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Self-regulated learning lens on trainee perceptions of the mini-CEX: a qualitative study

Objectives The formative aspect of the mini-clinical evaluation exercise (mini-CEX) in postgraduate medical workplace-based assessment is intended to afford opportunities for active learning. Yet, there is little understanding of the perceived relationship between the mini-CEX and how trainees self-regulate their learning. Our objective was to explore trainees’ perceptions of their mini-CEX experiences from a learning perspective, using Zimmerman’s self-regulated learning theoretical framework as an interpretive lens. Design Qualitative, using semi-structured interviews conducted in 2017. The interviews were analysed thematically. Setting Geriatric medicine training. Participants Purposive sampling was employed to recruit geriatric medicine trainees in Melbourne, Australia. Twelve advanced trainees participated in the interviews. Results Four themes were found with a cyclical inter-relationship between three of these themes: namely, goal setting, task translation and perceived outcome. These themes reflect the phases of the self-regulated learning framework. Each phase was influenced by the fourth theme, supervisor co-regulation. Goal setting had motivational properties that had significant impact on the later phases of the cycle. A ‘tick box’ goal aligned with an opportunistic approach and poorer perceived educational outcomes. Participants reported that external feedback following assessment was critical for their self-evaluation, affective responses and perceived outcomes. Conclusions Trainees perceived the performance of a mini-CEX as a complex, inter-related cyclical process, influenced at all stages by the supervisor. Based on our trainee perspectives of the mini-CEX, we conclude that supervisor engagement is essential to support trainees to individually regulate their learning in the clinical environment.


Article Summary
Strengths and limitations of this study: • Zimmerman's self-regulated learning framework provided an interpretive lens on participants' perspectives of the mini-CEX. • This study brings to light the personal, interpersonal, and contextual influences on a trainee's self-regulated learning. • Interview data were only collected in Melbourne with geriatric medicine trainees whose experiences may not fully represent the experiences of other specialist trainees. • The study relied on trainees' recalled experiences of their workplacebased assessment experiences.
Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests' statement: The authors have no competing interests to declare.

Keywords:
Medical education, self-regulated learning, workplace based assessment, mini-CEX, geriatric medicine One promise of competency-based medical education is that learning is emphasised in the assessment process [1,2]. Consequently, formative assessment is a key component in the design of competency-based assessment in post-graduate training [3][4][5]. Assessment should fulfil three key purposes: certify achievement, facilitate feedback to the learner to drive improvement, and foster self-assessment to promote life-long learning [6,7].
It has been argued by Nichol and others that effective, formative assessment should incorporate these principles to enhance trainees' selfregulated learning [8,9].
Norcini developed the mini-CEX assessment tool to facilitate observationbased feedback and promote trainee self-assessment in the workplace [10]; it is a widely used tool in post-graduate medical education (PGME) [11,12].
Mini-CEXs are conceptualised as an encounter that involves a supervisor observing a trainee performing a nominated, routine clinical task for approximately 10-15 minutes, with the supervisor providing verbal and written feedback using a standardised marking template [10].
Studies have explored the experiences and perceptions of trainees with a focus on the educational effect of the individual assessment tool [13,14].
Since 2004, there have been over forty studies examining both trainee and assessor perceptions of workplace based assessment (WBA) [15]. These studies have evaluated the educational effect by eliciting learners' attitudes towards the use of the instruments [16]. Most have been conducted in the United Kingdom (UK), with many of the studies using surveys to explore trainee perceptions [4,[17][18][19][20][21][22]. The efficacy of feedback following the assessment is a prominent theme in most studies. Trainees have reported that the use of the mini-CEX has increased the quantity of feedback [3,[18][19][20]22], whilst in other studies both the quantity and quality of feedback is reportedly improved [19,21,23]. Other studies report that the provision of feedback does not always encourage self-assessment, nor translate to an action plan for improvement [20,22,24].
Overall, the literature conveys a mixed picture of the influence of the mini-CEX tool on feedback. Trainees have expressed a lack of understanding regarding the purpose of the mini-CEX, reporting difficulty distinguishing the formative nature from the evaluative aspects of the assessment [5,25,26].The confusion possibly explains affective aspects such as trainee anxiety and stress attributed to these assessments, although being observed by a supervisor may evoke these emotions [18,25,27]. Further, trainees have reported valuing the close contact with the assessor and the reassurance of competency that assessment provides, but they are reluctant to display their weaknesses [18,22,25].The influence of workplace culture is also a strong theme, with negativity centred on the time commitment and the difficulties associated with organising an assessor [3,17,18,20,22,28].
A systematic review of user perceptions reported stakeholder disengagement and low morale impacting assessment performance [15]. The perceived assessment burden has contributed to a "tick box culture" [20,29]. This approach leads to WBA tools being misused and trivialised by stakeholders, and the potential loss of a useful learning opportunity [15,30].
According to Brydges and Butler, a different approach to examine the educational effect of the mini-CEX is to focus on active learning, since trainees' learning in the clinical environment is highly influenced by their capacity for self-regulated learning (SRL) [31]. Self-regulation refers to the "self-generated thoughts, feelings, and behaviours that are planned and cyclically adapted to the attainment of personal goals" [32]. Self-regulation is cyclical because the feedback from prior performance is used to make adjustments during current or future efforts [32]. However, the relationship between the mini-CEX and the complex interactive process of a trainee's SRL has not yet been elucidated.
Self-regulation, according to Zimmerman, is an interaction of personal, behavioural and environmental triadic processes [33]. From a social cognitive perspective, self-regulatory learning processes comprise the forethought phase, the performance phase, and the self-reflection phase.
Although there have been many previous studies examining the perceptions of post-graduate trainees of the mini-CEX in WBA [34,35], none have utilised the SRL framework as an interpretive lens. In particular, the covert integration of personal, interpersonal and contextual influences on a trainee's self-regulated learning has not been explored. This study adopts The study has a qualitative design to systematically explore how trainees experience the mini-CEX assessment in order to understand their meaning [36]. We used individual semi-structured interviews to explore participants' lived experiences and perceptions. The interpretation of the data is underpinned by a social constructivist theory, which acknowledges that reality is co-constructed between the researcher and the researched and shaped by experiences and context [37]. The research team consisted of a specialist clinician in geriatric medicine who has experience as a supervisor with the mini-CEX, and two medical education researchers, one of whom is also a clinician with supervisory experience. Reporting of the research has been guided by the COREQ checklist within the constraints of the word limit.

