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Introduction: Patient feedback is relevant information for improvement of health care professionals' performance. Engaging patients in feedback conversations can help to harness patient feedback as a powerful tool for learning. However, health care settings may prevent patients and health care professionals to effectively engage in a feedback dialogue. To advance our understanding of how feedback conversations may support learning in and from practice, we sought to explore patients' and health care providers' perspectives on engaging patients in feedback conversations as informal learning opportunities. Methods: For this qualitative study, we used a pragmatic approach and conducted semi‐structured interviews with 12 health care providers and 10 patient consultants. We applied an inductive approach to thematic analysis to understand interviewees' perceptions regarding patient feedback for workplace learning. Results: Participants attributed importance to patient feedback and described how the feedback may improve treatment relationships, professionals' performance and care processes on the team level and the organisational level. Participants experienced conflicting roles as patient and educator or expert and learner, respectively. Changing relationships, feelings of vulnerability and perceived power dynamics in treatment relationships would affect participants' engagement in feedback conversations. Patients and professionals alike saw a role for themselves in giving or inviting feedback but often missed the tools for engaging in feedback conversations. Discussion: Patient feedback can contribute to professionals' practice‐based learning but requires navigating tensions around conflicting roles and power dynamics in the treatment relationship. Both patients and health care professionals need to embrace vulnerability and may need facilitation and guidance to use patient feedback effectively. Attention to power dynamics, if not a shift towards collaborative relationships, is however crucial to engage patients in feedback conversations, thereby capitalising the power patients posses. While feedback conversations can contribute to professionals' workplace learning, this study highlights how tensions around conflicting roles and power dynamics in the professional‐patient relationship must be navigated. [ABSTRACT FROM AUTHOR]

While portfolios are increasingly used to assess competence, the validity of such portfolio-based assessments has hitherto remained unconfirmed. The purpose of the present research is therefore to further our understanding of how assessors form judgments when interpreting the complex data included in a competency-based portfolio. Eighteen assessors appraised one of three competency-based mock portfolios while thinking aloud, before taking part in semi-structured interviews. A thematic analysis of the think-aloud protocols and interviews revealed that assessors reached judgments through a 3-phase cyclical cognitive process of acquiring, organizing, and integrating evidence. Upon conclusion of the first cycle, assessors reviewed the remaining portfolio evidence to look for confirming or disconfirming evidence. Assessors were inclined to stick to their initial judgments even when confronted with seemingly disconfirming evidence. Although assessors reached similar final (pass-fail) judgments of students' professional competence, they differed in their information-processing approaches and the reasoning behind their judgments. Differences sprung from assessors' divergent assessment beliefs, performance theories, and inferences about the student. Assessment beliefs refer to assessors' opinions about what kind of evidence gives the most valuable and trustworthy information about the student's competence, whereas assessors' performance theories concern their conceptualizations of what constitutes professional competence and competent performance. Even when using the same pieces of information, assessors furthermore differed with respect to inferences about the student as a person as well as a (future) professional. Our findings support the notion that assessors' reasoning in judgment and decision-making varies and is guided by their mental models of performance assessment, potentially impacting feedback and the credibility of decisions. Our findings also lend further credence to the assertion that portfolios should be judged by multiple assessors who should, moreover, thoroughly substantiate their judgments. Finally, it is suggested that portfolios be designed in such a way that they facilitate the selection of and navigation through the portfolio evidence.

Workplace-Based Assessment (WBA) plays a pivotal role in present-day competency-based medical curricula. Validity in WBA mainly depends on how stakeholders (e.g. clinical supervisors and learners) use the assessments--rather than on the intrinsic qualities of instruments and methods. Current research on assessment in clinical contexts seems to imply that variable behaviours during performance assessment of both assessors and learners may well reflect their respective beliefs and perspectives towards WBA. We therefore performed a Q methodological study to explore perspectives underlying stakeholders' behaviours in WBA in a postgraduate medical training program. Five different perspectives on performance assessment were extracted: Agency, Mutuality, Objectivity, Adaptivity and Accountability. These perspectives reflect both differences and similarities in stakeholder perceptions and preferences regarding the utility of WBA. In comparing and contrasting the various perspectives, we identified two key areas of disagreement, specifically "the locus of regulation of learning" (i.e., self-regulated versus externally regulated learning) and 'the extent to which assessment should be standardised' (i.e., tailored versus standardised assessment). Differing perspectives may variously affect stakeholders' acceptance, use--and, consequently, the effectiveness--of assessment programmes. Continuous interaction between all stakeholders is essential to monitor, adapt and improve assessment practices and to stimulate the development of a shared mental model. Better understanding of underlying stakeholder perspectives could be an important step in bridging the gap between psychometric and socio-constructivist approaches in WBA.

