Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes.

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one's self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.

Features of assessment learners use to make informed self-assessments of clinical performance.

CONTEXT: Conceptualisations of self-assessment are changing as its role in professional development comes to be viewed more broadly as needing to be both externally and internally informed through activities that enable access to and the interpretation and integration of data from external sources. Education programmes use various activities to promote learners' reflection and self-direction, yet we know little about how effective these activities are in 'informing' learners' self-assessments. OBJECTIVES: This study aimed to increase understanding of the specific ways in which undergraduate and postgraduate learners used learning and assessment activities to inform self-assessments of their clinical performance. METHODS: We conducted an international qualitative study using focus groups and drawing on principles of grounded theory. We recruited volunteer participants from three undergraduate and two postgraduate programmes using structured self-assessment activities (e.g. portfolios). We asked learners to describe their perceptions of and experiences with formal and informal activities intended to inform self-assessment. We conducted analysis as a team using a constant comparative process. RESULTS: Eighty-five learners (53 undergraduate, 32 postgraduate) participated in 10 focus groups. Two main findings emerged. Firstly, the perceived effectiveness of formal and informal assessment activities in informing self-assessment appeared to be both person- and context-specific. No curricular activities were considered to be generally effective or ineffective. However, the availability of high-quality performance data and standards was thought to increase the effectiveness of an activity in informing self-assessment. Secondly, the fostering and informing of self-assessment was believed to require credible and engaged supervisors. CONCLUSIONS: Several contextual and personal conditions consistently influenced learners' perceptions of the extent to which assessment activities were useful in informing self-assessments of performance. Although learners are not guaranteed to be accurate in their perceptions of which factors influence their efforts to improve performance, their perceptions must be taken into account; assessment strategies that are perceived as providing untrustworthy information can be anticipated to have negligible impact.

Feedback data sources that inform physician self-assessment.

BACKGROUND: Self-assessment is a process of interpreting data about one's performance and comparing it to explicit or implicit standards. AIM: To examine the external data sources physicians used to monitor themselves. METHODS: Focus groups were conducted with physicians who participated in three practice improvement activities: a multisource feedback program; a program providing patient and chart audit data; and practice-based learning groups. We used grounded theory strategies to understand the external sources that stimulated self-assessment and how they worked. RESULTS: Data from seven focus groups (49 physicians) were analyzed. Physicians used information from structured programs, other educational activities, professional colleagues, and patients. Data were of varying quality, often from non-formal sources with implicit (not explicit) standards. Mandatory programs elicited variable responses, whereas data and activities the physicians selected themselves were more likely to be accepted. Physicians used the information to create a reference point against which they could weigh their performance using it variably depending on their personal interpretation of its accuracy, application, and utility. CONCLUSIONS: Physicians use and interpret data and standards of varying quality to inform self-assessment. Physicians may benefit from regular and routine feedback and guidance on how to seek out data for self-assessment.

Perceptions of Graduating Health Professional Students of Their Interprofessional Education Experiences during Pre-Licensure Education.

The purpose of this qualitative descriptive study was to identify graduating students' perspectives on what makes prelicensure interprofessional education (IPE) and interprofessional collaboration (IPC) experiences valuable and effective and to identify other opportunities for effective IPE. We conducted telephone interviews with 12 students in medicine, nursing, pharmacy, and physiotherapy during their final year of training and thematically analyzed the verbatim transcripts. We found factors that make existing IPE experiences valuable and effective and could facilitate leverage of other curricular opportunities include: 1) experiential learning in clinical and classroom contexts, 2) relevancy of the IPE experiences, 3) opportunities for role clarification, 4) supervisors' influence (e.g., modeling collaborative skills), and 5) integration of IPE and IPC experiences into the existing curriculum.

Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict.

