Considering the interdependence of clinical performance: implications for assessment and entrustment

Introduction

Our ability to assess independent trainee performance is a key element of competency‐based medical education (CBME). In workplace‐based clinical settings, however, the performance of a trainee can be deeply entangled with others on the team. This presents a fundamental challenge, given the need to assess and entrust trainees based on the evolution of their independent clinical performance. The purpose of this study, therefore, was to understand what faculty members and senior postgraduate trainees believe constitutes independent performance in a variety of clinical specialty contexts.

Methods

Following constructivist grounded theory, and using both purposive and theoretical sampling, we conducted individual interviews with 11 clinical teaching faculty members and 10 senior trainees (postgraduate year 4/5) across 12 postgraduate specialties. Constant comparative inductive analysis was conducted. Return of findings was also carried out using one‐to‐one sessions with key informants and public presentations.

Results

Although some independent performances were described, participants spoke mostly about the exceptions to and disclaimers about these, elaborating their sense of the interdependence of trainee performances. Our analysis of these interdependence patterns identified multiple configurations of coupling, with the dominant being coupling of trainee and supervisor performance. We consider how the concept of coupling could advance workplace‐based assessment efforts by supporting models that account for the collective dimensions of clinical performance.

Conclusion

These findings call into question the assumption of independent performance, and offer an important step toward measuring coupled performance. An understanding of coupling can help both to better distinguish independent and interdependent performances, and to consider revising workplace‐based assessment approaches for CBME.     

Feedback for simulation-based procedural skills training: a meta-analysis and critical narrative synthesis

Although feedback has been identified as a key instructional feature in simulation based medical education (SBME), we remain uncertain as to the magnitude of its effectiveness and the mechanisms by which it may be effective. We employed a meta-analysis and critical narrative synthesis to examine the effectiveness of feedback for SBME procedural skills training and to examine how it works in this context. Our results demonstrate that feedback is moderately effective during procedural skills training in SBME, with a pooled effect size favoring feedback for skill outcomes of 0.74 (95 % CI 0.38–1.09; p < .001). Terminal feedback appears more effective than concurrent feedback for novice learners’ skill retention. Multiple sources of feedback, including instructor feedback, lead to short-term performance gains although data on long-term effects is lacking. The mechanism by which feedback may be operating is consistent with the guidance hypothesis, with more research needed to examine other mechanisms such as cognitive load theory and social development theory.     

Should we teach using schemas? Evidence from a randomised trial

Medical Education 2012: 46: 815–822 Context Schema‐based instruction may alter knowledge organisation and diagnostic reasoning strategies through the provision of structured knowledge to novice trainees. The effects of schema‐based instruction on diagnostic accuracy and knowledge organisation have not been rigorously tested. Methods Year 2 medical students were randomised to learn four cardiac diagnoses using schema‐based instruction (n = 26) or traditional instruction (n = 27) on a high‐fidelity cardiopulmonary simulator (CPS). Students completed case‐based learning in groups of two to five and underwent individual written and practical tests. The written test consisted of questions testing features that linked or distinguished diagnoses (structured knowledge) and questions testing features of individual diagnoses (factual knowledge). A practical test of diagnostic accuracy on the CPS was performed for two diagnoses present in the learning phase (taught lesions) and two untaught lesions. A majority of students (n = 37, 70%) voluntarily returned for follow‐up written testing 2–4 weeks later. Results Learning time and accuracy did not differ between students on schema‐based and those on traditional instruction. Students receiving schema‐based instruction performed better on structured knowledge questions (p < 0.001) and no differently on factual knowledge questions (p = 0.7). Relative differences between groups remained unchanged on follow‐up testing. Diagnostic success was higher in the schema‐based instruction group for taught lesions (mean difference = 38%, 95% confidence interval [CI] 20–56; p < 0.001) and untaught lesions (mean difference = 31%, 95% CI 15–48; p < 0.001). Conclusions Schema‐based instruction was associated with improved retention of structured knowledge and diagnostic performance among novices. This study provides important proof‐of‐concept for a schema‐based approach and suggests there is substantial benefit to using this approach with novice trainees.     

