Developing an initial programme theory for a model of social care in prisons and on release (empowered together): A realist synthesis approach.

Many people are living in prison with a range of social care needs, for example, requiring support with washing, eating, getting around safely, and/or maintaining relationships. However, social care for this vulnerable group is generally inadequate. There is uncertainty and confusion about who is legally responsible for this and how it can best be provided, and a lack of integration with healthcare. We used realist-informed approaches to develop an initial programme theory (IPT) for identifying/assessing social care needs of, and providing care to, male adults in prison and on release. IPT development was an iterative process involving (a) an initial scoping of the international prison literature; (b) scoping prison and community social care policy documents and guidelines; (c) full systematic search of the international prison social care literature; (d) insights from the community social care literature; (e) stakeholder workshops. Information from 189 documents/sources and stakeholder feedback informed the IPT, which recommended that models of prison social care should be: trauma-informed; well integrated with health, criminal justice, third-sector services and families; and person-centred involving service-users in all aspects including co-production of care plans, goals, and staff training/awareness programmes. Our IPT provides an initial gold standard model for social care provision for people in prison and on release. The model, named Empowered Together, will be evaluated in a future trial and will be of interest to those working in the criminal justice system, care providers and commissioners, local authorities, housing authorities, voluntary groups, and service-users and their families.

Connected for life: How social connectedness can help prevent suicide in American Indian and Alaska Native communities.

Enhancing social support and connectedness can reduce suicide risk, yet few studies have examined this effect in American Indian and Alaska Native (AI/AN) adults. We assessed suicidal ideation and behavior, thwarted belongingness, social support, enculturation, historical trauma, and traumatic life events in 709 AI/AN adults at high risk of suicide from five AI/AN communities. Suicidal ideation was associated with thwarted belongingness and protected against by social support and engaging in AI/AN ceremonies. Among those who made lifetime suicide attempts, traumatic life events, symptoms of depression/anxiety due to historical trauma, and thwarted belongingness were linked to more attempts. More engagement in cultural practices was associated with fewer suicide attempts. Higher levels of social support were associated with more suicide attempts, an observation potentially attributable to the cross-sectional nature of the study. Interventions should focus on protective factors and context-specific interventions emphasizing community history, values, and strengths.

Culturally tailoring a secondary suicide prevention intervention for American Indian and Alaska Native people in substance use treatment.

BACKGROUND: Substance use treatment programs are ideal places for suicide prevention interventions. People who misuse substances are at elevated risk for suicide compared to the general population. However, most treatment programs do not incorporate suicide prevention, and none have been adapted for American Indian and Alaska Native (AI/AN) people. Preventing Addiction Related Suicide (PARS) is a suicide prevention module developed for use with people in treatment for substance misuse. A previous study demonstrated increased suicide help-seeking among this population. OBJECTIVE: Culturally adapt PARS for use with AI/AN communities. METHODS: We conducted focus groups and interviews with stakeholders in three Tribal health systems. We elicited feedback on PARS content, structure, and implementation. Data were analyzed using constant comparison. Results were used to adapt PARS and member checking was used to refine it. RESULTS: Participants unanimously endorsed using PARS in their health systems. Suggested adaptations included shortening the module, using community-specific information, removing jargon and stigmatizing language, and emphasizing cultural connectedness. DISCUSSION: This community-based, qualitative study adapted the PARS module for use with AI/AN communities. Research is needed to evaluate the clinical effectiveness of the adapted module. If found effective, this would represent the first evidence-based suicide prevention intervention among AI/AN individuals in treatment for substance misuse.

The courage to advocate: How two professions approach public advocacy work.

BACKGROUND: While health advocacy is an established physician role, most of the educational attention to advocacy has been at the individual patient level. Public advocacy-efforts to effect change at the level of communities, populations or society-remains a poorly defined concept whose educational foundation is underdeveloped. To enrich our understanding of public advocacy, we explored how professionals in two disciplines-medicine and law-have approached its tasks and experienced its challenges. METHODS: Using constructivist grounded theory, we interviewed 18 professionals (nine physicians, eight lawyers and one qualified in both disciplines) who engage in public advocacy. We used constant comparison throughout an iterative process of data collection and analysis to develop an understanding of what it means to be a professional in the public domain. RESULTS: Public advocacy work occurs at the intersection of personal and professional identities. Lawyers perceived public advocacy as an embedded element of their professional identity, while physicians more often viewed it as outside their core professional scope. Nonetheless, professional identity influenced how both groups conducted their work. Physicians were more likely to draw on professional attitudes (e.g. their orientation towards evidence and their trusted social position), while lawyers were more likely to draw on professional skills (e.g. building an argument and litigating test cases). The work requires courage and often demands that individuals tolerate personal and professional risk. CONCLUSION: While medicine has enshrined advocacy in its competency frameworks, it is the legal profession whose practitioners more fully embrace advocacy as intrinsic to professional identity, suggesting that roles are difficult to engineer or impose. Collaboration across public-facing professions like medicine and law creates opportunities to reimagine public advocacy, to identify the skills required to do it well and to refresh educational strategies.