Purpose: This study aims to investigate quality of feedback as offered by supervisor-assessors with varying levels of assessor expertise following assessment of performance in residency training in a health care setting. It furthermore investigates if and how different levels of assessor expertise influence feedback characteristics. Design/methodology/approach: Experienced (n = 18) and non-experienced (n = 16) supervisor-assessors with different levels of assessor expertise in general practice (GP) watched two videotapes, each presenting a trainee in a "real-life" patient encounter. After watching each videotape, participants documented performance ratings, wrote down narrative feedback comments and verbalized their feedback. Deductive content analysis of feedback protocols was used to explore quality of feedback. Between-group differences were assessed using qualitative-based quantitative analysis of feedback data. Findings: Overall, specificity and usefulness of both written and verbal feedback was limited. Differences in assessor expertise did not seem to affect feedback quality. Research limitations/implications: Results of the study are limited to a specific setting (GP) and assessment context. Further study in other settings and larger sample sizes may contribute to better understanding of the relation between assessor characteristics and feedback quality. Practical implications: Findings suggest that even with supervisor-assessors with varying levels of assessor expertise who are trained in performance assessment and the provision of performance feedback, high-quality feedback is not self-evident; coaching "on the job" of feedback providers and continuous evaluation of feedback processes in performance management systems is crucial. Instruments should facilitate provision of meaningful feedback in writing. Originality/value: The paper investigates quality of feedback immediately following assessment of performance, and links feedback quality to assessor expertise. Findings can contribute to improvement of performance management systems and assessments for developmental purposes. (Contains 2 tables and 2 figures.)

Context: In-training assessment (ITA), defined as multiple assessments of performance in the setting of day-to-day practice, is an invaluable tool in assessment programmes which aim to assess professional competence in a comprehensive and valid way. Research on clinical performance ratings, however, consistently shows weaknesses concerning accuracy, reliability and validity. Attempts to improve the psychometric characteristics of ITA focusing on standardisation and objectivity of measurement thus far result in limited improvement of ITA-practices. Purpose: The aim of the paper is to demonstrate that the psychometric framework may limit more meaningful educational approaches to performance assessment, because it does not take into account key issues in the mechanics of the assessment process. Based on insights from other disciplines, we propose an approach to ITA that takes a constructivist, social-psychological perspective and integrates elements of theories of cognition, motivation and decision making. A central assumption in the proposed framework is that performance assessment is a judgment and decision making process, in which rating outcomes are influenced by interactions between individuals and the social context in which assessment occurs. Discussion: The issues raised in the article and the proposed assessment framework bring forward a number of implications for current performance assessment practice. It is argued that focusing on the context of performance assessment may be more effective in improving ITA practices than focusing strictly on raters and rating instruments. Furthermore, the constructivist approach towards assessment has important implications for assessment procedures as well as the evaluation of assessment quality. Finally, it is argued that further research into performance assessment should contribute towards a better understanding of the factors that influence rating outcomes, such as rater motivation, assessment procedures and other contextual variables.

Introduction: In health science education clinical clerkships serve the twofold purpose of guiding student learning and assessment of performance. Evidently, both formative and summative assessment procedures are needed in clerkship assessment. In-training evaluation (ITE) has the potential to serve both assessment functions. Implementation of effective ITE, however, has been shown to be problematic, partly because integration of assessment functions may have negative consequences for teaching and learning. This study investigates student perceptions of the impact of an integrated assessment approach, seeking to refine criteria for effective ITE. Method: In the curriculum of Maastricht Midwifery School (MMS), clerkship assessment is based on ITE serving both assessment functions. The ITE model is based on principles of extensive work sampling, and frequent documentation of performance. A focus group technique was used to explore student perceptions on the impact of the ITE approach on student learning and supervisor teaching behaviour, and on the usefulness of information for decision making. Results: Results indicate that the assessment approach is effective in guidance of student learning. Furthermore, students consider the frequent performance documentation essential in clerkship grading. Acceptance and effectivity of ITE requires a learning environment which is safe and respectful. Transparency of assessment processes is the key to success. Suggestions for improvement focus on variation in evaluation formats, improvement of feedback (narrative, complete) and student involvement in assessment. Conclusion: ITE can fulfill both its formative and summative purposes when some crucial conditions are taken into account. Careful training of both supervisors and students in the use of ITE for student learning and performance measurement is essential.

