Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations

ORIGINAL REPORTS

Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations$ Kevin Real, PhD,* Katelyn Fields-Elswick, MA,† and Andrew C. Bernard, MD, FACS‡ Department of Communication, University of Kentucky, Lexington, Kentucky; †Graduate Program in Communication, University of Kentucky, Lexington, Kentucky; and ‡Department of Surgery, UK Healthcare, University of Kentucky, Lexington, Kentucky *

OBJECTIVE: Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices. Surgical educators are challenged with the need to address resident core competencies, some of which may be facilitated by higher levels of mindfulness. This study explores whether mindful residents perform better than their peers as members of the health care team. DESIGN: This study employed a multiphase, multimethod design to assess resident mindfulness, communication, and clinical performance. SETTING: Academic, tertiary medical center. PARTICIPANTS: Residents (N ¼ 51) working in an

intensive care unit. In phase I, medical residents completed a self-report survey of mindfulness, communication, emotional affect, and clinical decision-making. In phase II, resident performance was assessed using independent ratings of mindfulness and clinical decision-making by attending physicians and registered nurses. RESULTS: In phase 1, a significant positive relationship was

found between resident performance and mindfulness, positive affect (PA), and communication. In phase 2, attending physicians/registered nurses’ perceptions of residents’ mindfulness were positively correlated with communication and inversely related to negative affect (NA). The top quartile of residents for performance and mindfulness had the lowest NA. Higher-rated residents underestimated their performance/mindfulness, whereas those in the lowest quartile overestimated these factors. ☆ This study received $1500 in support from the College of Communication and Information at the University of Kentucky. Correspondence: Inquiries to Andrew C. Bernard, MD, FACS, Department of Surgery, UK Healthcare, University of Kentucky, MN-268, AB Chandler Medical Center, 800 Rose Street, Lexington, KY 40536-0298; e-mail: [email protected]

CONCLUSIONS: This study offers a number of implica-

tions for medical resident education. First, mindfulness was perceived to be a significant contributor to self-assessments of competency and performance. Second, both PA and NA were important to mindfulness and performance. Third, communication was associated with resident performance, mindfulness, and PA. These implications suggest that individual characteristics of mindfulness, communication, and affect, all potentially modifiable, influence care quality and safety. To improve low performers, surgical educators could screen and identify residents with inaccurate selfassessments. Residents open to feedback will improve faster and develop awareness toward situations and interactions with patients, colleagues, attending physicians, and staff. C 2016 Association of Program ( J Surg Ed ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: medical residents, resident performance,

mindfulness, communication, clinical decision-making, emotions COMPETENCIES: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Practice-Based Learning and Improvement, Systems-Based Practice

INTRODUCTION Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices designed to improve present-moment awareness.1,2 Fostering better communication and mindful practice in medical residents in critical care rotations and surgical education leads to better patient outcomes.1-6 Medical residents train in complex environments characterized by uncertainty, time pressure, conflicting and ambiguous information, risk,

Journal of Surgical Education  & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.11.010

