Application of the R2C2 Model to In-the-Moment Feedback and Coaching.

PURPOSE: The R2C2 (relationship, reaction, content, coaching) model is an iterative, evidence-based, theory-informed approach to feedback and coaching that enables preceptors and learners to build relationships, explore reactions and reflections, confirm content, and coach for change and cocreate an action plan. This study explored application of the R2C2 model for in-the-moment feedback conversations between preceptors and learners and the factors that influence its use. METHOD: A qualitative study using framework analysis through the lens of experiential learning was undertaken with 15 trained preceptor-learner dyads. Data were collected during feedback sessions and follow-up interviews between March 2021 and July 2022. The research team familiarized themselves with the data, used a coding template to document examples of the model's application, reviewed the initial framework and revised the coding template, indexed and summarized the data, created a summary document, examined the transcripts for alignment with each model phase, and identified illustrative quotations and overarching themes. RESULTS: Fifteen dyads were recruited from 8 disciplines (11 preceptors were paired with a single resident [n = 9] or a single medical student [n = 2]; 2 preceptors each had 2 residents). All dyads were able to apply the R2C2 phases of building relationships, exploring reactions and reflections, and confirming content. Many struggled with the coaching components, specifically in creating an action plan and follow-up arrangements. Preceptor skill in applying the model, time available for feedback conversations, and the nature of the relationship impacted how the model was applied. CONCLUSIONS: The R2C2 model can be adapted to contexts where in-the-moment feedback conversations occur shortly after a clinical encounter. Experiential learning approaches applying the R2C2 model are critical. Skillful application of the model requires that learners and preceptors go beyond confirming an area of change and deliberately engage in coaching and cocreating an action plan.

Family Physician Quality Improvement Plans: A Realist Inquiry Into What Works, for Whom, Under What Circumstances.

INTRODUCTION: Evaluation of quality improvement programs shows variable impact on physician performance often neglecting to examine how implementation varies across contexts and mechanisms that affect uptake. Realist evaluation enables the generation, refinement, and testing theories of change by unpacking what works for whom under what circumstances and why. This study used realist methods to explore relationships between outcomes, mechanisms (resources and reasoning), and context factors of a national multisource feedback (MSF) program. METHODS: Linked data for 50 physicians were examined to determine relationships between action plan completion status (outcomes), MSF ratings, MSF comments and prescribing data (resource mechanisms), a report summarizing the conversation between a facilitator and physician (reasoning mechanism), and practice risk factors (context). Working backward from outcomes enabled exploration of similarities and differences in mechanisms and context. RESULTS: The derived model showed that the completion status of plans was influenced by interaction of resource and reasoning mechanisms with context mediating the relationships. Two patterns were emerged. Physicians who implemented all their plans within six months received feedback with consistent messaging, reviewed data ahead of facilitation, coconstructed plan(s) with the facilitator, and had fewer risks to competence (dyscompetence). Physicians who were unable to implement any plans had data with fewer repeated messages and did not incorporate these into plans, had difficult plans, or needed to involve others and were physician-led, and were at higher risk for dyscompetence. DISCUSSION: Evaluation of quality improvement initiatives should examine program outcomes taking into consideration the interplay of resources, reasoning, and risk factors for dyscompetence.

Exploring the development of interprofessional competence and professional identity: A Situated Learning Theory study.

Workplace-based learning provides medical students exposure to interprofessional competencies through repeated exposures and active participation in interprofessional learning activities. Using Situated Learning Theory as our theoretical lens, we explored with medical students how interacting with existing interprofessional teams contributes to development of an expanded health care professional identity. An embedded mixed methods study using semi-structured interviews and questionnaires to assess readiness for interprofessional learning was conducted with 14 medical students completing an elective at an interprofessional pain medicine clinic. Within this workplace-based context, a model identifying key themes and supporting factors contributing to the development of an extended professional identity was developed. These findings help describe the processes by which students gain interprofessional collaboration competence.

Multisource feedback: an overview of its use and application as a formative assessment.

Multisource feedback (MSF), often termed 360-degree feedback, is a formative performance assessment in which data about an individual's observable workplace behaviors are collected through questionnaires from those interacting with the individual; data are aggregated for anonymity and confidentiality; the aggregated data, along with self-assessment if available, are provided to the individual; and the recipient meets with a trusted individual to review the data and develop an action plan. It is used along the continuum of medical education. This article provides an overview of MSF's utility, its evidence base and cautions.