Cognitive load theory in health professional education: design principles and strategies

Context Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long‐term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long‐term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load. Objectives This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load. Discussion Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal‐free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple‐to‐complex ordering of learning tasks and working from low‐ to high‐fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self‐explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well‐designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed. Medical Education 2010: 44 : 85–93     

How effective is self‐guided learning of clinical technical skills? It’s all about process

Objectives  Mounting evidence suggests that trainees acquire psychomotor skills better when they are allowed self-guided access to instructional material and when they set goals that are related to performance processes rather than performance outcomes. The present study assessed whether self-guided access to instruction and the setting of process goals lead to better acquisition of clinical technical skills.
Methods  To learn wound closure skills, 48 medical students were randomly assigned to one of four groups in a 2 × 2 study design. Self-guided participants were able to access the instructional video freely, whereas control participants were restricted to watching only those video segments accessed by their matched self-guided participant. Each group was further divided into two subgroups, comprising a process goal subgroup, where participants set goals focused on performance mechanisms, and an outcome goal subgroup, where participants set goals focused on performance products. Performance on pre-, post-, retention and transfer tests was assessed with hand motion measures and expert evaluations. Group differences were evaluated using one-way anova s.
Results  The self-guided group with process goals showed greater skill retention than its matched control group, whereas the self-guided group with outcome goals did not. Furthermore, the groups with process goals performed better on the transfer test than the outcome goal groups. Outcome goal participants accessed the instructional video most frequently.
Conclusions  Our findings advance the study of independent learning in medical education. Trainees used interactive and structured instructional materials to effectively self-guide their learning of clinical technical skills. However, a self-guided benefit was demonstrated only when trainees set process goals.     

The k‐in‐a‐row up‐and‐down design,revisited

The percentile‐finding experimental design known variously as ‘forced‐choice fixed‐staircase’, ‘geometric up‐and‐down’ or ‘k‐in‐a‐row’ (KR) was introduced by Wetherill four decades ago. To date, KR has been by far the most widely used up‐and‐down (U&D) design for estimating non‐median percentiles; it is implemented most commonly in sensory studies. However, its statistical properties have not been fully documented, and the existence of a unique mode in its asymptotic treatment distribution has been recently disputed. Here we revisit the KR design and its basic properties. We find that KR does generate a unique stationary mode near its target percentile, and also displays better operational characteristics than two other U&D designs that have been studied more extensively. Supporting proofs and numerical calculations are presented. A recent experimental example from anesthesiology serves to highlight some of the ‘up‐and‐down’ design family's properties and advantages. Copyright © 2009 John Wiley & Sons, Ltd.     

Knowing How and Knowing Why: testing the effect of instruction designed for cognitive integration on procedural skills transfer

Transfer is a desired outcome of simulation-based training, yet evidence for how instructional design features promote transfer is lacking. In clinical reasoning, transfer is improved when trainees experience instruction integrating basic science explanations with clinical signs and symptoms. To test whether integrated instruction has similar effects in procedural skills (i.e., psychomotor skills) training, we studied the impact of instruction that integrates conceptual (why) and procedural (how) knowledge on the retention and transfer of simulation-based lumbar puncture (LP) skill. Medical students (N = 30) were randomized into two groups that accessed different instructional videos during a 60-min self-regulated training session. An unintegrated video provided procedural How instruction via step-by-step demonstrations of LP, and an integrated video provided the same How instruction with integrated conceptual Why explanations (e.g., anatomy) for key steps. Two blinded raters scored post-test, retention, and transfer performances using a global rating scale. Participants also completed written procedural and conceptual knowledge tests. We used simple mediation regression analyses to assess the total and indirect effects (mediated by conceptual knowledge) of integrated instruction on retention and transfer. Integrated instruction was associated with improved conceptual (p < .001) but not procedural knowledge test scores (p = .11). We found no total effect of group (p > .05). We did find a positive indirect group effect on skill retention (B _ab  = .93, p < .05) and transfer (B _ab  = .59, p < .05), mediated through participants improved conceptual knowledge. Integrated instruction may improve trainees’ skill retention and transfer through gains in conceptual knowledge. Such integrated instruction may be an instructional design feature for simulation-based training aimed at improving transfer outcomes.     

