Introduction
Methods
Design
Sampling
Procedure
Analysis
Results
Behavioural descriptors | Representative quotes |
---|---|
Identified by faculty and trainees | |
Advocacy
• Being the patient’s advocate • Being vocal/assertive about the patient’s best treatment/care • Challenging the team as needed |
‘…advocacy for the patient within the system; doing what’s right for them, even when it is a hassle’
|
‘…advocate for the course of action they believe is in their patient’s best interest’
| |
Autonomy
• Independence • Self-awareness (including own limitations) • Seeking consultation when needed • Thinking critically • Decision-making |
‘I am impressed when residents manage problems that arise on their own, or after asking for my input, rather than always turning things over to me’
|
‘Feeling comfortable making autonomous decisions and using attending as a consultant, when advice is needed’
| |
‘Offer a plan to your attending for revision, but make sure you HAVE a plan and, if appropriate, a contingency plan’
| |
Commitment
• Putting professional responsibilities first • Going the extra mile • Engagement • Actively participating • Being invested • Providing excellent care to patients seen on cross-cover or for a shift |
‘Ownership should not only apply to patients on your service, but also patients you are cross-covering for, e.g., on weekends. With an increase in hand-offs with more regular work hours, residents must learn to take ownership for patients they have temporary responsibility for’
|
‘Not just to be medication prescriber but to be actively involved in all aspects of patient care such as disposition plan, follow up, talk with outpatient provider and family members’
| |
Communication
• Communicating with patients, families, other providers regarding transitions of care |
‘Coordination of care, including effective and inclusive communication with all team members and family’
|
‘Call families and outpatient providers’
| |
‘Providing up to date, comprehensive, and informative sign out’
| |
‘Physician is able to articulate goals of treatment/plans to patient’
| |
Follow-through
• Being thorough, dependable, conscientious, diligent, responsive, accountable • Coordinating care • Taking care of detail • Carrying out the treatment plan • Making sure things do not fall through the cracks |
‘Physician follows up on labs/test/medications that he/she has ordered. Does not need to be reminded. Takes full responsibility for all aspects of care’
|
‘YOU make sure that all the loose ends are tied together, tests have been ordered and results checked, treatment changes have been carried out, scheduled meetings have taken place, etc’
| |
‘Actively participates in the daily work necessary to enact treatment plan’
| |
Knowledge
• Reading and learning all about the patient |
‘…knowledge of the patient’s presenting concerns, the goals for hospitalization, the status of these goals and what that resident/fellow needs to do as a team member to move the case forward’
|
‘Knowing the labs and the past history, being generally up-to-date before rounds start, trying to do some patient-specific learning when the treatment plan isn’t cut and dried’
| |
‘Strives to know more about the patient than any other person on the team; the ‘go-to’ person for knowledge about the patient’
| |
Teamwork
• Collaboration • Awareness of one’s role within the health care team • Taking ownership for the part of the care you are responsible for • Shared/team responsibility for the patient • Being considerate of the team in scheduling absences, other activities |
‘…a sense of shared primary responsibility for part of the care of a patient’
|
‘Considers impact on ward/service functioning when scheduling elective absences (doctor appointments, supervision, etc.)’
