Medical Teacher, Vol. 27, No. 6, 2005, pp. 509–513
Formative assessment: a key to deep learning?
ALISON RUSHTON
University of Birmingham, Edgbaston, Birmingham, UK
SUMMARY A paradigm shift in assessment culture has
emphasized the importance of formative assessment. The existing
evidence supports the identification of feedback as the central
component of formative assessment. Feedback provides information
about the existing gap between the actual and desired levels of
performance. The existing evidence suggests various characteristics
of effective feedback, for example, ensuring that feedback is
construct-referenced and student referenced. An exploration of the
existing educational literature provides evidence for the emphasis
on formative assessment. This paper evaluates the pedagogical
implications of formative assessment to deep learning. A
constructivist approach, emphasizing the principles of adult
learning and placing emphasis on the student is advocated.
However, in applying the wider educational literature to
healthcare, it is questioned if the paradigm shift in assessment
culture has occurred as the majority of the existing literature is
centred on summative assessment.
Introduction
Many purposes and roles of assessment are utilized throughout the existing educational systems, the most acknowledged
of which is the evaluation of learning outcomes through
summative assessment. Gipps (1994) describes a paradigm
shift within assessment from a testing to assessment culture,
and despite this historical focus on summative assessment
there is considerable evidence supporting the importance
of formative assessment as highlighted by Black and Wiliam’s
(1998) pivotal review.
Formative assessment can be considered as a construct,
although contemplation of its description is problematic
as evidenced by the literature. A commonly used definition
describes formative assessment as:
‘‘encompassing all those activities undertaken by
teachers, and/or by their students, which provide
information to be used as feedback to modify the
teaching and learning activities in which they are
engaged’’.
(Black & Wiliam, 1998, pp. 7–8)
This paper explores feedback as central to formative
assessment and its links to deep learning, seeking to explore
the educational literature and its pedagogical lessons for
healthcare educational practice, acknowledging from the
outset that there is minimal attention to formative assessment
within the healthcare literature.
The centrality of feedback to formative assessment is
supported by a synthesis of meta-analyses that found feedback to produce the most powerful single effect on
achievement (Hattie, 1987). Ramprasad (1983) defined
feedback as information about the existing ‘gap’ between
actual level and the reference level of performance, stressing
that information was only ’feedback’ if used to alter the gap.
Messick (1975) had previously documented the necessity
of information gained to close the gap of being constructreferenced, and therefore related to a developmental framework in the area being addressed. For example, providing
the student with a tool to assist planning of the physical
examination of a patient to enable the development of
clinical reasoning skills when assessing a patient, the tool then
forming the basis of subsequent discussion. Sadler (1989)
highlighted that progress is inhibited if this gap is too
wide, and emphasized the role of the student in taking
action to affect the gap.
Feedback can usefully be considered as possessing two
key components, the teacher providing feedback and the
student receiving feedback (Hattie & Jaeger, 1998). This
necessitates consideration of the different ways in which
feedback may be provided and perceived, dependent upon an
individual’s model of self-esteem. Biggs (1998) argues that
the effectiveness of formative assessment is dependent upon
the student’s accurate perception of the gap, as well as their
motivation to address it. This argument is facilitated from
a constructivist perspective that views the student’s involvement in the process as essential, and therefore advocates
the use of strategies such as self assessment. Sadler (1998)
identifies this important dimension of feedback as the
student’s interpretation of it, suggesting that students
need to be educated to interpret feedback in the context of
their current and future work. By definition, formative
assessment is criterion referenced, which Harlen and
James (1997) develop further to also describe it as ipsative
(student-referenced). As the aim of the formative assessment process is to assist the development of the learner,
an ipsative assessment therefore permits consideration of
an individual’s particular circumstances as highlighted
above. This focus on the quality of feedback interestingly
excludes some aspects of healthcare practice described as
formative assessment, for example, feedback on class standings/test scores in isolation with no reference to content
as described in some papers (Houghton & Wall, 2001;
Khan et al., 2001; Sibert et al., 2001; Townsend et al., 2001).