Setting and Participants
The study was conducted in 2017 in Melbourne, Australia, with trainees in geriatric medicine. Geriatric medicine training is a seven-year post-graduate program, overseen by supervisors who are specialist clinicians. In the final three years, these senior trainees are described as advanced. Each advanced trainee must complete four formative mini-CEX assessments per year.
Participants who were invited to participate in the study were advanced trainees who had completed a minimum of two mini-CEXs. There are 80 advanced trainees in Melbourne. Purposive sampling was adopted to include trainees across the final two years of advanced training in order to ensure that potential participants had enough experience with the mini-CEX.
Trainees who were currently working alongside or being directly supervised by Author 1 were excluded from the study to avoid any unequal relationships between trainees and the researcher. Author 1 introduced the study at a training program in April, 2017, and interested participants were invited to contact the first author. Potential participants received a plain language statement. Written consent was obtained from participants. No patients were involved in this research.

Patient and public involvement
There were no patients in this study. There was also no patient information (medical records) accessed for this study. Participants were medical doctors who gave their permission to be interviewed.

Data collection and analysis
All interviews were conducted in a private office at each participant's workplace by the first author. The interviews were audio-taped, transcribed,  Researchers agreed that data saturation was reached after the eighth participant, with no new themes emerging with further data collection and analysis. The data analysis was thematic, following the systematic six phases approach described by Braun and Clarke [38]. Ethics approval for the study was provided by the Human Ethics Advisory Group, University of Melbourne. Ethics ID: 1748832.
Data sharing statement: The ethics approval for this project does not allow the raw interview data to be shared.

Results
Twelve advanced trainees participated in the project. All interviews were  Table 1. As can be seen from this  Most participants described either a learning or a performance goal preference when selecting tasks; however, several were aware of a perceived conflict and tension in their orientation. These participants were reluctant to select tasks that were challenging but more beneficial for their learning, preferring to demonstrate their strengths in a competitive employment environment.

Task Translation
The second theme, task translation, describes the conversion by participants of the conceptualised goal from the first phase, into the real-time clinical setting. The universal word used by participants in describing the translation process was "opportunistic": the activity is performed when the right set of

