Towards a pedagogy for noticing: Piloting a novel intervention for health professions students.

Teaching students to 'notice' what is happening around them, to be more attuned to what is going on within themselves, and nurturing self-inquiry into one's practice is desirable yet difficult to achieve. We sought to teach the metacognitive skill of 'noticing' to pre-registration health professions students in the context of interprofessional collaborative practice (IPCP). A three-part curriculum was designed: an e-module focused on 'noticing' in IPCP; a team-based workplace learning observation and interprofessional debrief; and a written reflective assignment. We found that students concentrated on the disciplinary content of IPCP in the assignments, which 'overshadowed' the metacognitive content. We learned that: we had underestimated the challenges of retrofitting new content into existing curricula; that we had not paid enough attention to students' perceptions about what they want to learn; and working with a large and diverse group of educators requires adequate preparation. The next iteration of this program will improve the constructive alignment between learning outcomes and assessments and provide better support for educators. In the future we will temper decisions to act quickly to implement curricular innovations. More broadly, we suggest that educational design that seeks to take account of qualitatively different but intersecting knowledge domains, such as IPCP and 'noticing', is worthy of further study.

Leaders' experiences of embedding a simulation-based education programme in a teaching hospital: an interview study informed by normalisation process theory.

There is limited research on the experiences of people in working to embed, integrate and sustain simulation programmes. This interview-based study explored leaders' experiences of normalising a simulation-based education programme in a teaching hospital. Fourteen known simulation leaders across Australia and North America were interviewed. Semi-structured interviews were analysed using reflexive thematic analysis sensitised by normalisation process theory, an implementation science theory which defines 'normal' as something being embedded, integrated and sustained. We used a combined social and experiential constructivist approach. Four themes were generated from the data: (1) Leadership, (2) business startup mindset, (3) poor understanding of simulation undermines normalisation and (4) tension of competing objectives. These themes were interlinked and represented how leaders experienced the process of normalising simulation. There was a focus on the relationships that influence decision-making of simulation leaders and organisational buy-in, such that what started as a discrete programme becomes part of normal hospital operations. The discourse of 'survival' was strong, and this indicated that simulation being normal or embedded and sustained was still more a goal than a reality. The concept of being like a 'business startup' was regarded as significant as was the feature of leadership and how simulation leaders influenced organisational change. Participants spoke of trying to normalise simulation for patient safety, but there was also a strong sense that they needed to be agile and innovative and that this status is implied when simulation is not yet 'normal'. Leadership, change management and entrepreneurship in addition to implementation science may all contribute towards understanding how to embed, integrate and sustain simulation in teaching hospitals without losing responsiveness. Further research on how all stakeholders view simulation as a normal part of a teaching hospital is warranted, including simulation participants, quality and safety teams and hospital executives. This study has highlighted that a shared understanding of the purpose and breadth of simulation is a prerequisite for embedding and sustaining simulation. An approach of marketing simulation beyond simulation-based education as a patient safety and systems improvement mindset, not just a technique nor technology, may assist towards simulation being sustainably embedded within teaching hospitals.

The work performed through interprofessional meeting discourse: an observational study.

The effectiveness of work performed through interprofessional practice is contingent on the nature and extent of communication between professionals. To date, there is little research exploring how the patterns of communication may impact interprofessional work. This study focused on communication during interprofessional meetings to better understand the interprofessional work performed through these encounters. Specifically, it examined how interactional discourse, that is, the patterns of language, influenced work performed during interprofessional meetings. A series of four interprofessional meetings in a rehabilitation unit were observed. Twenty-one participants were observed, including medical, nursing, allied health clinicians, and health professions students. Follow-up stimulated-recall interviews were conducted with five meeting participants. The data collection consisted of video and audio recordings and detailed field notes. Data were analyzed using a combination of genre analysis, a form of discourse analysis, and activity system analysis, drawing on Cultural Historical Activity Theory. This facilitated an in-depth examination of the structure of discourse and its influence on meeting outcomes. The meeting structure was defined and predictable. Two distinct forms of discourse were identified and labeled scripted and unscripted. Scripted discourse was prompted by standardized documents and facilitated the completion of organizational work. In contrast, unscripted discourse was spontaneous dialogue used to co-construct knowledge and contributed to collaboration. There was constant shifting between scripted and unscripted discourse throughout meetings which was orchestrated by experienced clinicians. Rather than fragmenting the discussion, this shifting enabled shared decision making. This research provides further insights into the interprofessional work performed during interprofessional meetings. The scripted discourse was highly influenced by artifacts (communication tools) in meetings, and these were used to ensure organizational imperatives were met. Unscripted discourse facilitated not only new insights and decisions but also social cohesion that may influence work within and outside the meeting.

