Are We Trustworthy? Flipping Entrustment on Its Head

• In Event: Entrustment as Workplace-Based Assessment in Health Professions Education: Taking the Consequences of Assessment Seriously

Abstract

Studies of how clinical supervisors make entrustment decisions have confirmed the importance of learner attributes related to integrity and humility. From a teacher/clinical supervisor perspective, we expect our learners to be honest and to admit limitations and ask for help when needed.1 When our learners fail to rise to this standard, our tendency is to blame the learner. We approach this as a unidirectional phenomenon and say that the learner is not ready for entrustment, or worse, “not trustworthy”.
However, learner behaviors can be viewed from Bandura’s framework of triadic reciprocal causation where there are interactions among a learner’s personal factors, the environment, and the learner’s behaviors. Here, behaviors are determined not just by a learner’s moral standards but are influenced by the environment and the learner’s outcome expectations for the behaviors.2 In other words, if there are attributes we desire in our learners, the learning environment should be designed to bring them forward. Therefore, as educators and stewards of the learning environment, instead of blaming learners, we need to be asking instead, Are we trustworthy in our own behaviors? Do we model honesty and humility? Can learners trust us to respond positively instead of negatively to their honesty and humility?
The learning environment, as a concept, is large and can be defined as everything surrounding learning. Gruppen et al. suggests viewing it as four interactive components: personal, social, organizational, physical/virtual spaces. The personal includes learner interactions with the environment and their trust or lack of trust in the system. The social includes the relationships between learners and teachers and others, such as team members, that shape their perceptions and behaviors. The organizational includes curricular structure and resources, and institutional culture, practices, and policies.3 Philibert et al. further subdivides the organizational space into the microsystem (rotation/unit/department) that provides the immediate context and the larger organization which may impact norms and practices and in which the training and microsystem are situated.4
Practical examples will be provided for how we might signal whether we are trustworthy or not at the social and organizational levels via our teaching interactions with learners, microsystem culture, and organizational processes and policies. Attention will be placed on the concepts of bidirectional trust5, educational alliance6, just culture7, and psychological safety8 as potential approaches to the learning environment.
Exemplary health professions learning environments have been described as clinical workplaces where learners and teachers work together to deliver quality care - where there is a shared goal of improving health and where learning is work and work is learning.9 From this standpoint, we cannot deliver optimal and safe care unless we and our institutions are trustworthy enough to enable our learners to demonstrate their trustworthiness.

Author

• Huiju Carrie Chen, Georgetown University
  Presenting Author