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Inadequate supervision is a significant contributing factor to medical errors involving trainees but supervision in high-risk settings such as the Intensive Care Unit (ICU) is not well studied.
We explored how residents in the ICU experienced supervision related to medication safety not only from supervising physicians but also from other professionals.
Using qualitative methods, we examined in-depth interviews with 17 residents working in ICUs of three tertiary-care hospitals. We analyzed residents' perspectives on receiving and initiating supervision from physicians within the traditional medical hierarchy and from other professionals, including nurses, staff pharmacists and clinical pharmacists (“interprofessional supervision”).
While initiating their own supervision within the traditional hierarchy, residents believed in seeking assistance from fellows and attendings and articulated rules of thumb for doing so; however, they also experienced difficulties. Some residents were concerned that their questions would reflect poorly on them; others were embarrassed by their mistaken decisions. Conversely, residents described receiving interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Residents relied on nurses and pharmacists for non-judgmental answers to their queries, especially after-hours. To enhance both types of supervision, residents emphasized the importance of improving interpersonal communication skills.
Residents depended on interprofessional supervision when making decisions regarding medications in the ICU. Improving interprofessional supervision, which thus far has been under-recognized and underemphasized in graduate medical education, can potentially improve medication safety in high-risk settings.
Close supervision of residents leads to fewer errors, lower patient mortality, and improved quality of care.1–9 An Institute of Medicine (IOM) report3 recommended improving supervision through more frequent consultations between residents and their supervisors. Although current Accreditation Council for Graduate Medical Education (ACGME) guidelines also recommend that attending physicians (attendings) supervise residents, detailed guidance about what constitutes adequate supervision and how it should be implemented is not well defined.10,11 The ACGME stresses that supervision should promote resident autonomy in clinical care.10 However, when trainees act independently, it might lead to critical communication breakdowns and other patient safety concerns.5,6,12–14 Although attendings can encourage (or discourage) residents from seeking advice,15,16 residents also play important roles in asking for help (i.e., initiating their own supervision).17–19 Additional research is needed on how residents walk the fine line between exercising independence and seeking supervision.
Lack of resident supervision is especially problematic in high-risk settings such as the medical intensive care unit (ICU), where medical errors are as frequent as 1.7 errors per patient per day20,21 and the adverse drug event rate is twice that of non-ICU settings.22 Because medication errors are one of the most common errors residents make,23,24 resident interactions with nursing and pharmacy staff may significantly influence medication safety in error-prone ICUs.25–29 Studies of traditional hierarchical supervision tend to overlook how interactions with other professionals influence resident training.12,18,30,31
We define supervision as a process of providing trainees with “monitoring, guidance, and feedback”9 (pg 828) as they care for patients.3 Whereas traditionally, supervisors are identified by their positions of formal authority in the medical chain of command; we conceptualize supervision as a process in which professionals engaged in supervisory activities need not have formal authority over their trainees.
To examine how residents seek supervision through both traditional medical channels (i.e., hierarchical medical chain of command including attendings, fellows and senior residents) and interprofessional communication channels (including nursing and pharmacy staff), we conducted a qualitative study of residents working in ICUs in three tertiary care hospitals. Using semi-structured interviews, we asked residents to describe how they experienced supervision as they provided medications to patients. Two broad research questions guided data analysis:
We conducted a qualitative study using data from interviews with 17 residents working in the medical ICUs of three large tertiary care hospitals (henceforth referred to as South, West, and North hospitals). The interviews were conducted as part of a longitudinal research project that examined how hospitals learn from medication errors.32 The research project, focused on hospitals where medication error prevention was salient because of a vulnerable patient population and/or extensive high-hazard drug usage. For each ICU, the research design included interviews with 6 attendings , 6 fellows, and a purposeful random sample33 of 6 residents. The goal was to reduce bias from supervisors selecting study participants and thus, enhance the credibility of the small sample, rather than generalize from it.32 Surgical residents were excluded, because of the medication focus. The local Institutional Review Boards approved the research.
Drawing on preliminary analyses of research project data, we designed the current study to examine how residents experienced supervision.33 A qualitative research design was particularly appropriate, because this study is exploratory34 and examines the processes of how supervision is implemented.33 By gathering longitudinal data from 2001– 2007 and from ICUs in different hospitals, we were able to search for persistent patterns (and systematic variations over time) in how residents experienced supervision that might not have been revealed by a cross-sectional study in one hospital ICU.
