Professionalism Mini-Evaluation Exercise Research Articles

Perception of dental students and faculty regarding the practice of professionalism in dentistry using the Professionalism Mini Evaluation Exercise (P-MEX).

Professionalism is one of the fundamental traits which includes behaviors, commitments, standards, and goals that helps define a profession. This study aimed to assess the attitude of dental students and graduates regarding the practice of professionalism in dentistry using the Professionalism Mini Evaluation Exercise (P-MEX) questionnaire. This cross-sectional study was conducted amongst the dental undergraduates, lecturers and postgraduate faculty. Views regarding professionalism were assessed using the P-MEX. The 24-questions based survey form is comprised of questions related to doctor and patient relationship skills, reflective abilities, time management, and lastly, interprofessional relationship expertise. Data was analyzed using SPSS version 23. Descriptive statistics were done using mean and SD, whilst associations between responses were assessed using Mann-Whitney U and Kruskal-Wallis tests. P value less than 0.05 was considered significant. From a total of 201 participants, 95 (47.3%) were males and 106 (52.7%) were females. Statistically significant association was seen between time management, reflective skills, and interpersonal skills with gender, as well as the domains of P-MEX and years of education. The use of P-MEX provides a valid confirmation for the assessment and awareness of professionalism amongst the dental faculty and students. Females demonstrated higher traits of professionalism as compared to males. The findings from the current study identify that students and faculty members had sufficient awareness regarding professionalism and the practice of professionalism was routinely followed.

Adaptation of the professionalism mini-evaluation exercise instrument into Turkish: a validity and reliability study

BackgroundThere is an ongoing search for standardized scales appropriate for each culture to evaluate professionalism, which is one of the basic competencies of a physician. The Professionalism Mini-evaluation Exercise (P-MEX) instrument was originally developed in Canada to meet this need. In this study, it was aimed to adapt the P-MEX to Turkish and to evaluate the validity and reliability of the Turkish version.MethodsA total of 58 residents at Bakirkoy Dr. Sadi Konuk Training and Research Hospital were assessed with the Turkish version of P-MEX by 24 raters consisting of faculty members, attending physicians, peer residents, and nurses during patient room visits, outpatient clinic and group practices. For construct validity, the confirmatory factor analysis was performed. For reliability, Cronbach’s alpha scores were calculated. Generalizibility and decision studies were undertaken to predict the reliability of the validated tool under different conditions. After the administration of P-MEX was completed, the participants were asked to provide feedback on the acceptability, feasibility, and educational impact of the instrument.ResultsA total of 696 forms were obtained from the administration of P-MEX. The content validity of P-MEX was found to be appropriate by the faculty members. In the confirmatory factor analysis of the original structure of the 24-item Turkish scale, the goodness-of-fit parameters were calculated as follows: CFI = 0.675, TLI = 0.604, and RMSEA = 0.089. In the second stage, the factors on which the items loaded were changed without removing any item, and the model was modified. For the modified model, the CFI, TLI, and RMSEA values were calculated as 0.857, 0.834, and 0.057, respectively. The decision study on the results obtained from the use of P-MEX in a Turkish population revealed the necessity to perform this evaluation 18 times to correctly evaluate professionalism with this instrument. Cronbach’s alpha score was 0.844. All the faculty members provided positive feedback on the acceptability, feasibility, and educational impact of the adapted P-MEX.ConclusionThe findings of this study showed that the Turkish version of P-MEX had sufficient validity and reliability in assessing professionalism among residents. Similarly, the acceptability and feasibility of the instrument were found to be high, and it had a positive impact on education.Trial registration2020/249, Bakirkoy Dr. Sadi Konuk Training and Research Hospital.

Assessment of the Medical Professionalism of Young Healthcare Specialists

The purpose of this studywas to reach consensus among stakeholders in residency programs on items to be used to assess medical professionalism in a multi-ethnic and multi-cultural context. These elements can form the basis for a medical professionalism assessment tool within residency programs.Methods. In this qualitative study, four 1½ h focus groups were conducted with the participation of 24 medical residents and 15 experts involved in the residency programs of the University of Western Kazakhstan, and the results were analyzed using thematic analysis. Focus group discussions were recorded on audio and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Results. The results of the study confirmed the four areas of medical professionalism reflected in P-MEX: doctor-patient relationship, reflective skills, time management, and inter-professional relationship skills. Based on the data obtained, a new sub-domain "Practical Class Attendance" was introduced into the time management domain, proposed by experts to assess the professionalism of residents.Conclusion. The domains of professionalism in Kazakhstan were similar to previous studies. This study allows to form professionalism in the training of young medical specialists in a multinational state.Keywords: professionalism, medical education, residency, experts, assessment of medical professionalism

Oncological big data platforms for promoting digital competencies and professionalism in Chinese medical students: a cross-sectional study

ObjectivesAdvancements in big data technology are reshaping the healthcare system in China. This study aims to explore the role of medical big data in promoting digital competencies and professionalism among...

