The impact of facilitators and rural immersion on medical student engagement during a Child and Adolescent Psychiatry Videoconference workshop.

Background: Child and adolescent mental health disorders are a major public health problem worldwide therefore medical students need robust child and adolescent psychiatry (CAP) training. Facilitators are known to enhance student engagement during CAP education. The Rural Clinical School of Western Australia CAP training is provided locally, supplemented by a multi-site annual VC workshop involving specialists collaborating with facilitators on site. We aimed to investigate how student engagement during a CAP VC workshop is inuenced by the presence, role and/or context of facilitators; establish if presenting a clinical case inuences student engagement; and explore how immersion at a rural site inuences CAP learning. Methods: All students and facilitators were invited to participate in a semi-structured interviews conducted after the workshop. Purposive sampling was used to select student participants. Interviews were conducted until data saturation was reached. Data analysis was inductive, commencing with immersion in the data. Transcripts were then coded, with codes aggregated to categories analysed thematically . Results: Student engagement during a rural CAP VC workshop is strongly inuenced by the physical presence of facilitators, their personality attributes and facilitation skills. Facilitator personality attributes, non-teaching skills and supportive behaviour may have a more signicant impact on engagement than clinical expertise. Students perceived they had limited clinical exposure to CAP, contrasting with facilitators who perceived students had sucient, but unrecognised, exposure. Conclusions: Facilitator personality attributes, non-teaching skills and supportive behaviours have a signicant impact on student engagement and learning. Facilitators can assist students to recognize CAP presentations in patients they encounter, to maximise learning opportunities. the physical presence, role and/or context of teacher facilitators; led case and immersion in rural sites. at undergraduate level.


Background
Child and adolescent mental health disorders are a major public health problem. The World Health Organisation (WHO) estimates 10-20% of children experience one or more psychiatric disorders, with an estimated prevalence of 14% in Australia. 1 This public health issue is compounded by a shortage of child and adolescent psychiatrists in Australia and internationally. 1 Availability of mental health services is further limited for rural patients, with psychiatrists more likely to be concentrated in metropolitan areas in Australia, 2 and internationally. 3,4 Paediatricians and GPs in rural areas are therefore essential to identify, assess and manage common child and adolescent psychiatric (CAP) presentations 1,4−6 yet it is known that GPs can experience di culty with regards to recognizing and managing mental health problems. 6,7 To prepare students for postgraduate work as doctors, CAP teaching needs to ensure graduates have knowledge of common CAP disorders, and the skills to assess children with mental health presentations. 6,8 The care of children with CAP presentations could be improved by enhancing medical education to re ect the future needs of GPs, including supporting CAP to have a proportionate emphasis in the medical curriculum. 9 To date, however, CAP education in medical schools has been limited, 1,5,8 with enormous variation in curricula internationally. 6 CAP teaching aims are frequently ambiguous and there is no consensus on which core topics should be taught or the optimum number of hours of teaching required. 9 Teaching methods that encourage an active role for students, such as interactive case discussions, 1 improve enjoyment and interest in clinical cases, 10 yet didactic lectures and seminars remain the most commonly used CAP teaching methods in Australian medical schools. 1 Given these limitations, optimal student-teacher engagement is crucial to maximize learning during CAP teaching. 11 Facilitators can assist with student engagement during CAP education, 4

with bene ts of co-facilitation by rural
GPs and a child psychiatrist demonstrated in rural CAP teaching workshops. 4 Effective facilitation can occur by videoconference (VC), with the facilitator located remotely. 12 Quality of facilitation and facilitator expertise strongly in uenced student learning experiences with perceived quality of facilitation skills related to the facilitator's individual personality attributes and their ability to guide the process and encourage participation. 12 While these studies provide some data on CAP education and effective facilitation via VC, 4,12 to our knowledge, there are no published qualitative studies on medical student CAP teaching in rural and remote settings in Australia.
