By: Dr. Arvin DamodaranFollowing eras of psychometrics, judgement and programmatic assessment, Carretta Wyer et al. in their considered and compelling article, recently challenged the healthcare education community to move into a new assessment era of trust as critcal for systematic credibilty (Caretta-Weyer, Smirnova et al. 2024). While the article is a serious call to arms and should be mandatory reading for healthcare education decision makers, I have some thoughts on conceptualising trust as an era.
The problem with eras is the implicit transience. Lately, assessment eras seem to be shifting faster than a Tay Tay costume change. Marking beginnings and endings can also be complex. Whether the post ice age Holocene epoch has given way to the Anthropocene is still a hot topic if you are a geologist (National-Geographic-Society 2023). Human influence is seen in the carbon spike of the industrial revolution, but atomic fallout is also a dramatic mark in the geological strata. The Caretta-Weyer article beautifully articulates a shift towards trust in assessment; ten Cate’s entrustable professional activities (ten Cate 2005) brought trust into the education lexicon. Either could be seen as the dawn of an era in assessment. However, even acknowledging these seminal developments, trust patently existed before and outside of our appropriation for competency based education. Clinicians and patients have preexisting conceptions of trust (Damodaran, Jones et al. 2021), and we understand trust to be fundamental to healthcare relationships whether therapeutic, supervisory or organizational (Damodaran, Shulruf et al. 2017).
If the mission is continuous improvement in healthcare, rather than an era, would more durable, testable, shared formulations of trust be useful? I would invite an implementation scientist to jump in and correct me, especially since I’ve historically used these words incorrectly and may still be doing so. Nevertheless, here’s my hot take on frameworks, theories and models: Frameworks generally draw on pre-existing concepts and evidence to structure research approaches to complex problems, for instance, we refer to ‘research frameworks’. Models and theories are both sets of constructs used to explain and predict phenomena. Theories, for example ‘learning theories’, tend to be more scientific formulations, challengeable and ideally acquiring evidence and acceptability over time. Models are designed to illustrate and simplify complex process phenomenon, making them understandable and actionable, such as an ‘operating modal’ used to run a business.
There are certainly oodles of these loose in the wild. A recent review counted more than 300 distinct theories and models (the terms often used interchangeably) just in the health education literature (Lacasse, Douville et al. 2019). Whist there are a multitude of models, theories and frameworks, these are not necessarily exclusive or disconnected from one another. Using multiple theories to examine learning phenomena can bring attention to different aspects or perspectives (Dong, Lio et al. 2021).
Whatever we call them, few relationship models would be as durable and influential as the Mayer, Davis, Schoorman ‘Integrative model of organizational trust’ (Mayer, Davis et al. 1995). This model identifies the relevant constructs and relationships that predict a trust yes/no decision, simplifying and illuminating this complex social phenomenon. The Mayer model stands on generations of trust research, is innumerably applied and cited, and is basic reading for anyone interested in the scholarship of trust. The model is super informative in unpacking healthcare education relationships, particularly where trust is required as one means to deal with workplace risk (Damodaran, Shulruf et al. 2017).
Trust also works as framework or theory if we choose to use these words in a nuanced fashion. If one were launching a research program in healthcare and healthcare education, using a trust-risk framework might be appropriate, which I didn’t appreciate when I wrote a chapter on the subject (Damodaran and Shulruf 2024). With application to scholarship of teaching and learning, I would like to see clever education boffins neatly re-formulate trust-risk as a learning theory.
Considering trust as a learning theory would not obviate contemporary workplace education concepts such as constructivism or situated learning. Considering trust and risk does however add to existing learning theories, helping to explain complex workplace phenomena, such as trust/task delegation decisions between patients, students, clinical teachers and managers each of whom will have a unique perception of personal and organisational risk.
The importance of trust in relationships no doubt predates the language used to express these concepts. Era or otherwise, I’m pretty sure trust is not going anywhere.
References
- Caretta-Weyer, H. A., A. Smirnova, M. A. Barone, J. R. Frank, T. Hernandez-Boussard, D. Levinson, K. Lombarts, K. D. Lomis, A. Martini, D. J. Schumacher, D. A. Turner and A. Schuh (2024). “The Next Era of Assessment: Building a Trustworthy Assessment System.” Perspect Med Educ 13(1): 12-23.
- Damodaran, A., P. Jones and B. Shulruf (2021). “Trust and risk pitfalls in medical education: a qualitative study of clinical teachers.” Medical Teacher 43(11): 1309-1316.
- Damodaran, A. and B. Shulruf (2024). Trust in healthcare professions’ education: an interdisciplinary research agenda. A Research Agenda for Trust, Interdisciplinary Perspectives. R. C. Mayer and B. M. Mayer. Northampton, MA, USA, Edward Elgar Publishing, Inc.: 185-198.
- Damodaran, A., B. Shulruf and P. Jones (2017). “Trust and risk: a model for medical education.” Medical Education 51(9): 892-902.
- Dong, H., J. Lio, R. Sherer and I. Jiang (2021). “Some Learning Theories for Medical Educators.” Medical Science Educator 31(3): 1157-1172.
- Lacasse, M., F. Douville, J. Gagnon, C. Simard and L. Côté (2019). “Theories and Models in Health Sciences Education – a Literature Review.” The Canadian Journal for the Scholarship of Teaching and Learning 10(3).
- Mayer, R. C., J. H. Davis and F. D. Schoorman (1995). “An Integrative Model of Organizational Trust.” Academy of Management Review 20(3): 709-734.
- National-Geographic-Society. (2023). “Anthropocene.” from https://education.nationalgeographic.org/resource/anthropocene/.
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