Assessment of professionalism and ethics among final year part I undergraduate students of Kurnool Medical College, Kurnool, Andhra Pradesh

Background: Professionalism is a core competency of physicians. Erstwhile Medical Council of India envisioned competency-based medical education with Attitude, Ethics and Communication module as its forerunner. Objectives: The aim of this study was to objectively assess professionalism and ethics (P&E) by introducing multiple choice questions (MCQs) and Professionalism Mini-Evaluation Exercise (PMEX) as P&E assessment tools for MBBS students, by sensitizing the faculty and students. Materials and Methods: A mixed-method study was conducted during June to December 2019, among final MBBS part I undergraduate students, posted in the Department of Community Medicine, Kurnool Medical College, Kurnool. After obtaining IEC clearance and written informed consent from the study participants, a 3-day workshop on P&E was conducted with interactive teaching session on day 2, pretest on day 1, and posttest on day 3, in the form of five standardized patient interactions in OSCE stations rated using PMEX tool and five response stations for MCQs. Descriptive and inferential statistical analysis was done in IBM SPSS version 21.0 to see difference in pre- and posttest scores. Qualitative analysis using manual thematic coding was done to assess the perception of faculty and students. Results: A statistically significant difference in means was observed in pretest and posttest scores using PMEX tool (t test = −22.12, P value = 0.0001). 75% of students considered MCQs and PMEX as a feasible tool, out of a total of 29 study participants. Conclusion: MCQs and PMEX are effective tools to assess P&E among medical undergraduate students.

Scope of Professionalism Mini-evaluation Exercise Tool in Teaching and Assessing Professionalism among Medical Students

Medical professionalism refers to a set of values or behaviors, which eventually establishes the trust that the general population has on healthcare professionals. It will not be wrong to document that conventional assessment tools were not able to assess the complex domains of professionalism. Workplace-based assessment tools have been identified as the solution to assess professionalism among medical students during the routine clinical practice and accordingly multiple such tools have been tried under heterogeneous settings. The Professionalism Mini-Evaluation Exercise tool is an effective method to assess inter-professional skills, doctor-patient relationship, reflective abilities, and time management. In conclusion, medical professionalism plays a defining role in shaping the careers of medical students. It is the need of the hour to employ the professionalism mini-evaluation exercise tool in the field of medical education as both a learning and an assessment tool to inculcate the different aspects of professionalism among students.

A Meaningful and Actionable Professionalism Assessment: Validity Evidence for the Professionalism Mini-Evaluation Exercise (P-MEX) Across 8 Years.

With the growing importance of professionalism in medical education, it is imperative to develop professionalism assessments that demonstrate robust validity evidence. The Professionalism Mini-Evaluation Exercise (P-MEX) is an assessment that has demonstrated validity evidence in the authentic clinical setting. Identifying the factorial structure of professionalism assessments determines professionalism constructs that can be used to provide diagnostic and actionable feedback. This study examines validity evidence for the P-MEX, a focused and standardized assessment of professionalism, in a simulated patient setting. The P-MEX was administered to 275 pediatric residency applicants as part of a 3-station standardized patient encounter, pooling data over an 8-year period (2012 to 2019 residency admission years). Reliability and construct validity for the P-MEX were evaluated using Cronbach's alpha, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA). Cronbach's alpha for the P-MEX was 0.91. The EFA yielded 4 factors: doctor-patient relationship skills, interprofessional skills, professional demeanor, and reflective skills. The CFA demonstrated good model fit with a root-mean-square error of approximation of .058 and a comparative fit index of .92, confirming the reproducibility of the 4-factor structure of professionalism. The P-MEX demonstrates construct validity as an assessment of professionalism, with 4 underlying subdomains in doctor-patient relationship skills, interprofessional skills, professional demeanor, and reflective skills. These results yield new confidence in providing diagnostic and actionable subscores within the P-MEX assessment. Educators may wish to integrate the P-MEX assessment into their professionalism curricula.