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distractions, multiple tasks, and the presence of many different professions/occupations.3 It is essential that in their training they develop the ability to recognize their clinical and communicative capabilities as they work and interact with attending physicians (MDs), staff, and patients.5 Mindfulness, the quality of being fully present and attentive during ordinary work/task activities,1,2 has consequences for resident development, performance, and patient safety. Mindfulness and mindful practice, which emphasize awareness, attentiveness, flexibility, and reflection, have been linked to better clinical decision-making, willingness to learn, attention to the present moment, and patient-centered relationship skills.1-6 By contrast, mindless patterns and routines reduce the willingness to look for unexpected events in the course of patient care.1,7 On the other hand, mindful practices increase awareness and may improve core competencies such as interpersonal and communication skills.1,5,8 We believe that in surgical education, residents who are more mindful perform better as members of the health care team. Mindfulness is attention-based and is a type of expertise that residents can learn.9-12 Research by Wald et al.12 indicates that mindfulness, together with faculty/peer relationships, adequate feedback, and collaborative learning environments are important to developing resilient physicians. Residents are mindful to the extent they focus their attention on present-moment events and interactions with patients and other members of their team. Higher levels of awareness, close attention to the unexpected, and relationships characterized by open, clear communication will lead to improved decision-making by surgeons and surgical residents.9-11 Mindful medical residents are often alert, open to feedback, share information, display resilience, and listen to floor staff.12,13 The purpose of this study is to understand the relationship between resident mindfulness, performance, emotional affect, and communication in critical care medicine using a multiphase, multimethod approach examining resident as well as faculty and nurse perceptions. Our study is important because it highlights a novel means of understanding resident performance and health care quality in the intensive care unit (ICU). We make a contribution to the literature by providing insights into medical resident mindfulness in academic medical settings. Understanding the relationship between performance, mindfulness, communication, and emotion can lead to improved quality of care. Given the value in understanding how mindfulness and other factors are important to medical resident education and training, the following research questions were developed: How do residents see themselves in terms of mindfulness and clinical decision-making? How do attending physicians and experienced nurses view residents in regard to mindfulness and clinical decision-making? What role do emotion and communication play in resident development? 2

METHODS The Institutional Review Board at the University of Kentucky approved this study. Participating residents signed written informed consent forms. Pilot interviews were conducted and analyzed first, and then study data were collected in 2 phases. In phase 1, a medical resident survey was conducted. In phase 2, independent ratings of residents by 14 MDs/registered nurses (RNs) were done to understand how residents were judged by those with whom they worked. Pilot Interviews Pilot interviews with 2 experienced RNs were conducted to better understand the role of mindfulness in resident training. Both nurses had more than 10 years of experience working with residents in critical care and recognized the value of residents being aware and paying attention to their present workload. Each nurse described how social and situational awareness, prior interaction, workload and experience affect the quality of work, communication, and overall performance. These interviews informed the research design in this study. Sample The phase 1 sample comprised residents (N ¼ 51) with recent experience in the ICU and was composed of 19 General Surgery residents, 17 Internal Medicine residents, 8 Pulmonary Medicine residents, and 7 Emergency Medicine residents. Residents, 27 of whom were female, ranged in age from 26 to 48 years (mean [M] ¼ 31.04, standard deviation [SD] ¼ 4.37) and program year ranged from 1 to 7 (M ¼ 3.1, SD ¼1.4). Residents were recruited through e-mails and the study was described as examining communication in critical care rotations. Each resident received a coffee gift card for participating. Surveys were hard copy and all participations were voluntary. Phase 1 Measures and Procedures In the survey, resident mindfulness was assessed using a 9item safety organizing scale theoretically grounded in studies of mindfulness in high-reliability organizations; the scale was validated in a study of mindfulness in a hospital context.14 Items were adapted for residents, such as “I have a good ‘mental map’ or ‘concept’ of other’s talents and skills.” Responses were averaged into an index (α ¼ 0.79); (M ¼ 4.1, SD ¼ 64). Clinical decision-making was measured by 2 items that asked residents about their ability to gather accurate patient information and base decisions on sound clinical judgment, qualities considered crucial to working in the ICU, (α ¼ 0.75); (M ¼ 4.5, SD ¼ 0.67). Communication was conceptualized in 3 distinct ways: openness, voice, and feedback, each of which is critical to Journal of Surgical Education  Volume ]/Number ]  ] 2016