Processes involved in the regulation of learning have been researched for decades, because of its impact on academic and workplace performance. In fact, self‐regulated learning is the focus of countless studies in health professions education and higher education in general. While we will always need competent individuals who are able to regulate their own learning, developments in healthcare require a shift from a focus on the individual to the collective: collaboration within and between healthcare teams is at the heart of high‐quality patient care. Concepts of collaborative learning and collective competence challenge commonly held conceptualisations of regulatory learning and call for a focus on the social embeddedness of regulatory learning and processes regulating the learning of the collective. Therefore, this article questions the alignment of current conceptualisations of regulation of learning with demands for collaboration in current healthcare. We explore different conceptualisations of regulation of learning (self‐, co‐, and socially shared regulation of learning), and elaborate on how the integration of these conceptualisations adds to our understanding of regulatory learning in healthcare settings. Building on these insights, we furthermore suggest ways forward for research and educational practice. Bransen et al. explore the concept of 'self' to argue that the health professions need to shift from striving to optimize self‐regulation to understanding how to effectively regulate across self‐, co‐, and shared‐regulation. [ABSTRACT FROM AUTHOR]

Context: Medical students are expected to self‐regulate their learning within complex and unpredictable clinical learning environments. Research increasingly focuses on the effects of social interactions on the development of self‐regulation in workplace settings, a notion embodied within the concept of co‐regulated learning (CRL). Creating workplace learning environments that effectively foster lifelong self‐regulated learning (SRL) requires a deeper understanding of the relationship between CRL and SRL. The aim of this study was therefore to explore medical students' perceptions of CRL in clinical clerkships and its perceived impact on the development of their SRL. Methods: We conducted semi‐structured interviews with 11 purposively sampled medical students enrolled in clinical clerkships at one undergraduate competency‐based medical school. Data collection and analysis were conducted iteratively, informed by principles of constructivist grounded theory. Data analysis followed stages of open, axial and selective coding, which enabled us to conceptualise how co‐regulation influences the development of students' self‐regulation. Results: Data revealed three interrelated shifts in CRL and SRL as students progressed through clerkships. First, students' CRL shifted from a focus on peers to co‐regulation with clinician role models. Second, self‐regulated behaviour shifted from being externally driven to being internally driven. Last, self‐regulation shifted from a task‐oriented approach towards a more comprehensive approach focusing on professional competence and identity formation. Students indicated that if they felt able to confidently and proactively self‐regulate their learning, the threshold for engaging others in meaningful CRL seemed to be lowered, enhancing further development of SRL skills. Conclusions: Findings from the current study emphasise the notion that SRL and its development are grounded in CRL in clinical settings. To optimally support the development of students' SRL, we need to focus on facilitating and organising learners' engagement in CRL from the start of the medical curriculum. Is self‐regulated learning entirely self‐regulated? Bransen et al. share data demonstrating it to be embedded in co‐regulated learning, characterized shifts in regulatory focus, drivers for regulation, and co‐regulation partners. [ABSTRACT FROM AUTHOR]

Background: Despite increasing calls for patient and public involvement in health‐care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention. Objective: The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence. Design: A qualitative study based on semi‐structured interviews. Setting and Participants: The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling. Methods: Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment. Results: The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor‐patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance. Discussion and conclusion: Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback. [ABSTRACT FROM AUTHOR]

Context: In health professions education, assessment systems are bound to be rife with tensions as they must fulfil formative and summative assessment purposes, be efficient and effective, and meet the needs of learners and education institutes, as well as those of patients and health care organisations. The way we respond to these tensions determines the fate of assessment practices and reform. In this study, we argue that traditional 'fix‐the‐problem' approaches (i.e. either–or solutions) are generally inadequate and that we need alternative strategies to help us further understand, accept and actually engage with the multiple recurring tensions in assessment programmes. Methods: Drawing from research in organisation science and health care, we outline how the Polarity Thinking™ model and its 'both–and' approach offer ways to systematically leverage assessment tensions as opportunities to drive improvement, rather than as intractable problems. In reviewing the assessment literature, we highlight and discuss exemplars of specific assessment polarities and tensions in educational settings. Using key concepts and principles of the Polarity Thinking™ model, and two examples of common tensions in assessment design, we describe how the model can be applied in a stepwise approach to the management of key polarities in assessment. Discussion: Assessment polarities and tensions are likely to surface with the continued rise of complexity and change in education and health care organisations. With increasing pressures of accountability in times of stretched resources, assessment tensions and dilemmas will become more pronounced. We propose to add to our repertoire of strategies for managing key dilemmas in education and assessment design through the adoption of the polarity framework. Its 'both–and' approach may advance our efforts to transform assessment systems to meet complex 21st century education, health and health care needs. The authors argue that traditional 'either‐or' solutions to assessment problems need to be replaced with 'both‐and' strategies if we are to advance our efforts to transform assessment in the era of competency‐based education. [ABSTRACT FROM AUTHOR]