Assessment of Professionalism in the Graduate Medical Education Environment

Assessment of Professionalism in the Graduate Medical Education Environment

Assessment of medical professionalism using the Professionalism Mini-Evaluation Exercise (P-MEX): A survey of faculty perception of relevance, feasibility and comprehensiveness

Introduction: This study aimed to examine the perception of faculty on the relevance, feasibility and comprehensiveness of the Professionalism Mini Evaluation Exercise (P-MEX) in the assessment of medical professionalism in residency programmes in an Asian postgraduate training centre. Methods: Cross-sectional survey data was collected from faculty in 33 residency programmes. Items were deemed to be relevant to assessment of medical professionalism when at least 80% of the faculty gave a rating of ≥8 on a 0-10 numerical rating scale (0 representing not relevant, 10 representing very relevant). Feedback regarding the feasibility and comprehensiveness of the P-MEX assessment was also collected from the faculty through open-ended questions. Results: In total, 555 faculty from 33 residency programmes participated in the survey. Of the 21 items in the P-MEX, 17 items were deemed to be relevant. For the remaining four items ‘maintained appropriate appearance’, ‘extended his/herself to meet patient needs’, ‘solicited feedback’, and ‘advocated on behalf of a patient’, the percentage of faculty who gave a rating of ≥8 was 78%, 75%, 74%, and 69% respectively. Of the 333 respondents to the open-ended question on feasibility, 34% (n=113) felt that there were too many questions in the P-MEX. Faculty also reported that assessments about ‘collegiality’ and ‘communication with empathy’ were missing in the current P-MEX. Conclusion: The P-MEX is relevant and feasible for assessment of medical professionalism. There may be a need for greater emphasis on the assessment of collegiality and empathetic communication in the P-MEX.

Asian medical students’ attitudes towards professionalism

ABSTRACT Background: Professionalism is the basis of trust in patient–physician relationships; however, there is very limited evidence focusing on attitudes towards professionalism among medical students. Hence, the main aim of our study was to investigate Malaysian medical students’ attitudes towards professionalism with specific emphasis on the comparison between pre-clinical and clinical students. Our secondary aim was to compare the differences in perception of medical students in Malaysia (pre-clinical and clinical) with Asian medical students studying in Dublin, Ireland Methods: This study utilized the Professionalism Mini-Evaluation Exercise (P-MEX) instrument which consists of 25 items that represent four skill categories: Doctor–Patient Relationship skills, Reflective skills, Time Management and Inter-Professional Relationship skills. Descriptive statistics were used to describe the demographic information of students and given the ordinal nature of the data, Mann–Whitney U-tests were used. Results: Overall, students have positive attitudes to all the professionalism items with more than 80% of the students agreeing that each of the professionalism attributes is important or very important. There was evidence of a significant difference between Malaysian pre-clinical and clinical students in relation to ‘avoiding derogatory language’ only (p = 0.015). When comparing between Malaysian and Dublin Asian students, there was a statistically significant difference in relation to ‘show interest in patient as a person’ (p < 0.003) for clinical students. Conclusion: Our results point to several curriculum implications such as 1) assessing students’ attitudes towards professional attributes is essential when developing the professionalism curriculum, 2) integrating more effective clinical modules early in the curriculum and 3) considering geographical and cultural factors when assessing perception towards professional attributes.

Assessment of dental residents' professionalism through Professionalism Mini-Evaluation Exercise (P-MEX).

The aim of the study was to assess the professional behavior of dental residents through Professionalism Mini-Evaluation Exercise (P-MEX). This was a descriptive-analytical study. Content validity of P-MEX form was investigated for use in the context of dentistry. A total of 24-item version of P-MEX consisted of doctor-patient relationship skills (n=7), reflective skills (n=5), time management (n=3), and interprofessional relationship skills (n=9) was used in the present study. Residents in different dental specialties (n=56) were evaluated by trained raters (448 times). Data were analyzed by descriptive (mean, SD) and analytical tests (Pearson, ANOVA, and post hoc test (Bonferroni)). Validity of P-MEX was approved in the field of dentistry. The mean score of professional behavior in residents were reported 2.79 ± 0.24, with minimum and maximum scores of 2.17 and 3.62, respectively. The residents' professional behavior in the domain of reflective skills and doctor-patient relationship skills were lower than the other domains. The results showed that the scores of professional behavior among dental residents were classified in the below expectation level and their scores have followed a downward trend from the second year. Therefore, planning for training and continuous assessment of professional behavior among residents in the faculty of dentistry should be considered.

