Deciding what is to be assessed

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The areas chosen to assess in workplace-based assessment are usually articulated as a series of competencies. These should be blueprinted against the curriculum, and most importantly encourage trainee development. Let us look at those three issues in a little more detail.

Competency based

Workplace-based assessment is usually competency based. Despite recent criticisms of competency-based education as a whole (Talbot, 2004), concerns are usually expressed where competencies are viewed as narrow, reductionist and overly simplistic. Competencies used for the purpose of designing workplace-based assessments are best written as holistic statements which are framed as ‘a complex structuring of attributes needed for intelligent performance in specific situations’ (Gonczi, 1994).

The following 12 competencies serve as an example and have been developed for use in the workplace-based assessment component of the nMRCGP, the exit assessment for general practice training.

Workplace-based assessment competencies for the nMRCGP (RCGP, 2007)

Communication and consultation skills: this competency is about communication with patients, and the use of recognised consultation techniques.
Practising holistically: this competency is about the ability of the doctor to operate in physical, psychological, socioeconomic and cultural dimensions.
Data gathering and interpretation: this competency is about the gathering and use of data for clinical judgement, the choice of physical examination and investigations, and their interpretation.
Making a diagnosis/making decisions: this competency is about a conscious, structured approach to decision making.
Clinical management: this competency is about the recognition and management of common medical conditions in primary care.
Managing medical complexity and promoting health: this competency is about aspects of care beyond managing straightforward problems, including the management of co-morbidity, uncertainty, risk and the approach to health rather than just illness.
Primary care administration and IMT: this competency is about the appropriate use of primary care administration systems, effective record keeping and information technology for the benefit of patient care.
Working with colleagues and in teams: this competency is about working effectively with other professionals to ensure patient care, including the sharing of information with colleagues.
Community orientation: this competency is about the management of the health and social care of the practice population and local community.
Maintaining performance, learning and teaching: this competency is about maintaining the performance and effective continuing professional development of oneself and others.
Maintaining an ethical approach to practice: this competency is about practising ethically with integrity and a respect for diversity.
Fitness to practise: this competency is about the doctor’s awareness of when their own performance, conduct or health, or that of others, might put patients at risk and the action taken to protect patients.

Blueprinted in the curriculum

To ensure that assessments are integrated with the curriculum, competencies chosen for assessment should map directly back to the curriculum to ensure that the curriculum is being adequately covered, and that the assessment methods used sample across all the competencies and therefore there is widespread sampling of the curriculum. See attached Teachers’ Toolbox item on Assessment blueprinting.

Developmental

As already discussed, workplace-based assessment offers the opportunity to link teaching, learning and assessment effectively, and the developmental nature of the assessment should therefore be a key feature.

To enhance educational impact, the use of holistic competencies and a developmental continuum is recommended. Developmental progressions in the literature, such as that described by Dreyfus and Dreyfus (1986) may be helpful in constructing the developmental continuum. These progressions work through the following stages to from novice to expertise:

novice
advanced beginner
competent
proficient
expert.

The figure below gives an example of how progression statements can be developed in relation to a competency. In this case the competency is that of ‘practising holistically’ taken from one of the 12 competencies of workplace-based assessment for the nMRCGP assessment of the RCGP.

Example of a competency progression statement (RCCP, 2007)

2	Practising holistically
This competency is about the ability of the doctor to operate in physical, psychological, socioeconomic and cultural dimensions, taking into account feelings as well as thoughts.
Insufficient evidence From the available evidence, the doctor’s performance cannot be placed on a higher point of this developmental scale.	Needs further development Enquires into both physical and psychological aspects of the patient’s problem.	Competent Demonstrates understanding of the patient in relation to their socioeconomic and cultural background.	Excellent Uses this understanding to inform discussion and to generate practical suggestions for patient management.
	Recognises the impact of the problem on the patient.	Additionally, recognises the impact of the problem on the patient’s family/carers.	Recognises and shows understanding of the limits of the doctor’s ability to intervene in the holistic care of the patient.
	Uses themself as the sole means of supporting the patient.	Utilises appropriate support agencies (including primary healthcare team members) targeted to the needs of the patient.	Organises appropriate support for the patient’s family and carers.

Such a continuum has the advantage of explicitly illustrating the direction of travel for trainees, rather than merely pointing out the level below which they should not fall.

This supports the concept of ongoing evidence collection throughout the training period, but with regular, well-circumscribed staging reviews at which the developmental framework is reviewed and the learner’s progress through it judged.

So workplace-based assessment must provide detailed formative and developmental feedback to the learner. This raises the tension of potentially mixing formative and summative elements, but it is possible to address this through the careful design of the assessment system. Separating the interpretation of evidence from its elicitation is one way around the problem (William and Black, 1996).

Thinking point

In practical terms what might you do to address the tension between the formative supervisory role and the summative assessment requirements of being an educational supervisor?