Results from Quantitative Analysis:
The data was screened for missing and/or invalid values. The sampling adequacy was measured by Kaiser-Meyer-Olkin measure of sampling adequacy (KMO). There was sufficient inter item correlation; KMO =.905, indicating that the patterns of correlation are relatively compact. The correlation matrix was significantly different from the identity matrix (Bartlett’s χ2(28), = 485, p<.001).. Therefore these distributional properties of the data allowed principal component analysis to yield distinct and reliable factors.25 Since our MSF form is an 8-item questionnaire/ instrument, our sample size of 103 meets requirements for factor analysis. The reliability for the full set of items1–8 (Cronbach’s α) was.915
Table 1 shows total variance explained with initial eigenvalues of eight items and sums of squared loadings. On Principal component analysis only one factor had eigenvalue over Kaiser’s criterion of 1 and this factor alone explained 63% of variance.
The component matrix is shown in Table 2, displays the coefficient (loadings) that relates the variables to the unrotated factors (components). It is evident here that all the performance dimensions are highly correlated with a single factor, which seems to encompass aspects of professional behavior.
Our MSF instrument was an eight-item questionnaire. Factor analysis indicates that the performance dimensions in the MSF questionnaire arerelated to a single construct that encompasses various elements of what is generally defined as “professional behavior.”3
Results from Qualitative Analysis:
The 29 interviews resulted in 184 pages of text for analysis. Analysis showed considerable overlapping, but also meaningful differences in performance theories of residents and the nurses. Figure 1 shows at a glance the major overlapping and distinct themes and subthemes emerging from our data. Analysis of the transcripts resulted in seven major themes related to performance theories of nurses and residents, namely; communication skills, patient care, accessibility, teamwork skills, responsibility, medical knowledge and professional attitude, The next section will describe these themes in further details, and provide quotations that most accurately depict the themes and dimensions in participants’ performance theories. Figures indicating participant number are given in parentheses. Table 3 summarizes major findings and provides positive and negative descriptors of residents behaviour and performance.
Performance theories, communalities and differences along with representative quotes
Communication turned out to be the most salient performance dimension in evaluation of resident performance, as this was mentioned and elaborated by all residents and nurses, mostly at the very start of the interview. Both groups indicated that according to them, communication is the key competency or performance domain which differentiates residents as being outstanding, problematic or just average. Particularly good counseling skills make up an excellent resident.
“Basically what I feel is that the quality that an outstanding resident must possess is communication skills”(Nurse–10, describing outstanding resident performance),
"Even the agitated patients used to come around after speaking with him” "They felt like they got an answer and felt that the person understands.”(Resident–5, describing qualities of an outstanding resident),
“He never discussed in the corridors or at the counter but rather he used to counsel the family in a settled environment”.(Nurse–3, describing qualities of an outstanding resident),
“Overall with nurses too she communicated very well and still does so.” (Resident–12, describing qualities of an outstanding resident),
“Their communication with the family is really pathetic sometimes. Even they say, “it’s your wish if you want to get treated, this is how it is here”.(Nurse–14, describing qualities of an problematic resident),
The next dominant and common theme was patient care. Both nurses and residents emphasized that excellent residents are able to manage patients well with appropriate and high levels of confidence, consistently resulting in high levels of satisfaction in their patients. High-performing residents are compassionate as well as take the right decisions at the right time.
"In my opinion the outstanding resident is one who goes with the patient treatment plan and focuses on the basic needs of the patient” (Nurse–4; describing qualities of an outstanding resident)
“With regard to patient care, he feels no responsibility towards the patient and leaves the management of the patient to the junior doctors from day–1.” (Resident–8; describing qualities of an problematic resident)
Both residents and nurses also emphasized teamwork skills. The subthemes identified by both the groups within this category were team involvement, working together as partners in patient care, and leadership.