Feedback
Black and Wiliam (1998) perceive feedback as central to
formative assessment, defining it as:
‘‘Any information that is provided to the performer
of any action about that performance’’ (p. 53).
Correspondence: Alison Rushton, Lecturer/Programme Director, School of
Health Sciences, 52 Pritchatts Road, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK. Tel: 0121-415-8597; email: a.b.rushton@
bham.ac.uk
ISSN 0142–159X print/ISSN 1466–187X online/05/060509-5 ß 2005 Taylor & Francis
DOI: 10.1080/01421590500129159
509
A. Rushton
Feedback is part of the interactive components of teaching and learning and can therefore be seen as central
to pedagogy. There are many ways in which teachers can
provide feedback to assist the development of student
learning. The important issue is that whatever the selected
method, it must be able to provide information about
what the student does and does not know, as well as
providing direction for improvement (Hattie & Jaeger, 1998).
Feedback can be provided on an individual and group
basis. Interestingly, this is not an issue explored in detail in
the literature, although Hattie (1987) found that the
combination of feedback and individualization produced a
powerful effect size for achievement. However, it was
acknowledged that based upon existing work the key to the
effect size was the feedback itself. Task centred feedback
as compared to that linked to personal self esteem (i.e. goal
orientated), has been shown to have the most positive effect
on attitudes and achievement (Black & Wiliam, 1998). Little
of the healthcare literature addresses this issue with few
papers planning individual and task centred feedback, with
the exception of Rahman (2001). The experience of the
teacher is therefore an important factor in formative
assessment. An experienced teacher will possess skills,
knowledge, attitudes, awareness of standards, and expertise
in evaluative skills (Sadler, 1998) that have contributed to
their tacit professional knowledge. An experienced teacher
will also have developed automaticity (Chi et al., 1988) in key
aspects of practice, so that they are more able to invest time
in providing feedback to students.
In referring back to Black and Wiliam’s (1998) narrow
definition of feedback, it can therefore be seen clearly that
feedback that enhances learning must be wider than this.
Hattie and Jaeger (1998) develop this to define feedback as
the:
‘‘provision of information related to the understanding of the constructions that students have
made from the learned/taught information’’,
and
‘‘polymorphous, referring to subsequent information aimed at assisting the learner in meeting
the goals of the learning process’’ (p. 113).
Their considered use of the word ‘subsequent’ emphasizes
the ongoing dimension to feedback, suggestive of a continued rather than a one off process, an issue that is often
overlooked in the healthcare literature where formative
assessment is frequently seen as a single event in a similar
way to summative assessment in papers (Houghton & Wall,
2001; Khan et al., 2001; Sibert et al., 2001; Townsend
et al., 2001).
Learning
Learning can be considered to encompass ‘deep learning’
that includes understanding and interpretation (Entwistle
& Entwistle, 1991), although the authors acknowledge
that teachers and institutions encourage the lower levels of
learning through an essentially quantitative approach to
assessment. Gipps (1994) recognized the potential that
assessment has for affecting learning and the intricate links
are now widely recognized informing pedagogy. However, in
510
the literature formative assessment is linked more strongly to
teaching rather than learning. The literature highlights many
claims regarding the positive effects of formative assessment on learning, although justifiably Torrance and Pryor
(1998) contend that claims are overstated and undertheorized, particularly when considering deep learning.
Further work applying the existing theories into practice is
therefore necessitated. Klenowski (1996) emphasizes the
importance of teachers’ awareness of the interrelationship between the three areas of assessment, curriculum,
and pedagogy; highlighting that a move to encourage
formative assessment necessitates changes in curriculum
and pedagogy.
There are many aspects of classroom interaction that
contribute to formative assessment, such as discourse,
questioning, giving tests and observation. Black and Wiliam
(1998) also discuss documented changes in pedagogy that
have taken a strategic approach to developing the use of
formative assessment, for example the development of
mastery learning, curriculum based assessment and portfolio systems. In particular in healthcare, portfolio systems
(Friedman Ben David et al., 2001; Pitts et al., 2002) and an
emphasis on Problem Based Learning have illustrated this
development (Schwartz et al., 2001).