high functioning of ICU teamwork. Openness refers to the ability to participate in the exchange of ideas. Residents were asked 4 questions adapted from prior research15 about the extent to which they can participate in discussions and express opinions, (α ¼ 0.71); (M ¼ 4.8, SD ¼ 0.66). Voice refers to the ability of residents to speak up when necessary and to communicate their knowledge with others at work15 (α ¼ 0.86); (M ¼ 4.8, SD ¼ 0.74). Feedback refers to information residents receive about their performance, 4 questions were asked about the timeliness, valence, frequency, and specificity of the feedback,16 (α ¼ 0.76); (M ¼ 4.05, SD ¼ 0.88). These communication variables were then combined using second-order factor analysis17 and averaged into one index, creating a single communication factor (α ¼ 0.83); (M ¼ 4.6, SD ¼ 0.66). Positive affect (PA) and negative affect (NA) were drawn from personality research and are 2 general factors related to positive and negative emotions, which have been found to be related to mindfulness in a recent meta-analysis of personality and affect.18 Items were derived from the Positive and Negative Affect Schedule, which has been validated in prior research and represents the primary dimensions of emotional experience.19,20 Positive and Negative Affect Schedule consists of two 10-item scales for PA and NA, respectively. The scale consists of 20 words that describe PA and NA. Responses for PA were averaged into an index (α ¼ 0.87); (M ¼ 3.7, SD ¼ 0.56) as well as for NA, (α ¼ 0.83);(M ¼ 2.03, SD ¼ 0.58).

(mean) scores were employed. For research question 3, correlation and cross-tabulation comparisons of quartile groups were conducted.

RESULTS Resident Mindfulness and Performance

To address the first 2 research questions, descriptive statistics, t-tests, and assessments of differences in average

Results for residents’ perceptions of their mindfulness and clinical decision-making, including means and standard deviations for each item and the indexed variables, are listed in Table 1. Additionally, ratings by MDs and RNs, using the same scales are listed in Table 1. Results of statistical tests for each item as well as overall indices are presented to examine similarities and differences in perceptions between residents and the MDs and RNs who rated them. Interestingly, on 6 of the 9 individual mindfulness items, MDs or RNs or both had higher perceptions of resident mindfulness than did residents. For example, MDs and RNs significantly rated residents higher than they did themselves on having a good “mental map” or “concept” of other’s talents and skills (residents ¼ 3.9; MDs ¼ 4.3, p o 0.05; RNs ¼ 4.6, p o 0.001). Both attending faculty and RNs significantly evaluated residents higher than residents did themselves that they “discuss the unique skills of others so [they] know who on the unit has relevant specialized skills and knowledge” (residents ¼ 3.1; MDs ¼ 4.1, p o 0.001; RNs ¼ 4.5, p o 0.001). This was also the case that residents “discuss alternatives as to how to go about normal work activities” in that MDs (3.8, p o 0.01) and RNs (4.4, p o 0.001) rated them higher than did residents (3.2). There was 1 item where residents agreed more strongly than raters, “When a patient crisis occurs, I believe in rapidly pooling our collective expertise to attempt to resolve it.” Residents (5.2) were significantly higher in their beliefs than MDs (4.6, p o 0.001) and slightly higher than RNs (4.9). Analysis of clinical decision-making in Table 1 provided a similar pattern. MDs assessed residents higher than residents did themselves that residents could “gather accurate and appropriate patient information” (p o 0.05). RNs believed more strongly that residents “make decisions based on sound clinical judgment” (p o 0.05). Overall, MDs/ RNs rated residents higher on mindfulness and clinical decision-making in absolute terms than did the residents themselves (and statistically significant terms in 3 of 4 indices). The extent to which residents differed in their selfassessments from those of MDs/RNs was computed using self-assessment—mean differences (Table 2). Residents in the lowest quartile overestimated both their performance and mindfulness when the difference between their selfassessment and that of the raters was calculated. In the lowest-performing quartile, average faculty ratings were 0.8 below that of average self-assessments by residents. On the other hand, residents in the top-performing quartile

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Phase 2 Measures and Procedures In phase 2 of the study, independent assessments of resident performance and mindfulness were conducted. Each resident was rated by 6 MDs (3 surgical, 2 internal/pulmonary medicine, and 1 cardiac ICU), and 8 RNs (3 surgical/trauma ICU, 3 medical, and 2 cardiac ICU). Faculty and nurse surveys of resident performance and mindfulness were performed during a 1-month period and were based upon the collective impression of each resident, sometimes formed over multiple different rotations on the ICU service. To prompt recall, raters were provided with a list of resident names along with their pictures to affirm identity. Residents were rated using the 9-item mindfulness scale14 and the 2-item clinical decision-making scale used by residents in phase 1. MDs completed the ratings independently and were paid a nominal fee. Nurses were compensated with lunch and completed their evaluations in groups of 2 to 3. Having physician/nurse raters from across specialties evaluate the residents enabled us to provide a composite evaluation of each resident in the study. These ratings from nurses and physicians supported the reliability and validity of residents’ self-reported perceptions. Analysis

