Making goals count: A theory‐informed approach to on‐shift learning goals

Abstract

Supervisors often ask emergency medicine trainees for their learning goals at the start of a clinical shift, though they may do so without considering the reasons for this practice. Recognizing the underlying rationale for voicing on‐shift learning goals and proactively considering solutions for some of the associated challenges can help learners and supervisors employ this practice to its full potential. Goal articulation is rooted in educational principles such as self‐regulated learning, targeted performance feedback, and collaborative relationships between learner and supervisor. Despite the potential for on‐shift learning goals to augment learning, there are numerous barriers that make it challenging for learners and supervisors alike to create or follow up on meaningful goals. Learner‐related challenges include uncertainty about how to develop goals within an unpredictable clinical environment and creating goals too narrow or broad in scope. Supervisor‐related challenges include difficulties integrating direct observation into the clinical workflow and a desire to avoid negative feedback. The learning environment also presents inherent challenges, such as lack of longitudinal supervisor–learner relationships, time constraints, space limitations, and incentives for learners to conceal their knowledge gaps. The authors discuss these challenges to effective on‐shift learning goals and propose solutions that target the learner's approach, the supervisor's approach, and the learning environment itself.

CASE PRESENTATION: WHAT ARE YOUR GOALS FOR THIS SHIFT?

Dr. Avery, a second‐year emergency medicine resident, arrives for his evening shift in the emergency department (ED). He steps around the occupied patient beds lining the hallways and casts a weary glance at a tracking board displaying a waiting room census in double digits. He is greeted by Dr. Chu, the oncoming attending physician.

“Nice to see you, Dr. Avery. What are your goals for this shift?”

“Oh, uh, hm… Always trying to be more efficient, I guess.”

Sensing that Dr. Avery is eager to get to work, Dr. Chu nods, “Sounds good!”

With that, they log in to their workstations and prepare for patient handover.

ON‐SHIFT LEARNING GOALS: WHERE DOES THIS PRACTICE COME FROM?

There is a widespread practice of asking emergency medicine students and residents for their learning goals at the start of clinical shifts, ¹ , ² , ³ though many supervisors may do so out of habit and without consideration of its purpose. In our experiences as trainees and clinical supervisors, it can be difficult to articulate learning goals in the moment, and learning goals often remain unaddressed by the end of a shift. Recognizing the underlying rationale for discussing on‐shift learning goals and proactively considering solutions for some of the associated challenges can help learners and supervisors employ this practice to its full potential.

The trend of asking trainees to propose their own learning goals has developed in parallel with shifts in medical training more broadly. To address the challenges of increasingly complex health systems, an ever‐expanding body of medical knowledge, and persistently poor public health outcomes, educators have emphasized evidence‐based teaching practices and individualized learning plans that aim to foster skills for lifelong learning. ⁴ Rather than treating trainees as passive recipients of knowledge, there is an identified need for a more learning‐centered approach, emphasizing the development of adaptability and self‐motivated learning behaviors to accommodate for continually changing practice environments. ⁵

Self‐regulated learning (SRL), a framework developed within the field of educational psychology, ⁶ , ⁷ has been advanced within health professions education to explain how and why learners must be active planners in their own approaches to workplace learning. ⁵ , ⁸ , ⁹ Broadly, SRL refers to the ability to internally modulate “affective, cognitive and behavioral processes throughout a learning experience,” ⁸ a skillset that can be developed in training and carried forward into a career of lifelong learning. ¹⁰ In explaining how this framework translates to the context of medical training, White et al. ¹¹ have described a four‐phase cycle of SRL, involving planning, learning, assessment, and adjustment. Goal setting, as an underlying process for the planning phase, sets the table for the rest of the cycle to follow. Asking a learner to develop and articulate their own learning goals should therefore be an integral practice for instilling SRL behaviors.