The Rural Clinical School of Western Australia (RCSWA) is well placed to conduct a qualitative study on CAP medical student education in rural settings. RCSWA students are located in 14 widely dispersed rural or remote (RA2-3) 13 sites up to 2175 miles (3500 km) from the city campus. During the forty-week Rural Integrated Clerkship, which comprises one year of their four-year postgraduate medical degree, students are predominantly community based, with access to small regional hospitals. Teaching is mostly by GPs, with few sites having resident child and adolescent psychiatrists and/or paediatricians. The remaining sites mostly have access to visiting specialist psychiatry and paediatric services.
RCSWA teaching includes an annual half day CAP VC workshop, involving rural GP facilitators and a panel consisting of rural and urban child and adolescent psychiatrists and an urban paediatrician. The workshop objectives align with medical education recommendations for CAP teaching 6 and provide students with CAP knowledge and skills, through learning from rural cases. Students are actively involved in the learning process during the workshop with on-site GP facilitators present at some sites. It is unproven if the current workshop format, and the students being immersed in a rural context produce an effective and engaging student learning experience.
This qualitative study aimed to explore and understand the factors that impact on student engagement during a CAP VC workshop including but not limited to: the physical presence, role and/or context of teacher facilitators; student led case presentations and immersion in rural sites. The study ndings will inform the development of future effective methods to engage students in learning about CAP 14 at an undergraduate level.

Methods
The methodological approach used for the study was informed by the principles of phenomenology. Through exploration of RCSWA student and facilitator experiences and views we sought to capture the meaning and shared features of the CAP VC workshop learning experience. 15 Ethical approval was granted by the University of Western Australia Human Ethics Committee, approval number RA/4/20/5452. All RCSWA students and workshop facilitators, located in 14 RCSWA sites, were invited to participate in the study by the site administrator, responsible for site organisation, during routine meetings. A total of 47 students and 5 facilitators from 11 sites consented to participate in the study. Purposive sampling was used to select RCSWA students from a variety of different sites and include perspectives of sites with and without facilitators present during the workshop. This was done in order to capture rich, relevant and diverse data pertinent to the research questions. Convenience sampling was used for facilitators, with those able to be contacted interviewed. 16 During the four-hour workshop, six clinical cases relevant to CAP were presented by selected sites. In preparation for the workshop, students and facilitators were provided with online access to CAP learning modules, 17 and each site was allocated a task -a case presentation, posing questions to the CAP expert panel, or psychiatric formulation presentation. Psychiatric formulation is considered to be a core competency of psychiatric practice 18 and is a succinct description of the key features of a case, with hypotheses about the aetiology and perpetuating factors, and translation into suggested speci c individualised treatment approaches. 19,20 Following each presentation, students created a case formulation with their peers, involving their site facilitator, where present. The allocated site then presented their formulation to the whole VC workshop. The panel provided interactive teaching during the workshop, including examples of case formulations, feedback, and inviting on-site facilitators to give rural GP expertise. Twelve sites had a facilitator present, who were largely experienced GPs and senior medical practitioners. One facilitator was a rural psychiatrist so had a dual role as an expert panel member.
Semi-structured interviews were conducted with the participants to explore the experiences of participants and the meanings they attributed to them. 21 Students' and facilitators' experiences were collected in face-to-face interviews either in person or via VC, used routinely in RCSWA, and for prior qualitative research. 22 Interviews were conducted by the rst author, a second-year psychiatry registrar at the time of the study who was independent of RCSWA in order to provide an impartial perspective. 14 Interviews were between 12 and 40 minutes in duration, and were conducted in the two weeks following the workshop to capture participants' experiences while they were still recent.