There is some evidence to suggest that students prefer
frequent testing (Iverson et al., 1994) and that feedback
provided by frequent testing can improve learning
(Scheerens, 1991). A review of the evidence (Peckham &
Roe, 1977) found that earlier studies saw the effects as
beneficial to learning and student motivation, but that
later research suggested that the benefits were dependent
upon other variables including the context. In a meta-analysis
of the literature, Bangert-Drowns et al. (1991a) found that
students taking more than one test in a term scored
higher than those taking no tests. Interestingly, they also
found that the degree of improvement reduced as the
frequency of testing increased. Dempster (1992) in a review
of the literature on tests to facilitate learning highlighted key
issues to ensure proper use of testing, for example, testing
material soon after delivery, frequent and cumulative use of
tests and providing feedback soon after testing. In their
meta-analysis, Bangert-Drowns et al. (1991b) found that
feedback was the greatest influence on performance if
provided prior to provision of the answers. There is
considerable literature addressing this area, but there is
considerable variation between the existing studies that limits
the internal validity of using such meta-analyses to inform
practice.
Application of theory to practice
Torrance and Pryor (1998) define two heuristic models of
’convergent’ and ’divergent’ assessment to facilitate understanding of formative assessment. Convergent assessment
is characterized by a behaviourist rigid focus on teaching
using a pre-planned programme (Bloom, 1971), with
formative assessment considered as continuous or repeated
summative assessment. This teacher-centred approach
deconstructs knowledge and uses hierarchies of learning
and testing of the parts and is commonplace in the healthcare
literature (Houghton & Wall, 2001; Khan et al., 2001; Sibert
et al., 2001; Townsend et al., 2001), although the ongoing
Formative assessment: a key to deep learning?
approach to formative assessment is absent. In contrast,
divergent assessment is characterized by a constructivist
approach with an adaptable process placing emphasis on
the student (student-centred). For this model the intention
is to teach in the zone of proximal development (Vygotsky,
1978), contributing to a joint assessment process between
the teacher and the student (Pryor & Torrance, 1996);
arguing that formative assessment taking place in the zone
between student and teacher facilitates the best performance.
The process involves the teacher and student collaborating
to enable the best performance by the student, something
that is recognized in teaching but merits further attention
in assessment, again highlighting the importance of the
student within the process. There are to date few examples
in the healthcare literature that draw attention to this issue.
Some studies, for example, Rahman et al. (2001) go some
way towards addressing this issue by using a 1:1 discussion
to analyse performance, although they remain focused on the
assessment of learning outcomes in the absence of summative
assessment.
In translating the constructivist approach into activity
in a classroom, the emphasis moves towards key issues of
teacher-student interaction, understanding of the effect of
the process on the student, the scaffolding of learning to
progress tasks, collaboration and being forward focused, and
the ‘appropriation’ of learning (Torrance & Pryor, 1998).
Formative assessment can therefore be seen as a dynamic,
interactive, and evolving process emphasizing its complexity
(Lidz, 1995), with the teacher as a facilitator. It is therefore
central to pedagogy, emphasizing the necessity of linking
the information from assessment to context (Tittle, 1994).
Harlen and James (1997) support this by arguing that validity is essential but as an assessment is not formative unless
it follows through to take action for the development of
learning. This supports the move to authentic assessment in
education (Guba & Lincoln, 1989).
Current educational models within post-secondary
education such as lifelong learning, authentic learning, and
self-directed learning support a constructivist approach.
