“It’s Kind of a Rite of Passage”: An Exploration Into Residents’ Experience of Learning in a Critical Care Setting

Many residents rotate through an intensive care unit (ICU) during their training.^1-3  Previous research into resident ICU experiences has focused primarily on the optimal delivery of critical care content, with studies describing the application of asynchronous e-learning, learning passports, flipped classroom models, reflective learning, and high-fidelity simulation.^4-10  Recent studies have also reported on the negative effects on residents of rotating through the ICU, such as increased incidences of depression, emotional exhaustion, moral distress, and burnout, during and after their ICU rotations.^11-13  However, few studies have directly explored the resident experience of rotating in a critical care setting, which is a crucial next step toward understanding how residents learn in the ICU and what might improve previously reported negative effects of ICU training on resident wellness and professional development.

We sought to explore the resident ICU experience by focusing on pediatric medicine (PM) and emergency medicine (EM) residents rotating through the pediatric ICU (PICU) for the first time. The ICU is a unique, technologically driven, high-stress environment, where clinicians grapple with critical illness, extreme social and ethical dilemmas, and end-of-life care.¹⁴  PM and EM trainees represent various personality types, have trained in multiple settings, and include a diversity of learner characteristics.¹⁵  Additionally, the PICU exemplifies a high-stakes training environment, where caring for critically ill children and their families adds an additional layer of emotional intensity. Prior to a PICU rotation, for example, many residents have not yet witnessed a patient death.^16,17  However, in the PICU, 2% to 5% of their patients will die, most commonly due to acute abusive head traumas in previously healthy children.^18,19 

For these reasons, studying PM and EM learning experiences in a rich environment such as the PICU may shed light on the consequences to residents—intended or unintended—that occur during an ICU rotation. The knowledge gained from this exploration may be applicable to all critical care environments’ curriculum development, educational practices, learner assessment, program evaluations, and decisions regarding residency requirements, especially regarding attempts to tackle any negative effects of ICU training on wellness and professional development.

This qualitative study applies an interpretivist paradigm and a phenomenological approach to explore the resident PICU experience.²⁰  While phenomenology is broad, we used hermeneutic phenomenology, as described by van Manen because it is well-suited to study learners’ experiences in a way that can bring us closer to their worldviews and ensure our educational interactions with them may be more tactful.²¹  As such, hermeneutic phenomenology provides avenues for generating powerful pedagogical knowledge.²¹  We aimed to develop a rich description of PM and EM residents’ behaviors in and reactions to the PICU, which critical care educators can utilize to more effectively guide trainees through the PICU.^22,23  We strove for results that provide illuminating, meaningful, and impactful insights, which van Manen argues the strength of any phenomenological study must be based on.²⁴ 

This was a preplanned, secondary phase of a previously published study, where we had interviewed residents prior to their PICU rotations. The first investigation used grounded theory methods to explore residents’ expectations, perceptions, and preparations for the PICU.¹⁶  This study focuses on the residents’ lived experience of rotating through the PICU. Data collection for both studies occurred simultaneously, and we allowed insights from our first study to influence iterative revisions to our interview protocol for this study.

We conducted our research in an academic children’s hospital with level 1 trauma designation, which is located in the Pacific Northwest and has EM and PM training programs with 11 and 18 residents per year, respectively. During their second postgraduate year, PM and EM residents are required to rotate together through a 20-bed, quaternary PICU.²⁵  Prior to this, a minority had experienced the PICU as medical students, while all EM residents had rotated through adult ICUs.¹⁶  In the PICU, residents care for medical and postoperative surgical patients for 3 to 4 weeks, alongside 2 third-year PM residents. In this PICU, attending pediatric intensivists remain in-house at all times. Additionally, pediatric cardiologists and cardiothoracic surgeons comanage congenital cardiac surgical patients. Residents serve as “first call,” or primary point-of-contact, for all patients, within a multidisciplinary team of nurses, fellows, pharmacists, respiratory therapists, dietitians, pediatric nurse practitioners, consultants, and patients’ families.