The interviews covered three broad topics including the role of facilitators, the impact of case presentation on student engagement during the workshop and how immersion at a rural site in uenced CAP learning. Open-ended questions were asked (Appendix 1) and the semi-structured format ensured consistent exploration of all topics across all interviews whilst allowing for the introduction of new themes. Interviews were conducted until data saturation was reached. 21 The interviews and coding were conducted by the rst author alone with rigour enhanced through measures such as bracketing and regular consultation with research team members. 15 Interviews were audio-recorded and transcribed with de-identi ed transcripts imported into NVivo 12. Data analysis was inductive, commencing with immersion in the data with repeated reading and re-reading of interview transcripts. Following this the transcripts were coded in consultation with the research team and an agreed list of codes was developed as coding progressed. Codes, for example, facilitator personality, facilitator perspectives, facilitator expertise, facilitator role and physical presence were then aggregated to categories e.g. 'Facilitators'.
Themes were then identi ed from the categories. 23 Supporting quotations are provided in order to illustrate the themes identi ed, with quotations from different participants in order to add transparency and trustworthiness to the ndings. 21

Results
Page 5/17 21 students and 3 facilitators from 10 different RCSWA sites were interviewed. Table 1 indicates the breakdown of the participants from each site. Seven of the interviewed sites had a facilitator present, two sites had no facilitator present during the workshop and one site had a facilitator for only the second half of the workshop. Three main themes emerged which appeared to impact student engagement in learning about CAP. These

Student perception of facilitators
The data shows that having a facilitator physically present was widely experienced as positive and contributed towards greater student engagement. Facilitator presence optimized the bene ts that facilitator skills and personality attributes brought to the workshop experience and had practical bene ts, such as the ability of facilitators to debrief students following the workshop.
Several students described positive perceptions of their facilitator's personality attributes describing them as wellsuited to their facilitator role with characteristics of warmth, friendliness, and approachability. This resulted in students feeling comfortable in the workshop learning environment, enhancing their learning experience. An established relationship with the facilitator prior to the workshop also increased students' comfort level with their facilitator. Facilitators commented that personality attributes rather than clinical expertise were more important for their role during the workshop.
Although they did not directly experience this, facilitators and students postulated that facilitator personality attributes that resulted in students feeling intimidated, placed under pressure, and judged could have negatively affected the student workshop experience.
The perception of the quality of facilitation skills was strongly linked to student engagement. Comments from students both with and without a facilitator present re ected a perceived need for the facilitator to be physically present in the room for these skills to have maximum impact. Guidance, discussion and encouraging peer-to-peer interactions and participation increased engagement, and students felt their facilitator's presence kept them focused and minimized distractions.
Facilitators took on the role of motivator when required, both prior to and during the workshop. At one site, during pre-workshop discussions with their facilitator, students revealed that they had not done their pre-workshop preparation as they thought that CAP was "boring". After discussion with their facilitator the students experienced a shift in their attitudes, ultimately nding the workshop an interesting, enjoyable and useful learning experience.
Independent of engagement, the presence of facilitators enabled the provision of emotional support and a debrief, which students valued. Facilitators helped reframe cases involving complex psychosocial situations with a positive perspective, drawing students' attention to opportunities for intervention and clinical improvement. Due to the potentially distressing nature of the CAP cases presented during the workshop, both facilitators and students were concerned about negative emotional consequences for the students if a facilitator was not present.
The two students from the sites without facilitators identi ed advantages and disadvantages of learning without an educator present. Bene ts of learning without a facilitator including feeling more at ease and relaxed in their learning environment, and having greater opportunity to lead their learning. Had a facilitator been present, students felt that the learning experience would have been enhanced through discussion, enquiry and the provision of guidance and feedback.
Students and facilitators at some sites felt there was a need for clari cation of the role of the facilitator prior to and during the workshop, with role confusion potentially leading to an underutilisation of facilitator skills and expertise. ' I think it's probably more about who the facilitator is as a person and probably the more exposure you'd have to these cases. The good thing about GPs is that you get exposed to them [patients] in their acute unwell time that they are now getting presented but you also see them when they've recovered from that and they're -they've got a cold and they're planning a pregnancy and so I think you probably have a little bit more of that balance of the whole human.' Facilitator 1, Site 10 Facilitation skills 'I think the major thing was just adding another perspective in discussions, and also being able to t things into categories we weren't sure about, she was really helpful. Clinical Exposure in the Rural setting Some students felt that learning within a rural context during their RCSWA time had reduced their opportunities for clinical exposure to and engagement in CAP learning, while others described a positive experience with rich learning opportunities in CAP in the rural general practice context.