This is reflected in the students’ active involvement in their
own development (Savery & Duffy, 1995), the movement
from a focus on teaching to learning, and a teacher-centred
to a student-centred approach. A practical emphasis on
group learning also facilitates the educational benefits of
cooperative learning (Dewey, 1938). Key premises are that
the students are self-directed and autonomous adult
learners (Knowles, 1990), with the concept of critical
reflection being pivotal (Brookfield, 1987). In addition, by
developing Vygotsky’s work, the literature acknowledges
that post-secondary education encourages transformation; a
process where the student is facilitated in an exploration
of how they view themselves and the world (Mezirow, 1994).
The self-evaluative skills of the student are therefore integral
to learning. The philosophy of student-centred learning
supports the development of this process, with feedback an
integral component (Klenowski, 1995). Courses therefore
need to develop a student’s self-evaluation as part of the
process of formative assessment. A limitation of this approach however, is the student who lacks the metacognitive
skills to accurately evaluate their own learning. Depending
upon the nature of a particular lesson, it is necessary to adapt
the relationship between teacher and student to facilitate
formative assessment. For example in a session exploring a
student’s clinical reasoning skills, metacognition is a key
component and the students themselves are therefore an
important resource for feedback.
Cowie and Bell (1999) usefully classified formative
assessment as either planned or interactive, with interactive
being formative assessment that occurs spontaneously in a
classroom in an unplanned way. Using a combination of
observation, interview and survey, the authors described how
the teachers used planned formative assessment to assess
progress of the whole class, and interactive formative
assessment to mediate learning. The dimensions of the
interactive model were all influenced by their previous
experiences and pedagogical approach. Interestingly, the
teachers saw interactive formative assessment as central
to teaching and learning, the process being implicit in
healthcare education, but not explicit within the existing
literature.
It has been argued that the move towards the modularization of courses has reduced the opportunity for formative
assessment (Yorke, 1998), although this could be debated
as having the opposite effect by focusing the nature of
formative assessment to the subject area contained within
a single module. As long as formative assessment is built
into the planned curriculum there should be no reason why
its opportunity is reduced. What does favour Yorke’s opinion
is that the formative assessment will be limited by the
separation of different subject areas into different modules as
commonly seen in the theoretical modules of healthcare
courses, and the ‘whole’ may be missed from the formative
assessment (and summative assessment!). It can therefore
be argued that developing formative assessment should
involve a much wider perspective of reviewing the whole
model of assessment developed for a particular course,
aiding coherence across a course. This is an aspect explored
explicitly in healthcare curriculum planning, and all components of the curriculum are subsequently integrated in
clinically-based learning modules where boundaries are
removed.
In the current climate of lifelong learning, Boud (2000)
argues that a new concept of ‘sustainable assessment’ needs
to be recognized, encompassing the characteristics necessitated to underpin activities of lifelong learning. This concept
develops the role of assessment to equip students with the
preparation required to continue independent assessment of
their future learning experiences. At the centre of this
argument lies the premise that assessment is a key feature
of lifelong learning, and in light of the previous discussion
perhaps many assessment strategies inhibit this development
at present. Boud (2000) therefore views the process of selfassessment as pivotal, although consideration of this metaprocess is limited to the recent literature. In exploring this
pedagogically, the creation of a climate using interactive
feedback can perhaps develop lifelong learning.
Conclusion
Gipps (1994) drew attention to the necessity of a move
away from a testing culture towards that of an assessment
culture with emphasis on the evaluation of learning in the
wider educational literature. It is clear from the above
discourse that there has been a change in consideration of
511
A. Rushton
assessment and its associated issues over the years. As the
existing evidence suggests however, further changes are
required in practice to enable effective development of
formative assessment involving the consideration of teaching
and learning strategies, and in particular the provision of
feedback.
As illustrated in the above discussion, a search of the
healthcare literature found few empirical studies addressing
formative assessment. In addition, although the studies
purported to discuss formative assessment, by using definition and debate from the wider educational literature the
application of the paradigm shift to healthcare can be
questioned based on the research available to date.
To ensure the success of developing formative assessment
it must therefore be established within models of pedagogy
to be successful. This necessitates a further move away from
the current emphasis on procedures and products of
assessment to an emphasis on the processes of assessment
and learning.
Practice points
.