Discussion:
This study of trainees' perceptions of the mini-CEX has been informed by the self-regulated learning theoretical framework. The findings suggest that the performance of a mini-CEX was perceived by trainees as a complex, inter-related cyclical process that was influenced at all stages by the supervisor. Additionally, there was a self-reported range in ability amongst the participants to optimally self-regulate their learning when performing a mini-CEX. The three themes of goal setting, task translation, and the perceived outcome, resonate with the three phases described earlier by Zimmerman's SRL framework [33] with elaboration on the significance of goals, and feedback following the assessment. The theme of supervisor co-  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   19   regulation for trainees' reports of self-regulated learning behaviour may have   been influenced by the relational roles of the interview context (supervisortrainee roles). These elements are discussed below.
For the participants, the approach to the mini-CEX was influenced by their perceived individual goal setting and goal orientation. Goal setting and goal orientation are seen as powerful motivational factors in self-regulated learning theory [39,40]. The motivational properties of goals contribute to our understanding of the findings, as well as those previously reported. In our study, trainees who reported approaching the tasks with a specific learning goal also described selecting more challenging tasks for the assessment. They also described expending more effort in the strategic planning of the assessment during the task translation phase to ensure attainment of their goals. These participants were more likely to report positive outcomes from their assessment experiences, with the important proviso that the feedback had effectively targeted their goals. There is evidence that process goal attainment can be intrinsically motivating in its own right for these learners [33].This finding underscores the cyclical nature of the process, with the forethought phase determining significant downstream effects. These "proactive" participants reported behaviours that resonated with more developed self-regulatory processes as described in the Zimmerman SRL framework. Zimmerman believes that proactive learners self-regulate more effectively because they engage in high quality forethought, which in turn improves their self-regulatory functioning during  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 20 subsequent phases. [41] The "tick box" approach by trainees to WBA [20,42] was evident in this study. The significance of this goal and its implications for learning is more fully appreciated when seen as part of the SRL forethought processes. Those trainees who described adopting a "tick box" goal, generally took an opportunistic approach in the translation phase and consequently perceived less positive outcomes of the mini-CEX.
Previous studies have found that goal orientation can influence trainees' perceptions of formative assessment [43]. A study exploring medical students' SRL in the clinical environment also reported goals as an influential motivational factor for learning [44].This study illustrates the dual significance of trainees' goal setting and goal orientation to the approach of a mini-CEX and the impact on the subsequent phases of the SRL cycle. In addition, feedback from the supervisor to our participants was a key factor in all the processes that occurred after the performance. These processes included self-evaluation, affective responses and self-reflection. Although the literature has focussed on perceived feedback, it has not fully captured the power of feedback as contextualised in the SRL framework. For goals set in the first phase of SRL to be effective, learners need summary feedback that reveals progress in relation to their goals [45]. Summary feedback is believed to be a moderator of goal effects, in that the combination of goals plus feedback is accepted to be more effective than goals alone [45]. Some participants in this study reported difficulty obtaining observation-based feedback from supervisors, a finding previously reported  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 21 [46]. The mini-CEX was a means of securing this desirable information for progress towards their goals. The multi-faceted nature of effective feedback has been previously described, including its benefit in formative assessment [9,47,48].
The central role of the supervisor in facilitating all aspects of the SRL cycle emerged as a major theme in the study, a finding which resonates with previous studies of WBA [20,22,49]. In addition, a key feature of a social cognitive model of self-regulation is the roles of social, environmental, and self-influences [32]. Educational research has established that an ideal form of self-regulation cannot be assumed when opportunities for self-regulation are provided [31]. The engagement of supervisors is necessary to support the challenges that arise as individual trainees learn how to focus their selfregulated activities to meet the demands of the clinical environment [31,50].The relationship with supervisors and the perception by trainees of the lack of supervisor engagement in WBA have both been previously reported in the literature [15,49]. This study provides new insights because it identifies the co-regulation at all stages of a trainee's SRL cycle by the supervisor. The supervisor's role is also contextualised as a support to the SRL of each individual trainee as required.
It should be noted that although the interviewer was reflexive and endeavoured to bracket herself [51], her role as a practising physician in geriatric medicine and as a supervisor is a source of potential bias in the

Appendix Semi-Structured Interview Questions
A Tell me about you background • What year of advanced training are you?
• What training alliance are you currently employed at?
• Where was your degree in Medicine obtained? Was it a bachelor degree or a postgraduate one?

B Learning
• What stimulates your learning of Geriatric Medicine?
• What do you consider to be the most challenging clinical skills for you personally?
C. Mini CEX • We might start with you telling me about a recent mini-CEX assessment. Can you describe the whole episode to me? (prompts; what went well, what didn't, was this the norm for your CEX experiences) Now I would like to talk about your general experience and perception of the mini-CEX: • How many mini-CEXs have you done in your advanced training so far?
• What do you believe the intended purpose of the mini-CEX is, in your training program?
• Have you ever had any training about how to perform a mini-CEX or read any information about it? • What activities have you chosen so far for your mini-CEX assessment tasks during your advanced training? (prompts; why did you choose these? Were they related to the skills you want to improve?) • Once you have chosen the activity, can you tell me about what preparation you do for a mini-CEX?
• How anxious do you feel being observed during the actual encounter?
• After the activity, please tell me about the feedback you receive from the assessor? (prompts: does the assessor give you the score or give you descriptive feedback? explore quantitative/qualitative feedback • How useful was this feedback? (prompts: Did you use it to guide your future learning? Can you think of an example when you used the feedback from a mini-CEX to change how you practice?) • Was there anything in particular that made this feedback more useful? (Explore relationship with assessor) • After the assessment episode is over, how do you feel, and do you reflect on the episode later? Did it lead you to think about the experience in anyway? • Thinking specifically about your learning, do you find the mini-CEX useful for your learning?
Does it influence your learning in anyway? • Earlier in the interview I asked you what you think are the main drivers of your learning in Geriatric Medicine? How much does the mini-CEX contribute to this?
Any suggestions to improve the mini-CEX for Geriatric Medicine?
Thank you for your co-operation.