La rétroaction multisource (RMS), ou rétroaction 360 degrés, est une évaluation formative du rendement dans laquelle des informations sur les comportements observables d'un individu dans son lieu de travail sont recueillies par le biais de questionnaires auprès de ceux avec qui il interagit. Après avoir été agrégées pour garantir l'anonymat et la confidentialité, ces données, et l'auto-évaluation s'il y a lieu, sont remises à la personne évaluée. Accompagnée d'une personne de confiance, elle les examinera et élaborera un plan d'action, qui sera utilisé tout au long du continuum de sa formation médicale. Cet article présente un aperçu de l'utilité et des fondements de la RMS, ainsi que quelques mises en garde.

Only When They Seek: Exploring Supervisor and Resident Perspectives and Positions on Upward Feedback.

INTRODUCTION: Verbal feedback from trainees to supervisors is rare in medical education, although valuable for improvement in teaching skills. Research has mostly examined narrative comments on resident evaluations of their supervisors. This study aimed to explore supervisors' and residents' beliefs and experiences with upward feedback, along with recommendations to initiate and facilitate effective conversations. METHODS: Using 60-minute focus group discussions, a previous study explored opinions of internal medicine residents and clinical supervisors at the Brigham and Women's Hospital regarding the impact of institutional culture on feedback conversations. For this study, we conducted a thematic analysis of the transcribed, anonymous data to identify key concepts pertaining only to verbal upward feedback, through the theoretical lens of Positioning theory. RESULTS: Twenty-two supervisors and 29 residents participated in three and five focus groups, respectively. Identified themes were mapped to three research questions regarding (1) existing beliefs (lack of impact, risks to giving supervisors feedback, need for preparation and reflection), (2) experiences (nonspecific language, avoidance of upward feedback, bypassing the supervisor), and (3) recommended approaches (setting clear expectations, seeking specific feedback, emphasizing interest in growth). DISCUSSION: Study participants appeared to assume learner-teacher positions during feedback conversations, resulting in residents' concerns of adverse consequences, beliefs that supervisors will neither accept feedback nor change their behaviors, and avoidance of constructive upward feedback. Residents suggested that emphasis on mutual professional growth and regular feedback seeking by supervisors could encourage them to take on the role of feedback providers. Their recommendations could be a valuable starting point for faculty development initiatives on upward feedback.

Guiding, Intermediating, Facilitating, and Teaching (GIFT): A Conceptual Framework for Simulation Educator Roles in Healthcare Debriefing.

INTRODUCTION: Use of frameworks for simulation debriefing represents best practice, although available frameworks provide only general guidance. Debriefers may experience difficulties implementing broad recommendations, especially in challenging debriefing situations that require more specific strategies. This study describes how debriefers approach challenges in postsimulation debriefing. METHODS: Ten experienced simulation educators participated in 3 simulated debriefings. Think-aloud interviews before and after the simulations were used to explore roles that debriefers adopted and the associated strategies they used to achieve specific goals. All data were audio recorded and transcribed, and a constructivist grounded theory approach was used for analysis. RESULTS: 4 roles in debriefing were identified: guiding, (inter)mediating, facilitating integration, and teaching. Each role was associated with specific goals and strategies that were adopted to achieve these goals. The goal of creating and maintaining a psychologically safe learning environment was common across all roles. These findings were conceptualized as the GIFT debriefing framework. CONCLUSIONS: Our findings highlight the multiple roles debriefers play and how these roles are enacted in postsimulation debriefing. These results may inform future professional development and mentorship programs for debriefing in both simulation-based education and healthcare settings.

Approaches to interpersonal conflict in simulation debriefings: A qualitative study.

CONTEXT: Conflict during simulation debriefing can interfere with learning when psychological safety is threatened. Debriefers often feel unprepared to address conflict between learners and the literature does not provide evidence-based guidance within the simulation setting. The purpose of this study was to describe debriefers' approach to mediating interpersonal conflict and explore when, why and how they adopt mediation strategies. METHODS: We performed a secondary analysis of qualitative data collected as part of a larger study examining simulation debriefers' approaches to debriefing scenarios with different learner characteristics. For this study, we applied thematic analysis to transcripts from simulated debriefings (n = 10) and the associated pre-simulation (n = 11) and post-simulation (n = 10) interviews that focused on interpersonal conflict between learners. RESULTS: Debriefers described struggling with mediating conflict and the importance of self-awareness. Specific mediation strategies included intervening, addressing power relations, reconciling unproductive differences, leveraging different perspectives, circumventing the conflict, and shifting beyond the conflict; each of these strategies encompassed a number of particular skills. Situations that triggered a mediation approach were related to psychological safety, emotional intensity, and opportunities for shared understanding and productive learning. Debriefers applied mediation strategies and skills in a flexible and creative way. CONCLUSIONS: The strategies we have described for mediating interpersonal conflict between learners in simulation debriefing align with notions of psychological safety and may be useful in guiding future professional development for simulation educators.