The accounts of students and facilitators demonstrated contrasting opinions regarding the amount of prior clinical exposure to CAP students had experienced. Di culty identifying relevant CAP cases to present due to a perceived lack of prior clinical exposure was a common concern among students, and a source of stress. Many students perceived they had limited clinical exposure to CAP throughout their medical training and during their RCSWA placements. Students reported lack of clinical exposure was due to irregular visiting specialist psychiatric teaching at RCSWA sites and limited rural psychiatric services. Students felt the integrated RCSWA curriculum contributed to their lack of exposure as there was no formal CAP clinical term, something students perceived they might have in the city and felt they might be missing out on. Facilitators, in contrast to many of the students, believed students had experienced extensive exposure to CAP patients during their RCSWA time but may not recognize these experiences as CAP cases.
Some students recognized that their CAP learning had been integrated during the clinical year. Learning within the RCS context had given them insight into the important role of rural GPs and the unique issues they face in managing CAP, given the lack of specialist psychiatrists and reduced access to services in remote and rural areas.
Students highly valued the exposure to a diverse range of clinical case presentations during the workshop, particularly given their perceived lack of clinical exposure. CAP expertise and Aboriginal cultural perspectives provided by an Aboriginal facilitator were highly valued by students and facilitators, and felt to be highly relevant to the rural context.  'In general, the RCS way of learning is a lot more, like less structured and less organized. But maybe more real life, and I really like it in a lot of ways. But I feel like maybe psych is one of the areas that we haven't had quite as consistent teaching. I feel like it's one of the areas where our knowledge is lacking. I think I speak for all the students at this site. Maybe potentially being a small site as well, we don't have a big psych unit or much access to child psychiatrists or anything up here.' Student 12, Site 5, Facilitator present 'We do see a lot of children but the child and adolescent mental health side of things is often not so much addressed. I see children a lot in ED and things and the primary presentation isn't necessarily the mental health side of things. I do think about this a lot. It surprises me because there's a lot of those trauma and a lot of rough stuff going on up here. I think being in the country I do get exposed to probably more given that I'm not on a paediatric, psychiatric term. But I think in the city if I was on a psych term or something like that or maybe in a GP practice in the city, I might get more exposure then.' Student 8, Site 3, Facilitator present 'I understand that there's a degree of, you know, I should be more proactive in my own learning in terms of seeking out the opportunities and I think they probably are there if you are proactive about it, but I don't feel like they -it's not like if you're in the city and you're doing a block of psych for three weeks, that's all you do. It's sort of a bit informal I guess, which can be challenging to learning.' Student 13, Site 5, Facilitator present 'I mean it's certainly opened our eyes to things like rurality and just that massive impact that has on accessing services and then once you've accessed services to then being able to continue or any of those things are just so impacted by living far away from everything.' Student 20, Site 9, Facilitator present second half Clinical exposure -facilitator perception 'And there was this urry of panic. What case? We didn't know we had to do a case. And one of the students emailed back in this group email and said, I haven't seen any childhood psychiatry in [RCSWA site] this year. And I just that -as if you haven't seen any childhood psychiatry in ED, GP, AMS -they've kind of, it hasn't been handed on a platter, sitting with a psychiatrist in a room. And so, we had a bit of chat about that […]And I was like what do you think about all thisanyway. So, then I think he realized then that there was lots of childhood psych.

