CHAPTER 

13

Formative Assessment
Diana Wood
School of Clinical Medicine, University of Cambridge, Cambridge, UK

OVERVIEW Box 13.1  Assessment – roles and characteristics

• Formative assessment is an active process, embedded in the curriculum
and linked to both learning outcomes and summative assessment Formative assessment – ‘assessment for learning’

• It places learning at the heart of assessment and is characterised • Promotes more effective student learning
by a series of interactions between teachers and learners which • Frequent, informal, motivational for students
are frequent, informal, unthreatening and non‐judgmental • Provides feedback to learners about their progress
• Qualitative – helps students to focus and direct their learning
• In a programme of formative assessment, learning follows
• Non‐judgmental
constructive feedback and students are encouraged to develop
• Indicates achievement of personal goals to students
lifelong learning skills and high levels of self‐regulation
• Should influence curriculum development
• The process should be motivating for both students and teachers
and make a major contribution to institutional education quality Summative assessment – ‘assessment of learning’
improvement • Measures the achievement of learning outcomes at the end of a course
• Infrequent, formal
• Little or no feedback to students
Assessment forms a major part of any educational programme and • Quantitative
can be broadly considered to have three main roles: • Allows grades to be awarded
• Summarises achievement
• formative assessment or ‘assessment for learning’; • Acts as a marker for progression
• summative assessment or ‘assessment of learning’; • Indicates achievement of institutional goals
• assessment for institutional accountability or ‘assessment for
Assessment for accountability – ‘assessment for quality
quality assurance’. assurance’
• Reviews all assessments to ensure institutional standards are met
The roles of assessment can thus be seen to promote, measure and
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• Infrequent, formal, high‐level

quality assure student learning and the educational programme as a
whole (see Box 13.1).
Whilst these are useful definitions for considering different types
of assessment, it is important that, within a teaching programme,
they are considered together alongside curriculum development
and review and blueprinted against curriculum content, so that
assessment facilitates learning by being clearly linked to learning
outcomes. Each assessment should be planned according to the
stage of the course and the students’ development, and within an
overall framework such as Bloom’s taxonomy (see Chapter  5),
which will reflect progression of the assessment process towards
• Provides information for curriculum and programme development
• Informs educational management
• Promotes faculty development
• Satisfies external regulators
complex data synthesis and analysis, rather than simple knowledge
retention. A programmatic approach to assessment, meaning that
the elements are strategically planned alongside each other,
produces a coherent structure which allows the assessment
­
­programme in its entirety to achieve its three main objectives.

ABC of Learning and Teaching in Medicine, Third Edition. Edited by Peter Cantillon, Diana Wood and Sarah Yardley.
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 60 ABC of Learning and Teaching in Medicine
What is formative assessment?
Formative assessment should constitute a series of frequent, infor-
mal contacts in which constructive feedback is provided by the
teacher to the learner or learners. It is an interactive and dynamic
process, based on effective learning through feedback and it should
be seen as a way in which students can become lifelong, reflective
learners in addition to demonstrating their knowledge or skills
acquisition. Although the overall benefits of formative assessment
on student learning are difficult to assess, mainly because of a lack
of clear research evidence, the theoretical principles of social con-
structivism support its widespread use. The key features of forma-
tive assessment are shown in Box 13.1.
Black and William (2009) considered the simple definition of
formative assessment and expanded it to provide a set of five strate-
gies needed for formative assessment to be most effective (Box 13.2).
Box 13.2  Formative assessment
Definition
Formative assessment directly aids learning by the provision of feed-
back. It encompasses ‘… 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).
Strategies for effective formative assessment (Black &
William, 2009)
• Clarifying and sharing learning intentions and criteria for success
• Engineering effective classroom discussions and other learning
tasks that elicit evidence of student understanding
• Providing feedback that moves learners forward
• Activating students as instructional resources for one another
• Activating students as the owners of their own learning.
These strategies emphasise the importance of student engage-
ment with assessment, not just in receiving feedback but in devel-
oping an understanding of the whole educational process, including
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the necessary criteria for success. Students must understand how to
evaluate their own learning needs, but should also be encouraged to
interact with others, including by means of formative peer review
and assessment, in order to gain a better understanding of their
subject. Good formative assessment also encourages students to
develop their skills of self‐regulation. Self‐regulated learners are
aware of their own beliefs and cognitive skills and they use internal
mechanisms, such as motivation and understanding, to interpret
external feedback, monitor their learning behaviour and change
the  latter, if appropriate. Students who are highly self‐regulated
are  more effective learners, and ultimately more successful, so a
well‐designed programme of formative assessment can have major
benefits for students and staff alike.
A programme of formative assessment within a curriculum
could involve regular planned assessments, e.g. to review pieces of
submitted written work, or it could consist of a series of unplanned
and informal interactions, such as those that frequently occur
in  clinical teaching. Crucially, formative assessment should be
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Box 13.3  Principles of learning‐orientated assessment
Learning‐orientated assessment:
• makes assessment tasks into learning tasks
• involves students in all aspects of assessment
• provides constructive feedback.
Principles of learning‐orientated assessment
These include (Carless, 2007):
1 Assessment tasks should be designed to stimulate sound learning
practices amongst students.
2 Assessment should involve students actively in engaging with
criteria, quality, their own and/or peers’ performance.
3 Feedback should be timely and forward‐looking so as to support
current and future student learning.
non‐threatening and non‐judgmental – the more often it occurs, the
easier this is to achieve. Furthermore, if the amount of learning that
has occurred, rather than the measurement of knowledge, becomes
the main aim of the assessment (so‐called ‘learning‐orientated
assessment’; see Box  13.3) then a programme of learner‐centred
formative assessment can be designed within a curriculum.
There is a direct relationship between the time students spend on
an individual task and their subsequent performance in summative
assessments. A series of formative assessment tasks that promote
deep learning and understanding will thus encourage students to
spend time studying a particular topic, thereby optimising their
chances of success.
Feedback in formative assessment
Feedback is central to formative assessment as it constitutes the
process by which assessment becomes a tool for learning. Feedback
is positively correlated with student achievement, although the
quality of the feedback is an important factor. Poor‐quality feed-
back may have no, or even negative, effects on learning. Feedback is
discussed in Chapter 7.
Formative assessment should be beneficial not just to students,
but also to the teaching faculty, in curriculum design and in institu-
tional quality assurance (see Figure 13.1).
The student perspective
At the most basic level, students should be made aware of the aims
of a programme of formative assessment, and should understand
the criteria for success. Moving on, once students are aware of, and
understand, the purpose of the assessment process as a means to
improve learning, then formative assessment can be developed to
promote deep learning and enhance students’ motivation to learn.
It should raise their self‐esteem, identify problems in learning and
develop ways in which they might address them. Students should
be encouraged to develop skills of self‐evaluation, enabling them to
review their own work in a constructive manner. Information pro-
vided in the formative assessment process should help them to
understand the gaps in their knowledge identified by effective
­feedback and to consider ways in which they can close those gaps
successfully. Formative assessment also facilitates peer assessment,
 Formative Assessment 61

