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

PURPOSE: Postgraduate training programs are incorporating feedback from registered nurses (RNs) to facilitate holistic assessments of resident performance. RNs are a potentially rich source of feedback because they often observe trainees during clinical encounters when physician supervisors are not present. However, RN perspectives about sharing feedback have not been deeply explored. This study investigated RN perspectives about providing feedback and explored the facilitators and barriers influencing their engagement. METHOD: Constructivist grounded theory methodology was used in interviewing 11 emergency medicine and 8 internal medicine RNs at 2 campuses of a tertiary care academic medical center in Ontario, Canada, between July 2019 and March 2020. Interviews explored RN experiences working with and observing residents in clinical practice. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis. RESULTS: RNs felt they could observe authentic day-to-day behaviors of residents often unwitnessed by supervising physicians and offer unique feedback related to patient advocacy, communication, leadership, collaboration, and professionalism. Despite a strong desire to contribute to resident education, RNs were apprehensive about sharing feedback and reported barriers related to hierarchy, power differentials, and a fear of overstepping professional boundaries. Although infrequent, a key stimulus that enabled RNs to feel safe in sharing feedback was an invitation from the supervising physician to provide input. CONCLUSIONS: Perceived hierarchy in academic medicine is a critical barrier to engaging RNs in feedback for residents. Accessing RN feedback on authentic resident behaviors requires dismantling the negative effects of hierarchy and fostering a collaborative interprofessional working environment. A critical step toward this goal may require supervising physicians to model feedback-seeking behavior by inviting RNs to share feedback. Until a workplace culture is established that validates nurses' input and creates safe opportunities for them to contribute to resident education, the voices of nurses will remain unheard.

What trainees grapple with: a study of threshold concepts on the medicine ward.

OBJECTIVES: Socialisation theories of professional identity formation (PIF) consider clinical rotations to be critically intense transformative experiences. However, few studies have explored what trainees grapple with during these transformative experiences or their influence on performance. Applying a threshold concepts (TCs) lens, this study investigates and documents 'troublesome' and 'transformative' concepts that junior trainees may encounter during a clinical rotation. Insights gained are essential for supporting trainee development. METHODS: Constructivist grounded theory was used to guide the collection and analysis of data for this two-phase study. Phase 1 involved direct observation and field interviews with 17 junior trainees over two observation periods and phase 2 involved in-depth interviews with 13 attending physicians. The theory of TCs was used as a sensitising concept. RESULTS: In total, nine TCs were identified and thematically grouped under the headings: Developing as a Professional, Providing Patient Care and Working Collectively. Across the interviewed attending physicians, there appeared to be a shared understanding of TCs strong trainees had crossed and weaker trainees struggled with. Observational and field interview data suggested that individual trainee actions were strongly influenced by the identified TC and whether or not the trainee appeared to have crossed any given threshold. Moreover, individual clinical practices could be influenced by more than one TC. Trainees were also observed to vary in the thresholds they had already crossed or struggled with. CONCLUSIONS: The identified TCs offer important insights into the relationship between trainee actions and how they conceptualise practice. At their heart, many appeared to represent ideals of practice that trainees should incorporate into their developing identities as they explore what it means to be a physician. Future research should explore how to incorporate TCs into assessment and the support of trainee development.

Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres.

OBJECTIVES: The suboptimal provision of analgesia to children in the emergency department (ED) is well-described. A yet unexplored barrier is caregiver or child refusal of analgesia. We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED. METHODS: We conducted a two-centre cross-sectional study of 743 caregivers of children 4­17 years presenting to the pediatric ED with an acutely painful condition using a survey and medical record review. The primary outcome was the proportion of children/caregiver pairs who accepted analgesia in the ED. RESULTS: The median (IQR) age of children was 11 (7) years, and 339/743 (45.6%) were female. The overall survey response rate was 73% (743/1018). In the 24 hours preceding ED arrival, the median (IQR) maximal pain score rated by children and caregivers was 8/10 (4) and 5/10 (2), respectively, and 30.4% (226/743) of caregivers offered analgesia. In the ED, children reported a median (IQR) pain score of 8/10 (2) and 54.9% (408/743) were offered analgesia. When offered in the ED, analgesia was accepted by 91% (373/408). Overall, 55.7% (414/743) of children received some form of analgesia. CONCLUSIONS: Most caregivers/children accept analgesia when offered by ED personnel, suggesting refusal is not a major barrier to optimal management of children's pain and highlighting the importance of ED personnel in encouraging adequate analgesia. A large proportion of children in pain are not offered analgesia by caregivers or ED personnel. Educational strategies for recognizing and treating pain should be directed at children, caregivers, and ED personnel.