**2. Methods**

#### **2.1 Study design**

In order to explore the potential content of patient feedback, a qualitative approach was chosen to investigate the perspectives of both patients and residents regarding patient feedback topics. Two different qualitative methods were used. The first perspective was gathered by means of semi-structured interviews to enable patients to explain their thoughts on patient feedback more in-depth as knowledge of patients' perspectives is limited [18, 19]. Whereas the perspective of residents was collected with the use of fully qualitative questionnaires. Qualitative questionnaires

*Patient Feedback to Enhance Residents' Learning: A Patient and a Resident Perspective DOI: http://dx.doi.org/10.5772/intechopen.108569*

are used to collect qualitative data. The qualitative questionnaire consisted of a set of open-ended questions which allowed residents to write responses in their *own* words, instead of choosing from fixed response options. By means of this, residents' ideas on patient feedback topics were explored, while not investigating the depth [19, 20].

#### **2.2 Setting**

In order to ensure that residents possess a range of various different intertwined competencies, the CanMEDS competency framework is integrated with all PGME programs in the Netherlands [10, 21]. This framework consists of seven medical competency roles: medical expert, communicator, collaborator, health advocate, scholar, leader, and professional (**Table 1**) [10]. Residents receive feedback on these roles in order to become competent physician. This study was conducted at OLVG hospital in the Netherlands. This hospital is one of the largest teaching hospitals in the Netherlands facilitating more than 20 different PGME programs.

#### **2.3 Sampling and recruitment**

During the study period from January 2017 to May 2017, both patients and residents were sampled purposefully. Patients visiting the outpatient clinic of several departments were informed about this study and asked to participate by the main researcher (MN). After informed consent was given, the interview took place after


#### **Table 1.** *CanMEDS competency roles examples.*

their consultation with their medical doctor. During a resident lunch meeting, residents working at the OLVG hospital were also recruited face-to-face by the main researcher (MN). The researcher had no personal or professional ties with the participants or the medical doctors whose patients were approached. The sample size was not calculated prior to the study as we aimed for data sufficiency, which means that the data should be rich enough to answer the research question [22]. We determined data sufficiency by reaching a consensus with the research team.

#### **2.4 Data collection**

All in-depth interviews were performed with an interview guide, including example questions and probing questions (Appendix I). Frames were used in order to understand a patients' reasoning on feedback topics [18]. During the interview, the patient had the freedom to discuss their perspective on the topics they considered valuable to be discussed. Afterward, the interviews were summarized for member checking by the participants. All interviews were performed, audiotaped, and transcribed verbatim by the main researcher (MN). After transcription, the audiotapes were erased and the transcripts were anonymized.

To understand what feedback topics residents would like to receive from patients, qualitative questionnaires were handed out during a resident lunch meeting at OLVG hospital (Appendix II). The main researcher (MN) was present during completion of the questionnaires. The qualitative questionnaire consisted of six questions and took approximately 5 minutes to fill in. All questionnaires were anonymous as they did not require to fill out names.

#### **2.5 Data analysis**

A content analysis inspired by the grounded theory was used. Both the interview and questionnaire data were analyzed separately before comparison. To allow new insights, open, inductive coding was used. All transcripts were coded by the main researcher (MN). The analysis started immediately after the first interview. The transcripts were coded by attaching keywords ("codes") to all text fragments that were considered relevant to help answer the research question, subsequently, the codes were categorized. To enhance reliability, two interviews were analyzed by a second researcher (LB) using open coding and then discussed extensively. During this discussion, differences in interpretation were discussed and some codes were refined which led to the creation of the first version of the code tree. After coding 15 transcripts, no new codes were derived. The answers to the open-ended questions of the questionnaires were analyzed by the use of open coding as well. Subsequently, the derived codes were categorized, creating a separate code tree. Thereafter, the derived key themes from the interviews and questionnaire were discussed and compared in depth within the research team until a consensus was reached. All coding was performed using qualitative data analysis software (MaxQDA, version 12). We followed the consolidated criteria guidelines for reporting qualitative studies (COREQ ) when writing the article [23].

After identifying the different feedback topics described by the participants, these topics were then categorized depending on which feedback level it is aimed at. Feedback can be aimed at a task level, which describes feedback about specific procedures and how well certain task is performed. Feedback on the process level is more specific to processes related to accomplishing a certain task. The self-level feedback

*Patient Feedback to Enhance Residents' Learning: A Patient and a Resident Perspective DOI: http://dx.doi.org/10.5772/intechopen.108569*

describes feedback on the person's self, whereas self-regulation feedback includes interaction between control, confidence, and commitment [8, 9].

#### **2.6 Ethical considerations**

The study was approved by the ethical review board of OLVG hospital (WO 17–050). All participants received an information letter explaining the purpose and procedure of this study as well as the voluntary nature of participation. Informed consent was obtained from all patients.
