On this episode of the Academic Medicine Podcast, guests Chirag Bhat, MD, and Warren Cheung, MD, MMEd, join hosts Toni Gallo and associate editor Teresa Chan, MD, MHPE, to discuss their research into nurses’ perspectives about giving feedback on residents’ clinical performance. They share their findings regarding the unique perspective nurses can offer, the barriers nurses face in providing feedback, and some possible ways to overcome these barriers.
This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.
A transcript is below.
Read the article discussed in this episode:
Bhat C, LaDonna K, Dewhirst S, et al. Unobserved observers: Nurses’ perspectives about sharing feedback on the performance of resident physicians. Acad Med. 2022;97:271-277.
Transcript
Toni Gallo:
Hi everyone. I’m Toni Gallo. I’m a staff editor with Academic Medicine, and one of the hosts of today’s episode. I am joined by Dr. Teresa Chan, one of the journal’s associate editors. She’s my co-host for our episode. We’ll be talking to Drs. Chirag Bhat and Warren Cheung about their study, “Unobserved Observers: Nurses’ Perspectives about Sharing Feedback on the Performance of Resident Physicians.” That article appeared in our February issue. It’s available to read for free on academicmedicine.org. I’ll put the link for listeners in the notes for this episode.
Teresa Chan:
All right. Hello everyone. My name’s Teresa Chan. I’m at McMaster University here in Hamilton, Ontario, Canada. I have the pleasure of interviewing some of my colleagues that I’ve known for a long time. I’m going to kick it over to Chirag to introduce himself.
Chirag Bhat:
Perfect. Thanks so much, Teresa. So I’m Chirag Bhat. I’m one of the fourth-year emergency medicine residents at the University of Ottawa. I’m really thankful for the invitation to be part of this.
Teresa Chan:
All right. Over to Warren.
Warren Cheung:
Thanks for having us, Teresa. My name’s Warren Cheung. I’m an emerg doc in Ottawa, Canada, and the director of assessment in our program.
Toni Gallo:
Well, thank you all for being on the podcast today. I wonder if you could start and just tell us a little bit about why you wanted to study nurses and their role in giving feedback to residents. What drew you to this research question?
Chirag Bhat:
This project actually originally started as a simple resident research project. Warren and I began chatting about kinda key moments in our residency, where we were really influenced or we learned quite a bit. As we talked, it dawned on us that a lot of these moments involved allied health and nurses. We started talking about whether nurses giving feedback could play a important role in resident education. As we talked some more, we realized that, while attending physicians see a lot that residents do, they don’t see everything. In fact, there’s a lot that they probably don’t see. RNs might see things that attending physicians don’t see. So when we started looking through the data into RNs giving feedback on resident physician performance, we saw that there were a lot of different tools out there that were already being implemented, but there really wasn’t a lot of research into how nurses thought about and felt about giving feedback or sharing feedback with resident physicians. There wasn’t really any research into their perspective on this issue. That ultimately is what led us into thinking about this some more and forming our research team and studying this more in depth.
Warren Cheung:
I’ll just add that, in our early conversations as we were conceptualizing the research project and the research question, Chirag and I really talked about how you know whenever I’ve asked a nurse to provide some feedback, they’ve been really, one, really surprised that someone asked them, and two, very willing to provide feedback to the trainee, either directly to the trainee or through myself as a supervising physician. So we knew that we were onto something there because when you get that type of reaction from someone, it means that there’s something underlying that reaction. That really spawned into this research project.
Teresa Chan:
Okay. I’m going to head into the next question. Could you briefly describe your methodology and the study findings? Specifically, one of the things that cues to me is that there might be a gendered layer to all of this. I was just wondering how your study group handled some of that, or if that’s something that you think would be a natural next step in diving deeper into that?
Chirag Bhat:
So the study methodology really revolved around using constructivist grounded theory. We chose to use that because the idea of a nurse’s role in medical education is still fairly under theorized. We ended up conducting … semi-structured interviews with 19 nurses, 11 of whom were in the emergency department and 9 were in the internal medicine ward. We asked our participants to kinda reflect on recent experiences with residents and share times when they either did or did not share feedback with the residents. Then we analyzed the data as per constructivist grounded theory.
