An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents' perspective

Abstract

Background: Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity.

Methods: Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC).

Results: Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development.

Conclusion: Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

Keywords: Assessment for learning; Clinical settings; Competence-by-design; Feedback; Interpretive phenomenology; Resident feedback.

Fig. 1

Cultural Historical Activity Theory (CHAT) framework and the Miller’s Pyramid of Clinical Competence. The role of feedback is highlighted as mediating the residents’ interactions and activities towards increasing level of competence. Based on the work in Engestrom, Y. Learning by expanding: An activity-theoretical approach to developmental research. 2nd Ed. Helsinki: Orienta-Konsultit; 1987. and Miller GE. Assessment of clinical skills/competence/performance. Acad Med 1990;9:63–67

Fig. 2

Emotional valence and meaning of feedback - code-proximity maps of thematic co-occurrence (individual/group analysis). Feedback that was seen by residents as inaccurate was perceived as unfair and was often disregarded. Residents’ respect for the faculty providing feedback influenced the meaning – a highly respected faculty giving critical feedback could evoke a sense of shame and failure, however this could in parallel be highly motivating if the feedback was actionable. Criticism from faculty who are perceived as rigid, “picky” and unfair, was universally demoralizing and often dismissed. Humor was used often when poor feedback skills (or routine avoidance of feedback) were centered on faculty (“read more”). Sarcasm was common when these poor skills resulted in feedback that was perceived as personally unfair or unjust. These occurrences gave rise to a sense of resentment. In both individual comments and group discussions, face to face feedback was universally perceived as most useful. Residents felt that it necessitated being observed, although these comments were often accompanied by use of humor, suggesting a mild level of discomfort. Discomfort can be psychologically healthy; it indicates motivation to change, which is a necessary component of learning. In individual and group comments, dishonest feedback was met with sarcasm. Group discussion provided compare-and-contrast discussion (increased frequency and wider linking of co-occurrence), with residents expressing humor and sarcasm on behalf of their peers. Analysis performed using MAXQDA 2020. Berlin: VERBI Software, 2019