.
.
Formative assessment is an important process to
enable learning, and in particular deep learning.
Feedback is the central component of effective
formative assessment.
Further consideration of formative assessment in
healthcare education is required to change our
existing assessment culture which places emphasis
on summative assessment.
Notes on contributor
ALISON RUSHTON, EdD. MSc. Grad Dip Phys. Cert Ed. Dip TP.
mMACP is a Lecturer in Physiotherapy at the University of Birmingham,
UK. Alison contributes to undergraduate physiotherapy education
and postgraduate education for all healthcare professionals, through
teaching and research. Alison is the Programme Director for the MSc
Advancing Practice programmes. This work was completed as part of a
Doctorate in Education at Warwick University, which had its central
focus on the clinical component of healthcare professional education at
Masters level.
References
BANGERT–DROWNS, R.L., KULIK, J.A. & KULIK, C.C. (1991a) Effects
of frequent classroom testing, Journal of Educational Research, 85,
pp. 89–99.
BANGERT–DROWNS, R.L., KULIK, C.L.C., KULIK, J.A. & MORGAN, M.T.
(1991b) The instructional effect of feedback in test–like events,
Review of Educational Research, 61, pp. 213–238.
BIGGS, J. (1998) Assessment and classroom learning: a role for
summative assessment? Assessment in Education, 5, pp. 103–110.
BLACK, P. & WILIAM, D. (1998) Assessment and classroom learning,
Assessment in Education, 5, pp. 7–75.
BLOOM, B.S. (1971) Mastery learning, in: J.H. BLOCK (Ed)
Mastery Learning: theory and Practice (New York, Holt, Rinehart &
Winston).
BOUD, D. (2000) Sustainable assessment: rethinking assessment
for the learning society, Studies in Continuing Education, 22, pp. 151–167.
BROOKFIELD, S. (1987) Developing Critical Thinkers (Milton Keynes,
Open University Press).
512
CHI, M., GLASER, R. & FARR, M. (1988) The Nature of Expertise
(Hillsdale NJ, Erlbaum).
COWIE, B. & BELL, B. (1999) A model of formative assessment in science
education, Assessment in Education, 6, pp. 101–116.
DEMPSTER, F.N. (1992) Using tests to promote learning: a neglected
classroom resource, Journal of Research and Development in Education,
25, pp. 213–217.
DEWEY, J. (1938) Experience and Education (London, Collier Macmillan).
ENTWISTLE, N.J. & ENTWISTLE, A.C. (1991) Forms of understanding
for degree examinations: the pupil experience and its implications,
Higher Education, 22, pp. 205–227.
FRIEDMAN BEN DAVID, M., DAVIS, M.H., HARDEN, R.M., HOWIE, P.W.,
KER, J. & PIPPARD, M.J. (2001) AMEE medical education guide,
No 24: portfolios as a method of student assessment, Medical Teacher,
23, pp. 535–551,
GIPPS, C. (1994) Beyond Testing: towards a Theory of Educational Assessment
(London, Falmer Press).
GUBA, E.G. & LINCOLN, Y.S. (1989) Fourth Generation Evaluation
(Newberry Park, CA, Sage Publications).
HARLEN, W. & JAMES, M. (1997) Assessment and learning: differences
and relationships between formative and summative assessment,
Assessment in Education, 4, pp. 365–379.
HATTIE, J.A. (1987) Identifying the salient factors of a model of
student learning: a synthesis of meta–analyses, International Journal of
Educational Research, 11, pp. 187–212.
HATTIE, J. & JAEGER, R. (1998) Assessment and classroom learning: a
deductive approach, Assessment in Education, 5, pp. 111–122.
HOUGHTON, G. & WALL, D. (2001) Trainers’ evaluations of the West
Midlands formative assessment package for GP registrar assessment,
Medical Teacher, 22, pp. 399–405.
IVERSON, A.M., IVERSON, G.L. & LUKIN, L.E. (1994) Frequent, ungraded
testing as an instructional strategy, Journal of Experimental Education,
62, pp. 93–101.
