Graded autonomy and grounded self-determination in health professions education

A key goal in health professions education is to support trainee development toward readiness for unsupervised clinical practice. Curricula can use entrustable professional activities (EPAs) and entrustment decision-making to structure and optimize this development. Trainees begin at the periphery of the health care community and gradually learn to think, feel, and act as a professional as they increasingly engage with the work of the community, step by step and EPA by EPA. Learning in the classroom and in the clinical workplace should be approached as integrated rather than separate phases. Classroom learning aims to prepare trainees for clinical practice, and learning through clinical practice can start early, with full supervision that decreases over time. Clinical supervisors must balance supervision for patient safety and trainee support with trainee autonomy and practice of clinical responsibilities. Under- or over-supervision has negative implications not just for patient safety but also for learning and development. Various theories and models support the importance of graded autonomy, including self-determination theory, cognitive apprenticeship theory, and learning-oriented teaching. Curricula designed to support graded autonomy need to adequately prepare trainees to contribute to the workplace via classroom education and exposure to the workplace followed by clinical experiences that allow for increasing trainee contributions to patient care. Entrustment is a forward-facing decision. As trainees achieve levels of entrustment for patient care activities, this achievement is not just a completion of a learning stage but a start of the acquisition of more responsibilities as health care team members.