Keele Research Repository

Context Grades are commonly used in formative workplace-based assessment (WPBA) in medical education and training but may draw attention away from feedback about the task. The dilemma is that the self-regulatory focus of a trainee must include self-awareness relative to agreed standards, which implies grading. In this study we aimed to understand the meaning which medical students construct from WPBA feedback with and without grades, and what influences this. Methods Year 3 students were invited to take part in a randomised crossover study in which each student was their own control. Each student had one WPBA with and one without grades, and then chose whether or not to have grades with their third WPBA. These preferences were explored via semi-structured interviews. A realist approach to analysis was used to gain understanding of student preferences and the impact of feedback with and without grades. Results and discussion Of students who had feedback with and without grades, 65 (78%) then chose to have feedback with grades and 18 (22%) without grades their third WPBA. 24 students were interviewed. Students described how grades locate their performance and calibrate their self-assessment. For some, low grades focused attention and effort. Satisfactory and high grades enhanced self-efficacy. Grades are also concrete, powerful and blunt, can be harmful and need explanation to help students create helpful meaning from them. Low grades risk reducing self-efficacy in some and may encourage others to focus on proving their ability rather than on improvement. A metaphor of the semi-permeable membrane is introduced to understand how students reduced potential negative effects and enhanced the positive effects of feedback with grades by selective filtering and pumping.