155 Appendices | 8 Summary Medical training programmes across the world have implemented portfolios to support self-regulated learning (SRL) during clinical workplace learning (WPL). However, much is still unknown regarding its effectiveness, as portfolio research in this field has mainly focused on other purposes of portfolio use (e.g. assessment). The aim of this thesis was to gain insight into what extent, in which ways and under what circumstances portfolio use supports SRL during clinical WPL. In order to reach this aim a central research question was formulated: How does portfolio use affect SRL during clinical WPL? We performed a realist review in order to describe the evidence base that considers how and under what circumstances portfolio use supports SRL. In Chapter 2, the two phases of this realist review are described. In the first phase, stakeholder interviews and a scoping search were performed to formulate a programme theory that explains how portfolio use may support SRL. In the second phase, an in-depth literature search was conducted, which resulted in the inclusion of 16 papers. We extracted context-mechanism- outcome configurations from these papers, that described in which ways and under what circumstances portfolio use resulted in changes in SRL. This process helped to establish two working mechanisms of portfolio use: documenting as a moment of contemplation (learners analyse experiences while writing portfolio reports) and documentation as a reminder of past events (learners are reminded of past experiences when reading previously documented portfolio reports). These two mechanisms can explain the positive relationship between portfolio use and self-assessment, reflection and feedback processes that was identified. However, there was limited evidence that portfolio use also supported the two other SRL constructs that health professions education literature considers related to portfolio use: formulation of learning objectives and plans, and monitoring. While this review showed that portfolio use has the potential to support SRL, it also showed that the working mechanisms of portfolio use – and with that SRL – are easily disrupted by interference of contextual factors (e.g. system of assessment) and other factors related to portfolio use (e.g. how the portfolio is used during mentoring). Many of these disruptions seem to relate to tensions between different portfolio purposes, which may undermine motivation of learners. Moreover, this reviewdemonstrated that previous portfolio studies were falling short both theoretically - in defining and conceptualising SRL - and methodologically. In order to further develop the evidence base concerning portfolio use for the support of SRL, it was of relevance to gain insight into the presence of SRL constructs within portfolio documentation. Therefore, a content analysis of the portfolios of general practitioner (GP) trainees was performed, which is described in Chapter 3. While SRL consists of many constructs, the focus of this study was on the constructs that health profession education considers to be supported by portfolio use: reflection and feedback (as these are expected to contribute to self-assessment), goal-setting and planning, and monitoring. A codebook was formulated by use of literature that describes criteria for
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