Supervisory knowing in practice across medical specialities.

Clinical supervisors play key roles in facilitating trainee learning. Yet combining that role with patient care complicates both roles. So, we need to know how both roles can effectively co-occur. When facilitating their trainees' learning through practice, supervisors draw on their skills - clinical and supervisory - and available opportunities in their practice. This process can be conceptualised as supervisory knowing in practice (or contextual knowing) and offers ways to elaborate on how facilitating trainees' learning can be optimised. The practice-based study presented and discussed here examined clinical supervisors' knowing in practice related to facilitating trainee learning, across three medical specialities. Nineteen clinical supervisors from emergency medicine, internal medicine and surgery, were interviewed about their roles and engagement with trainees. Interview transcripts were analysed in two stages. Firstly, a framework analysis, informed by interdependent learning theory was conducted, focussing on affordances and individual engagement. Secondly, drawing on practice theory, a further layer of analysis was undertaken interrogating supervisors' knowing in practice. We identified two common domains of supervisor practice used to facilitate trainee learning: (1) orientating and assessing trainees' readiness (or capabilities), (2) sequencing and enriching pedagogic practices. Yet across the speciality groups the supervisors' knowing in practice differed and were shaped by a trio of: (i) disciplinary practices, (ii) situational requirements and (iii) clinician preference. Overall, we offer a new reading of clinical supervision as practice differences generated distinct supervisory knowing in practice. These findings emphasise clinical supervision as fundamentally entwined in the speciality's practice; and reinforce alignments with patient care.

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study.

CONTEXT: Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention. METHODS: In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2). RESULTS: Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order). CONCLUSION: Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

The influence of psychological safety on feedback conversations in general practice training.

INTRODUCTION: Fostering trainee psychological safety is increasingly being recognised as necessary for effective feedback conversations. Emerging literature has explored psychological safety in peer learning, formal feedback and simulation debrief. Yet, the conditions required for psychologically safe feedback conversations in clinical contexts, and the subsequent effects on feedback, have not been explored. METHODS: We conducted a qualitative study using interviews and longitudinal audio-diaries with 12 rural general practice trainees. The data were analysed using framework thematic analysis to identify factors across the data and as individual participant case studies with illustrative vignettes of dynamic interleaving of factors in judgements about feedback conversations. FINDINGS: Findings identify the influence of intrapersonal (e.g. confidence and comfort to seek help), interpersonal (e.g. trust and relationship) and sociocultural factors (e.g. living and working in a rural community) that contribute to psychological safety in the context of everyday feedback conversations. Multiple factors interplayed in feedback conversations where registrars could feel safe and unsafe within one location and even at the one time. DISCUSSION: Participants felt psychologically safe to engage their educators in sanctioned systems of conversation related to the immediate care of the patient and yet unsafe to engage in less patient related performance conversations despite the presence of multiple positive interpersonal factors. The concept of a safe 'container' (contained space) is perhaps idealised when it comes to feedback conversations about performance in the informal and emergent spaces of postgraduate training. More research is needed into understanding how clinical environments can sanction feedback conversations in clinical environments.

Using video-reflexive ethnography to understand complexity and change practice.

CONTEXT: A range of research methods have been used to understand effective workplace learning in the health professions. The impact of findings from this research usually requires knowledge translation activities in the form of faculty development initiatives, such as supervisor workshops. Far rarer, but with greater potential, are research approaches that concurrently seek to understand and change practice through empowering clinicians to refine aspects of their practice. METHODS: In this methodological article, we describe video-reflexive ethnography (VRE), a collaborative visual research approach that seeks to capture, illuminate and optimise in situ work and education practices. Video-reflexive ethnography usually has three phases: (a) initial familiarisation with practice through field observations; (b) video-recording of practice, and (c) reflexive sessions about the edited footage with participants and researchers. Drawing on our own experiences as researchers using VRE, we discuss four key principles of VRE: (a) exnovation; (b) collaboration; (c) reflexivity, and (d) care. DISCUSSION: Although VRE has been used to illuminate and understand health professionals education, its potential for changing clinical education practices has yet to be realised. Video-reflexive ethnography enables observation of the social and relational interactions in health care practice and allows individual (and group) perspectives to be articulated and analysed. The approach can prompt fresh perspectives and insights into health care education and practice for researchers and clinicians through shared deliberations about how practice might be reimagined and enacted.

Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task.

CONTEXT: Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future-facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits. METHODS: We tackle three myths of feedback: (a) feedback needs praise-criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature. CONCLUSIONS: Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity.

"It's yours to take": generating learner feedback literacy in the workplace.

Feedback can improve students' learning and performance on clinical placements, yet students are often dissatisfied with the process. Attempts to improve feedback frequently focus on faculty development programs without addressing learners' capabilities to engage with feedback. For feedback to be effective, students need to understand its processes and to translate this into practice. Developing student feedback literacy may enhance feedback engagement and, therefore, learning outcomes. This qualitative interview study aimed to problematise student feedback literacy in the healthcare setting, from the learner's perspective. Before commencing placements, 105 healthcare students at an Australian teaching hospital participated in a feedback literacy program. After their placements, 27 students engaged in semi-structured interviews to explore their feedback experiences. Informed by workplace learning theory, interview transcripts were analysed using the framework method of qualitative analysis. Students reported reframing feedback as a process they could initiate and engage in, rather one they were subjected to. When they took an intentional stance, students noted that feedback conversations generated plans for improvement which they were enacting. However, students had to work hard against orthodox feedback expectations and habits in healthcare. They privileged intraprofessional supervisor feedback over interprofessional practitioners, patients, or peers. Findings suggest that student engagement with feedback can be augmented with focussed retraining. However, further research examining the structural and cultural influences on students' capacity to be active in workplace feedback is warranted.

Outcomes of a funding initiative to promote allied health research activity: a qualitative realist evaluation.

BACKGROUND: Providing funding for clinicians to have protected time to undertake research can address a commonly cited barrier to research - lack of time. However, limited research has evaluated the impact or mechanisms of such funding initiatives. In the current economic environment, it is important that funding is used efficiently and judiciously and that mechanisms and contexts that may assist with maximising outcomes of funding initiatives are identified. This study aimed to describe the medium-term outcomes of a funding initiative to promote allied health research activity and to identify the key mechanisms and contexts that facilitated these outcomes. METHODS: We used a qualitative research design informed by a realist evaluation, to conduct 10 semi-structured interviews with allied health professionals who had participated in a funding initiative 1-3 years ago. Questions explored outcomes, mechanisms and contexts of the funding initiative. Data was thematically coded into context-mechanism-outcome configurations. RESULTS: Medium term outcomes included increased individual research opportunities, influence on team research culture and impact on clinical work/practice. Other outcomes included increased clinician confidence, knowledge and skill, and research outputs. However, some participants still had difficulties progressing research. Four context-mechanism-outcome configurations were identified to explain which contexts and mechanisms produced these outcomes. Examples of contexts included perception of managerial support, undertaking a research-based higher degree and joint applications, while mechanisms included accessing infrastructure and resources as well as individual researcher factors like motivation. CONCLUSION: Providing funding to allied health professionals to undertake and complete research can lead to important outcomes, including increased research opportunities, capacity and culture, increased research outputs, and changes to clinical practice. Outcomes are influenced by unique contexts and mechanisms and these should be considered in future implementation of similar funding initiatives.

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study.

