Teach a skill, give feedback and calibrate supervision — the bedside teaching encounter

Teach the skill — Peyton's four-stage approach. The principle of Peyton's method is that the trainee performs the skill, not merely watches it, and the progression from passive observation to active performance is staged so the motor and cognitive components are separated and rehearsed.^[1]

• Stage 1 — Demonstrate. I perform the whole intercostal catheter insertion at normal speed, in silence, on the model or the prepared patient. The trainee sees the finished product.
• Stage 2 — Deconstruct. I perform the skill again, slowly, narrating every step — the safe-triangle landmark, the local anaesthetic infiltration (maximal dose, intradermal then deeper), the incision, the blunt dissection, the finger sweep to confirm entry into the pleura, the tube insertion, the connection to the underwater seal, the suturing and the dressing. The trainee sees the component parts.
• Stage 3 — Demonstrate while the trainee narrates. I perform the skill while the trainee narrates each step aloud. The trainee now supplies the cognitive script while I supply the motor performance.
• Stage 4 — The trainee performs while narrating, under my supervision. The trainee performs the insertion while narrating each step aloud, with me scrubbed and ready to step in. This is the step that confirms the skill is learned.^[1]

Feedback — the R2C2 facilitated reflective model. After the procedure I give feedback using R2C2 (Sargeant, Lockyer), which supersedes the rigid positive-first structure of Pendleton and is built on the recognition that feedback works only when the recipient engages with, accepts and acts on it.^[2] The sequence is:

• Build Relationship. Set a respectful, learning-focused tone; ask permission to give feedback; explore what the trainee wants from the conversation. Relationship is the substrate on which the rest depends.
• Explore Reactions. Invite and accept the trainee's emotional reaction — defensiveness, surprise, disappointment — without judgement, before any content. The reaction is surfaced and worked through first.
• Explore Content. Examine the specific observations together — what I saw, where the gap lies — as a shared inquiry, not a pronouncement. The trainee contributes to the interpretation: 'Your landmarking was accurate and your asepsis was sound; the finger sweep was too shallow to confirm pleural entry before the tube passed.'
• Coach for performance change. Collaborate on a concrete, specific, achievable action plan — 'on the next attempt, advance the finger fully to confirm you are in the pleura before the tube' — and commit to follow-up. The goal is behaviour change, not delivery of the message.^[2]

I avoid the feedback sandwich (positive, correction, positive): it primes the trainee to dismiss the correction, erodes my credibility, and drives vague, non-specific positives. I deliver the specific, behaviour-focused correction directly, surrounded by genuine, specific reinforcement where it is earned.^[2]

Entrustment level — and the justification. The entrustable professional activity (EPA) is 'insert an intercostal catheter for a traumatic pneumothorax'.^[3] I assign entrustment level 2 — act with direct, proactive supervision: the trainee performs under my direct observation, in the room, ready to step in.^[4] I justify the level on the evidence: this is the trainee's first supervised attempt (level 1 would be observe only), the skill has not yet been demonstrated independently, and the entrustment decision is driven by the supervisor's judgement of the trainee's competence on the specific task and the context. I name the level explicitly to the trainee and state the progression criterion: 'I want to see two more under direct supervision before you move to reactive supervision (level 3).' I document the level so the supervision is legible and the progression deliberate, not left to drift by default. Entrustment is task- and context-specific — the same trainee at level 3 on a simple laceration is dropped to level 1 or 2 on the difficult airway.^[3][4]