Mechanisms of learner engagement in competency-based medical education: A grounded theory study in emergency medicine

INTRODUCTION: Competency-based medical education (CBME) positions workplace-based assessment and feedback as developmental processes, yet translating these principles into clinical practice is challenging. CBME often becomes administratively driven rather than developmentally meaningful. Learner studies consistently report superficial feedback, diminished psychological safety, and variable engagement, but most evidence comes from Western contexts and in the early stages of CBME adoption. Limited research has examined how residents in mature systems interpret and enact assessment and feedback. This study explored these interpretive processes to identify mechanisms that shape learner engagement in CBME. METHODS: We conducted a constructivist grounded theory study using semi-structured interviews with emergency medicine residents. Data were analyzed iteratively through initial, focused, and theoretical coding, supported by constant comparison, memo-writing, and team triangulation across learner, program, and system levels within a fully implemented CBME system in East Asia. RESULTS: Residents' engagement with CBME was dynamic and context-dependent, shaped through ongoing interpretation of assessment encounters. Theme 1 described forces shaping navigation, including learner orientations or mindsets, supervisory interactions, and structural and cultural conditions, such as workload, assessment design, and the social weight of assessment. Theme 2 illustrated how system adaptations shaped enactment: shared educational literacy supported clarity and alignment; structured direct observation enabled focused feedback; and responsiveness in assessment content and processes influenced whether documentation felt meaningful. Across themes, engagement emerged through the interplay of learner orientations, supervisory interactions, structural conditions, and system responsiveness, with alignment supporting authentic engagement. DISCUSSION: These findings are synthesized into a mechanism-oriented framework in which system responsiveness acts as a key driver shaping how structures and interactions support learners' meaningful engagement. We further conceptualize learner engagement as situated agency, an interpretive and context-sensitive process through which learners calibrate their orientations and participation in response to evolving relational and structural conditions within implemented CBME systems.