A Grounded Theory Investigation into the Otolaryngology Resident Learning Experience

A Grounded Theory Investigation into the Otolaryngology Resident Learning Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Grounded Theory Investigation into the Otolaryngology Resident Learning Experience Megan Noonan, Zoë Fullerton, Karthik Balakrishnan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5760451/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Otolaryngologic residency operative education is a unique process that teaches technical and reasoning skills during high-stakes situations. However, there is no consensus on what qualities of a teacher or environment create a positive surgical learning experience. This study aims to use qualitative assessment to identify key elements of effective otolaryngologic residency education. Methods Purposive sampling was used to select a heterogeneous cohort from our institution’s Otolaryngology department between March and December 2023. Interviewees were categorized as either “Learners” (residents) or “Teachers” (attending) and either “Junior” or “Senior.” A trained interviewer conducted semi-structured interviews until thematic saturation was reached. Constant comparative analysis using coding, memoing, and categorization was conducted using grounded theory methodology. Results Twenty-one participants completed interviews, averaging 42 minutes. A total of 87 codes and 15 concepts were extracted from the data. Advanced coding and theoretical integration revealed four themes that are essential to the creation of a positive teaching experience: “Investment in Learner/Education,” “Communication,” “Discerning Learner Capacity,” and “Creation of Learning Environment.” “Investment” and “Discerning Capacity” represent the ability and desire of the teacher to assess and advance learner progress during surgery. “Communication” refers to the ability to convey information clearly and succinctly. “Creation” reflects the ability of the teacher/surgeon to navigate the complex operative environment to create a safe and effective learning experience within the context of a surgical operation. Conclusions This study suggests that positive operative learning experiences rely on four thematic elements. A teacher's conscious attention to these elements and feedback from learners targeting them may assist in creating a more effective surgical learning environment. Further research is needed to understand the nuance of learner and teacher experience and how best to optimize and operationalize these concepts in diverse surgical educational settings. Clinical trial number: not applicable communication grounded theory operative education otolaryngology psychological safety Figures Figure 1 Background Otolaryngologic education exists within a unique environment. The operating room (OR), which remains the primary site of training, represents a potentially high-stakes situation in which learning often involves trainees performing procedures, or portions of procedures, under the guidance of a surgical teacher, based on the principle of graduated autonomy. Errors on the part of a trainee have the potential for tangible harm to all parties involved, and experiences within the operating room can have a lasting impact on the patient, learner, and teacher. 1 Therefore, the task of otolaryngologic teachers and learners is not to be taken lightly. A teacher must safely and ably guide a trainee through a procedure while ensuring a safe and positive outcome for the patient. Despite this, surgical teachers rarely have formal training in adult learning. Instead, they rely on their own learning experiences, insights, and general “on-the-job training” to formulate and refine teaching styles and behaviors. 2 Otolaryngologic education is often impacted by changes in the healthcare system and residency structure. The traditional model of surgical education was structured around apprenticeship. However, due to the increasing number of faculty and trainees at institutions, resident and attending dyads may spend less time together. Additionally, recent changes in time constraints from both a work hour and a hospital efficiency standpoint have placed further stress on the training environment. 3 These changes may affect learning dynamics and require teachers and learners to employ deliberate educational behaviors to achieve optimal learning experience. While a growing emphasis on simulation training may alleviate some issues with time constraints from a technical skills development standpoint, surgical experience within the operative setting remains essential to training competent surgeons. 4 It is imperative, therefore, to ensure that trainees' learning experiences within an operating room setting are optimized to be maximally beneficial. Within the field of Otolaryngology, there has been increasing recognition of the importance of effective and efficient teaching. 5 – 8 However, the essential elements that create a positive teaching experience are still unknown. In this study, we use grounded theory, an inductive theory-generating qualitative analysis, to explore the experiences of otolaryngologic learners and teachers to better understand what constitutes a positive teaching experience within the operating room setting. Methods Data Collection All participants were recruited from the Stanford University Department of Otolaryngology-Head & Neck Surgery using IRB-approved email messaging during the 2023 calendar year. Purposive sampling was used to ensure a diverse data set representing all stages of residency training and faculty career within the department. 9 Interviews were recorded using a specialized password-protected application. 10 Transcription was performed initially with Microsoft Word transcription services, then reviewed and edited by the interviewer to ensure accuracy. 11 All recordings were deleted immediately following transcription. Interviews were conducted in a semi-structured fashion by a single interviewer with training in qualitative interview procedures. Initial interview questions were created with input from three authors and designed to encompass issues previously identified in relevant literature and ad hoc discussions with stakeholders in the department. Interview topics included previous positive and negative teaching and learning experiences, conceptions of the ideal form of learner or teacher, observations about the effects of the operative environment on otolaryngologic teaching and learning, and experiences surrounding the particulars of interpersonal communication within a surgical environment with a focus on teaching in the operating room. An emphasis was placed on providing open-ended questions and facilitating organic discussion around the experiences and viewpoints of each participant. Questions were iteratively refined during data collection and analysis to allow for further deepening and refinement of emerging concepts and themes [Supplemental Table 1]. Interviews were labeled along two dimensions as teacher/learner and junior/senior level but were otherwise anonymized for analysis. Participants included 6 Junior Faculty Members (Less than five years’ experience), 7 Senior Faculty Members (5 or more years’ experience), 4 Senior Residents (PGY-4, PGY-5), and 4 Junior Residents (PGY-2, PGY-3). Data Analysis Grounded theory methodology was chosen for this project because it allows for the deconstruction and reconstruction of qualitative data to generate theories and insights relating to complex phenomena, such as teaching experiences and behaviors. Theory generation is performed using detailed analysis of data acquired from individuals embedded within the context of the research question and is not rooted in a priori constructs, allowing for the emerging theory to be “grounded” and, therefore, supported by the data from which it arose. 12 , 13 In accordance with this, two researchers independently coded each interview transcription. A line-by-line analysis was performed. Coding, or the assignment of descriptive labels to data segments to allow for the deconstruction of data into discrete components for analysis, was performed. Initial codes were created to identify and categorize participants’ experiences, observations, and descriptions. 12 , 13 The initial coding of each interview was done independently. Codebooks were then compared, and differences were reconciled by consensus discussion between the two initial coders, with any discrepancies resolved by a third researcher. Each researcher created memos based on initial coding. These memos, or “field notes”, represented ideas and thoughts generated through researcher interaction with the data and guided additional questions and inquiries in future interviews. Interviews were conducted until no new codes or memos emerged from two successive interviews. Two researchers performed intermediate coding or compiling initial codes to form categories and subcategories, or concepts . A third researcher then reviewed these for content validity; revisions were made following a consensus discussion. The researchers' different training positions (medical student, resident, and senior attending) were leveraged for increased content validity. Advanced coding was then performed through iterative combination and comparison of concepts and codes until themes were defined. We then conducted a sub-analysis to evaluate how each subgroup of teachers and learners contributed to the identified themes. Analysis was conducted within each theme, with concepts and codes categorized according to their original subgroup. We then analyzed this data to identify commonalities across all groups as well as those codes and concepts that were expressed and prioritized by one subgroup. This project was approved by the Stanford Institutional Review Board. Results Between March 2023 and December 2023, 21 Stanford Department of Otolaryngology members participated in interviews. The response rate was 21/24 (87.5%). Interviews were conducted in person (18) or on IRB-approved video conferencing sites (3). 