Commentary: Supervisory dynamics in workplace-based assessment

Abstract

All assessments can serve as powerful learning stimuli in medical education.¹ Yet the way assessment events and feedback information can be leveraged to provide learning benefits are dependent on the type of assessment tool. Our work in multiple choice assessment shows that post-test item-level and/or conceptual feedback can improve learning and longer-term retention, supporting knowledge acquisition and application.² Yet our work, and that of many others, also suggests that learners do not necessarily instinctively know how (or have the motivation to) take that feedback, interpret it correctly and use it to guide their future learning.^3-5 A number of innovations have been introduced to address this challenge—ranging from assessment and feedback literacy programmes through to formalised relationships between learners and ‘learning coaches’ to assist with the sense making process and next step planning often required for learners to fully benefit.^{6, 7}

When compared with a MCQ assessment, workplace-based assessments by their very nature are far more complex. Their real-life health care practice setting means they are inherently complex and messy and far less reliable when considered from an assessment measurement perspective. Unlike MCQ assessment (largely impersonal with written text and computer-based marking), WBA involves human interaction with intersecting relationships and competing needs, all secondary to patient care.⁸ This dynamic and relational context can be seen as advantageous when compared with less authentic forms of assessment in that a supervisor is present to provide nuanced and personalised feedback in real time, to a learner who is embedded in their learning and working environment with the most powerful motivation of improving patient care.⁸ And it is logical to expect that an extended duration of relationship between supervisor and learner could have additional benefits in terms of value of feedback and accuracy of judgements.

Consistent with this logic, there is some evidence to suggest there is potential for increased learner benefit when supervisory relationships are longitudinal.⁹ Amongst the benefits described are increased skill development, improved psychological safety, enhanced autonomy and progressive achievement of goals.^{10, 11} In response, many health professional educational programmes have attempted to provide learners with longer-term relationships either by formal longitudinal clerkship type arrangements or by extending the duration of fewer placements.¹²

In contrast, many of us have anecdotal experience of longitudinal relationships that have not reached their potential, or even more concerning, that have been challenging or even detrimental for one or both members of the supervisory pair. More recently, some of this complexity is reflected in the review literature,¹³ suggesting additional complexities to supervisor and learner relationships in the context of workplace-based assessments. And it is to this body of work that Lee and colleagues' exploration of supervisor and resident perceptions of episodic and continuous relationships contributes.¹⁴

Lee et al.'s paper presents a comparison between episodic and continuous supervision in which they find relative strengths and challenges for assessment and feedback in both supervisory relationships. While acknowledging its superficiality, they highlight variety and diversity of feedback as strengths in episodic relationships, and identify four subtypes of continuous relationship—three of which present challenges for feedback and assessment.¹⁴ Relationships they describe as ‘not developing’, ‘deteriorating’ or ‘becoming a friendship’ have less than ideal impact on learning and assessment, with ‘developing’ relationships embodying the kind of relationships likely to lead to the positive findings we have all come to understand as the great potential benefit of longitudinal supervision in WBA.¹⁴

While more work is to be done in understanding these findings and their implications, the authors suggestion that programme designers should be aware of the potential of each type of supervisory relationship, rather than attempting to only provide longitudinal relationships, is a welcome and practical suggestion. These findings can also be used to inform the pressing work many of us are undertaking to building supportive curriculum content in assessment and feedback literacy—for learners and supervisors.^{6, 7}

Lee and colleagues suggest that learners can be enabled to seek feedback from the right relationships—I would extend this to suggest that learners should be encouraged to consider the feedback in the context of their relationship type, recognising that different assessors (and assessor/learner relationships) provide varied but valuable information requiring interpretation.

This paper also highlights the potential for us to think differently about how we might use and interpret WBA data to support supervisor development—encouraging supervisors to be mindful about the relationships they have with each of their learners (or the relationships they tend to develop with their learners more generally), and what that might mean for learner receptivity to their feedback and the potential for the learner to continue to grow and develop. Further, it provides some interesting stimulus to think about what findings like this might mean for robust decision making in the context of programmatic decision making¹⁵—how should we think about assessment data when it has been generated in the context of relationships that are of a subtype, which is less than ideal.

Workplace based assessment continues to be a vital component in systems of assessment throughout health care professional training. While complex to implement, its authenticity, potential for immediate feedback, and ability to improve clinical practice make it valuable. As we continue to improve the potential for learning from all assessment formats, further work to understand the complexity and nuances of the relationships which support WBA will continue to guide implementation and support learners and supervisors in developing insights and making robust judgements as they strive to continually improve their practice.