Chirag Bhat:
Probably one of the biggest findings that we had was that our participants had a lot to say about residents and actually really wanted to participate and be more involved in giving resident feedback, but they found significant barriers to actually sharing that feedback. What our nurses in our study highlighted was that there was this big power dynamic that they noticed. They felt that the power was really kiltered towards residents and towards supervising physicians. They felt that they had significant difficulty sharing feedback through this hierarchy and through these power differentials.
Chirag Bhat:
Unfortunately, they often didn’t share feedback because of this. Ultimately, they felt that resident physicians and supervising physicians often worked in silos and were working separately from nurses. There were some instances when nurses really felt empowered and motivated to share feedback. Those revolved around key motivating events, such as patient safety events or when they were explicitly asked to share feedback, but those events happen fairly rarely.
Chirag Bhat:
I think your second question, Teresa, was around potential gender bias. Now, the majority of the nurses who were participants in our study were associated with female gender. Two of them self-identified as male gender. Towards the end of our study, we did chat, our research team did talk the potential of gender bias playing a role here. Ultimately, we didn’t ask questions specifically targeting that in our original research methodology. I think, as you mentioned, it’s a really great stepping off point for further research because it’s very possible that gender could play a role in nurses feeling comfortable or having certain additional barriers to sharing feedback, but I think that needs to be further explored still.
Warren Cheung:
You know Teresa, your original question related around the methodology of this study. I want to give a big shout-out to Dr. Kori LaDonna, who is one of our co-investigators, who is tremendously helpful in walking us through CGT approaches and really wrapping our minds around this qualitative piece. Thank you, Kori. We really appreciate it.
Chirag Bhat:
Yeah, she was amazing.
Toni Gallo:
I want to come back to this idea of hierarchical relationships. You talk in your paper a little bit about some of these power differentials and this hierarchy and how it affected nurses’ sense of safety and whether they were really able to provide feedback or felt like that was something that was part of their role. I wonder if you have any suggestions that came out of this work or in thinking about the topic for how to create that sense of psychological safety. What would foster a culture that would allow nurses to feel comfortable and able to share feedback on residents’ performance, maybe anything else that you heard from them around how to make that an easier situation?
Chirag Bhat:
I think the first part of this issue is trying to figure out why nurse weren’t comfortable sharing feedback, why they didn’t feel safe to share feedback. And so when we asked our participants about that, one of the ideas that came out was that there was a fear that resident physicians or supervising physicians might use their position of power for retribution in future patient care events or they might use their positions to make nursing duties more difficult. And so that, I think, is a really important thing to keep in mind as we think about what’s important and how to make a safe space for nurses. One of the key ways that nurses actually identified in our paper, that they said they would appreciate, is if attending physicians or resident physicians actually explicitly asked for their feedback. I think one of our participants actually highlighted that act of asking for feedback kinda makes the conversation more open and free flowing and establishes safety for all the participants. And so I think that’s probably one of the most useful things that physicians can do, is to explicitly invite feedback by nurses.
Warren Cheung:
Toni, you talk about the culture shift. I think we have to start, you know, we acknowledge that nurses are part of the patient care team, but I think there needs to be a shift to recognize that nurses can participate in part of the resident training team as well. That they’re an important stakeholder in these residents’ professional development, right? These residents will become attending physicians who will work very closely with nurses in the future. So why shouldn’t nurses be engaged and involved in their training? I think that’s something that we could be better at doing, particularly in the early stages of medical training and undergraduate, because really, medical trainees don’t engage with nurses until their clinical training begins, which is usually, at least in Canada, in their third and fourth year of medical school. If we can start breaking down some of those interprofessional barriers earlier in training, I think we can make some headway in that culture shift.
