Resident physicians need consistent and constructive feedback to support their clinical and professional development. 1,2 Although feedback is typically provided to residents from supervising physicians, there is growing recognition within residency programs that feedback from sources other than supervising physicians may lead to a richer, more holistic understanding of a resident’s performance. 3,4 For example, residency programs have traditionally experienced challenges with supervising physicians assessing the humanistic and relational competencies of medical practice—attributes that are instead more frequently demonstrated during interactions with other health professionals, such as registered nurses (RNs). 5–8 RNs have been identified as a key source for formative feedback because they frequently interact directly with residents and have the opportunity to witness residents’ day-to-day actions in the clinical workplace. 9,10 Moreover, because RNs approach patient care from a different perspective than physicians, they may notice or observe different resident behaviors and practices than those noticed by physician supervisors. 11,12 Additionally, the interdisciplinary teamwork approach to nursing education may prime RNs to remark on these behaviors and offer feedback to residents that has the “potential to change trainee behavior and ultimately improve patient care.” 3,11,13
Several studies have found that when assessing the same trainee, RNs and supervising physicians tend to provide substantially different feedback. 9,14–18 Pollock et al found that whereas supervising physicians focused on deficiencies in medical knowledge, RNs commented on behaviors related to communication and collaboration. 15 Because feedback from RNs in these domains may be more reliable than feedback from supervising physicians, many new feedback tools include sections that solicit RN input on resident performance. 2,9,19 Although these feedback tools have been demonstrated to be reliable and feasible, 2 many were developed without input from RNs and are often based on an underlying assumption that there are specific aspects of workplace performance about which RNs feel they can provide feedback. 1,2,20,21 This assumption has been sparsely investigated, and our understanding of RN perspectives on contributing to feedback for residents and the factors that influence the provision of feedback is limited. 21,22
To effectively implement a system of feedback that includes RN input, a deeper understanding of their perspectives as primary stakeholders is needed. Specifically, assumptions about the resident behaviors and actions on which RNs can offer feedback require clarification. Furthermore, establishing a better understanding of the mediators that influence RNs’ ability and willingness to contribute feedback could help residency programs determine how best to operationalize input from RNs, enabling access to potentially rich and holistic information to supplement existing methods of assessment. This study, therefore, sought to explore RNs’ perspectives on sharing feedback, including the aspects of workplace performance on which they feel capable of offering input, as well as the facilitators of and barriers to contributing this feedback.
Method
Because nurses’ role in medical education is undertheorized, we used constructivist grounded theory (CGT) to explore RN perspectives about sharing feedback on resident performance. 23 CGT provides a rigorous blueprint for systematically collecting and analyzing data about complex social interactions and processes such as the provision of feedback. 23,24 Because CGT is influenced by the interaction between the researchers and the participants, we formed a research team of individuals from a variety of backgrounds. The research team consisted of 1 emergency medicine resident, 2 attending emergency medicine clinician–educators, 1 attending internal medicine clinician–educator, 1 RN, 1 PhD-trained qualitative methodologist and medical education researcher, and 1 research assistant with qualitative research expertise. This research study was approved by the Ottawa Health Science Network Research Ethics Board.
We sent a recruitment email to all emergency medicine and internal medicine RNs at 2 campuses of a tertiary care academic medical center in Ontario, Canada. The email, sent through nursing managers, invited RNs to participate in semistructured interviews exploring their perspectives about providing feedback on residents’ clinical performance. RNs from academic medical centers were chosen because of the frequent interactions they have with residents during patient care. Because workplace context might influence RN perspectives about sharing feedback, we purposefully recruited RNs from emergency medicine and internal medicine—specialties in which both aspects of patient care and the structure of residency education appear to foster different types of interactions between RNs and residents. Emergency medicine RNs typically work with residents who engage in shift work, and the RN–resident relationship often involves working directly alongside one another in a space conducive to direct and frequent interactions. In contrast, internal medicine RNs work with residents who are on call, and their interactions are often more indirect (such as phone calls) while having shared longitudinal exposures with patients. We sampled from these 2 clinical settings to explore how workplace and sociocultural factors might affect RNs’ views on resident feedback. Nineteen RNs (n = 11 emergency; n = 8 internal medicine) participated in the study, and no participants withdrew. Their experience working with residents varied (junior <5 years [n = 4]; intermediate 5–10 years [n= 9]; senior >10 years [n= 6]), and their ages ranged from 26 to 58. Two RNs identified as male, and 17 identified as female.