Physician engagement in regularly scheduled rounds.

BACKGROUND: Physician participation in regularly scheduled series (RSS), also known as grand rounds, was explored with a particular focus on physician perceptions about the elements that affected their engagement in RSS and the unanticipated benefits to RSS. METHODS: A qualitative study using semi-structured interviews and thematic analysis examined physicians' perception of their knowledge and educational needs and the factors that contributed to engagement in their local hospital RSS. RESULTS: Physician engagement in RSS was affected by four major themes: Features that Affect the RSS' Quality; Collegial Interactions; Perceived Outcomes of RSS; and Barriers to participation in RSS. Features that Affect RSS' Quality were specific modifiable features that impacted the perceived quality of the RSS. Collegial Interactions were interactions that occurred between colleagues directly or indirectly as a result of attending RSS. Outcomes of RSS were specific outcome measures used in RSS sessions. Barriers were seen as reasons why physicians were unwilling or unable to participate in RSS. All of the elements identified within the four themes contributed to the development of physician engagement. Physicians also identified changes directly and indirectly due to RSS. DISCUSSION: Specific features of RSS result in enhanced physician engagement. There are benefits that may not be accounted for in continuing medical education (CME) outcome study designs.

CONTEXTE: Nous examinons la participation des médecins aux séries de conférences planifiées (SCP) planifiées à l'avance, également connues sous le nom de séances scientifiques, plus particulièrement sous l'angle des perceptions des médecins quant aux éléments qui ont déterminé leur participation et quant aux avantages inattendus des SAR. MÉTHODE: La perception qu'ont les médecins de leurs connaissances et de leurs besoins de formation, ainsi que des facteurs qui les ont poussés à participer aux SCP de leur hôpital sont examinés par le biais d'une étude qualitative comprenant des entretiens semi-dirigés et une analyse thématique. RÉSULTATS: Les facteurs qui déterminent la participation des médecins aux SCP se classent en quatre grands thèmes : les caractéristiques qui affectent la qualité des SCP, l'interaction entre collègues, les résultats perçus des SAR et les obstacles à leur participation aux SCP. Les premières sont des caractéristiques modifiables précises, qui influencent la qualité perçue des SCP. Les secondes sont les interactions entre collègues qui se produisent directement ou indirectement à la suite de la participation à une SCP. Les résultats des SCP sont des indicateurs de résultats précis utilisés dans les séances d'activités régulières. Sont considérés comme obstacles les raisons pour lesquelles les médecins ne voulaient pas ou ne pouvaient pas prendre part aux SCP. Tous les éléments décelés de chacun des quatre thèmes ont contribué à favoriser la participation des médecins. Les médecins ont également trouvé des changements qui sont directement ou indirectement liés aux SCP. DISCUSSION: Certains traits spécifiques des SCP favorisent une participation accrue des médecins. Il est possible que les études de résultats du développement professionnel continu (DPC) ne tiennent pas compte de tous les avantages que les SCP procurent.

An evaluation of Acute Care of at-Risk Newborns (ACoRN), a Canadian education program, in Chinese neonatal nurseries.

BACKGROUND: The Acute Care of at-Risk Newborns (ACoRN) program was developed in Canada to train health care providers in the identification and management of newborns who are at-risk and/or become unwell after birth. The ACoRN process follows a stepwise framework that enables evaluation, decision, and action irrespective of caregiver experience. This study examined the hypothesis that the ACoRN educational program improved clinical practices and outcomes in China. METHODS: In a before-and-after study, ACoRN training was provided to physicians, neonatal nurses, and administrators in 16 county hospitals in Zhejiang, PRC. Demographic and clinical data were collected on babies admitted to neonatal units before (May 1, 2008 to March 31, 2009) and after (June 1, 2010 to April 30, 2012) training. RESULTS: A total of 4,310 babies (1,865 pre- and 2,445 post-training) from 14 sites were included. There were more in-hospital births (97.8% versus 95.6%, P<0.01) in the post-training epoch, fewer babies needing resuscitation (12.7% versus 16.0%, P=0.02), and more babies finishing their care in hospital (67.4% versus 53.1%, P<0.0001). After training, significantly more babies were evaluated as having respiratory distress at admission (14.2% versus 9.4%, P<0.0001); more babies had saturation, glucose and temperature measured on admission and at discharge; and more babies received intravenous fluids (86.3% versus 72.8%, P<0.0001). No significant improvements were noted in mortality (0.49% [post] versus 0.8% [pre], P=0.19 and adjusted odds ratio 0.54, 95% confidence interval: 0.23 to 1.29). CONCLUSIONS: ACoRN training significantly increased patient evaluations and changed clinical practices. However, we were unable to ascertain improvement in morbidity or mortality.

