Alternative Grading in Clinical Laboratory Sciences Education: Students’ Perspectives

INTRODUCTION

Grading is commonplace throughout all levels and fields of education. Grades are often provided in the form of letters or percentages, and the letter grade and 100-point percentage scale that educators and students are familiar with today were introduced not long ago in the early 1900s.^1,2 These letters and percentages are often used as a way to represent students’ knowledge, performance in a course, and content mastery. Health science programs often rely on grades as a predictor of success on board and licensure exams that graduates will take before entering the workforce. Interestingly, grading was initially introduced into education to standardize and communicate between schools, yet standardization between organizations is lacking as evidenced by the varying grading scales published on academic institutions’ web pages. The lack of standardization should raise concerns among educators, as we can presume inherent inequities and inaccessibility would arise from such inconsistencies. Therefore, the reliability of grades as a communication tool and predictor of success for postgraduation certifying exams is questionable.

The issue of accessibility and inequity stems even deeper than the lack of standardization between academic institutions. Grading practices are inequitable and often include factors that are unreliable measures of knowledge, such as behavioral factors.^3⇓⇓⇓-7 Although grading practices may include factors unrelated to knowledge, academic programs often rely on grading to assess students’ intellect and performance in class. These grading systems do not consider the starting point of individual students but rather treat each student as the same with uniform expectations regardless of their previous academic experiences. Additionally, many instructors have implicit biases that can impact students’ grades.³

Compounding the issues of inequity and inaccessibility, grading can lead to negative effects on the student and inhibit the learning process.^{8⇓⇓⇓-12} These effects contradict the goal many educators share: to instill knowledge that will benefit the students in their personal and professional lives. Thus, alternative assessment approaches (eg, ungrading or alternative grading) have become more popular, especially in the wake of the COVID-19 pandemic. Despite the growing popularity of alternative grading, educators feel pressure to use the 100-point percentage scale and letter grades because of institutional requirements and other factors. Health professions educators, in particular, need to ensure their students are competent enough to perform job tasks without risking any harm to the patient. To assess competence, health professions often have certifying or licensure exams that must be passed before an individual is allowed to practice. Naturally, educators use grading as a way to assess students’ readiness and ability to pass these exams.

The combination of the negative effects of grading and the pressure to prepare students for certifying or licensure exams places health professions educators in an interesting situation. We need to promote learning but also ensure that students are prepared to pass the certifying or licensure exams, and more importantly, provide safe and reliable patient care. It is understandable that health professions educators might have an interest in implementing alternative assessment approaches but remain skeptical of their utility in health professions education. Therefore, the purpose of this study was to explore the utility and impact of alternative assessment approaches in various clinical laboratory science (CLS) courses.

BACKGROUND

MENTAL HEALTH

Undergraduate and graduate students report high levels of anxiety, depression, and other mental health disorders, and this rate appears to have increased over time.¹⁴ A contributing factor to these issues is academic stress. Academic stress, such as stress related to poor grades, may contribute not only to mental health disorders such as depression and anxiety but also to substance use, sleep issues, and even a student’s physical health.¹⁵ As these issues increase in prevalence, it is increasingly important to consider ways to combat student stress and its associated negative outcomes. One way to do this may be to use alternative assessment methods. Traditional grading scales have been shown to increase student stress and anxiety across a variety of majors and education levels.^16⇓-18 Alternative assessments provide a way to reduce this burden. One study in medical students showed that students assessed on a pass/fail system reported less stress and better cooperation with their peers.¹⁹ Another school implemented a reduced number of grading levels as a part of an overall wellness program designed to reduce stress and competition among medical students.²⁰ A gradeless approach will also likely benefit undergraduates in this area.

McMorran et al surveyed undergraduate students at a university in which the first year is gradeless.²¹ In an open-ended question about what they thought the benefits of this gradeless year would be, 36% of all respondents responded that they thought that stress would be reduced using this system.²¹ As alternative assessments are increasingly implemented, it will be important to study how this impacts the mental health of students.

