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Affective learning outcomes are difficult to objectively analyze and assess as they refer to feelings and internal processes of the mind and heart. These cannot be quantified by traditional testing methods. The available methods rely on qualitative self-reflection and the observation of simple to complex internally consistent qualities of character. Just as in the other domains of learning, the validity and reliability of these assessments need to be ensured. The assessment of the affective domain requires careful observation of specified behaviours by multiple observers. Miller’s pyramid, Krathwohl’s levels and Epstein’s conceptual frameworks can be used to devise suitable assessment plans for the complex and varied competencies in this domain. Many techniques including paper-based tests, self- administered rating scales, faculty and peer assessment, simulations, reflections, portfolios, observed clinical encounters, collated views of co-workers, records of incidents of unprofessionalism, critical incident reports, patient surveys, and global views of supervisor have been used for assessment of affective domain. The effective utilization of these assessment tools needs to factor in the ground realities that exist in different medical colleges. The acceptability and feasibility of using resource- intensive assessment methods need to be carefully balanced against their contributions toward increasing validity and reliability.

Keywords: AETCOM, assessment tools, India
Introduction

The affective domain of learning encompasses aspects such as attitudes, communication skills, ethics, professionalism, empathy and compassion (Singh et al., 2013). This domain is as important as the cognitive and psychomotor domains in contributing to the quality of patient care (Rogers et al., 2017). Previous studies have shown that students who exhibit unprofessional behaviour during their training are more likely to do so in their subsequent clinical practice (Modi et al., 2014). It is therefore critical that an Indian Medical Graduate (IMG) attains competence in the affective domain and that the associated value systems become internalized.

The AETCOM (Attitudes, EThics, and Communication) modules introduced by the National Medical Council in India as a part of the new Competency Based Curriculum (CBC) is a step in this direction (Medical Council of India, 2018).

Teaching faculty across medical colleges in India face challenges in the teaching and assessment of the affective domain. Most faculty have limited training in the application of teaching-learning (TL) and assessment methods used for the affective domain. A toolkit containing different TL methods that can be used for the affective domain has been published earlier (Fathima et al., 2022). The aim of this article is to introduce some theoretical constructs and methods that can be applied for the assessment of the affective domain so that these can be effectively utilized by faculty members to implement the AETCOM modules.

Need and challenges in assessment of the affective domain There are compelling reasons for assessing the affective domain with as much rigor as the cognitive and psychomotor domains (Modi et al., 2014). When learning objectives in the affective domain are assessed, they are taken more seriously by both teachers and students. If the affective domain is not assessed, there is a likelihood that ill-prepared students are allowed to graduate, thereby contributing to suboptimal patient care and its attendant consequences. The assessment of the affective domain requires careful observation of specified behaviours by multiple observers. This contributes to a greater emphasis being placed on these behaviours and consequently a positive change in the learning culture (Ten Cate and & De Haes, 2000).Affective learning outcomes are difficult to objectively analyze and assess as they refer to feelings and internal processes of the mind and heart. These cannot be quantified by traditional testing methods (Wu et al., 2019). The available methods rely on qualitative self-reflection and the observation of simple to complex internally consistent qualities of character. Just as in the other domains of learning, the validity and reliability of these assessments need to be ensured. The threats to validity in the affective domain include fake responses in self-reported assessments which may cushion failures by maximizing virtues and minimizing faults. Additionally, students with superior language skills may have an undue advantage over others (Ngozi, 2018).Theoretical frameworks for assessing the affective domainMiller’s pyramid is a widely used four-level framework for assessment (Miller, 1990). These levels include ‘knows’, ‘knows how’, ‘shows how’, and ‘does’. The level of competence being assessed increases as one moves from the ‘knows’ to the ‘does’. Competencies that contain learning objectives related to the affective domain can be assessed at these four levels. An example of taking informed consent can be used to demonstratehow these four levels can be used. The basic theoretical components of taking informed consent (‘knows’) can be assessed using any of the numerous written assessment tools available such as multiple choice, short answer, and essay questions. A contextual application of this knowledge (‘knows how’) can also be assessed using the methods mentioned for the ‘knows’ component. The questions could be modified to include realistic case scenarios for taking informed consent. An objective structured clinical examination (OSCE) using a simulated patient from whom informed consent for a medical or surgical procedure must be taken could be utilized to assess the ‘shows how’ component. When students reach their internship, they could be observed taking informed consent from an actual patient (‘does’) using a workplace-based assessment method such as the mini-clinical evaluation exercise (mini-CEX).

Krathwohl described five levels of affective learning, namely receiving, responding, valuing, organization, and characterization (Rogers et al., 2017). At the receiving level, students become aware of certain aspects of an experience that may eventually result in effective learning. When students respond, some amount of reflection about an experience occurs and they exhibit some intellectual and emotional reactions to it. This may then lead to insight about oneself, termed valuing. The organization occurs when this insight can be related to future professional practice. Finally, characterization refers to a translation of a value system into professional behaviour. (Rogers et al., 2017) These levels of learning have been used to develop a scale for assessing student reflections (Rogers et al., 2018).

Epstein’s conceptual framework identifies three stages in affective domain development (Stephens & Ormandy, 2019). Stage 1 is compliance. In this stage, students exhibit certain attitudes or behaviours to earn praise or avoid punishment. The next stage (stage 2) is identification, where attitudes and behaviours are assumed to maintain rewarding relationships with individuals or a group. In stage 3 (internalization), new attitudes and

behaviours are imbibed as they are intrinsically fulfilling (Stephens & Ormandy, 2019). This framework has been used to identify progress made by learners in affective domain development. (Stephens & Ormandy, 2019).

Toolkit for assessment of the affective domain

Wilkinson classified assessment tools for professionalism into nine broad areas (Wilkinson et al., 2009). This classification has since been widely adopted by many authors (Goldie, 2013; Guraya et al., 2016; Li et al., 2017; Smith et al., 2021). A similar classification could be used for assessment tools in the affective domain (Table 1). It was noted that many of these tools were used to assess residents and doctors rather than medical students. Miller’s pyramid provides a convenient framework for selecting appropriate assessment tools based on the stage in the

course where the student is placed (Modi et al., 2014). It must be emphasized that specific learning objectives for each of the competencies mentioned in the AETCOM module need to be formulated for the selection of the most appropriate assessment tools (Andrusyszyn, 1989). The conceptual frameworks of Krathwohl and Epstein are useful to define and assess the depth of learning in the affective domain (Rogers et al., 2017; Stephens & Ormandy, 2019; Yanofsky et al., 2010). The effective utilization of these assessment tools needs to factor in the ground realities that exist in different medical colleges. The acceptability and feasibility of using resource intensive assessment methods needs to be carefully balanced against their contributions towards increasing validity and reliability. An example of an assessment plan using some of the previously mentioned tools for an AETCOM module is shown in Table 2.

Table 1: Assessment toolkit for the affective domain (Goldie, 2013; Guraya et al., 2016; Lee and Wimmers, 2015; Li et al., 2017; Smith et al., 2021; Wilkinson et al., 2009; Yielder et al., 2012)