The framework of EPAs went through many iterations before it was consolidated. Among the issues that required special attention was the application of a supervision levels scale for sign-off, the necessity to cover all relevant clinical content while not labeling too many small tasks each as a separate EPA, methods of EPA-focused assessment in the workplace and the creation of an e-portfolio model to serve assessment and entrustment.

Background Receiving feedback while in the clinical workplace is probably the most frequently voiced desire of students. In clinical learning environments, providing and seeking performance-relevant information is often difficult for both supervisors and students. The use of entrustable professional activities (EPAs) can help to improve student assessment within competency-based education. This study aimed to illustrate what students' perceptions are of meaningful feedback viewed as conducive in preparing for performing EPA unsupervised. Methods In a qualitative multicentre study we explored students' perceptions on meaningful feedback related to EPAs in the clinical workplace. Focus groups were conducted in three different healthcare institutes. Based on concepts from the literature, the transcripts were coded, iteratively reduced and displayed. Results Participants' preferences regarding meaningful feedback on EPAs were quite similar, irrespective of their institution or type of clerkship. Participants explicitly mentioned that feedback on EPAs could come from a variety of sources. Feedback must come from a credible, trustworthy supervisor who knows the student well, be delivered in a safe environment and stress both strengths and points for improvement. The feedback should be provided immediately after the observed activity and include instructions for follow-up. Students would appreciate feedback that refers to their ability to act unsupervised. Conclusion There is abundant literature on how feedback should be provided, and what factors influence how feedback is sought by students. This study showed that students who are training to perform an EPA unsupervised have clear ideas about how, when and from whom feedback should be delivered. Keywords Entrustable professional activities · Feedback · Competency based · Clinical workplace · Veterinary education · Medical education · Students · Focus group What this paper addsTo enhance the educational environment in the workplace, meaningful feedback and valid assessment of students are required. As the literature shows, it is difficult to successfully apply workplace-based assessments in clinical practice. The use of entrustable professional activities (EPAs) can help to improve student assessment within competencybased education. However, there still is little evidence about what students perceive as useful information to prepare for performing an EPA with less than full supervision. This study aimed to illustrate what students' perceptions are of meaningful feedback viewed as conducive to prepare for the performance of an EPA unsupervised Am I ready for it? Students' perceptions of meaningful feedback on entrustable professional activities 257

IntroductionClinical training programs increasingly use entrustable professional activities (EPAs) as focus of assessment. However, questions remain about which information should ground decisions to trust learners. This qualitative study aimed to identify decision variables in the workplace that clinical teachers find relevant in the elaboration of the entrustment decision processes. The findings can substantiate entrustment decision-making in the clinical workplace.MethodsFocus groups were conducted with medical and veterinary clinical teachers, using the structured consensus method of the Nominal Group Technique to generate decision variables. A ranking was made based on a relevance score assigned by the clinical teachers to the different decision variables. Field notes, audio recordings and flip chart lists were analyzed and subsequently translated and, as a form of axial coding, merged into one list, combining the decision variables that were similar in their meaning.ResultsA list of 11 and 17 decision variables were acknowledged as relevant by the medical and veterinary teacher groups, respectively. The focus groups yielded 21 unique decision variables that were considered relevant to inform readiness to perform a clinical task on a designated level of supervision. The decision variables consisted of skills, generic qualities, characteristics, previous performance or other information. We were able to group the decision variables into five categories: ability, humility, integrity, reliability and adequate exposure.DiscussionTo entrust a learner to perform a task at a specific level of supervision, a supervisor needs information to support such a judgement. This trust cannot be credited on a single case at a single moment of assessment, but requires different variables and multiple sources of information. This study provides an overview of decision variables giving evidence to justify the multifactorial process of making an entrustment decision.

None

This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Background: To be able to practice evidence-based medicine (EBM) when making decisions for individual patients, it is important to learn how to combine the best available evidence with the patient's preferences and the physician's clinical expertise. In general practice training, these skills can be learned at the workplace using learning conversations: meetings between the supervising general practitioner (GP) and GP trainee to discuss medical practice, selected topics or professional performance. This study aimed to give insight into the perceptions of GP trainees on their EBM learning processes during learning conversations. Methods: We held semi-structured video-stimulated elicitation interviews (n = 22) with GP trainees affiliated to GP training institutes in the Netherlands and Belgium. GP trainees were shown fragments of their learning conversations, enabling reflection during the interview. Taking an inductive approach, interview recordings were transcribed verbatim and analysed with NVivo software. Results: GP trainees perceived learning conversations as useful for learning and discussing EBM. Multiple EBM learning activities were identified, such as discussing evidence together, relating evidence to cases in daily practice and discussing the supervisor's experience and the specific local context in the light of what the evidence recommends. However, for learning to occur, trainees need and expect specific behaviour, both from their supervisors and themselves. Supervisors should supply well-substantiated answers that are applicable in practice and give the trainee confirmation. In turn, the trainee needs to prepare well in order to ask focused, in-depth questions. A safe space allowing equal and open discussion between trainee and supervisor is perceived as an essential context for optimal EBM learning. Conclusions: Our findings show that trainees find learning conversations useful for EBM learning in general practice. To bring EBM learning to its full potential, attention should be paid to optimising the behavioural and contextual factors found relevant to enhancing EBM learning.

Phenomenon: Supervisors and trainees can learn skills related to evidence-based medicine from each other in the workplace by collaborating and interacting, in this way benefiting from each other's strengths. This study explores supervisors' perceptions of how they currently learn evidence-based medicine by engaging in learning conversations with their trainee. Approach: Semi-structured, video-stimulated elicitation interviews were held with twenty-two Dutch and Belgian supervisors in general practice. Supervisors were shown fragments of their video-recorded learning conversations, allowing them to reflect. Recorded interviews were analyzed using a grounded theory-based approach.Findings: Supervisors did not immediately perceive workplace learning conversations as an opportunity to learn evidence-based medicine from their trainee. They mostly saw these conversations as a learning opportunity for trainees and a chance to maintain the quality of care within their practice. Nevertheless, during the interviews, supervisors did acknowledge that learning conversations help them to gain up-to-date knowledge and search skills or more awareness of their own knowledge or gaps in their knowledge. Not identified as a learning outcome was how to apply evidence-based medicine within a clinical practice by combining evidence with clinical expertise and the patient's preferences. Insights: Supervisors acknowledge that they learn elements of the three aspects of evidence-based medicine by having learning conversations with their trainee, but they currently see this as secondary to the trainee's learning process. Emphasizing opportunities for bidirectional learning could improve learning of evidence-based medicine during workplace learning conversations.

Background: Evidence-based medicine (EBM) in general practice involves applying a complex combination of bestavailable evidence, the patient's preferences and the general practitioner's (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other's consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other's EBM behaviour through observation, and by identifying aspects that influence their recognition. Methods:We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner's consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner's actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other's considerations well with those who did not, we developed a model describing the aspects that influence the observer's recognition of an actor's EBM behaviour.Results: Overall, there was moderate similarity between an actor's EBM behaviour and the observer's recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role.Conclusions: GP trainees and supervisors do not fully recognise EBM behaviour through observing each other's consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decisionmaking is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.