Progressive Autonomy Research Articles

Children’s rights in the field of early education

ABSTRACT The psychologist’s work in education is a field permanently under construction, crossed by multiple tensions. Some tensions are macrosocial, where the design of educational policy obliges us to study the impacts that policy produces in the microspaces of power and professional practice. Uruguay’s education law, enacted in 2008, clearly adopts a rights perspective, recognizing children as subjects of law. This raises the issue of how, in their daily work, professionals see and perform their role as guarantors of children’s rights. At a microsocial level, educational centres become privileged places to deploy rights promotion practices. Our research group in Early Childhood and Early Education has carried out qualitative studies with the objective of contributing to the integration of a children’s rights perspective in the field of Early Education. This article reports on two studies. In one the teachers take progressive autonomy as an axis of analysis while in the other the axis of analysis is the participation of children in educational practices. The data collection techniques used were discussion groups, participant observation and in-depth interviews. The results show that although many of the teachers’ educational actions reflect a conception of the child as a subject of rights, the teachers do not see these actions in terms of guaranteeing children’s rights. The dialogue generated by these results has fed back and enriched the analysis of the dimensions studied, as well as our rights-promoting interventions in the Early Education centres.

A Systematic Observation of Early Childhood Educators Accompanying Young Children's Free Play at Emmi Pikler Nursery School: Instrumental Behaviors and Their Relational Value.

A significant number of literature documents young children’s innate interest in discovering their surroundings and gradually developing more complex activities and thoughts. It has been demonstrated that when environments support young children’s innate interest and progressive autonomy, they help children acquire a self-determined behavior. However, little is known about the application of this evidence in the daily practice of early childhood educational settings. This study examines Emmi Pikler Nursery School, a center that implements an autonomy-supportive educational approach. We conducted a systematic observation of two experienced Pikler educators while they accompanied young children’s free play. Our objective was to assess: if educators’ instrumental action follows a systematic behavioral sequence, if specific relational behaviors support each instrumental action, and if educators display differentiated intervention levels concerning children’s free play through the adaptation of the relational dimension. We conducted a lag sequential analysis to find behavioral patterns and concurrences between the observed behaviors. Our findings indicate that educators perform systematic action sequences and that each of the instrumental actions of those sequences has a specific relational value. We conclude that educators display three differentiated intervention levels depending on the child and the circumstances of the moment, providing appropriate autonomy support and reinforcing children’s self-determination.

A Sustainable and Scalable Multidisciplinary Airway Teaching Mission: The Operation Airway 10-Year Experience.

To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy. Consecutive case series with chart review. This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic. Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes. A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded. This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Residents’ method for gaining operative autonomy

IntroductionThe goal of this study was to explore the resident construct for their perceived successful method of actions that lead to OR autonomy during residency and the strategies they employed. MethodsWe conducted focus group interviews with residents from the General Surgery (GS) and Obstetrics & Gynecology (OBGYN) departments at a single academic institution across all clinical postgraduate years (PGY) using convenience sampling. Audio recordings of each interview were transcribed, analyzed and emergent themes were identified using a framework method. ResultsA total of 38 residents participated. A 3-stage resident method to gain operative autonomy emerged. This progresses from building rapport, developing mutual entrustment, and finally to obtaining autonomy. We identified 4 common strategies used by residents to construct this method: smart communication, attention to attending preferences, helpful allies and visible attributes. ConclusionOur findings provide insight into resident strategies to achieve progressive autonomy in the OR helping programs improve resident’s learning efficiency.

Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles

Progressive autonomy leading to conditional independence is necessary to achieve competence in surgical skills and decision making. Trust and transparency are ethical imperatives, but practices vary regarding the extent of disclosure of specific resident roles. We tested whether a standardized preoperative script would improve patient acceptance of resident involvement in perioperative care. Patients admitted to a resident-run acute care general surgery service between October 2017 and October 2018 were enrolled in an IRB-approved study. During the first half of the rotation (control), operative consent was obtained according to individual practice without specified explanation of resident roles. During the second half (intervention), the senior resident read a short semistructured script specifically explaining team roles and responsibilities, including the degree of resident independence and supervision by attendings. On postoperative day 3, patients completed a survey assessing understanding of their surgical care. Sixty-two patients under the care of 10 rotating chief residents were enrolled; 46 patients completed the survey, 23 in each arm (74% response rate). Ten patients in the control arm (43%) compared to only 3 (13%) in the intervention arm indicated that residents should not be allowed to perform portions of operations (odds ratio 4.94, p = 0.047). Patients in the intervention arm felt that care team roles were more adequately explained to them before their operation (p = 0.002). There was no difference in the number of patients naming a resident as "their doctor." Use of a short script specifying resident roles improves patient acceptance of trainee participation in perioperative care.

Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool.

Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision. A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level. Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established. We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.

Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles

Background Progressive autonomy leading to conditional independence is necessary to achieve competence in surgical skills and decision making. Trust and transparency are ethical imperatives, but practices vary regarding the extent of disclosure of specific resident roles. We tested whether a standardized preoperative script would improve patient acceptance of resident involvement in perioperative care. Methods Patients admitted to a resident-run acute care general surgery service between October 2017 and October 2018 were enrolled in an IRB-approved study. During the first half of the rotation (control), operative consent was obtained according to individual practice without specified explanation of resident roles. During the second half (intervention), the senior resident read a short semistructured script specifically explaining team roles and responsibilities, including the degree of resident independence and supervision by attendings. On postoperative day 3, patients completed a survey assessing understanding of surgical care. Results Sixty-two patients under the care of 10 rotating chief residents were enrolled; 46 patients completed the survey, 23 in each arm (74% response rate). Ten patients in the control arm (43%) compared to only 3 (13%) in the intervention arm indicated that residents should not be allowed to perform portions of operations (odds ratio 4.94, p = 0.047). Patients in the intervention arm felt that care team roles were more adequately explained to them before operation (p = 0.002). There was no difference in the number of patients naming a resident as their doctor. Conclusions Use of a short script specifying resident roles improves patient acceptance of trainee participation in perioperative care.

81. COMFORT AND PERCEIVED VALUE: PARENT VIEWS OF TRAINEE PARTICIPATION IN PEDIATRIC CARE

Intro Trainees require progressive autonomy to prepare for unsupervised practice as physicians. Studies show that patients largely accept trainee participation in their own medical care, but little is known about parental perceptions of medical student and resident engagement in pediatric care. Methods We conducted a national cross-sectional online survey of parents with at least one child under 18 years. The survey used 5-point Likert scale to explore acceptability, desirability, and perceived value of medical student and resident involvement in pediatric care. The survey also assessed parent comfort with progressive trainee autonomy in the clinical encounter. The Wilcoxon rank sum test was used to compare means for Likert scale responses, p Results A total of 3,000 parents completed the survey, of whom 87.9% were female, 82.5% were white, 32.3% had prior experience with medical students and 38.4% had experience with residents in their child's care. Parents appreciated the importance of trainee participation (4.0±1.1 for students, 3.9±1.0 for residents) and enjoyed having trainees present (3.8±1.0 for students, 3.9±1.1 for residents). Parents, regardless of exposure to trainees, were more comfortable with resident autonomy than student autonomy at each stage of the clinical encounter (p Conclusion Parents valued and enjoyed trainee participation in the care of their children and were more comfortable with progressive autonomy for residents than students. Prior exposure to students or residents increased parental comfort with autonomy for respective trainee types. Further studies should investigate how parent and child characteristics correlate with how parents view trainee involvement in pediatric care.

79. RESIDENT AUTONOMY: ARE ATTENDINGS AROUND TOO MUCH?

Background According to guidelines from the ACGME, residents must demonstrate progressive autonomy over the course of training that affords them the ability to act in a supervisory role under faculty guidance in preparation for independent practice. As adult learning theory supports, autonomy within a supportive climate can have a significant impact in motivating learners to expand their knowledge base and practice methods. We created a needs assessment survey to help obtain information regarding the current opinions surrounding autonomy within our own residency program. Objective We sought to determine residents’ perception of autonomy during their pediatric residency training with a secondary objective of preliminary assessment for an attending-less rounding experience to address autonomy and supervisory elements within the residency curriculum. Methods In 2018, graduating PGY3 Pediatric residents and PGY4 combined Internal Medicine/Pediatric residents were electronically sent an anonymous novel survey. The questions focused on overall level of supervision as well as how valuable they would find rounding without an attending in terms of building their own autonomy. Numerical responses were collected for statistical interpretation. Results We obtained surveys from 33/36 graduating residents within their final month of residency training. Respondents reported a mean value of 72/100 (Scale: 0/100 = significantly unsupervised, 50/100 adequately supervised, 100/100 significantly over-supervised) when asked about their level of supervision on pediatric services. This cohort also reported a mean value of 82.42/100 and 83.27/100 when asked how valuable and how enjoyable, respectively, attending-less rounding on our Hospitalist service would be for resident autonomy. Conclusions Clinical settings within pediatric residency training programs can find it hard to balance autonomy given the extrinsic forces that are present. However, our residents demonstrate a perception of being over-supervised and support creating space for greater decision-making responsibilities and increased autonomy through revised inpatient service structure.