| |
‘…facilitated the smooth functioning of the team …understood and respected my role as an attending, but this did not stop him from taking ownership of the team’
| |
‘Making collaborative decisions about the patient’
| |
‘Checking in with team members – i.e. overnight nursing staff’
| |
Identified by faculty only | |
Continuity of care
• Ensuring good care even when you are not there (e.g., sign-outs, handoffs) |
‘I am concerned that there is a process of ‘hand offs’ where each person hangs in there for their ‘shift’ hoping that nothing goes wrong … until they can hand off the patient to the next person in the queue’
|
‘Ensuring continuity of care when you are absent from the service’
| |
Excellence
• Providing high quality of care |
‘YOU have primary responsibility for the patient receiving high quality of care and having a good outcome’
|
‘Making all efforts needed to deliver best care despite the time and individual sacrifices that may entail’
| |
Extra time
• Spending extra time • Availability after regular hours • Being the patient’s doctor 24/7 |
‘…coming in early to read about the patients and staying late to read the scientific literature’
|
‘Tending to all the patients’ needs…after hours if needed’
| |
Initiative
• Being proactive rather than passive |
‘It means being the patient’s doctor, in what I guess is the old-fashioned sense of that term: you are the one who calls to check on how they are doing, you are their contact person within the system, you take the initiative to involve their family members when appropriate…, you interact with the [social worker] to get referrals taken care of…, you call other services…, you make sure that they are scheduled back appropriately and that they have this information’
|
‘…being thorough and proactive in patient care rather than waiting to have the attending tell them what to do’
| |
Sense of vocation or calling
• Having a deeply personal sense of responsibility • Altruism • Sacrifice • Earning and being worthy of trust |
‘… the deep sense that I have an abiding duty to my patients that transcends incidentals of schedules, shifts, hours worked…’
|
‘a sense of personal commitment’
| |
Identified by trainees only | |
Hierarchical tension
• Struggles with attendings regarding degree of autonomy/independence |
‘Taking an active part in discussions with the patient as opposed to just letting attendings decide what they want to do’
|
‘To have the attending defer to you during morning rounds with the nurses’
| |
Leading
• Being in charge |
‘Primary provider in discussions, management, and treatment decisions with the patient’
|
‘To get paged for all issues from the nursing staff first’
|
Discussion of qualitative study
Diagnosing ownership problems
Theory of planned behaviour in assessing ownership attitudes
Case 1: Ann, a first-year trainee on her first rotation, has difficulty completing tasks assigned in rounds. As a first step, her supervisor identifies this as a problem with follow-through. When given feedback, Ann is embarrassed and says that she cannot keep track of everything that she needs to do. Her supervisor conceptualizes this as a skills deficit, and teaches Ann to keep a structured to-do list with boxes to check when she completes each task. |
Case 2: Charlie is half way through training. He knows about his patients, completes assigned tasks, and gives knowledgeable answers to questions. However, he looks to the supervisor to interview patients, lead team meetings, and determine diagnoses and treatment plans. The supervisor identifies a deficit in autonomy, realizes that he has not specifically reviewed his expectations with Charlie, but learns that Charlie has shown more initiative on prior rotations. He suspects an attitude issue, but nevertheless reviews with Charlie his expectations that Charlie be the team leader. Using the theory of planned behaviour, he explores Charlie’s views of the importance, social norms around, and difficulty with taking on this role. Charlie states that he considers this goal meaningful, but that he has found it difficult and unimportant that he be more autonomous and serve as the team leader on this rotation, since the supervisor takes care of everything. The supervisor considers that he might be ‘micro-managing,’ which is interfering with Charlie’s ability to take ownership of patient care. Together, they make an action plan that Charlie will act as the team leader, with specific goals for what this entails. The supervisor agrees to allow Charlie to be more autonomous, while ensuring patient safety. |
Case 3: Stephanie, early in her second year of training, is eager to take on responsibility for patients and ‘own’ patient care. She confidently gives her opinion of diagnoses and treatment plans, but considers a very narrow differential diagnosis and displays lack of appropriate knowledge or clinical reasoning to back up her diagnoses and plans. Her supervisor views her as an ‘over-owner’, taking on more ownership than warranted by her clinical skills. In this case, the supervisor’s feedback and guidance can acknowledge Stephanie’s high level of ownership and desire to take on responsibility, but focus on the need to develop other competencies (differential diagnosis, medical knowledge, responsiveness to constructive feedback) to enhance her clinical skills. |
Discussion
Conclusions
Essentials
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Behavioural definitions are necessary in order for supervisors to systematically and objectively evaluate trainees.
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A consensus-derived behavioural definition of ownership of patient care is presented and includes the following elements: advocacy, autonomy, commitment, communication, follow-through, knowledge and teamwork.
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A two-step process for identifying trainee deficits in ownership begins by determining which behaviour needs improvement and then considering whether the deficit is one of knowledge, skill or attitude.
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The TPB is applied to better understand the relationship between attitudes, intentions and subsequent behaviour.
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Deficits are best explored and remediated in the practice environment within the supervisory relationship.