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

We 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.