MOTIVATION AND LEARNING

One of the most touted benefits of a traditional grading system is its ability to motivate students to learn. This makes many instructors and institutions hesitant to adopt alternative grading practices. However, the evidence for this supposed benefit is lacking, and there are potential consequences to using this external motivation source as a means of enhancing student learning. On one hand, there are several studies that suggest that traditional grades can be linked to more motivated students and increased professional success. For example, one study found that students at the boundary between a B and a C on the first test in a course were more likely to achieve a higher score on the subsequent test.²² The authors suggest that this shows increased motivation as the result of a letter grade. However, this study does not demonstrate if there is any long-term benefit for learning. Another study found that when accounting courses used a stricter grading scale, the results of grades in the course more closely lined up with success on professional exams.²³ The authors suggest that this provides evidence that stricter grading scales are a greater source of motivation for students; however, alternative explanations should also be explored. While professional examinations are only a single measure of professional success, this evidence should be considered in other fields in which such exams exist, such as in the health professions. However, evidence to the contrary has also been found. For example, one study on medical students found that in a pass/fail system, there was no difference in external measures of student success such as professional exams and residency placement.²⁴ The authors further suggest that this pass/fail system better lays the foundation for self-regulated and long-term learning, which is key for long-standing professional success. Indeed, there is evidence that shows that external motivation, such as that provided by grades, does not enhance learning or motivation in the long term and may actually distract students from deeper learning.¹⁶ Students in traditionally graded coursework have reported that their grades are more important to them than learning.^17,25 This is clearly at odds with the ultimate goals of higher education and thus changes should be strongly considered.

CHOICE OF MAJOR OR COURSES

Another concern with traditional grading approaches is that it may lead capable students to change from more difficult majors to easier ones or to avoid beneficial but difficult courses as a means to preserve GPA. This is of particular concern in STEM fields as uneven grading practices are often seen between STEM and non-STEM fields, with grades in STEM courses generally trending lower.^26,27 Indeed, several studies have suggested that higher grades in major courses are associated with greater persistence in a major, while lower grades in major subject courses can lead a student to change majors.^28,29 However, this effect may not be seen across all majors and may affect certain groups of students differently. For example, in one study of economics students, final letter grade in a course was not found to have an influence on a student’s decision to change majors.²² Another study found that female students were more likely to major in economics based on a final course grade of “A” in an entry economics class, but this was not seen in male students.³⁰ Grading systems can even influence students at the course or instructor level. This was acutely shown in the results of several survey studies, with responding students reporting that they avoid courses and instructors that they feel may negatively impact their GPA and that they generally value getting an “A” in a course over taking a challenging course.^16,25

This has obvious potential impacts on student learning and intellectual growth. Although there is an inadequate amount of research in this area, alternative grading systems provide a potential means to retain qualified students in difficult majors. One study showed that a successful/unsuccessful grading system in an engineering department led to greater student retention.³¹ At another university in which students can participate in a first semester without grades, surveyed students reported feeling that the gradeless approach would allow them greater opportunity to take academic risks.²¹ Students’ focus on grades has the potential to undermine their self-confidence and drive them away from fields in which they could ultimately be successful; alternative assessment approaches have the potential to lessen this behavior.

CHEATING AND OTHER NEGATIVE STUDENT BEHAVIORS

There is also some evidence to suggest that negative student behaviors such as cheating and “grade-grubbing” may be encouraged by letter grading systems. This may have important consequences such as failing to detect students who do not understand course material, grade inflation, and students receiving unequal treatment. It has been shown by studies across several decades that students cite the importance of grades as a reason to cheat on their coursework.^32⇓-34 This behavior appears to be more pronounced in students who have lower course grades or GPA.^33,35 If the student is able to get away with cheating or if the consequences for cheating are minimal, this may result in a student with a poor understanding of course material moving on to more advanced courses for which they are not prepared. More study is needed, but anecdotally alternative means of assessing student knowledge may discourage student cheating.³⁶

Another problematic student behavior is “grade-grubbing” or when a student pressures an instructor to give them points on an assignment that they potentially did not earn. Surveys have reported increased incidences of grade-focused interactions between students and instructors in recent years.^25,37 These interactions may not be beneficial to student learning if the primary goal is to receive points and not to clear up misunderstandings. This also has the potential to lead to unfairness in a course if an instructor agrees to change the grade of only the grade-negotiating students. Alternative assessments have the potential to make student–instructor interactions more beneficial to learning, with one instructor reporting fewer instances of grade- grubbing and more discussion of ways to improve student work in student meetings.³⁸

METHODS

Qualitative and quantitative methods were used to evaluate the impacts of ungrading on student performance and perspectives of growth in 3 CLS classes in the Fall of 2022. This study evaluated the use of ungrading in 2 undergraduate medical laboratory science (MLS) courses and 1 doctorate in CLS (DCLS) course. Additionally, this study aimed to explore students’ achievement of course objectives when compared to a previous, traditionally graded course. This study addressed the following research question:

• What impact does ungrading have on students’ reported learning and growth in CLS courses?