Instructions to authors
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In your methods section, say that you used the SRQR reporting guidelines, and cite them as: The interviews were analysed thematically.
Setting: Geriatric medicine training.
Participants: Purposive sampling was employed to recruit geriatric medicine trainees in Melbourne, Australia. Twelve advanced trainees participated in the interviews.
Results: Four themes were found with a cyclical inter-relationship between three of these themes: namely, goal setting, task translation, and perceived outcome. These themes reflect the phases of the self-regulated learning framework. Each phase was influenced by the fourth theme, supervisor coregulation. Goal setting had motivational properties that had significant impact on the later phases of the cycle. A "tick box" goal aligned with an opportunistic approach and poorer perceived educational outcomes.
Participants reported that external feedback following assessment was critical for their self-evaluation, affective responses, and perceived outcomes.

Article Summary
Strengths and limitations of this study:  Zimmerman's self-regulated learning framework provided an interpretive lens on participants' perspectives of the mini-CEX.  This study brings to light the personal, interpersonal, and contextual influences on a trainee's self-regulated learning.  Interview data were only collected in Melbourne with geriatric medicine trainees whose experiences may not fully represent the experiences of other specialist trainees.  The study relied on trainees' recalled experiences of their workplacebased assessment experiences.

Funding statement:
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests' statement: The authors have no competing interests to declare.

Keywords:
Medical education, self-regulated learning, workplace based assessment, mini-CEX, geriatric medicine One promise of competency-based medical education is that learning is emphasised in the assessment process [1,2]. Consequently, formative assessment is a key component in the design of competency-based assessment in post-graduate training [3][4][5]. Assessment should fulfil three key purposes: certify achievement, facilitate feedback to the learner to drive improvement, and foster self-assessment to promote life-long learning [6,7].
It has been argued by Nichol and others that effective, formative assessment should incorporate these principles to enhance trainees' selfregulated learning [8,9].
Norcini developed the Mini-Clinical Evaluation Exercise (mini-CEX) assessment tool to facilitate observation-based feedback and promote trainee self-assessment in the workplace [10]; it is a widely used tool in postgraduate medical education (PGME) [11,12]. Mini-CEXs are conceptualised as an encounter that involves a supervisor observing a trainee performing a nominated, routine clinical task for approximately 10-15 minutes, with the supervisor providing verbal and written feedback using a standardised marking template [10].
Studies have explored the experiences and perceptions of trainees with a focus on the educational effect of the individual assessment tool [13,14].
Since 2004, there have been over forty studies examining both trainee and assessor perceptions of workplace based assessment (WBA) [15]. These  [16]. Many of the studies have been conducted in the United Kingdom (UK), using surveys to explore trainee perceptions [4,[17][18][19][20][21][22]. The efficacy of feedback following the assessment is a prominent theme in most studies. Trainees have reported that the use of the mini-CEX has increased the quantity of feedback [3,[18][19][20]22], whilst in other studies both the quantity and quality of feedback is reportedly improved [19,21,23]. Other studies report that the provision of feedback does not always encourage self-assessment, nor translate to an action plan for improvement [20,22,24].
Overall, the literature conveys a mixed picture of the influence of the mini-CEX tool on feedback. Trainees have expressed a lack of understanding regarding the purpose of the mini-CEX, reporting difficulty distinguishing the formative nature from the evaluative aspects of the assessment [5,25,26].The confusion possibly explains affective aspects such as trainee anxiety and stress attributed to these assessments, although being observed by a supervisor may evoke these emotions [18,25,27]. Further, trainees have reported valuing the close contact with the assessor and the reassurance of competency that assessment provides, but they are reluctant to display their weaknesses [18,22,25].The influence of workplace culture is also a strong theme, with negativity centred on the time commitment and the difficulties associated with organising an assessor [3,17,18,20,22,28].
A systematic review of user perceptions reported stakeholder  [15].
The perceived assessment burden has contributed to a "tick box culture" [20,29]. This approach leads to WBA tools being misused and trivialised by stakeholders, and the potential loss of a useful learning opportunity [15,30]. According to Brydges and Butler, a different approach to examine the educational effect of the mini-CEX is to focus on active learning, since trainees' learning in the clinical environment is highly influenced by their capacity for self-regulated learning (SRL) [31]. Self-regulation refers to the "self-generated thoughts, feelings, and behaviours that are planned and cyclically adapted to the attainment of personal goals" [32]. Self-regulation is cyclical because the feedback from prior performance is used to make adjustments during current or future efforts [32]. However, the relationship between the mini-CEX and the complex interactive process of a trainee's SRL has not yet been elucidated.
Self-regulation, according to Zimmerman, is an interaction of personal, behavioural and environmental triadic processes [33]. From a social cognitive perspective, self-regulatory learning processes comprise the forethought phase, the performance phase, and the self-reflection phase.
Although there have been many previous studies examining the perceptions of post-graduate trainees of the mini-CEX in WBA [34,35], to the best of our knowledge, none have utilised the SRL framework as an interpretive lens. In particular, the covert integration of personal, interpersonal and contextual  The study has a qualitative design to systematically explore how trainees experience the mini-CEX assessment in order to understand their meaning [36]. We used individual semi-structured interviews to explore participants' lived experiences and perceptions. The interpretation of the data is underpinned by a social constructivist theory, which acknowledges that reality is co-constructed between the researcher and the researched and shaped by experiences and context [37]. The research team consisted of a specialist clinician in geriatric medicine who has experience as a supervisor with the mini-CEX, and two medical education researchers, one of whom is also a clinician with supervisory experience. Reporting of the research has been guided by the COREQ checklist within the constraints of the word limit [38].