At the conception of this research, A.J.K. was a first-year pediatric critical care medicine fellow. He began interviewing the residents in his second year, analyzed the data as a graduating fellow, and is currently a junior attending in another academic PICU located in the Southwestern United States. B.W.S. is an attending outpatient pediatrician, and K.F. is an attending pediatric intensivist. S.P.K. is a PICU nurse practitioner who manages the medical student, nurse practitioner, physician assistant, and resident PICU rotations. Lastly, L.M.Y. is an attending pediatric EM physician, the immediate past EM residency program director, and the current Vice Chair for Education. All bring their experiences as graduated trainees and current pediatric health care professionals, as well as graduate medical education faculty, to this research.

A.J.K. invited all second-year residents who rotated in the PICU from July 2019 through March 2020 to participate in an hour-long, one-on-one, post-rotational interview. Interviews were conducted within the first few weeks after residents completed their rotation; however, due to scheduling difficulties, some were delayed up to 6 months. Interviews took place just prior to and during the initial months of the COVID-19 pandemic.²⁶  This convenience sampling strategy, with no exclusion criteria, aimed to capture our most current resident PICU experience. Consequently, A.J.K., S.P.K., and K.F., all precepted these residents in the PICU, while L.M.Y. supervised them as the EM residency program director, during the study.

We developed an interview guide with the intent to explore the entire resident PICU experience. Items were developed based on content areas from our initial study, iterative discussions among our team, and a literature review, to optimize content validity. A.J.K. began each interview by asking, “So, how was your rotation?” He then explored the residents’ PICU-specific learning processes, encounters with bad patient outcomes or deaths, overall wellness during and after their rotation, and key lessons or takeaways. Foremost, A.J.K. encouraged residents to relay stories and personal memories from their rotation. He ended each interview by reviewing the residents’ responses from their pre-rotational interviews to gauge how their perspectives may have changed. As the experiential meaning emerged, additional prompts were iteratively incorporated into future interviews (online supplementary data).

A.J.K. audio recorded, transcribed, and pseudonymized all interviews. Interviews that could not be completed in-person, due to COVID-19 social distancing restraints, were captured via Webex, a secure online video-conference platform. Unlike other research methodologies, phenomenology utilizes smaller sample sizes to ensure the rich mosaic of experiential data remain manageable and appropriately represented.²¹  After 12 interviews, our team determined thematic sufficiency had been achieved, as no new themes were emerging. We felt the ample dataset justifiably encapsulated the resident PICU experience and, therefore, ended participant enrollment.

After conducting all interviews, A.J.K. randomly divided the transcripts between B.W.S., S.P.K., and K.F. He met with each co-investigator, one-on-one, to discuss each. For reflexivity, these discussions included reflections on personal experiences and reactions. On average, each meeting consisted of 1 to 2 hours of exposition. A.J.K. took notes and maintained an audit trail from these conversations. Afterward, he shared all impressions with the research team via email. Over the course of 3 consensus meetings, we inductively organized our insights into a coding scheme. Using QDA Miner Lite (Provalis Research), each transcript was then doubly coded and examined for idiosyncratic language, by A.J.K. and either B.W.S., S.P.K., or K.F., who were assigned different transcripts than before. The team convened once more to finalize the overall themes and exemplar quotes that characterized the resident PICU experience.²⁷ 

Consistent with various phenomenological traditions, we also constructed composite phenomenological examples to illustrate each theme, by weaving verbatim quotes from the dataset together into representations of what rotating through the PICU is like for residents. These serve as rhetorical devices created to evoke deep appreciations of the phenomena central to each theme.²⁸  In the presentation of results, the phenomenological examples represent the residents’ voices, while the descriptions of themes contain the authors’ investigational analysis.