Interviews were conducted by a research assistant (K.S.) between July 2019 and March 2020. K.S. had no prior professional or nonprofessional relationship with any of the study participants and had prior training and experience conducting interviews as part of qualitative research. Participants were asked to describe their day-to-day work with residents and their opportunities to observe resident workplace performance. Participants were also asked to reflect on and share instances when they either did or did not choose to provide resident feedback. We then asked probing questions to explore the purpose, facilitators, and mechanisms of and barriers to providing resident feedback. New questions were added to the interview guide during data collection to explore ideas described by participants in early interviews. The interview guide is provided as Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B196.
Data were analyzed concurrently with data collection and in iterative cycles, as per CGT. 23 More specifically, analysis was performed in 3 progressively interpretive stages: initial, focused, and theoretical. During the initial stage, 2 members of the research team (C.B. and S.D.) independently analyzed 3 transcripts line by line and coded for key action words and phrases. The goal of this stage was to capture and describe the underlying thought processes behind the participants’ perspectives. In the focused stage of analysis, C.B. and S.D. analyzed an additional 4 transcripts and consolidated initial codes into preliminary themes. The entire research team met frequently to discuss preliminary coding and evolving analytical insights. During the theoretical stage, team members identified patterns by making comparisons within and across transcripts, then interpreting these patterns to construct high-level analytical story lines about the data. Ultimately, the team developed a list of abstract theoretical codes by consensus that was used to code and then recode the entire dataset. Any differences in coding or identified themes were resolved by discussion and consensus of all research team members.
During this process, the team identified themes that required additional data to generate a more robust understanding and probed for these themes in subsequent interviews and analysis. For instance, our initial data suggested that the seniority of nurses influenced their provision of feedback. We therefore theoretically sampled senior RNs to explore this finding in greater depth. Sampling continued until all members of the research team agreed that theoretical sufficiency—the point at which new interviews generated data that supported the analysis rather than provided new insights—had been reached. 23 Furthermore, after 19 interviews, our team agreed that, while continuing data collection would undoubtedly generate nuance, the collected data were sufficient for answering the exploratory research question. The entire data analysis process involved writing memos that enabled the research team to reflect on how our own backgrounds and experiences influenced data collection and analysis. 25 We used NVivo 12 software (QSR International, Doncaster, Australia) to manage data and assist in data coding and analysis. Quotations below from participants illustrate the themes and are presented with the participant identification number in parentheses.
Results
RN feedback: A unique perspective
Regardless of their seniority or the clinical context in which they worked, participants indicated that they had a “lot to say” about resident performance and wished that nurses were “more involved” with resident feedback (RN 03). RNs perceived that their hands-on role in patient care provided them with a unique vantage point for observing residents:
We actually get to see the residents, how they interact at the bedside, their orders, how they respond when we’re asking them for things, and I think the [supervising] physicians don’t see a lot of that stuff. (RN 07)
RNs also perceived that residents modified behaviors in the presence of their supervising physicians and instead displayed more genuine and authentic workplace behaviors and clinical skills around nurses:
When the [supervising physician] is there, they [residents] act one way, right, because ... they feel they’re being tested. So we see them when they’re not in that situation [and] how they’re going to function when there’s nobody watching them. (RN 06)
RNs indicated that observing such “unguarded behavior” afforded them the unique opportunity to provide resident feedback about skills that supervising physicians may have difficulty observing (RN 09). For instance, RNs were particularly attuned to how residents interacted with patients and felt they could offer constructive feedback to help residents improve their communication skills, such as in body language, and become more effective and compassionate communicators:
