Competency-based medical education (CBME) emphasises the assessment of trainees through direct observation and feedback using workplace-based assessments (WBA).1 These assessments are designed to support continuous learning and competency development through meaningful feedback.2 Effective implementation of WBA requires trainers who are willing and able to provide constructive feedback,3 4 5 and trainees who are motivated to seek and use feedback. This active engagement with feedback is the essence of feedback literacy, defined by Carless and Boud6 as “the understandings, capacities, and dispositions needed to make sense of information and use it to enhance work or learning strategies”. The construct of intention, based on the theory of planned behaviour, highlights that an individual’s willingness to perform a behaviour is influenced by their attitudes, subjective norms, and perceived behavioural control.7 Intention is emphasised as the best predictor of behaviour, especially where constraints or barriers exist. In the context of WBA, focusing on intention helps us understand the underlying motivations and readiness of trainers and trainees to engage in feedback practices. Trainers’ intentions are shaped by their beliefs about the value of feedback, the expectations of peers, and their confidence in their ability to provide that feedback. Dawson et al,8 building on the works of Carless and Boud6 and Molloy et al,9 conceptualised feedback literacy as five key skills: seeking feedback, making sense of information, using feedback, managing emotional responses, and providing feedback. Based on this framework, effective training is essential for fostering engagement and capability in meaningful feedback practices.

Faculty development is often implemented to enhance trainers’ skills, whereas separate sessions aim to build feedback literacy among trainees. However, specialties with small numbers of trainers and trainees face unique challenges in implementing WBA, including limited opportunities to conduct separate training sessions. A conjoint WBA workshop, where both groups train together, may offer an innovative solution to these constraints. Potential benefits include promoting mutual understanding, aligning feedback practices, and fostering a consistent approach to WBA implementation.10 However, concerns regarding power imbalances and psychological safety in mixed-group settings could undermine its effectiveness.11 Thus far, there have been no studies regarding such conjoint workshops; the actual participant experience, including potential advantages and disadvantages, remains unexplored.

Therefore, this study aimed to address the following research questions:

1. Can conjoint training improve the intention of trainers to participate in WBA?
2. Can conjoint training improve the feedback literacy of trainees?
3. What are the experiences of trainers in a conjoint training setting?
4. What are the experiences of trainees in a conjoint training setting?

This study was designed according to the requirements of the SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education) guidelines for educational improvement.12

The study was conducted with trainers and trainees of the Hong Kong College of Otorhinolaryngologists (HKCORL), a specialty college under the Hong Kong Academy of Medicine. The HKCORL is responsible for training and accrediting specialists in otorhinolaryngology, and has been integrating WBAs into its training curriculum since 2021. The College currently has a total of 206 fellows, 57 of whom are trainers. In May 2023, 20 trainers participated in a WBA workshop specifically designed for them. During the first 2 years, basic surgical trainees are under the Hong Kong Intercollegiate Board of Surgical Colleges and rotate through different surgical specialties. Specialist training in otorhinolaryngology takes place only during the 4 years of higher training. Over the past 5 years, the annual intake of higher trainees has ranged from four to 11. Currently, there are 31 higher trainees, 26 of whom participated in a WBA workshop for trainees held in September 2023. Relationships among fellows and trainees are strengthened through regular training courses, academic lectures, workshops, and an annual scientific meeting, complemented by active participation from the Young Fellows Chapter to enhance engagement in College activities. Camaraderie is also fostered through sports activities and social events.

All participants in the workshop were invited by email to participate in this study on a voluntary basis. All 13 trainers and five trainees enrolled in the workshop volunteered to participate in the study. The cohort of trainers was relatively young; 11 were within 10 years of obtaining their fellowship, and seven had only 1 to 2 years of experience as specialists.

The 4-hour workshop was designed based on the first principles of instruction, emphasising task-centred learning as the core instructional approach.13 Participants engaged in two authentic learning tasks: procedural-based assessment and case-based discussion, each followed by guided reflection. These tasks provided opportunities to practise giving and receiving feedback, which was the main focus of the workshop.

To prepare for these tasks, participants first completed a pre-course e-learning module consisting of five interactive videos (total duration: 53 minutes). These videos introduced essential concepts, including CBME, self-regulated learning, feedback literacy, and the procedures of WBA. The workshop began with an activity to establish psychological safety, following the recommendations of Rudolph et al,14 ensuring that participants felt comfortable to learn and engage openly. Subsequently, participants’ knowledge was reactivated through interactive lectures and demonstrations, effectively preparing them for the practice activities.