80. DOES MY TEAM REALLY NEED OUR ATTENDING? PERCEIVED AUTONOMY OF ATTENDING-LESS ROUNDS

Background According to accreditation guidelines, residents must demonstrate progressive autonomy over the course of training. Although desired, there is little data showing the impact on the perceived sense of autonomy of housestaff when rounding without an attending on an inpatient service. Objective Determine residents’ and interns’ perception of autonomy with and without the attending present on family centered rounds on a hospitalist general pediatric service in a tertiary children's hospital. Methods Residents and interns who participated in standard family centered rounds and attending-less family centered rounds were given anonymous surveys asking about their ability to complete tasks autonomously on a Likert-type scale. Attendings completed a similar survey assessing their upper level resident. We averaged the standard rounds responses (pre-forms) and compared them to the attending-less rounds responses (post-forms). Comments were allowed for qualitative data. Results We obtained surveys from 15 interns, 10 upper levels and 7 attendings who participated. Compared to the pre-surveys, residents felt more autonomous in 7/11 areas queried (p Conclusions Attending-less rounds appear to improve residents’ and interns’ self-perception of autonomy compared to standard family centered rounds with the attending present. This suggests attending-less rounds offer educational benefits that warrant consideration into future service structure.

Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability.

This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model

To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design. In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis. General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System. A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty. Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes. This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

Participation and progressive autonomy of the adolescent. School democratization in Buenos Aires (Argentina)

(descriptivo): la consideración del adolescente como sujeto de derecho, que goza de una ciudadanía plena, y con un ejercicio progresivo de su autonomía, es el eje de esta investigación. ¿Ha podido la escuela adaptar sus reglas y prácticas a estos principios convencionales? A partir del relevamiento de los acuerdos de convivencia de las escuelas secundarias de la Región Metropolitana Norte de la provincia de Buenos Aires, y de entrevistas y encuestas a miembros de la comunidad educativa, el estudio describe esa brecha. La participación adolescente en el diseño de las pautas de su vida escolar y los modos en los que se gestiona su intervención, no alcanzan aún los estándares previstos en la Convención de los Derechos del Niño para una ciudadanía plena en la infancia.

See one, do one, teach one: A randomized controlled study evaluating the benefit of autonomy in surgical education

Introduction"See one, do one, teach one" has represented the model for surgical education for over a century, however recent changes in education have reduced autonomy in training. The goal of this study was to assess the impact of autonomy on learning a procedural skill. MethodsSenior medical students were randomized and trained to performance a vascular anastomosis utilizing progressive autonomy vs. constant supervision. Performance was tested using videotaped technical grading and anastomotic pressure testing. ResultsMean baseline performance times and technical ratings were similar in both groups. Final completion times was faster in the autonomy group, 14:03min vs. 19:09min (p = 0.02). Final technical ratings were similar, 40.0 vs. 39.2points (max = 50), for each group and both demonstrated similar improvement in leak test against a standardized sample. ConclusionTeaching a procedure, as a final step in graded autonomy, results in superior performance in timing while maintaining equal technical performance compared to trainees with less autonomy.

Progressive Autonomy in the Era of Increased Supervision: AOA Critical Issues.

The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy.Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.

La protección del derecho a la vivienda de niños, niñas y adolescentes en el Derecho de las Familias

El Derecho de las Familias como se lo denomina con mayor precisión de manera contemporánea, se asienta sobre los principios de igualdad, autonomía y solidaridad, otorgando a las personas vulnerables un lugar primordial en el Código Civil y Comercial de la Nación (CCyC). Ello adquiere efectos jurídicos concretos en el cruce entre protección de la vivienda y derechos de niños, niñas y adolescentes (NNA), desde un régimen renovado tanto de la vivienda familiar, como del ejercicio de derechos por parte de las personas menores de 18 años a la luz del principio de autonomía progresiva. Así, nos proponemos en el presente artículo revisar críticamente, el referido cruce a través de las normas que componen el actual Derecho de las Familias, así como el panorama jurisprudencial, a partir de la vigencia del CCyC. Para este fin, se propone analizar 4 ejes que reflejan problemáticas bien actuales en la materia: I) el ejercicio de derechos de NNA respecto a la vivienda familiar por la atribución de su uso frente a crisis entre los progenitores, II) el derecho a la protección de la vivienda de NNA en las relaciones extrafamiliares, principalmente los casos de desalojos, III) los adolescentes, la autonomía progresiva y el acceso a la vivienda a partir del supuesto especial que prevé la Ley 27.364 de egreso asistido para adolescentes sin cuidados parentales, y IV) la obligada perspectiva de género a la luz del rol que las mujeres ocupan frente a la protección de la vivienda de sus hijos e hijas.

Resident hesitation in the operating room: does uncertainty equal incompetence?

