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Assessing clinical skill competence of nursing students through

Objective Structured Clinical Examination

Dragana Milutinovi

Department of Nursing, School of Medicine, University of Novi Sad, Novi Sad, Serbia

Aim To investigate the possibility of assessing clinical skill com-
petence of nursing students by using the Objective Structured
Clinical Examination (OSCE).
Methods The search for empirical articles on the assessment
of clinical skill competence of nursing students was based on
the SCOPUS electronic database. Search strategy included the
utilization of two or three key words based on the MeSH in-
dex (OSCE, nursing students and clinical competence). The
analysis was restricted to papers in the English language during
the last ten years. Bibliography of selected papers was used to
search for additional empirical studies as well.
Corresponding author: Results A review of the literature showed that since 1975,
Dragana Milutinovi when the first objective structured clinical examination was in-
Department of Nursing, School of troduced, there has been a growing interest in the assessment
Medicine, University of Novi Sad
utilization of clinical skill competence of nursing students.
This method of assessment included direct evaluation of cli-
Hajduk Veljkova 3, 21000 Novi Sad,
nical skills in the classroom or hospital room. Application of
objective structured examination required a good organization,
Phone: +381 21 420 677;
prepared checklists, as well as a number of examiners, time and
fax: +381 21 624 153;
money. By analyzing the efficiency of this method some aut-
Email address: hors have pointed out that the use of this method could lead to
considering health care as a simple set of tasks to be performed,
while others have emphasized that by a customized implemen-
tation of this method other clinical skill competence of nursing
students can be also evaluated. Students opinion about this
Original submission: method of assessment is different.
05 December 2012; Conclusion The widespread use of OSCE for the assessment
Revised submission: of clinical skill competence also imposes a number of questions
06 January 2013; for those involved in its planning, implementation and asse-
14 January 2013. Key words: nurse education, skills checklists, practice, standar-
dized patient, educational measurement, evaluation.
SEEHSJ 2013; 3(1):13-18

South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 1, May 2013

INTRODUCTION ration of 5 to 10 minutes at which the respon-

dents i.e. students are required to demonstrate
In addition to learning, assessment of clinical competence in the given task, at every station.
competence is an essential component of nu- Test stations are two component stations: one
rsing education, as clinical competence is the station for questions and one for tasks. At the
foundation of their professional practice (1,2). task station a student is given to perform vir-
For nearly fifty years nurse educators have been tually any task (history taking, physical exami-
trying to assess them objectively by using a va- nation, blood pressure measurement, interpre-
riety of techniques (3). The lack of a clear defi- tation of laboratory results, splint sets and the
nition of the concept of competency is one of like.). At station for questions students should
the reasons that complicate an objective asse- answer the questions, which are related to the
ssment of clinical competence in nursing (4). task at the previous station, which the student
However, Yanhua and Watson (5), reviewing has received (assimilated) during the training.
current assessment of clinical competence in Students performance is assessed by examiner
nursing, indicated that there was a significant who has checklists with detailed and objecti-
progress in the clarification of the concept. ve criteria related to the components of the
Respectively, the researchers and regulatory observed skills (1,10). The first OSCE exams
bodies advocated for the implementation of were conducted in real clinical settings, and
the holistic concept of competence including today can be implemented in skill classrooms,
knowledge, skills, habits, attitudes and valu- usually on a standardized patient or gyms with
es, allowing for more precise development of the video camera (3,10).
standards and instruments for their measure- In relation to a framework for development of
ment. The Nursing and Midwifery Council in clinical competence described by Miller (12)
the UK, for example, defines competence as who outlines four levels: knows, knows how,
possessing a comprehensive set of knowledge, shows how and does, implementation of the
skills and attitudes required for lawful, safe and OSCE may conform to the achievement of the
effective professional practice without direct third level of competence. This means that it is
supervision (6), while the Australian Nursing focused on assessment of performance of spe-
and Midwifery Council defines competence cific skills in a controlled setting. Knows and
as a combination of skills, knowledge, attitu- knows how levels are traditionally assessed by
des, values and skills that are the foundation of different types of written exams (essay, MCQ,
successful and / or extraordinary performance etc.) or an oral exam, while the level does can
of duties in a professional / practice setting (7). be evaluated only in a real clinical setting (12).
One way to assess clinical competence of nur- Given that a large number of papers and re-
sing students is the objective structured clini- searches of OSCE implementation were ori-
cal examination (OSCE) (4). It is defined as a ginally used in education of physicians, the
method of assessment of clinical competence objective of this study was to examine the fe-
in which the components of competence are asibility assessment of clinical competence of
evaluated in a well-planned and structured nursing students using the objective structured
way, with attention focused on the objective clinical examination (OSCE).
(8), or as an assessment of certain clinical skills
(9). Originally, it was a method of the asse- MATERIALS AND METHODS
ssment of clinical competence in the mid-70s
of the last century, created and used by Harden The search for empirical articles on the asse-
et al, in the education of physicians (10). Alt- ssment of clinical skill competence of nursing
hough OSCE was initially invented by the Bri- students was based on the electronic database
tish school, its implementation quickly spread SCOPUS. The search strategy included the
throughout North America, Canada, Australia utilization of keywords based on the MeSH
and other Western countries (11). So, ten years index. It was the combination of two key wor-
later, the OSCE, according to Ross et al, was ds OSCE and nursing student that resul-
for the first time adapted and implemented in ted in 65 papers, whereas during the scope of
the education of nurses at Mac Master Univer- ten years, from 2002 to 2012, 54 papers were
sity in 1984 (3). selected. The combination of three key wor-
Traditional OSCE consists of a number of test ds OSCE, nursing students and clinical
stations (10 to 20), with the limited time du- competence selected 48 papers, 39 of which