I think we get to see a lot of the bedside manner that the staff doesn’t see. You can definitely see who has better bedside manner than others ... just the way they stand in the room, the way they talk to the patient: are they rushing the patient, are they listening to them?... So, I think we get to see that a lot more than the staff do, and I think that’s pretty helpful. (RN 11)
RNs also said that they felt they could give feedback on resident behaviors related to leadership, collaboration, patient advocacy, and professionalism. One participant highlighted a situation in which the RN observed a resident’s ability to manage a critically ill patient and commented on the resident’s leadership and collaboration:
I think a lot of times it’s the way they [residents] handle situations. When a situation arises, they’re not flustered or confused, they’re able to give you orders and direction quickly, and ... they’re also open to discussion. So that they’re open to having a conversation and say, “What do you think?” or “Do you think we should go that way?” ... and that collaborative piece is really important. (RN 12)
This participant also described a scenario in which the participant noted and commented on a resident’s poor professional behavior:
This resident didn’t come into the bedside; he was out of the hospital and during our phone conversations he was just, I found him to be rude, and he was giving me incorrect orders, like orders that I thought were absurd, that I didn’t agree with, and he wasn’t receptive to any of my feedback. (RN 12)
Although RNs in both the emergency department and inpatient internal medicine wards felt they were able to provide specific, concrete, and constructive feedback about a range of likely authentic resident behaviors, they often had difficulty sharing this feedback. When this tension was explored in the interviews, participants revealed several key barriers.
Hierarchy and power differentials as barriers to feedback
RNs overwhelmingly perceived that they were located at the bottom of an unspoken hierarchy resulting from a “power struggle between nurses and doctors” where the “power is just so ‘kiltered’” toward resident and supervising physicians (RN 01 and RN 02). RNs reported being “intimidated” by resident and supervising physicians and were apprehensive about offering resident feedback because of the potential for retribution (RN 05). RNs worried that conveying feedback on residents’ behaviors would lead to future workplace conflicts and that resident physicians would use their position and power to make RN duties more difficult:
They’re afraid that the next encounter, of what the doctor’s going to say.... They’re just scared that the next time they have to page or if they have to talk to that resident for another patient, then it might not go well. (RN 19)
Even if they perceived that a resident might be receptive, RNs remained reluctant to share constructive feedback, worrying it might impede communication essential for safe patient care:
I wouldn’t want to ruin that relationship because we work with them all the time, and we have to be really close, and they have to be able to feel comfortable telling us things. (RN 11)
Junior RNs were particularly influenced by perceived hierarchy and power differentials as a barrier to sharing feedback. Participants indicated that junior RNs were “more hesitant on communicating,” while senior RNs tended to be more willing to share feedback despite the perceived power differentials (RN 01).
Central to these power differentials was a feeling that physicians did not “really understand that [an RN’s] knowledge base is different but important” (RN 18). As a result, RNs commonly perceived the status quo in health care to be for physicians and nurses to work and learn in silos, and thus they felt it was not their place to provide feedback about residents. As one RN made clear, residents were viewed as being under the sole supervision of the physician and providing feedback could be viewed as a breach of hierarchy:
It seems to be a very hard line. They are learners, and they are the physician’s learners; they are not ours.... It’s a teaching hospital, and because the residents kind of belong to the physicians, I just don’t feel like it’s our place. (RN 13)
RNs perceived that due to hierarchy and these professional boundaries, their feedback would be neither wanted nor valued by residents and supervising physicians:
There is a sort of hierarchy, and even if I want to give feedback, I would be thinking hey, are they really bothered about it ... [do] they really want feedback from a nurse about their resident ...? (RN 03)
This notion was reinforced by how feedback was received by the resident and supervising physicians in the rare instances when nurses provided it. RNs relied on past interactions with residents and supervising physicians to judge how their feedback would be received. When residents and supervising physicians were previously dismissive of RN viewpoints, RNs were less likely to provide subsequent feedback because the experience reinforced their perceptions that physicians “don’t care” about nursing insights and their opinions were “not important” (RN 03). RNs often discussed how residents typically responded to feedback and reported that they shared residents’ reputations with each other:
And as a new nurse, the more experienced nurses will tell you, Dr. So-and-So, don’t even bother [giving feedback] ... don’t talk to this person directly because you will get shut down. (RN 05)
A resident’s reputation carried forward and influenced RNs’ willingness to provide any further feedback to that resident:
If I know that this resident is not receptive to the feedback, I won’t give it to them ... you get to know people’s personalities and then, at the same time, you’ll get the word of mouth also.... I will be very hesitant to provide that feedback if I’ve had a bad interaction once already. (RN 12)
RNs’ motivation to give feedback
Hierarchy in academic medicine was such a potent barrier that RNs rarely shared feedback unless compelled to by a patient safety event that posed “a danger to somebody’s life” (RN 06). When prompted by such patient safety events, RNs often circumvented perceived hierarchy and chose not to give feedback to the resident directly, relying instead on other avenues. RNs would often share feedback with the supervising physician rather than the resident to get a “second opinion” on the resident’s response to the patient safety event, as well as to flag for supervising physicians that “somebody needs to be watching [the resident]” (RN 13 and RN 06). Alternatively, RNs would approach their own nursing supervisors or managers to give resident feedback:
[If] you are imminently going to kill this patient ... I will go to my supervisor ... and get them to deal with it. And usually when the care facilitator [nursing supervisor] comes up to a resident and says, “You need to do something about this right now or I’m calling your staff [supervising physician],” it gets dealt with. (RN 05)
RNs relied on their own supervisors because they felt they would “have their back” and support their point of view, thus increasing their credibility (RN 11).
Another critical motivator for RNs to share resident feedback was explicit prompting by physicians. RNs were much more willing to share feedback if they were asked to give their input; for example, one participant would provide feedback “if the [supervising physician] comes up to me and asks for feedback or a resident sends an email asking for feedback” (RN 12). Explicitly inviting RNs to share their unique perspective on resident behaviors allowed RNs to feel “comfortable with the staff [supervising physician]” and share feedback directly with the individual asking (RN 12). Furthermore, prompting allowed RNs to have “an easy flowing feedback conversation” while feeling safe to do so because they “know [the physician] would be receptive” (RN 12). Participants felt that this invitation served as a critical act in dismantling the negative effects of hierarchy and allowed RNs the opportunity to share their insights about the resident’s performance.
Such invitations were rare, however, even among physicians whom RNs regarded as approachable and friendly. One RN stated:
I’ve never had a staff [supervising physician] say ... “At the end of your shift can you let me know how this person [resident] did?”... I see them doing their own evaluations, but they’ve never included us in their actual evaluations. (RN 13)
RNs were frustrated that they were rarely asked for their perspective, even though they could “offer so much input to help [residents]” (RN 14). RNs perceived themselves to be an “untapped resource” and wished their unique perspective to observe and comment on authentic resident workplace performance was incorporated more regularly to help residents improve (RN 14).
Discussion
Our study suggests that nurses working in academic medicine environments may have unique insights into resident performance that could augment feedback processes. Although the RNs in our study wanted to engage in feedback conversations, they were largely reluctant to do so because of perceived power differentials between nurses, supervising physicians, and residents. Most RNs were only willing to risk navigating sociocultural obstacles in extraordinary circumstances, such as patient safety events or when explicitly prompted by physicians to share feedback.
To date, few studies have explored RNs’ perspectives on providing resident feedback. 11,21,26 RNs in our study perceived a role in sharing resident feedback as unobserved observers who witness authentic day-to-day actions and behaviors of residents. RNs expressed a willingness to participate in the feedback process, perceiving that through their workplace interactions they were well positioned to provide feedback about genuine resident behaviors related to communication, teamwork, professionalism, patient advocacy, and leadership. The findings from this study resonate with the literature that feedback from RNs on resident performance that supervising physicians do not routinely observe may help to address a gap in medical training. 11 However, we offer that the true value of feedback from RNs may be derived from authentic observations that may be less vulnerable to the “observer effect.”