The trend of soliciting learning goals may also be motivated in part by shortcomings of the feedback culture within medical education. Medical students and residents often report receiving inadequate feedback on clinical performance. ¹² , ¹³ From a supervisor's standpoint, asking about learning goals at the start of a shift serves the practical purpose of enabling better feedback, by identifying key aspects of workplace performance for direct observation and subsequent discussion. Moreover, inviting trainees to consider their own learning goals reflects modern conceptions of feedback as a responsibility shared by supervisor and learner, in which trainees are encouraged to actively seek feedback. ¹⁴ , ¹⁵ Approaching supervisory relationships as educational alliances, in which both parties establish mutual learning goals, “reframes the feedback process from one of information transmission (from supervisor to trainee) to one of negotiation and dialogue,” thus supporting the learner's active role in learning and feedback processes. ¹⁶ Finally, inviting learners to share their learning goals can mitigate perceived barriers to seeking feedback, such as the anxiety associated with “the ask” for feedback ¹⁷ or the perception that feedback might present an unreasonable burden during a busy clinical shift. ¹⁸

BARRIERS AND POSSIBLE SOLUTIONS

In practice, there are numerous barriers that can prevent questions such as “what are you working on this shift” from resulting in meaningful goal development or feedback. ¹ Similar to other feedback seeking practices, ¹⁹ the success (or failure) of on‐shift learning goals depends on interrelated factors relating to the learner, supervisor, and learning environment in which the exchange takes place. While there are many obstacles to goal setting—including systems‐based, structural issues and characteristics that are intrinsic to the individual learner and supervisor—we focus our discussion on barriers related to the learner, supervisor, and learning environment that one may practically address during a typical shift.

Learners may not feel empowered to identify specific goals for workplace learning. Due to emergency medicine's vast scope and unpredictable nature, learners have little control over what pathology they might encounter on a given shift. ²⁰ Accordingly, their learning goals may be either too narrow (“I want to perform a pericardiocentesis this shift”) or so broad as to be aimless (“I'm planning to see whatever comes through the door”). Probing questions can direct a learner's goals toward a more appropriate scope while fostering communication between supervisor and learner. This not only promotes SRL but embodies the ideals of coregulated learning, in which social influences (e.g., a supervisor's expertise) help to shape the learner's approach. ²¹ , ²² A nonspecific goal such as “being more efficient” could be followed up with questions about perceived areas of inefficiency. This may then lead to an opportunity to discuss strategies for workflow management that can then be directly observed and serve as the basis for feedback in the moment or after shift. As illustrated by competency frameworks such as the ACGME Milestones, ²³ learners at different stages of training will benefit from goals focused on different aspects of practice, ranging from foundational medical knowledge to more systems‐oriented and managerial aims. ²⁴ For senior residents who are approaching graduation, taking time to reflect on the resources and expectations of their anticipated future practice settings may help identify aspects of work that they can focus on now to improve their preparedness.

While learning goals should be driven by the learner, supervisors must play an active role in guiding goal development and reflection. ²¹ , ²⁵ The direct observation that is so crucial to feedback may be impeded by environmental factors, such as the ED's fast pace, unpredictable workflow, and need to care for critically ill patients. ²⁶ , ²⁷ Supervisors may be reluctant to solicit learning goals because they lack confidence that they will be able to address them during a busy shift. However, with intention and practice, supervisors can integrate goal‐setting, direct observation, and focused feedback into the clinical workflow. ²⁸ To follow up on learning goals, supervisors must deliver honest feedback, a practice that is often avoided to preserve the relationship with the trainee or avoid retaliation in the form of a negative evaluation. ²⁹ The trainee and their supervisor should approach the discussion around shift goals as a chance to negotiate how a particular learning goal will be addressed as part of authentic workplace learning.