Divergence in student and educator conceptual structures during auscultation training

Context Simulation‐based medical education allows trainees to engage in self‐regulated learning (SRL), yet research aimed at elucidating the mechanisms of SRL in this context is relatively absent. We compared ‘unguided’ SRL with ‘directed’ SRL (DSRL), wherein learners followed an expert‐designed booklet. Methods Year 1 medical students (n = 37) were randomly assigned to practise identifying seven cardiac murmurs using a simulator and video only (SRL group) or a simulator and video plus the booklet (DSRL group). All participants completed a 22‐item test 3 weeks later. To compare interventions, we analysed students’ diagnostic accuracy. As a novel source of evidence, we documented how participants autonomously sequenced the seven murmurs during initial and delayed practice sessions. In addition, we surveyed clinical educators (n = 17) to find out how they would sequence their teaching of these murmurs. Results The DSRL group used 50% more training time than the SRL group (p < 0.001). The groups’ diagnostic accuracy, however, did not differ significantly on the post‐test, retention test or transfer test items (p > 0.12). Despite practising with the expert‐defined ‘timing‐based’ approach to murmur diagnosis (i.e. systolic versus diastolic), 84% of DSRL participants implemented a location‐based approach (i.e. practising aortic murmurs separately from mitral murmurs) during a second, unguided practice session. Notably, most SRL participants used that same approach spontaneously. By contrast, clinical educators were split in their use of the timing‐based (n = 10) and the location‐based (n = 6) approaches. Chi‐squared analyses suggested educators’ conceptions for organising murmurs differed significantly from students’ conceptions. Conclusions Contrary to our predictions, directing students’ SRL produced no additional benefit and increased their practice time. Our findings suggest one potential source of these results was a divergence between student and educator conceptions for structuring the practice of cardiac auscultation skills. This phenomenon has not been well articulated in the medical education literature, and may have important implications in many (especially technology‐mediated) educational contexts.     

Educational impact of in-training assessment (ITA) in postgraduate medical education: a qualitative study of an ITA programme in actual practice

Objectives To investigate the experiences and opinions of programme directors, clinical supervisors and trainees on an in‐training assessment (ITA) programme on a broad spectrum of competence for first year training in anaesthesiology. How does the programme work in practice and what are the benefits and barriers? What are the users' experiences and thoughts about its effect on training, teaching and learning? What are their attitudes towards this concept of assessment? Methods Semistructured interviews were conducted with programme directors, supervisors and trainees from 3 departments. Interviews were audiotaped and transcribed. The content of the interviews was analysed in a consensus process among the authors. Results The programme was of benefit in making goals and objectives clear, in structuring training, teaching and learning, and in monitoring progress and managing problem trainees. There was a generally positive attitude towards assessment. Trainees especially appreciated the coupling of theory with practice and, in general, the programme inspired an academic dialogue. Issues of uncertainty regarding standards of performance and conflict with service declined over time and experience with the programme, and departments tended to resolve practical problems through structured planning. Discussion Three interrelated factors appeared to influence the perceived value of assessment in postgraduate education: (1) the link between patient safety and individual practice when assessment is used as a licence to practise without supervision rather than as an end‐of‐training examination; (2) its benefits to educators and learners as an educational process rather than as merely a method of documenting competence, and (3) the attitude and rigour of assessment practice.     