The observer effect, in which individuals modify their behavior in response to knowingly being observed, has been reported in the medical education literature. 27,28 Direct observation by a faculty supervisor can evoke significant anxiety among residents, leading them to exchange their usual practice for a “staged” performance. 28 Consequently, the validity and credibility of the feedback generated from such observations may be threatened if what was observed does not reflect true workplace behaviors. 29 Whereas residents may modify their practice with supervising physicians, RNs in our study noted that residents tended to show more genuine behaviors in the absence of supervising physicians. LaDonna et al suggest that the impact of an observer’s presence may differ based on the role of the observer and that the impact may be greatest when the observer is “perceived to have the same scope of practice or be in a position to provide a formal assessment.” 28 RNs in our study were not formally involved in resident assessment and instead interacted with trainees as part of the care team in their day-to-day work. We speculate that this interaction affords RNs a unique vantage point as an unobserved observer to remark on the genuine workplace practices of residents.
Although RNs may be uniquely positioned to observe authentic resident behaviors, systemic barriers limit access to this rich source of feedback. Power differentials in medicine strongly influence interactions between nurses and physicians in multiple domains, and historically, these interactions have been hierarchical, reflecting physician dominance and nursing subservience. 30–32 This dynamic is likely influenced by professional socialization, a process by which normative expectations and values for practice are transmitted by the profession and internalized by novices. 33,34 While nurses in our study perceived the power imbalance to favor physicians, residents have also been reported to hold this perception. 22,35 Situated learning theory would suggest that these perceptions of hierarchical norms have been shaped through nurses’ and residents’ interactions with their environment, including the “hidden curriculum” of organizational culture, and imparted over time through social interactions within their communities of practice. 36,37 This power dynamic has been identified as a major barrier to the provision and acceptance of feedback from nurses. 22 Although there is evidence that physician–nurse relationships are improving and shifting toward more collegial and collaborative models, studies continue to report that nurses perceive that their efforts and professional assessments are not valued by physicians. 31,38–41 RNs in our study reported feeling apprehensive about sharing feedback because their input had been dismissed by residents or supervising physicians previously. Similarly, other studies have reported that nurses often feel humiliated and intimidated after interactions with domineering physicians, resulting in unease and trepidation around future communication. 38,40,41 These physician behaviors and the resulting dissonance perpetuate the divide between professions and risk reducing interactions to limited formal exchanges necessary to fulfill their responsibility to patients, which participants in our study often described as “working in silos.” 42,43
However, the negotiated order perspective suggests that the distribution of power and boundary demarcations between professional roles in health care are not impenetrable but rather dynamic, contextual, and negotiated. 44,45 Although RNs perceived being rigidly bound by power differentials, extraordinary circumstances such as patient safety events would compel RNs to exert agency and share feedback. RNs in our study did so indirectly through nursing supervisors or supervising physicians; the use of such indirect channels suggests that while RNs are still constrained by boundaries, they have developed strategies to navigate hierarchy. Additionally, factors such as seniority may have influenced RNs’ willingness to exert agency and share feedback. Senior RNs reported being more willing to share feedback than their junior colleagues, which may suggest that as RNs gain seniority and are progressively accepted into the core of their community of practice, they may feel empowered to exercise greater agency. 46,47
The negotiated order perspective also suggests, however, that RNs, through their decisions and actions, can play a role in coconstructing hierarchical boundaries with physicians. 44,45 The actions that RNs take can inadvertently either challenge existing power structures or serve to maintain the status quo. 44,45 For example, in a study by Miles et al, power differentials influenced RNs’ strong preference for sharing resident feedback anonymously; however, the act of remaining anonymous served to diminish RN credibility in the eyes of residents and unintentionally reinforced existing power structures. 48 Yet, while RNs have agency in contributing to resident feedback, the permeating influence of clinical workplace structures and social norms cannot be disregarded. Participants in our study clearly expressed that to effectively engage RNs in contributing to resident feedback, RNs need to feel safe, which requires dismantling existing power structures and fostering a working environment characterized by physician–nurse collaboration and respect. In a study by Baggs and Schmitt, a critical antecedent condition to a collaborative dynamic between nurses and physicians was the notion of “being receptive,” having respect for and demonstrating an active interest in the viewpoints of the other profession. 35 Therefore, modeling feedback-seeking behavior through the critical act of inviting RNs to contribute feedback about resident performance may be an important first step that supervising physicians can take to dismantle the harmful effects that hierarchy can have on feedback sharing. 49