14 [Supplemental Table 2]. Interviews ranged from 29 to 58 minutes (average 42 minutes) in length. Initial analysis produced 87 distinct codes; intermediate coding produced 15 distinct concepts. [Figure 1 ] Four themes or categories emerged from advanced coding: Discernment of Learner Capacity, Communication, Investment in Learner/Education, and Creation of the Learning Environment. [Table 1 ] Each of these was noted to be distinct in the concepts that it encompassed; it was therefore determined that further attempts to combine would result in loss of nuance and dimensionality of subsequent theory. Table 1 Themes, Concepts, and Codes derived from grounded theory analysis of data. Theme Concepts Codes Discernment of Learner Capacity Understanding of Learner/Learner’s Context Empathizing with learner’s experiences [neg] Losing understanding of learner experience over time [neg] Difficulty remembering learner mindset Patience with learner Struggle Utilizing own struggles, mistakes Understanding learner capabilities Using personal learning experiences as context Using proximity to learner as a source of empathy Challenging Learners Building confidence by pushing learners Allowing controlled struggling Encouraging appropriate learner independence Empowering Learners Allowing learner to take ownership Encouraging problem solving Allowing learner to lead Adapting to Learner Needs Respect for struggles of learning Adapting expectations to learner Changing teaching method to reflect learner Meeting learner at current level Unassuming of learner abilities at onset Intuiting learner knowledge Identifying gaps in learner knowledge Investment in Learner/Education Teacher/Learner Relationship Valuing the relationships of teacher/learner Cultivating Trust with Learner Collaborating with Learner Openness to feedback in teaching methods Enthusiasm for Teaching Self-identifying as teacher Respecting teaching as a skill Personal pride/fulfillment from teaching Interest in Education Joy in Teaching Sharing in student success [neg] disengagement Recognizing privilege of teaching Engaging Learners Verbally engaging learner to extract enthusiasm Grounding information in approachable scenarios Engaging students through questions Investment in Learner Providing learner opportunities Prioritizing learner experience Patience for learning process Taking ownership for learner education Learner’s perception of teacher investment Investment in Teaching Teaching generalizable skills Dedicating time to the learning process Prioritizing learning in OR Reflecting on positive teaching experiences Desiring to improve teaching Critical reflection on negative experiences Communication Explanatory Communication Contextualizing information Creating framework of ideas Repetition Organizing communication/instruction Presenting information in multiple ways Building knowledge base in steps Coaching through difficulties Providing Examples Closed Loop communication Collaborative Communication Explaining thought/decision processes Explaining reasoning behind actions Encouraging Dialogue Verbalizing thoughts Communicating wants for experience Communicating expectations Setting learning goals Encouraging engagement through communication Feedback Constructive feedback Honest feedback Real time feedback Creation of Learning Environment Controlling Environment Addressing multiple needs in OR environment Ability to correct learner mistakes Navigation of high stakes situations Setting tone of space through leadership Sensitivity to needs of environment Managing patient/time stressors [neg] perceived lack of control Managing Personal OR Presence Battling with own sense of control/focus Maintaining composure Tolerating stress and stress response Confidence in skill set Recognizing effects of demeanor on environment Perception of Teacher Confidence/Control [neg] transmission of stress onto others Creating Space for Learning Creating a welcoming environment Maintaining approachability Responding to requests for help Navigating response to error Growth mindset around learning [neg] Large response to small error Reducing Hierarchy Discernment of Learner Capacity The core category of “Discernment of Learner Capacity” comprises codes and concepts centered around the ability of the teacher to create and tailor teaching experiences that appropriately challenge the learner and their ability within a procedure. This involved the teacher’s ability to assess the individual learner's current skills, understand the learner’s potential, and intuit how best to advance and expand their abilities within the procedure's context and the greater context of their learning. This core theme encompasses the concepts of “Understanding Learner/Learner’s Context”, “Adapting to Learner Needs”, “Challenging Learners” and “Empowering Learners”. [Table 1 ] Subanalysis showed that senior teachers voiced difficulty with remembering and understanding the learner mindset and struggled with a sense of personal distance from the learner. [Table 2 ] Junior teachers were notable for discussing the utilization of their proximity to the learner and remembering their own learning experiences and mistakes to understand the learner’s context better. Senior learners addressed the importance of being allowed to struggle; junior learners showed concern about assumptions of learner abilities and prioritized patience with the learner. Both senior learners and senior teachers emphasized the importance of allowing learners to struggle in a guided or controlled manner. Table 2 Subanalysis of themes showing Codes standard in all Groups and those specifically emphasized by Subgroups. Discernment of Learner Capacity Commonalities Empathizing with learner’s experiences Building confidence by pushing learners Understanding learner capabilities Encouraging appropriate learner independence Allowing learner to take ownership Encouraging problem solving Respect for struggles of learning Adapting expectations to learner Changing teaching method to reflect learner Intuiting learner knowledge Identifying gaps in learner knowledge Allowing learner to lead Senior Teachers Junior Teachers Senior Learners Junior Learners [neg] Losing understanding of learner experience over time [neg] Difficulty remembering learner mindset Utilizing own struggles, mistakes Using personal learning experiences as context Using proximity to learner as a source of empathy Allowing controlled struggling Unassuming of learner abilities at onset Patience with learner Struggle Investment in Learner/Education Commonalities Self-identifying as teacher Personal pride/fulfillment from teaching Interest in Education Verbally engaging learner to extract enthusiasm Valuing the relationships of teacher/learner Cultivating Trust with Learner Providing learner opportunities Prioritizing learner experience Taking ownership for learner education Openness to feedback in teaching methods Joy in Teaching Sharing in student success Patience for learning process Dedicating time to the learning process Prioritizing learning in OR Desiring to improve teaching Critical reflection on negative experiences Senior Teachers Junior Teachers Senior Learners Junior Learners Respecting teaching as a skill Teaching generalizable skills Reflecting on positive teaching experiences Collaborating with Learner Recognizing privilege of teaching Learner’s perception of teacher investment* [neg] disengagement Learner’s perception of teacher investment* Engaging students through questions Communication Commonalities Explaining thought/decision processes Explaining reasoning behind actions Encouraging Dialogue Communicating wants for experience Communicating expectations Setting learning goals Honest feedback Presenting information in multiple ways Repetition Constructive feedback Organizing communication/instruction Real time feedback Verbalizing thoughts Senior Teachers Junior Teachers Senior Learners Junior Learners Contextualizing information* Creating framework of ideas Encouraging engagement through communication Contextualizing information* Providing Examples Coaching through difficulties Building knowledge base in steps Creation of Learning Environment Commonalities Ability to correct learner mistakes Navigation of high stakes situations Confidence in skill set Sensitivity to needs of environment Growth mindset around learning Creating a welcoming environment Maintaining approachability Responding to requests for help Navigating response to error Senior Teachers Junior Teachers Senior Learners Junior Learners Battling with own sense of control/focus* Tolerating stress and stress response Addressing multiple needs in OR environment Recognizing effects of demeanor on environment Battling with own sense of control/focus* Maintaining composure Reducing Hierarchy Managing patient/time stressors Setting tone of space through leadership [neg] perceived lack of control [neg] Large response to small error Perception of Teacher Confidence/Control [neg] Transmission of stress onto others * Indicates two or more subgroups emphasize code Investment in Learner Education “Investment in Learner Education” includes codes and concepts relating to a teacher’s desire to engage with the learner and the surgical education process. The concepts contained within this theme include “Teacher/Learner Relationship”, “Enthusiasm for Teaching”, “Engaging Learners”, “Investment in Learner”, and “Investment in Teaching”. The codes within these concepts address an individual teacher’s investment in the learner’s education, their broader investment in a relationship with the learner, and the practice of surgical education. [Table 1 ] Codes focused on an educator’s commitment to the learner interpersonally (through the pursuit of a longitudinal relationship), situationally (through the prioritization of the learner’s education within the operating room setting), and broadly (through their commitment to and enthusiasm for the art of surgical teaching). Subanalysis showed that within individual groups, learners emphasized the importance of the learner’s perception of teacher investment, referring to both the ability of the teacher to communicate this investment and the learner to appreciate it. Learners also emphasized the impact of the teacher's engagement in the procedure. Both senior and junior teachers discussed their efforts to self-reflect on and improve their teaching practices, as well as their respect for the art of teaching. Senior teachers expressed their desire to teach generalizable, durable skills as evidence of their commitment to education while more junior teachers emphasized collaboration as a method of showing investment. [Table 2 ] Clear Communication The core theme of “Communication” encompasses communication strategies for teaching and interacting with students in the OR setting. All parties distinctly emphasized feedback as a necessary aspect of teaching. The concepts contained within Communication include “Explanatory Communication,” “Collaborative communication,” and “Feedback.” [Table 1 ] Explanatory communication codes focus on communication strategies to encourage learning, whereas collaboratory communication codes focus on interpersonal methods of establishing rapport and a shared experience with the learner. On subanalysis, senior teachers and learners prioritized contextualizing information and incorporating learning into a larger conceptual understanding. In contrast, junior learners prioritized the simple delivery of information, including “Building knowledge base in steps,” “Coaching through difficulties,” and “Providing Examples.” [Table 2 ] Creation of the Learning Environment “Creation of the Learning Environment” consists of concepts and codes that address the ability of the teacher to manage their struggles in the operating room and create an environment for the learner that is conducive to learning and encouraging learner growth. Concepts included “Managing Personal OR Presence,” “Controlling Environment,” and “Creating Space for Learning.” [Table 1 ] “Controlling Environment” codes describe a teacher's ability to understand and meet the needs of the OR setting, while “OR presence” codes refer to a teacher’s management of individual stressors. The “Creation” codes refer specifically to the teacher's ability to create an educationally oriented environment within the OR setting. Subanalysis showed that junior and senior teachers frequently spoke about the tensions between working through their struggles and emotions elicited by the environment while working to create a productive setting for their learners. On the other hand, learners discussed the importance of the perception of a teacher's confidence and control within the OR in creating a productive learning environment. Learners also spoke of the potentially negative impacts of overemphasizing learner error and transmission of stress into the environment. [Table 2 ] Discussion This study is the first to utilize grounded theory methods to explore what creates a positive teaching experience for otolaryngologic teachers and learners in the operating room setting. In this study, 21 participants at varying training and career stages at a single center underwent in-depth interviews about their experiences and observations surrounding otolaryngologic teaching. Analysis of their responses using a grounded theory methodology revealed four themes that contribute to the creation of a positive otolaryngologic teaching experience: “Investment in Learner/Education,” “Communication,” “Discernment of Learner Capacity,” and “Creation of Learning Environment.” Subanalysis showed that teachers and learners prioritize many of the same things but may place specific emphasis on certain elements, reflecting their own experiences and interactions with the learning environment. One of the themes of a positive surgical education experience relates to how the teacher creates the learning environment. A psychologically safe learning environment has been increasingly understood as an essential element of the learning process. 