Implementing a Metabolism-Informed Approach for Smoking Cessation in an Alaska Tribal Health System: Study Protocol for a Single-Arm Implementation Pilot Trial.

Background: Individualized treatment for commercial tobacco smoking cessation, such as through the utilization of the nicotine metabolite ratio (NMR), offers substantial clinical benefit. NMR is a metabolism-informed biomarker that can be used to guide medication selection. NMR testing is particularly promising for tobacco cessation efforts in populations with high rates of smoking, such as some Alaska Native and American Indian (AN/AI) communities. To date, no prior study has evaluated the implementation of NMR-guided tobacco cessation with AN/AI populations. Methods: The present "QUIT" protocol is a two-phase study that will occur at Southcentral Foundation (SCF), an Alaska Native-owned health system, serving 70,000 AN/AI people, based in Anchorage, Alaska. In Phase one, qualitative interviews with customer-owners (patients), providers and administrators (n = 36) and a 10-participant beta-test will be used to refine a strategy to implement NMR testing in the health system. Phase two will involve a single-arm pilot trial (n = 50) and qualitative interviews throughout data collection (n = 48) to evaluate the implementation strategy and explore the real-world acceptability and feasibility of NMR testing to guide tobacco cessation with AN/AI populations. Discussion: This study utilizes a community-based participatory approach to refine and implement a nicotine metabolism-informed smoking cessation program in a Tribal healthcare setting. The process and findings from this study will reflect the importance of customer-owner choice and honor the lived experience involved in quitting commercial tobacco. Pilot study data will inform the effect and sample sizes required for a future pragmatic trial of NMR-guided smoking cessation.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review.

BACKGROUND: High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison. METHODS: Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text. RESULTS: Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity. CONCLUSIONS: It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

Trainee selection of tasks in postgraduate medical education: Is there a role for 'cherry-picking' to optimise learning?

PURPOSE: Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non-learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model. METHODS: Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi-structured interviews. Aligning with a theory-informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes. RESULTS: Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals. CONCLUSION: Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks.

Suicide-related care among patients who have experienced an opioid-involved overdose.

OBJECTIVE: Our objective was to describe suicide prevention care for individuals prescribed opioids or with opioid use disorder (OUD) and identify opportunities for improving this care. METHODS: Adult patients (n = 65) from four health systems with an opioid-involved overdose and clinicians (n = 21) who had contact with similar patients completed 30-60-min semi-structured interviews. A community advisory board contributed to development of all procedures, and interpretation and summary of findings. RESULTS: Patients were mostly female (59%), White (63%) and non-Hispanic (77%); 52 were prescribed opioids, 49% had diagnosed OUD, and 42% experienced an intentional opioid-involved overdose. Findings included: 1) when prescribed an opioid or treated for OUD, suicide risks were typically not discussed; 2) 35% of those with an intentional opioid-involved overdose and over 80% with an unintentional overdose reported no discussion of suicidal ideation when treated for the overdose; and 3) suicide-related follow-up care was uncommon among those with unintentional overdoses despite suicidal ideation being reported by >20%. Clinicians reported that when prescribing opioids or treating OUD, post-overdose suicide-related screening or counseling was not done routinely. CONCLUSIONS: There were several opportunities to tailor suicide prevention care for patients who were treated for opioid-involved overdoses within health systems.

What emotions do male prisoners experience in the lead-up to suicide and violence? A participatory visual method study.

