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For trainees to participate meaningfully in workplace-based assessment (WBA) they must have trust in their assessor. However, the trainee's dependent position complicates such trust. Understanding how power and trust influence WBAs may help us make them more effective learning opportunities. We conducted semi-structured interviews with 17 postgraduate anesthesia trainees across Australia and New Zealand. Sensitised by notions of power, we used constructivist grounded theory methodology to examine trainees' experiences with trusting their supervisors in WBAs. In our trainee accounts, we found that supervisors held significant power to mediate access to learning opportunities and influence trainee progress in training. All episodes where supervisors could observe trainees, from simply working together to formal WBAs, were seen to generate assessment information with potential consequences. In response, trainees actively acquiesced to a deferential role, which helped them access desirable expertise and minimise the risk of reputational harm. Trainees granted trust based on how they anticipated a supervisor would use the power inherent in their role. Trainees learned to ration exposure of their authentic practice to supervisors in proportion to their trust in them. Trainees were more trusting and open to learning when supervisors used their power for the trainee's benefit, and avoided WBAs with supervisors they perceived as less trustworthy. If assessment for learning is to flourish, then the trainee-supervisor power dynamic must evolve. Enhancing supervisor behaviour through reflection and professional development to better reward trainee trust would invite more trainee participation in assessment for learning. Modifying the assessment system design to nudge the power balance towards the trainee may also help. Modifications could include designated formative and summative assessments, or empowering trainees to select which assessments count towards progress decisions.

PURPOSE: In competency-based medical education, workplace-based assessment provides trainees with an opportunity for guidance and supervisors the opportunity to judge the trainees' clinical practice. Learning from assessment is enhanced when trainees reveal their thinking and are open to critique, which requires trust in the assessor. If supervisors knew more about how trainees come to trust them in workplace-based assessment, they could better engender trainee trust and improve trainees' learning experience. METHOD(S): From August 2018 to September 2019, semistructured interviews were conducted with 17 postgraduate anesthesia trainees across Australia and New Zealand. The transcripts were analyzed using constructivist grounded theory methods sensitized by a sociocultural view of learning informed by Wenger's communities of practice theory. RESULT(S): Participants described a continuum from a necessary initial trust to an experience-informed dynamic trust. Trainees assumed initial trust in supervisors based on accreditation, reputation, and a perceived obligation of trustworthiness inherent in the supervisor's role. With experience and time, trainees' trust evolved based on supervisor actions. Deeper levels of trainee trust arose in response to perceived supervisor investment and allowed trainees to devote more emotional and cognitive resources to patient care and learning rather than impression management. Across the continuum from initial trust to experience-informed trust, trainees made rapid trust judgments that were not preceded by conscious deliberation; instead, they represented a learned "feel for the game." CONCLUSION(S): While other factors are involved, our results indicate that the trainee behavior observed in workplace-based assessment is a product of supervisor invitation. Supervisor trustworthiness and investment in trainee development invite trainees to work and present in authentic ways in workplace-based assessment. This authentic engagement, where

Medical educators are tasked with decisions on trainee progression and credentialing for independent clinical practice, which requires robust evidence from workplace-based assessment. It is unclear how the current promotion of workplace-based assessment as a pedagogical approach to promote learning has impacted this use of assessments for decision-making; meeting both these purposes may present unforeseen challenges. In this study we explored how supervisors make decisions on trainee progress in practice. We conducted semi-structured interviews with 19 supervisors of postgraduate anesthesia training across Australia and New Zealand and undertook thematic analysis of the transcripts. Supervisors looked beyond the formal assessment portfolio when making performance decisions. They instead used assessment 'shadow systems' based on their own observation and confidential judgements from trusted colleagues. Supervisors' decision making involved expert judgement of the perceived salient aspects of performance and the standard to be attained while making allowances for the opportunities and constraints of the local learning environment. Supervisors found making progress decisions an emotional burden. When faced with difficult decisions, they found ways to share the responsibility and balance the potential consequences for the trainee with the need to protect their patients. Viewed through the lens of community of practice theory, the development of assessment 'shadow systems' indicates a lack of alignment between local workplace assessment practices and the prescribed programmatic assessment approach to high-stakes progress decisions. Avenues for improvement include cooperative development of formal assessment processes to better meet local needs or incorporating the information in 'shadow systems' into formal assessment processes.