The principal investigator (PI; MT) interviewed residents to gather data about their experiences with medication safety and supervision when providing medication to ICU patients. A general interview guide33 addressed residents' personal experiences with ordering medications, receiving supervision, and their perceptions of institutional medication safety programs (Table 1, available online only). The interviewer consistently prompted residents to provide examples of their supervision experiences. The PI conducted confidential interviews in a private location near the ICU. Using confidential open-ended, in-depth interviews33 enabled the participating residents to provide frank answers to potentially sensitive questions.
The current study focuses on interviews with 17 residents; 8 from South Hospital, 6 from West Hospital, and 3 from North Hospital ICUs. Residents were at different training stages (years 1–4), and none declined participation. Interviews were audio-recorded, transcribed professionally, checked for accuracy of transcription, and de-identified. On average, each interview lasted about an hour, resulted in a 30-page transcript, and focused on how residents experienced supervision for over two-thirds of the transcript. Interviewees frequently described specific examples in vivid detail, yielding “rich information.” These data are consistent with Patton's observation that “the validity, meaningfulness, and insights generated from qualitative inquiry have more to do with the information richness of the cases selected…than with sample size.”33 (p.245) Field notes, document review, and observations of routine activities supplemented the interviews.
We coded and analyzed interview transcripts by applying the constant comparative method, in which we systematically examined and refined variations in the concepts that emerged from the data.33 To focus on the residents' perceptions of their training experiences, we began the data analysis without pre-existing codes. We refined and reconstructed the coding scheme in several iterative stages. Based on the initial review by two investigators (MT, HS), the PI and the coding team (TDG, SM) developed a preliminary coding scheme by induction, considering the residents' description of their experiences in the context of organizational research.34 They applied the coding scheme to three interview transcripts, reevaluated and revised it based on comments from other investigators (HS, EJT).
To ensure consistent data analysis,34 the PI and the coding team met regularly to review and refine the codes. The PI and the coding team finalized the coding scheme only after it was validated by two other investigators and reapplied to the first set of interview transcripts. Constructing a detailed coding guide, we defined specific codes and classified them under seven broad themes.
We engaged in an iterative coding process to ensure credibility.33 Both coding team members independently coded each interview and resolved differences through consensus. The PI reviewed each coded transcript and met with the team to resolve any remaining coding disagreements. We used Atlas.ti 5.0 software to manage data, assist in detecting patterns, and compile relevant quotations.
We observed patterns in the data; we inductively identified themes that emerged from the data as well as those related to organizational research. During the period that we conducted interviews, new rules limiting residents' working hours were implemented.10 We did not discern any pattern changes before and after the new rules. To enhance data analysis credibility,34 two investigators (HS, EJT), serving as “peer debriefers”,35 examined whether the themes accurately reflected the data and rigorously searched for counter-examples that contradicted the proposed themes.
Residents described how they were supervised not only by other physicians within the traditional medical hierarchy, but also by “other professionals,” including nurses, staff pharmacists, and clinical pharmacists i.e. “interprofessional” supervision (Figure 1 Appendix). After presenting these results, we examine how physicians and other professionals used communication strategies during interprofessional supervision. Here we use the term “residents” to include trainees at all levels, from interns to upper level residents, and male pronouns for de-identification.
Residents described teaching rounds as the formal setting where the attending and other team members guided and gave feedback on their medication-related decisions. After rounds, residents referred to the formal chain of command (from senior resident to fellow or attending) for their questions. However, residents also described enacting their own supervision by deciding when and how to ask for advice.
Residents developed different strategies for initiating supervision (Table 2). Some described a “rule of thumb” or personal decision making routine for determining when to approach a supervising physician with a question (e.g., if the patient is in serious condition) (Table 2, Columns 1 & 2). Others described how they decided when and how to ask an attending about their mistakes (Table 2, Columns 3 & 4). As might be expected, residents' strategies usually reflected a desire for professional autonomy tempered with varying assessments of their own limitations (Table 2, Columns 1 & 2, See Autonomy).
We also identified patterns in how residents and their supervising physicians communicated when residents initiated supervision (Table 3, Column 1). In general, residents considered attendings and fellows to be receptive to their questions. One resident explained: “There is no one here who is unapproachable…even an attending.” Nonetheless, residents reported using deferential language when initiating supervision (Table 3, Column 1, Row 2). Residents noted that attendings and fellows varied in their responses to questions and mistakes, as reflected in how they communicated with residents (Table 3, Column 1, Rows 1 & 3).