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TABLE 1. Individual Items and Indices, Mindfulness and Clinical Decision-Making, Residents and Raters Residents by Specialty and Total (Phase 1) Individual Items

SURG

INT MED

PULM

EMERG

TOTAL

Raters (Phase 2) MD

RN

14

Mindfulness 1. I have a good “mental map” or “concept” of other's talents and skills.

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4.1 (0.8)

3.8 (1.1)

3.9 (0.8)

3.6 (0.8)

3.9 (0.9)

4.3 (0.1)*

4.6 (0.1)***

2. I talk about my mistakes and ways to learn from them.

4.4 (1.1)

4.1 (1.4)

4.1 (1.0)

3.7 (0.8)

4.2 (1.1)

4.3 (0.1)

4.0 (1.2)

3. I discuss the unique skills of others so we know who on the unit has relevant specialized skills and knowledge.

2.8 (1.3)

3.1 (1.5)

3.7(1.0)

3.3 (0.5)

3.1 (1.3)

4.1 (0.9)***

4.5 (1.0)***

4. I discuss alternatives as to how to go about our normal work activities.

3.3 (1.4)

3.2 (1.2)

3.8 (1.2)

2.6 (1.0)

3.2 (1.2)

3.8 (1.2)**

4.4 (1.0)***

5. When giving report to an oncoming team, physician or nurse, I usually discuss what to look out for.

5.0 (0.9)

4.5 (1.1)

4.8 (0.9)

4.0 (1.0)

4.7 (1.0)

4.7 (0.9)

4.7 (0.9)

6. When attempting to resolve a problem, I take advantage of the unique skills of others (our nursing colleagues, residents, faculty, or other staff).

4.2 (0.8)

3.9 (1.1)

4.4 (1.2)

4.6 (0.8)

4.2 (1.0)

4.4 (1.0)

4.6 (1.1)*

7. I spend time identifying activities I do not want to go wrong.

4.3 (1.0)

4.2 (1.2)

4.4 (1.2)

4.1 (0.7)

4.3 (1.0)

4.2 (1.0)

4.4 (1.1)

8. When errors happen, I discuss how they could have been prevented.

4.3 (0.7)

3.8 (0.8)

4.7 (0.9)

4.0 (1.2)

4.1 (0.9)

4.4 (0.9)

4.0 (1.2)

9. When a patient crisis occurs, I believe in rapidly pooling our collective expertise to attempt to resolve it.

5.3 (0.8)

5.1 (0.9)

5.0 (0.9)

5.6 (0.5)

5.2 (0.8)

4.6 (0.9)***

4.9 (0.9)

4.2 (0.6)

4.0 (0.8)

4.3 (0.7)

3.9 (0.3)

4.1 (0.6)

4.3 (0.9)

4.5 (1.0)*

4.8 (0.71) 4.6 (0.69) 4.7 (0.61)

4.5 (1.0) 4.4 (0.79) 4.5 (0.82)

4.5 (0.53) 4.5 (0.93) 4.5 (0.71)

4.4 (0.53) 4.1 (0.38) 4.3 (0.39)

4.6 (0.78) 4.5 (0.73) 4.5 (0.67)

4.9 (0.83)* 4.6 (0.96) 4.8 (0.85)*

4.8 (0.88) 4.9 (0.95)* 4.9 (0.91)*

Mindfulness (9-item scale; α ¼ 0.79) Clinical decision-making I gather accurate and appropriate patient information I make decisions based on sound clinical judgment Clinical decision-making (2-item scale; α ¼ 0.75)

SURG, Surgical; INT MED, Internal Medicine; PULM, Pulmonary; EMERG, Emergency Medicine; Resident vs. MD or RN p value: A p o 0.05 indicates that differences are not due to chance. Standard deviation, which quantifies the amount of variation for each average value, is reported in parentheses next to each reported average. *p o 0.05. **p o 0.01. ***p o 0.001.