Rates of suicide and violence are higher amongst male prisoners than the general population. This study aimed to explore the emotional experiences of male prisoners in the distal and immediate lead-up to acts of suicide and violence. Nine male prisoners created drawings of their emotions in the lead-up to an act of suicide and/or violence. Accompanying verbal interview data was collected to explore the narrative of these drawings. Polytextual thematic analysis was conducted on both the visual and audio data. Three themes were found. 'The outside picture' depicted the emotions that male prisoners exhibited externally. 'The inside picture' illustrated the internal emotions felt by male prisoners which were often complex and abstract. 'The complexity of the picture' denotes the complicated relationship between emotions and suicide/violence. Male prisoners experience a range of emotions in the lead up to acts of suicide and violence, with a similar set of emotions being experienced immediately prior to both suicide and violence. This study has illustrated the benefits of using a novel and creative methodology, and has demonstrated that future research with male prisoners could benefit from adopting a participatory visual methodology.

Investigating Secondary Alcohol Outcomes in a Contingency Management Intervention among American Indian and Alaska Native Adults.

OBJECTIVE: The aim of the study is to investigate clinically meaningful, secondary outcomes in a randomized trial of a culturally adapted contingency management (CM) intervention for alcohol use in 3 diverse American Indian and Alaska Native communities. METHODS: Three American Indian and Alaska Native communities located in the Northern Plains, Alaska, and the Inland Northwest were partnering sites. A total of 158 individuals were randomized to either a 12-week CM intervention or a noncontingent (NC) control group. The CM group received reinforcers for providing alcohol-negative ethyl glucuronide (EtG < 150 ng/mL) urine samples, while the NC group received reinforcers unconditionally. Outcomes included EtG as a continuous measure (range, 0-2,000 ng/mL), EtG > 499 ng/mL (a measure of higher levels of recent alcohol use), longest duration of abstinence, and time-to-first alcohol-positive EtG during the trial. Generalized estimating equations along with Cox proportional hazard and negative binomial regressions were used. RESULTS: Participants randomized to the CM group had lower mean EtG levels (-241.9 ng/mL; 95% confidence interval [CI], -379.0 to -104.8 ng/mL) and 45.7% lower odds (95% CI, 0.31 to 0.95) of providing an EtG sample indicating higher levels of alcohol use during the intervention. Longest duration of abstinence was 43% longer for the CM group than the NC group (95% CI, 1.0 to 1.9). Risk of time-to-first drink during treatment did not differ significantly. CONCLUSIONS: These secondary outcome analyses provide evidence that CM is associated with reductions in alcohol use and longer durations of abstinence (as assessed by EtG), both clinically meaningful endpoints and analyses that differ from the primary study outcome.

"Keep up the messages, sometimes it was a lifesaver": Effects of cultural adaptation on a suicide prevention clinical trial in American Indian/Alaska Native communities.

Suicide disproportionately affects many American Indian/Alaska Native (AI/AN) communities. Caring Contacts is one of the few suicide prevention interventions with demonstrated success in diverse populations, but its acceptability and effectiveness have not been evaluated in AI/AN communities. Using community-based participatory research (Phase 1), we conducted focus groups and semi-structured interviews with AI/AN adults, healthcare providers, and leaders in four communities to improve study design and maximize intervention acceptability and effectiveness for implementation in a randomized controlled trial (Phase 2). This paper describes how adaptations made during Phase 1 affected the acceptability, fit, and responsiveness of the study features to the communities' needs. Acceptability of the study procedures and materials in this community appears to be high, with 92% of participants indicating the initial assessment interview was a positive experience. Broadening eligibility criteria with regard to age and possession of a cellular device resulted in the recruitment of an additional 48% and 46% of participants, respectively. Inclusion of locally-informed methods of self-harm allowed us to capture a wider range of suicidal behavior than would have otherwise been identified. Clinical trials would benefit from community-engaged, cultural adaptation studies with populations in which the interventions would eventually be applied.

Developing and authenticating an electronic health record-based report card for assessing residents' clinical performance.

Purpose: The electronic health record (EHR) is frequently identified as a source of assessment data regarding residents' clinical performance. To better understand how to harness EHR data for education purposes, the authors developed and authenticated a prototype resident report card. This report card used EHR data exclusively and was authenticated with various stakeholders to understand individuals' reactions to and interpretations of EHR data when presented in this way. Methods: Using principles derived from participatory action research and participatory evaluation, this study brought together residents, faculty, a program director, and medical education researchers (n = 19) to develop and authenticate a prototype report card for residents. From February to September 2019, participants were invited to take part in a semistructured interview that explored their reactions to the prototype and provided insights about how they interpreted the EHR data. Results: Our results highlighted three themes: data representation, data value, and data literacy. Participants varied in terms of the best way to present the various EHR metrics and felt pertinent contextual information should be included. All participants agreed that the EHR data presented were valuable, but most had concerns about using it for assessment. Finally, participants had difficulties interpreting the data, suggesting that these data could be presented more intuitively and that residents and faculty may require additional training to fully appreciate these EHR data. Conclusions: This work demonstrated how EHR data could be used to assess residents' clinical performance, but it also identified areas that warrant further consideration, especially pertaining to data representation and subsequent interpretation. Providing residents and faculty with EHR data in a resident report card was viewed as most valuable when used to guide feedback and coaching conversations.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study.