Milutinovi Clinical competence of nursing students

were over the last ten years. The analysis was valent knowledge. For example, a student may
restricted to the papers written at full length in be able to give an injection without under-
the English language. Bibliography of selected standing why it is given or what complications
papers was used to search for additional empi- might arise from its use (15,18).
rical studies as well. In nursing education OSCE was implemented
The analysis included historical development both as a tool for summative and formative
of the OSCE, various applications of this asse- assessment, and as a learning tool (1,13,14).
ssment, its reliability and validity as well as For the successful implementation of the
advantages and disadvantages, then students OSCE, it was important to test its reliability
and lectures perceptions of the process and and validity. Unlike its implementation in the
outcomes of OSCE. education of physicians, only in a small num-
ber of studies the implementation of OSCE
RESULTS has been tested for its reliability and validity
(1,11). The authors tested reliability and vali-
According to analysis of available publications, dity of the OSCE in the education of nurses by
the implementation of OSCE in nursing edu- assessment of the degree of agreement between
cation has increased significantly over the last examiner /assessor, internal consistency, test-
ten years. The OSCE has been successfully used retest, as well as by testing face, content and
to assess the clinical competence of nursing criterion validity checklists (23-25). An im-
students at different levels of study (1,11,13- portant component of reliability and validity
15) in different fields: orthopedics, psychiatry, was a passing grade, as well (11).
intensive care, rheumatology, pediatrics and so Roberts & Norman (1990), for example, in
on (16-20) and different educational systems the assessment of clinical competence of the
(e.g. distance learning) (21). 71st student of the first year of nursing studi-
Regarding the number and duration of test sta- es at the 10-station OSCE, have found that a
tions they were different among the analyzed high inter rater reliability (IRR) (0.80-0.99)
studies, and they both differed in comparison test-retest reliability for the same station was
to the traditional OSCE. Clarke et al at Queens good (0.66-0.86), but the correlation between
University in Belfast implemented 60-minute stations was low (23).
OSCE with 5 stations, lasting for 10-minu- The important component that contributed to
tes and a one 10-minute rest station to assess the reliability and validity of the OSCE was a
competence in orthopedics (16). Selim et al checklist (11). The checklist is a tool for asse-
at the University of Alexandria in Egypt deve- ssing in which the observed task is divided into
loped 13-station OSCE lasting for 5 minutes a number of individual actions. Options for
with 11 working stations and 2 rest stations to assessing each item were different; for exam-
assess undergraduate psychiatric nursing stu- ple, a two-column did or did not do to mul-
dents clinical skills (17), while Brosnan et al in tiple columns excellent, satisfactory, needs
Ireland designed 3 stations with a time limit of more practice or points on the Likert scale
5 minutes. Exceptions were made by Khattab measured from 0 to 5 (2,11,16).
and Rawlings from Bournemouth University The issue, which could also affect the reliability
who modified the assessment of the traditional and validity of the OSCE, with all above, was
OSCE, and to assess clinical competence using the exam passing grade (11). Basically, 40%
two test stations with a time limit of 70 minu- was the passing grade at the undergraduate
tes for the station no. 1 and 40 minutes for the studies, and 50% at master studies (15). To re-
station no. 2, respectively. A rest time for stu- duce the possibility that the student passes the
dents was placed between the stations, during exam with 60% poorly performed or missed
which the examiner filled in a final written re- nursing procedures, some schools have used
port on students performance (15). the so-called mandatory or red flag questi-
The contents of all OSCEs were evaluated thro- ons (11,15). In order to increase the reliability
ugh different aspects of learning by Blooms and validity of the OSCE in recent studies the
taxonomy which includes psychomotor skills, procedures of standardization or harmoniza-
knowledge and attitudes. Special attention was tion of passing grades are increasingly being
paid to the cognitive aspects, because one stu- used (2). The most commonly used method
dent may have practical knowledge without of standardization was Angoff method or its
having at the same time conceptual, or equi- modified version which proved to be better

