Illusions of specificity in power-laden clinical performance assessment

The practice of observation-based assessment is synonymous with clinical performance assessment methods employed on many academic programs that lead to health professional qualifications. Typically, health professional students undertake apprenticeship-type practice placements during which time they are assessed by a supervising clinical educator, that is, a clinician who has undertaken the facilitation and assessment of a student’s clinical performance while continuing with their primary service role. Clinical performance is determined through the achievement of learning outcomes identified on clinical performance assessment tools, or through tick-box or global rating scales in which students’ observed performance is matched against preset learning outcomes. These high-stakes assessments yield grades that are critical to students’ progression and entry into their chosen profession. In this paper, we critically question the centrality of observation-based assessment of practice, probing the assumptions underpinning its use. We outline the highly performative nature of clinical performance assessment and argue that the tenet upon which observation-based assessment is constructed does not pay sufficient attention to issues of power in the student–assessor relationship. To date, critiques of the clinical performance assessment model have largely focused on the psychometric properties of assessment instruments used and the inter-rater reliability of assessors (Govaerts et al. 2013). We argue that insufficient attention has been given to the influence of student-assessor power relations on the process and judgments associated with observation-based assessment. Furthermore, we illustrate using a Foucauldian framework how students’ performances are fundamentally aligned with their estimations of what their clinical educators want of them rather than an actual calculation of what is required in a particular clinical setting. According to Foucault (Foucault 1995), hierarchical control is subtle but pervasive and is enacted in three main ways. These features of control include “hierarchical observation”, “normative judgement” and the “technology of the examination”. All three features are evident within observation-based assessment in the health professions. Hierarchical observation – the observation of one by another – can significantly influence the behavior of the student ensuring that they remain compliant with the perceived expectations of the observer, i.e. the assessor. Being subject to this “calculated gaze” (Foucault 1995) influences behavior more significantly than more explicit forms of control. In this context the student’s “performance” becomes an act; a form of dressage so to speak, displaying compliance with the routines and practices associated with “being” a competent physiotherapist, doctor, nurse. The assessment does not necessarily shed light on the underlying thought processes underpinning the action. Foucault’s second concept that of normative judgement, is evident in the observation-based process. Whilst the assessor has access to an assessment instrument with defined descriptors or indicators of performance, suggesting a form of criterion-referenced assessment is being employed, in reality judgements are normatively referenced, based on comparison with similar students or practicing professionals. In that context “being” a physiotherapist, nurse or doctor equates to replicating and complying with others’ practices. Therefore while the assessment instruments provide the “illusion of specificity” in terms of the application of criteria, one cannot remove the assessment process from the normative judging that underpins control. Use of complex grading rubrics may give the impression that set criteria are being objectively applied by assessors but this ignores the likelihood that assessors are also using subjective criteria based on implicit normative expectations grounded in experience. The third dimension outlined by Foucault refers to the “technology of the examination” (Foucault 1995). This is the culmination of the previous two dimensions where hierarchical observation combined with normative judgement is employed to examine the student. The examination constitutes a formalized process, a ritual of power “that makes it possible to qualify, to classify and to punish” (Foucault 1995). Foucault referred to this when he described the organization of hospitals in the eighteenth century as “examining machines”, and likewise, the examination processes conducted in schools as “sites of perpetual examination” (Foucault 1995). Similarly the health professional student is a “case” subjected to constant scrutiny by the assessor, which in itself becomes a further exercise of power. Additionally, documented evidence pertaining to the student’s performance exposes them to ongoing measurement and analysis by their assessors and comparison to their peers, further empowering assessors throughout the process. Evidence provides support for Foucault’s concepts. For example, it has been shown that assessor’s decision-making is often intuitive rather than objective. Assessors use implicit definitions of effective behaviors based on what they