Anticipation and the reality of workload

One of the most consistently positive responses was appreciation of early communication. Stakeholder engagement through in-person presentations, online events and a College webinar was widely valued. However, this receptivity was frequently tempered by concerns about workload. Even where reforms were intended to replace rather than add assessments, many clinicians perceived them as an additional burden. One consultant commented: ‘Bad enough I struggle to get patient/carer feedback, I now have to help my residents also’.

This reflects a broader tension within contemporary psychiatric practice, where clinical, administrative and educational demands compete for limited time. Perceived burden appeared to influence attitudes towards reform as much as any objectively measurable increase in workload.

Although the intended benefits included greater standardisation, improved documentation of progression and closer alignment with competency-based training standards, these gains were often weighed against concerns regarding feasibility and sustainability.

Formative intent and perceived utility

A central aim of the reforms was to move workplace-based assessments beyond procedural completion towards meaningful formative learning. Although patient and carer feedback was generally viewed positively in principle, clinicians questioned whether it would result in tangible educational benefit or become another administrative requirement.

These concerns suggest that clinicians are resistant not to reflection itself but to processes that risk becoming disconnected from authentic learning. In psychiatry, where understanding is often relational and contextual, highly structured approaches may sometimes be perceived as reductive.

Entrustability and the challenge of judgement

The introduction of entrustability scales generated the greatest discussion. For trainers, the change represented a move towards making explicit the judgements they routinely make regarding resident doctors’ autonomy.

Concerns clustered around three areas:

• • subjectivity and potential bias

• • lack of clarity regarding application

• • accountability associated with recorded decisions.

These concerns illustrate an important paradox. Psychiatry relies heavily on nuanced professional judgement, yet clinicians may feel less comfortable when those judgements become formalised within assessment systems (Govaerts Reference Govaerts and van der Vleuten2013; ten Cate Reference ten Cate2013; Varvari Reference Varvari, Duddu and Ranjith2024).

An unexpected observation was that resident doctors often appeared more comfortable with entrustability than trainers were. For residents, the concept reflected their own experience of graduated responsibility. Trainers, by contrast, expressed greater concern regarding consistency, defensibility and potential consequences.

These discussions highlighted the need for ongoing refinement, guidance and evaluation, reinforcing the idea that implementation should be viewed as a continuing process rather than a completed reform.

The perceived drift towards summative assessment

A recurrent concern was that formative tools might gradually acquire summative functions. Although the reforms are explicitly developmental, many clinicians anticipated that entrustability ratings and structured feedback could eventually influence progression decisions more directly.

This raises an important question: Can any assessment within a high-stakes training system remain entirely formative?

The anxieties expressed by clinicians appeared to reflect concern about the quantification of complex professional competence rather than opposition to assessment itself. Once data are generated, there is often pressure for them to be used in decision-making processes. The perceived instability of the boundary between formative and summative assessment remained an important source of caution.

Formulation: reconnecting with psychiatric identity

In contrast to the ambivalence associated with some reforms, the explicit inclusion of formulation in case presentations was met with almost universal enthusiasm.

Clinicians described this as:

• • ‘bringing back the long case’

• • restoring depth to clinical discussion

• • reaffirming the biopsychosocial foundations of psychiatric practice.

This response was strikingly consistent across settings. It suggested that acceptance of educational reform depends not only on educational theory but also on the extent to which changes resonate with professional identity.

Notably, clinicians also requested additional training and guidance on formulation. Unlike some assessment changes, formulation was viewed as educationally meaningful and directly relevant to everyday clinical work, rather than as an additional administrative requirement (Norcini Reference Norcini and Burch2007).

Expanding non-clinical competencies

The expansion of direct observation of non-clinical skills (DONCS), particularly following engagement with RCPsych special interest groups, was broadly welcomed. Clinicians recognised the importance of leadership, advocacy, public mental health and system-level thinking in modern psychiatric practice.

However, many sought practical guidance and examples to help translate these domains into observable behaviours suitable for assessment. This highlighted the continuing challenge of assessing non-clinical competencies in routine training.

Implementation as a relational process

Across presentations of the reforms, a consistent pattern emerged. Initial curiosity was followed by selective acceptance and then by ongoing negotiation regarding meaning, application and purpose.

Change occurred not through transmission of information alone but through dialogue, interpretation and adaptation. In this respect, implementation closely resembled clinical practice itself.

Assessment reform is therefore not simply a technical exercise. It is a relational process requiring trust, communication and attention to the experiences of those affected. The response to these reforms suggests that successful implementation depends as much on clinician engagement as on the design of the assessment tools themselves.

Several themes emerged repeatedly:

• • workload strongly shapes perceptions of change

• • formalising professional judgement can generate discomfort

• • trainers and resident doctors may respond differently to innovation

• • reforms aligned with psychiatric identity are more readily embraced.

These observations reinforce the importance of humility in educational reform. Systems that appear coherent in design may be experienced quite differently in practice.