To ensure scientific rigor, A.J.K., S.P.K., K.F., and B.W.S. analyzed varying transcripts, while L.M.Y. remained blinded to all transcripts, providing an additional layer of interpretive clarification and trustworthiness. We invited nonparticipating residents and a pediatric residency program director to read our manuscript, as a form of indirect member checking. Finally, we presented our findings at 2 pediatric department-wide seminars, using that feedback to help refine our conclusions.²⁹  Upon completion of our principal draft, each team member reviewed and revised the manuscript until all could attest to its fidelity to the participants’ voiced experiences.

The Oregon Health & Science University Institutional Review Board approved this research (IRB #20134) with a waiver of written consent.

After their first PICU rotation, residents described experiences evoking the following themes: (1) Trainees perceive the PICU as a challenging environment for independent, self-driven, and active learning, due to the fast-paced, high-stakes, and stressful work climate; (2) Trainees suffer adverse psychologic effects from their PICU experience, leading some to “give up” and/or endure a period of post-PICU acute traumatic stress; and (3) Despite the challenges in the PICU, trainees report increased comfort with caring for children who are critically ill, or “sick kids,” at the completion of their rotation. All initial draft readers and audiences remarked on how these findings validated their own past ICU training experiences. The themes are described below and summarized along with exemplar quotes in the Table. Boxes 1 to 3 present the phenomenological examples for each theme.

Residents describe learning in the PICU as incredibly intense. The PICU feels like a completely different world, one that intimidates them by the gravity of its work and constant flashing alarms. During their PICU rotation, everything is weight-based and titratable, and everyday feels frenetically paced, protocol-driven, and ethically charged. So much happens at once. Work-related tasks, such as writing notes, checking off to-dos, placing orders, and ensuring all lines of communication remain open between the PICU and many consulting teams, generate high extraneous cognitive loads, especially under the barrage of constant interruptions. Thus, it feels as though learning must occur somewhat passively in the PICU, without conscious effort, through random exposures to critical concepts over the duration of their work.

For instance, during their PICU rotation, residents are supported by a variety of team members who act as local guides, mentors, and allies. Residents rely on them to provide supplementary lessons and on-demand answers to their clinical questions, rarely identifying textbooks, journal articles, or other online references, as chosen resources. However, due to the high acuity of patients’ conditions, these individuals also often prevent residents from assuming ownership of the clinical management. As a result, residents feel they must adopt an observership role during their PICU rotation.

Though residents resent this role regression, they gain important lessons from such vantage points. Residents enjoy listening to attendings and following their thought processes, especially while they converse with other physicians. Additionally, residents take part in end-of-life care conversations with families, where they learn to model the compassionate communication styles of PICU clinicians. Finally, residents observe code events, where the composure of attendings, fellows, and nurses leaves a lasting impression.

According to residents, the main priority during their PICU rotation seems to be the clerical work they need to complete, then bedside patient care, and finally learning. Still, in the fast-paced PICU, residents acquire a new appreciation for alternative educational opportunities, which they previously perhaps thought of as undesirable, and recognize how learning often occurs simultaneously with the work they must complete. For instance, residents acknowledge how writing daily progress notes or patient transfer summaries helps them to organize their thoughts. They also gain experiential knowledge while listening to other residents’ management plans, and subsequent attending feedback, during rounds. Finally, lessons solidify after caring for the same pathologies multiple times.

For residents, rotating through the PICU can be particularly difficult. Many describe feeling the most depressed while on their PICU rotation. At a baseline, residents see multiple tragic cases. Some of these encounters can feel further complicated by medical errors, conflicts between medical teams, or challenges with patients’ families. Residents may also witness patient deaths that are both unexpected and upsetting to them. Though they recognize the negative effects these encounters have on their attitude, mood, and ability to learn, residents attempt to maintain composure and defer processing these traumas to a future time.