15 “Psychological safety” and its derivative, “educational safety,” refer to atmospheres where learners can focus on learning and professional growth without worrying about repercussions from interpersonal encounters. Psychological safety has been shown to play a role in success and teamwork within an OR setting. 16 However, how best to create this space is less well understood. In this study, senior and junior learners emphasized the importance of confidence in their teacher and the teacher’s ability to provide measured responses to and offer corrections or solutions for mistakes. This emphasis on teacher confidence is juxtaposed with the concerns voiced by senior and junior teachers, who focus on the difficulties of self-regulation and tolerance of personal stress in the OR setting. While prior research has shown that resilience and management of intraoperative stress may play a role in trainees’ experience in the OR, little is known about how these issues may affect surgical teachers, especially those in the early stages of their careers. 17 Further research into how best to support otolaryngologic educators may benefit teachers and learners. The ability to discern a learner’s capabilities and understand how to safely but appropriately progress their learning is complex. In this study, both learners and teachers emphasized the importance of presenting learners with educational opportunities appropriate for their level but also challenging enough to allow for growth. While graduated autonomy is a commonly known concept in surgical education, the techniques of ensuring this progression and assessing skills in determining it are less wholly understood. 18 In the past, when learners and teachers existed within an apprenticeship model, longitudinal relationships may have lessened the need for a teacher to intuit learner skills and abilities quickly. In the modern training environment, a teacher may be frequently required to rapidly and accurately assess a trainee’s abilities. In our study, junior teachers discussed using their recent experiences with the learning process to help ascertain the learner’s current state. On the other hand, senior teachers discussed struggling with identifying with the learner in this way and relying instead on experience. Recent research into machine learning assessment of surgical skills, surgical self-evaluation, and program tracking of core competencies have shown positive results in their ability to assess trainee surgical proficiency objectively. 19 – 23 Formal incorporation of these methods within the otolaryngologic training setting may be helpful for training situations where issues with this assessment are common. The importance of thoughtful and efficient communication in the operating room has been well established. 24 – 26 In otolaryngologic education, deliberate communication is vital as learning and teamwork occur in tandem. We see this reflected in how all groups prioritized explanatory and collaborative communication. However, the results of this study also speak to the importance of the multiple approaches to communication needed to be an effective otolaryngologic educator. In this study, more senior learners discussed their desire for contextualized information, while more junior learners discussed desiring smaller, more digestible, and direct methods of communication. Attention to these nuances and needs may assist otolaryngologic teachers hoping to better communicate with learners. In today’s learning environment, otolaryngologic teachers are frequently faculty members whose job involves the tripartite mission of clinical work, research, and teaching. Clinical productivity is often a driving factor in evaluation for faculty members, and operative efficiency is an essential keystone of that productivity. Given this, the extra time one spends in a particular case becomes a valuable commodity that must be consciously allocated to the teaching process. 27 In this study, one of the themes of a positive otolaryngologic teaching experience was the teacher's investment in the student and the education process. One example of educator investment was investing time in the learner and learning process. Teachers discussed prioritizing time both within the OR and outside of it to improve their teaching and give students time to learn. Learners discussed recognizing and appreciating teachers who dedicated this time to their education. However, in many current environments, the dedication of time to learning may be at odds with the pressures for operating room efficiency and productivity and associated financial and career incentives. As a result, even those otolaryngologic teachers who are invested in education may experience difficulties providing learners with appropriate opportunities. 28 , 29 Though these concerns may always be present, improving support for otolaryngologic teachers who invest time in trainee education may benefit the learning experience. While this study offers valuable insights into the experience of otolaryngologic education, multiple limitations must be considered. This study comprises twenty-one participants within a single center, all operating within the same surgical settings. Despite their diverse backgrounds, this shared context may limit the generalizability of the findings to other environments. Furthermore, while purposive sampling was utilized to introduce a variation of viewpoints, it may have inadvertently introduced bias. Although the response rate for this study was high, there may have been self-selection bias among participants with the most interest in education, and we did not have a practical way to control for the teaching skill of the teachers or the self-awareness of the teachers and learners who participated. Additionally, all participants were interviewed by a single interviewer known to each interviewee. While every effort was made to minimize any impact of this familiarity through anonymity, immediate deletion of recordings after transcription, and reassurance, it may have introduced bias into the interview responses. Data analysis was performed independently by two researchers from different institutions at different stages of training; however, as with all qualitative research, there is still a possibility that researchers’ biases and perspectives may have unconsciously influenced analysis. Finally, we did not account for specific teacher or learner identity and intersectionality, or for differences in program or department culture with other institutions, both of which are important areas for future investigation. Conclusions This grounded theory analysis of otolaryngologic teaching revealed four themes that create the experience of a positive education environment. Each of these–“Communication,” “Investment in Learner/Education,” “Discernment of Learner Capacity,” and “Creation of Learning Environment”– address distinct components of the otolaryngologic teacher-learner experience. While further research is needed to validate these findings, these insights may provide an opportunity for a deeper understanding of the nuances inherent in creating a positive teaching experience. Attention to these elements may aid otolaryngologic educators and learners in fostering a more enriching education environment and offer potential inspiration for those looking to improve the otolaryngologic teaching experience at both an individual and a program level. Abbreviations OR: operating room Declarations Ethics approval and consent to participate This project was approved by the Stanford Institutional Review Board, committee reference number IRB-67791. Consent for publication Not applicable Availability of data and materials The datasets supporting the conclusions of this article are included within the article and its supplementary files. Competing interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, or publication of this article. Authors' contributions ZF and MN contributed equally to this project and share first authorship. ZF conducted interviews and reviewed transcripts for accuracy. MN and ZF developed codebooks from transcriptions individually which were then compared and compiled. ZF and MN also created memoing throughout coding process and performed intermediate and advanced coding to generate concepts and themes. KB reconciled code discrepancies and reviewed advanced coding for content validity. All authors developed initial interview questions and had consensus discussion to revise codes, concepts, and themes. All authors read and approved the final manuscript. Acknowledgements The authors would like to give a special thank you to the interviewees in the Stanford Department of Otolaryngology for their contributions to this project. References Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. doi:10.1136/bmj.320.7237.726. Johnson JT. Teaching the teacher: an essential obligation. Laryngoscope. 2014;124(5):1049-1050. doi:10.1002/lary.24620. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-1053. doi:10.1097/SLA.0000000000000595. Clifton N, Klingmann C, Khalil H. Teaching otolaryngology skills through simulation. Eur Arch Otorhinolaryngol. 2011;268(7):949-953. doi:10.1007/s00405-011-1554-6. Cramer JD, Chi DH, Schaitkin BM, Eibling DE, Johnson JT. Teach the teacher: training otolaryngology fellows to become academic educators. Laryngoscope. 2018;128(9):2034-2048. doi:10.1002/lary.27156. Zhao NW, O’Sullivan PS, Huang E. Enhancing operative feedback: a descriptive trajectory for surgical development in otolaryngology. J Surg Educ. 2020;77(3):572-581. doi:10.1016/j.jsurg.2019.11.009. Chen JX, Gray ST. A paired curriculum for surgical faculty and residents on adult education. Laryngoscope Investig Otolaryngol. 