Journal Club

Bannister SL, Hilliard RI, Regehr G, Lingard L. Technical skills in paediatrics: a qualitative study of acquisition, attitudes and assumptions in the neonatal intensive care unit. Medical Education 2003;37:1082 - 1090

Reviewed by Bruce Morgenstern, MD, Mayo Medical School

When you are Canadian, publishing in a journal out of the UK, you get to spell pediatrics in a more "worldly" way. This paper uses qualitative research tools (field observation, structured interviews and focus groups) to evaluate the acquisition and mastering of skills in an NICU. Clearly, this article is more focused on residents than students, but the observations of the authors may be generalizable.

In addition to 10 residents who were study subjects, nurses, respiratory therapists, a dietician, neonatology fellows and neonatologists were interviewed as the teacher population. The qualitative techniques identified 5 themes: feedback, opportunities, multiple demands, competing priorities, and teachers' and learners' differing perceptions.

Observations included:

1. Feedback: Residents felt that specific, detailed feedback was beneficial. When successful procedures were compared with failures, there was no apparent relationship between outcome and the content and amount of feedback.

2. Opportunities to learn: Positively factors in creating the residents' opportunity to learn included the frequency that procedures are performed, the availability of the learner and teacher, and the attitudes of the learner and teachers. Negative factors included competition from other learners, unstable patients or difficult procedures, negative learning climates and learners' other clinical responsibilities.

3. Multiple demands: "'Work' often interrupts ‘school'." Teaching of the procedure was often interrupted by conversations about the status of other patients or by the teacher having to leave to attend to another urgency.

4. Competing priorities: The NICU setting has many competing priorities that influenced residents' choices to learn skills versus to learn and practice medicine. Competing priorities (as opposed to multiple demands) refers to the residents' decisions about whether to even attempt or seek out a procedure. "Someone asks you ‘Do you want to do this?' and ‘Well yeah, but no thank you.' Not a lot, but occasionally, I d have to say no. There was just too much going on."

5. Differing perceptions: Cutting across the 4 other themes, differing perceptions existed about the role of feedback, opportunities to learn, multiple demands and competing priorities between teachers and learners. Teachers world claim that they watched a resident perform a particular procedure several times before the resident was allowed independence and that they tried not to hover in order not to make the residents nervous. Learners, on the other hand, felt that they were not observed enough and would have appreciated direct and graduated supervision.

Suggestions included:

1. Recognizing that multiple demands in a busy setting interfere with immediate post-procedure feedback, staff needs to "reopen discussions" about the procedure when time allows.

2. Recognize that competing priorities affect the learning opportunities, and that a spiral of performance has been seen, wherein residents who are technically good may be sought out or themselves seek to perform procedures and, while residents who struggle with technical skills may be bypassed or seek the opportunities less often. Residents need to be explicitly informed of the expectations for procedural skills. Staff needs to understand that a choice not to perform a procedure does not always mean that a learner is lacking in initiative, but may be making thoughtful choices under the circumstances.

3. A workshop for teachers that defines the areas in which teachers and learners have conflicting perceptions and helps the teachers develop mechanisms to identify and bridge these altered perceptions.

Morgenstern comments: In many ways, the results are not at all surprising. The power of qualitative research approaches is that they can identify themes that may underlie what seems intuitive. Several themes were identified not by the authors' observations of workflow in the NICU, but as a result of the structured interviews and focus groups, and the residents or the staff had not observed them, either. Opportunities to better orient the residents and to develop the teaching skills of the staff were clarified by this approach. The opportunities also offer opportunities for research that approaches that may be more quantitative.

On another level, I was not cognizant of these themes. I may have noted the issues as they apply to my work as attending on our General Pediatrics inpatient service, but not this well organized. This may help me better approach my orientation to the students and my efforts to work with residents as teachers.

(Another example of qualitative research. Once again, the difference between how learners and teachers see the same thing is amazing. How do you keep track of what the "scuttlebutt on your clerkship is?

Do you have someone other than yourself debrief the experience in a focused group style?

Do you think this should be done for all clerkships?

Steve Miller)