Exploring Well Water Testing Behaviour Through the Health Belief Model.

Health problems can arise from consuming contaminated well water. Well water testing can help prevent negative health outcomes associated with consuming contaminated water. The aim of this study was to understand the factors influencing well owner decisions to conduct water testing through the theoretical lens of the Health Belief Model. We conducted semi-structured interviews with 20 well owners and used framework analysis to sort and analyse the data. The results demonstrated that well owners' perceived susceptibility to well water contamination was low, while the perceived severity of contamination, benefits of testing, and self-efficacy towards testing were high. Cues to action to promote testing focused on increasing well owner education and awareness through well stewardship programmes and reminders to test. Participants faced some barriers to water testing. Increasing education and awareness about well water contamination and water testing, while reducing logistical barriers to testing, may improve compliance with water testing.

In Our Own Time: Medical Students' Informal Social Studying and Learning.

Phenomenon: Social studying and learning (SSL) is any independent, elective, self-directed and self-organized approach to learning that involves students working with their peers for the purposes of study, learning, or revision. While in-class collaborative learning has been relatively well-explored, very little is known about how medical students engage in informal SSL or about the impacts it can have. The purpose of this study was to explore medical students' practices and perceptions regarding SSL, and the ways in which this shaped their overall learning experiences. Approach: A constructivist grounded theory study was conducted at the University of Calgary. Data were collected from 23 semi-structured student interviews, which were audio recorded and transcribed. Data were analyzed using iterative data collection, memo-ing, and focused coding. Findings: Despite SSL being a common part of students' medical school experience and something that was promoted by academic advisors, how students actually engaged with SSL varied substantially, including who made use of SSL, how they made use of it, the size and focus of SSL groups, how these groups functioned, and what individuals sought to get out of them. Some students found SSL helped them to be more efficient and focused in their studying, while others benefited from comparing their knowledge and skills with those of their peers. Not everyone benefited, as some students found SSL stressful, unproductive, or socially uncomfortable. While student engagement in SSL was an enabler of academic success for some it could also be an indicator of social isolation and low self-esteem for others. Insights: Understanding how SSL can influence student experiences has the potential to inform students how and why they might engage in SSL, and it can help educators better support their students, particularly in those schools that actively encourage SSL.

An Examination of Self-Reported Assessment Activities Documented by Specialist Physicians for Maintenance of Certification.

INTRODUCTION: Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes. METHODS: E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations. RESULTS: A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change. CONCLUSIONS AND DISCUSSION: Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.

In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context.

BACKGROUND: The R2C2, a 4-phase feedback and coaching model, builds relationships, explores reactions, determines content and coaches for change, and facilitates formal feedback conversations between clinical supervisors/preceptors and residents. Formal discussions about performance are typically based on collated information from daily encounter sheets, objective structured clinical examinations, multisource feedback, and other data. This model has not been studied in settings where brief feedback and coaching conversations occur immediately after a specific clinical experience. OBJECTIVE: We explored how supervisors adapt the R2C2 model for in-the-moment feedback and coaching and developed a guide for its use in this context. METHODS: Eleven purposefully selected supervisors were interviewed in 2018 to explore where they used the R2C2 model, how they adapted it for in-the-moment conversations, and phrases used corresponding to each phase that could guide design of a new R2C2 in-the-moment model. RESULTS: Participants readily adapted the model to varied feedback situations; each of the 4 phases were relevant for conversations. Phase-specific phrases that could enable effective coaching conversations in a limited amount of time were identified. Data facilitated a revision of the original R2C2 model for in-the-moment feedback and coaching conversations and design of an accompanying trifold brochure to enable its effective use. CONCLUSIONS: The R2C2 in-the-moment model offers a systematic approach to feedback and coaching that builds on the original model, yet addresses time constraints and the need for an iterative conversation between the reaction and content phases. The model enables supervisors to coach and co-create an action plan with residents to improve performance.