• Additionally, this study explored the following secondary research question:

• How do students rate the appropriateness of ungrading?

Alternative assessment approaches were implemented in the 3 courses in the Fall of 2022, including limited grading, grade-free zones, and self-assessments. This study implemented both qualitative and quantitative methods. However, the study population was too small to provide reliable statistics and therefore was approached as an exploratory study. A supplemental questionnaire was provided to students after they completed all course requirements, and their grades were documented with the university. The questionnaire included open- and closed-ended questions that were analyzed qualitatively and quantitatively, respectively. Learning activities that were completed as part of the course were also qualitatively analyzed.

UNDERGRADUATE COURSES

Both undergraduate courses are taken by MLS students during the first semester of the program. The first course is phlebotomy, which is required for all students who do not work as phlebotomists. The course covers the theory of blood collection, the practical skills required to successfully perform blood collection procedures, and a 2-day clinical experience in an outpatient phlebotomy setting. The other course is a fundamentals course that introduces the analytical techniques used in a clinical laboratory, quality control, basic laboratory operations, and urinalysis. Both undergraduate courses have didactic and laboratory components.

ALTERNATIVE APPROACHES

The undergraduate fundamentals course contained some components that were graded on a traditional grading scale and other components that were assessed for comprehension and graded on a complete/incomplete basis. Tests and laboratory practical exams were graded based on a traditional grading scale. Laboratory assignments and prelab quizzes were graded as complete/incomplete with complete meaning that the student received full credit, while an incomplete resulted in no credit. On the prelab quizzes a student needed to answer 70% of the questions correctly in order to participate in laboratory activities for the week. If this was attained, then the quiz was marked as complete; if this was not attained, the student was encouraged to ask questions and retake the quiz until a 70% was achieved. In addition, the students had weekly laboratory assignments that were assessed for completeness as well as student comprehension. Written feedback was provided to students on each assignment. If the assignment was not fully complete, it was marked as incomplete. If the instructor felt that there were major errors in the assignment or that the student did not understand the assignment, written feedback was provided to the student, and the student was asked to redo the assignment or submit an additional assignment in order to achieve credit.

The phlebotomy course was assessed with a competency exam, student memos, clinical preceptor evaluations, and self-evaluations. The only graded item in the course was the competency exam, and students were required to achieve at least a 70% on the exam. Students were evaluated on their skills and professionalism during clinical. They were required to receive adequate evaluations from their preceptors, with no more than 1 “needs improvement” or “does not meet expectations” marked (Appendix A). Student memos were marked as complete or incomplete. Lastly, students were required to evaluate themselves. A rubric was provided that outlined the course objectives and provided prompts to address (Appendix B). With this self-evaluation, students could reflect on what they learned and how they applied that knowledge to practical skills. They also assigned themselves a course grade. Given that all other requirements in the course were met, the self-assigned grade was the final grade submitted to the University.

The syllabus, however, did have a disclaimer that grades may be raised or lowered if the instructor disagreed with the self-assessment. The instructor would meet with the students in this case before assigning a different grade, but there were no incidents of grade disagreement.

GRADUATE COURSE

The DCLS course included in this study is an introductory research methods course in the DCLS program. It is a 2-credit course required for the DCLS and is typically completed in the first semester of the program. Before ungrading the course in 2022, it was graded using point values on individual assignments that were separated into weighted categories to determine the overall course grade. In the Fall of 2022, the course was ungraded and utilized a variety of alternative assessment approaches.

ALTERNATIVE APPROACHES

Grade-free zones were implemented, and learning activities were classified as optional or required. Optional learning activities included module memos, discussion boards, and article critiques. Required learning activities were research papers in parts, a research proposal presentation, and an IRB protocol. Submissions for all of the required assignments were necessary to pass the course. All learning activities were assessed as complete or incomplete, with an emphasis on providing substantial written feedback on all submitted assignments.