Professionalism in traditional Chinese medicine (TCM) practitioners: a qualitative study

BackgroundMedical professionalism is important for establishing public trust in doctors. Its definition is culture-sensitive. However, no research has explored medical professionalism in Traditional Chinese Medicine (TCM) practitioners. This study aims to (a) establish the domains of professionalism in TCM practitioners in Singapore, and to (b) compare the domains of professionalism of practitioners trained in TCM and practitioners trained in conventional medicine.MethodsData for this qualitative study was collected through in-depth interviews (IDIs) with TCM practitioners. IDIs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using the Professionalism Mini-Evaluation Exercise (P-MEX) as a framework. The domains of professionalism in TCM and conventional medicine were then compared, using data from a similar study on professionalism in practitioners trained in conventional medicine.ResultsA total of 27 TCM practitioners (40.7% male) participated in this study. The four domains of professionalism in the P-MEX, namely doctor-patient relationship skills, reflective skills, time management and inter-professional relationship skills, and two new sub-domains, “communicated effectively with patient” and “demonstrated understanding and integrated with conventional medicine”, were relevant to TCM practitioners. This is largely similar to that of practitioners trained in conventional medicine, with a few differences, including “ensured continuity of care” and “used health resources appropriately”.ConclusionThe domains of professionalism in TCM practitioners were established and they are similar to that of practitioners trained in conventional medicine. This study is the first to define medical professionalism in TCM practitioners. Findings will provide guidance on the education of professionalism in TCM practitioners.

Assessment of medical professionalism using the Professionalism Mini Evaluation Exercise (P-MEX) in a multi-ethnic society: a Delphi study

BackgroundThe importance of medical professionalism and its assessment has been well documented in the literature. However, there is currently no culturally-adapted tool to assess medical professionalism in Singapore. This study sets out to find consensus on relevance of the items from the Professionalism Mini Evaluation Exercise (P-MEX) for assessing medical professionalism in Singapore.MethodsA two-round Delphi survey was completed by an expert panel consisting of program directors, associate designated institutional officials, and designated institutional official (n = 15) from residency programs in Singapore. Round 1 comprised of 23 items from the P-MEX rated on a 5-point scale (1 = Definitely include, 2 = Possibly include, 3 = Neutral, 4 = Possibly exclude, 5 = Definitely exclude). In round 2, the experts received feedback from the previous round, and were asked to re-rate the items which did not achieve consensus in the previous round. The threshold for consensus in the study was defined as 70% or greater agreement among experts.ResultsCompleted questionnaires for both rounds were received from all 15 experts. In round 1, 18 items (78%) achieved consensus to be included. In round 2, 1 (4%) item achieved consensus to be included. However, none of the remaining items achieved consensus to be removed, and they exhibited stability in responses. A list of 19 items covering four domains of medical professionalism (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) was obtained during the two-rounds of Delphi survey.ConclusionsNineteen items in the P-MEX had garnered consensus and is suitable for assessing medical professionalism in Singapore. The findings of this study can provide guidance for faculty and institutions who want to assess medical professionalism of their medical trainees.

Assessment of medical professionalism: preliminary results of a qualitative study

BackgroundThe importance of medical professionalism has been well documented in the literature. Cultural background affects the constituents of professionalism. However, few studies have explored the domains of medical professionalism in an Asian context. We aim to describe the views and experiences of both patients and faculty on medical professionalism in an urban Asian city state.MethodsData for this qualitative study were collected through focus group discussions (FGDs) with patients and in-depth interviews (IDIs) with faculty members. The IDIs and FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Sociodemographic data of faculty members and patients were obtained through brief questionnaires.ResultsA total of 31 patients (58.1% male, all had visited healthcare facilities within the past year) and 26 faculty members (42.3% male, 38.5% from medical disciplines, median years as faculty is 11) participated in this study. The results supported the four domains of medical professionalism - Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills. Two new sub-domains which emerged from data were (1) communicated effectively with patient and (2) demonstrated collegiality.ConclusionsThe domains of professionalism in Singapore were similar to previous studies. This study allows a better understanding of medical professionalism to enhance the assessment and ultimately, the teaching of medical professionalism in an urban multi-ethnic Asian city.

