25 Realist review | 2 Step 7: Extracting CMOs. The research question guided the formulation of applied definitions for context, mechanism and outcome: Context: T he external factors that affect portfolio use for the support of SRL. These factors could still exist without the portfolio present. Mechanism: T he processes set in motion by portfolio use that influence the degree and/or level of SRL. These processes would not exist without the portfolio present. Outcome: SRL that is generated by portfolio use. The reviewers individually coded the included papers for phrases that described contexts, mechanisms or outcomes as defined above. We only included phrases directly linked to the study that was performed by the authors of the paper, as the focus was on primary data. Subsequently, the reviewers discussed their coding to reach consensus about the CMOs present. It was decided to also include incomplete CMOs, as these can help to clarify how portfolio use works for the support of SRL. Multiple iterations of coding and discussion were performed to formulate the final CMOs. Coding was supported by NVIVO (https://www.qsrinternational.com/nvivo) and Atlas.ti (https://atlasti.com/). Step 8: Synthesising CMOs. To synthesise the CMOs, we visualised each CMO by putting arrows between its context, mechanism and outcome with the use of mindmapping software (http://www.mindomo.com). This enabled us to easily (re)order different contexts, mechanisms and/or outcomes inductively, without losing the connection between individual CMOs. In that way, we could identify overarching contextual factors, by grouping similar contexts together. Likewise, similar mechanisms were abstracted into overarching portfolio (related) mechanisms. We deductively organised the outcomes of the CMOs according to the SRL outcomes of the programme theory: self-assessment, reflection, feedback, learning objectives and plans, and monitoring. Finally, we used the identified contextual factors, portfolio (related) mechanisms and SRL outcomes to compose a model that illustrates how portfolio use supports SRL during clinical WPL. Results Study characteristics We included sixteen papers (See Appendix F for a flowchart of the extraction process).31-46 These papers originated from eleven countries across Africa (2), Asia (3), Europe (8) and North America (3). Studies were conducted in undergraduate medical settings - (5) and postgraduate medical ones (11). Most papers describe an evaluation of portfolio implementation (14). Although quantitative, qualitative and mixed methods designs are present, the questionnaire was the most popular method of data collection (10). Only four
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