title: Putting performance in context: the perceived influence of environmental factors on work-based performance.
abstract: BACKGROUND
  Context shapes behaviours yet is seldom considered when assessing competence. Our objective was to explore attending physicians' and trainees' perceptions of the Internal Medicine Clinical Teaching Unit (CTU) environment and how they thought contextual factors affected their performance.
  
  
  METHODS
  29 individuals recently completing CTU rotations participated in nine level-specific focus groups (2 with attending physicians, 3 with senior and 2 with junior residents, and 2 with students). Participants were asked to identify environmental factors on the CTU and to describe how these factors influenced their own performance across CanMEDS roles. Discussions were analyzed using constructivist grounded theory.
  
  
  RESULTS
  Five major contextual factors were identified: Busyness, Multiple Hats, Other People, Educational Structures, and Hospital Resources and Policies. Busyness emerged as the most important, but all factors had a substantial perceived impact on performance. Participants felt their performance on the Manager and Scholar roles was most affected by environmental factors (mostly negatively, due to decreased efficiency and impact on learning).
  
  
  CONCLUSIONS
  In complex workplace environments, numerous factors shape performance. These contextual factors and their impact need to be considered in observations and judgements made about performance in the workplace, as without this understanding conclusions about competency may be flawed.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Canada. lynfa.stroud@sunnybrook.ca.|Wilson Centre for Research in Education, University Health Network, University of Toronto, Toronto, Canada. lynfa.stroud@sunnybrook.ca.
authors.forename: Lynfa
authors.initials: L
authors.lastname: Stroud
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Canada.
authors.forename: Pier
authors.initials: P
authors.lastname: Bryden
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Bochra
authors.initials: B
authors.lastname: Kurabi
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Canada.|Wilson Centre for Research in Education, University Health Network, University of Toronto, Toronto, Canada.
authors.forename: Shiphra
authors.initials: S
authors.lastname: Ginsburg
keywords: Competency; Medical education; Qualitative methods; Work-based assessment