Non-cognitive Attributes Research Articles

Grit, academic resilience, and mindset of nursing students: A cross-sectional study

BackgroundNursing students engage with the complex health system for competence development. These students are exposed to nerve-wrecking experience in addition to their everyday personal and social challenges. Non-cognitive attributes, namely grit, resilience and mindset can influence students’ ability to overcome complexities as they become nurses resulting in academic success and well-being. Insights into the state of non-cognitive attributes among undergraduate nursing students are essential in developing tailor-made educational programmes to enhance their grit, resilience, and mindset. ObjectivesTo describe the undergraduate nursing students’ grit, academic resilience, and mindset at a university in South Africa DesignA quantitative descriptive cross-sectional design. SettingA School of Nursing at a public multi-campus university in South Africa. ParticipantsAll students (N = 315) registered for the undergraduate nursing programme were invited to participate, and 70 % (N = 221) chose to participate. MethodsData were collected using self-administered questionnaires that included a 7-item demographic survey, the 30-item Academic Resilience Scale (ARS-30) that measures affective, cognitive, and behavioural responses in an educational context, the 16-item Dweck Mindset Scale (DMI) that measures a personal belief about whether intelligence and talent are fixed or amenable to change, and the 8-item Grit-S scale measuring passion for long term goals and perseverance. The collected quantitative data were analysed statistically through the Statistical Analysis Software Version 9.4 computer programme. FindingsThe findings revealed that the participants have normal grit and a growth mindset, but low academic resilience. ConclusionsTailor-made educational programmes that target non-cognitive attributes must integrate interventions that are focused on enhancing academic resilience for undergraduate nursing students.

Facilitating Integration of Interprofessional Education-related Entrustable Professional Activities into the Medical Curriculum

Abstract In competency-based education, entrustable professional activities (EPAs) play a defining role in developing the competence of students by providing contextual relevance. EPAs aid in the assessment of both cognitive and noncognitive (namely teamwork, leadership, communication skills, professionalism, etc.) attributes of the student. In fact, the inclusion of EPAs targeting interprofessional education (IPE) in the curriculum strengthens collaborative learning. The process of integration of EPAs related to IPE in the medical curriculum requires systematic planning and implementation to encourage collaborative learning and prepare students for medical practice. Assessment of IPE-related competencies using EPAs can be carried out with the help of different methods. In conclusion, EPAs can significantly strengthen the delivery of IPE by promoting collaboration and teamwork. There is an immense need to integrate IPE-related EPAs into the medical curriculum to improve the quality of care and patient-related outcomes.

Beyond milestones and percentiles: Revisiting non-cognitive and non-interpretive skills in radiology

While there is no precise formula for a great radiology resident, certain attributes and achievements may herald success during training. We briefly review prior works exploring predictive factors and evaluation metrics of top resident performance, noting that those focusing on non-cognitive attributes are over twenty years old. As radiology practice and education has substantially evolved in the interim, we revisit this topic from a contemporary perspective. Inspired by the literature and our own personal experiences, we suggest that the following non-cognitive traits are invaluable for radiology trainees: communication expertise, workplace adaptability, self-awareness, tech savvy and genuine interest in one's individual work and greater community. These characteristics should be highlighted by applicants, sought by selection committees, cultivated by mentors, evaluated by programs and valued by colleagues.

Predicting Surgical Resident Performance With Situational Judgment Tests.

Situational judgment tests (SJTs) have been proposed as an efficient, effective, and equitable approach to residency program applicant selection. This study examined how SJTs can predict milestone performance during early residency. General surgery residency program applicants during 3 selection cycles (2018-2019, 2019-2020, 2020-2021) completed SJTs. Accreditation Council for Graduate Medical Education milestone performance data from selected applicants were collected in March and April 2019, 2020, and 2021 and from residents in March 2020, August 2020, March 2021, September 2021, and March 2022. Descriptive statistics and correlations were computed and analysis of variance tests performed to examine differences among 4 SJT performance groups: green, top 10% to 25%; yellow, next 25% to 50%; red, bottom 50%; and unknown, did not complete the SJT. Data were collected for 70 residents from 7 surgery residency programs. Differences were found for patient care ( F3,189 = 3.19, P = .03), medical knowledge ( F3,176 = 3.22, P = .02), practice-based learning and improvement ( F3,189 = 3.18, P = .04), professionalism ( F3,189 = 3.82, P = .01), interpersonal and communication skills ( F3,190 = 3.35, P = .02), and overall milestone score ( F3,189 = 3.44, P = .02). The green group performed better on patient care, medical knowledge, practice-based learning and improvement, professionalism, and overall milestone score. The yellow group performed better than the red group on professionalism and overall milestone score, better than the green group on interpersonal and communication skills, and better than the unknown group on all but practice-based learning and improvement. The red group outperformed the unknown group on all but professionalism and outperformed the green group on medical knowledge. SJTs demonstrate promise for assessing important noncognitive attributes in residency applicants and align with national efforts to review candidates more holistically and minimize potential biases.

