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Purpose: Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non‐learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model. Methods: Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi‐structured interviews. Aligning with a theory‐informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes. Results: Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals. Conclusion: Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks. Furthering understanding of workplace‐based learning, Blissett et al. demonstrate how trainees take on low complexity tasks to allow mental effort to recharge, thus facilitating maximal engagement with tasks within their Zone of Proximal Development. [ABSTRACT FROM AUTHOR]

Abstract Phenomenon: Competency-based medical education (CBME) relies on workplace-based assessment (WBA) to generate formative feedback (assessment for learning—AfL) and make inferences about competence (assessment of learning—AoL). When approaches to CBME rely on residents to initiate WBA, learners experience tension between seeking WBA for learning and for establishing competence. How learners resolve this tension may lead to unintended consequences for both AfL and AoL. We sought to explore the factors that impact both decisions to seek and not to seek WBA and use the findings to build a model of assessment-seeking strategy used by residents. In building this model we consider how the link between WBA and promotion or progression within a program impacts an individual’s assessment-seeking strategy. Approach: We conducted 20 semi-structured interviews with internal medicine residents at Queen’s University about the factors that influence their decision to seek or avoid WBA. Using grounded theory methodology, we applied a constant comparative analysis to collect data iteratively and identify themes. A conceptual model was developed to describe the interaction of factors impacting the decision to seek and initiate WBA. Findings: Participants identified two main motivations when deciding to seek assessments: the need to fulfill program requirements and the desire to receive feedback for learning. Analysis suggested that these motivations are often at odds with each other. Participants also described several moderating factors that impact the decision to initiate assessments, irrespective of the primary underlying motivation. These included resident performance, assessor factors, training program expectations, and clinical context. A conceptual framework was developed to describe the factors that lead to strategic assessment-seeking behaviors. Insights: Faced with the dual purpose of WBA in CBME, resident behavior in initiating assessment is guided by specific assessment-seeking strategies. Strategies reflect individual underlying motivations, influenced by four moderating factors. These findings have broad implications for programmatic assessment in a CBME context including validity considerations for assessment data used in summative decision-making including readiness for unsupervised practice. [ABSTRACT FROM AUTHOR]

Introduction: Competency‐based medical education (CBME) led to the widespread adoption of workplace‐based assessment (WBA) with the promise of achieving assessment for learning. Despite this, studies have illustrated tensions between the summative and formative role of WBA which undermine learning goals. Models of workplace‐based learning (WBL) provide insight, however, these models excluded WBA. This scoping review synthesizes the primary literature addressing the role of WBA to guide learning in postgraduate medical education, with the goal of identifying gaps to address in future studies. Methods: The search was applied to OVID Medline, Web of Science, ERIC and CINAHL databases, articles up to September 2020 were included. Titles and abstracts were screened by two reviewers, followed by a full text review. Two members independently extracted and analysed quantitative and qualitative data using a descriptive‐analytic technique rooted in Billett's four premises of WBL. Themes were synthesized and discussed until consensus. Results: All 33 papers focused on the perception of learning through WBA. The majority applied qualitative methodology (70%), and 12 studies (36%) made explicit reference to theory. Aligning with Billett's first premise, results reinforce that learning always occurs in the workplace. WBA helped guide learning goals and enhanced feedback frequency and specificity. Billett's remaining premises provided an important lens to understand how tensions that existed in WBL have been exacerbated with frequent WBA. As individuals engage in both work and WBA, they are slowly transforming the workplace. Culture and context frame individual experiences and the perceived authenticity of WBA. Finally, individuals will have different goals, and learn different things, from the same experience. Conclusion: Analysing WBA literature through the lens of WBL theory allows us to reframe previously described tensions. We propose that future studies attend to learning theory, and demonstrate alignment with philosophical position, to advance our understanding of assessment‐for‐learning in the workplace. The authors' synthesis of literature that focuses on the overlap between workplace learning and workplace assessment highlights gaps and identifies key strategies for enabling "assessment for learning" in the workplace. [ABSTRACT FROM AUTHOR]

Introduction: Postgraduate competency‐based medical education has been implemented with programmatic assessment that relies on entrustment‐based ratings. Yet, in less procedurally oriented specialties such as internal medicine, the relationship between entrustment and supervision remains unclear. We undertook the current study to address how internal medicine supervisors conceptualise entrusting senior medical residents while supervising them on the acute care wards. Methods: Guided by constructivist grounded theory, we interviewed 19 physicians who regularly supervised senior internal medicine residents on inpatient wards at three Canadian universities. We developed a theoretical model through iterative cycles of data collection and analysis using a constant comparative process. Results: On the internal medicine ward, the senior resident role is viewed as a fundamentally managerial and rudimentary version of the supervisor's role. Supervisors come to trust their residents in the senior role through an early 'hands‐on' period of assessment followed by a gradual withdrawal of support to promote independence. When considering entrustment, supervisors focused on entrusting a particular scope of the senior resident role as opposed to entrustment of individual tasks. Irrespective of the scope of the role that was entrusted, supervisors at times stepped in and stepped back to support specific tasks. Conclusion: Supervisors' stepping in and stepping back to support individual tasks on the acute care ward has an inconsistent relationship to their entrustment of the resident with a particular scope of the senior resident role. In this context, entrustment‐based assessment would need to capture more of the holistic perspective of the supervisor's entrustment of the senior resident role. Understanding the dance of supervision, from relatively static overall support of the resident in their role, to fluidly stepping in and out for specific patient care tasks, allows us insight into the affordances of the supervisory relationship and how it may be leveraged for assessment. Hatala et al. demonstrate that, for less procedurally focussed specialties like internal medicine, supervisors consider entrustment a matter of determining residents' role more than a matter of entrusting for individual tasks. [ABSTRACT FROM AUTHOR]