Unobserved Observers: Nurses' Perspectives About Sharing Feedback on the Performance of Resident Physicians

Physician development through interprofessional workplace interactions: A critical review

INTRODUCTION

Increasingly, medical training aims to develop physicians who are competent collaborators. Although interprofessional interactions are inevitable elements of medical trainees' workplace learning experiences, the existing literature lacks a cohesive model to conceptualise the learning potential residing in these interactions.

METHODS

We conducted a critical review of the health professions and related educational literatures to generate an empirically and theoretically informed description of medical trainees' workplace interactions with other health professionals, including learning mechanisms and outcomes. Informed by Teunissen's conceptualisation of workplace learning, we highlight the individual, social and situated dimensions of learning from interprofessional workplace interactions.

RESULTS

Workplace interactions between medical trainees and other health professionals tend to be brief, spontaneous, informal and often implicit without the predefined educational goals and roles that structure trainees' relationships with physician supervisors. Yet they hold potential for developing trainees' knowledge and skills germane to the work of a physician as well as building their capacity for collaboration. Our review identified a spectrum of learning theories helpful for examining what and how trainees learn from these interactions. Self-regulated learning theories focus attention on how learning depends on trainees interpreting and judging the cues offered by other health professionals. Sociocultural frameworks including the zone of proximal development and legitimate peripheral participation emphasise the ways other health professionals support trainees in performing tasks at the border of their abilities and facilitate trainees' participation in clinical work. Both the landscapes of practice theory and cultural historical activity theory highlight the influence of surrounding social, cultural and material environments. These theories are unified into cohesive model and demonstrated through an illustrative example.

CONCLUSION

Interprofessional workplace interactions harbour a range of learning opportunities for medical trainees. Capitalising on their potential can contribute to training collaborative practice-ready physicians alongside traditional intra-professional interactions between physicians and merits future research.

Cultural Adaptation and Pilot Testing of a Basic Palliative Care Curriculum for Practicing Physicians and Nurses in Mainland China

Background: To meet the growing palliative care (PC) needs of China's aging population, we culturally adapted and pilot tested an evidence-based basic PC training program for practicing clinicians. Design: Barrera's framework guided a multistage, surface, and deep structural adaptation of an existing course. We pilot tested the final curricula with 51 participants in September 2022. Participant demographics and postcourse satisfaction survey were descriptively analyzed. Results: A total of 20 nurses and 29 physicians completed the course and instruments. Majority of participants were between 31 and 50 years old (n = 39, 79.6%), female (n = 41, 83.7%), internal medicine trained (n = 30, 61.2%), and worked in tertiary hospitals (n = 47, 95.9). Most participants considered the course quality to be "high" or "very high" (n = 47, 95.9%). Conclusions: Practicing physicians and nurses in mainland China consider this culturally adapted basic PC training to be feasible and acceptable. Future studies should evaluate the effectiveness of PC training and develop strategies to overcome implementation challenges.

Nurse perspectives on the assessment of emergency medicine residents: A qualitative study

Background

Multisource and 360-degree feedback are emerging methods in the medical education assessment literature. Nursing feedback in particular has been identified as a point of emphasis regarding what medical education leadership would most value for incorporating into their evaluations. There is no currently accepted tool for multisource feedback in the emergency department (ED). To answer this call, we conducted a qualitative study to elucidate nurse perspectives on evaluation of emergency medicine residents.

Methods

We conducted individual semistructured interviews of ED nurses with experience working alongside residents via volunteer recruitment. Transcripts were coded independently by each author and then reviewed collaboratively to resolve differences. Codes were created by inductive thematic analysis and subsequently underwent constant comparison and classical content analysis. Recruitment continued until analysis of transcripts showed thematic saturation.

Results

We organized the interview transcript into chunks of information, arranging 407 quotes from the 10 interview transcripts into 17 codes and six themes regarding observable resident behaviors. Representative quotes and exemplar cases added detailed description to the meaning of these codes. The identified themes for observable resident behaviors included "general communication style," "medical knowledge," "efficiency," "patient communication," "nurse communication," and "professionalism." An additional 13 codes addressed the themes of barriers and catalysts for feedback.

Conclusions

The identified themes on observable resident behaviors aligned well with prior literature and with the Accreditation Council for Graduate Medical Education (ACGME) Milestones. The interviews also highlighted nurse perspectives on barriers and catalysts for feedback that would be useful to incorporate into the design of an assessment tool.

The Ottawa resident observation form for nurses (O-RON): evaluation of an assessment tool's psychometric properties in different specialties

BACKGROUND

Workplace-based assessment (WBA) used in post-graduate medical education relies on physician supervisors' feedback. However, in a training environment where supervisors are unavailable to assess certain aspects of a resident's performance, nurses are well-positioned to do so. The Ottawa Resident Observation Form for Nurses (O-RON) was developed to capture nurses' assessment of trainee performance and results have demonstrated strong evidence for validity in Orthopedic Surgery. However, different clinical settings may impact a tool's performance. This project studied the use of the O-RON in three different specialties at the University of Ottawa.

METHODS

O-RON forms were distributed on Internal Medicine, General Surgery, and Obstetrical wards at the University of Ottawa over nine months. Validity evidence related to quantitative data was collected. Exit interviews with nurse managers were performed and content was thematically analyzed.