BACKGROUND: There is a pressing need to improve end-of-life care in acute settings. This requires meeting the learning needs of all acute care healthcare professionals to develop broader clinical expertise and bring about positive change. The UK experience with the Liverpool Care of the Dying Pathway (LCP), also demonstrates a greater focus on implementation processes and daily working practices is necessary. METHODS: This qualitative study, informed by Normalisation Process Theory (NPT), investigates how a tool for end-of-life care was embedded in a large Australian teaching hospital. The study identified contextual barriers and facilitators captured in real time, as the 'Clinical Guidelines for Dying Patients' (CgDp) were implemented. A purposive sample of 28 acute ward (allied health 7 [including occupational therapist, pharmacists, physiotherapist, psychologist, speech pathologist], nursing 10, medical 8) and palliative care (medical 2, nursing 1) staff participated. Interviews (n = 18) and focus groups (n = 2), were audio-recorded and transcribed verbatim. Data were analysed using an a priori framework of NPT constructs; coherence, cognitive participation, collective action and reflexive monitoring. RESULTS: The CgDp afforded staff support, but the reality of the clinical process was invariably perceived as more complex than the guidelines suggested. The CgDp 'made sense' to nursing and medical staff, but, because allied health staff were not ward-based, they were not as engaged (coherence). Implementation was challenged by competing concerns in the acute setting where most patients required a different care approach (cognitive participation). The CgDp is designed to start when a patient is dying, yet staff found it difficult to diagnose dying. Staff were concerned that they lacked ready access to experts (collective action) to support this. Participants believed using CgDp improved patient care, but there was an absence of participation in real time monitoring or quality improvement activity. CONCLUSIONS: We propose a model, which addresses the risks and barriers identified, to guide implementation of end-of-life care tools in acute settings. The model promotes interprofessional and interdisciplinary working and learning strategies to develop capabilities for embedding end of life (EOL) care excellence whilst guided by experienced palliative care teams. Further research is needed to determine if this model can be prospectively applied to positively influence EOL practices.

Implementing an integrated pathway to care for the dying: is your organisation ready?

BACKGROUND: Integrated pathways for care of the dying aim to promote the delivery of high-quality palliative care, regardless of access to specialist services. AIM: To produce a heuristic technique to assist with planning and evaluating the integration of the care of the dying pathway into everyday work. METHODS: Electronic databases were searched to identify research papers focused on the implementation of integrated pathways for care of the dying in acute hospital settings. RESULTS: A total of 13 articles were reviewed using the four elements of normalisation process theory-coherence, cognitive participation, collective action and reflexive monitoring. These results informed the development of a heuristic for organisational readiness. CONCLUSION: The organisational readiness heuristic provides an evidence-based checklist for organisational leaders who are planning to introduce new, or evaluate current, integrated pathways for care of the dying. The next step is to trial the heuristic for feasibility in practice.

Learning to prescribe through co-working: junior doctors, pharmacists and consultants.

CONTEXT: Learning to prescribe is challenging for junior doctors. Significant efforts have been made to improve prescribing education, especially in view of the high rates of prescribing errors made by junior doctors. However, considerations of educational options often overlook the fact that learning to prescribe and prescribing practices rely on practice-based interactions with informed practitioners, such as pharmacists and consultants. Pharmacists have long made important contributions to developing prescribing capacities. OBJECTIVES: The present study examines the potential of everyday co-working between junior doctors and pharmacists, in conjunction with consultants, as an accessible means of developing effective prescribing practices. METHODS: A qualitative interview study was conducted in an Australian tertiary hospital using thematic analysis to explore junior doctors', pharmacists' and consultants' perspectives on how co-working supports learning to prescribe in an acute tertiary hospital setting. Participants included 34 practitioners, comprising junior doctors (n = 11), consultants (n = 10) and pharmacists (n = 13). The thematic analysis was informed by workplace learning theory. RESULTS: Learning to prescribe was found to be a highly interdependent process. In particular, junior doctors were dependent on co-working with consultants and pharmacists. Three interrelated themes related to co-working and learning to prescribe in the workplace were identified: (i) prescribing readiness of junior doctors; (ii) need for guidance, and (iii) the challenges of pharmacists co-working as outsiders. CONCLUSIONS: Co-working with pharmacists and consultants contributes positively to junior doctors' prescribing practices. However, co-working is complex and is influenced by differing understandings of prescribing practices. These insights assist in informing how co-working can be enacted routinely in hospital settings to promote safe and effective prescribing practices. Consideration should be given to when and how co-working between junior doctors and pharmacists is initiated, including during medical school. In clinical settings, strategies such as having pharmacists attend ward rounds and adopt a role of learning facilitation rather than error identification may augment everyday opportunities for co-working and learning.

