Barriers and Enablers to Direct Observation of Trainees’ Clinical Performance: A Qualitative Study Using the Theoretical Domains Framework

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Direct observation is essential to assess and provide feedback to medical trainees. However, calls for its increased use in medical training persist as learners report that direct observation occurs infrequently. This study applied a theory-driven approach to systematically investigate barriers and enablers to direct observation in residency training.


From September 2016 to July 2017, semi-structured interviews of faculty and residents at The Ottawa Hospital were conducted and analyzed. An interview guide based on the Theoretical Domains Framework (TDF) was used to capture 14 domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices.


Twenty-five interviews (12 resident, 13 faculty) were conducted, representing 10 specialties. Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social/professional role and identity, intention, goals, memory/attention/decision processes, environmental context and resources, social influences, and behavioral regulation. Discord between faculty and resident intentions, coupled with social expectations that residents should be responsible for ensuring that observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as a pervasive theme.


This study identified key barriers and enablers to direct observation. These influencing factors provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.

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