What and when to debrief: a scoping review examining interprofessional clinical debriefing.

INTRODUCTION: Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts. METHODS: Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches. RESULTS: Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD. CONCLUSIONS: The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

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.

Meaning making about performance: A comparison of two specialty feedback cultures.

INTRODUCTION: Specialty trainees often struggle to understand how well they are performing, and feedback is commonly seen as a solution to this problem. However, medical education tends to approach feedback as acontextual rather than located in a specialty-specific cultural world. This study therefore compares how specialty trainees in surgery and intensive care medicine (ICM) make meaning about the quality of their performance and the role of feedback conversations in this process. METHODS: We conducted a qualitative interview study in the constructivist grounded theory tradition. We interviewed 17 trainees from across Australia in 2020, eight from ICM and nine from surgery, and iterated between data collection and analytic discussions. We employed open, focused, axial and theoretical coding. FINDINGS: There were significant divergences between specialties. Surgical trainees had more opportunity to work directly with supervisors, and there was a strong link between patient outcome and quality of care, with a focus on performance information about operative skills. ICM was a highly uncertain practice environment, where patient outcome could not be relied upon as a source of performance information; valued performance information was diffuse and included tacit emotional support. These different 'specialty feedback cultures' strongly influenced how trainees orchestrated opportunities for feedback, made meaning of their performance in their day-to-day patient care tasks and 'patched together' experiences and inputs into an evolving sense of overall progress. DISCUSSION: We identified two types of meaning-making about performance: first, trainees' understanding of an immediate performance in a patient-care task and, second, a 'patched together' sense of overall progress from incomplete performance information. This study suggests approaches to feedback should attend to both, but also take account of the cultural worlds of specialty practice, with their attendant complexities. In particular, feedback conversations could better acknowledge the variable quality of performance information and specialty specific levels of uncertainty.

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.

Dynamic and distributed exchanges: an interview study of interprofessional communication in rehabilitation.

PURPOSE: Interprofessional communication (IPC) in rehabilitation is important for patient care yet it has been shown to be variable and challenging. Existing research does not address the complexity of IPC in this setting. Understanding the influence of contextual factors on IPC may guide improvements to increase the effectiveness of communication within interprofessional teams. METHODS: From July 2020 to February 2021 semi-structured interviews were conducted with 24 healthcare professionals across Australia and New Zealand. Cultural Historical Activity Theory provided a guiding theoretical and analytical framework for this qualitative study. RESULTS: Participants described engaging in IPC through evolving interactions, piecing together information that underpinned patient care. Meetings occurred frequently, however communication extended well beyond formalised interactions, often requiring individuals to balance clinical workload with communication tasks. IPC reportedly relied on communication tools, however navigating information from multiple sources was demanding. CONCLUSIONS: Our results indicate that IPC contributes significantly to the workload of healthcare professionals in rehabilitation. IPC was integral in the provision of cohesive patient care, however it proved time consuming, effortful and at times frustrating and potentially erroneous. Our findings promote the need for rigorous examination of communication practices to ensure they are meeting the needs of an increasingly interprofessional workforce. IMPLICATIONS FOR REHABILITATIONHealthcare professionals should recognise that time spent communicating within their team is a legitimate and important part of patient care.Rehabilitation teams should consider how they allocate resources for communication tasks.Teams should reconsider how they can use communication more effectively to save time by reducing repetition and errors.

'Noticing' in health professions education: Time to pay attention?