Picking the Right Tool for the Job: A Reliability Study of 4 Assessment Tools for Central Venous Catheter Insertion.

BACKGROUND: Determining procedural competence requires psychometrically sound assessment tools. A variety of instruments are available to determine procedural performance for central venous catheter (CVC) insertion, but it is not clear which ones should be used in the context of competency-based medical education. OBJECTIVE: We compared several commonly used instruments to determine which should be preferentially used to assess competence in CVC insertion. METHODS: Junior residents completing their first intensive care unit rotation between July 31, 2006, and March 9, 2007, were video-recorded performing CVC insertion on task trainer mannequins. Between June 1, 2016, and September 30, 2016, 3 experienced raters judged procedural competence on the historical video recordings of resident performance using 4 separate tools, including an itemized checklist, Objective Structured Assessment of Technical Skills (OSATS), a critical error assessment tool, and the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). Generalizability theory (G-theory) was used to compare the performance characteristics among the tools. A decision study predicted the optimal testing environment using the tools. RESULTS: At the time of the original recording, 127 residents rotated through intensive care units at the University of Calgary, Alberta, Canada. Seventy-seven of them (61%) met inclusion criteria, and 55 of those residents (71%) agreed to participate. Results from the generalizability study (G-study) demonstrated that scores from O-SCORE and OSATS were the most dependable. Dependability could be maintained for O-SCORE and OSATS with 2 raters. CONCLUSIONS: Our results suggest that global rating scales, such as the OSATS or the O-SCORE tools, should be preferentially utilized for assessment of competence in CVC insertion.

Identifying coaching skills to improve feedback use in postgraduate medical education.

OBJECTIVES: Coaching in medical education has recently gained prominence, but minimal attention has been given to key skills and determining how they work to effectively ensure residents are progressing and developing self-assessment skills. This study examined process-oriented and content-oriented coaching skills used in coaching sessions, with particular attention to how supervisors use them to enhance resident acceptance of feedback to enhance learning. METHODS: This qualitative study analysed secondary audiotaped data from 15 supervisors: resident dyads during two feedback sessions, 4 months apart. The R2C2 model was used to engage the resident, build a relationship, explore reactions to feedback, explore resident perceptions of content, and coach for change. Framework analysis was used, including familiarisation with the data, identifying the thematic framework, indexing and charting the data and mapping and interpretation. RESULTS: Process skills included preparation, relationship development, using micro communication skills and techniques to promote reflection and self-assessment by the resident and supervisor flexibility. Content skills related to the specific feedback content included engaging the resident in discussion, ensuring the discussion was collaborative and focused on goal setting, co-developing a Learning Change Plan, ensuring resident commitment and following up on the plan. Together, these skills foster agency in the resident learner. Three overarching themes emerged from the analysis: the interconnectedness of process and content; tensions between encouraging self-direction and ensuring progress and competence; and balancing a coaching dialogue and a teaching monologue. CONCLUSIONS: Effective coaching by supervisors requires a combination of specific process and content skills that are chosen depending on the needs of the individual resident. Mastering these skills helps residents engage and develop agency in their own professional development. These outcomes depend on faculty maintaining a balance between coaching and teaching, encouraging resident self-direction and ensuring progression to competence.

Assessment and Change: An Exploration of Documented Assessment Activities and Outcomes by Canadian Psychiatrists.

INTRODUCTION: Fellows of the Royal College of Physicians and Surgeons of Canada are required to participate in assessment activities for all new 5-year cycles beginning on or after January 2014 to meet the maintenance of certification program requirements. This study examined the assessment activities which psychiatrists reported in their maintenance of certification e-portfolios to determine the types and frequency of activities reported; the resultant learning, planned learning, and/or changes to the practice they planned or implemented; and the interrelationship between the types of assessment activities, learning that was affirmed or planned, and changes planned or implemented. METHODS: A total of 5000 entries from 2195 psychiatrists were examined. A thematic analysis drawing on the framework analysis was undertaken of the 2016 entries. RESULTS: There were 3841 entries for analysis; 1159 entries did not meet the criteria for assessment. The most commonly reported activities were self-assessment programs, feedback on teaching, regular performance reviews, and chart reviews. Less frequent were direct observation, peer supervision, and reviews by provincial medical regulatory authorities. In response to the data, psychiatrists affirmed that their practices were appropriate, identified gaps they intended to address, planned future learning, and/or planned or implemented changes. The assessment activities were internally or externally initiated and resulted in no or small changes (accommodations and adjustments) or redirections. DISCUSSION: Psychiatrists reported participating in a variety of assessment activities that resulted in variable impact on learning and change. The study underscores the need to ensure that assessments being undertaken are purposeful, relevant, and designed to enable identification of outcomes that impact practice.