1. Trainee feedback literacy: The Feedback Literacy Behaviour Scale was used to assess changes in trainees’ feedback literacy. It measures five subscales: Seeking Feedback, Making Sense of Feedback, Using Feedback, Providing Feedback, and Managing Affect.8
2. Trainer engagement in WBA: Trainers’ engagement was measured using the Continuing Professional Development (CPD)–Reaction Questionnaire, based on social cognitive theories (theory of planned behaviour and Triandis’ theory of interpersonal behaviour). It measures intention, social influence, beliefs about capabilities, beliefs about consequences, and moral norms.7 15 16

Both surveys were administered before participants began their e-learning and repeated after completion of the workshop.

Paired t tests were utilised to compare pre- and post-intervention scores for both groups because this method offers more precise estimates of the effect and improved control over confounding variables compared with an unpaired t test, particularly given the small sample size. Descriptive statistics, including means, standard deviations, and Cohen’s d effect sizes, were calculated for each measure using Jamovi (desktop version 2.3.28).17

Separate focus group interviews were conducted for trainers and trainees immediately after the workshop, using Cantonese. The two moderators were research staff trained by the authors. Semi-structured interviews were conducted using an interview guide created by the authors (online Appendix). The interviews were audio-recorded, anonymised, and transcribed verbatim. Transcripts were analysed using Braun and Clarke’s thematic analysis approach,18 assisted by ATLAS.ti software (version 8.4.5; ATLAS.ti Scientific Software Development, Berlin, Germany).19

To enhance the credibility of the qualitative findings, results were sent back to participants after thematic analysis to confirm whether they agreed with the interpretation and whether they wished to share additional views. This process helped strengthen the credibility of the qualitative findings.

The first author, an intensivist and educationist with a Master’s degree in Health Professions Education, played a key role in designing the conjoint workshop and framing WBA as a learning tool. The second author, a consultant otorhinolaryngologist and CBME advocate, proposed the joint training concept to address challenges in organising separate trainer and trainee sessions. Support from the seventh author, president of HKCORL, was critical for workshop implementation. Other authors contributed diverse clinical and educational expertise: the third author, a consultant anaesthetist and faculty development chair of the Jockey Club Institute for Medical Education and Development of the Hong Kong Academy of Medicine; the fifth author, an obstetrics and gynaecology consultant with expertise in healthcare quality and simulation; the sixth author, an orthopaedic surgeon and former college censor; and the fourth author, a neurosurgeon experienced in WBA workshops.

Their collective advocacy for CBME and WBA informed the study design and interpretation. While offering rich, multifaceted insights into WBA, this commitment may have influenced the emphasis on the conjoint workshop’s benefits, shaping research questions and conclusions accordingly.

Among the trainees, the total Feedback Literacy Score significantly increased (pre=96.8 ± 4.04, post=125.2 ± 9.93; P<0.001), associated with a large effect size (d= –3.488). There was no statistically significant difference in the subscales of the Feedback Literacy Score (Table 1).

Among the trainers, the CPD–Reaction Scores showed statistically significant improvement in intention (pre=10.27 ± 1.65, post=11.09 ± 1.88; P=0.036), beliefs about capabilities (pre=15.55 ± 2.01, post=16.73 ± 2.25; P=0.015), beliefs about consequences (pre=10.27 ± 1.65, post=11.45 ± 1.88; P=0.049), and total score (pre=60.18 ± 5.04, post=65.82 ± 5.93; P=0.008). The effect sizes were moderate to large for intention (d= –0.750), moderate for beliefs about capabilities (d= –0.543) and beliefs about consequences (d= –0.631), and large for the total score (d= –0.801) [Table 2].

Four themes were identified: understanding WBA assessment, enhancing feedback literacy, presence of trainers in the workshop, and workshop design and delivery. Subthemes and quotations under each theme are listed in online supplementary Table 1.

Four themes were identified: perceptions of WBA, improvement in feedback skills, presence of trainees in the workshop, and workshop design and delivery. Subthemes and quotations under each theme are listed in online supplementary Table 2.

This mixed-methods study evaluated the impact of a conjoint WBA workshop designed to enhance both trainer intention to participate in WBA and trainee feedback literacy. The quantitative and qualitative data converged to show that the conjoint workshop improved trainer intention and appreciation of feedback skills; it also enhanced trainee feedback literacy and confidence in managing feedback during their learning process. Specifically, the quantitative results showed statistically significant improvement in trainer intention to participate in WBA as measured by the CPD–Reaction Questionnaire, and in trainee feedback literacy as measured by the Feedback Literacy Behaviour Score. Moreover, the qualitative findings suggested that trainers appreciated the use of open-ended questions and integration of feedback into micro-moments as valuable strategies, whereas trainees reported increased confidence in managing feedback and constructively applying it to their learning processes.

