Exploring Pediatric Residents’ Experiences with Decision-Making in Complex Hospital-Based Clinical Learning Environments in the United States

PhenomenonResidents traditionally developed decision-making skills through increasingly independent practice, but many now report diminished roles in decision-making leading to concerns about readiness for practice. The clinical learning environment (CLE) shapes residents' experiences through interacting social, personal, and organizational factors that create tensions residents must navigate. Such tensions likely impact if and how residents engage in clinical decision-making, and understanding these tensions may offer insights into how to best support residents in today's CLE. This study aimed to explore how residents perceive navigating tensions in the CLE through their participation in clinical decision-making. ApproachAs part of a larger qualitative study on resident decision-making, we conducted semi-structured interviews with 38 second- and third-year pediatric residents across three academic medical centers in the United States. Using a constructivist paradigm and template analysis, we analyzed narrative excerpts focused on tensions in hospital-based clinical decision-making. We selected three representative narratives and present them in their entirety to illustrate a more complete picture of the complexity of the CLE. FindingsThe narratives described tensions in 1) who makes decisions, 2) when and where decisions are made, and 3) how decisions are made. Sometimes residents successfully addressed these tensions and described learning, but other times they described being marginalized, resulting in disengagement. InsightsWe propose a model for understanding residents' involvement in clinical decision-making in the CLE that combines elements of Lave and Wenger's Communities of Practice and Vygotsky's Zone of Proximal Development (ZPD). In this new model, residents can be in their ZPD as either central or peripheral participants in clinical decision-making or be marginalized participants and disengaged from learning. By highlighting the workplace tensions that different interacting factors in the CLE create, we propose new ways to support residents' development of decision-making skills in increasingly complex clinical contexts. We suggest conscious deliberation for residents, supervisors, and education leaders. By paying close attention to the context of each dynamic, evolving decision-making process, residents can adjust their expectations for participation; supervisors can support residents within their ZPD as central or peripheral participants; and education and clinical leaders can strive to create schedules, team structures, and workflows that support resident involvement in patient care. Successful navigation of CLE complexity is necessary to ensure that residents develop decision-making skills for future independent practice.