Development and psychometric properties testing of the Non-Cognitive Skills Scale for nursing students

BackgroundNon-cognitive skills are crucial for nursing students to achieve their academic performance successfully and perform clinical practice effectively. Although different non-cognitive assessment tools have been established in various disciplines, few are focused on nursing students. ObjectiveThe study aims to develop and psychometrically validate the Non-Cognitive Skills Scale (NCSS) for nursing students. DesignQualitative and quantitative research design. SettingOne university in Singapore. ParticipantsA total of 347 nursing educators and students participated in this study. MethodsA two-phase design was used. In the first phase, focus group discussions and literature reviews were conducted to generate the preliminary items of the NCSS. Content validity was established with an expert panel of 10 members, and the tool was pilot tested on 20 students. In the second phase, the number of items was reduced based on correlation coefficients and factor loading. The psychometric properties of the NCSS were tested on survey responses from 300 students. The Brief Resilience Scale, Trait Emotional Intelligence Questionnaire, and Big Five Inventory-10 were used to investigate concurrent and convergent validity. ResultsA 39-item six-factor NCSS was developed with satisfactory model fit indices (χ2/df: 1.60, IFI: 0.92, TLI: 0.90, CFI: 0.92 and RMSEA: 0.05). Content validity was confirmed with a content validity index of 0.90. A pilot test was conducted to improve readability and clarity. Known-group validity discriminated against age and gender group differences in a predictable way. Concurrent validity and convergent validity were confirmed with acceptable correlation coefficients. Cronbach's α was 0.91, and test-retest reliability was 0.84. ConclusionsThe NCSS is a reliable and valid tool for assessing the non-cognitive attributes of nursing students. This scale can be considered an admission tool for selecting the suitability of nursing applicants for nursing programmes. Further validation of NCSS is needed using a longitudinal study design in multiple settings across countries.

MBBS admission criteria as predictor of academic performance in a medical college of Pakistan.

To determine the relationship between scores obtained by students in assessments considered as admission criteria (cognitive and non-cognitive) with their academic performance in medical college. This correlational study used the data of students who got admission in Shalamar Medical and Dental College (SMDC) in 2015. Spearman correlation and Multiple regression tests were carried out to determine the relationship between admission criteria (Matric, FSC, MDCAT and MMI) and academic performance in medical college (pre-clinical and clinical years). There was significant positive correlation between scores obtained in MDCAT and pre-clinical years. When combined, MDCAT and MMI scores showed a significant positive correlation with scores obtained by students in clinical years. Scores obtained by students in pre-clinical years strongly correlated with their performance in clinical years. While scores obtained by students in FSC showed negative correlation with clinical year scores, significantly. It is concluded that the tools used for admission criteria should include both cognitive and non-cognitive elements. MDCAT is a good predictor of academic performance in pre-clinical years however it can only predict performance in clinical years when combined with MMI since MMI assesses the non-cognitive attributes (communication, empathy, ethics etc.) required in those years. FSC should not be given weightage as admission criteria owing to a lot of variability in the exams and scoring of different academic boards of the country.

Perception of Quiet Students in Emergency Medicine: An Exploration of Narratives in the Standardized Letter of Evaluation.