Despite recognizing the importance of asking questions, several residents expressed conflicting beliefs; they raised concerns about the personal consequences of seeking assistance. For instance, one resident advocated: “My point of view is I think it's wonderful when you ask questions. Cause that means you're conscientious enough to care about the patients--enough to do the right thing.” However, we observed that when he interrupted the research interview to consult with a fellow, he prefaced his query with: “Hey, I think this is a dumb question.” Some residents expressed contradictory beliefs when they described their embarrassment over appearing “stupid” and fears of looking “weak” in front of supervising physicians, even those they perceived as being approachable. Indeed, for one resident, the attending's accessibility increased his anxiety: “I don't want to lose respect by asking a stupid question.”
Residents described how other professionals used various methods of supervising their decision making (Table 4). Nurses and pharmacists intercepted medication orders and asked for clarifications, whereas clinical pharmacists also advised residents on ordering alternative medications (Table 4, Row 1). Other professionals regularly double-checked order implementation (Table 4, Row 2). Nurses, in particular, also routinely guided the future actions of residents by giving them cues and suggesting the next therapeutic tasks they should perform (Table 4, Row 3). When assessing residents' clinical decisions, these professionals applied different guidelines (Table 5). Nurses compared residents' clinical decisions to their expectations for “usual” experience-based practices (Table 5, Column 1); pharmacists consulted and noticed deviations from national and hospital pharmacy standards (Table 5, Column 2); and clinical pharmacists supplemented pharmacy standards with their professional judgment (Table 5, Column 3).
Residents, in turn, sought advice from other professionals. They actively engaged pharmacists in their supervision by asking questions ranging from basic clarifications to complex technical queries. “You can just take [the clinical pharmacist] to the side and say, `Hey listen. I forgot this medication. What am I supposed to give? It starts with an L,'” explained a resident. Other residents consulted clinical pharmacists for specialized expertise: “The [clinical pharmacists] usually have a protocol that they like to follow that a lot of the residents and probably even a lot of the attendings aren't aware of.” In one hospital, residents depended on the clinical pharmacists “They're always available and they really help out the team.” In another hospital, unit-based (on-site) pharmacists served as an informal but “extremely useful” resource. Residents also “relied on” central pharmacy-based staff, who provided essential backup, especially after-hours:
[The pharmacy is] always available, like if you have a question… There's a medicine you've never given, but it's the middle of the night, nobody else around, you want to call the pharmacist.
Unlike the medical hierarchy that clearly differentiates among residents, fellows, and attendings, interdisciplinary differences were less clearly delineated. Residents were perceived as having higher status than other professionals due, in part, to their medical education and responsibility for signing orders. Nurses and pharmacists, however, often had extensive experience and/or specialized training and thus, more expertise than residents. For instance, residents noticed their ambiguous status compared to nurses:
I don't know if some people might psychologically think it was better or worse, worse because it was coming from a nurse and maybe somebody would think that they wouldn't know as much or something like that. But other people would think of it as, they're a team member and they have the perfect right to know more. And maybe it's better because that way like maybe the fellow or attending wouldn't find out that you made a mistake. (emphasis added)
The resident acknowledged that nurses had expertise to catch mistakes, but had less status than he did and lacked authority to evaluate his performance.
To manage the ambiguous differences in their status, experience, and expertise, residents and other professionals used various communication strategies (Table 3, Column 2). Residents consistently recounted that pharmacists and nurses used deferential language, for example, by asking questions, rather than directly stating their concerns (Table 3, Column 2, Row 2). One resident appreciated the unit-nurses' indirect language: “Over here they're really cool about it. They'll say, `Is this right, are you sure about this?'” However, some residents also recalled that nurses used more direct language, such as “I am not comfortable,” especially when giving residents feedback on IV drug administration. In contrast, when asking pharmacists questions, residents consistently reported using non-judgmental language, but not deferential language. However, some residents used judgmental language when they disagreed with a pharmacist's intervention.
Individual residents bitterly recalled their encounters with other professionals during previous rotations. One described nurses who were “resident-unfriendly” and used judgmental language to mock a resident's choice of medications (Table 3, Column 2, Row 3). Another worked with clinical pharmacists who “feel like they are teaching the residents and they are above the residents.” These interactions illustrate how communication choices can create interprofessional tensions, especially when differences in status and expertise conflict or are unclear.
We analyzed interviews of residents working in medical ICUs to understand their supervision experiences related to medication safety. Although residents espoused beliefs in seeking assistance from supervising physicians and articulated strategies for doing so, many experienced difficulties in initiating supervision through the traditional medical hierarchy. Some residents were embarrassed by their mistaken decisions; others were concerned that their questions would reflect poorly on them.