PURPOSE: Informed self-assessment describes the set of processes through which individuals use external and internal data to generate an appraisal of their own abilities. The purpose of this project was to explore the tensions described by learners and professionals when informing their self-assessments of clinical performance. METHOD: This 2008 qualitative study was guided by principles of grounded theory. Eight programs in five countries across undergraduate, postgraduate, and continuing medical education were purposively sampled. Seventeen focus groups were held (134 participants). Detailed analyses were conducted iteratively to understand themes and relationships. RESULTS: Participants experienced multiple tensions in informed self-assessment. Three categories of tensions emerged: within people (e.g., wanting feedback, yet fearing disconfirming feedback), between people (e.g., providing genuine feedback yet wanting to preserve relationships), and in the learning/practice environment (e.g., engaging in authentic self-assessment activities versus "playing the evaluation game"). Tensions were ongoing, contextual, and dynamic; they prevailed across participant groups, infusing all components of informed self-assessment. They also were present in varied contexts and at all levels of learners and practicing physicians. CONCLUSIONS: Multiple tensions, requiring ongoing negotiation and renegotiation, are inherent in informed self-assessment. Tensions are both intraindividual and interindividual and they are culturally situated, reflecting both professional and institutional influences. Social learning theories (social cognitive theory) and sociocultural theories of learning (situated learning and communities of practice) may inform our understanding and interpretation of the study findings. The findings suggest that educational interventions should be directed at individual, collective, and institutional cultural levels. Implications for practice are presented.

The processes and dimensions of informed self-assessment: a conceptual model.

PURPOSE: To determine how learners and physicians engaged in various structured interventions to inform self-assessment, how they perceived and used self-assessment in clinical learning and practice, and the components and processes comprising informed self-assessment and factors that influence these. METHOD: This was a qualitative study guided by principles of grounded theory. Using purposive sampling, eight programs were selected in Canada, the United States, the United Kingdom, the Netherlands, and Belgium, representing low, medium, and high degrees of structure/rigor in self-assessment activities. In 2008, 17 focus groups were conducted with 134 participants (53 undergraduate learners, 32 postgraduate learners, 49 physicians). Focus-group transcripts were analyzed interactively and iteratively by the research team to identify themes and compare and confirm findings. RESULTS: Informed self-assessment appeared as a flexible, dynamic process of accessing, interpreting, and responding to varied external and internal data. It was characterized by multiple tensions arising from complex interactions among competing internal and external data and multiple influencing conditions. The complex process was evident across the continuum of medical education and practice. A conceptual model of informed self-assessment emerged. CONCLUSIONS: Central challenges to informing self-assessment are the dynamic interrelationships and underlying tensions among the components comprising self-assessment. Realizing this increases understanding of why self-assessment accuracy seems frequently unreliable. Findings suggest the need for attention to the varied influencing conditions and inherent tensions to progress in understanding self-assessment, how it is informed, and its role in self-directed learning and professional self-regulation. Informed self-assessment is a multidimensional, complex construct requiring further research.

Effective interprofessional teams: "contact is not enough" to build a team.

INTRODUCTION: Teamwork and interprofessional practice and learning are becoming integral to health care. It is anticipated that these approaches can maximize professional resources and optimize patient care. Current research, however, suggests that primary health care teams may lack the capacity to function at a level that enhances the individual contributions of their members and team effectiveness. This study explores perceptions of effective primary health care teams to determine the related learning needs of primary health care professionals. METHODS: Primary health care team members with a particular interest in teamwork shared perspectives of effective teamwork and educational needs in interprofessional focus groups. Transcripts from nine focus groups with a total of 61 participants were analyzed using content analysis and grounded hermeneutic approaches to identify themes. RESULTS: Five themes of primary care team effectiveness emerged: (1) understanding and respecting team members' roles, (2) recognizing that teams require work, (3) understanding primary health care, (4) working together: practical "know-how" for sharing patient care, and (5) communication. Communication was identified as the essential factor in effective primary health care teams. DISCUSSION: Several characteristics of effective primary health care teams and the related knowledge and skills that professionals require as effective team members are identified. Effective teamwork requires specific cognitive, technical, and affective competence.

Responding to rising cancer caseloads: family physician learning needs and challenges in cancer care.

BACKGROUND: In this study, we addressed physicians' learning needs and practice challenges throughout the continuum of cancer care using an interprofessional approach. METHODS: Data sources and tools included (1) 150 family physician questionnaires, (2) 11 oncologist interviews, (3) 13 focus groups with 125 health care providers, and (4) secondary sources. RESULTS: Family physicians wish to play a larger role in their cancer patients' care. Their self-reported learning needs were confirmed by other data sources. Important practice and systemic challenges to improving care exist. CONCLUSION: Decreasing cancer rates and improving cancer care are complex issues requiring educational interventions as well as organizational and communications initiatives.