The Standardized Letter of Evaluation (SLOE) is designed to assist emergency medicine (EM) residency programs in differentiating applicants and in selecting those to interview. The SLOE narrative component summarizes the student's clinical skills as well as their non-cognitive attributes. The purpose of this qualitative investigation was to explore how students described in the SLOE as quiet are perceived by faculty and to better understand how this may impact their residency candidacy. This retrospective cohort study included all SLOEs submitted to one EM residency program during one application cycle. We analyzed sentences in the SLOE narrative describing students as "quiet," "shy," and/or "reserved." Using grounded theory, thematic content analysis with a constructivist approach, we identified five mutually exclusive themes that best characterized the usage of these target words. We identified five themes: 1) quiet traits portrayed as implied-negative attributes (62.4%); 2) quiet students portrayed as overshadowed by more extraverted peers (10.3%); 3) quiet students portrayed as unfit for fast-paced clinical settings (3.4%); 4) "quiet" portrayed as a positive attribute (10.3%); and 5) "quiet" comments deemed difficult to assess due to lack of context (15.6%). We found that quiet personality traits were often portrayed as negative attributes. Further, comments often lacked clinical context, leaving them vulnerable to misunderstanding or bias. More research is needed to determine how quiet students perform compared to their non-quiet peers and to determine what changes to instructional practices may support the quiet student and help create a more inclusive learning environment.

Type of Health Care Experience Impact on PA Education Association End of Rotation Exam Scores.

The physician assistant (PA) profession is based on previous healthcare experience (HCE), yet few studies have examined the influence of HCE on outcomes. This exploratory study examined possible differences between type of HCE and End of Rotation scores as a surrogate for clinical acumen and medical knowledge. Participants included consecutive classes of PA students (2017-2020) from a single public institution (N = 196). Self-reported HCE was used to classify students into HCE groups: group 1, lower decision-making professions; and group 2, higher decision-making professions. Group 1 (n = 124) and group 2 (n = 72) had no significant difference in the 7 individual End of Rotation exam scores and HCE ( p =.163 to .907). A correlation was found between average End of Rotation exam score and PANCE scores ( r =.80, p ≤ .001). The impact of HCE during the clinical year of education and its influence on noncognitive attributes, such as communication skills and professionalism, is not known. HCE might have a role in hard to measure noncognitive, nonquantifiable qualities.

A Monitoring and Early Intervention Program for At-Risk Students on Advanced Pharmacy Practice Experiences

Objective. To describe a monitoring and early intervention process for students at risk of substandard performance on advanced pharmacy practice experiences (APPEs).Methods. Using a dashboard of key indicators, students with potential deficits in knowledge, skills, or noncognitive attributes were identified as at risk of substandard performance on APPEs and placed on a list of students to be monitored during the APPE year. Employing a traffic light-based approach, at-risk students were initially designated with a monitoring status of red. If no issues were identified, students were de-escalated to yellow status and, subsequently, to green status. Monitored students who had issues or received a substandard evaluation on APPEs had a deficit-specific action plan implemented.Results. For the 2018-2019 and 2019-2020 academic years, 87 of 499 students entering APPEs were monitored. Of those 87 students, 77 (88.5%) completed experiences successfully on the first attempt, but 66 (75.9%) did require extended higher-level (red or yellow) monitoring. Over these two years, 54 (62.1%) of the 87 students deemed at risk did not have a substandard performance on APPEs, with 26 in the 2018-2019 year and 28 in the 2019-2020 year.Conclusion. A student monitoring and early intervention process may be beneficial in assisting at-risk students to successfully complete APPEs.

Design and Evaluation of an APPE Readiness Dashboard Tool

ObjectiveTo describe the design and evaluation of a dashboard tool to assess the readiness for advanced pharmacy practice experiences (APPEs). MethodsThe investigators developed a dashboard tool for the appraisal of APPE readiness consisting of indicators of pharmacy student knowledge, skills, and noncognitive attributes. For the 2018–2019 and 2019–2020 rotation years, a panel of stakeholders used the dashboard to evaluate APPE readiness. Students deemed not ready (5 or more dashboard indicators) had a remediation experience before the APPEs. The investigators monitored the students who were deemed ready but at risk for substandard performance (3 or 4 indicators or completion of remediation experience) and tracked the incidence of substandard performance for all APPE students. The outcomes were presented using descriptive statistics. Performance of the tool between years was compared using the χ2 test. ResultsFor 2 APPE rotation cycles, the investigators evaluated readiness in 499 students. A total of 3 students were deemed not ready, and 78 students were considered at risk for substandard performance. The tool predicted 52.1% of students who experienced a substandard performance. It had a negative predictive value of 93.6% and a positive predictive value of 38.5% for substandard performance. The predictive value was similar across the risk categories of knowledge, skills, and noncognitive attributes. ConclusionA dashboard tool facilitating holistic evaluation of APPE readiness was helpful in identifying students who were not ready for APPEs or at risk for substandard performance. The next steps include refinement of the tool through the evaluation of characteristics of students who experienced substandard performance and were not identified by the tool.