…. yes you have to kind of reframe their ideas of what's in -it's just laughable that they say there's no children in [RCSWA site]…
….And then to try and tell me that there's no child psychiatry stuff happening. So, then we just talked about -well what do you think about the school avoidance and the kids that come with anxiety and the kids that are -oh, yeah, okay, all right. But we don't see psychotic kids, they say. Yes, okay, well, that's one small part of psychiatry really. But, I guess, that's what medical students are like, they want see the pointy end of stuff rather than realising its all on a spectrum.' Facilitator 2, Site 3 'That's what I quite like about them having to nd a case because then they have to start thinking about what that might look like[…]But I think nding -thinking about cases and where you might nd them, I think in the city you'd be looking for a child and adolescent psych rotation to nd a child and adolescent psych list. And we have -we do have child and adolescent psychiatry services here but they're not freely available, so I think that bigger picture thinking is probably more -it comes easier to these guys after a year here'. Impact of external factors on engagement External factors other than the presence of facilitators impacted on student engagement. These included preparation prior to the workshop, VC logistics, the allocation of an active role, and the ability to engage interactively with expert panel members and peers during the workshop.
Students who had interactions with their facilitator and peers for preparation prior to the workshop tended to report they felt more actively involved in the workshop on the day. This contrasted to situations where one student prepared the case in isolation, resulting in the other students at the site feeling they had no active involvement in the workshop.
Having an active role during the workshop was strongly linked to engagement, with formulation and question roles perceived by some to be more engaging than presenting a case. Completing the formulations during the workshop increased engagement and facilitated peer-to-peer interaction as well as discussion with the facilitator, if present. Students also valued the formulation examples and feedback provided by the expert panel. Students wished they could have had more opportunity to ask spontaneous questions of the whole VC workshop. The limited ability to ask questions during the workshop increased the value students placed on having a facilitator physically present at the local site to quickly and easily ask questions.
VC audio-visual communication di culties negatively impacted on student engagement, however students were accepting of these issues when balanced against the opportunity to access CAP teaching. Students suggested that having fewer sites involved would have enabled them to have more of an active role and be more engaged.
Time pressure and the length of the workshop were factors in reducing engagement. Students frequently reported feeling fatigued towards the end -related to workshop length, the emotional intensity of the CAP cases presented, and whether they felt actively engaged or not. Students and facilitators noted that time constraints due to teaching timetables and clinical commitments limited the opportunity for debrief to be provided. Student suggestions for future workshops included increasing active engagement during the workshop, spontaneous questioning rather than assigned roles, better utilisation of technology such as an interactive live feed for comments and questions, more time allocated for questions, smaller number of sites involved, and conducting the workshop over two days. Table 4 Impact of external factors on engagement Preparation 'Before the workshop, prior to the workshop, we went through our case that we were presenting because he [the facilitator] wanted to know a bit more about it in a bit more detail and he was quite interested in it as well[…]it makes you more engaged in the workshop when your site has to present a case. Because I mean you have to prepare. Like it has to be thought about and you discuss it.' Student 15, Site 6, Facilitator present 'My feedback for our […] facilitator […] would be to get more involved with the students earlier on and make sure we had a good case to present because obviously having never done of those workshops before, we weren't really sure what sort of case we were supposed to present and how we were supposed to present it.
I mean sites had prepared slideshows and everything to present their case, whereas we didn't even really realize we were supposed to have found a case until a few days beforehand and then everyone was scrambling to nd something suitable.' Student 20, Site 9, Facilitator present second half Active Role 'For us, if we were presenting a case, we'd be more involved with the whole seminar, but the fact that we were just -we asked one question. Because when we had that break, we came up with a list of ve questions, I think it was, that we wanted answered, but obviously because of the time -so I didn't feel we were as involved as the other sites were as well. Obviously knowing everyone can't -it'd be way too long if everyone was to present a formulation and things like that, but I don't know how you would make us more involved, do you know?' Student 10, Site 3, Facilitator present 'I think being the site that ask questions is good because it sort of makes sure you really engaged, and it forces you to think, to extend the learning beyond what's being presented to you. But I do appreciate that from -you know, if you're running a 15-site VC with a site for the psychologist or psychiatrist as well, then it's not feasible to have 18 groups present 18 questions for every single case. But it was bene cial, you know, whether there was maybe some extended learning like within your sites come up with a question for each case and you guys can discuss it with your MC's afterwards or something like that, which I guess we could have done independently anyway. But I did think that being the question, or I guess the formulators as well, really improved what you got out of that case.'