BACKGROUND: Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. METHODS: Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS). RESULTS: Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability. CONCLUSIONS: We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.

Recovery from alcohol among urban Alaska Native and American Indian people.

Alaska Native and American Indian (ANAI) people experience dramatic alcohol-related health disparities compared to the general US population. Although the majority of ANAI people reside in urban settings (>70%), data are sparse on alcohol abstinence among urban ANAI people with alcohol use disorder (AUD). We conducted a qualitative study using a phenomenological approach to examine the experiences of 20 urban ANAI adults recovering from AUD. Participants' narratives had their own unique dimensions but shared a clear, interrelated trajectory of pre-alcohol recovery, a turning point, and ongoing alcohol recovery. All participants reported a combination of external and internal motivation to stop using alcohol.

Culturally Adapting Caring Contacts for Suicide Prevention in Four Alaska Native and American Indian Communities.

AIM: Despite substantial tribal, state, and federal effort, American Indian and Alaska Native (AI/AN) suicide rates have changed little in the last 30 years, prompting attention to new and innovative approaches to this persistent health disparity. Suicide prevention interventions with demonstrated success in other populations may be useful in AI/AN communities. Caring Contacts is a suicide prevention intervention that has been adapted and shown to reduce suicide ideation, attempts, and deaths in other populations. CONCLUSION: Overall, AI/AN study participants in four diverse AI/AN communities endorsed the use of Caring Contacts for suicide prevention in their communities. Intervention adaptations for use in these communities centered primarily on message frequency and timing as well as expanding access to Caring Contacts. The results of this study may be applicable to other populations that experience suicide-related health disparities. METHODS: We used a community-based participatory research approach to gather qualitative data from community members, healthcare providers, and leaders in four AI/AN communities. These data were analyzed thematically and used to adapt Caring Contacts for use in a subsequent clinical trial with AI/AN people at high risk for suicide. RESULTS: A total of 189 community members and other health system stakeholders in four tribal communities participated in focus groups and interviews. Caring Contacts was perceived in all communities to be acceptable. Feedback for intervention adaptations focused on the themes of trial eligibility criteria; instruments; message frequency, timing, and content; and cultural considerations.

'For the most part it works': Exploring how authors navigate peer review feedback.

BACKGROUND: Peer review aims to provide meaningful feedback to research authors so that they may improve their work, and yet it constitutes a particularly challenging context for the exchange of feedback. We explore how research authors navigate the process of interpreting and responding to peer review feedback, in order to elaborate how feedback functions when some of the conditions thought to be necessary for it to be effective are not met. METHODS: Using constructivist grounded theory methodology, we interviewed 17 recently published health professions education researchers about their experiences with the peer review process. Data collection and analysis were concurrent and iterative. We used constant comparison to identify themes and to develop a conceptual model of how feedback functions in this setting. RESULTS: Although participants expressed faith in peer review, they acknowledged that the process was emotionally trying and raised concerns about its consistency and credibility. These potential threats were mitigated by factors including time, team support, experience and the exercise of autonomy. Additionally, the perceived engagement of reviewers and the cultural norms and expectations surrounding the process strengthened authors' willingness and capacity to respond productively. Our analysis suggests a model of feedback within which its perceived usefulness turns on the balance of threats and countermeasures. CONCLUSIONS: Feedback is a balancing act. Although threats to the productive uptake of peer review feedback abound, these threats may be neutralised by a range of countermeasures. Among these, opportunities for autonomy and cultural normalisation of both the professional responsibility to engage with feedback and the challenge of doing so may be especially influential and may have implications beyond the peer review setting.

Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study.

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Measuring Attitudes About Alcohol Misuse and Dependence Among Alaska Native People Within a Tribal Health Care System.