2023;8(3):636-638. doi:10.1002/lio2.1066. Lackey TG, Abaza MM. Is “see one, do one, teach one” the best way to learn procedures? Laryngoscope. 2024;134(1):1-2. doi:10.1002/lary.30853. Birks M, Mills J. Grounded theory: a practical guide. 3rd edition. SAGE Publications; 2023. Dayana Networks Ltd. Voice Record Pro 7 Full. Microsoft Corporation, ed. Microsoft Word. Version 5.0. Microsoft Corp; 1991. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Aldine Pub. Co; 1967. Strauss AL, Corbin JM, eds. Grounded theory in practice. SAGE Publications; 1997. Zoom.us. Published online 2023. Arad D, Finkelstein A, Rozenblum R, Magnezi R. Patient safety and staff psychological safety: a mixed methods study on aspects of teamwork in the operating room. Front Public Health. 2022;10:1060473. doi:10.3389/fpubh.2022.1060473. Williamson AJH, Jensen RM, Smith BK. Educational safety for the surgical learner. J Surg Educ. 2022;79(5):1083-1087. doi:10.1016/j.jsurg.2022.04.007. Ng R, Chahine S, Lanting B, Howard J. Unpacking the literature on stress and resiliency: a narrative review focused on learners in the operating room. J Surg Educ. 2019;76(2):343-353. doi:10.1016/j.jsurg.2018.07.025. Miles VP, Schroll RW, Beaty JS. Empowering the resident learner. J Surg Educ. 2022;79(4):909-917. doi:10.1016/j.jsurg.2022.03.009. Mohamadipanah H, Kearse L, Witt A, et al. Can deep learning algorithms help identify surgical workflow and techniques? J Surg Res. 2021;268:318-325. doi:10.1016/j.jss.2021.07.003. Pugh CM, Hashimoto DA, Korndorffer JR. The what? How? And who? Of video based assessment. Am J Surg. 2021;221(1):13-18. doi:10.1016/j.amjsurg.2020.06.027. Santander MJ, Sepúlveda V, Iribarren J, et al. Development and validation of a laryngeal microsurgery simulation training system for otolaryngology residents. Otolaryngol Head Neck Surg. 2023;169(4):971-987. doi:10.1002/ohn.376. Kim AH, Vaughn CA, King DL, Maizels M, Meade P, Stack BC. Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment. Head Neck. 2020;42(12):3551-3557. doi:10.1002/hed.26420. Rohde RL, Mace JC, North LM, et al. Development of a novel self-assessment tool following endoscopic sinus surgery in the management of chronic rhinosinusitis. Am J Otolaryngol. 2024;45(5):104365. doi:10.1016/j.amjoto.2024.104365. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-334. doi:10.1136/qshc.2003.008425. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-151. doi:10.1111/j.1399-6576.2008.01717.x. Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173. doi:10.1016/j.surg.2005.07.037. Woelfel I, Wang T, Pieper H, Meara M, Chen XP. Distortions in the balance between teaching and efficiency in the operating room. J Surg Res. 2023;283:110-117. doi:10.1016/j.jss.2022.10.032. Chow MS, Gordon AJ, Talwar A, Lydiatt WM, Yueh B, Givi B. The RVU compensation model and head and neck surgical education. Laryngoscope. 2024;134(1):113-119. doi:10.1002/lary.30807. Nwokedi U, Graviss EA, Nguyen DT, Pei KY. Work relative value units undervalue the clinical effort associated with teaching cases: an ACS-NSQIP analysis. Am J Surg. 2024;227:117-122. doi:10.1016/j.amjsurg.2023.09.051. Additional Declarations No competing interests reported. Supplementary Files SupplementalTables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jan, 2025 Editor assigned by journal 08 Jan, 2025 Submission checks completed at journal 08 Jan, 2025 First submitted to journal 03 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5760451","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":399739389,"identity":"94b6c3be-6dcd-44bb-a27f-f4070cefb408","order_by":0,"name":"Megan Noonan","email":"","orcid":"","institution":"Lewis Katz School of Medicine at Temple University","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Noonan","suffix":""},{"id":399739390,"identity":"8fea9bbc-3120-4ae4-82b9-33823618e0e7","order_by":1,"name":"Zoë Fullerton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYDACCcaHD0A0ewOQzcDATIwWZmMDhgQGBp4DJGgxkyBNi/zsZrbKnz/s8njYex/eYKiwTmwgpIVxzmG22zwJycU8PMeNLRjOpBPWwiyRf+w2QwJz4n6JNDYJxrbDhLWwSSSzFf5IqE/sAWv5R4QWHqAWBp6Ew1AtDURokZBIZpbmSTue2MNzjNki4Vi6MUEt8jOSGT/+sKlO7GFvY7zxocZalqAWVJBAmvJRMApGwSgYBbgAAENJNsl6A6jcAAAAAElFTkSuQmCC","orcid":"","institution":"Stanford University Department of Otolaryngology","correspondingAuthor":true,"prefix":"","firstName":"Zoë","middleName":"","lastName":"Fullerton","suffix":""},{"id":399739391,"identity":"6b3ab9ff-7a59-472b-8603-6ebb422ccc23","order_by":2,"name":"Karthik Balakrishnan","email":"","orcid":"","institution":"Stanford University Department of Otolaryngology","correspondingAuthor":false,"prefix":"","firstName":"Karthik","middleName":"","lastName":"Balakrishnan","suffix":""}],"badges":[],"createdAt":"2025-01-03 21:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5760451/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5760451/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73676739,"identity":"5a2796fe-4863-44c4-9f06-2e9e10a8f6bc","added_by":"auto","created_at":"2025-01-13 13:11:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":400621,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic of grounded theory methodology with examples from current study. The iterative nature of the constant comparative coding process is exemplified in the multidirectional nature of the arrows.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5760451/v1/dfdb337003adf8889a4306cc.png"},{"id":73677194,"identity":"dd0c09a4-d55f-4369-8a22-178001fe60ef","added_by":"auto","created_at":"2025-01-13 13:19:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":986154,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5760451/v1/069da04d-b81c-47a2-b928-f33bb684c4cd.pdf"},{"id":73674141,"identity":"d45287d8-9eac-4a37-980c-43c5de667d87","added_by":"auto","created_at":"2025-01-13 12:55:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31333,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5760451/v1/5fce4e7d0b45e52ea0aba3ee.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Grounded Theory Investigation into the Otolaryngology Resident Learning Experience","fulltext":[{"header":"Background","content":"\u003cp\u003eOtolaryngologic education exists within a unique environment. The operating room (OR), which remains the primary site of training, represents a potentially high-stakes situation in which learning often involves trainees performing procedures, or portions of procedures, under the guidance of a surgical teacher, based on the principle of graduated autonomy. Errors on the part of a trainee have the potential for tangible harm to all parties involved, and experiences within the operating room can have a lasting impact on the patient, learner, and teacher.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Therefore, the task of otolaryngologic teachers and learners is not to be taken lightly. A teacher must safely and ably guide a trainee through a procedure while ensuring a safe and positive outcome for the patient. Despite this, surgical teachers rarely have formal training in adult learning. Instead, they rely on their own learning experiences, insights, and general \u0026ldquo;on-the-job training\u0026rdquo; to formulate and refine teaching styles and behaviors.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOtolaryngologic education is often impacted by changes in the healthcare system and residency structure. The traditional model of surgical education was structured around apprenticeship. However, due to the increasing number of faculty and trainees at institutions, resident and attending dyads may spend less time together. Additionally, recent changes in time constraints from both a work hour and a hospital efficiency standpoint have placed further stress on the training environment.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e These changes may affect learning dynamics and require teachers and learners to employ deliberate educational behaviors to achieve optimal learning experience. While a growing emphasis on simulation training may alleviate some issues with time constraints from a technical skills development standpoint, surgical experience within the operative setting remains essential to training competent surgeons.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e It is imperative, therefore, to ensure that trainees' learning experiences within an operating room setting are optimized to be maximally beneficial.\u003c/p\u003e \u003cp\u003eWithin the field of Otolaryngology, there has been increasing recognition of the importance of effective and efficient teaching.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, the essential elements that create a positive teaching experience are still unknown. In this study, we use grounded theory, an inductive theory-generating qualitative analysis, to explore the experiences of otolaryngologic learners and teachers to better understand what constitutes a positive teaching experience within the operating room setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eAll participants were recruited from the Stanford University Department of Otolaryngology-Head \u0026amp; Neck Surgery using IRB-approved email messaging during the 2023 calendar year. Purposive sampling was used to ensure a diverse data set representing all stages of residency training and faculty career within the department.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Interviews were recorded using a specialized password-protected application.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Transcription was performed initially with Microsoft Word transcription services, then reviewed and edited by the interviewer to ensure accuracy.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e All recordings were deleted immediately following transcription.\u003c/p\u003e \u003cp\u003eInterviews were conducted in a semi-structured fashion by a single interviewer with training in qualitative interview procedures. Initial interview questions were created with input from three authors and designed to encompass issues previously identified in relevant literature and ad hoc discussions with stakeholders in the department. Interview topics included previous positive and negative teaching and learning experiences, conceptions of the ideal form of learner or teacher, observations about the effects of the operative environment on otolaryngologic teaching and learning, and experiences surrounding the particulars of interpersonal communication within a surgical environment with a focus on teaching in the operating room. An emphasis was placed on providing open-ended questions and facilitating organic discussion around the experiences and viewpoints of each participant. Questions were iteratively refined during data collection and analysis to allow for further deepening and refinement of emerging concepts and themes [Supplemental Table\u0026nbsp;1]. Interviews were labeled along two dimensions as teacher/learner and junior/senior level but were otherwise anonymized for analysis. Participants included 6 Junior Faculty Members (Less than five years\u0026rsquo; experience), 7 Senior Faculty Members (5 or more years\u0026rsquo; experience), 4 Senior Residents (PGY-4, PGY-5), and 4 Junior Residents (PGY-2, PGY-3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eGrounded theory methodology was chosen for this project because it allows for the deconstruction and reconstruction of qualitative data to generate theories and insights relating to complex phenomena, such as teaching experiences and behaviors. Theory generation is performed using detailed analysis of data acquired from individuals embedded within the context of the research question and is not rooted in a priori constructs, allowing for the emerging theory to be \u0026ldquo;grounded\u0026rdquo; and, therefore, supported by the data from which it arose.