The Influence of Relationship-Centered Coaching on Physician Perceptions of Peer Review in the Context of Mandated Regulatory Practices

Supporting the Nurse Preceptor Role: Implementing the R2C2 Feedback Model

Nurse preceptors are key to the successful transition of graduate nurses to practice and experienced nurses to a new organization. Providing ongoing preceptor development is essential to support nurses in this vital role. The evidence-based R2C2 (relationship, reaction, content, coach) feedback and coaching model was implemented to facilitate the delivery of constructive feedback from nurse preceptors to their orientees. Post-intervention survey results suggest an overall positive response to the use of the feedback model in practice.

Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

When Feedback is Not Perceived as Feedback: Challenges for Regulatory Body-Mandated Peer Review

PURPOSE

Safe and competent patient care depends on physicians recognizing and correcting performance deficiencies. Generating effective insight depends on feedback from credible sources. Unfortunately, physicians often have limited access to meaningful guidance. To facilitate quality improvement, many regulatory authorities have designed peer-facilitated practice enhancement programs. Their mandate to ensure practice quality, however, can create tension between formative intentions and risk (perceived or otherwise) of summative repercussions. This study explored how physicians engage with feedback when required to undergo review.

METHOD

Between October 2018 and May 2020, 30 physicians representing various specialties and career stages were interviewed about their experiences with peer review in the context of regulatory body-mandated programs. Twenty had been reviewees and reviewers and, hence, spoke from both vantage points. Interview transcripts were analyzed using a 3-stage coding process informed by constructivist grounded theory.

RESULTS

Perceptions about the learning value of mandated peer review were mixed. Most saw value but felt anxiety about being selected due to being wary of regulatory bodies. Recognizing barriers such perceptions could create, reviewers described techniques for optimizing the value of interactions with reviewees. Their strategies aligned well with the R2C2 feedback and coaching model with which they had been trained but did not always overcome reviewees' concerns. Reasons included that most feedback was "validating," aimed at "tweaks" rather than substantial change.

CONCLUSIONS

This study establishes an intriguing and challenging paradox: feedback appears often to not be recognized as feedback when it poses no threat, yet feedback that carries such threat is known to be suboptimal for inducing performance improvement. In efforts to reconcile that tension, the authors suggest that peer review for individuals with a high likelihood of strong performance may be more effective if expectations are managed through feedforward rather than feedback.

Recasting Assessment in Continuing Professional Development as a Person-Focused Activity

ABSTRACT

In this article, we examine assessment as conceptualized and enacted in continuing professional development (CPD). Assessment is pervasive throughout the life of an individual health professional, serving many different purposes compounded by varied and unique contexts, each with their own drivers and consequences, usually casting the person as the object of assessment. Assessment is often assumed as an included part in CPD development conceptualization. Research on assessment in CPD is often focused on systems, utility, and quality instead of intentionally examining the link between assessment and the person. We present an alternative view of assessment in CPD as person-centered, practice-informed, situated and bound by capability, and enacted in social and material contexts. With this lens of assessment as an inherently personal experience, we introduce the concept of subjectification, as described by educationalist Gert Biesta. We propose that subjectification may be a fruitful way of examining assessment in a CPD context. Although the CPD community, researchers, and educators consider this further, we offer some early implications of adopting a subjectification lens on the design and enactment of assessment in CPD.

Exploring Content Relationships Among Components of a Multisource Feedback Program

INTRODUCTION

A new multisource feedback (MSF) program was specifically designed to support physician quality improvement (QI) around the CanMEDS roles of Collaborator , Communicator , and Professional . Quantitative ratings and qualitative comments are collected from a sample of physician colleagues, co-workers (C), and patients (PT). These data are supplemented with self-ratings and given back to physicians in individualized reports. Each physician reviews the report with a trained feedback facilitator and creates one-to-three action plans for QI. This study explores how the content of the four aforementioned multisource feedback program components supports the elicitation and translation of feedback into a QI plan for change.

METHODS

Data included survey items, rater comments, a portion of facilitator reports, and action plans components for 159 physicians. Word frequency queries were used to identify common words and explore relationships among data sources.

RESULTS

Overlap between high frequency words in surveys and rater comments was substantial. The language used to describe goals in physician action plans was highly related to respondent comments, but less so to survey items. High frequency words in facilitator reports related heavily to action plan content.

DISCUSSION

All components of the program relate to one another indicating that each plays a part in the process. Patterns of overlap suggest unique functions conducted by program components. This demonstration of coherence across components of this program is one piece of evidence that supports the program's validity.

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.

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.

The Hiker's Guide to the RIME Supplement: Choosing Directions in Research

In this Commentary, the authors seek to build on prior RIME commentaries by considering how researchers transition from worldviews, focal lengths, and research goals to research directions and methodological choices. The authors use the analogy of a hiker to illustrate how different researchers studying a similar phenomenon can choose among different research directions, which lead down different paths and offer different perspectives on a problem. Following the hiker analogy, the authors use the "Research Compass" to categorize the 15 research papers included in the 2020 Research in Medical Education supplement according to their research aim and corresponding methodological approach. The authors then discuss implications of the relative balance of these study types within this supplement and within health professions education research at large, emphasizing the critical importance of studying a topic from multiple vantage points to construct a richer and more nuanced understanding of health professions education challenges. The authors conclude by recognizing the challenges we face in the current era of COVID-19 and by calling health professions education researchers and practitioners to continue our collective efforts to improve learner education and patient care, as we together navigate the unfamiliar terrain of the present day.