Students had to exhibit an application of feedback to subsequent assignments to receive a complete.

Although the courses were ungraded, the program requires letter grades to be submitted to the university. Course grades were determined by the completion of all required assignments with evidence of growth. Additionally, students were required to complete a self-evaluation (Appendix C) that asked them to assess their achievement of course objectives and assign themselves a grade that was used as their final grade. However, the syllabus did explain that the instructor could use their discretion if they did not agree with the student’s evaluation. The instructor would meet with the students in this case before assigning a different grade, but there were no incidents of grade disagreement.

RESULTS

The results of this study demonstrated favorable outcomes of alternative assessment in the courses. Although the sample size is too small to provide definitive conclusions, the responses to supplementary questionnaires provide insight into how ungrading impacted student learning.

Additionally, the open-ended items on the questionnaire and the course assignments demonstrate that students felt a great benefit from the alternative assessment approaches that were implemented in 2022.

Quantitative Results

Most students did not have previous experience with a course that was ungraded. Most of the students did not have previous experience with alternative grading or ungrading. However, the feedback about the assessment approaches used was primarily positive. All 6 graduate students reported that they either slightly or strongly agreed that ungrading was appropriate for the course and that it was fair. Furthermore, all graduate students reported that they slightly or strongly agreed that it contributed to their growth in the course, while all strongly agreed that they were able to focus on their learning. Similarly, all undergraduate respondents indicated that they somewhat or strongly agreed that the grading approach was appropriate for the course(s) and that they were able to focus on their learning and mastery of course material. One difference between undergraduate and graduate students is that the undergraduates did not agree as strongly that the grading approaches contributed to their learning. None of the students, regardless of education level, expressed that they would have liked more concrete or traditional grades. Frequencies for each questionnaire item are provided in Figures 1 and 2.

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Figure 1.

Graduate students’ perceptions of ungrading. Note: Graduate students were asked to rate how strongly they agree or disagree with the above statements; N = 6.

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Figure 2.

Undergraduate students’ perceptions of ungrading. Note: Undergraduate students were asked to rate how strongly they agree or disagree with the above statements; N = 13.

STRENGTHS AND LIMITATIONS

This study utilized courses that were already using alternative grading to assess its impact on student learning. The main limitation of the study is its sample size. CLS programs are often small, and the courses included in this study enrolled a range of 9–18 students. To effectively assess any association between alternative grading or ungrading on CLS students’ learning, we would need a much larger sample size. Additionally, it would be beneficial to include CLS programs that have fully adopted alternative grading in all courses to truly evaluate the impact. To evaluate the impact of alternative grading on certifying examination scores, we would need to compare scores for students who attended traditionally graded programs to those who attended alternative graded programs. At this point, such a study is not feasible.

DISCUSSION AND IMPLICATIONS

Ungrading and alternative grading are not new concepts in higher education. Many elite medical schools use pass/fail assessments, but the literature on the practice in other health professions is lacking.³⁹ While there are limitations to this exploratory study, it provides an understanding of the students’ experiences with alternative grading and ungrading.

The students in these courses reported that they had positive experiences with alternative grading. Alternative grading allowed them to feel like they were learning more with less stress. Students felt less discouraged when faced with difficulties in coursework, which allowed them to focus on learning the course materials. This is particularly important in health professions education because learning in the classroom will translate to patient care.

As educators, we want our students to gain knowledge and competency in the field. However, traditional grading has placed unnecessary stress on students. This stress counteracts the teaching we do and can limit the learning accomplished in the classroom. Many students study to “pass the test,” and the pressure to make the grade may limit their ability to truly learn the material.

This is an important consideration for health professions educators because our students will eventually care for and treat patients. If students are not learning the material in the classroom, this could lead to deficiencies in their clinical competency. Ungrading or alternative grading may be valid approaches to increase learning and content mastery in laboratory professions. While we have yet to determine the impact of ungrading on Board of Certification scores or other competency measurements, the effect on meeting course objectives has shown to be positive. If alternative grading is appropriately executed, students should learn and master course content just as they would in traditionally graded courses. However, further research should be done to determine if there is a greater impact of ungrading on certification examinations and/or clinical competency for laboratory professionals.