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e In accordance with this, two researchers independently coded each interview transcription. A line-by-line analysis was performed. Coding, or the assignment of descriptive labels to data segments to allow for the deconstruction of data into discrete components for analysis, was performed. Initial codes were created to identify and categorize participants\u0026rsquo; experiences, observations, and descriptions.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The initial coding of each interview was done independently. Codebooks were then compared, and differences were reconciled by consensus discussion between the two initial coders, with any discrepancies resolved by a third researcher. Each researcher created memos based on initial coding. These memos, or \u0026ldquo;field notes\u0026rdquo;, represented ideas and thoughts generated through researcher interaction with the data and guided additional questions and inquiries in future interviews. Interviews were conducted until no new codes or memos emerged from two successive interviews.\u003c/p\u003e \u003cp\u003eTwo researchers performed intermediate coding or compiling initial codes to form categories and subcategories, or \u003cem\u003econcepts\u003c/em\u003e. A third researcher then reviewed these for content validity; revisions were made following a consensus discussion. The researchers' different training positions (medical student, resident, and senior attending) were leveraged for increased content validity. Advanced coding was then performed through iterative combination and comparison of concepts and codes until themes were defined.\u003c/p\u003e \u003cp\u003eWe then conducted a sub-analysis to evaluate how each subgroup of teachers and learners contributed to the identified themes. Analysis was conducted within each theme, with concepts and codes categorized according to their original subgroup. We then analyzed this data to identify commonalities across all groups as well as those codes and concepts that were expressed and prioritized by one subgroup. This project was approved by the Stanford Institutional Review Board.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween March 2023 and December 2023, 21 Stanford Department of Otolaryngology members participated in interviews. The response rate was 21/24 (87.5%). Interviews were conducted in person (18) or on IRB-approved video conferencing sites (3).\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e [Supplemental Table\u0026nbsp;2]. Interviews ranged from 29 to 58 minutes (average 42 minutes) in length.\u003c/p\u003e \u003cp\u003eInitial analysis produced 87 distinct codes; intermediate coding produced 15 distinct concepts. [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] Four themes or categories emerged from advanced coding: Discernment of Learner Capacity, Communication, Investment in Learner/Education, and Creation of the Learning Environment. [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] Each of these was noted to be distinct in the concepts that it encompassed; it was therefore determined that further attempts to combine would result in loss of nuance and dimensionality of subsequent theory.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, Concepts, and Codes derived from grounded theory analysis of data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcepts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDiscernment of Learner Capacity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstanding of Learner/Learner\u0026rsquo;s Context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmpathizing with learner\u0026rsquo;s experiences\u003c/p\u003e \u003cp\u003e[neg] Losing understanding of learner experience over time\u003c/p\u003e \u003cp\u003e[neg] Difficulty remembering learner mindset\u003c/p\u003e \u003cp\u003ePatience with learner Struggle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUtilizing own struggles, mistakes\u003c/p\u003e \u003cp\u003eUnderstanding learner capabilities\u003c/p\u003e \u003cp\u003eUsing personal learning experiences as context\u003c/p\u003e \u003cp\u003eUsing proximity to learner as a source of empathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenging Learners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBuilding confidence by pushing learners\u003c/p\u003e \u003cp\u003eAllowing controlled struggling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEncouraging appropriate learner independence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpowering Learners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAllowing learner to take ownership\u003c/p\u003e \u003cp\u003eEncouraging problem solving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAllowing learner to lead\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdapting to Learner Needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRespect for struggles of learning\u003c/p\u003e \u003cp\u003eAdapting expectations to learner\u003c/p\u003e \u003cp\u003eChanging teaching method to reflect learner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeeting learner at current level\u003c/p\u003e \u003cp\u003eUnassuming of learner abilities at onset\u003c/p\u003e \u003cp\u003eIntuiting learner knowledge\u003c/p\u003e \u003cp\u003eIdentifying gaps in learner knowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eInvestment in Learner/Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeacher/Learner Relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValuing the relationships of teacher/learner\u003c/p\u003e \u003cp\u003eCultivating Trust with Learner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCollaborating with Learner\u003c/p\u003e \u003cp\u003eOpenness to feedback in teaching methods\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnthusiasm for Teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-identifying as teacher\u003c/p\u003e \u003cp\u003eRespecting teaching as a skill\u003c/p\u003e \u003cp\u003ePersonal pride/fulfillment from teaching\u003c/p\u003e \u003cp\u003eInterest in Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJoy in Teaching\u003c/p\u003e \u003cp\u003eSharing in student success\u003c/p\u003e \u003cp\u003e[neg] disengagement\u003c/p\u003e \u003cp\u003eRecognizing privilege of teaching\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEngaging Learners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbally engaging learner to extract enthusiasm\u003c/p\u003e \u003cp\u003eGrounding information in approachable scenarios\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEngaging students through questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvestment in Learner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProviding learner opportunities\u003c/p\u003e \u003cp\u003ePrioritizing learner experience\u003c/p\u003e \u003cp\u003ePatience for learning process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTaking ownership for learner education\u003c/p\u003e \u003cp\u003eLearner\u0026rsquo;s perception of teacher investment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvestment in Teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeaching generalizable skills\u003c/p\u003e \u003cp\u003eDedicating time to the learning process\u003c/p\u003e \u003cp\u003ePrioritizing learning in OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReflecting on positive teaching experiences\u003c/p\u003e \u003cp\u003eDesiring to improve teaching\u003c/p\u003e \u003cp\u003eCritical reflection on negative experiences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCommunication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplanatory Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContextualizing information\u003c/p\u003e \u003cp\u003eCreating framework of ideas\u003c/p\u003e \u003cp\u003eRepetition\u003c/p\u003e \u003cp\u003eOrganizing communication/instruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePresenting information in multiple ways\u003c/p\u003e \u003cp\u003eBuilding knowledge base in steps\u003c/p\u003e \u003cp\u003eCoaching through difficulties\u003c/p\u003e \u003cp\u003eProviding Examples\u003c/p\u003e \u003cp\u003eClosed Loop communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaborative Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExplaining thought/decision processes\u003c/p\u003e \u003cp\u003eExplaining reasoning behind actions\u003c/p\u003e \u003cp\u003eEncouraging Dialogue\u003c/p\u003e \u003cp\u003eVerbalizing thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunicating wants for experience\u003c/p\u003e \u003cp\u003eCommunicating expectations\u003c/p\u003e \u003cp\u003eSetting learning goals\u003c/p\u003e \u003cp\u003eEncouraging engagement through communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConstructive feedback\u003c/p\u003e \u003cp\u003eHonest feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReal time feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCreation of Learning Environment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControlling Environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAddressing multiple needs in OR environment\u003c/p\u003e \u003cp\u003eAbility to correct learner mistakes\u003c/p\u003e \u003cp\u003eNavigation of high stakes situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting tone of space through leadership\u003c/p\u003e \u003cp\u003eSensitivity to needs of environment\u003c/p\u003e \u003cp\u003eManaging patient/time stressors\u003c/p\u003e \u003cp\u003e[neg] perceived lack of control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManaging Personal OR Presence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBattling with own sense of control/focus\u003c/p\u003e \u003cp\u003eMaintaining composure\u003c/p\u003e \u003cp\u003eTolerating stress and stress response\u003c/p\u003e \u003cp\u003eConfidence in skill set\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRecognizing effects of demeanor on environment\u003c/p\u003e \u003cp\u003ePerception of Teacher Confidence/Control\u003c/p\u003e \u003cp\u003e[neg] transmission of stress onto others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCreating Space for Learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCreating a welcoming environment\u003c/p\u003e \u003cp\u003eMaintaining approachability\u003c/p\u003e \u003cp\u003eResponding to requests for help\u003c/p\u003e \u003cp\u003eNavigating response to error\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrowth mindset around learning\u003c/p\u003e \u003cp\u003e[neg] Large response to small error\u003c/p\u003e \u003cp\u003eReducing Hierarchy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eDiscernment of Learner Capacity\u003c/h3\u003e\n\u003cp\u003eThe core category of \u0026ldquo;Discernment of Learner Capacity\u0026rdquo; comprises codes and concepts centered around the ability of the teacher to create and tailor teaching experiences that appropriately challenge the learner and their ability within a procedure. This involved the teacher\u0026rsquo;s ability to assess the individual learner's current skills, understand the learner\u0026rsquo;s potential, and intuit how best to advance and expand their abilities within the procedure's context and the greater context of their learning. This core theme encompasses the concepts of \u0026ldquo;Understanding Learner/Learner\u0026rsquo;s Context\u0026rdquo;, \u0026ldquo;Adapting to Learner Needs\u0026rdquo;, \u0026ldquo;Challenging Learners\u0026rdquo; and \u0026ldquo;Empowering Learners\u0026rdquo;. [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSubanalysis showed that senior teachers voiced difficulty with remembering and understanding the learner mindset and struggled with a sense of personal distance from the learner. [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e] Junior teachers were notable for discussing the utilization of their proximity to the learner and remembering their own learning experiences and mistakes to understand the learner\u0026rsquo;s context better. Senior learners addressed the importance of being allowed to struggle; junior learners showed concern about assumptions of learner abilities and prioritized patience with the learner. Both senior learners and senior teachers emphasized the importance of allowing learners to struggle in a guided or controlled manner.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubanalysis of themes showing Codes standard in all Groups and those specifically emphasized by Subgroups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eDiscernment of Learner Capacity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCommonalities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpathizing with learner\u0026rsquo;s experiences\u003c/p\u003e \u003cp\u003eBuilding confidence by pushing learners\u003c/p\u003e \u003cp\u003eUnderstanding learner capabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEncouraging appropriate learner independence\u003c/p\u003e \u003cp\u003eAllowing learner to take ownership\u003c/p\u003e \u003cp\u003eEncouraging problem solving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eRespect for struggles of learning\u003c/p\u003e \u003cp\u003eAdapting expectations to learner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eChanging teaching method to reflect learner\u003c/p\u003e \u003cp\u003eIntuiting learner knowledge\u003c/p\u003e \u003cp\u003eIdentifying gaps in learner knowledge\u003c/p\u003e \u003cp\u003eAllowing learner to lead\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSenior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eJunior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSenior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eJunior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[neg] Losing understanding of learner experience over time\u003c/p\u003e \u003cp\u003e[neg] Difficulty remembering learner mindset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUtilizing own struggles, mistakes\u003c/p\u003e \u003cp\u003eUsing personal learning experiences as context\u003c/p\u003e \u003cp\u003eUsing proximity to learner as a source of empathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAllowing controlled struggling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eUnassuming of learner abilities at onset\u003c/p\u003e \u003cp\u003ePatience with learner Struggle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInvestment in Learner/Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCommonalities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-identifying as teacher\u003c/p\u003e \u003cp\u003ePersonal pride/fulfillment from teaching\u003c/p\u003e \u003cp\u003eInterest in Education\u003c/p\u003e \u003cp\u003eVerbally engaging learner to extract enthusiasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValuing the relationships of teacher/learner\u003c/p\u003e \u003cp\u003eCultivating Trust with Learner\u003c/p\u003e \u003cp\u003eProviding learner opportunities\u003c/p\u003e \u003cp\u003ePrioritizing learner experience\u003c/p\u003e \u003cp\u003eTaking ownership for learner education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eOpenness to feedback in teaching methods\u003c/p\u003e \u003cp\u003eJoy in Teaching\u003c/p\u003e \u003cp\u003eSharing in student success\u003c/p\u003e \u003cp\u003ePatience for learning process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eDedicating time to the learning process\u003c/p\u003e \u003cp\u003ePrioritizing learning in OR\u003c/p\u003e \u003cp\u003eDesiring to improve teaching\u003c/p\u003e \u003cp\u003eCritical reflection on negative experiences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSenior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eJunior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSenior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eJunior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespecting teaching as a skill\u003c/p\u003e \u003cp\u003eTeaching generalizable skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflecting on positive teaching experiences\u003c/p\u003e \u003cp\u003eCollaborating with Learner\u003c/p\u003e \u003cp\u003eRecognizing privilege of teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLearner\u0026rsquo;s perception of teacher investment*\u003c/p\u003e \u003cp\u003e[neg] disengagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eLearner\u0026rsquo;s perception of teacher investment*\u003c/p\u003e \u003cp\u003eEngaging students through questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCommonalities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExplaining thought/decision processes\u003c/p\u003e \u003cp\u003eExplaining reasoning behind actions\u003c/p\u003e \u003cp\u003eEncouraging Dialogue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunicating wants for experience\u003c/p\u003e \u003cp\u003eCommunicating expectations\u003c/p\u003e \u003cp\u003eSetting learning goals\u003c/p\u003e \u003cp\u003eHonest feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003ePresenting information in multiple ways\u003c/p\u003e \u003cp\u003eRepetition\u003c/p\u003e \u003cp\u003eConstructive feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOrganizing communication/instruction\u003c/p\u003e \u003cp\u003eReal time feedback\u003c/p\u003e \u003cp\u003eVerbalizing thoughts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSenior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eJunior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSenior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eJunior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContextualizing information*\u003c/p\u003e \u003cp\u003eCreating framework of ideas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEncouraging engagement through communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eContextualizing information*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eProviding Examples\u003c/p\u003e \u003cp\u003eCoaching through difficulties\u003c/p\u003e \u003cp\u003eBuilding knowledge base in steps\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreation of Learning Environment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCommonalities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to correct learner mistakes\u003c/p\u003e \u003cp\u003eNavigation of high stakes situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfidence in skill set\u003c/p\u003e \u003cp\u003eSensitivity to needs of environment\u003c/p\u003e \u003cp\u003eGrowth mindset around learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCreating a welcoming environment\u003c/p\u003e \u003cp\u003eMaintaining approachability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eResponding to requests for help\u003c/p\u003e \u003cp\u003eNavigating response to error\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSenior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eJunior Teachers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSenior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003eJunior Learners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBattling with own sense of control/focus*\u003c/p\u003e \u003cp\u003eTolerating stress and stress response\u003c/p\u003e \u003cp\u003eAddressing multiple needs in OR environment\u003c/p\u003e \u003cp\u003eRecognizing effects of demeanor on environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBattling with own sense of control/focus*\u003c/p\u003e \u003cp\u003eMaintaining composure\u003c/p\u003e \u003cp\u003eReducing Hierarchy\u003c/p\u003e \u003cp\u003eManaging patient/time stressors\u003c/p\u003e \u003cp\u003eSetting tone of space through leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e[neg] perceived lack of control\u003c/p\u003e \u003cp\u003e[neg] Large response to small error\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePerception of Teacher Confidence/Control\u003c/p\u003e \u003cp\u003e[neg] Transmission of stress onto others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003e*\u003c/b\u003e Indicates two or more subgroups emphasize code\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eInvestment in Learner Education\u003c/h3\u003e\n\u003cp\u003e\u0026ldquo;Investment in Learner Education\u0026rdquo; includes codes and concepts relating to a teacher\u0026rsquo;s desire to engage with the learner and the surgical education process. The concepts contained within this theme include \u0026ldquo;Teacher/Learner Relationship\u0026rdquo;, \u0026ldquo;Enthusiasm for Teaching\u0026rdquo;, \u0026ldquo;Engaging Learners\u0026rdquo;, \u0026ldquo;Investment in Learner\u0026rdquo;, and \u0026ldquo;Investment in Teaching\u0026rdquo;. The codes within these concepts address an individual teacher\u0026rsquo;s investment in the learner\u0026rsquo;s education, their broader investment in a relationship with the learner, and the practice of surgical education. [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] Codes focused on an educator\u0026rsquo;s commitment to the learner interpersonally (through the pursuit of a longitudinal relationship), situationally (through the prioritization of the learner\u0026rsquo;s education within the operating room setting), and broadly (through their commitment to and enthusiasm for the art of surgical teaching).