Giving Literal Thanks: An ACGME-Sponsored Initiative to Bring Residents Back to the Bedside.

Background Resident burnout is at an all-time high. In response, the Accreditation Council for Graduate Medical Education (ACGME) developed the Back to Bedside grant for resident-led burnout interventions that increase the time residents spend with patients. Objective We designed a resident-patient reading intervention, Giving Literal Thanks (GLT), intended to increase meaningful time residents spend with patients and thereby decrease burnout. Methods All 65 pediatric residents rotating through our academic hospital's inpatient units from Fall 2019 through Fall 2021 were invited to read and gift books to their patients. We studied our intervention's relationship to resident burnout using a convergent mixed-methods design, including anonymous, unlinked pre-, peri-, and post-intervention surveys and focus groups. Qualitative and quantitative data were analyzed separately, then integrated to describe burnout pre- and post-intervention. Results Forty-one of 65 residents (63.1%) completed pre-intervention surveys, and 8 of 65 (12.3%) completed post-intervention surveys. Twenty-seven resident-patient reading interactions were recorded, and 2 focus groups were held (1 pre- and 1 post-intervention). Five themes were identified: (1) limited opportunities exist to spend time at the bedside; (2) spending time at the bedside is valuable; (3) other responsibilities may preclude time at the bedside; (4) GLT could promote positive outcomes; and (5) GLT might not be the right tool to reduce burnout. Further quantitative data analysis was prevented by low survey response rates. While GLT was positively received and feasible, we were unable to show an improvement in burnout. Conclusions GLT was well-regarded but may not improve resident burnout.

A Nurse/Intern Partnership Program Accelerates Positive Relationship Formation Between Pediatric Interns and Pediatric Nurses.

BACKGROUND: The relationship between nurses and interns affects the quality of patient care; efforts to improve this relationship are necessary for optimal care. Previously, relationship formation was found to depend on mutual trust, respect, effective communication, and undergoing the process of role formation, all of which require time. This led to the hypothesis that instituting a Nurse/Intern Partnership Program (NIPP) would accelerate relationship formation. METHODS: Using a semi-structured interview guide, prior to NIPP implementation, one nurse (n = 5) and 2 second-year resident (total n = 6) focus groups were held. After implementation, one nurse (n = 6) and one intern (n = 9) focus group were held. The focus group data were analyzed using the 5 stages of qualitative research framework. RESULTS: Thematic data analysis with 3 independent coders supported the previously developed model of relationship formation; the NIPP accelerated relationship formation between nurses and interns through creating an early ally, improving communication, and increasing role understanding. The program may have improved the culture of the pediatric unit. The interns reported more of a positive impact of the NIPP on nurse/intern relationship than the nurses. CONCLUSIONS: The NIPP was positively received by pediatric residents and nurses and successfully accelerated relationship formation between the 2 groups.

Confidence of Faculty in Writing Letters of Recommendation for Pediatric Fellowship Applicants.

BACKGROUND: The assessment of pediatric residents applying to subspecialty fellowship programs relies on faculty letters of recommendation (LOR). However, it is unclear if pediatric faculty are confident that their LOR are effective. OBJECTIVE: This study aims to assess the confidence of pediatric faculty in writing an effective LOR for pediatric residents applying to subspecialty fellowship programs. METHODS: Survey development was conducted using evidence-based best practices. Surveys were distributed via email in 2021 to all full-time pediatric faculty members who taught pediatric residents in a large academic medical center. Categorical values were compared by chi-square test. RESULTS: Eighty-five out of 150 (57%) faculty members completed the survey. Forty-one percent of participants were very confident that their LOR provided adequate content to assess residents during the application process. Confidence was associated with higher academic rank (p=0.02), frequent contact with residents (p=0.01), and writing >2 LOR in the last five years (p=0.0002). Confident LOR writers were more likely to describe their own background, details about the resident's scholarly activity, and the resident's ability to work as part of a team. Thirty-five percent of respondents reported never considering gender bias when writing LOR, whereas 28% reported always considering gender bias. Eighty-seven percent of respondents reported an interest in receiving LOR writing guidelines. CONCLUSION: Half of the faculty respondents were not very confident in their ability to write an effective LOR for pediatric residents applying for a fellowship. Faculty development and standardized instructions on writing effective LOR may be helpful both at the institutional and national levels, including the importance of considering gender bias when writing LOR.

Psychological safety between pediatric residents and nurses and the impact of an interdisciplinary simulation curriculum.

