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
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.