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Formative Assessment in Health Care Education

Authors:

Abstract

This paper is the result of a substantial review of the literature on formative and summative assessment in education. The authors incorporate common challenges in health care educational programs, while presenting opportunities to overcome them. The goal of assessment is to measure learning; however students often view assessment as the assigning of discriminatory summative grades. Health care educators work within a system that rewards “teaching to the test” leaving students with vast knowledge gaps and an inability to become a lifelong learner. Upon graduation, students find themselves unable to adapt to an evolving discipline specific knowledge base which requires self motivation for continuing their education. The literature demonstrates how changing from a summative assessment model to a formative assessment model can improve health care educator’s abilities to create self-regulated learners.
International Journal of Education and Social Science www.ijessnet.com Vol. 1 No. 3; October 2014
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Formative Assessment in Health Care Education
Thomas J. Wing, MHS, RRT
Assistant Professor of Respiratory Care
Department of Respiratory Care
Boise State University, Boise, ID
College of Health Science
United States of America
Megan S. Koster, MHS, RRT
Clinical Assistant Professor of Respiratory Care
Department of Respiratory Care
Boise State University, Boise, ID
College of Health Science
United States of America
Lutana H. Haan, MHS, RRT, RPSGT
Assistant Professor of Respiratory Care
Department of Respiratory Care
Boise State University, Boise, ID
College of Health Science
1910 University Drive, Boise, Idaho
United States of America
Abstract
This paper is the result of a substantial review of the literature on formative and summative
assessment in education. The authors incorporate common challenges in health care educational
programs, while presenting opportunities to overcome them. The goal of assessment is to
measure learning; however students often view assessment as the assigning of discriminatory
summative grades. Health care educators work within a system that rewards “teaching to the
test” leaving students with vast knowledge gaps and an inability to become a lifelong learner.
Upon graduation, students find themselves unable to adapt to an evolving discipline specific
knowledge base which requires self motivation for continuing their education. The literature
demonstrates how changing from a summative assessment model to a formative assessment
model can improve health care educator’s abilities to create self-regulated learners.
Key Words: Formative assessment, summative assessment, feedback, self-regulated learner
Introduction
Health educators have long reported the difficulty in authentically evaluating student learning within an
educational culture committed to assigning discriminatory quantitative grades.1, 2,3 Under ideal conditions
assessment results can be used to help guide instructional practices, providing educators as well as learners a
vehicle for successfully achieving learning objectives set forth in a course.4 In health care education, a disconnect
exists in the continued assessment of graduates based on score, grade, or rank rather than the assessment of
knowledge obtained through adult learning. Current literature concerning assessment focuses on the technical
underpinnings of methodologies educators use such as: Summative, Formative, Assessment for Learning and
Assessment of Learning.5
©Research Institute for Progression of Knowledge www.ripknet.org
33
Broadfoot et al. defined assessment for learning as a more detailed version of formative assessment, addressing
evidence of where the student is at and using that evidence to determine the best course of action.6 Summative
assessment and assessment of learning are concerned with “validation and accreditation” purposes, providing little
guidance for future success for both educators and students.7
The utilization of appropriate assessment techniques is paramount to the effective dissemination of knowledge to
learners.8 Health education inherently lends itself to a traditional discriminatory summative approach to student
assessment (i.e. A, B, C, D, F), even though the ultimate outcome a practitioner’s credential is frequently viewed
as pass-fail in nature. A summative approach, or the assessment of learning, has been the foundation of many a
health care curricula; the thought being, this approach is easily standardized and provides clear outcome
measurement.9 Summative assessment can be thought of as the ‘destination’ outcome. A student is deemed as
‘having arrived’ at the destination (e.g. successful completion of a task), but may have little knowledge about how
they arrived at that destination. Students desiring a degree in a health care related field are commonly described as
highly competitive and therefore often successful in achieving summative desired outcomes (e.g. the highest
score, grade or rank). 10 However, the problem this competitive nature can create is often competitive health care
practitioners in lieu of collaborative health care practitioners.10 As the landscape of health care in the United
States transforms, there is an opportunity to evaluate the effectiveness of assessment practices utilized in the
educational system. A paradigm shift is in order, which necessitates an examination of assessment methods,
perhaps focused around ones collaborative ability as a student; which ultimately fosters an effective clinician in a
multidisciplinary setting.10
Regardless of assessment strategy, it is safe to assume the goal of any health care program is to produce
competent clinicians. The problem then, lies in the method of evaluating competency. Epstein defines competence
in medicine as an inclusive mixture of a student’s ability to effectively communicate knowledge, technical skill,
and clinical reasoning as well as reflect on knowledge and application towards the benefit of those being served.
