Abstract
BACKGROUND: With the introduction of the UK Medical Licensing Assessment (UKMLA), many medical schools have adopted a sequential Objective Structured Clinical Examination (OSCE) format to evaluate clinical competence more efficiently. Sequential testing was designed to improve diagnostic accuracy and maximise the effectiveness of testing resources by administering a relatively shorter screening test for all students, followed by a confirmation test only for students who did not meet the passing threshold of the first test. While its psychometric robustness is well established, little is known about how students experience and interpret this assessment format. This study explores how psychological and contextual factors shape students' self-efficacy, motivation and engagement within sequential OSCEs. METHODS: Semi-structured interviews with 22 medical students were conducted following two full sequences of sequential OSCEs in the third and final year of study. Data were analysed using framework analysis informed by self-efficacy and attribution theory. RESULTS: Students described multiple positive sources of self-efficacy, including sequential practice opportunities, peer and senior modelling, verbal reassurance, effective faculty-student communication and well-timed testing intervals. Negative influences included uncertainty about the format, emotional distress, unclear pass threshold, lack of assessment clarity, delayed feedback and insufficient support. Students who viewed sequential testing as a developmental opportunity reported higher confidence and adaptive attributions, whereas those who perceived it as punitive described heightened anxiety and reduced motivation. These patterns reveal an anxiety-achievement paradox - high objective success rates coexisting with persistent psychological stress. CONCLUSIONS: Sequential OSCEs can support learning when implemented with transparent communication, equitable access to preparation resources, and timely, supportive feedback. Attending to the emotional and motivational dimensions of assessment may improve the educational value of sequential testing and promote student well-being within high-stakes clinical assessment systems.