Teresa Chan:
All right. This takes us to the next part. I think you’ve already started discussing this a little bit, but you highlighted so far some things that supervising physicians can do to break down some of those silos. I was wondering if you could discuss a little bit about how supervising physicians and nurses can establish for the residents the credibility of nurses’ feedback so that residents can see it as something that they can seek out on their own or with the scaffolding of a staff physician or an attending physician helping them. What are some things that people might do, like on a particular shift? What implications might they have for how we conduct ourselves in our emergency departments specifically or in other units as well?
Chirag Bhat:
I think you mentioned, Teresa, about scaffolding. I think that’s a really interesting term to apply here because one of the things that we mentioned in our paper was the idea of supervising physicians modeling feedback seeking to their residents. You know it strikes me that’s actually kind of scaffolding for residents to realize that feedback from nurses is valuable and important. When I started residency, which was not so long ago, I didn’t see very many people asking me explicitly for feedback. I think now, if I was to go on shift and I was working with Warren, for example, and Warren was to go up to a nurse and ask them for feedback about my performance during the shift, I think that would cue me to realize that not only is my supervising physician seeing and valuing this feedback as very important, but that probably I should see this as important too. I think supervising physicians taking on that onus of modeling feedback to their learners and to their trainees could play a very important role in the future.
Warren Cheung:
Yeah, to Chirag’s point, I think we have a strong body of literature that exists that demonstrates that the trainees’ behavior in the future is very closely linked or aligned with the behaviors of their supervisors. You see that in the role modeling literature, as well as in the, sort of, predictive outcome literature in medical trainees. I think it starts with the supervising physicians demonstrating, or reflecting, that they value the input of their nursing colleagues and allowing that to transmit to their trainees.
Toni Gallo:
So given this importance of role modeling, have either of you changed your behavior since doing this study? Have you sought out feedback from the nurses more often or changed the way you’ve done that? I’m curious if it’s affected the way that you practice.
Chirag Bhat:
One thing that I’ve really started doing is using, kinda, the infrastructure we already have at Ottawa to get more feedback from our nurses regarding my own performance. What I mean by that is one of the things that we often do in the emergency department where I primarily work, after a big resuscitation or a big critical case, we often have debriefs with all the members that were involved, which includes the nursing staff. Oftentimes, after these debriefs, I’ll pull the nurses aside and just chat with them one on one and ask them specifically how I could have done things differently. I primarily do this when I’m leading, although as I think about it more, it’s probably useful to get their feedback even when I’m not leading, but that’s one thing that I’ve definitely started doing differently since the study.
Warren Cheung:
Yeah, it’s something that I occasionally try to integrate into my practice when supervising trainees, particularly if a trainee has spent a particular duration of time with an individual nurse who has had the time to observe them and offer some insights, whether it be related to a resuscitation in the emerg or they’ve worked on a procedure together like a lumbar puncture or even a difficult conversation that the resident has had with the patient and the nurse has been by there observing as well. I think it does offer a lot of valuable insight into sort of the humanistic qualities of that trainee that is oftentimes so hard to capture on our traditional forms of assessment.
Teresa Chan:
All right. I’m going to ask a little bit of a zinger, so I’m just giving you fair warning, but every study has its limitations. One of the things in positivist cultured studies, when I talk about generalizability, in this case, it’d probably be more about transferability. Are there any limits to the transferability of your results to other cultures or other circumstances and other units? How would you guide people towards thinking about that?
Chirag Bhat:
Yeah, certainly there are limitations, as you mentioned. One of the things to keep in mind is that our study was conducted in a tertiary care center where nurses work very regularly with resident physicians. So closely with resident physicians that oftentimes nurses will have long-term friendships as well with residents, which is something to keep in mind. The other thing to mention is that our clinical context involves nurses in the emergency department as well as nurses on the internal medicine ward. Now, we specifically chose those two clinical contexts because they have different working relationships between the nurses and the resident physicians, meaning that, in the emergency department, nurses tend to work more side by side with resident physicians, while on the internal medicine wards, they tend to work more longitudinally as opposed to directly side by side with the residents. Again, that’s all a bit of a generalization there.
