36 | Chapter 2 Discussion We conducted a realist review to better understand when and how portfolio use supports SRL during clinical WPL. Based on the CMOs of sixteen included papers, we developed a model to describe how contextual factors and portfolio (related) mechanisms can influence SRL outcomes. In contrast to the programme theory, our realist review found limited evidence for the assumption that portfolio use supports the formulation of learning objectives and plans, and monitoring. Our findings do describe a relationship between portfolio use and the other SRL outcomes of the programme theory: self-assessment, reflection and feedback. However, these SRL outcomes were found in isolation, contrary to the programme theory that describes a learning cycle, in which the different SRL outcomes flow into each other. The limited support for the programme theory can be explained by characteristics of the included papers: learning objectives and monitoring were included less as outcome of interest than the other SRL outcomes, and the study designs were often not suitable to explore interactional relationships between SRL outcomes. However, our findings also indicate that the contextual factors in interaction with the portfolio related mechanisms can easily disrupt the primary portfolio mechanisms – documenting as a moment of contemplation and documentation as a reminder of past events -, and with that SRL. The most prominent contextual factors that emerged from the CMOs were WPL in interaction with the assessment programme: learners in a busy clinical setting can easily get overwhelmed by time constraints and/or the wish to perform well. But the portfolio related mechanisms indicate that the pressures of WPL can be avoided by ensuring sufficient time and opportunities for learners to use the portfolio during workdays. In contrast, our results did not highlight any solutions for the tensions that result from (summative) portfolio assessment. This aligns with an ongoing debate about the desirability of multipurpose portfolios: should we use the portfolio for both assessment and to support SRL?2,9 It is likely that tensions between these two potentially contrasting portfolio purposes undermine learner motivation and thereby limit SRL. While motivation is an important construct in many SRL theories,47 other motivation theories might help explain this relationship, such as self-determination theory (SDT).48 The foundation of SDT consists of a series of principles about human nature, that explain a continuum from amotivation to intrinsic motivation. SDT states that three innate needs must be fulfilled for intrinsic motivation to endure: the need for autonomy, the need for competence and the need for relatedness with others. It is conceivable that portfolio assessment can frustrate the need for autonomy (freedom of choice is limited by the system of assessment) and for competence (during assessment one might be confronted with (fear of ) incompetence), and thereby limits intrinsic motivation. Since intrinsic motivation is described by concepts such as autonomy and self-regulation and is associated with better learning,48 it is likely that a decline in intrinsic motivation is in essence a decline in SRL.
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