OBJECTIVES: Attitudes about alcohol misuse and dependence influence alcohol use and help-seeking behavior. Alaska Native and American Indian (AN/AI) people have higher rates of alcohol-related morbidity and mortality but engage in treatment at lower rates than the general population. No validated instruments exist to assess attitudes of AN/AI people about alcohol misuse and dependence to inform treatment and prevention efforts. This study aimed to develop an instrument to assess public attitudes among AN/AI people of alcohol misuse and dependence. METHODS: This multiphase, mixed-methods study was conducted at Southcentral Foundation, a tribally owned health system serving 65,000 AN/AI people in Alaska. We conducted focus groups and interviews with health system users, providers, and leaders to adapt the Public Attitudes About Addiction Survey. The adapted instrument was piloted with 200 people. Cognitive interviews and exploratory and confirmatory factor analyses were used to refine the instrument, which were then administered to 777 AN/AI people. RESULTS: Initial exploratory factor analysis identified 5 factors, including 3 from the original Public Attitudes About Addiction Survey (moral, disease, nature), a combined psychology and sociology factor (psychosocial), and a new factor (environment). A final 4-factor model (psychosocial, moral, disease, nature) with 14 items had good fit with root mean square error of approximation (0.035; comparative fit index = 0.977; Tucker-Lewis index = 0.970; standardized root mean residual = 0.040) and loadings ranging from 0.41 to 0.80. CONCLUSIONS: This study developed the first instrument to assess AN/AI attitudes about alcohol misuse and dependence. This instrument has potential to inform alcohol-related treatment in AN/AI communities. Future research is warranted to adequately measure place-based contributors salient to AN/AI people.

Caring Texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods.

BACKGROUND: Despite their intrinsic strengths and resilience, some American Indian and Alaska Native (AI/AN) communities experience among the highest rates of suicide of any racial and ethnic group. Caring Contacts is one of the only interventions shown to reduce suicide in clinical trials, but it has not been tested in AI/AN settings. OBJECTIVE: To compare the effectiveness of Enhanced Usual Care (control) to Enhanced Usual Care augmented with a culturally adapted version of Caring Contacts (intervention) for reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations. METHODS: We are implementing a single blind randomized controlled trial of Caring Contacts in five AI/AN communities across the country (South Dakota, Montana, Oklahoma, and Alaska). Eligible participants have to be (1) actively suicidal or have made a suicide attempt within the past year; (2) at least 18 years of age; (3) AI/AN; (4) able to speak and read English; (5) able to participate voluntarily; (6) willing to be contacted by text, email or postal mail; and (7) able to provide consent. Following consent and baseline assessment, participants are randomized to receive either Enhanced Usual Care alone, or Enhanced Usual Care with 12 months (25 messages) of culturally adapted Caring Contacts. Follow-up assessments are conducted at 12 and 18 months. CONCLUSIONS: If effective, this study of Caring Contacts will inform programs to reduce suicide in the study communities as well as inform future research on Caring Contacts in other tribal settings. Modifications to continue the trial during the COVID-19 pandemic are discussed. CLINICAL TRIALS REGISTRATION: NCT02825771.

Facilitating Residents' Understanding of Electronic Health Record Report Card Data Using Faculty Feedback and Coaching.

PURPOSE: Feedback continues to present a challenge for competency-based medical education. Clear, consistent, and credible feedback is vital to supporting one's ongoing development, yet it can be difficult to gather clinical performance data about residents. This study sought to determine whether providing residents with electronic health record (EHR)-based report cards, as well as an opportunity to discuss these data with faculty trained using the R2C2 model, can help residents understand and interpret their clinical performance metrics. METHOD: Using action research methodology, the author team collected EHR data from July 2017 to February 2020, for all residents (n = 21) in one 5-year Emergency Medicine program and created personalized report cards for each resident. During October 6-17, 2020, 8 out of 17 eligible residents agreed to have their feedback conversations recorded and participate in a subsequent interview with a nonphysician member of the research team. Data were analyzed using thematic analysis, and the authors used inductive analysis to identify themes in the data. RESULTS: In analyzing both the feedback conversations as well as the individual interviews with faculty and residents, the authors identified 2 main themes: (1) Reactions and responses to receiving personalized EHR data and (2) The value of EHR data for assessment and feedback purposes. All participants believed that EHR data metrics are useful for prompting self-reflection, and many pointed to their utility in providing suggestions for actionable changes in their clinical practice. For faculty, having a tool through which underperforming residents can be shown "objective" data about their clinical performance helps underscore the need for improvement, particularly when residents are resistant. CONCLUSIONS: The EHR is a valuable source of educational data, and this study demonstrates one of the many thoughtful ways it can be used for assessment and feedback purposes.