BACKGROUND: Health professions education teaches students to notice particular things, but has given little attention to teaching 'noticing' as a form of personal inquiry. The former is self-evidently important, as it develops a way of seeing and behaving that is uniquely relevant to each health profession. Despite this emphasis, health professionals may fail to notice 'warning signs' in patients, be unaware of their own biases or develop unrecognised habits that have moved away from accepted standards. It has been suggested that such 'not noticing' is currently endemic. APPROACH: We situate our exploration of noticing in the mathematics and science education literature and John Mason's treatise on 'The discipline of noticing', differentiating between the observations that people make as they go about their lives ('ordinary' noticing), the specialised noticing that underpins professional expertise (Professional Noticing) and practices that can enhance the capacity to notice and to learn from experience (Intentional Noticing). We make the case for teaching health professions students about these conceptualisations of noticing, being able to notice with all our senses, and learning about the practices of Intentional Noticing in particular, which we suggest will have utility across health professional careers and personal lives. IMPLICATIONS: We acknowledge the difficulties in transferring heterogenous finding from one field to another but suggest that there are gains to be made in applying these noticing concepts to health professions education. We tentatively propose some strategies and activities for developing Professional Noticing and the practices of Intentional Noticing and link them to a new module that we are piloting with health professions students. As well as aiding health professionals sharpen their noticing abilities, reinvigorate their practice and interrogate assumptions that underpin health care, we suggest that ideas about 'noticing' may also help educators and researchers in the health professions reimagine their work.

Exploring the contribution of clinical placement to student learning: A sequential mixed methods study.

BACKGROUND: Increasing demand and limited supply of clinical placements in nursing underscore the need to better understand the role of clinical placements in students' learning. Identifying pedagogically rich activities that support work place learning alongside factors that influence educational outcomes has the potential to optimise professional placement experiences. OBJECTIVE: To explore student nurses perceptions of the value of nursing clinical placements to their learning. DESIGN AND METHODS: A descriptive research design was employed using a sequential mixed method approach. A cross-sectional student survey captured students' perceptions of work integrated learning based on the perceived contribution of a pre-determined list of activities undertaken on clinical placement. SETTING AND PARTICIPANTS: Four Australian universities took part. Participants included students undertaking entry to practice programs. RESULTS: Four hundred and sixty-nine students completed the survey. Thirty-eight students participated in 12 focus groups. Participants rated PRA including interacting and time with patients and performing assessments as the most useful activities. Less useful, were activities that took them away from the patient. CONCLUSIONS: To maximise workplace learning, consideration must be given to ensuring students are presented with goal directed activities that support learning and are focused on an expanding scope of practice with opportunities to discuss and engage with staff.

Communication in interprofessional rehabilitation teams: a scoping review.

PURPOSE: Effective communication in interprofessional rehabilitation teams is essential for optimal patient care. Despite the established importance, it remains unclear how interprofessional communication (IPC) within teams contributes to rehabilitation service delivery. The aim of this scoping review was to investigate how IPC has been described in rehabilitation literature. METHODS: Databases (Medline, CINAHL, ERIC, Embase, PsychInfo, and Academic Search Complete) were searched for studies including rehabilitation interprofessional communication. Inclusion and exclusion criteria were identified and applied, data were charted, and thematic analysis conducted. RESULTS: Twenty-nine papers were identified, and analysis revealed interrelated themes: communication processes, and inputs and effects. Formal communication processes were most prevalent, portraying variability in professional participation and a lack of patient involvement in dialogue and decision making. Inputs and effects were described at an organisational, team and individual level, highlighting the importance of communication throughout the healthcare hierarchy. CONCLUSIONS: IPC in rehabilitation is central to effective team function and patient care. To further our understanding, empirical studies examining everyday informal IPC, as well as formal ritualised encounters are needed. Additionally, conceptualisations of IPC would benefit from including the patients' perspective and by using theoretical framing to attend to places, spaces, and artefacts identified in this review.

Trust, power and learning in workplace-based assessment: The trainee perspective.

