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When Examinees Cannot Test: The Pandemic's Assault on Certification and Licensure

As outlined in the Special Section Introduction (this issue), the COVID-19 pandemic wreaked havoc on the world economy as shelter-in-place regulations forced individuals to stay at and work from home. Brick and mortar testing centers, whether run as part of a for-profit company, a cooperating educational facility with a history of paper and pencil administrations, or centers established for performance assessments, were largely forced to close to comply both domestically and internationally. As a result, assessment organizations who rely on vendors or partners to provide physical space saw their primary, and in many cases, sole test delivery channel collapse overnight. This short, invited manuscript focuses on the implications for certification and licensure assessment organizations as a result of these widespread disruptions. Although we touch briefly on issues that will resonate for any assessment organization, we have attempted to share more details on issues that are more likely, challenging, and specific to the certification and licensure space. In the specific context of our organization and other organizations in the health care space, demand for health care providers has soared, setting up a paradox whereby the same force that amplified the need for essential workers stilted the educational, certification, and licensure pathways responsible for introducing new providers into the work force. Certification and licensure organizations were left in the uncomfortable position of needing to advocate for the continued value of testing in upholding minimal competency to protect the health of the public, while also being unable to deliver that value to either the examinees needing to test nor the public requiring the services of health providers in greater number. This was complicated by a multitude of secondary uses, including progression within educational programs, graduation requirements for students, accreditation for institutions that provide educational programs, and selection decisions for specialized training. The impact of this pandemic on examinees, educational institutions, regulatory bodies, and assessment organizations has been immediate, yet the changes, whether correctly or incorrectly assumed to be temporary or permanent, will reverberate into the future of testing in the professions.

As outlined in the Special Section Introduction (this issue), the COVID-19 pandemic wreaked havoc on the world economy as shelter-in-place regulations forced individuals to stay at and work from home. Brick and mortar testing centers, whether run as part of a for-profit company, a cooperating educational facility with a history of paper and pencil administrations, or centers established for performance assessments, were largely forced to close to comply both domestically and internationally. As a result, assessment organizations who rely on vendors or partners to provide physical space saw their primary, and in many cases, sole test delivery channel collapse overnight. This short, invited manuscript focuses on the implications for certification and licensure assessment organizations as a result of these widespread disruptions. Although we touch briefly on issues that will resonate for any assessment organization, we have attempted to share more details on issues that are more likely, challenging, and specific to the certification and licensure space.
In the specific context of our organization and other organizations in the health care space, demand for health care providers has soared, setting up a paradox whereby the same force that amplified the need for essential workers stilted the educational, certification, and licensure pathways responsible for introducing new providers into the work force. Certification and licensure organizations were left in the uncomfortable position of needing to advocate for the continued value of testing in upholding minimal competency to protect the health of the public, while also being unable to deliver that value to either the examinees needing to test nor the public requiring the services of health providers in greater number. This was complicated by a multitude of secondary uses, including progression within educational programs, graduation requirements for students, accreditation for institutions that provide educational programs, and selection decisions for specialized training. The impact of this pandemic on examinees, educational institutions, regulatory bodies, and assessment organizations has been immediate, yet the changes, whether correctly or incorrectly assumed to be temporary or permanent, will reverberate into the future of testing in the professions.

Impact on Stakeholders
The first stakeholder immediately impacted by pandemic regulations were examinees who awoke to phone calls and emails from test centers that their scheduled exams were canceled as test centers closed. And these were among, in some sense, the "lucky" examinees: many test takers had their testing events stopped partway through their testing experience as select centers closed part way through their normal operating hours. In response to these interruptions, our organization executed preexisting processes normally executed in response to small-scale issues (e.g., a power outage at a specific site) that use statistical models to ensure appropriate pass-fail decisions are honored, thus insuring both public protection responsibilities while minimizing impact on examinees (Feinberg, 2020). For licensure examinations that are often very long to minimize misclassification errors and for students testing under accommodations where exams might span multiple days, these approaches had significant positive impact compared to policies and approaches that count all unadministered items as incorrect and require score expungement and retakes that may not be possible.
As uncomfortable as cancelations were, the uncertainty surrounding when testing would resume and when a rescheduled slot would be next available was arguably worse. Test takers requiring scores to graduate from one year to the next, or to obtain a certification or license needed to enter a profession, were suddenly denied the opportunity to leverage their educational efforts to enter their profession of choice. As the crisis further developed and institutions and governmental authorities extended stay-at-home orders in 2-week increments, additional waves of cancelations were propagated. In some cases, individual examinees would no sooner find a new appointment than have that appointment canceled, only to start the process again. In the worst cases, this cycle could repeat numerous times. As we think about our own challenges managing personal, professional, and (inter)national upheaval, we have great empathy for examinees also dealing with these challenges. This was an untenable situation for examinees, testing organizations, test delivery vendors, and score users. Licensing and certification organizations and their vendors applied substantive resources to customer operations management and communications with multiple stakeholder groups and, on occasion, considerable resources into creating alternative delivery paths when plausible.
Institutions and regulatory bodies who use educational and assessment results as part of their graduation or regulation operations were forced to reckon with a backlog of students or applicants who, through no fault of their own, were unable to complete requirements either for graduation or as a condition for eligibility for licensure. This was especially true in the health care space. For example, numerous states provided guidance to nursing schools regarding modifying mandated learning or clinical experiences which may be a requirement for graduation, and consequently, a condition for licensure (https://www.ncsbn.org/Education-Requirement-Changes_COVID-19.pdf). Assessment professionals often mistakenly assume national licensing examinations have simple regulatory structures, but they are every bit and sometimes more complicated than other assessment domains. National exams may have acceptance in some or all US states and territories, but the specific eligibility requirements an examinee must meet to be allowed to test or minimum passing score or other policy-related restrictions may vary substantially. For example, in medicine there are some 70 state boards with relevant jurisdiction. This resource provides a further glimpse at the myriad of state-based regulations across numerous health care professions that have been impacted: https://www.ncsl.org/research/labor-and-employment/covid-19-occupational-licensing-in-public-emergencies.aspx.
Assessment organization processes and operations have likewise been significantly impacted. Test content in many cases requires subject matter expert review and potential modifications to test items, forms, and scoring. Such development and review is often completed by volunteer subject matter experts at in-person meetings that facilitate networking and professional development. Pandemic conditions restricted these interactions to online activities. Indeed, access to subject matter experts themselves was often restricted since the pandemic created existential crises and demand in their home organizations that required prioritization. In addition to the health care challenges already outlined, the economic collapse and the CARES Act created challenges across professions, including those in finance. Additional changes were required of every other aspect of the examination process. When test design and delivery changes could be made, they presumably required the creation and execution of additional operational processes. For example, additional delivery channels and the inclusion of remote proctoring should, at a minimum, result in additional comparability and security related statistical analyses. Finally, additional or new delivery channels, including remote proctoring and large-scale event tests, have a spider-web of implications and demands across organizations. Finance departments need to create contracts with new vendors; IT departments need to integrate new systems and processes; test developers and psychometricians need to create modified test designs and consider policies and other revisions to meet immediate needs while insuring ongoing testing program sustainability; customer support groups need to support examinee and institutional customers and stakeholders; product managers need to align these efforts and focus on communications challenges.
In addition to operational challenges, as disruptions to routine testing continue with uncertainty around resumption and potential pandemic resurgence, limited examinee access has turned into extraordinary examinee and stakeholder backlash. Organizations have faced increased stakeholder questioning of the value that independent external assessments add to educational qualifications. Of course, this is not a new phenomenon; many professional licensing and credentialing organizations face petitions and other movements from student and professional groups that have increased alongside broad antitesting and an-tiregulation sentiment. However, this crisis has created greater willingness to create both temporary and permanent changes. For example, the Washington State Supreme Court eliminated Bar exam requirements for previously registered examinees for the currently scheduled July or September administrations while maintaining other requirements including a JD degree from an accredited law school. This was after an earlier temporary reduction in the minimum passing score intended for these administrations (https://www.wsba.org/for-legal-professionals/jointhe-legal-profession-in-wa/lawyers/qualifications-to-takethe-bar-exam).
In other cases, performance exams faced and continue to face insurmountable obstacles in continuing operations. Recently our own organization announced the suspension of a standardized patient exam. This exam faces special challenges since it involves examinees moving through 12 rooms interacting with standardized patients (e.g., human actors that portray an illness in a room akin to a doctor's office) including performing physical examination activities. To control costs and maximize standardization, this assessment occurred at five regional testing sites across the country requiring substantive examinee travel. Together, both the travel and the close proximity of examinees and testing company employees led to the decision to close the assessment "to protect the health of examinees and test center staff" for 12-18 months while a new assessment was developed (https://covid.usmle.org/announcements/usmlesuspending-step-2-clinical-skills-examination).