Developing junior doctors' prescribing practices through collaborative practice: Sustaining and transforming the practice of communities.

Prescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors' prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists' contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors' prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.

Reimagining rural clinical education from lessons learnt during COVID.

BACKGROUND: Securing access to sufficient and focussed learning experiences is a perennial challenge for medical trainees. This challenge was accentuated during the COVID-19 pandemic lockdowns and with physical isolation processes that decreased in-person patient presentations and a shift to telehealth consultations. This situation has prompted the need to optimise the available experiences and educational responses to overcome the limitations in the number, quantum and range of available clinical learning experiences. METHODS: Semi-structured interviews were conducted with medical practice teams in four rural general practices to understand how medical trainees' education in rural general practices can be sustained in such circumstances. FINDINGS: Key considerations included optimising the available experiences to assist medical trainees to generate the kinds of mental models needed by trainees to conduct medical work, and particularly, when it became even more restricted through remote or physically distanced consultations. It also identified lessons learnt during COVID-19 pandemic lockdowns to inform and improve the provision of trainees' experiences in such practices. DISCUSSION: Providing experiences for trainees to participate fully in clinical activities is imperative. A sequenced set of experiences was proposed to incrementally prepare trainees to engage in and conduct clinical consultations remotely using digital technologies. CONCLUSION: Such an approach may not always be easy or possible to enact but offers a pathway of experiences most likely to lead to positive outcomes for the trainees whilst maintaining patient care and safety considerations.

How can healthcare organisations increase doctors' research engagement? A scoping review.

PURPOSE: Clinician engagement in research has positive impacts for healthcare, but is often difficult for healthcare organisations to support in light of limited resources. This scoping review aimed to describe the literature on health service-administered strategies for increasing research engagement by medical practitioners. DESIGN/METHODOLOGY/APPROACH: Medline, EMBASE and Web of Science databases were searched from 2000 to 2021 and two independent reviewers screened each record for inclusion. Inclusion criteria were that studies sampled medically qualified clinicians; reported empirical data; investigated effectiveness of an intervention in improving research engagement and addressed interventions implemented by an individual health service/hospital. FINDINGS: Of the 11,084 unique records, 257 studies were included. Most (78.2%) studies were conducted in the USA, and were targeted at residents (63.0%). Outcomes were measured in a variety of ways, most commonly publication-related outcomes (77.4%), though many studies used more than one outcome measure (70.4%). Pre-post (38.8%) and post-only (28.7%) study designs were the most common, while those using a contemporaneous control group were uncommon (11.5%). The most commonly reported interventions included Resident Research Programs (RRPs), protected time, mentorship and education programs. Many articles did not report key information needed for data extraction (e.g. sample size). ORIGINALITY/VALUE: This scoping review demonstrated that, despite a large volume of research, issues like poor reporting, infrequent use of robust study designs and heterogeneous outcome measures limited application. The most compelling available evidence pointed to RRPs, protected time and mentorship as effective interventions. Further high-quality evidence is needed to guide healthcare organisations on increasing medical research engagement.

The role of feedback in supporting trainees who underperform in clinical environments.