For trainees to participate meaningfully in workplace-based assessment (WBA), they must have trust in their assessor. However, the trainee's dependent position complicates such trust. Understanding how power and trust influence WBAs may help us make them more effective learning opportunities. We conducted semi-structured interviews with 17 postgraduate anaesthesia trainees across Australia and New Zealand. Sensitised by notions of power, we used constructivist grounded theory methodology to examine trainees' experiences with trusting their supervisors in WBAs. In our trainee accounts, we found that supervisors held significant power to mediate access to learning opportunities and influence trainee progress in training. All episodes where supervisors could observe trainees, from simply working together to formal WBAs, were seen to generate assessment information with potential consequences. In response, trainees actively acquiesced to a deferential role, which helped them access desirable expertise and minimise the risk of reputational harm. Trainees granted trust based on how they anticipated a supervisor would use the power inherent in their role. Trainees learned to ration exposure of their authentic practice to supervisors in proportion to their trust in them. Trainees were more trusting and open to learning when supervisors used their power for the trainee's benefit and avoided WBAs with supervisors they perceived as less trustworthy. If assessment for learning is to flourish, then the trainee-supervisor power dynamic must evolve. Enhancing supervisor behaviour through reflection and professional development to better reward trainee trust would invite more trainee participation in assessment for learning. Modifying the assessment system design to nudge the power balance towards the trainee may also help. Modifications could include designated formative and summative assessments or empowering trainees to select which assessments count towards progress decisions. Attending to power and trust in WBA may stimulate progress towards the previously aspirational goal of assessment for learning in the workplace.

How Trainees Come to Trust Supervisors in Workplace-Based Assessment: A Grounded Theory Study.

PURPOSE: In competency-based medical education, workplace-based assessment provides trainees with an opportunity for guidance and supervisors the opportunity to judge the trainees' clinical practice. Learning from assessment is enhanced when trainees reveal their thinking and are open to critique, which requires trust in the assessor. If supervisors knew more about how trainees come to trust them in workplace-based assessment, they could better engender trainee trust and improve trainees' learning experience. METHOD: From August 2018 to September 2019, semistructured interviews were conducted with 17 postgraduate anesthesia trainees across Australia and New Zealand. The transcripts were analyzed using constructivist grounded theory methods sensitized by a sociocultural view of learning informed by Wenger's communities of practice theory. RESULTS: Participants described a continuum from a necessary initial trust to an experience-informed dynamic trust. Trainees assumed initial trust in supervisors based on accreditation, reputation, and a perceived obligation of trustworthiness inherent in the supervisor's role. With experience and time, trainees' trust evolved based on supervisor actions. Deeper levels of trainee trust arose in response to perceived supervisor investment and allowed trainees to devote more emotional and cognitive resources to patient care and learning rather than impression management. Across the continuum from initial trust to experience-informed trust, trainees made rapid trust judgments that were not preceded by conscious deliberation; instead, they represented a learned "feel for the game." CONCLUSIONS: While other factors are involved, our results indicate that the trainee behavior observed in workplace-based assessment is a product of supervisor invitation. Supervisor trustworthiness and investment in trainee development invite trainees to work and present in authentic ways in workplace-based assessment. This authentic engagement, where learners "show themselves" to supervisors and take risks, creates assessment for learning.

Development of the Feedback Quality Instrument: a guide for health professional educators in fostering learner-centred discussions.