Through analysis of the qualitative data, we also identified three key factors that contributed to these findings: mutual understanding between trainers and trainees, clarification of the purpose of WBA, and effective instructional design.

A key finding of this study was the positive reception of the mixed-group learning experience. Both trainers and trainees valued the opportunity to directly engage with each other, which fostered mutual understanding of the assessment process and reduced discrepancies in feedback practices. Notably, the absence of prominent power dynamics was striking. This may be partially attributed to the relatively young cohort of trainers, which likely fostered a more collaborative atmosphere. Although previous literature suggests that hierarchical structures can hinder open communication in feedback settings,11 the present study demonstrated that in contexts with flatter hierarchies, conjoint workshops can be highly effective. Trainees indicated that the emphasis on psychological safety during the workshop helped prepare them for meaningful participation. Adherence to the recommendations of Rudolph et al14 to establish a safe environment likely contributed to this positive outcome. The close relationships already present between trainers and trainees within this small specialty could also have contributed. Existing literature supports the importance of trainer–trainee relationships in WBA.4 20 Interactions within this psychologically safe environment facilitated a more unified understanding of assessment standards and expectations, which helped minimise discrepancies in feedback practices. This alignment fostered trust that both trainers and trainees were working towards the shared goal of using WBA for learning purposes.

Our qualitative findings indicated that both groups reported a highly positive experience. The distinction lay in the focus: trainees emphasised gains in feedback literacy and confidence, whereas trainers valued new practical strategies and enhanced mutual understanding. According to the conceptual model of Castanelli et al,21 the level of trust in supervisors influences trainees’ perceptions of WBA. When trust is low, WBAs are regarded as performance evaluations, leading trainees to adopt risk-minimising strategies.22 Conversely, when trust is high, trainees perceive WBA as an assessment for learning, making them more willing to embrace vulnerability. Our findings suggest that, with appropriate measures to ensure psychological safety, a combined workshop setting may help align expectations, create a shared understanding of WBA practices, and strengthen trainees’ trust in their trainers.

Both trainers and trainees recognised that WBA serves as a formative tool that guides reflective practice and enhances clinical competence. This understanding is crucial because it aligns with the principles of adult learning, particularly the notion that adults are self-directed learners who take responsibility for their own education.23 When both trainers and trainees appreciate that WBA facilitates reflective practice, they engage in self-directed learning by utilising feedback to critically analyse their clinical performance. This process empowers them to identify areas for improvement and take actionable steps towards enhancing their skills. Moreover, adults are motivated to learn when the material is directly relevant to their professional needs.23 In this context, WBA’s role in guiding clinical competence is highly pertinent because it connects seamlessly with daily practice. Thus, WBA not only fosters a culture of continuous improvement but also effectively motivates adult learners by linking assessment to professional development. However, motivation alone is insufficient. Participants also noted barriers such as time constraints in the clinical setting and the need for effective evaluation of outcomes. These issues must be addressed to ensure that motivation remains long-lasting and that trainees continue to meaningfully engage with WBAs in their everyday practice.

The workshop was designed based on the first principles of instruction, an evidence-based model that emphasises moving beyond memorisation to active knowledge application through real-world tasks.13 24 This approach encourages learners to engage in practice, which is often challenging and requires specific support. To address this, support is twofold: cognitive and affective. Cognitive support helps learners understand key concepts through pre-course e-learning, reactivation of prior knowledge, demonstration, and facilitated reflection.13 Affective support focuses on ensuring psychological safety, which is crucial for effective engagement in practice.14 While overall improvement reflects the combined effect of e-learning and the workshop, the qualitative data indicate that the interactive, conjoint nature of the workshop itself was the primary catalyst for enhancing mutual understanding and feedback skills. Our analysis revealed that participants valued this design and highlighted two additional elements that supported their learning: cognitive aids and peer feedback.