Evaluation of feasibility, acceptability and utility of professionalism mini evaluation exercise (p-mex) tool in dental students of India: A preliminary report

Background: The importance of professionalism in health professional's education has been realised in the past few decades and few assessment tools have been innovated. One such tool is the professionalism mini-evaluation exercise (P-MEX) tool, which has been used widely in medical education for assessing professionalism. To the best of our knowledge, there is no study done to evaluate its feasibility, acceptability and utility in dental students across India. Our preliminary report has assessed these three attributes in dental students of our college. Aim: To pilot P-MEX tool for assessing professionalism in dental students. Methodology: This study was conducted among 3rd and 4th year dental students posted in clinical departments. An orientation workshop was conducted where faculty were trained to use the P-MEX tool. The students were assessed using the tool and after assessment, individual feedback was given to them. L ater, both student and faculty were asked to fill the feedback questionnaires. Results: A total of 21 students participated in the study. 75% of students and faculty considered P-MEX as a feasible tool. 60–75% students and faculty members agreed that they were comfortable with the use of the P-MEX tool. 80% of students and all faculty agreed that the tool was satisfactory and useful. 95% students and all faculty felt that the feedback given after P-MEX helped in identifying the lacunae in professional skills. Conclusion: P-MEX is a feasible, acceptable and useful tool to assess professionalism at our institutional setup.

Can Professionalism Mini-Evaluation Exercise Scores Predict Medical Residency Performance? Validity Evidence Across Five Longitudinal Cohorts.

The residency admissions process is a high-stakes assessment system with the purpose of identifying applicants who best meet standards of the residency program and the medical specialty. Prior studies have found that professionalism issues contribute significantly to residents in difficulty during training. This study examines the reliability (internal structure) and predictive (relations to other variables) validity evidence for a standardized patient (SP)-based Professionalism Mini-Evaluation Exercise (P-MEX) using longitudinal data from pediatrics candidates from admission to the end of the first year of postgraduate training. Data from 5 cohorts from 2012 to 2016 (195 invited applicants) were analyzed from the University of Geneva (Switzerland) Pediatrics Residency Program. Generalizability theory was used to examine the reliability and variance components of the P-MEX scores, gathered across 3 cases. Correlations and mixed-effects regression analyses were used to examine the predictive utility of SP-based P-MEX scores (gathered as part of the admissions process) with rotation evaluation scores (obtained during the first year of residency). Generalizability was moderate (G coefficient = 0.52). Regression analyses predicting P-MEX scores to first-year rotation evaluations indicated significant standardized effect sizes for attitude and personality (β = 0.36, P = .02), global evaluation (β = 0.27, P = .048), and total evaluation scores (β = 0.34, P = .04). Validity evidence supports the use of P-MEX scores as part of the admissions process to assess professionalism. P-MEX scores provide a snapshot of an applicant's level of professionalism and may predict performance during the first year of residency.

Validity, reliability and acceptability of Professionalism Mini-Evaluation Exercise (P-MEX) for emergency medicine residency training.

Professionalism is a core competency in the medical profession. In this paper, we aimed to confirm the validity, reliability and acceptability of the Professionalism Mini-Evaluation Exercise (P-MEX) instrument for the emergency medicine (EM) residency program. Twenty-two EM attending physicians completed 383 P-MEX forms (the Persian version) for 90 EM residents. Construct validity was assessed via structural equation modeling (SEM). The reliability coefficient was estimated by the generalizability theory, and acceptability was assessed using two researcher-made questionnaires to evaluate the perspectives of residents and assessors. There was a consensus among the participants regarding the content of P-MEX. According to the results of SEM, the first implementation of the original model was associated with a moderate fit and high item loadings. The model modified with correlated error variances for two pairs of items showed an appropriate fit. The reliability of P-MEX was 0.81 for 14 occasions. The perception survey indicated high acceptability for P-MEX from the viewpoint of the residents and increasing satisfaction with P-MEX among the assessors over time. According to the results of the research, P-MEX is a reliable, valid, and acceptable instrument for assessing professionalism in EM residents.