BACKGROUND: Face-to-face feedback plays an important role in health professionals' workplace learning. The literature describes guiding principles regarding effective feedback but it is not clear how to enact these. We aimed to create a Feedback Quality Instrument (FQI), underpinned by a social constructivist perspective, to assist educators in collaborating with learners to support learner-centred feedback interactions. In earlier research, we developed a set of observable educator behaviours designed to promote beneficial learner outcomes, supported by published research and expert consensus. This research focused on analysing and refining this provisional instrument, to create the FQI ready-to-use. METHODS: We collected videos of authentic face-to-face feedback discussions, involving educators (senior clinicians) and learners (clinicians or students), during routine clinical practice across a major metropolitan hospital network. Quantitative and qualitative analyses of the video data were used to refine the provisional instrument. Raters administered the provisional instrument to systematically analyse educators' feedback practice seen in the videos. This enabled usability testing and resulted in ratings data for psychometric analysis involving multifaceted Rasch model analysis and exploratory factor analysis. Parallel qualitative research of the video transcripts focused on two under-researched areas, psychological safety and evaluative judgement, to provide practical insights for item refinement. The provisional instrument was revised, using an iterative process, incorporating findings from usability testing, psychometric testing and parallel qualitative research and foundational research. RESULTS: Thirty-six videos involved diverse health professionals across medicine, nursing and physiotherapy. Administering the provisional instrument generated 174 data sets. Following refinements, the FQI contained 25 items, clustered into five domains characterising core concepts underpinning quality feedback: set the scene, analyse performance, plan improvements, foster learner agency, and foster psychological safety. CONCLUSIONS: The FQI describes practical, empirically-informed ways for educators to foster quality, learner-centred feedback discussions. The explicit descriptions offer guidance for educators and provide a foundation for the systematic analysis of the influence of specific educator behaviours on learner outcomes.

How do students offer value to organisations through work integrated learning? A qualitative study using Social Exchange Theory.

Learning through work is a common feature of preparing health professionals for practice. Current understandings of work-integrated learning or a 'work-based placement', focus on students being consumers of experiences rather than providing a reciprocal benefit to the organisation in which they are placed. More nuanced understanding of the ways that students can offer value to organisations may provide new opportunities and increased capacity for workplace learning. This study drew on Social Exchange Theory to explore the perceived value and benefits of work-integrated learning experiences to the organisations in which students are placed. The focus was on population health placements undertaken by dietetics students at a large Australian university. An interpretive approach was employed with interviews with placement educators and document analysis of student-generated products from their placement. Seventeen of 20 eligible placement educators were interviewed, with interview data coded using thematic framework analysis. These data were supported with document analysis of student scientific posters completed as part of assessment to develop themes which were interpreted with social exchange theory. Three themes were identified: (1) students add to the organisation's capacity, (2) benefits outweigh time cost of planning and supervising and (3) explicitly valuing students for their contributions may build trust and further potentiate bi-directional benefits. Results suggest that student placements can add value to organisations. This reciprocity of benefits should be communicated to all stakeholders involved in the university-community collaboration, including students. Social exchange theory sensitised researchers to nuanced findings that may support the translation of these study findings to other student work-integrated learning settings.

'It is a different type of learning'. A survey-based study on how simulation educators see and construct observer roles.

Background: Simulation is reported as an appropriate replacement for a significant number of clinical hours in pregraduate programmes. To increase access for learners, educators have looked to understanding and improving learning in observer roles. Studies report equivalent learning outcomes and less stress in observer roles. However, reports on the prevalence, use and perceived value of observer roles from the educator's perspective are lacking. Methods: An exploratory survey for Australian and New Zealand (ANZ) simulation educators based on literature findings was developed and piloted with a small sample (n=10) of like subjects for language, clarity, skip logic and completion time. The final survey comprised 36 questions. Quantitative data were analysed using Pearson's chi-squared test, Welch's ANOVA and exploratory factor analysis. Select qualitative data were analysed using content analysis and summarised with frequency counts and categorisation. Results: Two hundred and sixty-seven surveys were completed, with 221 meeting criteria for analysis. The observer role is widely used in ANZ and most learners experience both hands-on and observer roles. The location of observers is dependent upon several factors including facility design, learner immersion, scenario design and observer involvement. Verbal briefings and/or other guides are provided to 89% of observers to direct their focus and 98% participate in the debrief. Educators value observer roles but tend to believe the best learning is hands-on. Conclusions: The learning in observer roles is less valued by educators than hands-on roles. Focused observation provides opportunities for noticing and attributing meaning, an essential skill for clinical practice. Learning spaces require consideration of scenario design and learning objectives. Scenario design should include objectives for observer roles and incorporate the observer into all phases of simulation. Attention to these areas will help promote the value of the different type of learning available in observer roles.

Learning With Patients, Students, and Peers: Continuing Professional Development in the Solo Practitioner Workplace.