Residents also describe stressors unrelated to their patients’ clinical states. For instance, when residents enter the PICU, some report a demoralizing decrease in autonomy. They feel like medical students again, regarded only as a repositories of patient data. Sometimes, while presenting on rounds, attendings repeatedly interrupt, challenge, or even critique them in front of many people. Eventually, residents may begin to doubt whether they meaningfully contribute to patient care. They relay a tendency to quit and express disappointment over becoming the type of disengaged learner they never envisioned themselves to be. Likewise, when different attendings recommend contradictory treatment plans, residents express a sense of withdrawal and focus on tasks (eg, placing orders), rather than learning.

Moreover, residents seem to endure a form of emotional isolation during their PICU rotation. Even if they could convey the inexplicable occurrences to friends or loved ones, who often lack advanced medical literacy, they worry whether discussing tragic topics, such as dying children, with their support systems would be considered be too sad, burdensome, or taboo. In this way, learners describe feeling compelled to protect others from potential ricochet traumas. Residents also admit to avoiding critical emotional debriefs and residency educational events, due to fears of potentially retraumatizing their co-residents, who have completed a PICU rotation, and needing to return to the PICU immediately ready to get back to work.

In addition to these events—or perhaps as a result—residents report feeling physically and emotionally exhausted after completing their PICU rotation. They convey a period of decreased energy, apathy, anhedonia, and sleep disturbances. They suffer invasive thoughts and dreams and enter their next rotation feeling emotionally labile and irritable. These symptoms may last up to 3 weeks, after which residents seem to recover from their PICU experience.

Residents describe their PICU experience much like one might an immersion in a foreign culture. During their PICU rotation, they adopt PICU-specific language and protocols. They also aspire to assume characteristics believed to be valued by the PICU culture. In the PICU, they see pathophysiology in new ways. Familiar clinical scenarios, such as intentional toxic ingestions, are amplified. Residents also encounter death, either during codes or transitions toward comfort care. These experiences shape the meanings of patient death and subsequently inform how they view deaths as either “good” or “bad.” Ultimately, since residents witness countless examples of sick, very sick, and the sickest patients they have ever seen, they learn one of the most fundamental objectives of their training—how to recognize “sick” from “not sick” children.

Once residents complete their PICU rotations, they describe having attained an insider’s perspective of what happens before and after patients are transferred to and from the PICU. They feel better equipped for future rotations, including non-PICU rotations, and more familiar with basic resuscitative approaches. Although challenging and not necessarily desirable to revisit, they feel this journey has provided them with newfound comfort around caring for acutely ill patients. They return from the PICU to a seemingly different world. For instance, in the outpatient pediatric clinic, a child with uncomplicated community-acquired pneumonia may no longer seem as sick as they might have before the resident’s PICU experience. Instead, residents now find such encounters mundane.

In this study of residents’ first PICU rotation, we found that residents view the pediatric ICU as a challenging environment for independent, self-driven, and active learning; they experience adverse psychological effects and a period of post-PICU acute traumatic stress, yet they leave their PICU rotation with a newly acquired comfort and understanding of “sick” versus “not sick.”³⁰  Herzog et al described similar qualitative findings for residents rotating through a medical ICU.³¹  However, we believe our themes, along with the phenomenological examples, can potentially bring ICU educators closer to the resident’s worldview and help guide future educational interventions aimed to improve learning and resident wellness and development.²¹ 

Many of these themes relate to previously described concepts. For instance, our first and third themes can be similarly appreciated through Vygotsky’s zone of proximal development,³²  Lave’s and Wenger’s theory of workplace learning,^33,34  Eraut’s nonformal learning and tacit knowledge in professional work,³⁵  and the ongoing conflict between “service” versus “education” that plagues learners throughout the hospital.³⁶  Other, more novel, themes include the constellation of physical, emotional, cognitive, and psychosocial morbidities that residents endure during and after completing their ICU rotation. In our view, however, the most striking theme from our study is how residents describe their PICU rotation as a transformative “rite of passage,” where they learn to become “more comfortable” with caring for “sick kids.” Although physician comfort is a ubiquitous term,³⁷  with broad relevance across the gamut of medical education research, it is unclear how comfort correlates with knowledge, skills, and attitudes, or ultimate competency. Still, it is an outcome that was meaningful to our participants and may warrant further study.