\u003c/p\u003e \u003cp\u003eSubanalysis showed that within individual groups, learners emphasized the importance of the learner\u0026rsquo;s perception of teacher investment, referring to both the ability of the teacher to communicate this investment and the learner to appreciate it. Learners also emphasized the impact of the teacher's engagement in the procedure. Both senior and junior teachers discussed their efforts to self-reflect on and improve their teaching practices, as well as their respect for the art of teaching. Senior teachers expressed their desire to teach generalizable, durable skills as evidence of their commitment to education while more junior teachers emphasized collaboration as a method of showing investment. [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClear Communication\u003c/h2\u003e \u003cp\u003eThe core theme of \u0026ldquo;Communication\u0026rdquo; encompasses communication strategies for teaching and interacting with students in the OR setting. All parties distinctly emphasized feedback as a necessary aspect of teaching. The concepts contained within Communication include \u0026ldquo;Explanatory Communication,\u0026rdquo; \u0026ldquo;Collaborative communication,\u0026rdquo; and \u0026ldquo;Feedback.\u0026rdquo; [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] Explanatory communication codes focus on communication strategies to encourage learning, whereas collaboratory communication codes focus on interpersonal methods of establishing rapport and a shared experience with the learner.\u003c/p\u003e \u003cp\u003eOn subanalysis, senior teachers and learners prioritized contextualizing information and incorporating learning into a larger conceptual understanding. In contrast, junior learners prioritized the simple delivery of information, including \u0026ldquo;Building knowledge base in steps,\u0026rdquo; \u0026ldquo;Coaching through difficulties,\u0026rdquo; and \u0026ldquo;Providing Examples.\u0026rdquo; [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCreation of the Learning Environment\u003c/h3\u003e\n\u003cp\u003e\u0026ldquo;Creation of the Learning Environment\u0026rdquo; consists of concepts and codes that address the ability of the teacher to manage their struggles in the operating room and create an environment for the learner that is conducive to learning and encouraging learner growth. Concepts included \u0026ldquo;Managing Personal OR Presence,\u0026rdquo; \u0026ldquo;Controlling Environment,\u0026rdquo; and \u0026ldquo;Creating Space for Learning.\u0026rdquo; [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] \u0026ldquo;Controlling Environment\u0026rdquo; codes describe a teacher's ability to understand and meet the needs of the OR setting, while \u0026ldquo;OR presence\u0026rdquo; codes refer to a teacher\u0026rsquo;s management of individual stressors. The \u0026ldquo;Creation\u0026rdquo; codes refer specifically to the teacher's ability to create an educationally oriented environment within the OR setting.\u003c/p\u003e \u003cp\u003eSubanalysis showed that junior and senior teachers frequently spoke about the tensions between working through their struggles and emotions elicited by the environment while working to create a productive setting for their learners. On the other hand, learners discussed the importance of the perception of a teacher's confidence and control within the OR in creating a productive learning environment. Learners also spoke of the potentially negative impacts of overemphasizing learner error and transmission of stress into the environment. [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to utilize grounded theory methods to explore what creates a positive teaching experience for otolaryngologic teachers and learners in the operating room setting. In this study, 21 participants at varying training and career stages at a single center underwent in-depth interviews about their experiences and observations surrounding otolaryngologic teaching. Analysis of their responses using a grounded theory methodology revealed four themes that contribute to the creation of a positive otolaryngologic teaching experience: \u0026ldquo;Investment in Learner/Education,\u0026rdquo; \u0026ldquo;Communication,\u0026rdquo; \u0026ldquo;Discernment of Learner Capacity,\u0026rdquo; and \u0026ldquo;Creation of Learning Environment.\u0026rdquo; Subanalysis showed that teachers and learners prioritize many of the same things but may place specific emphasis on certain elements, reflecting their own experiences and interactions with the learning environment.\u003c/p\u003e \u003cp\u003eOne of the themes of a positive surgical education experience relates to how the teacher creates the learning environment. A psychologically safe learning environment has been increasingly understood as an essential element of the learning process.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e \u0026ldquo;Psychological safety\u0026rdquo; and its derivative, \u0026ldquo;educational safety,\u0026rdquo; refer to atmospheres where learners can focus on learning and professional growth without worrying about repercussions from interpersonal encounters. Psychological safety has been shown to play a role in success and teamwork within an OR setting.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e However, how best to create this space is less well understood. In this study, senior and junior learners emphasized the importance of confidence in their teacher and the teacher\u0026rsquo;s ability to provide measured responses to and offer corrections or solutions for mistakes. This emphasis on teacher confidence is juxtaposed with the concerns voiced by senior and junior teachers, who focus on the difficulties of self-regulation and tolerance of personal stress in the OR setting. While prior research has shown that resilience and management of intraoperative stress may play a role in trainees\u0026rsquo; experience in the OR, little is known about how these issues may affect surgical teachers, especially those in the early stages of their careers.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Further research into how best to support otolaryngologic educators may benefit teachers and learners.\u003c/p\u003e \u003cp\u003eThe ability to discern a learner\u0026rsquo;s capabilities and understand how to safely but appropriately progress their learning is complex. In this study, both learners and teachers emphasized the importance of presenting learners with educational opportunities appropriate for their level but also challenging enough to allow for growth. While graduated autonomy is a commonly known concept in surgical education, the techniques of ensuring this progression and assessing skills in determining it are less wholly understood.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In the past, when learners and teachers existed within an apprenticeship model, longitudinal relationships may have lessened the need for a teacher to intuit learner skills and abilities quickly. In the modern training environment, a teacher may be frequently required to rapidly and accurately assess a trainee\u0026rsquo;s abilities. In our study, junior teachers discussed using their recent experiences with the learning process to help ascertain the learner\u0026rsquo;s current state. On the other hand, senior teachers discussed struggling with identifying with the learner in this way and relying instead on experience. Recent research into machine learning assessment of surgical skills, surgical self-evaluation, and program tracking of core competencies have shown positive results in their ability to assess trainee surgical proficiency objectively.\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Formal incorporation of these methods within the otolaryngologic training setting may be helpful for training situations where issues with this assessment are common.\u003c/p\u003e \u003cp\u003eThe importance of thoughtful and efficient communication in the operating room has been well established.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In otolaryngologic education, deliberate communication is vital as learning and teamwork occur in tandem. We see this reflected in how all groups prioritized explanatory and collaborative communication. However, the results of this study also speak to the importance of the multiple approaches to communication needed to be an effective otolaryngologic educator. In this study, more senior learners discussed their desire for contextualized information, while more junior learners discussed desiring smaller, more digestible, and direct methods of communication. Attention to these nuances and needs may assist otolaryngologic teachers hoping to better communicate with learners.\u003c/p\u003e \u003cp\u003eIn today\u0026rsquo;s learning environment, otolaryngologic teachers are frequently faculty members whose job involves the tripartite mission of clinical work, research, and teaching. Clinical productivity is often a driving factor in evaluation for faculty members, and operative efficiency is an essential keystone of that productivity. Given this, the extra time one spends in a particular case becomes a valuable commodity that must be consciously allocated to the teaching process.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e In this study, one of the themes of a positive otolaryngologic teaching experience was the teacher's investment in the student and the education process. One example of educator investment was investing time in the learner and learning process. Teachers discussed prioritizing time both within the OR and outside of it to improve their teaching and give students time to learn. Learners discussed recognizing and appreciating teachers who dedicated this time to their education. However, in many current environments, the dedication of time to learning may be at odds with the pressures for operating room efficiency and productivity and associated financial and career incentives. As a result, even those otolaryngologic teachers who are invested in education may experience difficulties providing learners with appropriate opportunities.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Though these concerns may always be present, improving support for otolaryngologic teachers who invest time in trainee education may benefit the learning experience.