Directed self-regulated learning versus instructor-regulated learning in simulation training

Medical Education 2012: 46: 648–656 Objectives Simulation training offers opportunities for unsupervised, self‐regulated learning, yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills. We evaluated the effectiveness of directed self‐regulated learning (DSRL) and instructor‐regulated learning (IRL), respectively, for teaching lumbar puncture (LP) using simulation. Methods We randomly assigned internal medicine residents in postgraduate year 1 to either DSRL (‘directed’ to progress from easy to difficult LP simulators during self‐regulated learning) or IRL (in groups of four led by an instructor). All participants practised for up to 50 minutes and completed a pre‐test, post‐test and delayed (by 3 months) retention test on the simulator. Pairs of blinded trained experts independently rated all videotaped performances using a validated global rating scale and a modified version of a validated checklist. Participants provided measures of LP experience and self‐reported confidence. We analysed the pre–post (n = 42) and pre–post–retention performance scores (n = 23) using two separate repeated‐measures analyses of variance (anova s) and computed Pearson correlation coefficients between participants’ confidence and performance scores. Results Inter‐rater agreement was strong for both performance measures (intra‐class correlation coefficient > 0.81). The groups achieved similar pre‐test and post‐test scores (p > 0.05) and scores in both groups improved significantly from the pre‐ to the post‐test (p < 0.05). On retention, a significant interaction (F_2,42 = 3.92, p = 0.03) suggests the DSRL group maintained its post‐test performance, whereas that in the IRL group dropped significantly (p < 0.05). Correlations between self‐reported confidence and post‐test performance were positive and significant for the DSRL group, and negative and non‐significant for the IRL group. Conclusions Both IRL and DSRL led to improved LP performance immediately after practice. Whereas the IRL group’s skills declined after 3 months, the DSRL group’s performance was maintained, suggesting a potential long‐term benefit of this training. Participants in the DSRL group also developed a more accurate relationship between confidence and competence following practice. Further research is needed to clarify the mechanisms of self‐regulated learning and its role in simulation contexts.     

From rural beginnings to statewide roll‐out: Evaluation of facilitator training for a group‐based diabetes prevention program

Objective: To evaluate the approach used to train facilitators for a large‐scale group‐based diabetes prevention program developed from a rural implementation research project. Participants: Orientation day was attended by 224 health professionals; 188 submitted the self‐learning task; 175 achieved the satisfactory standard for the self‐learning task and attended the workshop; 156 completed the pre‐ and post‐training questionnaires. Main outcome measures: Two pre‐ and post‐training scales were developed to assess knowledge and confidence in group‐based diabetes prevention program facilitation. Principal component analysis found four factors for measuring training effectiveness: knowledge of diabetes prevention, knowledge of group facilitation, confidence to facilitate a group to improve health literacy and confidence in diabetes prevention program facilitation. Self‐learning task scores, training discontinuation rates and satisfaction scores were also assessed. Results: There was significant improvement in all four knowledge and confidence factors from pre‐ to post‐training (P < 0.001). The self‐learning task mean test score was 88.7/100 (SD = 7.7), and mean assignment score was 72.8/100 (SD = 16.1). Satisfaction with training scores were positive and ‘previous training’ interacted with ‘change in knowledge of diabetes prevention program facilitation’ but not with change in ‘confidence to facilitate.’ Conclusions: The training program was effective when analysed by change in facilitator knowledge and confidence and the positive mean satisfaction score. Learning task scores suggest tasks were manageable and the requirement contributed to facilitator self‐selection. Improvement in confidence scores in facilitating a group‐based diabetes prevention program, irrespective of previous training and experience, show that program‐specific skill development activities are necessary in curriculum design.     