Our previous study of residents’ perceptions prior to a PICU rotation suggested that many had experienced previous psychologically traumatic educational events, which we categorized as “adverse learning experiences.”¹⁶  In this study, we also found further descriptions of events residents describe as traumatic and persistent negative feelings for several weeks beyond the rotation. Considering these findings, we wonder whether a trauma-informed approach to medical education—where one considers, “What type of experiences might lead [a rational learner] to make certain [seemingly irrational] decisions or act in an [apparently detrimental] way?”³⁸—may be helpful. In the PICU, residents have the opportunity to involve themselves in the care of extremely ill pediatric patients.¹⁷  If properly nurtured, this can provide residents with a realistic sense of how acute illnesses present and the immediate, required resuscitative measures. Alternatively, if pushed too far by stress and disempowering encounters, some residents may lapse into a form of learned helplessness,^39,40  where they begin to feel emotionally withdrawn, ashamed,⁴¹  and discouraged from attempting independent assessments and plans. They may then describe a desire to avoid, or a “discomfort” around, autonomous management of certain types of patients, without immediate subspecialty intervention, in their future.

Recently, the Accreditation Council for Graduate Medical Education reduced the mandatory PICU training for PM residents from 8 to 4 weeks.⁴²  The results of our study, however, demonstrate the potential educational value of resident ICU experiences. ICU rotations seem to be opportunities for residents to discover personal safety or confidence with being involved in the management of an unstably ill patient. Furthermore, critical care rotations in general might be the key to uncovering what “being comfortable” in a clinical setting means. Although trainees experience units such as the PICU as stressful and challenging,¹²  a trauma-informed approach to medical education may help residents process these adverse learning experiences in ways that promotes post-traumatic growth rather than post-traumatic stress,⁴³  avoid burnout, and, ultimately, optimize critical care learning.

As a phenomenological investigation, our goal was not necessarily to assess training effectiveness in the PICU. For instance, we did not attempt to qualify actual learning or measure sequential performance data during the residents’ PICU rotations. Likewise, we conducted our study at a single site, where the interviewer and co-investigators were well-known to the subjects. This relationship with the investigators may have affected the comfort participants had to fully and honestly express their views on their rotation. However, all the interviews were conducted by A.J.K., who was a pediatric critical care medicine fellow, also in training, and had no role in evaluating the residents’ performance. Additionally, participants were assured all interviews would be transcribed under a unique pseudonym, their faculty would never hear the recording, and their participation would in no way affect their grades or academic standing.

This study also occurred during the COVID-19 pandemic.²⁶  While we hoped to interview all residents in-person and within 2 to 4 weeks of their first PICU rotation, it became very difficult to meet that time frame, and eventually we needed to transition to virtual interviews. This may have affected the residents’ recollections and made it difficult for us to differentiate between the residents’ interpretations versus their tacit understanding of the PICU experience. Likewise, the pandemic itself could have affected the residents’ training.²⁶  Still, we believe our interviews provided rich and vivid data for phenomenological interpretation.

Residents describe the PICU experience as a challenging learning opportunity that may lead to adverse psychological experiences. However, they also acknowledge growth as a result of their PICU rotation and, upon completion, are more comfortable with caring for children who are sick.

The authors would like to thank the Oregon Health & Science University (OHSU) emergency and pediatric medicine residents for volunteering to participate in this research, and members of the pediatric critical care division for supporting a department-wide growth mindset. As this study journeyed into histories of participant trauma, they want to acknowledge the work of the OHSU Student Health and Wellness Center, which provides free, off-the-record, and easily accessible counseling and psychiatric care for any student, trainee, or faculty member.

The online supplementary data contains the final interview protocol used in the study and a visual abstract.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.