An Exploration of the Content and Usability of Web-Based Resources Used by Individuals to Find and Access Family Physicians.

Background: The most commonly recommended strategy in Canada for patients wishing to find a regular family physician (FP) is through the use of websites with FP listings. We aimed to explore the content and usability of these websites. Methods: We identified publicly available websites with FP listings in Western Canada, analyzing them thematically through open coding for website content and conducting framework analysis for website usability. Results: Twelve unique websites were identified and grouped into three categories: (1) Physician regulatory authorities ("Colleges"); (2) Governmental; and (3) Miscellaneous. College websites provided the greatest detail about the FPs and enabled searching, though had low readability. Governmental websites listed basic contact information and were credible but contained less detail than College websites. Miscellaneous websites were narrower in focus and therefore easier to navigate but lacked updated and accurate information. Conclusions: Many websites help patients find FPs. Their content and usability are variable, suggesting a need for guidance in the development of these resources.

Adapting Feedback to Individual Residents: An Examination of Preceptor Challenges and Approaches.

Background: Feedback conversations between preceptors and residents usually occur in closed settings. Little is known about how preceptors address the challenges posed by residents with different skill sets, performance levels, and personal contexts. Objective: This study explored the challenges that preceptors experienced and approaches taken in adapting feedback conversations to individual residents. Methods: In 2015, 18 preceptors participated in feedback simulations portraying residents with variations in skill, insight, confidence, and distress, followed by debriefing of the feedback conversation with a facilitator. These interactions were recorded, transcribed, and analyzed using thematic and framework analysis. Results: The preceptors encountered common challenges with feedback conversations, including uncertainty in how to individualize feedback to residents and how to navigate tensions between resident- and preceptor-identified goals. Preceptors questioned their ability to enhance skills for highly performing residents, whether they could be directive when residents had insight gaps, how they could reframe the perceptions of the overly confident resident, and whether they should offer support to emotionally distressed residents or provide feedback about performance. Preceptors adapted their approach to feedback, drawing on techniques of coaching for highly performing residents, directing for residents with insight gaps, mediation with overly confident residents, and mentoring with emotionally distressed residents. Conclusions: Examining the feedback challenges preceptors encounter and the approaches taken to adapt feedback to individual residents can provide insight into how preceptors meet the challenges of competency-based medical education, in which frequent, focused feedback is essential for residents to achieve educational milestones and entrustable professional activity expectations.

Exploring Faculty Approaches to Feedback in the Simulated Setting: Are They Evidence Informed?

INTRODUCTION: Feedback in clinical education and after simulated experiences facilitates learning. Although evidence-based guidelines for feedback exist, faculty experience challenges in applying the guidelines. We set out to explore how faculty approach feedback and how these approaches align with current recommendations. METHODS: There is strong evidence for the following four components of feedback: feedback as a social interaction, tailoring content, providing specific descriptions of performance, and identifying actionable items. Faculty preceptors participated in feedback simulations followed by debriefing. The simulations were video recorded, transcribed, and analyzed qualitatively using template analysis to examine faculty approaches to feedback relative to evidence-informed recommendations. RESULTS: Recorded encounters involving 18 faculty and 11 facilitators yielded 111 videos. There was variability in the extent to which feedback approaches aligned with recommended practices. Faculty behaviors aligned with recommendations included a conversational approach, flexibly adapting feedback techniques to resident context, offering rich descriptions of observations with specific examples and concrete suggestions, achieving a shared understanding of strengths and gaps early on to allow sufficient time for problem-solving, and establishing a plan for ongoing development. Behaviors misaligned with guidelines included prioritizing the task of feedback over the relationship, lack of flexibility in techniques applied, using generic questions that did not explore residents' experiences, and ending with a vague plan for improvement. CONCLUSIONS: Faculty demonstrate variability in feedback skills in relation to recommended practices. Simulated feedback experiences may offer a safe environment for faculty to further develop the skills needed to help residents progress within competency-based medical education.