Supervising physicians inviting RNs to share their feedback about residents’ performance can help validate the interprofessional role that RNs play in resident education. 35 Additionally, such role-modeling can be a powerful driver for shaping the professional development of learners and has been shown to be effective in fostering positive interdisciplinary collaborative practices among health care trainees. 50–54 By seeking the input of RNs, supervising physicians may also address issues of inadequate feedback literacy among residents. 55 Feedback literacy necessitates an alliance between trainees and educators working collaboratively so trainees can understand, interpret, and use feedback to improve clinical practice. 56 Trainees’ role in the alliance involves appreciating and recognizing the value of feedback, which requires viewing the source of feedback as credible. 3,22,55–57 However, the literature suggests that in certain contexts, residents may not view RNs as credible sources. 58 Educators then have a responsibility to create an environment in which trainees perceive RN feedback as credible and valuable. 56,59 By modeling feedback seeking and inviting RNs to share resident feedback, supervising physicians can partner with nurses to help elevate the credibility of RN feedback as perceived by residents and encourage residents to seek feedback from varied sources for their own professional development. 60 Ultimately, educators, trainees, and nurses will need to work collaboratively to establish a workplace environment of trust, mutual respect, and safety where all are viewed as credible, equal partners in feedback conversations.
Future directions
Many questions surrounding nurses’ role in resident feedback still remain. In particular, our study focused on the RN perspective, but future studies should explore the resident and supervising physician perspective. Furthermore, the optimal method of implementing a system of RN feedback, as well as the impacts to RN–resident dynamics and the authenticity of observations, is unknown. If residents begin to perceive RNs as formally involved in resident feedback or assessment, they may modify their behaviors when observed by nurses. This idea follows the work of Goffman, who postulated that individuals will act to control how they are viewed in the presence of others. 61 Goffman’s theory has previously been linked to medical education by highlighting how residents undergoing observation try to amplify their strengths while hiding their weaknesses. 62 Thus, implementing a formal RN feedback system is nuanced and will require further study and consideration so that we do not inadvertently undermine the potential authenticity of RN feedback.
In particular, the ideal way of inviting RNs to share their feedback has not been determined. Literature on interprofessional simulation training suggests that facilitator-guided debriefing enables rich discussions with RNs that allow learners to reflect on their own performance while also improving the interprofessional team’s performance. 63 The notion that supervising physicians could adopt the role of “facilitator” to RN feedback regarding resident performance has been suggested. 48 However, if done poorly, implementing such a strategy risks perpetuating current power differentials and undermining perceptions of RN credibility. Further research is required to determine how physicians and RNs can effectively partner and best operationalize facilitated feedback in a way that emphasizes credibility as opposed to perpetuating perceived power imbalances. Importantly, one of the key tenets of facilitator-guided feedback is that the environment must be safe for learners and for those sharing feedback. 63 Without ensuring a safe and collaborative workplace environment, it is possible that inviting RNs to share feedback will simply be a symbolic gesture that leads to hollow and vague resident feedback as well as increased demands on RNs’ time. Thus, the manner, context, and consequences of such an invitation need further clarification.
Limitations
This study investigated the perspectives of RNs from 2 campuses of an academic medical center, and our findings are likely influenced by local cultural norms; consequently, we do not know whether most nurses working in teaching hospitals have a predilection to share feedback or if our findings reflect the views of nurses with a particular interest in medical education. However, residents and supervising physicians can use these findings to reflect on their own practices and attitudes toward feedback from RNs and how they may foster a more inclusive feedback culture at their institution.
Conclusions
Through observation of authentic workplace practice and behaviors, nurses are uniquely positioned to share valuable and insightful feedback on a number of resident physician competencies. However, tensions surrounding hierarchy and the power differentials that divide physicians and nurses remain barriers to this rich source of resident feedback. Until a workplace culture is established that validates nurses’ input and creates safe and collaborative opportunities for them to contribute to resident education, the valuable voices of nurses will remain unheard.
Acknowledgments:
The authors would like to thank the study participants for their time and involvement in the interviews.
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