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Barriers and Enablers to Direct Observation of Trainees’ Clinical Performance

A Qualitative Study Using the Theoretical Domains Framework

Cheung, Warren J., MD, MMEd, FRCPC; Patey, Andrea M., PhD; Frank, Jason R., MD, MA(Ed), FRCPC; Mackay, Meredith, MA; Boet, Sylvain, MD, PhD

doi: 10.1097/ACM.0000000000002396
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Purpose Direct observation is essential to assess and provide feedback to medical trainees. However, calls for its increased use in medical training persist as learners report that direct observation occurs infrequently. This study applied a theory-driven approach to systematically investigate barriers and enablers to direct observation in residency training.

Method From September 2016 to July 2017, semistructured interviews of faculty and residents at The Ottawa Hospital were conducted and analyzed. An interview guide based on the theoretical domains framework (TDF) was used to capture 14 domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices.

Results Twenty-five interviews (12 residents, 13 faculty) were conducted, representing 10 specialties. Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social/professional role and identity, intention, goals, memory/attention/decision processes, environmental context and resources, social influences, and behavioral regulation. Discord between faculty and resident intentions, coupled with social expectations that residents should be responsible for ensuring that observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as a pervasive theme.

Conclusions This study identified key barriers and enablers to direct observation. These influencing factors provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.

W.J. Cheung is assistant professor, Department of Emergency Medicine, Faculty of Medicine, University of Ottawa, and senior clinician–investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ORCID: https://orcid.org/0000-0002-2730-8190.

A.M. Patey is senior clinical research associate, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

J.R. Frank is director, Specialty Education, Strategy, and Standards, Royal College of Physicians and Surgeons of Canada, and associate professor and vice chair of education, Department of Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

M. Mackay is project assistant, Research Support Unit, Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

S. Boet is associate professor, Department of Anesthesiology and Pain Medicine, Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, and scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Funding/Support: Healthcare Professions Education Research Grant. Department of Innovation in Medical Education, University of Ottawa; Department of Emergency Medicine Academic Grant. Department of Emergency Medicine, University of Ottawa.

Other disclosures: None reported.

Ethical approval: Ethics approval for this study was provided by the Ottawa Health Science Network Research Ethics Board (protocol no. 20160242-01H, July 25, 2016).

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A582.

Correspondence should be addressed to Warren J. Cheung, Department of Emergency Medicine, University of Ottawa, F660 Clinical Epidemiology Program, 1053 Carling Ave., Ottawa, Ontario, Canada K1Y4E9; telephone: (613) 798-5555, ext. 17196; e-mail: wcheung@toh.ca or amarcantonio@ohri.ca; Twitter: @wjcheungem.

© 2019 by the Association of American Medical Colleges