Immediate Need to Innovate
Given current examinee backlogs and backlash, testing organizations face immediate pressure to respond. The response must balance two extremes and their related risks. The first extreme is not being responsive enough to examinee and stakeholder needs under pandemic conditions, leading to diminished confidence in the testing organization and pressure against the continued use of the services it provides. The second extreme is being hyper-responsive, with rushed decisions leading to potential technical failures or security breaches and the concomitant lack of confidence in the resulting scores. The most obvious first decision is to do nothing: to wait for pandemic concerns to abate and for vendors to resolve the issue by sequentially reopening previously existing testing capacity. The other choice is to create alternative testing channels.
With test center capacity experiencing previously unseen and dramatic contraction, alternate delivery channels have been both considered and utilized. Decision making on such channels rely on some combination of financial considerations, security concerns, technology and driver flexibility, and exclusivity clauses in vendor contracts. Our organization has rapidly worked with schools to establish temporary testing sites across North America and is currently planning largescale event tests to simultaneously administer examinations to thousands of examinees across the country. We are exploring the use of remote proctoring, which has seen an explosion of use across the industry, in both educational and certification and licensure examinations.
All examination programs face similar decisions and options. However, it is important to note that the most challenged implementations have been those that have simply applied an existing test design to a new delivery approach. These copy-and-paste designs have achieved, at best, uneven success. Regardless of approach, examination programs need to engage in flexible thinking about content exposure, long-term content sustainability, uneven security concerns and mitigation strategies, and the integration of numerous dependent end-to-end technology systems and processes. The same test design will not mitigate the disparate risks of the various possible delivery channels, nor will the technology platforms across channels necessarily support the delivery of the same content. Yet, programs wishing to do more than wait for brick and mortar vendors to address the issue need to proactively tackle the challenge of delivering examinations through alternate channels.

Future Need for Flexibility
Once the current pandemic subsides adequately to allow for the lifting of social distancing restrictions, testing organizations will need to reflect on their pandemic actions and which, if any, of those decisions will be made permanent. For example, organizations that have relied on vendors to manage proctoring and delivery services and have attempted to stand-up alternatives that faced challenges may well gain an appreciation for the enormous challenges the logistical component of executing to create a seamless examinee experience end to end entails. Test development and psychometrics are a necessary but insufficient basis for effective assessment.
Our opinion is that there is no one correct approach to responding to the immediate challenges of the epidemic. Similarly, there is not a correct or incorrect limit on flexibility, nor a specific innovation that will resolve test delivery issues in a widespread manner. We have seen an incredible range of reactions within credentialing and licensure alone before even considering the broad range of assessments represented across NCME membership. Instead, we encourage assessment professionals to be guided by the fundamental tenets of validity. Given the inferences an assessment is designed to support, what evidence can be brought to bear to support these inferences; what threats to these inferences exist and (how) can they be effectively mitigated? Remote proctoring has become one popular solution. This may be a perfectly reasonable solution in select cases, and is almost certainly not appropriate in others, depending on factors including specifics of implementation, context, and inference to name but three. There is no magic bullet. Instead, there is an opportunity for creative interdisciplinary science to solve these challenging problems. As is the case in creating test designs now, maintaining the right line of sight in decision making will be critical: scores that are too often heavily influenced by preknowledge or other nonconstruct relevant factors will not effectively support inferences, meet customer need, nor be self-sustaining in the long run.
Regardless of actions taken during the pandemic, organizations will be remiss if they do not take the opportunity to flesh out their contingency plans for future testing disruptions. Decisions will focus around delivery channels, balancing psychometric innovation with realistic technology implementation requirements, and reexamining the trend toward continuous testing. Programs will likely cement the need for contingency plans to proactively include the ability to quickly flip the switch on multiple examination delivery paths under various emergency scenarios. These will likely include site expansions, event tests, remote-proctored administrations, and perhaps even a return of computerized examinations to temporary paper and pencil administrations. And, with the realization of the need to quickly deliver via multiple delivery pathways, validity evidence surrounding innovative technology-enhanced item types will need to be weighed against the cost and complexity to support those items across multiple technology platforms that would be leveraged under emergency scenarios. Additionally, the rise of "customer choice" for delivery channels (i.e., the ability of an examinee to choose to test via brick and mortar, eventbased, or on-line remote-proctored administrations) may be accompanied by a fall in continuous testing opportunities to ameliorate security concerns that threaten score validity.
The COVID-19 pandemic has impacted all areas of our lives: where and how we work, how we socialize, and even where and how we eat. The testing industry is not exempt from disruption. The pipeline of examination stakeholders has been impacted, arguably most severely in the health professions where the pandemic has both increased the need for practitioners while breaching the pathway to practice. Testing organizations have varied in their response, yet all must be ready to respond to stakeholder inquires on their thinking around whether, and how, they plan to build additional testing capacity under social distancing guidelines and test center closures while maintaining existing validity arguments they have worked so hard to compose. The decisions made by testing organizations today will not only dictate their continued relevance to stakeholders and therefore their own survival, yet also dictate future examinee expectations, which will drive the ways in which examinations will be delivered moving forward.
Reference Feinberg, R. A. (2020). Practical approaches for estimating classification decision on interrupted high stakes tests. Paper to be presented at the Annual Meeting of the Psychometric Society (IMPS); New York, NY.