BACKGROUND: Effective teamwork in interdisciplinary healthcare teams is necessary for patient safety. Psychological safety is a key component of effective teamwork. The baseline psychological safety on pediatric inpatient healthcare teams is unknown. The purpose of this study is to determine the baseline psychological safety between pediatric nurses and residents and examine the impact of an interdisciplinary nighttime simulation curriculum. METHODS: A convergent, multistage mixed methods approach was used. An interprofessional simulation curriculum was implemented fall 2020 to spring 2021. Qualitative focus group data and quantitative survey data on team psychological safety were collected and compared, both pre- and post-intervention and across nurses and residents. Thematic analysis of the qualitative data was conducted, and themes integrated with survey findings. RESULTS: Data were collected from 30 nurses and 37 residents pre-intervention and 32 and 38 post-intervention, respectively. Residents and nurses negatively rated psychological safety (pre-intervention mean = 3.40 [SD = 0.72]; post-intervention mean = 3.35 [SD = 0.81]). At both times psychological safety was rated significantly lower for residents (pre-intervention mean = 3.11 [SD = 0.76], post-intervention mean = 2.98 [SD = 0.84]) than nurses (pre-intervention mean = 3.76 [SD = 0.45], post-intervention mean = 3.79 [SD = 0.50]), all P < .001. Qualitative analysis identified six integrated themes: (1) influence of existing relationships on future interactions, (2) unsatisfactory manner and frequency of communication, (3) unsatisfactory resolution of disagreements (4) overwhelming resident workload impairs collaboration, (5) interpersonal disrespect disrupts teamwork, and (6) interprofessional simulation was useful but not sufficient for culture improvement. CONCLUSION: Resident-nurse team psychological safety ratings were not positive. While interprofessional simulation curriculum shows promise, additional efforts are needed to improve psychological safety among residents and nurses.

The Acceptability of Avatar Patients for Teaching and Assessing Pediatric Residents in Communicating Medical Ambiguity.

Background: Simulation offers a means to assess resident competence in communication, but pediatric standardized patient simulation has limitations. A novel educational technology, avatar patients (APs), holds promise, but its acceptability to residents, educational relevance, and perception of realism have not been determined. Objective: To determine if APs are acceptable, provide a relevant educational experience, and are realistic for teaching and assessment of a complex communication topic. Methods: Pediatric residents at one academic institution participated in an AP experience from 2019 to 2021 consisting of 2 scenarios representing issues of medical ambiguity. After the experience, residents completed a survey on the emotional relevance, realism, and acceptability of the technology for assessment of their communication competence. Results: AP actor training required approximately 3 hours. Software and training was provided free of charge. Actors were paid $30/hour; the total estimated curricular cost is $50,000. Sixty-five of 89 (73%) pediatric residents participated in the AP experience; 61 (93.8%) completed the survey. Forty-eight (78.7%) were emotionally invested in the scenarios. The most cited emotions evoked were anxiety, uncertainty, concern, and empathy. The conversations were rated by 49 (80.3%) as realistic. APs were rated as beneficial for learning to communicate about medical ambiguity by 40 (65.5%), and 41 (66.7%) felt comfortable having APs used to assess their competence in this area. Conclusions: Pediatric residents were emotionally invested in the AP experience and found it to be realistic. The experience was rated as beneficial for learning and acceptable to be used for assessment of how to communicate medical ambiguity.

Going Virtual: Objective Structured Teaching Exercises as an Innovative Method for Formative Resident Education.

BACKGROUND: The coronavirus disease 2019 pandemic forced residency programs to adapt teaching to the virtual arena. Objective Structured Teaching Exercises (OSTEs) are a simulation-based session we previously implemented in our in-person pediatric curriculum. We aimed to assess feasibility of and resident satisfaction with the transition to virtual learning for simulation-based OSTEs. METHODS: The pediatrics residency program at our hospital has a weekly academic half-day for residents where the OSTEs were held annually in person 2018 to 2019 and virtually in 2020. Surveys were collected from participating residents and faculty to compare teaching experience, feedback quality, and satisfaction with the session. RESULTS: Over 3 academic years, there were 159 total teaching sessions, 3 of which were OSTEs. The OSTE session was highly rated each year and was the second highest rated virtual session. Residents felt the OSTEs improved their teaching regardless of the virtual versus in-person platform (P = .77), and the quality of feedback as rated by the resident teacher was higher for virtual sessions (P < .001). CONCLUSIONS: Transitioning the OSTE to a virtual platform was both feasible and effective when compared to the in-person OSTE. In the transition to virtual learning, educators should consider opportunities for simulation-based teaching such as OSTEs.

Simulated Umbilical Venous Catheter Placement Improves Resident Competence and Confidence.

