First-year residents' experiences of uncertainty in rural and urban emergency departments.

backgroundUncertainty is an inherent and challenging aspect of medical practice, particularly for first-year residents making the transition from theoretical education to clinical practice. We aimed to identify factors influencing uncertainty experienced by residents practicing within different organizational frameworks, which could serve as potential targets for supportive interventions.

methodsA qualitative study was conducted using semi-structured interviews with 20 first-year residents across five organizationally and geographically diverse hospitals in Norway. The reflective interviews were informed by participatory observation during emergency department shifts that provided verbal and behavioral cues signaling uncertainty. Data was transcribed and analyzed using Systematic Text Condensation.

resultsWe found four themes with factors influencing residents’ experiences of uncertainty: 1) Residents’ Competence: level of experience and knowledge affected level of uncertainty and confidence, 2) Clinical Complexity: level of patient complexity affected level of uncertainty and the need for consultative support. 3) Consultative Support: availability and predictability of consultative support from senior physician affected level of uncertainty. 4) Level of responsibility: greater responsibility of residents in rural hospitals, due to limited support, fostered faster learning but with the downside of greater initial uncertainty and suboptimal learning environment. We also found that additional factors outside of physicians control such as the number of concurrent patients, the urgency and severity of clinical cases, and related time pressure, further influenced the residents' experience of uncertainty.

conclusionFirst-year residents’ experience of uncertainty is influenced by a combination of personal and organizational factors. Rural hospital settings, which offer limited consultative support and greater responsibility, may foster more uncertainty initially but also promote a quicker transition towards autonomous uncertainty management and development of uncertainty tolerance. Urban settings offer more immediate uncertainty management support, but often under higher patient loads and time constraints, limiting residents’ experience with critically ill patients and responsibility in general. These findings can help hospitals, universities and management modify factors affecting residents’ experiences of uncertainty. This can also help in training medical students and residents so they can better understand, tolerate and manage uncertainty.

trial registrationThis is an observational study which does not include any intervention; therefore, it has not been registered.