TABLE 2. Self-Assessment vs. Other (MD/RN Raters), Mean Differences, by Quartile for Clinical Decision-Making and Mindfulness

TABLE 4. Rankings of Negative Affect and Rater Assessment of Mindfulness, by Quartile Rater Assessment of Mindfulness by Quartile

Rater Group and Competency Resident Quartiles

MD CDM

RN CDM

MD MDFL

RN MDFL

Resident Negative Lowest Middle Upper Top Affect by Quartiles 25% 25% 25% 25%

Top 25% Upper 25% Middle 25% Lowest 25%

1.26 0.44 0.25 0.72

1.41 0.42 0.1 0.57

1.12 0.57 0.21 1.03

1.22 0.88 0.3 0.89

Top 25% Upper 25% Middle 25% Lowest 25% Total

CDM, clinical decision-making; MDFL, mindfulness. For the top 25% of residents, faculty rated their performance 1.25 higher on average than they rated themselves. Conversely, in the lowest 25%, average faculty ratings were 0.8 below that of average self-assessments by residents.

underestimated both their performance and mindfulness (e.g., faculty rated their performance 1.25 higher on average than they rated themselves). Residents in both the middle and upper quartile groups underestimated their performance and mindfulness to some degree, but the greatest underestimation occurred in the highest quartile group. These differences between resident-MD/RN assessments were meaningful because lowest-performing residents overestimated their competence. To summarize the results for the first 2 research questions, there were meaningful differences between how residents perceived themselves and how faculty and nurses viewed residents in regard to mindfulness and clinical decision-making. Although it appeared at first glance that residents as a whole scored lower, further analysis revealed clear differences between the lowest- and highest-rated mindful residents. More mindful residents (as rated by MDs and RNs) were less likely to be overconfident than the lowest-level group of residents.

Emotion and Communication A series of analyses were conducted to examine research question 3. First, resident self-reported clinical decisionmaking was positively and significantly correlated with PA (r ¼ 0.39, p o 0.01), and communication (r ¼ 0.27, p o 0.05), and mindfulness (r ¼ 0.59, p o 0.001) (Table 3). Second, we assessed the relationship between MD/RN raters’ perceptions of resident mindfulness with resident TABLE 3. Correlation of Resident Clinical Decision-Making With Resident Mindfulness, Positive Affect, Communication Variable Phase Phase Phase Phase

I I I I

mindfulness positive emotional affect negative emotional affect communication

Coefficient

p

0.59 0.39 0.03 0.27

o0.001 o0.01 0.4 o0.05

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7 5 0 1 13

2 4 7 0 13

4 0 6 2 12

0 1 5 7 13

More than half of residents rated in the top 25% of mindfulness were in the lowest quartile for self-reported negative affect. Most lowestrated mindfulness group had the highest levels of self-reported negative affect.

communication and affect. As seen in Table 1, we already knew there was a significant difference in perceptions between MD/RN and residents regarding mindfulness and clinical decision-making. This was further borne out in the correlation analysis: there was no relationship between MDs/RNs and residents on these 2 factors. There was a significant relationship between resident self-reported communication and MDs’ perceptions of mindfulness (r ¼ 0.38, p o 0.01) and clinical decision-making (r ¼ 0.28, p o 0.05). Similarly, there was a marginally significant relationship between resident communication and RNs’ perceptions of mindfulness (r ¼ 0.22, p o 0.10) and clinical decision-making (r ¼ 0.28, p o 0.05). However, in stark contrast to phase 1 resident results, where NA was not a factor, there was a significant negative correlation between MD/RN perceptions of resident mindfulness and residents’ self-reported NA: 0.61 (p o 0.001) for MDs and 0.48 (p o 0.001) for RNs. This disparity in results between phase 1 and phase 2 analyses raised questions concerning the relationship between NA, mindfulness, and performance. To analyze this further, our third step was to cross-tabulate resident self-reported NA with ratings of mindfulness by faculty and nurses (Table 4). Residents rated in the top 25% of mindfulness were in the lowest quartile for self-reported NA. Conversely, those in the lowest-rated mindfulness group had the highest levels of self-reported NA. Fourth, these results prompted us to cross-tabulate resident self-reported NA with ratings of clinical decisionmaking by faculty and nurses. As seen in Table 5, all of the lowest 25% for clinical decision-making were in the upperto-top 25% of self-reported NA. On the other hand, almost all of the top performers were in middle-to-lower quartiles for NA. Nearly all (11/13) residents in the top 25% of performance had low levels of self-reported NA. Of those residents in the top 2 quartiles for performance, 77% were in the lower half of self-reported NA. Conversely, all of the lowest-quartile performers were in the top 2 quartiles of NA. These results indicate, beyond correlational analysis, a 5