During the course, we used cognitive aids to remind participants of this six-step framework (Fig), and they found the use of such a framework effective. Workplace-based assessments consist of recurrent constituent skills—the steps to follow—and non-recurrent constituent skills (eg, how to respond in the debriefing conversation). The use of a structured framework and just-in-time information, such as cognitive aids, has been shown to effectively support the learning of recurrent skills.25

During the guided reflection, we also engaged participants in peer feedback. Our analysis showed that participants found this practice enhanced their learning. Peer feedback enhances metacognitive perceptions by encouraging learners to reflect on their understanding and performance in relation to their peers. This fosters self-awareness as learners evaluate their work against others’, facilitating deeper insights into strengths and areas for improvement.26 There is evidence demonstrating the effectiveness of peer feedback in enhancing feedback literacy.27 28

Nonetheless, participants noted that the workshop could be improved by providing clearer instructions for role-playing exercises and using more medical-related cases for demonstration. Effective instruction is important. According to cognitive load theory, ineffective guidance can increase extrinsic cognitive load and impair learning, especially when the task itself is already demanding.29 We used a movie-based scenario not related to medicine to make the activity fun and interesting. However, the participants’ comment is valid, considering evidence that similarity between demonstration and practice is crucial for effective learning. When demonstrations closely resemble real-life applications, learners can better understand and apply concepts. This alignment enhances procedural knowledge, enabling learners to transition from observation to imitation and, eventually, autonomous practice. Furthermore, relevant demonstrations foster engagement and allow immediate feedback, which reinforces learning.30 31 Future workshops should focus on improving these aspects for better learning outcomes.

This study had some limitations. The quantitative findings are constrained by the small sample size, particularly among trainees (n=5), which limits statistical power. Furthermore, although participation in the workshop was encouraged by the College, the sample may still reflect a group more engaged in training initiatives, potentially affecting generalisability. While the qualitative data provided rich insights into participants’ experiences, a larger cohort could offer a broader understanding of the impact of this educational intervention. Additionally, the study did not assess long-term changes in behaviour or practice, which are needed to determine sustained effects of the conjoint training on WBA implementation. Future studies could explore the longitudinal impact of such workshops and investigate their applicability in larger specialties where power dynamics might differ. It would also be valuable to assess the scalability of conjoint workshops in different contexts, particularly those with more complex hierarchical structures, to better understand their potential for broader implementation.

This study provides evidence that conjoint WBA workshops for trainers and trainees may effectively enhance trainee feedback literacy and trainer engagement in CBME. The mixed-group learning experience promoted mutual understanding and aligned feedback practices without creating significant power imbalances, fostering positive trainer–trainee interactions and enhancing trust, provided measures are taken to ensure psychological safety. Despite the positive outcomes, the study’s limitations, including its small sample size and lack of long-term follow-up, should be considered. Future research could explore the longitudinal impact of conjoint workshops and their applicability in larger specialties with more complex power dynamics.

Concept or design: HY So, EWY Wong.
Acquisition of data: HY So, CM Ngai.
Analysis or interpretation of data: HY So, AKM Chan, GKC Wong.
Drafting of the manuscript: HY So.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank Mr CF Chan and Ms Cathy Ma of the Jockey Club Institute for Medical Education and Development of Hong Kong Academy of Medicine for valuable assistance in moderating the focus group discussions and preparing the transcripts. The authors also appreciate the logistical support provided by Ms Cindy Leung of The Hong Kong College of Otorhinolaryngologists, as well as Mr CF Chan, Ms Cathy Ma, and Ms Jojo Lee of the Jockey Club Institute for Medical Education and Development of Hong Kong Academy of Medicine in organising the workshop. Additionally, the authors wish to express their heartfelt thanks to Professor Jack Pun from the Department of English at The Chinese University of Hong Kong and Professor Stanley Sau-ching Wong from the Department of Anaesthesiology at The University of Hong Kong for insightful contributions to the preparation of the manuscript.

Findings from this study were presented at AMEE 2025 of the International Association for Health Professions Education, 23-27 August 2025, Barcelona, Spain.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong, Hong Kong (Ref No.: SBRE-23-0855). Information sheets regarding the study were provided to all participants, and signed consent was obtained from each participant prior to the study

The supplementary material was provided by the authors and some information may not have been peer reviewed. Accepted supplementary material will be published as submitted by the authors, without any editing or formatting. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by the Hong Kong Academy of Medicine and the Hong Kong Medical Association. The Hong Kong Academy of Medicine and the Hong Kong Medical Association disclaim all liability and responsibility arising from any reliance placed on the content.