The ED learning environment poses unique challenges such as a lack of longitudinal learner–supervisor partnerships, as well as frequent physical and time constraints. ²⁸ Due to system‐level issues, expectations of clinical care and departmental supervision often feel in opposition to educational activities such as goal setting and feedback. ³⁰ , ³¹ It is therefore essential that supervisors and learners intentionally shape the learning environment in ways that set the table for effective learning goals. They can take the simple but necessary step of ensuring dedicated time and space before shift for a brief discussion about learning goals. They can strive to foster a learning climate that promotes a learning orientation over performance orientation. ³² If trainees sense that they will be rewarded for demonstrating competency and penalized for exhibiting gaps in their knowledge or skill, they may identify goals with the intention of highlighting performance areas that are already strengths, avoiding areas that would actually benefit from feedback. ³³ Clinical supervisors can foster a learning orientation by sharing instances when they themselves do not know the answer to a clinical question, while highlighting which resources or team members they are engaging for help. Honest and transparent discussions about attending physicians’ mistakes or knowledge gaps can also help dispel stigmas around fallibility in medicine. ³⁴ Possible solutions for common barriers to on‐shift learning goals, with supporting frameworks and resources for additional reading, are provided in Table 1.

TABLE 1.

Solutions for barriers to on‐shift learning goals.

Barrier	Solutions	Associated frameworks and additional resources
Solutions targeting learners
Goal is not specific or measurable	Select one aspect of a multifaceted goal to work on during the shift Consider recent constructive feedback or challenging on‐shift situations as the basis for future learning goals Learn about rare procedures or pathologies by talking through hypothetical cases, or reviewing the component steps and instruments for a procedure	SMART objectives 35 SLR 7 , 8 Deliberate practice 36
Goal is not achievable or relevant	Consider relevant competencies and graduated responsibilities based on level of training Focus on learning goals in the context of preparing for future practice settings (e.g., senior residents preparing to enter independent practice)	SMART objectives 35 Competency‐based medical education 37 ACGME EM milestones 23
Goal is not time‐bound	Seek feedback in real time whenever possible Codevelop a plan for learner and supervisor to follow up on the goal by the end of shift	Self‐regulated learning 7 , 8 Coregulated learning 21
Solutions targeting supervisors
Difficulties incorporating direct observation	Plan ahead and bundle tasks to help incorporate direct observation into the workflow Agree ahead of time with the learner what aspect(s) of clinical care you plan to observe	Guidelines for the direct observation of clinical skills 38 Teacher as scribe model 39
Avoiding negative feedback	Acknowledge that giving and receiving constructive feedback is difficult Aim to provide nonjudgmental feedback by debriefing with good judgment Strive to foster relationships with trainees based on mutual respect and trust	The educational alliance 16 Debriefing with good judgment 40 Coaching 41
Solutions targeting the learning environment
Distractions and competing workplace demands	Intentionally create time and space for an engaging conversation about on‐shift learning goals Minimize interruptions relating to nonemergent patient care activities by moving to a different location or telling staff that you need an undisturbed moment for education	AAEM statement on interruptions in the ED 42
Prioritization of performance over learning	Foster a learning orientation by admitting knowledge gaps for both trainee and supervisor and prioritizing time for learning in addition to clinical efficiency Reduce stigma around physician fallibility by honestly discussing mistakes and debriefing challenging cases	Achievement goal theory 43 Discussing medical errors 34

Abbreviations: ACGME, Accreditation Council for Graduate Emergency Medicine; AAEM, American Academy of Emergency Medicine; SLR, self‐regulated learning.

CASE OUTCOME

Dr. Chu turns to Dr. Avery, “So your goal is to be more efficient. Can you tell me about a recent shift where you felt efficiency was a problem?”

“Yesterday, I felt like I was seeing plenty of new patients, but I could have figured out dispositions sooner.”

“Great. Let's talk about how we'll work on efficient dispositions today.”

“Well, it's often hard to know when we have enough information to admit a patient.”

“How about every time we sit down together, we quickly ‘run your list.’ I want you to focus on what additional data you need before you can disposition each patient. After shift, we can talk about whether that helped your workflow.”

AUTHOR CONTRIBUTIONS

All authors were involved in the planning, writing and critical review of this manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Griffith M, Zvonar I, Garrett A, Bayaa N. Making goals count: A theory‐informed approach to on‐shift learning goals. AEM Educ Train. 2024;8:e10993. doi: 10.1002/aet2.10993