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Context Multiple-choice questions (MCQs) are frequently used to assess students in health science disciplines. However, few educators have formal instruction in writing MCQs and MCQ items often have item-writing flaws. The purpose of this study was to examine the impact of item-writing flaws on student achievement in high-stakes assessments in a nursing programme in an English-language university in Hong Kong. Methods From a larger sample, we selected 10 summative test papers that were administered to undergraduate nursing students in 1 nursing department. All test items were reviewed for item-writing flaws by a 4-person consensus panel. Items were classified as ‘flawed’ if they contained ≥ 1 flaw. Items not containing item-writing violations were classified as ‘standard’. For each paper, 2 separate scales were computed: a total scale which reflected the characteristics of the assessment as administered and a standard scale which reflected the characteristics of a hypothetical assessment including only unflawed items. Results The proportion of flawed items on the 10 test papers ranged from 28–75%; 47.3% of all items were flawed. Fewer examinees passed the standard scale than the total scale (748 [90.6%] versus 779 [94.3%]). Conversely, the proportion of examinees obtaining a score ≥ 80% was higher on the standard scale than the total scale (173 [20.9%] versus 120 [14.5%]). Conclusions Flawed MCQ items were common in high-stakes nursing assessments but did not disadvantage borderline students, as has been previously demonstrated. Conversely, high-achieving students were more likely than borderline students to be penalised by flawed items. [ABSTRACT FROM AUTHOR]

Introduction: Many countries are driving forward policies and practices to train medical students for later rural practice. Previous research has investigated individual (e.g., rural upbringing) and structural factors (e.g., curricular exposure) associated with rural practice intention. However, the relationship between academic performance in medical school and rural practice intention has been neglected, although optimisation theory suggests there may be a relationship. To address this gap, our aim was to identify the relationship between academic performance and rural practice intention. Methods: Data were collected via a cross‐sectional (self‐report) survey in 2021. Participants were students from 60 of the 96 rural order directed (RODs) medical programmes across China. We asked students their rural practice intention. We conducted univariate analyses to test for associations between rural practice intention and independent variables, including socio‐demographics, ROD location, grade year and academic performance measures. We used multilevel logistic regression models to test whether students' academic performance in medical school could be used to predict rural practice intention, holding the other factors constant. Results: There were 13 123 respondents, representing roughly 77.6% of the student population from the 60 schools. There was a statistically significant relationship between student (self)‐reported academic performance in medical school and rural practice intention. Higher performers had a lower likelihood (ORs: 0.65–0.78) of rural practice intention. This held across all performance measures (GPA rank, academic awards and student leadership) and for the sub‐group with rural upbringing (ORs: 0.68–0.78). Discussion: This is the first study to identify a relationship between medical school performance and rural practice intention. The findings suggest that students maximise their utility when choosing career options, with higher performers having lower rural practice intention. These data provide insight into the complexity of medical career decision making and can be used by medical school and workforce planners to inform rural training, recruitment and retention strategies. You et al. report that medical students with higher perceived academic performance have lower rural practice intention, illustrating an important factor in students' consideration of career options. [ABSTRACT FROM AUTHOR]