Student 13, Site 5 Facilitator present
Ability to interact 'I think one of the key things I've learnt is throughout uni [university] is any time you have long blocks of teaching, if you're not -my pet peeve is if students aren't engaged in any degree, it becomes very easy for your concentration to like slip up, like an hour and half to two hours. But I suppose it's a good thing about having the facilitator and doing those formulations, like even just having those sheets, each time you're listening and you're writing down the things going on and then you're comparing to what [the facilitator] was doing on the board. Have I picked up key points that they've got and you're comparing to your peers when they feed back the formulation to [the facilitators] and it's like, have I got the same, got different?' Student 2, Site 1, Facilitator present -'But it [the case presentation] was prepared by one student, we didn't help at all, so yeah. I suppose the three of us didn't really interact with everyone else. I think if we had of had a facilitator who could have run it with us, practicing the formulations at the site would have been good as well, so it's just unfortunate we also didn't have that facilitator there, but there wasn't really anything that could be done about that.' Student 17, Site 7, No facilitator Workshop structure Preparation 'I think it was a fairly long morning, I think by the end we were kind of a bit dragged out. It dragged out a little bit and I think we were a bit kind of straining the brain to just keep on going.
I think it was just towards the end, especially for us because we didn't really have a formulation or anything, so we were just only passively observing. I think for us it kind of dragged out a bit, where maybe it wasn't the case for the other sites.' Student 19, Site 9, Facilitator present-'Just, I think it would be better if it was half the sites rather than all the sites, so that you played more of an active role in the whole process. So that for example, maybe you presented one of the cases and you did the formulation for another one or something, which was quite good. Also, it was very long, so I guess it could be a bit shorter. You justbecause it's such heavy content as well, it's so like it was just hard to concentrate for that long, when also dealing with something that's so… quite emotive and heavy.' Student 17, Site 7,No facilitator Discussion This study provides evidence that a local facilitator impacts student engagement during a rural CAP VC workshop.
The facilitator has most in uence on student engagement when they have an established relationship with the student, can assist students in recognising CAP cases in their rural context, and can address external factors related to the workshop learning environment such as preparation, VC logistics, the allocation of an active role, and the ability to engage interactively. Recommendations for optimal facilitation are in Fig. 1.
The importance of having a facilitator physically present to create an engaging learning experience was clear in this study. Facilitators, embedded in the rural community, provided real-life context to CAP cases and offered clinical wisdom and insights. The student-facilitator relationship and facilitator personality attributes impacted on student engagement and enabled student re ection. Facilitators enhanced learning and performance by promoting a safe learning environment and providing feedback. The importance of facilitators for CAP workshops has been reported previously, 4 but there has been a lack of consensus on whether facilitator expertise or facilitation skills were the more valuable attribute for student learning with remotely located facilitators. 12 By being physically present, the positive bene ts provided through the facilitator's personality attributes and skills could be maximized.
In our study it became apparent that students valued facilitator personality attributes of warmth, empathy and supportiveness. These ndings are in keeping with literature where postgraduate psychiatry trainees undergoing clinical supervision place greater emphasis on non-teaching skills and supportive behaviour than clinical competence. 24 Feeling at ease in their facilitator's presence created a non-judgemental setting where students could discuss the frequently intense and negative emotions. Similarly, there are known bene ts of established student-facilitator relationships during Longitudinal Integrated Clerkships (LIC). 25 There is potential for facilitator attributes to negatively in uence student engagement. Students raised concerns that facilitator personality attributes that resulted in students feeling intimidated, placed under pressure and judged could have affected their experience negatively, although none of the participants interviewed in this study had this experience. Effective facilitators were exible and responsive to the dynamic workshop situation, and students' descriptions of their facilitator's role illustrated facilitators' abilities to create a re ective space to deconstruct the case complexity, be emotionally attuned and consider the human interpersonal aspects of interactions with patients.