A framework for residents' pursuit of excellence based upon non-cognitive and cognitive attributes.

Excellence, although variably conceptualized, is commonly used in medicine and the resident excellence literature is limited. Both cognitive attributes (CAs) and non-cognitive attributes (NCAs) are essential for academic and clinical performance; however, the latter are difficult to evaluate. Undergirded by an inclusive and non-competitive approach and utilizing CAs and NCAs, we propose a criterion-referenced behavioral framework of resident excellence. Perceptions of multiple stakeholders (educational administrators, faculty, and residents), gathered by survey (n = 218), document analysis (n = 52), and focus group (n = 23), were analyzed. Inductive thematic analysis was followed by deductive interpretation and categorization using sensitizing concepts for excellence, NCAs, and CAs. Chi-squared tests were used to determine stakeholder perception differences. All stakeholders had similar perceptions (P > .05) and 13 behavioral attributes in 6 themes undergirded by insight and conscientiousness were identified. The NCAs included: interpersonal skills (works with others, available, humble), professional (compassionate, trustworthy), commitment to profession (visible, volunteers), commitment to learn (proactively seeks feedback, creates learning opportunities), and work-life balance/integration (calm demeanor, inspirational). The CA (medical knowledge and intellect) included: applies knowledge to gain expertise and improves program's caliber. Resident excellence is posited as a pursuit. The attributes are non-competitive, inclusionary, potentially achievable by all, and do not negatively affect freedom of choice. However, contextual and cultural differences are likely and these need validation across societal equity segments. There are implications for learners (adaptive reflection and learning goal orientation), faculty (reduced bias and whole-person feedback), and system leaders (enhancing culture and learning environments) to foster excellence.

Computer-Based Assessment of Non-Cognitive Attributes of Occupational Therapy Students: A Pilot Evaluation

Purpose: Holistic admissions tools have been considered for use to diversify student admissions. The ability to screen non-cognitive attributes of applicants is an important element of holistic admissions. The objective of this study was to establish instrument reliability, inter-rater reliability, validity, item discrimination, item difficulty, and bias of the Computerized Assessment of Non-Cognitive Attributes of Health Care Professionals (CANA-HP). Methods: A novel methodology was developed to screen non-cognitive attributes of health profession applicants. Using a cross-sectional design, a convenience sample of students invited for interviews into a Mid-western occupational therapy program were recruited for participation. The 37 participants who consented, completed a demographic survey followed by the 12 question CANA-HP. Results: Open-ended questions had adequate internal reliability, discrimination, and difficulty. Multiple choice questions had low reliability and discrimination. No correlation was found between the CANA-HP and standardized cognitive assessments, except non-science GPA which was significantly correlated to the total open-ended (essay) scores and total overall score. Conclusions and Recommendations: The CANA-HP was not biased toward individuals from varied demographic backgrounds. Predictive validity of this tool and non-cognitive measurements of success are still needed. Occupational therapists in educational settings could consider adding open-ended ethical questions to the application process when interviews are not feasible. Classes in the non-sciences and other non-cognitive markers of success may also help identify students with ‘grit’ and critical reasoning which are important to practicing clinicians

Effect of Holistic Review, Interview Blinding, and Structured Questions in Resident Selection: Can we Predict Who Will Do Well in a Residency Interview?