User perceptions of multi‐source feedback tools for junior doctors

Medical Education 2010: 44 : 165–176 Context The effectiveness of multi‐source feedback (MSF) tools, which are increasingly important in medical careers, will be influenced by their users’ attitudes. This study compared perceptions of two tools for giving MSF to UK junior doctors, of which one provides mainly textual feedback and one provides mainly numerical feedback. We then compared the perceptions of three groups, including: trainees; raters giving feedback, and supervisors delivering feedback. Methods Postal questionnaires about the usability, usefulness and validity of a feedback system were distributed to trainees, raters and supervisors across the north of England. Results Questionnaire responses were analysed to compare opinions of the two tools and among the different user groups. Overall there were few differences. Attitudes towards MSF in principle were positive and the tools were felt to be usable, but there was little agreement that they could effectively identify doctors in difficulty or provide developmental feedback. The text‐oriented tool was rated as more useful for giving feedback on communication and attitude, and as more useful for identifying a doctor in difficulty. Raters were more positive than other users about the usefulness of numerical feedback, but, overall, text was felt to be more useful. Some trainees expressed concern that feedback was based on insufficient knowledge of their work. This was not supported by raters’ responses, although many did use indirect information. Trainees selected raters mainly for the perceived value of their feedback, but also based on personal relationships and the simple pragmatics of getting a tool completed. Discussion Despite positive attitudes to MSF, the perceived effectiveness of the tools was low. There are small but significant preferences for textual feedback, although raters may prefer numerical scales. Concerns about validity imply that greater awareness of contextual and psychological influences on feedback generation is necessary to allow the formative benefits of MSF to be optimised and to negate the risk of misuse in high‐stakes contexts.     

The testing of clinical skills in dietetic students prior to entering clinical placement

Background One of the most important requirements for contemporary education of a health care professional is to develop a framework for theory and practise which results in attainment of professional competencies suitably robust for a lifetime of practise ( Howe, 2002 ). In the context of those educating preregistration dietitians, this offers the challenge of presenting the student with innovative curricula designed to deliver the appropriate level of knowledge and understanding together with emphasis on skill and attitude development. The purpose of this study was to allow preregistration students the opportunity to practise key clinical skills prior to clinical placement and test skills acquisition using the model of an objective structured clinical examination (OSCE). Methods The learning experience of the student was altered to accommodate a more conceptually‐driven, problem‐centred, case‐based approach. The curriculum was adjusted to incorporate a short clinical skills programme where emphasis was deliberately placed on skill acquisition. At the conclusion of this clinical skills programme, and prior to the students entering clinical placement, skill performance by students was tested using the OSCE. The method of testing was also evaluated by students. Results The OSCE was delivered to 37 preclinical students. Four of the test candidates (11%) failed in at least one of the skill areas: these students performed similarly during clinical placement. Twenty‐one (57%) students returned the post‐OSCE questionnaire. Twenty (95%) students reported a positive experience; 20 (95%) students reported initial anxiety that diminished as the test progressed. Conclusion The Project Team was confident with the novel approach taken in re‐designing the curriculum: to include a dedicated clinical skills programme, together with addition of the testing of clinical skills using the OSCE model. These curriculum changes were deemed to be highly appropriate additions to the student experience in determination of skill performance of students prior to clinical placement.     

A client‐centred,occupation‐based occupational therapy programme for adults with psychiatric diagnoses

The purpose of this study was to assess the effectiveness of a client‐centred, occupation‐based occupational therapy programme for individuals with psychiatric diagnoses. The study took place in a college campus. A pre‐test/post‐test design was used. There were 38 participants which included college students and community members who desired to attend college, work and/or address life skill goals. The Canadian Occupational Performance Measure (COPM) was used as a pre‐ and post‐test measure. Goals were based on problems identified in the COPM, reflected academic, vocational, life skill, and leisure goals, and were systematically addressed weekly through activities developed by the participant and a graduate occupational therapy student who acted as a mentor. The Participant Overall Satisfaction Scale was completed by each participant. A case study was used to describe the programme in more depth. The results support that the client‐centred, occupation‐based occupational therapy programme increased client scores on satisfaction and performance of occupational performance problems identified on the COPM. Further research is recommended to explore how client‐centred occupational therapy programmes can be effective in improving academic, vocational and life skill goals. Copyright © 2010 John Wiley & Sons, Ltd.     