Setting and Participants
The study was conducted in 2017 in Melbourne, Australia, with trainees in geriatric medicine. Geriatric medicine training is a seven-year post-graduate program, overseen by supervisors who are specialist clinicians. In the final three years, these senior trainees are described as advanced. Each advanced trainee must complete four formative mini-CEX assessments per year.
Participants who were invited to participate in the study were advanced trainees who had completed a minimum of two mini-CEXs. There are 80 advanced trainees in Melbourne. Heterogeneous purposive sampling [39] was adopted to include trainees across the final two years of advanced training in order to ensure that potential participants had enough experience with the mini-CEX. Trainees who were currently working alongside or being directly supervised by Author 1 were excluded from the study to avoid any unequal relationships between trainees and the researcher. Author 1 introduced the study at a training program in April, 2017, and interested participants were invited to contact the first author. Potential participants received a plain language statement. Written consent was obtained from participants. No patients were involved in this research.

Patient and public involvement
There were no patients in this study. There was also no patient information (medical records) accessed for this study. Participants were medical doctors who gave their permission to be interviewed.

Data collection and analysis
All interviews were conducted in a private office at each participant's workplace by the first author. The interviews were audio-taped, transcribed, inductive, collaborative process with exploration and discussion by the group. The interpretation of the data was sensitised conceptually by the Zimmerman SRL theoretical framework [32].  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Researchers agreed that data saturation was reached after the eighth participant, with no new themes emerging with further data collection and analysis. The data analysis was thematic, following the systematic six phases approach described by Braun and Clarke [40]. Ethics approval for the study was provided by the Human Ethics Advisory Group, University of Melbourne. Ethics ID: 1748832.
Data sharing statement: The ethics approval for this project does not allow the raw interview data to be shared.

Results
Twelve advanced trainees participated in the project. All interviews were  Table 1. As can be seen from this Most participants described either a learning or a performance goal preference when selecting tasks; however, several were aware of a perceived conflict and tension in their orientation. These participants were reluctant to select tasks that were challenging but more beneficial for their learning, preferring to demonstrate their strengths in a competitive employment environment.

Task Translation
The second theme, task translation, describes the conversion by participants of the conceptualised goal from the first phase, into the real-time clinical setting. The universal word used by participants in describing the translation process was "opportunistic": the activity is performed when the right set of According to the participants, feedback was reportedly critically important in self-reflection, assisting with calibrating self-evaluation and self-reaction.

(Trainee 4)
In the translation phase, the collaboration of supervisors was essential for the performance of the assessment, with participants displaying sensitivity to the engagement of the supervisor. The perceived relationship with the supervisor reportedly impacted significantly on the goals that participants chose, the discomfort they felt during the performance, and their receptivity to feedback.