The afore mentioned paradigm shift then revolves around the idea that competence cannot be described as a
singular, high stakes achievement but rather a habit formed by learning for a lifetime.11 In order to promote
lifelong learning, educators must adapt to curricula more conducive to a student-centered approach.12 Integrating
formative assessment often referred to as the assessment for learning, into existing or new curricula is one way
this can be acheived.13 Formative assessment measures are often described as frequent low-stakes assessments
with feedback between instructor and learner in a ‘closed loop’ cycle. Assessment measures in a traditional face-
to-face (f2f) classroom are important, as an instructor is often able to provide feedback in real time as knowledge
gaps become apparent through instructor-student discourse.14 The ability to identify and remedy knowledge gaps
in a f2f setting helps students to stay on course, while further directing educators’ attention to needed changes in
order to achieve learning objectives. Formative assessment relies heavily on the identification of these knowledge
gaps and uses gaps as the basis for new instruction and learning.13 Utilizing two constructs, known as
‘convergent’ learning and ‘divergent’ learning (the former being the assessment for specific, retained knowledge
and the latter being the exploration of knowledge) formative assessment enables students to learn in two primary
ways: First, by utilizing feedback in order to refine a specific skill set and secondly by promoting a professional
identity through learned conversations in a social setting.13
The utilization of feedback in a learning environment is not new. Summative feedback allows a student to assume
a professional identity as well as an assumption of specific clinical competency to practitioner roles.13 However,
by capitalizing on the feedback construct of formative education an educator can assess the quality of a students’
performance in the desired clinical role.13 Rudolph et al contend this perspective as the ‘divergent’ portion of
formative feedback, or the exploration of what is known; suggesting this type of feedback positively fosters the
provisional or aspirational identity of a clinician and therefore encourages a collaborative mindset. This focus on
frequent low-stake feedback may be thought of as benchmark progress towards the overall outcome and aide in
reinforcing intrinsic motivation for success.9 Feedback delivered to students by educators, should be used to
bridge the knowledge gap between what is currently known and the desired learning objective. Several
researchers view formative assessment as a way to improve overall performance, in comparison to providing
summative grades with the hope students will understand how to bridge the knowledge gaps themselves.7, 8,15
Currently, there is a void in theories of how best to assess student performance in a health care setting and provide
effective feedback to further develop lifelong learners.5, 7,16
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Increased performance outcomes have been acknowledged by many theoreticians in the importance of developing
“self-regulated learners”, identifying where the knowledge gap exists is how educators help develop this type of
learner through assessment practices.8 Learner assessment performed by educators is a key performance indicator
in the effectiveness of instruction provided.8 Health educators need to not only be aware of the pros/cons of the
types of assessment they utilize, but also what the results are specifically indicating. According to Wiliam,
assessment is a key component in successful instruction; whereby the process of assessment is the primary source
in deciphering if instructional goals have resulted in anticipated learning outcomes.7
Assessment tasks assigned, whether in the form of exams, quizzes, papers or clinical practicum have value only to
the degree they provide feedback and remediation to both the educator and learner.17 The knowledge gained from
assessment results is only useful if instructors are willing to adapt course curriculum to help direct future
performance of their students.16
The Role of Assessment in Student Motivation
Formative assessment is most effective when a learning environment is created which emphasizes process over
performance.2 By focusing on the process of learning rather than the grade of a student, educators will increase
intrinsic motivation while decreasing extrinsic motivation.1 Intrinsic motivation develops a student’s desire to
learn for the sake of the learning process, where the concept of learning becomes the goal at hand. When students
have intrinsic motivation about their learning they become explorers of information, gaining a deeper perception
of information presented and an enhancement in the self-reflection processes that can increase educational
enjoyment. Extrinsic motivation is outcome focused placing the emphasis of success or failure on obtainment of
an external product. Thus, when students are externally focused on an outcome such as grades, they are much
more likely to engage in “surface learning” committing only enough time/effort which will grant them some
arbitrary external reward.18
Educators who place performance ahead of the process by awarding grades as a point of emphasis will find their
students are more competitive, less collaborative and have overall lower motivation.18 An example of this
phenomenon can be seen when educators evaluate a student’s writing assignment. Formative feedback can
reinforce a student’s focus on the process of learning, while helping them to be a better writer. The positive
effects of feedback received are decreased when a score/grade is presented at the top of an assignment.19 The
simple act of placing a score onto an assignment focuses the assignments objective on attainment of a high
performance in contrast to the process of becoming a better writer. Summative scoring then further decreases
motivation in students who are the most at risk. In a cyclical pattern a poor scoring performance will decrease the
likelihood feedback provided will be fully internalized, which has the potential to cause similar poor
performances on future assignments.20 Increased anxiety levels and poor collaboration skills are also associated
with the summative grading of assignments which further decreases a student’s motivation to learn and is linked
with decreased performance on subsequent assignments.1, 2
Health care educators can increase a student’s intrinsic motivation by providing only qualitative feedback on
assignments which encourage an emphasis on process over performance.4 Instructors are encouraged to provide
opportunities for students to cooperatively design assignments and overarching assessments, which will
encourage self-reflection and give the students a sense of ownership.19 Student autonomy is directly correlated
with engagement and increasing levels of motivation to learn, educators should actively seek out opportunities to
increase student control over educational practices.1 Intrinsic motivation is further developed when teachers are
engaged and supportive of students, helping to promote effective dialogue in a safe learning environment.
