Section 5: Guidelines for Difficult Conversations  

1.) Culturally Responsive and Trauma-Informed Approaches to Clinical Teaching

A culturally responsive and trauma-informed approach recognizes that students enter clinic with diverse backgrounds, communication styles, and lived experiences that shape how they learn, how they interact, and how they respond to feedback. Preceptors who adopt this lens are better equipped to interpret student behaviors accurately, deliver feedback compassionately, and foster an inclusive learning environment that supports all learners.

• Recognizing Cultural and Individual Differences
  When considering student performance or reactions to feedback, preceptors should be mindful of cultural context, ethnicity, underlying mental health conditions, or learning differences—including anxiety, depression, or ADHD—that may influence communication, confidence, or emotional regulation. Students may also be managing personal challenges at home or interpersonal stressors that impact their bandwidth in clinic. These factors can influence how students receive and process feedback, so it is essential not to expect a single “correct” response based on dominant cultural norms.
• Examples of Culturally and Trauma-Informed Awareness in Action
  • Cultural expression of respect:
    In many Asian cultures, lowering one’s eyes or speaking softly is a sign of respect toward authority. A quiet or hesitant student may not be disengaged but rather showing deference. A culturally sensitive inquiry might be:
    “I’ve noticed you tend to speak quietly when we discuss cases. I want to make sure I understand your thinking. Is there anything influencing how you communicate with me—culturally or otherwise—that you’d like me to know so I can better support you?”
  • Silent acceptance of feedback:
    In some cultures, it is respectful to receive feedback without verbal response or explanation. While this may seem dismissive to a preceptor, it may actually indicate full attentiveness. Open-ended questions can help determine whether the student has absorbed and understood the feedback.
    
  • Family stress and mental health:
    A student experiencing anxiety or depression due to family issues—such as illness, financial instability, or conflict—may appear withdrawn, overwhelmed, or unusually sensitive during feedback. These responses may reflect emotional strain rather than lack of motivation. A trauma-informed check-in might sound like:
    “I’ve noticed you seem more overwhelmed recently. You don’t need to share details, but if something outside of clinic is impacting your stress level, I want to be aware so I can support your learning. Is there anything you’d like me to know or anything that might help you feel more grounded here in clinic?”
    This approach acknowledges the student’s humanity, respects their boundaries, and avoids assumptions or pathologizing.
    
• Core Principles of Trauma-Informed Precepting
  Trauma-informed teaching does not require knowing students’ personal histories; instead, it relies on universal principles such as:
  • Safety: Creating an environment where students feel physically and emotionally safe to learn and ask questions.
    
  • Trustworthiness and Transparency: Clearly explaining expectations, processes, and academic implications.
  • Peer and Preceptor Support: Encouraging a team culture where interns help one another.
  • Collaboration: Framing feedback as a shared effort, not a hierarchical judgment.
  • Empowerment: Highlighting student strengths and reinforcing progress while identifying areas for growth.
  • Cultural Humility: Recognizing cultural influences on behavior and avoiding assumptions about intent or capability.
    

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• Why This Framework Matters
  Culturally responsive and trauma-informed precepting not only helps prevent misinterpretation of student behaviors but also enhances learning outcomes, strengthens professional identity formation, and supports equity in clinical education. By viewing students through a holistic lens and responding with curiosity rather than judgment, preceptors create a learning environment where all students—regardless of background, stressors, or neurodiversity—can thrive and reach their clinical potential.

2.)  Your tone matters just as much, if not more than your actual message.

 Put another way, “It’s not what you say, it’s how you say it.”

• Avoid sarcasm, condescending tone, and/or being curt. Be inviting, welcoming, and supportive in conversation.
• Many students are hypersensitive to negative feedback. Although it is not your job to accommodate every student’s sensitivities, keep in mind your main goal- to have feedback heard and incorporated.  You improve your chances of achieving this goal by delivering feedback with a supportive tone.  
• Preceptors encourage students to ask questions when they don’t understand the material. Many preceptors welcome questions – “There are no stupid questions.”  There are other preceptors, however, who will encourage questions, but then are disparaging, caustic, or disapproving in their response to questions. As a result of this approach, many students will respond by asking fewer questions. 
• Not everyone is aware of how their tone may be coming across or interpreted by others. Feedback from fellow peers may help with ways to improve tone when providing feedback.

3.) Keep your overall goal in mind: Creating the best environment to convey feedback and to have it received. You want students to hear your feedback and integrate it into their practice. Individuals are more receptive to feedback when their nervous systems are not dysregulated into a fight or flight response.  Continually ask yourself before and during feedback, “How can I give myself the best opportunity to be heard and understood?” Oftentimes, the answer to this question will involve assessing your tone versus your message. 

