How supervisors leverage stress to facilitate trainee learning in clinical settings: A six-element model

Background: Excessive stress can hinder learning, whereas moderate stress may enhance it by boosting motivation, memory and cognitive processing. Rudland et al. proposed a theoretical stress-learning pathway in which supervisors play a central role in shaping how stress influences learning. While this pathway offers a valuable high-level framework, the specific ways supervisors enact this role in clinical settings remain underexplored. Our study addresses this gap by examining how supervisors leverage stress to enhance trainee learning in clinical settings. Methods: In this constructivist grounded theory study, we interviewed supervisors (senior residents and attending physicians) whom paediatric residents identified as effectively leveraging stress to facilitate learning. We recorded and transcribed semi-structured interviews, which we analysed iteratively throughout the data collection period using constant comparative techniques. We created a model that extends Rudland et al.'s pathway by detailing specific ways that supervisors harness stress to facilitate learning. Results: We interviewed 23 supervisors (10 senior paediatric residents and 13 attending physicians), all of whom conceptualised stress as a dynamic, individualised experience that can promote learning and prepare trainees for unsupervised practice. Supervisors both introduced stressors and modulated naturally occurring stressors (e.g. delivering difficult news or managing a decompensating patient) as they supported trainees in challenging situations. Attending physicians, more than senior residents, reported difficulty gauging trainee stress, citing power dynamics as a barrier. Our analysis produced a six-element model explaining how supervisors use stress to support learning: setting the stage, assessing baseline stress, introducing or modulating stressors, re-assessing, and debriefing. Conclusions: Our findings suggest supervisors leverage stress to enhance learning in inpatient clinical environments but do so cautiously to ensure stress does not reach a level that impedes learning. Through a proactive approach, supervisors introduce and modulate stressors—thereby creating individualised learning experiences that they expect to prepare trainees for the demands of independent practice.