ObjectiveTo examine the Urology residency application process, particularly the interview. Historically, the residency interview has been vulnerable to bias and not determined to be a predictor of future residency performance. Our goal is to determine the relationship between pre-interview metrics and post-interview ranking using best practices for Urology resident selection including holistic review, blinded interviews, and structured behaviorally anchored questions. MethodsApplications were assessed on cognitive (Alpha Omega Alpha, class rank, junior year clinical clerkship grades) and non-cognitive attributes (letters of recommendation [LOR], personal statement [PS], demographics, research, personal characteristics) by reviewers blinded to USMLE scores and photograph. Interviewers were blinded to the application other than PS and LORs. Interviews consisted of a structured behaviorally anchored question (SBI) and an unstructured interview (UI). Odds ratios were determined comparing pre-interview and interview impressions. ResultsFifty-one applicants were included in the analysis. USMLE step 1 score (average 245) was associated with Alpha Omega Alpha, class rank, junior year clinical clerkship, and PS. The UI score was associated with the LOR (P = .04) whereas SBI scores were not (P = .5). Faculty rank was associated with SBI, UI, and overall interview (OI) scores (P < .001). Faculty rank was also associated with LOR. Resident impression of interviewees were associated with faculty interview scores (P = .001) and faculty rank (P < .001). ConclusionTraditional interviews may be biased toward application materials and may be balanced with behavioral questions. While Step 1 score does not offer additional information over other PI metrics, blinded interviews may offer discriminant validity over a PI rubric.

A Call to Action for Standardizing Letters of Recommendation.

A Call to Action for Standardizing Letters of Recommendation.

Evaluating the Whole Applicant: Use of Situational Judgment Testing and Personality Testing to Address Disparities in Resident Selection.

Purpose of ReviewUrology program directors are faced with increasing numbers of applications annually, making holistic review of each candidate progressively more difficult. Efforts to streamline evaluation using traditional cognitive metrics have fallen short as these do not predict overall resident performance. Situational judgment tests (SJTs) and personality assessment tools (PATs) have been used in business and industry for decades to evaluate candidates and measure non-cognitive attributes that better predict subsequent performance. The purpose of this review is to describe what these assessments are and the current literature on the use of these metrics in medical education.Recent FindingsSJTs relative to PATs have more original research. Data suggests that SJTs decrease bias, increase diversity, and may be predictive of performance in residency. PATs are also emerging with data to support use with ability to assess fit to program and certain traits identified more consistently among high-performing residents and correlation to performance on ACGME milestones. PATs may be more coachable than SJTs.SummarySJTs and PATs are emerging as techniques to supplement the current resident application review process. Early evidence supports their use in undergraduate medical education as does some early preliminary results in graduate medical education.

Use of situational judgment tests for assessing non-cognitive attributes of final year dental students.

Situational judgment tests (SJT) have been previously used in the admission process of medical and dental undergraduate programs, but their utilization as an assessment tool is fairly new. The objective of this study was to explore essential non-cognitive attributes of dental graduates. We also aimed to assess the attributes of final year dental students utilizing SJT and later collected participants' reactions on the test. A mixed-method exploratory sequential study was conducted. One-on-one and group discussions were done with subject matter experts (SMEs) to explore the essential attributes of fresh dental graduates. Based on the thematic analysis, 10 SJT items per domain were constructed by one group of SMEs and expert validated by a different group of SMEs and vice versa. The final dental-SJT was piloted online on final year dental students and their perceptions were collected using a five-point Likert scale questionnaire. Descriptive statistics and Cronbach's alpha were calculated for the test. The consultation with SMEs generated three main themes, namely, Conventional skills, Tribal skills, and Occupational skills. The 70-item dental-SJT piloted on 150 final year dental students revealed data were normally distributed. The internal reliability of test was good (0.738). Students scored highest in "management skills" (>70%) and lowest in "professional ethics" (56%) and "diverse experiences" (58%). The overall student perception about the test was good. SJT is an effective tool to assess non-cognitive attributes of dental students. It has an overall positive perception about perceived predictive validity, perceived fairness, face and content validity.

Standardized Interview Scoring Methodology for Neurosurgical Residency Applicant Selection.

Interviews are critical to the neurosurgery resident application process. The COVID-19 pandemic forced residency interview activities are conducted virtually. To maintain a degree of control during a period of uncertainty, our department implemented a standardized survey for interviewers to evaluate the noncognitive attributes and program compatibility of applicants. Our objective was to assess the reliability and biases associated with our standardized interviewer survey implemented in neurosurgical residency interviews. A 5-question interviewer survey to assess applicant interview performance and program compatibility was implemented during the 2020 to 2021 interview season. After the application cycle, survey metrics were retrospectively reviewed. Multiple cohort analyses were performed by dividing interviewers into cohorts based on status (faculty or resident) and sex. Applicant scores were assessed within sex subgroups for each aforementioned interviewer cohort. Intraclass correlation coefficients (ICCs) were calculated to assess survey reliability. Fifteen interviewers (8 faculty and 7 residents) and 35 applicants were included. Female applicants (17%) and interviewers (20%) comprised the minority. There were no differences between resident and faculty reviewer scores; however, female reviewers gave higher overall scores than male reviewers ( P = .003). There was no difference in total scores between female and male applicants when evaluating all reviewers or subgroups of faculty, residents, females, or males. ICC analysis demonstrated good (ICC 0.75-0.90) or excellent (ICC > 0.90) reliability for all questions and overall score. The standardized interviewer survey was a feasible and reliable method for evaluating noncognitive attributes during neurosurgery residency interviews. There was no perceptible evidence of sex bias in our single-program experience.