Educators who focus on developing activities to support high level authentic interactions between themselves and
students will create a safe learning environment with students exhibiting greater motivation, curiosity and deeper
learning.18
Assessment Feedback
As discussed, feedback is the primary vehicle through which educators and learners alike bridge the knowledge
gap between desired and actual performance.21 Effective external feedback, delivered to students by teachers,
should resemble a ‘dialog’ in which both parties actively participate in identifying solutions and clarifying
assessment objectives.21 Feedback should be delivered in a timely manner, which allows the student to take
corrective steps before an assignment is due.
©Research Institute for Progression of Knowledge www.ripknet.org
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Student peers are also capable of providing feedback from a different perspective, allowing students to gain
insights into an assessment task that might not otherwise have been known to the student. Further, peer feedback
is commonly viewed as less critical, encourages a sense of togetherness and can help identify “alternative tactics
and strategies” to be used in a course.21
Effective educators will use feedback gained from dialoging with students as well as student achievement of
learning objectives, to adjust content presented throughout a course.21 According to Clark, the theory of formative
assessment is predicated upon the successful adaptation of instruction to help bridge the knowledge gaps present
in learners.8 The cyclical nature of formative feedback from educator-learner, learner-learner and learner-educator
helps ensure optimal student learning as well as course delivery.21 Educators are encouraged to inform students
that the feedback they will receive on future assignments will be proximate in nature. Students who anticipate
immediate feedback after completion of an assignment have been shown to have increased performance.22 Lastly,
an overarching goal of quality formative feedback is focused on generating student self reflection, which
encourages students to actively participate in the self-regulation process.17
The Self-Regulated Learner
Self-regulated learning provides a degree of autonomy to the learner which requires less educator support during
the completion of assigned tasks.15 A hallmark of formative assessment is the effective feedback it can provide
when performed correctly, which is most beneficial when students are proactive in identifying their own strengths
and weaknesses.17 The process of self reflection helps transform a student into a “self-regulated learner” by
encouraging one to take ownership over their education. Self-regulation causes students to take responsibility for
the effort they put forth on assignments, interpretation of feedback given and ownership of the end products they
create, an important aspect of health care education.21 Self-regulated learning further increases the drive to
become a lifelong learner by increasing motivation, encouraging intellectual risks and increasing overall student
performance.8
Simulations as Formative Assessment
Certain educational settings in health care are more conducive to providing formative feedback than others.
Implementation of simulation in health care programs creates a unique opportunity to capitalize on the quality of
feedback between the learner and the instructor. An integral part of student-centered education is the self-
evaluative or critical reflection in linking assessment information into context.12 Rudolph et al explore the concept
of ‘debriefing’ as a formative assessment tool. Simulation and the consequent immediate debriefing periods
allow students to work backward through the feedback loop.13 Simulation debriefing as formative assessment tool
analyses the specific ‘framing’ of a clinical scenario, allowing the student to identify an observed performance
gap between actual actions and desired actions.13 Effective debriefing includes a facilitated discussion of the
interactions, allowing the student to discuss their thought process as to why they chose a specific action or not.