“an outstanding resident manages a team in a very organized manner”(Resident–3 describing qualities of an outstanding resident)
“If the team is fighting then the work will be bad,—————-This will bring quality down.” (Resident–13 describing qualities of an problematic resident)
Nurses in particular emphasized effective leadership, respect and residents ability to make them feel ‘part of the team’. They described an outstanding resident as someone who considers patient care to be a team work effort and nurses to be indispensable team members.
“He takes everybody along with him” (Nurse–5 describing qualities of an outstanding resident)
“She accepts criticism and identifies way of learning as well as ways of teaching us” (Nurse –1 describing qualities of an outstanding resident)
“He was very polite, well communicating when delegating tasks or communicating to his team or to nurses” (Nurse–9 describing qualities of an outstanding resident)
“His behavior with the juniors is like the relationship between a boss and his subordinates.” (Resident–8 describing qualities of problematic resident)
The sub-theme leadership and team guidance was discussed especially in relation to excellence, whereas the domain seemed to take on less importance in identification of problematic residents, particularly by nurses.
Accessibility was identified as major theme by nurses only. Almost all nurses identified this theme when describing resident performance, in contrast to residents who didn’t seem to identify and use accessibility as an important theme in performance evaluations. Nurses typically identified residents as problematic if it is difficult to contact them and if they do not answer their pagers on time.
“Often we have to page them 3–4 times and the resident does not reply” (Nurse–3 describing qualities of an problematic resident)
“There are a lot of delays with the incompetent and problematic doctors” (Nurse–4 describing qualities of an problematic resident).
In distinguishing outstanding residents from residents who are performing poorly, nurses as well as residents highlighted issues related to ‘responsibility’ and ‘professional attitude’.Both residents and nurses used trustworthiness, vigilance, honesty and dependability as key performance dimensions to identify excellence in resident performance. The nurses and residents felt that residents displaying these qualities can easily manage and deal with all sorts of problems.
“< outstanding residents> work with responsibility. Their main focus is on responsibility. They focus on the patient’s concerns. They are focused on the treatment plan as well. They follow up on small things such as bed sores management”. (Nurse 4- describing qualities of an outstanding resident)..
The problematic resident, on the other hand, was often described as lacking confidence in patient management and/or not taking responsibility for his patients:
“irresponsible with regard to patient care and medication”(Resident 13 describing qualities of an problematic resident)
" one who puts responsibility on the nurse and leaves” (Nurse–6 describing qualities of an problematic resident)
“Not taking up responsibilities of patients when work is being assigned, and work is then not done” (Resident–2 describing qualities of an problematic resident),
Problematic residents were also often typified as ‘lacking engagement’, ‘disinterested in their work’, ‘arrogant’ and ‘not committed to patients’ needs’.
Examples of typical quotes were:
"He has a totally dull and loose posture (Nurse–5 describing qualities of problematic resident).”
“Stubborn, disrespectful, thinks he knows too much and nobody knows anything” (Nurse –14describing qualities of problematic resident)
“He is rude, thinks that he is superior to us and to other colleagues. No doubt he is knowledgeable but thinks he is superior.”(Resident–7 describing qualities of problematic resident)
The participants’ responses clearly identified that problematic residents had issues in professional attitude and poor communication skills.
Medical knowledge was not put forward as an important performance dimension in evaluation of residents, neither by residents nor by nurses. The nurses did not discuss it at all, and the residents only referred to medical knowledge when describing outstanding residents.
"< an outstanding resident> has enough knowledge and is up to date with new research and other things” (Resident–13 describing qualities of an outstanding resident)
Defining performance dimensions for average residents was more difficult for our participants. However the general consensus from participants was that average residents can be thought of as competent (addressing patient care adequately) and responsible yet lacking in communication and teamwork skills. Average residents are actually sort of average, not demonstrating any conspicuous behaviours or competencies that attract attention—either positively or negatively.
When the data from qualitative and quantitative results were compared, it was seen that most of the performance dimensions in the questionnaires emerged as either a major theme or sub-themes in the interviews. Also, some of the themes that emerged as major themes in interviews are not included in the questionnaire though, such as patient care; responsibility and medical knowledge. Inclusion of these aspects would enhance the construct validity of the questionnaire.