TABLE 5. Rankings of Negative Affect and Rater Assessment of Performance, by Quartile

Our study of mindfulness among medical residents suggests that residents, faculty, and nurses view mindful practices as important to performance. Overall, all 3 groups perceived mindfulness, communication, and emotion as important to resident clinical decision-making. This study is significant because it employed a multiphase, multimethod approach to understanding medical resident mindfulness and performance in critical care rotations. If we had only conducted the first phase of the study, our findings would have suggested that residents with higher levels of mindfulness, PA, and communication ability were better performers. By adding faculty and nurse perceptions in the second phase, we were able to get a clearer picture of the role of NA. Residents high in negative emotions tended to be poor performers. Further analysis revealed residents in the lowestperforming quartile tended to overestimate their performance and mindfulness, whereas those in the upper quartile often underestimated their competencies. Thus, the phase 2 findings offer a different and more nuanced perspective of resident performance than phase 1 results alone. As a result, employing a multiphase approach provided richer insights into resident performance. This is not a trivial matter in the current environment of medicine. Surgical educators are challenged with the need to address core competencies that the Accreditation Council for Graduate Medical Education (ACGME) expects

residents to develop in their training. These competencies are patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. It is likely that mindful practice, training, and mentorship facilitate resident development in these core competencies.1,2,5,21-23 Training of medical residents increasingly involves the need to demonstrate social, cognitive, attitudinal, and behavioral activities related to quality and safe patient care.24 Residents likely welcome ways to improve their mindful practices, particularly because mindfulness has been found to reduce physician burnout and increase job satisfaction, quality of life, and compassion.25 Mindful clinicians have been found to be just as productive as less mindful colleagues, yet more focused, positive, and relationship-oriented during patient interactions.26 Patients are likely to be more satisfied with the care and communication skills of high-mindfulness clinicians compared to low-mindfulness clinicians.26 The importance of patient satisfaction has increased as it has become a quality incentive related to financial payment of hospitals.27 Increased mindfulness leads to greater awareness, understanding of the physician’s internal thought processes and emotions, and has implications for preventing bias and diagnostic errors.28 This study offers a number of implications for surgical education. First, mindfulness was perceived to be a significant contributor to higher-quality performance in both phases. This finding resonates with studies of mindfulness in aircraft carriers, disasters, nuclear power plants, chemical manufacturers, and air traffic control.29-31 Ongoing mindfulness is characterized by higher levels of awareness and performance, which set the stage for better-quality relationships and patient care. Residents who attend to interactions with attending MDs, nurses, other staff, and patients are more open to new information and willing to share information. Paying attention and being fully present in the moment during routine, patient-related activities are characterized by improved communication, decision-making, and patient outcomes. Our study found that the degree to which residents were mindful was linked to their perceptions of their own competency. As seen in Table 5, the lowest-quartile residents in mindfulness and clinical decision-making overestimated their abilities, whereas the upper and top quartiles underestimated their competencies. Why is this finding important? Research has shown that physicians, as a group, are less able to accurately assess their performance and often overestimate their capabilities.32 On the other hand, research indicates that top performers tend to underestimate their abilities across a number of competencies,33 suggesting that mindful residents may be relatively modest and respectful in their everyday work. There is evidence in the literature that lower-performing residents tend to be overconfident and least able to identify their weaknesses.33,34 As seen in Table 5, perceptions of the