Introduction: Underperformance in clinical environments can be costly and emotional for all stakeholders. Feedback is an important pedagogical strategy for working with underperformance - both formal and informal strategies can make a difference. Feedback is a typical feature of remediation programs, and yet there is little consensus on how feedback should unfold in the context of underperformance. Methods: This narrative review synthesises literature at the intersections of feedback and underperformance in clinical environments where service, learning and safety need to be considered. We do so with a critical eye towards generating insights for working with underperformance in the clinical environment. Synthesis and discussion: There are compounding and multi-level factors that contribute to underperformance and subsequent failure. This complexity overwrites simplistic notions of 'earned' failure through individual traits and deficit. Working with such complexity requires feedback that goes beyond educator input or 'telling'. When we shift beyond feedback as input to process, we recognise that these processes are fundamentally relational, where trust and safety are necessary for trainees to share their weaknesses and doubts. Emotions are always present and they signal action. Feedback literacy might help us consider how to engage trainees with feedback so that they take an active (autonomous) role in developing their evaluative judgements. Finally, feedback cultures can be influential and take effort to shift if at all. A key mechanism running through all these considerations of feedback is enabling internal motivation, and creating conditions for trainees to feel relatedness, competence and autonomy. Broadening our perceptions of feedback, beyond telling, might help create environments for learning to flourish.

How do dietetics students learn about sustainability? A scoping review.

AIM: Globally, sustainability and planetary health are emerging as areas of critical importance. In 2015, the 2030 Agenda for Sustainable Development was adopted by the United Nations member states. Since then, the United Nations Educational, Scientific and Cultural Organization and the Commonwealth Secretariat have published guidelines for educators to embed sustainability content into curricula. This scoping review aims to identify how student dietitians learn about sustainability, how learning opportunities are evaluated, their outcomes, and whether these guidelines have translated into teaching activities contained in dietetic degrees. METHODS: A scoping review was used to address the aims. Eight electronic databases and Google Scholar were searched from inception to March 2022 for articles describing dietetics students' participation in learning activities focused on sustainability. Data that addressed the research aims were charted independently by two researchers, then narratively synthesised. RESULTS: Twelve articles met the inclusion criteria. A range of teaching approaches and evaluation methods were used, from passive learning in lectures to experiential learning activities. A change in knowledge or behaviour was found for experiential learning activities (n = 5). For articles published after 2015 (n = 9), two mentioned the Sustainable Development Goals and no articles referenced the published guidelines. CONCLUSIONS: A paucity of evidence exists describing how dietetics students learn about sustainability and their learning outcomes. Of the 12 articles published, varied teaching approaches and evaluation methods have resulted in inconsistencies in the reporting of outcomes. The minimal reference to the Sustainable Development Goals and published guidelines suggests a slow translation of knowledge to practice.

Developing residents' feedback literacy in emergency medicine: Lessons from design-based research.

Objectives: Residents in emergency medicine have reported dissatisfaction with feedback. One strategy to improve feedback is to enhance learners' feedback literacy-i.e., capabilities as seekers, processors, and users of performance information. To do this, however, the context in which feedback occurs needs to be understood. We investigated how residents typically engage with feedback in an emergency department, along with the potential opportunities to improve feedback engagement in this context. We used this information to develop a program to improve learners' feedback literacy in context and traced the reported translation to practice. Methods: We conducted a year-long design-based research study informed by agentic feedback principles. Over five cycles in 2019, we interviewed residents and iteratively developed a feedback literacy program. Sixty-six residents participated and data collected included qualitative evaluation surveys (n = 55), educator-written reflections (n = 5), and semistructured interviews with residents (n = 21). Qualitative data were analyzed using framework analysis. Results: When adopting an agentic stance, residents reported changes to the frequency and tenor of their feedback conversations, rendering the interactions more helpful. Despite reporting overall shifts in their conceptions of feedback, they needed to adjust their feedback engagement depending on changing contextual factors such as workload. These microsocial adjustments suggest their feedback literacy develops through an interdependent process of individual intention for feedback engagement-informed by an agentic stance-and dynamic adjustment in response to the environment. Conclusions: Resident feedback literacy is profoundly contextualized, so developing feedback literacy in emergency contexts is more nuanced than previously reported. While feedback literacy can be supported through targeted education, our findings raise questions for understanding how emergency medicine environments afford and constrain learner feedback engagement. Our findings also challenge the extent to which this contextual feedback know-how can be "developed" purposefully outside of the everyday work.