The impact of non-cognitive factors on admission to selective universities: the case of Chile

ABSTRACT Some universities, often the most prestigious in a higher education system, select qualified applicants solely on the basis of their measured academic or cognitive abilities. The universities’ assumption is that these cognitive abilities are an accurate and complete measure of the applicants’ capacity to benefit from university study. This study assesses the extent to which the cognitive measures used are partially the result of other, non-cognitive factors unrelated to future academic performance. Sole reliance on cognitive measures skews university admission in favour of those of higher socioeconomic status. Data for the study were collected by the University of Chile’s Department of Evaluation, Measurement and Educational Registration (DEMRE) from 190,000 applicants seeking admission to Chile’s 39 selective universities in 2019. The analysis identifies the direct and indirect effects of variables measuring applicants’ cognitive and non-cognitive attributes. Logistic regression models were constructed to estimate the differential effect of the two types of factors on admission. The results indicate that non-cognitive factors have an indirect effect on admission through their effect on cognitive scores. Access to selective universities in Chile is partially influenced by students’ prior social, cultural, and economic conditions. As a consequence, university education is distributed partially on the basis of social origin and not just ability. The admission process should be changed to reduce discrimination against applicants based on their social origin.

Who Is Considered Gifted From a Teacher’s Perspective? A Representative Large-Scale Study

Teachers play important roles in identifying and promoting gifted students. An open question is: Which student characteristics do teachers use to evaluate whether a student is gifted or not? We used data from a representative sample of Dutch primary school teachers ( N = 1,304) who were asked whether or not they thought the students ( N = 26,720) in their class were gifted. We investigated students’ cognitive and noncognitive attributes as well as demographic factors that might be relevant for this judgment. In sum, the findings revealed that teachers considered students to be gifted when, in comparison with their peers, students were superior in cognitive domains, especially with respect to academic achievement, scored higher on openness to experience and lower on agreeableness, were male, were younger, and came from families with higher parental education. These findings are discussed in relation to research on teacher nominations, teachers’ representations of giftedness and gifted students, and theoretical conceptions of giftedness.

Attributes of excellent clinician teachers and barriers to recognizing and rewarding clinician teachers' performances and achievements: a narrative review.

BackgroundOver the last 31 years, there have been several institutional efforts to better recognize and reward clinician teachers. However, the perception of inadequate recognition and rewards by clinician teachers for their clinical teaching performance and achievements remains. The objective of this narrative review is two-fold: deepen understanding of the attributes of excellent clinician teachers considered for recognition and reward decisions and identify the barriers clinician teachers face in receiving recognition and rewards.MethodsWe searched OVID Medline, Embase, Education Source and Web of Science to identify relevant papers published between 1990 and 2020. After screening for eligibility, we conducted a content analysis of the findings from 43 relevant papers to identify key trends and issues in the literature.ResultsWe found the majority of relevant papers from the US context, a paucity of relevant papers from the Canadian context, and a declining international focus on the attributes of excellent clinician teachers and barriers to the recognition and rewarding of clinician teachers since 2010. ‘Provides feedback’, ‘excellent communication skills’, ‘good supervision’, and ‘organizational skills’ were common cognitive attributes considered for recognition and rewards. ‘Stimulates’, ‘passionate and enthusiastic’, and ‘creates supportive environment’, were common non-cognitive attributes considered for recognition and rewards. The devaluation of teaching, unclear criteria, and unreliable metrics were the main barriers to the recognition and rewarding of clinician teachers.ConclusionsThe findings of our narrative review highlight a need for local empirical research on recognition and reward issues to better inform local, context-specific reforms to policies and practices.