And I think I wouldn't put myself in that situation if I felt the consultant wasn't somebody who was good at understanding, you know, what it's like to be in your shoes. (Trainee 6)
Discussion: This study of trainees' perceptions of the mini-CEX has been informed by the self-regulated learning theoretical framework. The findings suggest that the performance of a mini-CEX was perceived by trainees as a complex process that was influenced at all stages by the supervisor. Additionally, there was a self-reported range in ability amongst the participants to optimally self-regulate their learning when performing a mini-CEX. The three themes of goal setting, task translation, and the perceived outcome, resonate with the three phases described earlier by Zimmerman's SRL framework [33] with elaboration on the significance of goals, and feedback following the assessment. The theme of supervisor co-regulation for For the participants, the approach to the mini-CEX was influenced by their perceived individual goal setting and goal orientation. Goal setting and goal orientation are seen as powerful motivational factors in self-regulated learning theory [41,42]. The motivational properties of goals contribute to our understanding of the findings, as well as those previously reported. In our study, trainees who reported approaching the tasks with a specific learning goal also described selecting more challenging tasks for the assessment. They also described expending more effort in the strategic planning of the assessment during the task translation phase to ensure attainment of their goals. These participants were more likely to report positive outcomes from their assessment experiences, with the important proviso that the feedback had effectively targeted their goals. There is evidence that process goal attainment can be intrinsically motivating in its own right for these learners [33].This finding underscores the cyclical nature of the process, with the forethought phase determining significant downstream effects. These "proactive" participants reported behaviours that resonated with more developed self-regulatory processes as described in the Zimmerman SRL framework. Zimmerman believes that proactive learners self-regulate more effectively because they engage in high quality forethought, which in turn improves their self-regulatory functioning during  [20,44] was evident in this study. The significance of this goal and its implications for learning is more fully appreciated when seen as part of the SRL forethought processes. Those trainees who described adopting a "tick box" goal, generally took an opportunistic approach in the translation phase and consequently perceived less positive outcomes of the mini-CEX.
Previous studies have found that goal orientation can influence trainees' perceptions of formative assessment [45]. A study exploring medical students' SRL in the clinical environment also reported goals as an influential motivational factor for learning [46].This study illustrates the dual significance of trainees' goal setting and goal orientation to the approach of a mini-CEX and the impact on the subsequent phases of the SRL cycle. In addition, feedback from the supervisor to our participants was a key factor in all the processes that occurred after the performance. These processes included self-evaluation, affective responses and self-reflection. Although the literature has focussed on perceived feedback, it has not fully captured the power of feedback as contextualised in the SRL framework. For goals set in the first phase of SRL to be effective, learners need summary feedback that reveals progress in relation to their goals [47]. Summary feedback is believed to be a moderator of goal effects, in that the combination of goals plus feedback is accepted to be more effective than goals alone [47]. Some participants in this study reported difficulty obtaining observation-based feedback from supervisors, a finding previously reported  [48]. The mini-CEX was a means of securing this desirable information for progress towards their goals. The multi-faceted nature of effective feedback has been previously described, including its benefit in formative assessment [9,49,50].
The central role of the supervisor in facilitating all aspects of the SRL cycle emerged as a major theme in the study, a finding which resonates with previous studies of WBA [20,22,51]. In addition, a key feature of a social cognitive model of self-regulation is the roles of social, environmental, and self-influences [32]. Educational research has established that an ideal form of self-regulation cannot be assumed when opportunities for self-regulation are provided [31]. The engagement of supervisors is necessary to support the challenges that arise as individual trainees learn how to focus their selfregulated activities to meet the demands of the clinical environment [31,52].The relationship with supervisors and the perception by trainees of the lack of supervisor engagement in WBA have both been previously reported in the literature [15,51]. This study provides new insights because it identifies the co-regulation at all stages of a trainee's SRL cycle by the supervisor. The supervisor's role is also contextualised as a support to the SRL of each individual trainee as required.
It should be noted that although the interviewer was reflexive and endeavoured to bracket herself [53], her role as a practising physician in geriatric medicine and as a supervisor is a source of potential bias in the  [37].

Instructions to authors
Complete this checklist by entering the page numbers from your manuscript where readers will find each of the items listed below.
Your article may not currently address all the items on the checklist. Please modify your text to include the missing information. If you are certain that an item does not apply, please write "n/a" and provide a short explanation.
Upload your completed checklist as an extra file when you submit to a journal.
Setting: Geriatric medicine training.
Participants: Purposive sampling was employed to recruit geriatric medicine trainees in Melbourne, Australia. Twelve advanced trainees participated in the interviews.
Results: Four themes were found with a cyclical inter-relationship between three of these themes: namely, goal setting, task translation, and perceived outcome. These themes reflect the phases of the self-regulated learning framework. Each phase was influenced by the fourth theme, supervisor coregulation. Goal setting had motivational properties that had significant impact on the later phases of the cycle. A "tick box" goal aligned with an opportunistic approach and poorer perceived educational outcomes.

Article Summary
Strengths and limitations of this study:  Zimmerman's self-regulated learning framework provided an interpretive lens on participants' perspectives of the mini-CEX.  This study brings to light the personal, interpersonal, and contextual influences on a trainee's self-regulated learning.  Interview data were only collected in Melbourne with geriatric medicine trainees whose experiences may not fully represent the experiences of other specialist trainees.  The study relied on trainees' recalled experiences of their workplacebased assessment experiences.

Funding statement:
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests' statement: The authors have no competing interests to declare.
It has been argued by Nichol and others that effective, formative assessment should incorporate these principles to enhance trainees' selfregulated learning [8,9].
Norcini developed the Mini-Clinical Evaluation Exercise (mini-CEX) assessment tool to facilitate observation-based feedback and promote trainee self-assessment in the workplace [10]; it is a widely used tool in postgraduate medical education (PGME) [11,12]. Mini-CEXs are conceptualised as an encounter that involves a supervisor observing a trainee performing a nominated, routine clinical task for approximately 10-15 minutes, with the supervisor providing verbal and written feedback using a standardised marking template [10].
Studies have explored the experiences and perceptions of trainees with a focus on the educational effect of the individual assessment tool [13,14].
Overall, the literature conveys a mixed picture of the influence of the mini-CEX tool on feedback. Trainees have expressed a lack of understanding regarding the purpose of the mini-CEX, reporting difficulty distinguishing the formative nature from the evaluative aspects of the assessment [5,25,26].The confusion possibly explains affective aspects such as trainee anxiety and stress attributed to these assessments, although being observed by a supervisor may evoke these emotions [18,25,27]. Further, trainees have reported valuing the close contact with the assessor and the reassurance of competency that assessment provides, but they are reluctant to display their weaknesses [18,22,25].The influence of workplace culture is also a strong theme, with negativity centred on the time commitment and the difficulties associated with organising an assessor [3,17,18,20,22,28].
The perceived assessment burden has contributed to a "tick box culture" [20,29]. This approach leads to WBA tools being misused and trivialised by stakeholders, and the potential loss of a useful learning opportunity [15,30]. According to Brydges and Butler, a different approach to examine the educational effect of the mini-CEX is to focus on active learning, since trainees' learning in the clinical environment is highly influenced by their capacity for self-regulated learning (SRL) [31]. Self-regulation refers to the "self-generated thoughts, feelings, and behaviours that are planned and cyclically adapted to the attainment of personal goals" [32]. Self-regulation is cyclical because the feedback from prior performance is used to make adjustments during current or future efforts [32]. However, the relationship between the mini-CEX and the complex interactive process of a trainee's SRL has not yet been elucidated.
Self-regulation, according to Zimmerman, is an interaction of personal, behavioural and environmental triadic processes [33]. From a social cognitive perspective, self-regulatory learning processes comprise the forethought phase, the performance phase, and the self-reflection phase.
Although there have been many previous studies examining the perceptions of post-graduate trainees of the mini-CEX in WBA [34,35], to the best of our knowledge, none have utilised the SRL framework as an interpretive lens. In particular, the covert integration of personal, interpersonal and contextual  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   7 influences on a trainee's self-regulated learning has not been explored. This study adopts Zimmerman's model of SRL [32] to examine the experiences and perceptions of physician trainees in geriatric medicine with the mini-CEX assessment. The research questions were: 1.What are the perceptions and experiences of specialist trainees in geriatric medicine of the mini-CEX exercise?
2. What is the perceived relationship between the mini-CEX and trainees' self-regulated learning?