STUDENTS

Encourages deep learning

Motivational
Raises self-esteem
Identifies problems and how to address
them

CURRICULUM
TEACHERS
Aids detailed Programmatic
feedback evaluation of
teaching and learning
Identifies students in
difficulty Formative aligned
with summative
Promotes self- assessment
directed learning
Identifies challenging
Develops teaching subjects
skills
Offers ongoing
quality assurance

INSTITUTION

Evidence that learning outcomes met

Demonstrates range of assessment
methods used
Informs faculty development
Satisfies external regulators

Figure 13.1  Effective formative assessment links the students and teaching staff with curriculum planning and institutional aims.

enabling students to review and evaluate work produced by others

at the same level of learning as themselves. Self‐assessment and Box 13.4  Characteristics of ‘highly competent’ teachers
peer assessment are useful ways for students to learn to recognise in formative assessment
elements of good work and to develop reflective skills.
• Knowledge
• Attitudes towards teaching and towards learners
The teacher perspective
• Skill in devising assessment tasks
Formative assessment helps teachers to develop their teaching skills • Understanding of appropriate standards and expectations of
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and use them to promote effective learning in their students. The
regular and informal nature of formative assessment is also a valuable
way to identify students in difficulty. The skills that the teacher devel-
ops through experience and a programme of faculty development in
assessment are essential, so that they understand the learning pro-
cess, are equipped to give constructive feedback and maintain a
meaningful ongoing relationship with the student to promote effec-
tive learning. This process also enhances teacher satisfaction. Six key
features of highly competent teachers were identified by Sadler (1998;
Box 13.4) and can be used as a benchmark for teacher development.
Formative assessment in curriculum design
In order to create a well‐designed curriculum or module, members
of the teaching faculty need to consider how assessment, feedback
and evaluation can be incorporated, using an iterative model of
data collection, review and change. If the formative and summative
assessment components are aligned and blueprinted against the
­student performance
• Experience in the use of judgments for the assessment task
• Expertise in giving effective feedback
Source: Sadler (1998).
curricular content, then a programmatic evaluation can occur,
including an evaluation of the assessment process itself. This over-
all ‘constructive curriculum alignment’ allows identification of sub-
jects that are challenging to students, and modification of the
content or teaching in an overall process of quality improvement.
Formative assessment for institutional
transformation
The programmatic approach to curriculum design, including
­specific alignment of the content and the teaching and learning
methods with formative and summative assessment, provides