\u003c/p\u003e \u003cp\u003eWhile this study offers valuable insights into the experience of otolaryngologic education, multiple limitations must be considered. This study comprises twenty-one participants within a single center, all operating within the same surgical settings. Despite their diverse backgrounds, this shared context may limit the generalizability of the findings to other environments. Furthermore, while purposive sampling was utilized to introduce a variation of viewpoints, it may have inadvertently introduced bias. Although the response rate for this study was high, there may have been self-selection bias among participants with the most interest in education, and we did not have a practical way to control for the teaching skill of the teachers or the self-awareness of the teachers and learners who participated. Additionally, all participants were interviewed by a single interviewer known to each interviewee. While every effort was made to minimize any impact of this familiarity through anonymity, immediate deletion of recordings after transcription, and reassurance, it may have introduced bias into the interview responses. Data analysis was performed independently by two researchers from different institutions at different stages of training; however, as with all qualitative research, there is still a possibility that researchers\u0026rsquo; biases and perspectives may have unconsciously influenced analysis. Finally, we did not account for specific teacher or learner identity and intersectionality, or for differences in program or department culture with other institutions, both of which are important areas for future investigation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis grounded theory analysis of otolaryngologic teaching revealed four themes that create the experience of a positive education environment. Each of these\u0026ndash;\u0026ldquo;Communication,\u0026rdquo; \u0026ldquo;Investment in Learner/Education,\u0026rdquo; \u0026ldquo;Discernment of Learner Capacity,\u0026rdquo; and \u0026ldquo;Creation of Learning Environment\u0026rdquo;\u0026ndash; address distinct components of the otolaryngologic teacher-learner experience. While further research is needed to validate these findings, these insights may provide an opportunity for a deeper understanding of the nuances inherent in creating a positive teaching experience. Attention to these elements may aid otolaryngologic educators and learners in fostering a more enriching education environment and offer potential inspiration for those looking to improve the otolaryngologic teaching experience at both an individual and a program level.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOR: operating room\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis project was approved by the Stanford Institutional Review Board, committee reference number IRB-67791. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article and its supplementary files.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eZF and MN contributed equally to this project and share first authorship. ZF conducted interviews and reviewed transcripts for accuracy. MN and ZF developed codebooks from transcriptions individually which were then compared and compiled. ZF and MN also created memoing throughout coding process and performed intermediate and advanced coding to generate concepts and themes. KB reconciled code discrepancies and reviewed advanced coding for content validity. All authors developed initial interview questions and had consensus discussion to revise codes, concepts, and themes. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to give a special thank you to the interviewees in the Stanford Department of Otolaryngology\u0026nbsp;for their contributions to this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. doi:10.1136/bmj.320.7237.726.\u003c/li\u003e\n\u003cli\u003eJohnson JT. Teaching the teacher: an essential obligation. Laryngoscope. 2014;124(5):1049-1050. doi:10.1002/lary.24620.\u003c/li\u003e\n\u003cli\u003eAhmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-1053. doi:10.1097/SLA.0000000000000595.\u003c/li\u003e\n\u003cli\u003eClifton N, Klingmann C, Khalil H. Teaching otolaryngology skills through simulation. Eur Arch Otorhinolaryngol. 2011;268(7):949-953. doi:10.1007/s00405-011-1554-6.\u003c/li\u003e\n\u003cli\u003eCramer JD, Chi DH, Schaitkin BM, Eibling DE, Johnson JT. Teach the teacher: training otolaryngology fellows to become academic educators. Laryngoscope. 2018;128(9):2034-2048. doi:10.1002/lary.27156.\u003c/li\u003e\n\u003cli\u003eZhao NW, O\u0026rsquo;Sullivan PS, Huang E. Enhancing operative feedback: a descriptive trajectory for surgical development in otolaryngology. J Surg Educ. 2020;77(3):572-581. doi:10.1016/j.jsurg.2019.11.009.\u003c/li\u003e\n\u003cli\u003eChen JX, Gray ST. A paired curriculum for surgical faculty and residents on adult education. Laryngoscope Investig Otolaryngol. 2023;8(3):636-638. doi:10.1002/lio2.1066.\u003c/li\u003e\n\u003cli\u003eLackey TG, Abaza MM. Is \u0026ldquo;see one, do one, teach one\u0026rdquo; the best way to learn procedures? Laryngoscope. 2024;134(1):1-2. doi:10.1002/lary.30853.\u003c/li\u003e\n\u003cli\u003eBirks M, Mills J. Grounded theory: a practical guide. 3rd edition. SAGE Publications; 2023.\u003c/li\u003e\n\u003cli\u003eDayana Networks Ltd. Voice Record Pro 7 Full.\u003c/li\u003e\n\u003cli\u003eMicrosoft Corporation, ed. Microsoft Word. Version 5.0. Microsoft Corp; 1991.\u003c/li\u003e\n\u003cli\u003eGlaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Aldine Pub. Co; 1967.\u003c/li\u003e\n\u003cli\u003eStrauss AL, Corbin JM, eds. Grounded theory in practice. SAGE Publications; 1997.\u003c/li\u003e\n\u003cli\u003eZoom.us. Published online 2023.\u003c/li\u003e\n\u003cli\u003eArad D, Finkelstein A, Rozenblum R, Magnezi R. Patient safety and staff psychological safety: a mixed methods study on aspects of teamwork in the operating room. Front Public Health. 2022;10:1060473. doi:10.3389/fpubh.2022.1060473.\u003c/li\u003e\n\u003cli\u003eWilliamson AJH, Jensen RM, Smith BK. Educational safety for the surgical learner. J Surg Educ. 2022;79(5):1083-1087. doi:10.1016/j.jsurg.2022.04.007.\u003c/li\u003e\n\u003cli\u003eNg R, Chahine S, Lanting B, Howard J. Unpacking the literature on stress and resiliency: a narrative review focused on learners in the operating room. J Surg Educ. 2019;76(2):343-353. doi:10.1016/j.jsurg.2018.07.025.\u003c/li\u003e\n\u003cli\u003eMiles VP, Schroll RW, Beaty JS. Empowering the resident learner. J Surg Educ. 2022;79(4):909-917. doi:10.1016/j.jsurg.2022.03.009.\u003c/li\u003e\n\u003cli\u003eMohamadipanah H, Kearse L, Witt A, et al. Can deep learning algorithms help identify surgical workflow and techniques? J Surg Res. 2021;268:318-325. doi:10.1016/j.jss.2021.07.003.\u003c/li\u003e\n\u003cli\u003ePugh CM, Hashimoto DA, Korndorffer JR. The what? How? And who? Of video based assessment. Am J Surg. 2021;221(1):13-18. doi:10.1016/j.amjsurg.2020.06.027.\u003c/li\u003e\n\u003cli\u003eSantander MJ, Sep\u0026uacute;lveda V, Iribarren J, et al. Development and validation of a laryngeal microsurgery simulation training system for otolaryngology residents. Otolaryngol Head Neck Surg. 2023;169(4):971-987. doi:10.1002/ohn.376.\u003c/li\u003e\n\u003cli\u003eKim AH, Vaughn CA, King DL, Maizels M, Meade P, Stack BC. Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment. Head Neck. 2020;42(12):3551-3557. doi:10.1002/hed.26420.\u003c/li\u003e\n\u003cli\u003eRohde RL, Mace JC, North LM, et al. Development of a novel self-assessment tool following endoscopic sinus surgery in the management of chronic rhinosinusitis. Am J Otolaryngol. 2024;45(5):104365. doi:10.1016/j.amjoto.2024.104365.\u003c/li\u003e\n\u003cli\u003eLingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-334. doi:10.1136/qshc.2003.008425.\u003c/li\u003e\n\u003cli\u003eManser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-151. doi:10.1111/j.1399-6576.2008.01717.x.\u003c/li\u003e\n\u003cli\u003eChristian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173. doi:10.1016/j.surg.2005.07.037.\u003c/li\u003e\n\u003cli\u003eWoelfel I, Wang T, Pieper H, Meara M, Chen XP. Distortions in the balance between teaching and efficiency in the operating room. J Surg Res. 2023;283:110-117. doi:10.1016/j.jss.2022.10.032.\u003c/li\u003e\n\u003cli\u003eChow MS, Gordon AJ, Talwar A, Lydiatt WM, Yueh B, Givi B. The RVU compensation model and head and neck surgical education. Laryngoscope. 2024;134(1):113-119. doi:10.1002/lary.30807.\u003c/li\u003e\n\u003cli\u003eNwokedi U, Graviss EA, Nguyen DT, Pei KY. Work relative value units undervalue the clinical effort associated with teaching cases: an ACS-NSQIP analysis. Am J Surg. 2024;227:117-122. doi:10.1016/j.amjsurg.2023.09.051.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"communication, grounded theory, operative education, otolaryngology, psychological safety","lastPublishedDoi":"10.21203/rs.3.rs-5760451/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5760451/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOtolaryngologic residency operative education is a unique process that teaches technical and reasoning skills during high-stakes situations. However, there is no consensus on what qualities of a teacher or environment create a positive surgical learning experience. This study aims to use qualitative assessment to identify key elements of effective otolaryngologic residency education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to select a heterogeneous cohort from our institution’s Otolaryngology department between March and December 2023. Interviewees were categorized as either “Learners” (residents) or “Teachers” (attending) and either “Junior” or “Senior.” A trained interviewer conducted semi-structured interviews until thematic saturation was reached. Constant comparative analysis using coding, memoing, and categorization was conducted using grounded theory methodology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-one participants completed interviews, averaging 42 minutes. A total of 87 codes and 15 concepts were extracted from the data. Advanced coding and theoretical integration revealed four themes that are essential to the creation of a positive teaching experience: “Investment in Learner/Education,” “Communication,” “Discerning Learner Capacity,” and “Creation of Learning Environment.” “Investment” and “Discerning Capacity” represent the ability and desire of the teacher to assess and advance learner progress during surgery. “Communication” refers to the ability to convey information clearly and succinctly. “Creation” reflects the ability of the teacher/surgeon to navigate the complex operative environment to create a safe and effective learning experience within the context of a surgical operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study suggests that positive operative learning experiences rely on four thematic elements. A teacher's conscious attention to these elements and feedback from learners targeting them may assist in creating a more effective surgical learning environment. Further research is needed to understand the nuance of learner and teacher experience and how best to optimize and operationalize these concepts in diverse surgical educational settings.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e","manuscriptTitle":"A Grounded Theory Investigation into the Otolaryngology Resident Learning Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 12:55:13","doi":"10.21203/rs.3.rs-5760451/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-09T05:33:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-08T12:47:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-08T12:47:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-01-03T21:05:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"98f7f90c-3dbe-4fb0-9271-b4ee897e3b7e","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T22:53:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-13 12:55:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5760451","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5760451","identity":"rs-5760451","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}