In postgraduate medical programmes, the progressive development of autonomy places residents in situations in which they must cope with uncertainty. We explored the phenomenon of hesitation, triggered by uncertainty, in the context of the operating room in order to understand the social behaviours surrounding supervision and progressive autonomy. Nine surgical residents and their supervising surgeons at a Canadian medical school were selected. Each resident-supervisor pair was observed during a surgical procedure and subsequently participated in separate post-observation, semi-structured interviews. Constructivist grounded theory was used to guide the collection and analysis of data. Three hesitation-related themes were identified: the principle of progress; the meaning of hesitation, and the judgement of competence. Supervisors and residents understood hesitation in the context of a core surgical principle we termed the 'principle of progress'. This principle reflects the supervisors' and residents' shared norm that maintaining progress throughout a surgical procedure is of utmost importance. Resident hesitation was perceived as the first indication of a disruption to this principle and was therefore interpreted by supervisors and residents alike as a sign of incompetence. This interpretation influenced the teaching-learning process during these moments when residents were working at the edge of their abilities. The principle of progress influences the meaning of hesitation which, in turn, shapes judgements of competence. This has important implications for teaching and learning in direct supervision settings such as surgery. Without efforts to change the perception that hesitation represents incompetence, these potential teaching-learning moments will not fully support progressive autonomy.

The progressive autonomy of the child and its participation in the judicial process

This research studies the issue of the progressive autonomy of children and adolescents and the problems of their participation in the various processes in which they are involved, particularly related to their right of access to justice and the exercise of their right to be heard in the judicial sphere.

Effect of Ongoing Assessment of Resident Operative Autonomy on the Operating Room Environment

We have previously demonstrated the feasibility and validity of a smartphone-based system called Procedural Autonomy and Supervision System (PASS), which uses the Zwisch autonomy scale to facilitate assessment of the operative performances of surgical residents and promote progressive autonomy. To determine whether the use of PASS in a general surgery residency program is associated with any negative consequences, we tested the null hypothesis that PASS implementation at our institution would not negatively affect resident or faculty satisfaction in the operating room (OR) nor increase mean OR times for cases performed together by residents and faculty. Mean OR times were obtained from the electronic medical record at Northwestern Memorial Hospital for the 20 procedures most commonly performed by faculty members with residents before and after PASS implementation. OR times were compared via two-sample t-test. The OR Educational Environment Measure tool was used to assess OR satisfaction with all clinically active general surgery residents (n = 31) and full-time general surgery faculty members (n = 27) before and after PASS implementation. Results were compared using the Mann-Whitney rank sum test. A significant prolongation in mean OR time between control and study period was found for only 1 of the 20 operative procedures performed at least 20 times by participating faculty members with residents. Based on the overall survey score, no significant differences were found between resident and faculty responses to the OR Educational Environment Measure survey before and after PASS implementation. When individual survey items were compared, while no differences were found with resident responses, differences were noted with faculty responses for 7 of the 35 items addressed although after Bonferroni correction none of these differences remained significant. Our data suggest that PASS does not increase mean OR times for the most commonly performed procedures. Resident OR satisfaction did not significantly change during PASS implementation, whereas some changes in faculty satisfaction were noted suggesting that PASS implementation may have had some negative effect with them. Although the effect on faculty satisfaction clearly requires further investigation, our findings support that use of an autonomy-based OR performance assessment system such as PASS does not appear to have a major negative influence on OR times nor OR satisfaction.

Program Strengths and Opportunities for Improvement Identified by Residents During ACGME Site Visits in 5 Surgical Specialties.

Background There is limited information about how residents in surgical specialties view program strengths and opportunities for improvement (OFIs). Objective This study aggregated surgical residents' perspectives on program strengths and OFIs to determine whether there was agreement in perspectives among residents in 5 surgical specialties. Methods Resident consensus lists of program strengths and areas for improvement were aggregated from site visits reports during 2012 and 2013 for obstetrics and gynecology, orthopaedic surgery, otolaryngology, plastic surgery, and surgery programs. Four trained individuals coded each strength or OFI in 1 of 3 categories: (1) factors common to all specialties; (2) program or institutional resources; and (3) factors unique to surgical specialties. Themes were classified as most frequent when listed by residents in more than 20% of the programs and less frequent when listed by residents in less than 20% of the programs. Results This study included a total of 359 programs, representing 27% to 49% of the Accreditation Council for Graduate Medical Education accredited programs in the 5 specialties. The most frequent strengths were progressive autonomy, collegiality, program leadership, and operative volume. Improving research and didactics, increasing faculty teaching and attendance at educational sessions, and increasing the number of nurse practitioners and physician assistants were common OFIs. Conclusions Factors identified as important by surgical residents related to their learning environment, their educational program, and program and institutional support. Across programs in the study, similar attributes were listed as both program strengths and OFIs.