RESULTS

179 O-RONs were completed on 30 residents. With four forms per resident, the ORON's reliability was 0.82. Global judgement response and frequency of concerns was correlated (r = 0.627, P < 0.001).

CONCLUSIONS

Consistent with the original study, the findings demonstrated strong evidence for validity. However, the number of forms collected was less than expected. Exit interviews identified factors impacting form completion, which included clinical workloads and interprofessional dynamics.

Set Up to Fail? Barriers Impeding Resident Communication Training in Neonatal Intensive Care Units

PURPOSE

Learning to navigate difficult clinical conversations is an essential feature of residency training, yet much of this learning occurs "on the job," often without the formative, multisource feedback trainees need. To generate insight into how on-the-job training influences trainee performance, the perspectives of parents and health care providers (HCPs) who engaged in or observed difficult conversations with Neonatal Intensive Care Unit (NICU) trainees were explored.

METHOD

The iterative data generation and analysis process was informed by constructivist grounded theory. Parents (n = 14) and HCPs (n = 10) from 2 Canadian NICUs were invited to participate in semistructured interviews informed by rich pictures-a visual elicitation technique useful for exploring complex phenomena like difficult conversations. Themes were identified using the constant comparative approach. The study was conducted between 2018 and 2021.

RESULTS

According to participants, misalignment between parents' and trainees' communication styles, HCPs intervening to protect parents when trainee-led communication went awry, the absence of feedback, and a culture of sole physician responsibility for communication all conspired against trainees trying to develop communication competence in the NICU. Given beliefs that trainees' experiential learning should not trump parents' well-being, some physicians perceived the art of communication was best learned by observing experts. Sometimes, already limited opportunities for trainees to lead conversations were further constricted by perceptions that trainees lacked the interest and motivation to focus on so-called "soft" skills like communication during their training.

CONCLUSIONS

Parents and NICU staff described that trainees face multiple barriers against learning to navigate difficult conversations that may set them up to fail. A deeper understanding of the layered challenges trainees face, and the hierarchies and sociocultural norms that interfere with teaching, may be the start of breaking down multiple barriers trainees and their clinician supervisors need to overcome to succeed.

Exploring nurses' role in guiding residents' workplace learning: A mixed-method study

INTRODUCTION

Understanding residents' workplace learning could be optimized by not only considering attending physicians' role but also the role of nurses. While previous studies described nurses' role during discrete activities (e.g. feedback), a more profound understanding of how nurses contribute to residents' learning remains warranted. Therefore, we used the educational concept of guidance and explored the extent to which residents' and nurses' perceptions align regarding nurses' guiding role and which reasons they provide for their perceptions.

METHODS

This mixed-method study was conducted at four Dutch university medical centres in 2021. We simultaneously collected quantitative and qualitative data from 103 residents and 401 nurses through a theory-informed questionnaire with a Likert-scale and open-ended questions. We analyzed quantitative data to explore respondents' perceptions of nurses' guiding role by using anova. The thematically analyzed qualitative open comments explored respondents' reasons for their perceptions.

RESULTS

Nurses indicated to provide significantly more support (p = .01) and guidance on learning from patient care (p < .01) than perceived by residents. Moreover, nurses indicated that attending physicians did not always involve them in guiding residents, whereas residents perceived nurses were being involved (p < .001). Themes suggest that nurses and residents could be divided into two groups: (i) respondents who felt that guiding was inextricably linked to good interprofessional collaboration and patient care and (ii) respondents who saw the guiding role as limited and emphasised the distinct fields of expertise between nurses and physicians.

CONCLUSIONS

Residents and nurses felt that nurses played an important role in guiding residents' workplace learning. However, some residents did not always perceive to be guided. To further capitalise on nurses' guiding role, we suggest that residents can be encouraged to engage in the learning opportunities nurses provide to achieve optimal team-based patient care.

A Unique Lens: Understanding What Nurses Are Best Positioned to Assess About Residents

BACKGROUND

Resident feedback is generally elicited from attending physicians, although nurses can also provide feedback on distinct domains. Physicians may be hesitant to accept feedback from nurses if they perceive that nurses are being asked about areas outside their expertise. Understanding specific resident behaviors that nurses are best suited to assess is critical to successful implementation of feedback from nurses to residents.

OBJECTIVE

To understand specific resident behaviors nurses are uniquely positioned to assess from the perspectives of both nurses and residents.

METHODS

We performed a qualitative study using thematic analysis of 5 focus groups with 20 residents and 5 focus groups with 17 nurses at a large free-standing children's hospital in 2020. Two reviewers developed a codebook and subsequently analyzed all transcripts. Codes were organized into themes and subthemes. Thematic saturation was achieved prior to analyzing the final transcript.

RESULTS

We identified 4 major themes. Nurses are positioned to provide feedback: (1) on residents' interprofessional collaborative practice; (2) on residents' communication with patients and their families; and (3) on behalf of patients and their families. Within each of these, we identified subthemes noting specific behaviors on which nurses can provide feedback. The fourth theme encompassed topics that may not be best suited for nursing feedback-medical decision-making and resident responsiveness.

CONCLUSIONS

Nurses and residents described specific resident behaviors that nurses were best positioned to assess.