance the quality of their learning process.

Discussion

In addition to supervisors’ ad hoc entrustment decisions, we found that organizational default delegation mechanisms shaped clinical supervision across postgraduate, clinical-teaching settings. Ad hoc entrustment was primarily driven by situational patient care needs rather than entrustment-based discussions or trainees’ need for supervision. Ideal supervision depended on its availability and frequency, the perceived trustworthiness of the supervisor, explicit clinical decision-making, and a psychologically safe environment. In contrast, delayed feedback, insufficient time for supervision, an ambivalent communication style, and opaque clinical decision-making were perceived as suboptimal. Three main coping styles of residents with perceived overentrustment were identified: (1) problem focused, (2) emotion focused, and (3) appraisal focused strategies.³² These strategies entailed planning clinical activities differently, approaching other attending physicians or health care professionals, withdrawing from the situation, and reassessing the urgency of the situation. Suggestions for workplace-based curricular improvement were related to specifically tailored teaching content and supervision and clinical teaching training for staff.

Although previous research has shown that context (including patient care needs) plays a role in entrustment decisions,^4,8,12 our results indicate that staffing and clinical care needs play a dominant role in ad hoc entrustment decisions in the workplace.^8,12,33 Ad hoc entrustment in postgraduate training may primarily depend on organizational-context factors. The use of EPAs in a workplace, where supervision levels cannot be realistically adjusted to individual learner needs, might undermine their successful implementation. Our results indicate that the design of curricula and assessments should consider that default entrustment might occur in workplaces and threaten instructional alignment. This risk might be greater in contexts in which residents play a critical role in the general care of patients and fewer educational resources are available. Our findings may be relevant for evaluating the validity of evidence of workplace-based assessments for EPAs. Thus, purposeful use of context-adapted workplace-based assessments, such as entrustment-based discussions, could help mitigate clinical care needs and trainees’ perceived need for supervision.³⁴ More general validity aspects of integrating workplace-based assessments of EPAs are discussed elsewhere.³⁵

Even the purposeful and formative use of workplace-based assessments might not solve the problem of understaffing and overentrustment. Residents in our study identified these aspects as central to improving their training. Their desire for the increased presence and availability of attending physicians for supervision aligns with other research suggesting adequate staffing fosters trust in the workplace.¹¹ Sufficient staffing is essential to prevent perceived overentrustment. However, the perceptions of residents also suggest that having attending physicians present might be insufficient. The residents’ recommendations emphasized the qualifications of the attendings in terms of specialization, supervision, and coaching skills, as well as the quality of the workplace-based curriculum. These recommendations are aligned with research showing that high-quality supervision and learner-centered curriculum designs are beneficial for establishing functional educational alliances between residents and supervisors.^36–38

Our results indicate that high-quality supervision is characterized by sufficient time and frequency, perceived trustworthiness of the supervisor, making clinical decisions explicit, and a psychologically safe environment. These results align with previous studies that have found that time and frequency of supervision and a safe workplace environment^16,17,39 are important enablers of trust and meaningful entrustment decisions.

In contrast, factors that threaten the quality of supervision include delayed feedback, insufficient time, and an ambivalent communication style. Reciprocal relationships, timing, communication style, and supervisors’ competence help establish trust between supervisors and residents.^{36,37,40–42} However, these studies were performed from the supervisor’s perspective, and only one study included both the supervisors’ and trainees’ perspectives. To cope with inadequate supervision, residents applied different coping strategies (problem-, emotion-, and appraisal-focused coping).^32,43 Previous research has found that emotion-focused coping (e.g., emotional withdrawal) among physicians is less adaptive than problem-focused coping (asking another colleague for support) to maintain physician well-being.^20,21 Accepting and explicitly acknowledging that ideal staffing and supervision are unrealistic might open new perspectives on how to coach residents. If staffing cannot be improved, clinical educators should help residents use the most effective coping strategies to maintain their well-being, thrive as learners, and provide safe patient care.

Further research is necessary to better understand how contextual factors drive entrustment decisions across disciplines and educational systems and how limited (staff) resources in health care can be allocated most effectively. Residents must be supported to actively engage with ad hoc entrustment decisions and use healthy coping styles to manage perceived over- and underentrustment. Teaching adaptive coping strategies has been suggested in undergraduate medical education.⁴⁴ Our findings support this idea, and context-specific coaching in postgraduate training should be provided.⁴⁵ Coaching strategies should include organizational aspects to ensure residents can use problem-focused coping strategies.

Limitations

One possible limitation of this study was not including residents in our research group. However, we piloted the interview guide with current residents to ensure that the content and questions were clear and meaningful to them. We also investigated the workplace context of one country and within one specialty (geriatric psychiatry). Thus, generalizability from a postpositive perspective might be limited. However, we believe that it was not the specialty that influenced our findings as much as the labor-market context, the health educational system (general structure of residency), and how residents entered professional life (level of supervision after graduating from medical school). Additional studies are needed to explore our findings in different contexts and specialties to inform local adaptations of competency-based medical education.

Conclusions

Entrustment is not confined to dyadic interactions between residents and supervisors. Rather, it is integrated into the workplace through structural and curriculum-related factors. These implicit and default entrustment decisions can lead to residents perceiving themselves as “left alone in the workplace.” Default entrustment decisions need to be explored and explicitly addressed to prevent overentrustment, meet residents’ need for supervision, and effectively coach residents to maintain their well-being.