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Rater Assessment of Performance by Quartile Resident Negative Lowest Middle Upper Top Affect by Quartiles 25% 25% 25% 25% Highest 25% Upper 25% Middle 25% Lowest 25% Total

6 7 0 0 13

2 2 7 1 12

4 0 6 3 13

1 1 5 6 13

All of the lowest 25% for clinical decision-making were in the upper 25% to top 25% of self-reported negative affect.

relationship between performance and self-reported NA. Residents with lower levels of NA tended to be higher performers. To recapitulate the findings for the role of emotion and communication in resident development, we found that residents with higher self-reported NA were rated lower in both performance and mindfulness. Communication, on the other hand, was moderately and positively related to performance and mindfulness. In short, NA had an adverse effect, whereas communication had a positive effect.

DISCUSSION

lowest-performing residents were 1.03 above that of faculty and nurse assessments. To address the issue of false confidence, regular feedback and training of residents could assess the discrepancies between residents actual versus selfperceived abilities. Teaching lower-performing residents the value of paying attention to and learning from others, including staff, is important; so is pointing out the obvious problems in overestimating one’s competency. Such an approach could lead to increased mindfulness, performance, and patient safety. These data lend an evidentiary basis to many cases of resident “underperformance” or grading as “needs improvement.” Training residents in mindfulness will likely improve resident performance and should certainly be considered for residents who have an opportunity to improve. Whether routine mindfulness training can improve performance in an entire cohort of residents remains to be studied. Second, both PA and NA appeared to be important factors in this study. In phase 1, PA was associated with performance, mindfulness, and communication. However, in phase 2, self-reported NA was linked to lower evaluations for performance and mindfulness. It must be reiterated here that raters did not evaluate residents on affect. Residents’ self-reported affect, both PA and NA, were assessed against MD/RN evaluations of mindfulness and performance. By doing so, we eliminated any potential bias for rating someone for NA and then performance or other characteristics. The relationship between NA and low evaluations is not limited to health care and is common across many industries.35 Getting along with others has been linked to higher performance appraisals and higher performance in teams.36 In this study, NA was linked to poor performance. For residents and experienced clinicians, less NA and more mindfulness are crucial to quality patient care. Beach and colleagues found that high-mindfulness physicians were more likely to interact well with patients and be viewed favorably by patients.26 Given the high mindfulness–low NA relationship, it may be that indirect approaches could be an effective remediation effort aimed at increasing emotional affect. Meditation has been shown to work in many cases10; another approach could draw from approaches to mindful organizing such as deference to the expertise of others, good communication, and related organizational competencies.7 Learning the value of working with and even relying on experienced staff, instead of going it alone, could improve the morale of stressed-out residents.1,9,10 Affect can stem from overall job satisfaction among residents. An unhealthy/understaffed work environment that creates a situation of excessive resident “scut” work can lead to feelings of negative emotion, stress, and other impediments to professional/ resident learning. Factors such as time off, team relationships, sense of value to the team, collegial environment, and even sleep and workload are likely to shape residents’ emotions. Job satisfaction in surgical education has been

