Table.

Supervisor Perspectives for Use of R2C2-in-the Moment Feedback and Coaching

Categories	Themes	Examples
Phase 1: Build relationships	New learner	“If I'm just starting out with a learner, it's always the best situation if a learner initiates that conversation and says, ‘I'm here to get this out of my rotation or I'm only here for a day, a half day, and I'd really like to learn about X or Y or Z today.' That doesn't always happen—I think that's an ideal scenario…the things that I try to do very early the first time I meet with a learner before we dive right into clinical activities is kind of setting expectations for whether it's the day or the rotation that I'm working with them on, get an understanding of where they're at in their training…If they're a medical student, getting a sense of what fields of medicine they're interested in or if it's a resident, I generally know a little bit more about what their goals are. But not necessarily with an off-service resident.” [Participant C]
	The learner with a pre-existing relationship	“…yesterday I had one of the second years [resident] with me and so I was her academic advisor last year. I've worked with her a lot and so it might just be a matter of ‘What have you been up to lately since you [we] last [met]?' Sort of just a little bit of that relationship… and just trying to figure out where they're at in their training, what their comfort level is with ped[iatric]s, if they have a specific goal.” [Participant I]
Phase 2: Explore reactions and reflections	Understanding the reaction	“For me it's really because I want them to feel comfortable sharing this information, and it's the reaction area that's the hardest for them to share. Who wants to say they feel stupid, that they feel that they should have known that? They shouldn't have missed that. That's where I think they oftentimes feel like they're the only one who this has happened to or that's why I really like the affirm, normalize part that that's what I'm trying to do in their reaction. To say that the feelings are fine, the feelings are normal, the reaction is normal, and get them to open up because they feel like that reaction is not what they should have they won't open up after that.” [Participant K] “I think this is a difficult stage because there's a big gap here…the clinical experience needs to occur between stage 1 and stage 2…once they've had that clinical experience, then I'm looking for them…in terms of those big exploring reactions and perceptions of the data, what we're doing, really, is exploring their presentation of the clinical experience, and so that is a source of data for me to then be able to explore the pieces that are working and aren't working.” [Participant D]
Phase 3: Confirm content	Exploring content	“…what's really important on the content portion is talking about observable behaviors that you have had over the last couple of days or over that single encounter and checking. This is where you really work to avoid inferences.” [Participant A] “I usually ask them 2 questions: ‘What one thing do you want to keep doing?, ‘What one thing worked in this encounter that you want to keep doing?' …there are many things that they do well and it's not just on the things I want them to change, but on the things I want them to keep doing well.” [Participant K] “Even if something has gone particularly well, I think ways to explore their understanding of how things went or what they would've done if things hadn't gone well is to say, ‘Well, your laryngoscopy was very smooth there. What would you have done if you couldn't see the vocal cords?'…more extrapolation techniques to try to get them to show that they have a really good understanding of the topic or the next steps or anticipation. So there's some things that I would go about doing if I'm finding it difficult to explore the content of the topic that we're using.” [Participant J]
	Confirming content	“...at the beginning of that next clinic, I said, ‘Today, I'd like to watch you do that procedure again. And if it's okay with you, I'll give you some feedback in-the-moment now that you're aware that you do this.' So actually, at the time of the procedure, he was really receptive to receiving that right then and there correction on the... position…I got the patient's consent to take some video of just his hand positions while he's doing the injection. And I showed him the video afterwards from different angles to see—when he looked at it, he said, ‘Oh, I didn't really think that I was doing that.' So I think that helped to improve his awareness…. Maybe the first time I watched him do it, he was saying, ‘Well, that's just a matter of your opinion.' And having that more objective video data, he was like, ‘Oh okay, I see what you're saying now.'” [Participant C]
Phase 4: Coach for change and co-create an action plan	Continue relationship building as needed	“I think in terms of what you need to do, I think coming back [to] the beginning and coming back to understanding that rapport is really important…to understand what their goals are, where they're at in their training and what should normally be expected of a trainee at that level. They need to have this kind of frame of reference but you also need to have had the conversation with them of what's realistic to assess and what are their individual goals…if you don't have that already established, I think that can really affect your credibility as a coach because if you don't really understand that and there's a big gap between what you're saying and what they're thinking. They're just going to dismiss what you're saying and not trust you as someone credible.” [Participant C]
	Need for specificity and commitment	“…it's specificity. Like I think whatever you are talking about has to be very clear… Make it specific, very to the point, and you cannot give feedback on 20 things. You have to pick your battles. Like, if there's 1 or 2 things that you want to highlight, just talk about those 2.” [Participant G] “Some learners are very engaged and they're very motivated and others aren't … if it's someone who's less motivated then they don't really have as many ideas, and it is hard to get engagement. I can sometimes get a sense at the end of it if they're going to really try to make these changes or if they're somewhat more reluctant to.” [Participant B] “I don't want people to see a patient with congestive heart failure and their goal is to review congestive heart failure and will talk about it next time. I feel that's not helpful…I actually try and get residents to really key in on what the area was that was problematic… for example, ‘Was their history adequate? Did they do an appropriate physical exam? Maybe their differential diagnosis was even okay, or maybe that's where the gap is, or maybe there are issues are around management.' …Rather than reading more generally…the expectation is that the beginning of next clinic, that we will be discussing the new knowledge that they've thought out around that particular issue, and discussing what the implications are for a particular patient… That occurs at the beginning of the next clinical day, before we then move into their next set of patients.” [Participant D]
	Co-creation of action plans	“I've been experimenting a little bit…it would almost be helpful to me and I'm trying to put something together that's on like a carbon paper that has some of the steps with the phrases and then the coaching plan so that when we write that coaching plan out, I can hand that piece of paper off to that person. And then I have a copy of it and they have it sort of in their pocket as a reminder to focus on … It was clear that between the dyad there was an understanding on that paper. The external person couldn't make heads or tails of the chicken scratch but [for] the 2 people it represented a shared mental model and it was helpful to write it down.” [Participant A] “…and usually in-the-moment feedback I do verbal commitment, less so than I tend not to do written. Commitment I'm doing the verbal.” [Participant K]