Evidence of transformative learning, a key aspect of adult learning where changes in perspective occur as the result of fundamental assumptions and beliefs being challenged, was demonstrated by the signi cant shifts in students' perspectives and attitudes. 26, 27 Students described the change in their emotional experience from viewing CAP as "hopeless", to a perspective of "hope" by becoming aware of protective and positive prognostic factors and how they could make a difference for a child.
In our study, students from sites without facilitators identi ed aspects of facilitation that they thought would have enhanced their learning experience. 'Noticing' is a vital step before being able to develop understanding of a learning experience and facilitators supported this by prompting, providing feedback and challenging pre-existing views and mental models. 27 The results suggest that when having a facilitator is not practical students may still have a positive learning experience with the opportunity for independence, autonomy, self-motivation, taking a leadership role and self-direction. 28 Educators could consider how they might increase these components for all students, regardless of facilitator presence, in future workshops.
A common perception amongst students was that they had limited clinical exposure to CAP during their rural LIC and some felt they were missing out compared to their urban counterparts. This was in contrast to facilitators who perceived students had ample and frequent exposure to CAP in general practice. The context in which learning occurs drives recognition of learning experiences 27 and our study ndings suggest students may need assistance to recognize CAP cases outside a formal CAP setting. Our ndings emphasize the important role of GP facilitators to help students identify CAP cases in routine clinical practice, and support recommendations for CAP teaching in primary care. 9 External factors in the workshop learning environment, distinct from the role of facilitators, impacted on student engagement and should be considered when planning a CAP workshop. The emotional impact of CAP cases can be signi cant. Debriefs are largely considered crucial throughout medical settings, 29 and would have enabled facilitators to assist students to process their experiences, but were not always provided. Future workshops should include a local pre-workshop session to assist students to identify CAP cases; implementation of student suggestions, which aligned with principles of effective online teaching; 30 and a formal post workshop debrief.
This study followed best practice methods for a qualitative study, however we acknowledge some limitations.
Ideally a wider variety of sites, a more even spread of student and facilitators from each site and more students from sites without facilitators would have been interviewed however this was affected by participant willingness to engage in the study, administration issues related to receiving consent form paperwork, inability to contact some consenting participants and time constraints. A lower number of facilitators were interviewed compared to students although this was proportional when comparing total student and facilitator numbers participating. The two-week time period to conduct the interviews could be seen as a limitation. However, some students were starting to have di culty recalling their experience of the workshop by the end of that timeframe, so a longer interview schedule may have been unreliable. A further limitation was that we were unable to quantify the effect individual factors had on student engagement through formal pre and post workshop evaluation however the study was able to highlight the various factors involved in student engagement in CAP learning. Further qualitative research into the development of facilitation skills, the importance of facilitator quali cation and background and methods for enhanced involvement in VCs is recommended.

Conclusion
This study has clearly demonstrated that student engagement during a rural CAP VC workshop is strongly in uenced by the physical presence of facilitators, their personality attributes and facilitation skills. The role of facilitators extends beyond the workshop day to include pre and post workshop sessions. In rural placements, facilitators should assist students to recognize CAP presentations in patients and families they encounter in diverse clinical contexts, to maximize opportunities for CAP learning, holistic care and re ective practice.
External factors such as time, size, pre and post workshop sessions and facilitating active participation must also be considered when looking to optimize student engagement. These recommendations can be considered for medical student workshops in other areas in order to provide effective teaching and optimize student engagement.

Declarations
Ethics approval and consent to participate Ethical approval was granted by the University of Western Australia Human Ethics Committee, approval number RA/4/20/5452. RCSWA students and workshop facilitators, were invited to participate in the study by the site administrator, responsible for site organisation, during routine meetings. Written consent was obtained from study participants.
Consent for publication -not applicable.

Availability of data and material
The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request. paper authorship. MC provided expertise as a rural psychiatrist and contributed signi cantly to the study (10%) by providing senior academic oversight and contributing to paper authorship.