The instructor in this setting is there to guide the discussion towards the objectives, while the student is
responsible for explaining the process. The concept of situational framing has the potential to highlight otherwise
unapparent deficits in the clinical, social and interpersonal decision making skills required of health care
professionals.13 The crucial impact of medical decision-making is a unique facet of health care that is very
difficult to effectively assess. Providing a safe and secure environment allows the learner to comfortably identify
and scrutinize their actions.13 In deconstructing a given clinical scenario with clearly defined objectives, students
are often able to identify knowledge gaps. This process also allows an instructor to effectively assess whether a
learner was able to achieve the predetermined objectives and provide constructive feedback regarding the clinical
scenario. This environment of ‘closed loop’ feedback also allows the instructor to develop and clarify new and
more effective objectives for future simulations.13
The Quantification of Learning
The ideal process of formative assessment is undermined by a cultural, societal and organizational fundamental
desire to quantify student progress.3 Educators are faced with a duality of pressures to provide summative grades
for each student while being aware the assignment of grades can decrease a student’s performance.19 Most
instructors work within a system where only surface formative assessment occurs, summative grades are reported
and student performance levels continue to decline.2 Authentic implementation of formative assessment is not
without its own limitations and issues; educators report increased time requirements, uncertainty due to the
flexible construct of implementation and a concern students will not perform well on standardized tests.20
International Journal of Education and Social Science www.ijessnet.com Vol. 1 No. 3; October 2014
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Only surface assessment is then performed by instructors where the simple act of providing feedback to a student
is considered formative assessment, the culmination of which is the reporting of a summative grade. Formative
assessment used for summative grading undermines student learning and engagement. Ideally, assessment and
feedback should be delivered without a corresponding grade, if optimal student performance is desired.19
In health care education, a cultural change is required before the full benefits of formative assessment can be
realized, one in which the awarding of discriminatory grades is eliminated and the adoption of a pass-fail system
is implemented.3 Grade distribution is a primary driving force behind student development of extrinsic
motivation, an emphasis on performance over process and a decrease in student well being.18 Educational
institutions which have abandoned a traditional grading system for pass-fail have reported increased authentic
student collaboration, less competition, increased satisfaction, deeper learning and increased self-regulated
learning processes.18
In a pass-fail grading system educators will find they have more time to focus on the process of learning,
distribution and reception of feedback, and the revision of course activities to best serve the needs of the
students.3, 19 The cyclical nature of assessment, instruction, embedded formative assessment and revision of
instruction helps keep educators engaged and students motivated to learn. Thus, students are more apt to set
“mastery goals” in which errors are seen as part of the process, in contrast to “performance goals” that encourage
surface learning and procrastination.4 Through the successful transition to a pass-fail system, increased authentic
formative assessment and increased educator commitment to process over performance, students will have the
best opportunities to develop into lifelong learners.3 A shift in assessment emphasis to a formative approach in the
realm of health care education and delivery is key to developing a new generation of intrinsically motivated health
care providers. The benefits of implementing a pass-fail grading system in health care education may possibly
extend beyond the learners themselves. Rohe et al determined that the implementation of a pass-fail grading
system reduced the level of stress experienced by a cohort of medical students when compared to a similar cohort
of students subjected to the traditional interval grading system. There is a possibility integrating a pass-fail
system, assessment measures that reflect respect, concern and accountability of students, will affect the attitude of
students towards future colleagues and patients.10 Altering the traditional educational paradigm which emphasizes
the dependence of students in a passive and competitive role to a newer model, which places students in an
independent and active role can have positive implications in the success of health care education programming
and reform.10
Conclusion
Educators looking to improve performance outcomes in the health care educational environment should employ
formative assessment techniques. The process of formative assessment and the ensuing feedback will help to
encourage students to become proactive in their learning, transforming students into self-regulated learners.17
Self-regulated learners have increased levels of engagement, motivation, and performance results based upon their
proactive nature.8 Through the process of formative assessment, the use of closed loop feedback and encouraging
self-regulated learning an educator can provide an environment which is conducive to the creation of lifelong
learners. A barrier to the implementation of authentic formative assessment is an educational culture of grading
which encourages the awarding of discriminatory grades. A proposed solution would be to adjust the current
grading methodology, replacing it with a summative pass-fail system that would help focus health care
educational objectives on a learner’s process of achievement, in lieu of their performance.3, 18
This literature review has focused on the value of utilizing formative assessment strategies in health care
environment, as well as the transition to a pass-fail grading scheme. Further research needs to be conducted
exploring a variety of issues surrounding the application of formative assessment and the impact of a new grading
philosophy. An exploration into techniques health care educators can utilize to give feedback to students in
didactic, clinical and simulated environments and vice versa needs to be investigated. Methods for educators to
adapt course content in real time or simulation that respond to students’ needs should be developed. Strategies
need to be developed and implemented to help educators facilitate formative feedback to students in a time-
crunched and content heavy environment.
Lastly, a prospective analysis on the effects of a pass-fail grading system and the development of lifelong learning
practices among students in health care programs should be further investigated.
©Research Institute for Progression of Knowledge www.ripknet.org
37
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... The research on "evaluation of the use of e-learning in undergraduate radiology education: a review" which was conducted in 2014 by Zafar et al. showed that Kirkpatrick's evaluation model could be used to evaluate the characteristics of information technology-based learning (especially e-learning) [6]. The obstacle which was found in the research that was conducted by Zafar et al. is the evaluation component that used is still focused on outcomes so that other evaluation components such as context, input, process, and product have not been revealed in depth [6]. 3 Wing et al. in a research that was conducted in 2014 on "formative assessment in health care education", explained that through a formative assessment model it can improve and inspire students to learn independently because there is no pressure in learning as the result of a fear at summative assessment that seems to be a threat [7]. The obstacle that is still found in Wing et al research is that it has not been able to show in detail what aspects of learning can cause the students excited for learning and what aspects that cause the students unexcited for learning, so that it will make it easier to give the follow-up of improvement/refinement to the learning process. ...
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