The positive effect of student-oriented clinical clerkship rounds employing role-play and peer review on the clinical performance and professionalism of clerkship students

Background: Role-play (RP) and peer review (PR) are occasionally used in training and evaluating communication skills in clinical clerkship (CC). Thus, we evaluated the effect of combining RP and PR during student-oriented CC rounds.Methods: Clerkship students conducted medical interviews with and performed physical examinations on their patients, which were reviewed by five peer students who observed their performance while role-playing as senior physicians or patients’ families. The peer reviewers then provided feedback to the students. The performance of the students was evaluated based on a mini-clinical evaluation exercise (Mini-CEX) and a professionalism mini-evaluation exercise (P-MEX) before and after the rounds by two attending physicians. After the CC, the students responded to questionnaires about the rounds.Results: Seventy-five students completed the rounds, and the duration of each round was 41.7 ± 7.1 min. Their communication skills and professionalism abilities on Mini-CEX and P-MEX showed significant improvement after the rounds. Improvements in medical interviewing and physical examinations were also noted. Additionally, the students recognized the importance of multiple viewpoints in patient care through experiences of the rounds.Conclusions: Combining RP and PR with CC rounds improves the students’ clinical performance and professionalism and promotes their awareness of the importance of multiple viewpoints in patient care.

A Systematic Review of the Quality and Utility of Observer-Based Instruments for Assessing Medical Professionalism.

Professionalism, which encompasses behavioral, ethical, and related domains, is a core competency of medical practice. While observer-based instruments to assess medical professionalism are available, information on their psychometric properties and utility is limited. We systematically reviewed the psychometric properties and utility of existing observer-based instruments for assessing professionalism in medical trainees. After selecting eligible studies, we employed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria to score study methodological quality. We identified eligible instruments and performed quality assessment of psychometric properties for each selected instrument. We scored the utility of each instrument based on the ability to distinguish performance levels over time, availability of objective scoring criteria, validity evidence in medical students and residents, and instrument length. Ten instruments from 16 studies met criteria for consideration, with studies having acceptable methodological quality. Psychometric properties were variably assessed. Among 10 instruments, the Education Outcomes Service (EOS) group questionnaire and Professionalism Mini-Evaluation Exercise (P-MEX) possessed the best psychometric properties, with the P-MEX scoring higher on utility than the EOS group questionnaire. We identified 2 instruments with best psychometric properties, with 1 also showing acceptable utility for assessing professionalism in trainees. The P-MEX may be an option for program directors to adopt as an observer-based instrument for formative assessment of medical professionalism. Further studies of the 2 instruments to aggregate additional validity evidence is recommended, particularly in the domain of content validity before they are used in specific cultural settings and in summative assessments.

The challenges of detecting progress in generic competencies in the clinical setting.

Competency-based medical education has spurred the implementation of longitudinal workplace-based assessment (WBA) programmes to track learners' development of competencies. These hinge on the appropriate use of assessment instruments by assessors. This study aimed to validate our assessment programme and specifically to explore whether assessors' beliefs and behaviours rendered the detection of progress possible. We implemented a longitudinal WBA programme in the third year of a primarily rotation-based clerkship. The programme used the professionalism mini-evaluation exercise (P-MEX) to detect progress in generic competencies. We used mixed methods: a retrospective psychometric examination of student assessment data in one academic year, and a prospective focus group and interview study of assessors' beliefs and reported behaviours related to the assessment. We analysed 1662 assessment forms for 186 students. We conducted interviews and focus groups with 21 assessors from different professions and disciplines. Scores were excellent from the outset (3.5-3.7/4), with no meaningful increase across blocks (average overall scores: 3.6 in block1 versus 3.7 in blocks 2 and 3; F=8.310, d.f. 2, p<0.001). The main source of variance was the forms (47%) and only 1% of variance was attributable to students, which led to low generalisability across forms (Eρ2 =0.18). Assessors reported using multiple observations to produce their assessments and were reluctant to harm students by consigning anything negative to writing. They justified the use of a consistent benchmark across time by citing the basic nature of the form or a belief that the 'competencies' assessed were in fact fixed attributes that were unlikely to change. Assessors may purposefully deviate from instructions in order to meet their ethical standards of good assessment. Furthermore, generic competencies may be viewed as intrinsic and fixed rather than as learnable. Implementing a longitudinal WBA programme is complex and requires careful consideration of assessors' beliefs and values.