1. So HY, Choi YF, Chan PT, Chan AK, Ng GW, Wong GK. Workplace-based assessments: what, why, and how to implement? Hong Kong Med J 2024;30:250-4. Crossref

2. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach 2010;32:676-82. Crossref

3. Anderson HL, Kurtz J, West DC. Implementation and use of workplace-based assessment in clinical learning environments: a scoping review. Acad Med 2021;96:S164-74. Crossref

4. Massie J, Ali JM. Workplace-based assessment: a review of user perceptions and strategies to address the identified shortcomings. Adv Heal Sci Educ Theory Pract 2016;21:455-73. Crossref

5. Lörwald AC, Lahner FM, Mooser B, et al. Influences on the implementation of Mini-CEX and DOPS for postgraduate medical trainees’ learning: a grounded theory study. Med Teach 2019;41:448-56. Crossref

6. Carless D, Boud D. The development of student feedback literacy: enabling uptake of feedback. Assess & Eval High Educ 2018;43:1315-25. Crossref

7. Ajzen I. The theory of planned behaviour. Organ Behav Hum Decis Processes 1991;50:179-211. Crossref

8. Dawson P, Yan Z, Lipnevich A, Tai J, Boud D, Mahoney P. Measuring what learners do in feedback: the Feedback Literacy Behaviour Scale. Assess Eval High Educ 2023;49:348-62. Crossref

9. Molloy E, Boud D, Henderson M. Developing a learning-centred framework for feedback literacy. Assess Eval High Educ 2020;45:527-40. Crossref

10. Illingworth P, Chelvanayagam S. Benefits of interprofessional education in health care. Br J Nurs 2007;16:121-4. Crossref

11. Brooks AK. Power and the production of knowledge: collective team learning in work organizations. Hum Resour Dev Q 1994;5:213-35. Crossref

12. Ogrinc G, Armstrong GE, Dolansky MA, Singh MK, Davies L. SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education): publication guidelines for educational improvement. Acad Med 2019;94:1461-70. Crossref

13. Merrill MD. First principles of instruction. In: Reigeluth CM, Carr-Chellman AA, editors. Instructional Design Theories and Models: Building a Common Knowledge Base. Vol III. New York: Routledge Publishers; 2009: 43-59.

14. Ruldolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc 2014;9:339-49. Crossref

15. Légaré F, Borduas F, Freitas A, et al. Development of a simple 12-item theory-based instrument to assess the impact of continuing professional development on clinical behavioral intentions. PLoS One 2014;9:e91013. Crossref

16. Triandis HC. Values, attitudes, and interpersonal behaviour. In: Howe HE Jr, Page MM, editors. Nebraska Symposium on Motivation. Lincoln: University of Nebraska Press; 1979: 195-259.

17. Jamovi Project. Jamovi (desktop version 2.3.28 for Mac). 2024. Available from: https://dev.jamovi.org. Accessed 25 Oct 2024.

18. Clarke V, Braun V. Thematic analysis. In Teo T, editor. Encyclopedia of Critical Psychology. New York: Springer; 2014: 1947-52. Crossref

19. ATLAS.ti Scientific Software Development GmbH. ATLAS.ti (software version 8.4.5). 2024. Available from: https://atlasti.com. Accessed 25 Oct 2024.

20. Baboolal SO, Singaram VS. Specialist training: workplace-based assessments impact on teaching, learning and feedback to support competency-based postgraduate programs. BMC Med Educ 2023;23:941. Crossref

21. Castanelli DJ, Weller JM, Molloy E, Bearman M. Trust, power and learning in workplace-based assessment: the trainee perspective. Med Educ 2022;56:280-91. Crossref

22. Gaunt A, Patel A, Rusius V, Royle TJ, Markham DH, Pawlikowska T. ‘Playing the game’: how do surgical trainees seek feedback using workplace-based assessment? Med Educ 2017;51:953-62. Crossref

23. Knowles MS, Holton EF III, Swanson RA. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development, 6th ed. Amsterdam: Elsevier; 2005.

24. Francom GM, Gardner J. What is task-centered learning? TechTrends 2014;58:27-35. Crossref

25. van Merriënboer JJ, Kirschner PA. Ten Steps to Complex Learning: A Systematic Approach to Four-Component Instructional Design. 3rd ed. New York: Routledge Publisher; 2018. Crossref

26. Lerchenfeldt S, Kamel-ElSayed S, Patino G, Loftus S, Thomas DM. A qualitative analysis on the effectiveness of peer feedback in team-based learning. Med Sci Educ 2023;33:893-902. Crossref

27. Man D, Kong B, Chau MH. Developing student feedback literacy through peer review training. RELC J 2024;55:408-21. Crossref

28. Little T, Dawson P, Boud D, Tai J. Can students’ feedback literacy be improved? A scoping review of interventions. Assess Eval High Educ 2023;49:39-52. Crossref

29. van Merriënboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010;44:85-93. Crossref

30. McLain M. Developing perspectives on ‘the demonstration’ as a signature pedagogy in design and technology education. Int J Tech Design Educ 2021;31:3-26. Crossref

31. Grossman R, Salas E, Pavlas D, Rosen MA. Using instructional features to enhance demonstration-based training in management education. Acad Manag Learn Educ 2012;12:219-43. Crossref