Conceptualizations of workplace learning have moved from knowledge acquisition to learning as participation in the practices and cultures of the workplace environment. Along with this has come an appreciation of applicability of sociocultural learning theories, which frame learning as occurring within "communities of practice" or learning being "situated" within a workplace environment where collaboration and social interaction are fundamental to the learning process. These conceptualizations of workplace learning are ideally suited to health professions where learners are supervised in clinical work environments and then continue to work in team-based environments as graduates. However, what happens to workplace learning for novice practitioners who have limited periods of clinical supervision and then graduate into solo or small group practices (which may also be in rural or remote locations) and embark on long working careers without supervision? This paper argues workplace learning needs to be scaffolded and supported to reach its full potential in these environments. Drawing on workplace-based learning theory, we highlight the ubiquitous nature of learning in the workplace, the importance of active engagement, reflection, and individual meaning making. Through this reframing of traditional notions of continuing professional development, we emphasize the importance of patients, students, and other practitioners as partners in workplace learning for solo practitioners. We also focus on the role of educators, professional associations, and regulators in helping solo practitioners recognize, access, and maximize the learning opportunities inherent in relatively isolated practice environments.

Psychological safety in feedback: What does it look like and how can educators work with learners to foster it?

CONTEXT: Feedback conversations play a central role in health professions workplace learning. However, learners face a dilemma: if they engage in productive learning behaviours (such as asking questions, raising difficulties, offering opinions or contesting ideas), they risk exposing their limitations or offending the educator. This highlights the importance of psychological safety in encouraging learners to candidly engage in interactive dialogue and the co-construction of knowledge. Previous research has recommended that building safety, trust or an educational alliance is key to productive feedback encounters. Yet it is unclear how to translate this into practice. Hence our research question was: What does psychological safety look like in workplace feedback and how can educators work with learners to foster it? METHODS: We analysed 36 videos of routine formal feedback episodes in clinical practice involving diverse health professionals. A psychologically safe learning environment was inferred when learners progressively disclosed information and engaged in productive learning behaviours during the conversation. We used thematic analysis to identify associated educator strategies, which seemed to promote psychological safety. RESULTS: Four themes were identified: (a) setting the scene for dialogue and candour; (b) educator as ally; (c) a continuing improvement orientation, and (d) encouraging interactive dialogue. Educators approaches captured within these themes, seemed to foster a psychologically safe environment by conveying a focus on learning, and demonstrating respect and support to learners. CONCLUSIONS: This study builds on claims regarding the importance of psychological safety in feedback by clarifying what psychological safety in workplace feedback conversations might look like and identifying associated educator approaches. The results may offer educators practical ways they could work with learners to encourage candid dialogue focused on improving performance.

Finding common ground: meta-synthesis of communication frameworks found in patient communication, supervision and simulation literature.

BACKGROUND: Effective communication between patients-clinicians, supervisors-learners and facilitators-participants within a simulation is a key priority in health profession education. There is a plethora of frameworks and recommendations to guide communication in each of these contexts, and they represent separate discourses with separate communities of practice and literature. Finding common ground within these frameworks has the potential to minimise cognitive load and maximise efficiency, which presents an opportunity to consolidate messages, strategies and skills throughout a communication curriculum and the possibility of expanding the research agenda regarding communication, feedback and debriefing in productive ways. METHODS: A meta-synthesis of the feedback, debriefing and clinical communication literature was conducted to achieve these objectives. RESULTS: Our analysis revealed that the concepts underlying the framework can be usefully categorised as stages, goals, strategies, micro-skills and meta-skills. Guidelines for conversations typically shared a common structure, and strategies aligned with a stage. Core transferrable communication skills (i.e., micro-skills) were identified across various types of conversation, and the major differences between frameworks were related to the way that power was distributed in the conversation and the evolution of conversations along the along the path of redistributing power. As part of the synthesis, an overarching framework "prepare-EMPOWER enact" was developed to capture these shared principles across discourses. CONCLUSIONS: Adopting frameworks for work-based communication that promote dialogue and empower individuals to contribute may represent an important step towards learner-centred education and person-centred care for patients.

"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.