In order to facilitate the adoption of a family-centered approach to care, it is not only important to educate learners about FCC, but to bolster their self-efficacy to deliver FCC as it occurs –in the clinical setting. Findings shed light on factors that support learner self-efficacy with FCC during rounds, highlighting the contributions of observing role models and having mastery experiences to learners’ self-efficacy. Students’ self-efficacy, however, was not related to attending/resident feedback regarding their performance. Further, the effects of the supportive experiences’ on self-efficacy with FCC during rounds in the clinical setting were mediated by self-efficacy with key FCC tasks.
Students often have identified exposure to role models as critical to developing their communication skills and professional bedside manner, even during the pre-clinical curriculum.32–35
Harrell et al also found a strong positive relationship between the mastery opportunities afforded in hands-on clinical opportunities and students’ confidence in caring for patients.36
This observation is the basis for much of today’s movement toward simulation-based education. For example, students who had more opportunities to observe and take part in discussions with patients about difficult news, wishes and values had a greater sense of preparedness to provide end-of-life care.37
Thus, allowing students opportunity to observe and practice skills is critical to their self-efficacy with FCC, and may be operationalized through simulation of care as it occurs in the clinical setting as has been done for other communication skills.38–41
In addition, these supportive experiences are congruent with the ACGME and American Board of Medical Specialties’ move toward competency-based medical education in that they are learner-centered, formative experiences faculty do with the learners rather than to the learners.42–44
Contrary to generally hypothesized positive influences of feedback on self-efficacy, feedback given to students about their performance during rounds did not impact their self-efficacy with FCC during rounds. Moreover, this finding is inconsistent with recent literature about the role of feedback in shaping medical students’ confidence in their abilities to care for patients45,46
and to the value students place on feedback in developing their communication skills, especially at the bedside.47
At least three plausible explanations for this finding arise from the evidence base about feedback. First, the manner in which feedback is given could hinder self-efficacy.48
According to Bandura, feedback that is framed in terms of short-falls is apt to weaken self-efficacy by highlighting one’s deficiencies.19
Using a competency-based approach, i.e., advising learners of the steps needed to advance in their development to be competent, rather than focusing on achievement of the final step, could reframe feedback on performance during family-centered rounds in a more positive light.
Second, the timing of the feedback may have undermined self-efficacy. One of the common concerns of trainees about family-centered rounds is being corrected in front of families.12–16
Thus, if residents or faculty delivered negative feedback during rounds, this may have weakened self-efficacy. Third, students report faculty and resident expectations of their performance during family-centered rounds are unclear.12
In recent interviews about family-centered rounds experiences (unpublished work) students noted that unclear or inconsistent expectations across attendings and residents can lead to unexpected negative feedback. Specifically, one student noted how she had been asked to eliminate medical jargon while presenting during family-centered rounds only to receive negative feedback at a later time, suggesting she “needs to learn and apply the language of medicine.” For these reasons, faculty (and resident) development regarding family-centered rounds might focus on helping team leaders to articulate a clear, uniform progression of competencies for rounds and to base private, constructive feedback on this progression.49
The impact of supportive experiences on self-efficacy with FCC during rounds was mediated by self-efficacy with key FCC tasks. The Dreyfus model of skill acquisition suggests learners advance through the developmental stages as they gain a sense of competence and experience, ultimately enabling them to perform tasks under varying conditions such as the stressors of clinical practice.50
We find that learners’ self-efficacy with FCC in the clinical setting operates through their self-efficacy with specific FCC tasks, highlighting the importance of developing basic FCC skills before expecting students to succeed during family-centered rounds. Students learning basic techniques for interacting with patients during the first and second year of medical school might benefit from an introduction to key FCC tasks, followed by opportunities to apply these skills during clinical years. This approach also would foster the acceptance of family-centered rounds as a model for inpatient care across all physician specialties.
This study has limitations that should be considered. First, students’ reports of their experiences with family-centered rounds may be subject to recall bias and not reflective of actual occurrences. These reports could be validated by seeking data from other sources such as recordings of rounding sessions or even the perceptions of families or other healthcare team members. Second, family-centered rounding is a relatively new model at our institution. Although our attendings and residents have been providing family-centered rounds consistently for nearly 4 years and many have received formal training about teaching during bedside rounds, students’ experiences may reflect the challenges of this new process. However, this model is new to many institutions, suggesting many students may have experiences similar to those of our students.51
Lastly, generalizability to other student populations is not demonstrated, although our findings parallel those of prior studies as discussed and our students are similar to those of medical schools nationally.52,53
In summary, we find that medical students’ self-efficacy with FCC during rounds is fostered by observing role models and having mastery experiences, both of which operate through self-efficacy with key FCC tasks. Feedback, often considered a key self-efficacy support and highly valued by learners at the bedside and for developing communication skills47
did not foster FCC self-efficacy for these students. Educators might consider providing exposure to FCC early in medical student education and implementing faculty development sessions centered on FCC during rounds.