Residents also received interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Other professionals evaluated residents' decisions by comparing them to distinctive professional guidelines and routinely used deferential language when conveying their concerns. Residents, in turn, asked other professionals for assistance.
We posit that interprofessional supervision clearly meets an accepted definition of supervision.3,9 Residents received “monitoring, guidance and feedback”9 (pg. 828) from other professionals, who engaged in routine monitoring and in situation specific double-checks of residents' clinical decisions, similar to those performed by supervising physicians.30 Moreover, other professionals demonstrated “the ability to anticipate a doctor's strengths and weaknesses in particular clinical situations in order to maximize patient safety.”9 (pg. 829)
Our study results have implications for graduate medical education (GME) reform. First, trainees experienced supervision as a two-way interaction.36 Residents balanced the countervailing pressures to act independently or to seek a supervising physician's advice, in part, by developing strategies for deciding when to ask questions. Kennedy et al identified similar “rhetorical strategies”.18 By asking questions about their clinical decisions, residents requested that supervising physicians guide their work; and thus, they proactively initiated and thereby enacted their own supervision. Fostering the conditions for initiating supervision is essential, especially given the association between lack of effective supervision and adverse outcomes,5,6,12–14 Second, residents expressed contradictory expectations about seeking advice from supervising physicians. Some residents were wary of approaching attending physicians for fear of appearing incompetent or being ridiculed.12,16,18,31 However, we found that other residents remained reluctant to seek advice despite simultaneously appreciating that attendings encouraged them to ask for assistance. Whereas the perceived approachability of supervising physicians was important,18,19 our exploratory findings suggest that it may be a necessary, but not a sufficient condition for creating a learning environment. Creating a supportive learning environment, in which residents feel comfortable in revealing their perceived shortcomings to supervising physicians,3 begins with cultural changes, such as building medical teams,6 but such changes can be slow to develop.
Third, interprofessional supervision offers a strategy for improving supervision. The ubiquitous involvement of nursing and pharmacy staff in monitoring and intervening in residents' medication-related decisions could result in overlooking their unique contributions to resident supervision. Mindful that supervising physicians evaluate them, residents selectively sought nonjudgmental advice from professionals outside the medical hierarchy. Therefore, improving supervision could entail offering residents ready access to other professionals who can advise them, especially during late night hours when supervising physicians usually are not present.17,27
The importance of interprofessional supervision has been under recognized and underemphasized in GME. Our study findings, if supported by future research, highlight how interpersonal communication techniques could influence both interprofessional supervision and hierarchical supervision among physicians. Medical team training programs37–39 emphasize developing skills, such as “mutual performance monitoring,”40 (pg. 13) by training providers to raise and respond to potentially sensitive questions. Improving supervision by enhancing interpersonal communication skills may be important not only when relative status differences are clear (i.e., physician hierarchy) but also when status differences are ambiguous (i.e., residents and other professionals). GME programs could consider incorporating these techniques into their formal curricula, as could programs for nursing and pharmacy staff.
Our study has several limitations. Because of the larger research project objectives, we focused on medication safety in medical ICU settings, where nurses and pharmacists may be especially vigilant and proactive in monitoring residents. Thus, our findings may be specific to medication issues and less relevant outside ICUs. We had a relatively small sample size and do not claim to generalize from it, although we believe it offers meaningful insights. We also did not continue enlarging our sample until reaching “redundancy”35 (pg. 202). Nevertheless, the purposeful random sample of residents produced rich information. Indeed, some study results are consistent with previous resident education research,18 adding validity to our findings. Although the interview protocol was not designed specifically to investigate supervision, the resulting interviews yielded abundant data containing residents' detailed descriptions of how they experienced supervision. Although we were careful to note whether particular perceptions were unique to one resident, or shared by others, we recognize that the value of residents' observations is assessed by the quality of the insights they provide, not necessarily by the number of residents who described the same experience.
In conclusion, we found that residents experienced difficulties in initiating traditional hierarchical supervision related to medication safety in the ICU. However, they reported ubiquitous interprofessional supervision, albeit limited in scope, which they relied upon for nonjudgmental guidance in their therapeutic decision making especially after-hours. In our study, interprofessional supervision proved crucial to improving medication safety in the ICU.
Funding: Project supported by AHRQ grant #1PO1HS1154401 and in part by the Houston VA HSR&D Center of Excellence (HFP90-020).
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
No conflicts of Interest