Feedback can occur before and after assessment submission, but needs to be useful in order for students to improve their subsequent performance. Arguably, undergraduate students, and particularly international, online and new students, are especially in need of feedback to effectively engage in academic and disciplinary expectations. Therefore, this article draws on survey data from students, disaggregated by mode of study, citizenship of enrolment and year of study, to explore their experiences of feedback usefulness both before and after assessment submission. Overall, undergraduate students were positive; however, this perception decreased according to their year level. Comparisons between online and international students also revealed key differences. A conclusion is that undergraduate students cannot be treated homogeneously, and educators need to attend to the feedback experiences of different student groups as they progress through their programme.

OBJECTIVE: The objective of this systematic review was to examine the effects of different balance exercise interventions compared with non-balance exercise controls on balance task performance in older adults. DESIGN: Systematic review. DATA SOURCES: Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus and Cochrane Database of Systematic Reviews were searched until July 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Systematic reviews and meta-analyses of randomised trials of balance exercise interventions for older adults were identified for extraction of eligible randomised trials. Eligibility criteria for inclusion of randomised trials in meta-analyses were comparison of a balance exercise intervention with a control group that did not perform balance exercises, report of at least one end-intervention balance outcome measurement that was consistent with the five subgroups of balance exercise identified, and full-text article available in English. RESULT(S): Ninety-five trials were included in meta-analyses and 80 in meta-regressions. For four balance exercise types (control centre of mass, multidimensional, mobility and reaching), significant effects for balance exercise interventions were found in meta-analyses (standardised mean difference (SMD) 0.31-0.50), however with considerable heterogeneity in observed effects (I2: 50.4%-80.6%). Risk of bias assessments (Physiotherapy Evidence Database score and funnel plots) did not explain heterogeneity. One significant relationship identified in the meta-regressions of SMD and balance exercise frequency, time and duration explained 2.1% of variance for the control centre of mass subgroup. CONCLUSION(S): Limitations to this study included the variability in design of balance interventions, incomplete reporting of data and statistical heterogeneity. The design of balance exercise programmes provides inadequate explanation of the observed benefits of these interventions.Copyright © Article

BACKGROUND: Effective communication between patients-clinicians, supervisors-learners and facilitators-participants within a simulation is a key priority in health profession education. There is a plethora of frameworks and recommendations to guide communication in each of these contexts, and they represent separate discourses with separate communities of practice and literature. Finding common ground within these frameworks has the potential to minimise cognitive load and maximise efficiency, which presents an opportunity to consolidate messages, strategies and skills throughout a communication curriculum and the possibility of expanding the research agenda regarding communication, feedback and debriefing in productive ways. METHODS: A meta-synthesis of the feedback, debriefing and clinical communication literature was conducted to achieve these objectives. RESULTS: Our analysis revealed that the concepts underlying the framework can be usefully categorised as stages, goals, strategies, micro-skills and meta-skills. Guidelines for conversations typically shared a common structure, and strategies aligned with a stage. Core transferrable communication skills (i.e., micro-skills) were identified across various types of conversation, and the major differences between frameworks were related to the way that power was distributed in the conversation and the evolution of conversations along the along the path of redistributing power. As part of the synthesis, an overarching framework "prepare-EMPOWER enact" was developed to capture these shared principles across discourses. CONCLUSIONS: Adopting frameworks for work-based communication that promote dialogue and empower individuals to contribute may represent an important step towards learner-centred education and person-centred care for patients.

Many clinicians who take on a formal role of supervising or teaching trainees need to be taught how to teach and then continuously improve as educators. We describe the research-informed design of a novel professional development intervention that may be perceived by clinical educators as challenging, but being based on the key features of effective professional development is likely to lead to changes in their teaching practices. The video-club brings together a small group of clinical educators who have a shared interest in exploring their educator role and their teaching practices. It supports their learning through collective inquiry, using video-recordings of their authentic teaching practices as stimuli for discussion. A pilot has produced findings that are promising in terms of outcomes and impact. Participants responded to the educational design in the way that was envisioned and engaged with the requisite risk-taking and vulnerability that was necessary for their own learning and promoting learning for others.

CONTEXT: Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future-facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits. METHODS: We tackle three myths of feedback: (a) feedback needs praise-criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature. CONCLUSIONS: Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity.