Traditional, positivist assessment approaches generally fail to capture the nuances of learners’ clinical competence in medical programmes. This has led to the implementation of an alternate assessment approach known as ‘programmatic assessment’, which embraces subjectivity of human judgement in holistic decision making in clinical settings. Faculty and staff have found the introduction of programmatic assessment to be challenging because it is a major, complex change to the traditional way of carrying out assessment. Extending our previous work, where we used critical (...) realism to explore students’ experiences of programmatic assessment, we here unpack the underlying conditions and mechanisms triggered by programmatic assessment’s implementation. We applied Bhaskar’s concept of ontological stratification, retroduction and Archer’s theoretical accounts of morphogenesis/stasis to theorize the interplay between the socio-cultural entities that constrain and enable desired changes in assessment practices, and those that condition students and staff to accept or reject the new ‘non-traditional’ assessment processes. (shrink)