Supporting student‐doctors from under‐resourced educational backgrounds: an academic development programme

Medical Education 2010: 44 : 917–925 Objectives Increased student diversity in medical schools is considered necessary. However, very few medical school applicants from under‐resourced educational backgrounds achieve competitive academic entrance scores. Pre‐admission development programmes that aim to produce competitive applicants may be inefficient in countries where under‐represented communities are majority populations. This study set out to determine: (i) whether an academic development programme (ADP) integrated into an existing South African medical training programme retained ADP students and enabled them to graduate within a reasonable period of time; (ii) the academic impact of the ADP, and (iii) whether performance in high school matriculation examinations predicted performance in medical school. Methods This retrospective study analysed records of medical students admitted between 1991 and 2001. Non‐ADP and ADP students were compared with respect to: student retention; time to graduation; matriculation scores, and performance in medical school. The association between matriculation scores and third‐year examination results was determined. Results The average student retention rates for the non‐ADP (1992–2001) and ADP (1991–2000) cohorts were 92% and 70%, respectively. Non‐ADP and ADP students who graduated were compared with respect to four parameters: the mean additional time required to graduate by each group was 0.16 years (95% confidence interval [CI] 0.13–0.18) and 0.38 years (0.27–0.48), respectively. Mean matriculation scores were 44.5 (95% CI 44.4–44.7) and 37.4 (95% CI 37.0–37.7) points, respectively (effect size = 3.2). Mean marks for third‐year courses were 65.0% (95% CI 64.6–65.4) and 58.7% (95% CI 57.7–59.6), respectively (effect size = 1.0). Mean marks for final‐year courses were 68.3% (95% CI 68.1–68.5) and 64.2% (95% CI 63.6–64.7), respectively; the effect size remained constant at 1.2. Third‐year marks for non‐ADP and ADP students, respectively, showed moderate (11%) and low (3%) association with matriculation scores. Conclusions Although the retention of ADP students was lower than that of non‐ADP students, the ADP enabled those who graduated to overcome the effects of under‐resourced schooling and to perform well in final‐year examinations.     

Generic skills in medical education: developing the tools for successful lifelong learning

Medical Education 2012: 46: 120–128 Context Higher education has invested in defining the role of generic skills in developing effective, adaptable graduates fit for a changing workplace. Research confirms that the development of generic skills that underpin effectiveness and adaptability in graduates is highly context‐dependent and is shaped by the discipline within which these skills are conceptualised, valued and taught. This places the responsibility for generic skills enhancement clearly within the remit of global medical education. Implications Many factors will influence the skill set with which students begin their medical training and experience at entry needs to be taken into account. Learning and teaching environments enhance effective skill development through active learning, teaching for understanding, feedback, and teacher–student and student–student interaction. Medical curricula need to provide students with opportunities to practise and develop their generic skills in a range of discipline‐specific contexts. Curricular design should include explicit and integrated generic skills objectives against which students’ progress can be monitored. Assessment and feedback serve as valuable reinforcements of the professed importance of generic skills to both learner and teacher, and will encourage students to self‐evaluate and take responsibility for their own skill development. The continual need for students to modify their practice in response to changes in their environment and the requirements of their roles will help students to develop the ability to transfer these skills at transition points in their training and future careers. Conclusions If they are to take their place in an ever‐changing profession, medical students need to be competent in the skills that underpin lifelong learning. Only then will the doctors of the future be well placed to adapt to changes in knowledge, update their practice in line with the changing evidence base, and continue to contribute effectively as societal needs change.     

Maternal literacy and health behavior: a Nepalese case study

This article addresses the question of whether literacy could be mediating the relationships of schooling to maternal health behavior in populations undergoing demographic transition. Recent studies in which literacy was directly assessed suggest a literacy pathway to demographic change. The literacy skills of 167 urban and rural mothers of school-aged children in Lalitpur District of the Kathmandu Valley of Nepal were assessed by tests of reading comprehension, academic language proficiency, health media skills and health narrative skill, as part of studies in the urban and rural communities that included a maternal interview and ethnographic fieldwork on the contexts of family life, health care and female schooling. Regression analysis of the data indicates the retention of literacy skills in adulthood and their influence on health behavior; ethnographic evidence shows that selective bias in school attainment does not account for the results. Further direct assessment studies are recommended.     

Overseas‐trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains

Objective: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs’ transition, integration and retention. Method: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co‐workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin. Results: Identity as ‘fluid’ emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process. Conclusion: The reconstruction of OTDs’ identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs’ integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains. Implications: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs’ capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.