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PURPOSE Postgraduate training programs are incorporating feedback from registered nurses (RNs) to facilitate holistic assessments of resident performance. RNs are a potentially rich source of feedback because they often observe trainees during clinical encounters when physician supervisors are not present. However, RN perspectives about sharing feedback have not been deeply explored. This study investigated RN perspectives about providing feedback and explored the facilitators and barriers influencing their engagement. METHOD Constructivist grounded theory methodology was used in interviewing 11 emergency medicine and 8 internal medicine RNs at 2 campuses of a tertiary care academic medical center in Ontario, Canada, between July 2019 and March 2020. Interviews explored RN experiences working with and observing residents in clinical practice. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis. RESULTS RNs felt they could observe authentic day-to-day behaviors of residents often unwitnessed by supervising physicians and offer unique feedback related to patient advocacy, communication, leadership, collaboration, and professionalism. Despite a strong desire to contribute to resident education, RNs were apprehensive about sharing feedback and reported barriers related to hierarchy, power differentials, and a fear of overstepping professional boundaries. Although infrequent, a key stimulus that enabled RNs to feel safe in sharing feedback was an invitation from the supervising physician to provide input. CONCLUSIONS Perceived hierarchy in academic medicine is a critical barrier to engaging RNs in feedback for residents. Accessing RN feedback on authentic resident behaviors requires dismantling the negative effects of hierarchy and fostering a collaborative interprofessional working environment. A critical step toward this goal may require supervising physicians to model feedback-seeking behavior by inviting RNs to share feedback. Until a workplace culture is established that validates nurses' input and creates safe opportunities for them to contribute to resident education, the voices of nurses will remain unheard.

Context Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. Methods We performed an ethnographic non‐participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in‐depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in‐depth interviews. We analysed the interviews iteratively following the data collection using template analysis. Results Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. Conclusions Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set‐up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor., While critically important, intraprofessional collaboration is not learnt spontaneously. Improvements in mindset, professional identity and power dynamics are crucial to its promotion.

Objectives The suboptimal provision of analgesia to children in the emergency department (ED) is well-described. A yet unexplored barrier is caregiver or child refusal of analgesia. We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED. Methods We conducted a two-centre cross-sectional study of 743 caregivers of children 4–17 years presenting to the pediatric ED with an acutely painful condition using a survey and medical record review. The primary outcome was the proportion of children/caregiver pairs who accepted analgesia in the ED. Results The median (IQR) age of children was 11 (7) years, and 339/743 (45.6%) were female. The overall survey response rate was 73% (743/1018). In the 24 hours preceding ED arrival, the median (IQR) maximal pain score rated by children and caregivers was 8/10 (4) and 5/10 (2), respectively, and 30.4% (226/743) of caregivers offered analgesia. In the ED, children reported a median (IQR) pain score of 8/10 (2) and 54.9% (408/743) were offered analgesia. When offered in the ED, analgesia was accepted by 91% (373/408). Overall, 55.7% (414/743) of children received some form of analgesia. Conclusions Most caregivers/children accept analgesia when offered by ED personnel, suggesting refusal is not a major barrier to optimal management of children’s pain and highlighting the importance of ED personnel in encouraging adequate analgesia. A large proportion of children in pain are not offered analgesia by caregivers or ED personnel. Educational strategies for recognizing and treating pain should be directed at children, caregivers, and ED personnel.

Purpose: Recent physician surveys show high self-reported rates of offering analgesia to children in the emergency department (ED). However, institutional audits of actual practice suggest sub-optimal analgesic administration persists. Reasons may include caregiver or patient refusal. Our objectives were to determine the proportions of children who were offered analgesia at home and children/caregivers who accepted analgesia in the ED. Methods: We conducted a multi-center prospective cohort study involving a caregiver survey and medical record review. We included children aged 4-17 years presenting to the ED with an acutely painful condition …

Objectives Socialisation theories of professional identity formation (PIF) consider clinical rotations to be critically intense transformative experiences. However, few studies have explored what trainees grapple with during these transformative experiences or their influence on performance. Applying a threshold concepts (TCs) lens, this study investigates and documents 'troublesome' and 'transformative' concepts that junior trainees may encounter during a clinical rotation. Insights gained are essential for supporting trainee development. Methods Constructivist grounded theory was used to guide the collection and analysis of data for this two-phase study. Phase 1 involved direct observation and field interviews with 17 junior trainees over two observation periods and phase 2 involved in-depth interviews with 13 attending physicians. The theory of TCs was used as a sensitising concept. Results In total, nine TCs were identified and thematically grouped under the headings: Developing as a Professional, Providing Patient Care and Working Collectively. Across the interviewed attending physicians, there appeared to be a shared understanding of TCs strong trainees had crossed and weaker trainees struggled with. Observational and field interview data suggested that individual trainee actions were strongly influenced by the identified TC and whether or not the trainee appeared to have crossed any given threshold. Moreover, individual clinical practices could be influenced by more than one TC. Trainees were also observed to vary in the thresholds they had already crossed or struggled with. Conclusions The identified TCs offer important insights into the relationship between trainee actions and how they conceptualise practice. At their heart, many appeared to represent ideals of practice that trainees should incorporate into their developing identities as they explore what it means to be a physician. Future research should explore how to incorporate TCs into assessment and the support of trainee development.

Introduction: The suboptimal management of children’s pain in the emergency department (ED) is well described. Although surveys of physicians show improvements in providing analgesia, institutional audits suggest otherwise. One reason may be patient refusal. Our objectives were to determine the proportion of caregivers that offered analgesia prior to arrival to the ED, accept analgesia in the ED, and identify reasons for withholding analgesia. Our results will inform knowledge translation initiatives to improve analgesic provision to children. Methods: A novel survey was designed to test the hypothesis that a large proportion of caregivers withhold and refuse analgesia. Over a 16-week period across two Canadian paediatric EDs, we surveyed caregivers of children aged 4-17 years with an acutely painful condition (headache, otalgia, sore throat, abdominal pain, or musculoskeletal injury). The primary outcome was the proportion of caregivers who offered analgesia up to 24 hours prior to ED arrival and accepted analgesia in the ED. Results: The response rate was 568/707 (80.3%). The majority of caregivers were female (426/568, 75%), aged 36 years or older (434/568, 76.4%), and had a post-secondary education (448/561, 79.9%). Their children included 320 males and 248 females with a mean age of 10.6 years. Most (514/564, 91.1%) reported being “able to tell when their child was in pain”. On average, children rated their maximal pain at 7.4/10. A total of 382/561 (68.1%) caregivers did not offer any form of analgesia prior to arrival. Common reasons included lack of time (124/561, 22.1%), fear of masking signs and symptoms (74/561, 13.2%) or the seriousness of their child’s condition (72/561, 12.8%), and lack of analgesia at home (71/561, 12.7%). Analgesia was offered to 328/560 (58.6%) children in the ED and 283/328 (72.6%) caregivers accepted. The most common reason for not accepting analgesia was child refusal (20/45, 44.4%). Conclusion: Most caregivers do not offer analgesia to their child prior to arriving in the ED despite high levels of pain and an awareness of it. Despite high rates of acceptance of analgesia in the ED, misconceptions are common. Knowledge translation strategies should dispel caregiver misconceptions, and highlight the impact of pain on children and the importance of analgesia at home.