Chirag Bhat:
Every leader and institution will have their own culture with how nurses work with residents and how involved they are in residency training. So I think, for the listeners and for the readers, that’s an important thing to keep in mind as they look at how our study findings are transferable to their own institution. So I think it’s a really valid point because they have to think about whether those clinical contexts might change how nurses perceive sharing feedback with residents and whether that changing clinical context changes the barriers that we identified. If those barriers that we identified are not the barriers that are at play at the reader’s clinical institution then everything changes. That’s really important to keep in mind.
Toni Gallo:
In your title, you used the phrase “Unobserved Observers.” This might have been a quote from one of the participants, but I wonder if you could just talk about that role. Some of your participants felt like they had a unique perspective to offer. How did that come up? What do you see the value of a nurse in that kind of role being able to offer about, what kind of feedback someone in that role could offer that maybe is different from the feedback that others offer? We’ve kinda touched on this a little bit, but I think that idea of the unobserved observer is an interesting one.
Chirag Bhat:
Yeah, it came up as we were discussing a lot of the interview findings more and more. One of the themes that kept coming up was that nurses were noticing that when residents were around attending physicians, they would act one way. The behavior that they displayed was not necessarily the behavior that they would adopt in clinical practice when attending physicians were not around. So our participants felt that likely there was some element of residents experiencing anxiety or having some sort of staged performance when attending physicians are around. That’s obviously not always the case, but there may be an element to that. But what nurses also noticed was that when residents were around nurses by themselves, and not with an attending physician, they tended to demonstrate the same behaviors that would be more reflective of their actual practice.
Chirag Bhat:
So our study group, sorry our research group, realized that nurses were influencing resident behaviors to a much lesser degree than attending physicians. Perhaps that would allow us to have a better window into how residents actually practice and the behaviors they actually do when no one is watching them. So that’s how that idea of nurses playing the role of an unobserved observer came up. I think it’s important to note though, that in our clinical context, RNs are not formally involved in resident assessment. They don’t formally fill out any assessment on resident physicians. That might play a significant role in them taking on this role of an unobserved observer.
Chirag Bhat:
So we don’t really know yet what will happen if we were to ask nurses to take on the role of assessing residents and how that would change the dynamic of RN-resident interactions. If we were to ask nurses to assess residents more formally, it’s very possible that we would end up causing resident physicians to start staging performances with nurses as well.
Chirag Bhat:
So essentially, all of this boils down to say that we don’t really know the optimal way of implementing RN feedback at this point. We still need to figure that out before we can actually do this in a way that is helpful to our residents and to our nurses.
Teresa Chan:
That’s great. All right. I think we’re going to go for a round of final thoughts from these two esteemed colleagues who have done some great work. Any final thoughts? Maybe we’ll go to Warren first.
Warren Cheung:
I would just say that this project, and I have to give kudos to Chirag, who really took this project under his wings and flew with it, that it was very … It was my first study using constructivist grounded theory approach. It was very enlightening. Again, shout out to Kori LaDonna who really held our hand and walked us through this. But I think we sometimes underestimate the value of qualitative research. I think this study is a great example of the rich data that we can really uncover through qualitative approaches and trying to understand the lived experiences of participants.
Teresa Chan:
Great. Over to Chirag.
Chirag Bhat:
The point that this study really highlighted to me is the internal conflict that many of our nursing colleagues experience, in that a lot of them really want to give feedback. They really want to share their expertise and help in resident education, but the fact that they’ve experienced so many barriers that prevent them from doing so is disheartening. So this study and understanding their perspectives a bit better about that has really helped open my eyes as to how much value nursing feedback can be for my own growth as I go through residency.
Teresa Chan:
All right. That’s a great response. Thank you so much to both of you for spending time with us.
Toni Gallo:
Yeah. I just want to thank you both again, like Teresa said. I want to encourage listeners to look for the paper that we discussed today, which is available on academicmedicine.org. Thanks a lot.
Warren Cheung:
Thanks for having us.
Chirag Bhat:
Thanks so much.
Toni Gallo:
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