4.) Stay calm.  

• Regulate your tone of voice (e.g., avoid raising your voice) and maintain an open body posture. Calm breeds calm.  Recall #3: A relaxed nervous system contributes to a receptive student.
• Open body posture and communication pointers:
  • Arms uncrossed
  • Body squared toward student
  • Eye contact
  • Leaning toward the student when listening 
  • Nodding
  • Paraphrasing student’s concerns/responses (e.g., “You’re confused as to why your grades do not match the feedback that I’m giving you.”)

5.) It is hard to stay calm all the time. Situations and people trigger us! Think about how you are feeling in the moment and how that might influence the situation. We might feel dismissed, unimportant, unheard, disrespected, etc.  These reactions occur in response to student behavior, but they are also related to our own sensitivities, biases, and our templates for relational patterns, particularly concerning authority figures.

6.) When you are calm, you can better help students regulate their emotions.  You want students to maintain an ideal level of anxiety during feedback. When students feel just enough anxiety to motivate them to change, but not so much anxiety that they freeze, they will fully understand and subsequently incorporate your feedback (recall: Do #3).  Some tools that may help de-escalate anxiety include empathizing, normalizing, and validating students’ emotions in response to receiving your feedback. Think about how you would want to be told this information or how you would share it with a loved one. 

• Empathizing: “I remember being in your shoes as a student- I also used to feel frustrated- and sometimes even angry- with myself and/or my preceptors when receiving feedback.” 
• Normalizing: “It’s normal to feel upset when you receive constructive criticism or negative feedback; many students with whom I work react the same way.” “Feedback is part of the process of becoming an optometrist- we’ve all been there!”
• Validating: “You’re feeling anxious right now. It’s okay to feel anxious.  Why don’t we take a few breaths together and then proceed when we’re feeling a little calmer.”

7.)  Collaborate with the student during a feedback session. Remind them that feedback isn’t intended to be taken personally and that it is an important part of the training process. Get the student’s ‘buy-in’ on how to deliver feedback. This will help them to feel more in control of their situation. Check-in with them and their emotional reactions. Help students understand what falls within their control to change versus what does not.

• Examples:
  • “I understand that feedback can feel like a personal attack sometimes. I wonder if you could reframe receiving feedback as being part of your job as a student. Feedback can be positive- it will help you achieve your ultimate goal of becoming an optometrist.”
  • “How do you prefer to get feedback from preceptors?” i.e.,  Do you like direct feedback?  Do you prefer to hear what you’ve done well and then what you need to work on?  If you get upset, do you prefer to be left alone to collect yourself or would you prefer that I stay with you to support you?  Are you someone who likes to be given specific tools to work on your skills or do you tend to like to figure things out on your own?  Do you prefer written or verbal feedback?
  • “You seem angry/anxious/upset.  Am I correct?  How can I support you right now?”
  • “You think you received poor scores from Dr. X because he doesn’t like you. That may be true and it may be untrue.  Regardless, you can’t control how he feels about you.  What can you control about this situation?”   

8.) Assume positive intent coming toward you and from you. Assume students want to learn. Assume that you have their best interests at heart.

1.)   Don’t take ‘it’ personally. When a student gets angry/cries/freezes up- you may become emotionally reactive. Their response to your feedback may have nothing to do with you. As mentioned above, you come to the interaction with your own set of sensitivities, biases, and templates for interactions with authority figures- your students do too! If you are applying the above “Do’s” and you know that you are not coming from a place of anger/manipulation/retribution when delivering feedback, then their response has nothing to do with you.  They are entitled to their feelings. Their behaviors, however, in response to their emotions may have consequences (e.g., professionalism citations).

2.)   Whenever possible, provide feedback without the presence of others.  Students can become very self-conscious, ashamed, and/or embarrassed when receiving feedback in front of their peers, patients, and other preceptors.  When they experience these negative emotions, they are less likely to attend to what you are saying.  Remember Do #3: Provide feedback so that your student hears you.

3.) Don’t jump to conclusions about your student.  Mislabeling your students as lazy, unmotivated, or disinterested, can be dangerous for subsequent interactions with them.  You could be misattributing their undesirable behavior.  Recall Do #8: Assume positive intent.

4.) Don’t get defensive when a student reacts negatively toward you and/or your feedback.  Your defensiveness and anger may breed the same response (or some other emotional response such as increased anxiety) in the other party. It can be hard not to get defensive, especially when a student blames YOU for their failure. When you’re feeling defensive, take a minute and notice it. Reflect back to the student, “You feel I could’ve done that differently.”  You don’t need to take on ownership/blame. People just want to be heard. Reflecting and/or paraphrasing shows that you are listening and hearing the student.  Once you reflect or paraphrase, move on with your feedback.