Power Moves: An Ethnographic Investigation of How Space, Place, and Pace Influence Equity in Pediatric Workplace-Based Assessment

Abstract – Purpose – Mounting evidence indicates that workplace-based assessments are inequitable despite well-intended efforts to address this phenomenon. Research suggests that the complexity of contexts in which workplace-based assessment takes place may thwart these efforts. This study aimed to investigate the contextual forces of power that may influence the equity of workplace-based assessment in a pediatric clinical learning environment. Method – Using a critical paradigm with a justice-oriented approach toward equity in assessment, the authors conducted an ethnography of workplace-based assessment in the pediatric emergency department at a large local pediatric residency program in an urban children’s hospital in the Northeast United States between April and September 2024. Codes were generated with the constant comparison method, data triangulated from all sources, and codes organized to further interpret and describe the data. Results – A total of 144 hours of observations were conducted across team 1 (73 hours) and team 2 (71 hours), observing 79 participants (28 attendings and 51 residents). Eleven brief field interviews (5 attendings and 6 residents) and 6 scheduled, in-depth interviews (3 attendings and 3 residents) were also conducted. Authors identified 3 major contextual forces affecting equity in workplace-based assessment: space, place, and pace. Space referred to the material reality of the learning environment: physical space, online space, and rules that governed how both spaces could be used and by whom. Place referred to how participants moved, navigated, and positioned themselves. Pace referred to the speed, character, and energy of the learning environment. Each contextual force was constituted of discrete subforces. Taken together, these forces illustrated how power moved within the clinical learning environment to either enable or cause inequity. Conclusions – This research illuminated that equity in workplace-based assessment is influenced by how power moves between and among people (attendings and residents) and things (material realities) in the clinical learning environment.