correlated with perceived quality of care delivery, ancillary services, empathy among nurses, quality of attending teaching and inversely with work hours, and erroneous calls and pages.37 These data and additional research suggest that institutional and cultural factors may strongly influence psychological health in residents.38 To enhance resident performance by encouraging a more PA, we as educators must consider the culture we create and maintain in the training program and the health of the entire organization. Third, communication, specifically feedback, voice, and openness, which were combined into one factor for analysis, were important to resident performance, mindfulness, and PA. Individually, these communication variables had robust relationships with mindfulness: feedback (r ¼ 0.46, p o 0.001), voice (r ¼ 0.4, p o 0.01), and openness (r ¼ 0.29, p o 0.05) and a modest relationship with performance: feedback (r ¼ 0.22, p o 0.10), voice (r ¼ 0.28, p o 0.05), and openness (r ¼ 0.19, p o 0.10). Communication overall had a robust relationship with affect: PA (r ¼ 0.38, p o 0.01) and negatively with NA (r ¼ 0.42, p o 0.001). These relationships suggest that residents open to feedback and who express themselves (voice) are less likely to experience negative emotions. Residents with PA are more likely to be upbeat in their interactions with patients, staff, and other physicians. Communication may be an avenue in which to address lower-performing residents who exhibit limited mindfulness or NA or both. For example, program directors could help residents manage expectations and encourage them to view feedback and communication positively. Residents encouraged to cultivate their voice may correspondingly develop both autonomy and belonging, and reduce the potentially negative emotional reactions to feedback. Surgical residents open to feedback will learn quicker, will develop attentiveness to interaction quality, and will develop sensitivity to the interrelated nature of medical care. Patient care includes a number of facets beyond clinical skills, including communication, emotion, working with others, and mindfulness. To improve low performers, medical directors could screen and identify residents with an inaccurate sense of their own competency and knowledge level. If residents mistakenly believe they have all the information and expertise they need, they will not seek information from other members of the team. However, if they view themselves as one of many interdependent agents in a complex care team, they are likely to draw upon the distributed expertise and interpretations available to them through communication and coordination.39 When residents assume they are fully knowledgeable, or they consider what they do not know to be irrelevant, then quality of care is jeopardized and patient safety is at risk.1,39 Developing remediation targeted at improving self-awareness, changing NA to PA, and increasing opportunities for communication can improve resident performance.

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The higher level of awareness that mindfulness engenders leads to improved performance, both in general professional duties and in specific situations. Resident mindfulness is a practice that guides present and future actions; fuller development of mindful practices can lead to improved patient relationships and safety. Patients prefer and seek out relationships characterized by caring, trust, physician expertise, and a degree of patient autonomy.40 As surgical residents increase their capacity to interact mindfully with patients, staff, and others, they are more likely to be present with them and consider each patient as a unique human being. The quality of being present and attentive to what is occurring in the moment will lead to better patient outcomes as a result of improved communication, decisionmaking, and performance. Limitations The findings of this study should be considered in view of its limitations. First, the research was conducted with a convenience sample of medical residents, which makes it vulnerable to selection and recruiting bias. Although this may limit the generalizability of our findings, the residents in our sample range across medical specialties, sex, age, and program year. Although this provides for greater breadth in sampling, further research is warranted to confirm that the relationship between resident mindfulness and performance applies to a broader sample of residents. Second, survey research has inherent limitations in particular related to whether residents answered the survey questions honestly. This is a valid concern for all survey research and one reason why the survey was anonymous. Future studies need to examine the applicability of mindfulness, communication, and NA for performance using multimethodological approaches. Third, the MD and RN raters may lack reliability due to recall bias if they were asked about residents with whom they had not worked with recently. This was addressed by having multiple physicians and nurses from across specialties evaluate the residents. Subsequent research should build on our findings using other methods, including direct observations and qualitative approaches.

CONCLUSIONS Despite these limitations, this study fills an important gap in surgical education. Medical residents who are judged to be the best clinical performers by nurses and MDs are also considered to be the most mindful. Those same highperforming, mindful residents rank themselves lower, indicating they are less likely to be overconfident. Unfortunately, the converse is also true. Lower-performing residents consider themselves higher, suggesting a lack of awareness that could contribute to performance issues, interpersonally 8

and clinically. Communication correlates with mindfulness and performance that compels us as academics to consider communication as a major component of both our routine training and how we approach the resident who needs improvement. Affect, measured by a list of common feelings and emotions, correlates with performance. Residents with lower NA had higher performance and mindfulness. This has important relevance to who we recruit into medicine as students, who we recruit as educators, the environment of our training programs, and the culture of the organization. In medicine today, personal wellness and professional satisfaction have greater recognition and priority than in the past. Here, we have shown how individual characteristics of mindfulness, communication, and affect, all potentially modifiable, can influence surgical and clinical performance, which relates directly to our patients and our organizations.

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