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phases of skill acquisition [30]. Questioning on the part of the trainer fosters active engagement and reflection and encourages the trainee to think independently and to consider potential solutions as opposed to simply being informed of the best option. Incorporation of problem‐solving and active decision‐making helps foster lasting skill development and build a trainee’s capability for self‐reflection which is key to developing conscious competence.

      Performing two tasks simultaneously can be challenging as humans only have a finite capacity to process information in their “short‐term” or working memory. When working memory becomes overloaded, learning and performance suffer. This phenomenon is termed cognitive overload or dual task interference [44]. In providing instruction during a training encounter, it is important for the trainer not to cognitively overload the trainee with too much information. In the context of endoscopy, continual feedback (concurrent feedback) has been showing to hinder learning [45] as it likely places a high extraneous cognitive load on trainees such that they focus their attention on listening to the feedback, as opposed to engaging in problem‐solving and learning from the task at hand. Additionally, the provision of continuous instruction may impose excessive cognitive demands on the trainer, ultimately disrupting the trainer’s concentration and impairing feedback provision. To minimize cognitive overload when providing performance enhancing instruction during a procedure, it is important for the trainer to ask the trainee to stop (assuming it is safe to do so), stabilize the endoscope, and direct their attention to the trainer. Additionally, feedback should focus on simple, well‐defined, and achievable points, and questions should be limited in number and complexity to avoid overburdening the trainee. This is particularly important for less experienced trainees who are struggling and have limited additional attentional capacity. For similar reasons, trainees should be encouraged to refrain from providing verbal commentary on their performance because this requires cognitive effort and can result in decreased performance and learning.

      Cognitive load can also impair training effectiveness if the training tasks are too difficult. Complex tasks drain cognitive resources and make a trainee less able to attend to and respond to instruction [46]. Studies carried out in the simulated environment suggest that learning is enhanced if task difficulty is gradually increased to align with a trainee’s developing skill level over time [47, 48]. To maximize learning early in training, tasks should be broken down into smaller units (e.g., torque steering, loop resolution) and objectives should be discrete and manageable (e.g., navigating the splenic flexure) [2]. This strategy, termed chunking (breaking up a complex procedure into smaller, more manageable parts or “chunks”), has been shown to be useful in many skill areas [49]. As the trainee improves at the task, difficulty can be increased and/or the amount of support a trainee is receiving (i.e., the amount of instruction) can be gradually withdrawn to challenge them [14, 50] (See also Chapter 2).

      Trainers must also be aware of the words and phrases they use to explain things. Often many different terms are used to explain the same concept (e.g., “deflect the tip down” yields the same results as “turn the big wheel up”) and non‐specific terminology is used (e.g., “go a little bit over there”). The use of non‐standardized terminology can lead to confusion. It is, therefore, recommended to use a common language to ensure consistency and clarity of instruction and avoid confusion. For example, directive instruction for colonoscopy can be restricted to the 14 terms:

      1 stop

      2 slow down/slowly

      3 advance

      4 pull back

      5 tip up

      6 tip down

      7 tip right

      8 tip left

      9 torque clockwise

      10 torque counterclockwise

      11 insufflate

      12 suck/aspirate

      13 rinse

      14 irrigate.

The use of common language makes clear what actions are required and enables the trainer to control the procedure while not handling the endoscope. Research has shown that when providing instruction, it is more beneficial for trainers to direct attention to the effects of a particular movement (external focus of attention) as compared to directing attention to the movements of the trainee (internal focus of attention) [51]. Therefore, instructions should always be provided in reference to the video monitor view as opposed referring to the trainee’s hands. For clarity, use of a “clock face” analogy can be useful (e.g., advance the tip toward 8 o’clock). It is important for the trainer to check in with the trainee throughout a session to ensure the trainee clearly understands the instructions they are receiving and for the trainer to modify their feedback as required.

      Wrap‐up

      The Wrap‐up phase is the period of time immediately following the training encounter, the aim of which is to review and reflect on the encounter as well as generate learning objectives for future training sessions. It is important for the trainee and trainer to meet briefly in a private area to reflect on the entire training session without being distracted. Too often during feedback sessions, the trainer merely summarizes what happened during the procedure. Although it is important to ensure that critical training moments are highlighted accurately, the key learning from any training session lies within the reflection on what happened as opposed to the description [4]. If the conversation is oriented solely toward past events, trainees too often become defensive or disengaged when reminded of their deficits, which impedes learning [52].

      The bulk of the feedback should be provided during the wrap‐up phase, providing the trainee time to reflect on their performance before hearing the trainer’s perspective. Constructive performance enhancing feedback, with reflection and active trainee engagement, is a cornerstone of effective training and is essential to reinforcing learning from the session. The effectiveness of feedback largely depends on what information is given, the manner in which it is delivered, and how it is interpreted. It is essential for the trainee to be allowed to reflect on their performance, as trainees generally have great insight if they are given the time to formulate their thoughts. Feedback should be a two‐way dialogue between the trainee and trainer that is objective and based on observable behaviors [53]. Merely “telling” the trainee ignores the active role they must play in constructing meaning from the feedback message. Feedback should be delivered in a nonjudgmental, constructive manner and focus on modifiable behaviors. Additionally, it should directly relate to the predetermined learning objectives whenever possible.

      Feedback should focus on observable behaviors and incorporate specific suggestions for improvement [30, 54, 55]. When the trainer is aware of an issue that the trainee does not raise, the trainer should present data (e.g., describe specifically what happened) in a nonjudgmental way, provide their interpretation of it, and then seek clarification from the trainee about their perspective or give them an opportunity to provide a rationale for their actions [53, 56]. Open‐ended questions, such as “Can you recall what prompted you to do that?” should be used to encourage trainees to explore their actions and, if appropriate, identify alternative behaviors. Trainees are more likely to retain knowledge if they are actively involved in the discussion and problem‐solving [52]. Additionally, trainee engagement helps the trainee feel empowered, builds self‐assessment skills, and helps the trainer gain insight into the trainee’s self‐perception [57].

Figure 4.4 ACT model of performance enhancing feedback: Ask the trainee, Conversation, Take‐home message.

Performance enhancing feedback can be delivered either in an informal manner or by using a formal structure, such as the ACT model of feedback (Figure

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