KHAN, K.S., DAVIES, D.A. & GUPTA, J.K. (2001) Formative self–
assessment using multiple true–false questions on the Internet:
feedback according to confidence about correct knowledge, Medical
Teacher, 23, pp. 158–163.
KLENOWSKI, V. (1995) Student self–evaluation processes in
student centred teaching and learning contexts of Australia and
England, Assessment in Education: principles, Policy and Practice, 2,
pp. 145–163.
KLENOWSKI, V. (1996) Connecting assessment and learning. British
Educational Research Association Annual Conference (Lancaster
University), September 12–15.
KNOWLES, M. (1990) The Adult Learner: a Neglected Species, 4th ed.
(London, Kogan Page).
LIDZ, C.S. (1995) Dynamic assessment and the legacy of L.S.Vygotsky,
School Psychology International, 16, pp. 143–153.
MESSICK, S. (1975) The standard problem: meaning and values in
measurement and evaluation, American Psychologist, 30, pp. 955–966.
MEZIROW, J. (1994) Understanding transformational theory, Adult
Education Quarterly, 44, pp. 222–235.
PECKHAM, P.D. & ROE, M.D. (1977) The effects of frequent testing,
Journal of Research and Development in Education, 10, pp. 40–50.
PITTS, J., COLES, C., THOMAS, P. & SMITH, F. (2002) Enhancing reliability
in portfolio assessment: discussion between assessors, Medical Teacher,
24, pp. 197–201.
PRYOR, J. & TORRANCE, H. (1996) Teacher–pupil interaction in formative
assessment: assessing the work or protecting the child? The Curriculum
Journal, 7, pp. 205–226.
RAHMAN, S.A. (2001) Promoting learning outcomes in paediatrics
through formative assessment, Medical Teacher, 23, pp. 467–470.
RAMPRASAD, A. (1983) On the definition of feedback, Behavioral Science,
28, pp. 4–13.
SADLER, R. (1989) Formative assessment and the design of instructional
systems, Instructional Science, 18, pp. 119–144.
SADLER, D.R. (1998) Formative assessment: revisiting the territory,
Assessment in Education, 5, pp. 77–84.
SAVERY, J.R. & DUFFY, T.M. (1995) Problem–based learning: an
instructional model and its constructivist framework, Educational
Technology, 35, pp. 31–37.
Formative assessment: a key to deep learning?
SCHEERENS, J. (1991) Process indicators of school functioning: a selection
based on research literature on school effectiveness, Studies in
Educational Evaluation, 17, pp. 371–403.
SCHWARTZ, P., MENNIN, S. & WEBB, G. (2001) Problem-based Learning:
case Studies, Experience and Practice (London, Kogan Page).
SIBERT, L., MAIRESSE, J., AULANIER, S., OLOMBEL, P., BECRET, F.,
THIBERVILLE, J., PERON, J., DOUCET, J. & WEBER, J. (2001)
Introducing the objective structured clinical examination to a general
practice residency programme: results of a French pilot study, Medical
Teacher, 23, pp. 383–388.
TITTLE, C.K. (1994) Towards an educational–psychology of assessment
for teaching and learning – theories, contexts, and validation
arguments, Educational Psychologist, 29, pp. 149–162.
TORRANCE, H. & PRYOR, J. (1998) Investigating Formative Assessment:
teaching, Learning and Assessment in the Classroom (Buckingham, Open
University Press).
TOWNSEND, A.H., MCLLVENNY, S., MILLER, C.J. & DUNN, E.V.
(2001) The use of an objective structured clinical examination
(OSCE) for formative and summative assessment in a general
practice clinical attachment and its relationship to final medical
school examination performance, Medical Education, 35, pp. 841–846.
VYGOTSKY, L. (1978) Mind in Society (London, Harvard University
Press).
YORKE, M. (1998) The management of assessment in Higher
Education, Assessment and Evaluation in Higher Education, 23,
pp. 101–116.
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