Method Design
The study has a qualitative design to systematically explore how trainees experience the mini-CEX assessment in order to understand their meaning [36]. We used individual semi-structured interviews to explore participants' lived experiences and perceptions. The interpretation of the data is underpinned by a social constructivist theory, which acknowledges that reality is co-constructed between the researcher and the researched and shaped by experiences and context [37]. The research team consisted of a specialist clinician in geriatric medicine who has experience as a supervisor with the mini-CEX, and two medical education researchers, one of whom is also a clinician with supervisory experience. Reporting of the research has been guided by the COREQ checklist within the constraints of the word limit [38].

Setting and Participants
The study was conducted in 2017 in Melbourne, Australia, with trainees in geriatric medicine. Geriatric medicine training is a seven-year post-graduate program, overseen by supervisors who are specialist clinicians. In the final three years, these senior trainees are described as advanced. Each advanced trainee must complete four formative mini-CEX assessments per year.
Participants who were invited to participate in the study were advanced trainees who had completed a minimum of two mini-CEXs. There are 80 advanced trainees in Melbourne. Purposive sampling [39] was adopted to include trainees across the final two years of advanced training in order to ensure that potential participants had enough experience with the mini-CEX.
Trainees who were currently working alongside or being directly supervised by Author 1 were excluded from the study to avoid any unequal relationships between trainees and the researcher. Author 1 introduced the study at a training program in April, 2017, and interested participants were invited to contact the first author. Potential participants received a plain language statement. Written consent was obtained from participants. No patients were involved in this research.

Data collection and analysis
All interviews were conducted in a private office at each participant's workplace by the first author. The interviews were audio-taped, transcribed, inductive, collaborative process with exploration and discussion by the group. The interpretation of the data was sensitised conceptually by the Zimmerman SRL theoretical framework [32]. Researchers agreed that data saturation was reached after the eighth participant, with no new themes emerging with further data collection and analysis. The data analysis was thematic, following the systematic six phases approach described by Braun and Clarke [40]. Ethics approval for the study was provided by the Human Ethics Advisory Group, University of Melbourne. Ethics ID: 1748832.
Data sharing statement: The ethics approval for this project does not allow the raw interview data to be shared.

Results
Twelve advanced trainees participated in the project. All interviews were  Table 1. As can be seen from this Most participants described either a learning or a performance goal preference when selecting tasks; however, several were aware of a perceived conflict and tension in their orientation. These participants were reluctant to select tasks that were challenging but more beneficial for their learning, preferring to demonstrate their strengths in a competitive employment environment.