Background Pediatric ACGME (Accreditation Council for Graduate Medical Education) requirements include demonstrated competence in umbilical line placement. Given a waning number of these procedures clinically available to residents, new methods of procedural teaching must be employed. We developed a simulation-based strategy, using adult-learning principles, to teach umbilical venous catheter (UVC) placement to pediatric residents. We also determined whether procedural teaching via simulation increased confidence and competence among pediatric residents in performing the procedure. Methods Out of 23 first-year pediatric residents, eight participated in the study. Participants completed a survey evaluating their self-perceived competence and confidence in umbilical line placement. Their simulated umbilical line placement was assessed using a standardized checklist. Residents were then trained on simulated line placement in small groups by neonatologists. Six months later, residents completed a post-training survey and were assessed while placing simulated lines. Statistical analysis was completed using a paired t-test for parametric data, Wilcoxon signed-rank sum test for non-parametric data, and McNemar's chi-squared test for categorical data. Spearman's correlation was used for ordinal variables and Pearson's correlation was used for continuous variables. Results Nine PGY-1 (post-graduate year-1) residents completed the pre-training survey and simulation, while eight residents completed the post-training survey and simulation. There was an increase in resident confidence in placing umbilical lines six months after completion of the training session (p = 0.015) even though there was no difference in the number of umbilical lines that residents had placed in the intervening time. The residents performed a greater number of steps correctly after the training compared to their performance before the training (p=0.001). There was a statistically significant positive correlation between resident confidence and the number of steps performed correctly (rs(14)= 0.649, p = 0.006). There was no correlation between confidence and the number of umbilical lines placed on live subjects. Conclusion A teaching strategy that allows pediatric residents to struggle to perform UVC placement in a simulated setting, before receiving expert instruction, is effective at increasing their confidence and competence, even in the absence of exposure to human subjects.

The Development of an Instrument for Faculty to Assess Resident-Led Large Group Teaching.

OBJECTIVE: The Accreditation Council on Graduate Medical Education requires residents to teach and many residency programs assess resident teaching competency. While much formal resident-led teaching is for large groups, no corresponding published assessment instrument with validity evidence exists. We developed an instrument for faculty to assess pediatric resident-led large group teaching and gathered preliminary validity evidence. METHODS: Literature review and our experience leading resident-as-teacher curricula informed initial instrument content. Resident focus groups from 3 northeastern pediatric residency programs provided stakeholder input. A modified Delphi panel of international experts provided iterative feedback. Three investigators piloted the instrument in 2018; each assessed 8 video recordings of resident-led teaching. We calculated Cronbach's alpha for internal consistency and intraclass correlation (ICC) for inter-rater reliability. RESULTS: The instrument has 6 elements: learning climate, goals/objectives, content, promotion of understanding/retention, session management, and closure. Each element contains behavioral subelements. Cronbach's alpha was .844. ICC was excellent for 6 subelements, good for 1, fair for 1, and poor for 3. CONCLUSIONS: We developed an instrument for faculty assessment of resident-led large group teaching. Pilot data showed assessed behaviors had good internal consistency, but inconsistent interrater reliability. With further development, this instrument has potential to assess resident teaching competency.

Medical Education Journal Club for the Millennial Resident: An Interactive, No-Prep Approach.

OBJECTIVE: The traditional journal club (JC) format of reviewing an article followed by group discussion may be misaligned with millennial learners' needs and may not rely on best principles of adult learning. Our objective was to deliver an interactive JC allowing pediatric residents to critically engage with medical education research without previous preparation. METHODS: We conducted 4 one-hour "interactive, no-prep" medical education JCs for pediatric residents in a medium-sized program in 2018. Without previous reading, participants developed methods to answer the study question, compared that with actual methods, analyzed the results, and extrapolated the findings. We developed a simple, anonymous evaluation tool to determine perceived educational impact, analyzed using mixed methods. RESULTS: A total of 52 of 59 participants (88% response rate) indicated on a 7-point scale that the JC helped them think about how to analyze a paper (mean = 5.32), use a paper to inform further study questions (mean = 5.42), and understand medical education research (mean = 6.00). Four qualitative themes indicated that, although improvement was possible, it provided a strong interactive learning experience. CONCLUSIONS: Our JC approach using active learning principles and requiring no advance preparation is proof of concept that faculty's objectives to teach critical literature evaluation and millennial needs for engagement can be simultaneously met.

Simulation for Milestone Assessment: Use of a Longitudinal Curriculum for Pediatric Residents.

INTRODUCTION: Determining clinical competency on the milestones requires direct observation of residents, which is difficult for faculty members who are also providing patient care. Simulation can potentially represent an effective standardized tool for high-stakes assessment. Using a longitudinal simulation curriculum with formative and summative components, we conducted a pilot investigation to examine whether (1) performance on the formative cases predicted performance on the summative cases and (2) performance on the summative cases correlated with the clinical competency committee's (CCC) milestone placement. METHODS: We developed 6 formative and 6 matched summative cases for pediatric interns that covered core pediatric topics. The interns progressed through the formative cases in pairs during the course of the academic year and then through the summative cases back to back individually at the end of the year. The interns were evaluated using a competency-based simulation evaluation. We determined the relationship between the formative and summative scores and between the summative scores and those from the CCC. RESULTS: The relationship between formative and summative scores was not statistically significant. There was a statistically significant relationship between summative and CCC scores. CONCLUSIONS: Significant methodological limitations preclude definite conclusions about the predictive power of simulation cases for Pediatric Milestones-based assessment. However, our work is an example of how simulation is a potentially useful tool for assessing residents' skill development on the Pediatric Milestones. More rigorous research is needed to determine the extent to which simulation can be used for high-stakes, milestones-based assessment.