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 62 ABC of Learning and Teaching in Medicine
v­ aluable information to the institution as a whole. If assessment for
learning is central to an organisation and used as part of a continu-
ous quality improvement process, it is referred to as ‘transformative
assessment’. This allows an institution to satisfy itself that learning
outcomes have been met, to develop appropriate faculty develop-
ment programmes and to meet the requirements of external regula-
tors. A meaningful and sustainable programme of formative
assessment, which is flexible and rapidly adaptable, should be cen-
tral to this transformative process and facilitate continuous quality
improvement.
Formative assessment in medical
education
Formative assessment in medical education at all levels (under-
graduate, postgraduate and in continuing professional develop-
ment) is a valuable way to promote the lifelong learning skills
required for a successful career in medicine. The opportunities
offered by ongoing, frequent, non‐judgmental and informal regular
interaction with clinical teachers should make the process highly
motivational. Good formative assessment encourages learners to
develop skills of deep learning, self‐regulation and reflection. The
external climate in which healthcare education occurs is changing,
with a greater emphasis on the requirements of external regulatory
bodies for summative evidence of achievement in both medical stu-
dents and doctors. However, a constructively aligned curriculum in
which summative and formative assessments are carefully blue-
printed and quality‐assured together, offers better evidence that the
learners have not only acquired knowledge, but have also devel-
oped the professional skills needed to become lifelong learners and
reflective practitioners.
Medical education takes place in a wide range of learning envi-
ronments, including lecture theatres, laboratories, classrooms,
hospital wards and clinics, GP surgeries and other community
care settings, including patients’ homes. A range of assessment
formats exists, the specific choice of which should reflect the
teaching methods and learning environment, and all of which
can be used in a programme of formative assessment (see
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Table 13.1). Triangulation of a range of testing formats facilitates
an overall picture of the students’ progress and achievement
across all the required domains.
Clinical education and assessment rely heavily on the direct
observation of learners either in simulated environments or
during clinical practice. It is important that all clinical teachers
are skilled in giving feedback in these situations, as a busy clini-
cal working environment can appear hostile and students may
be inhibited from seeking feedback, may misinterpret what has
been said or even not notice when it is given. Feedback that is
poorly delivered causes students to become defensive. Other
factors that may be involved include the students’ level of confi-
dence in their own performance such that even well‐constructed
feedback can have negative consequences if not handled
­carefully. If the feedback contrasts with the learner’s own per-
ception of their performance (even if the teacher’s view is more
positive than their own), then they may lose faith in the entire
system and become resistant to the whole process. One approach
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Table 13.1  Examples of formative assessment formats used in medical
education
Domain Formative assessment formats
Knowledge Progress testing
Paper‐based assessments
Problem‐based learning
Interactive on‐line quizzes
Skills Objective structured clinical examinations (OSCEs)
and other observed skills assessments
Mini‐Clinical Evaluation Exercise (Mini‐CEX)
Direct observation of practical skills
Attitudes Assessment in clinical placements
Bedside teaching
Direct observation of consultation
Professionalism Monitoring attendance, punctuality
Situated judgment tests
Observed skills assessments
360‐degree feedback
to dealing with these issues lies in the formative assessment
­programme. Students should be encouraged to collect their
feedback during clinical activities, e.g. in a portfolio or online
system, so that it can be reviewed with a familiar tutor or mentor
at a later date as part of regular, informal formative review. It
can  then be used constructively, helping the student to reflect
on  their ongoing clinical performance, accurately identify
their  strengths and weaknesses and construct a plan for
improvement.
Summary
Formative assessment requires commitment from both students
and teachers in order to develop and maintain a particular set of
skills related to learning through constructive feedback. Within
a curriculum, a programme of formative assessment should be
developed alongside the summative elements, with both clearly
reflecting the learning outcomes of the course. Students should
be educated about the role of formative assessment, so they
understand its importance both in achieving better performance
in their studies and in developing lifelong learning skills.
Frequent, informal and non‐judgmental formative assessment is
motivating for students and results in higher satisfaction for
both students and teachers alike. At the institutional level, a
­programme of formative assessment promotes a culture of learn-
ing and plays a major role in continuous educational quality
improvement. In medical education, the benefits of more
­effective learning at each stage coupled with the development of
lifelong learning skills should have positive effects on the quality
of the medical educational programme and, ultimately, on future
patient care.
References
Black P, Wiliam, D. Inside the black box: raising standards through classroom
assessment. PhiDeltaKappa International, 1998. Online: http://www.
pdkintl.org/kappan/kbla9810.htm
 Formative Assessment 63

Black P, Wiliam D. Developing the theory of formative assessment. Educ
Assess Eval Accountabil 2009; 21: 5–31.
Carless D. Learning‐orientated assessment: conceptual bases and practical
implications. Innov Educ Teach Int 2007; 44: 57–66.
Sadler DR. Formative assessment: revisiting the territory. Assess Educ 1998; 5:
77–84.
Further reading
Bennett RE. Formative assessment: a critical review. Assessment in Education:
Principles, Policy and Practice 2011; 18: 5–25.
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van der Vleuten CPM, Schuwirth LWT, Driessen EW et  al. A model for
programmatic assessment fit for purpose. Med Teacher 2012; 34:
205–214.
Wehlburg CM. Promoting Integrated and Transformative Assessment: a
Deeper Focus on Student Learning. San Francisco, CA: Jossey‐Bass,
2008.
Wood DF. Formative assessment. In Walsh K, ed. Oxford Textbook of Medical
Education. Oxford: Oxford University Press, 2013.

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