Discussion:
This study of trainees' perceptions of the mini-CEX has been informed by the self-regulated learning theoretical framework. The findings suggest that the performance of a mini-CEX was perceived by trainees as a complex process that was influenced at all stages by the supervisor. Additionally, there was a self-reported range in ability amongst the participants to optimally self-regulate their learning when performing a mini-CEX. The three themes of goal setting, task translation, and the perceived outcome, resonate with the three phases described earlier by Zimmerman's SRL framework [33] with elaboration on the significance of goals, and feedback following the assessment. The theme of supervisor co-regulation for  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   19 trainees' reports of self-regulated learning behaviour may have been influenced by the relational roles of the interview context (supervisor-trainee roles). These elements are discussed below.
For the participants, the approach to the mini-CEX was influenced by their perceived individual goal setting and goal orientation. Goal setting and goal orientation are seen as powerful motivational factors in self-regulated learning theory [41,42]. The motivational properties of goals contribute to our understanding of the findings, as well as those previously reported. In our study, trainees who reported approaching the tasks with a specific learning goal also described selecting more challenging tasks for the assessment. They also described expending more effort in the strategic planning of the assessment during the task translation phase to ensure attainment of their goals. These participants were more likely to report positive outcomes from their assessment experiences, with the important proviso that the feedback had effectively targeted their goals. There is evidence that process goal attainment can be intrinsically motivating in its own right for these learners [33].This finding underscores the cyclical nature of the process, with the forethought phase determining significant downstream effects. These "proactive" participants reported behaviours that resonated with more developed self-regulatory processes as described in the Zimmerman SRL framework. Zimmerman believes that proactive learners self-regulate more effectively because they engage in high quality forethought, which in turn improves their self-regulatory functioning during  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 20 subsequent phases. [43] The "tick box" approach by trainees to WBA [20,44] was evident in this study. The significance of this goal and its implications for learning is more fully appreciated when seen as part of the SRL forethought processes. Those trainees who described adopting a "tick box" goal, generally took an opportunistic approach in the translation phase and consequently perceived less positive outcomes of the mini-CEX.
Previous studies have found that goal orientation can influence trainees' perceptions of formative assessment [45]. A study exploring medical students' SRL in the clinical environment also reported goals as an influential motivational factor for learning [46].This study illustrates the dual significance of trainees' goal setting and goal orientation to the approach of a mini-CEX and the impact on the subsequent phases of the SRL cycle. In addition, feedback from the supervisor to our participants was a key factor in all the processes that occurred after the performance. These processes included self-evaluation, affective responses and self-reflection. Although the literature has focussed on perceived feedback, it has not fully captured the power of feedback as contextualised in the SRL framework. For goals set in the first phase of SRL to be effective, learners need summary feedback that reveals progress in relation to their goals [47]. Summary feedback is believed to be a moderator of goal effects, in that the combination of goals plus feedback is accepted to be more effective than goals alone [47]. Some participants in this study reported difficulty obtaining observation-based feedback from supervisors, a finding previously reported  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 21 [48]. The mini-CEX was a means of securing this desirable information for progress towards their goals. The multi-faceted nature of effective feedback has been previously described, including its benefit in formative assessment [9,49,50].
The central role of the supervisor in facilitating all aspects of the SRL cycle emerged as a major theme in the study, a finding which resonates with previous studies of WBA [20,22,51]. In addition, a key feature of a social cognitive model of self-regulation is the roles of social, environmental, and self-influences [32]. Educational research has established that an ideal form of self-regulation cannot be assumed when opportunities for self-regulation are provided [31]. The engagement of supervisors is necessary to support the challenges that arise as individual trainees learn how to focus their selfregulated activities to meet the demands of the clinical environment [31,52].The relationship with supervisors and the perception by trainees of the lack of supervisor engagement in WBA have both been previously reported in the literature [15,51]. This study provides new insights because it identifies the co-regulation at all stages of a trainee's SRL cycle by the supervisor. The supervisor's role is also contextualised as a support to the SRL of each individual trainee as required.
A further finding of this study was the range of activities that the participants reportedly included as part of their mini-CEX assessments. Some of these activities such as journal club participation were outside the scope of a clinical skill  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  her role as a practising physician in geriatric medicine and as a supervisor is a source of potential bias in the interpretation of the results, and is an accepted part of the constructivist paradigm [37].

Conclusions
By employing the SRL theoretical lens, new insights into the covert, complex interaction between a trainee's self-regulated learning and the performance of a mini-CEX in the clinical environment have been revealed. The findings highlight the supervisor as a key co-regulator of all stages of the SRL cycle.
Our participants were informed consumers of feedback with feedback quality contributing significantly to the perception of outcome and preparation for future efforts of WBA. The SRL theoretical framework has also facilitated a re-interpretation of the existing literature in a holistic, contextualised approach.
• What do you believe the intended purpose of the mini-CEX is, in your training program?
• Have you ever had any training about how to perform a mini-CEX or read any information about it? • What activities have you chosen so far for your mini-CEX assessment tasks during your advanced training? (prompts; why did you choose these? Were they related to the skills you want to improve?) • Once you have chosen the activity, can you tell me about what preparation you do for a mini-CEX? • How anxious do you feel being observed during the actual encounter?
• After the activity, please tell me about the feedback you receive from the assessor? (prompts: does the assessor give you the score or give you descriptive feedback? explore quantitative/qualitative feedback • How useful was this feedback? (prompts: Did you use it to guide your future learning? Can you think of an example when you used the feedback from a mini-CEX to change how you practice?) • Was there anything in particular that made this feedback more useful? (Explore relationship with assessor) • After the assessment episode is over, how do you feel, and do you reflect on the episode later? Did it lead you to think about the experience in anyway? • Thinking specifically about your learning, do you find the mini-CEX useful for your learning?
Does it influence your learning in anyway? • Earlier in the interview I asked you what you think are the main drivers of your learning in Geriatric Medicine? How much does the mini-CEX contribute to this?
Any suggestions to improve the mini-CEX for Geriatric Medicine?
Thank you for your co-operation.

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