Leveraging Self-regulated Learning in a Focused Direct-Observation and Feedback Model in the Ambulatory Setting for Improved Self-efficacy.

backgroundAmbulatory learning is time-limited, especially with regard to observation and feedback. Mini-Clinical Evaluation Exercises (CEX) can improve feedback and learner confidence but may overlook self-regulated learning (SRL), limiting the learner's role in the feedback continuum.

objectiveImplement a direct observation and feedback model within a fast-paced clinic setting based on mini-CEX combined with facilitative coaching with the goal of improving self-efficacy.

designMixed-methods post-implementation program evaluation.

participantsPrimary Care Track residents in an urban clinic serving an underserved population with complex needs. MAIN MEASURES: We assessed the model for participant experience through survey data and for resident perceived self-efficacy during the encounter through qualitative thematic analysis of narrative evaluations. KEY

resultsThis model was reported to be valuable by both faculty and resident respondents, but only half of direct observations were completed. A qualitative analysis of narrative assessments showed that incorporation of a pre-encounter discussion in the context of SRL leads to self-identified efficacy during the encounter, with emergence of five core themes: learner initiative drives encounters; failures are attributed to external locus of control; successes are perceived as growing internal outcomes; anticipatory framework encourages learner proactivity; and unique patient challenges demand learner reactivity.

conclusionThe pre-encounter priming of a direct observation improves the learner's ability to navigate external and internal factors of self-regulated learning and thereby improve self-efficacy. However, despite the design of this direct observation and feedback model to fit within known challenges of the ambulatory setting, there were still challenges to completion, often due to the resident's ability to navigate external factors. Ongoing iterations of direct observation and feedback models should be attentive to assisting learners in navigating external barriers, thereby building proactivity and reactivity in response to unexpected challenges in the encounter itself.