Workplace-Based Assessment (WBA) plays a pivotal role in present-day competency-based medical curricula. Validity in WBA mainly depends on how stakeholders (e.g. clinical supervisors and learners) use the assessments-rather than on the intrinsic qualities of instruments and methods. Current research on assessment in clinical contexts seems to imply that variable behaviours during performance assessment of both assessors and learners may well reflect their respective beliefs and perspectives towards WBA. We therefore performed a Q methodological study to explore perspectives underlying stakeholders' behaviours in WBA in a postgraduate medical training program. Five different perspectives on performance assessment were extracted: Agency, Mutuality, Objectivity, Adaptivity and Accountability. These perspectives reflect both differences and similarities in stakeholder perceptions and preferences regarding the utility of WBA. In comparing and contrasting the various perspectives, we identified two key areas of disagreement, specifically 'the locus of regulation of learning' (i.e., self-regulated versus externally regulated learning) and 'the extent to which assessment should be standardised' (i.e., tailored versus standardised assessment). Differing perspectives may variously affect stakeholders' acceptance, use-and, consequently, the effectiveness-of assessment programmes. Continuous interaction between all stakeholders is essential to monitor, adapt and improve assessment practices and to stimulate the development of a shared mental model. Better understanding of underlying stakeholder perspectives could be an important step in bridging the gap between psychometric and socio-constructivist approaches in WBA. [ABSTRACT FROM AUTHOR]

Background: Research has shown that patients' and practitioners' cultural orientations affect communication behaviors and interpretations in cross-cultural patient-practitioner interactions. Little is known about the effect of cultural orientations on assessment of communication behaviors in cross-cultural educational settings. The purpose of this study is to explore cultural orientation as a potential source of assessor idiosyncrasy or between-assessor variability in assessment of communication skills. More specifically, we explored if and how (expert) assessors' valuing of communication behaviours aligned with their cultural orientations (power-distance, masculinityfemininity, uncertainty avoidance, and individualism-collectivism). Methods: Twenty-five pharmacist-assessors watched 3 videotaped scenarios (patient-pharmacist interactions) and ranked each on a 5-point global rating scale. Videotaped scenarios demonstrated combinations of well-portrayed and borderline examples of instrumental and affective communication behaviours. We used stimulated recall and verbal protocol analysis to investigate assessors' interpretations and evaluations of communication behaviours. Uttered assessments of communication behaviours were coded as instrumental (task-oriented) or affective (socioemotional) and either positive or negative. Cultural orientations were measured using the Individual Cultural Values Scale. Correlations between cultural orientations and global scores, and frequencies of positive, negative, and total utterances of instrumental and affective behaviours were determined. Results: Correlations were found to be scenario specific. In videos with poor or good performance, no differences were found across cultural orientations. When borderline performance was demonstrated, high power-distance and masculinity were significantly associated with higher global ratings (r = .445, and .537 respectively, p < 0.05) as well as with fewer negative utterances regarding instrumental (task focused) behaviours (r = -.533 and - .529, respectively). Higher masculinity scores were furthermore associated with positive utterances of affective (socioemotional) behaviours (r = .441). Conclusions: Our findings thus confirm cultural orientation as a source of assessor idiosyncrasy and meaningful variations in interpretation of communication behaviours. Interestingly, expert assessors generally agreed on scenarios of good or poor performances but borderline performance was influenced by cultural orientation. Contrary to current practices of assessor and assessment instrument standardization, findings support the use of multiple assessors for patient-practitioner interactions and development of qualitative assessment tools to capture these varying, yet valid, interpretations of performance. [ABSTRACT FROM AUTHOR]

The article shares the author's insights on the need for an in-training assessment (ITA) in the clinical setting. An effective ITA strategy consists of systematic and ongoing assessment of the performance of trainees in the clinical practice setting. Its purpose includes giving feedback to the trainees to help improve their performance and to provide plausible and defensible data on quality of performance for making judgments and decision-making.