South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 1, May 2013

(2,16). In a modified version of this method, of anxiety and feelings of loss of control, they
a group of 6-8 experts who are familiar with believed that the execution of the task under
the OSCE and the level of student assessment, stress affected their performance in the exam
first discuss the required minimum level of but they showed a positive attitude about the
knowledge to pass the exams, and then each safety first which they had to demonstrate at
expert individually for each task item, accor- the examination (28).
ding to his opinion, determines the threshold
level of knowledge that students must meet in DISCUSSION
order to pass the exam. After that, the group
discuss their decisions with opportunities for The aim of this study was to determine the
individuals to change their attitudes. At the opportunities to assess the clinical competence
end the number of criteria set by each expert of practicing nursing students through objecti-
is recorded and their sum represents students ve structured clinical examination OSCE. Li-
passing grade (2). terature review shows the increase of the OSCE
OSCEs were accomplished with the standar- implementation over the last ten years, but
dized patient - a person who had been trained more attention should be paid to some issues
to reliably reproduce typical clinical case whose such as determining the reliability and validity
resolution is assessed (26,27). Depending on of performance and costs in order to have better
the study standardized patients were students and more often implementation (1,11,29). In
themselves, examiners, health personnel or spe- 2009 Palese conducted the study in order to
cially trained persons (14-17,19,26). In some determine a cost of the exam. The results show
studies, standardized patient task was also to that the cost of more expensive forms of the
provide descriptive assessment of students be- OSCE is 145.23 and cheaper 31.51 per stu-
havior (27). In addition, the requirements for dent. Regarding the economic crisis the work
training standardized patients were different. on reducing the cost of implementation of this
According to McMilliam&Botwinski cites, exam should be continued (29).
McDonalds recommendation is that standardi- Feedback (data that show the results) of the
zed patient has 10 hours of training for each sce- practicing nursing students and examiners
nario, but the attitudes of some authors are that who have undergone this type of clinical com-
every institution should determine the required petence testing are extremely positive (14).
number of hours of training in order to achie- However, as with other forms of assessment of
ve an adequate level of performance (26,27). clinical competence the OSCE has certain ad-
Certain ethical issues must be considered before vantages and certain disadvantages (11). Some
including a child as a standardized patient (20). of the major benefits include greater objecti-
For the successful implementation of the vity and less examiner biases, reduced ability
OSCE it was important to examine the par- to assess different students and different exa-
ticipants views of assessing clinical competen- miners, positive experiences of examiners and
ce in this manner (28). For this purpose, they students, opportunity to test a large number
used both qualitative and quantitative tech- of skills, possibility of lottery luck has been
niques (14,18). Students generally felt that reduced to a minimum, students motivation
the OSCE implementation makes sense, that for learning and a high level of reliability and
it is necessary and fair means of assessment, validity (11,15). The deficiencies cited in the
and they believed that after such examination literature include, first of all, stress that stu-
they were better prepared for clinical expe- dents are exposed to during the test, long-term
rience (14,16,26,28). Although known as a preparation, high prices, demand for more
stressful way of testing, results obtained from staff (11,29,30).
Brosnan et al study indicated that the greatest OSCE is the well-planned and objective asse-
stress was manifested in the hallway before en- ssment of clinical competence of nursing stu-
tering the classroom for assessment, and the dents. These claims are supported by the study
lowest stress was associated with the waiting results and conclusions of its implementation
time for feedback after the test (14). However, over the last ten years, collected during this
in the study that was conducted to assess the study. Although the organization of the OSCE
feelings, beliefs, and attitudes of pediatric care is an expensive process, the results indicate
students after implementing the OSCE in me- that the achievement of educational goal tasks
dicine dosing, students expressed high levels outweighs the costs.

Milutinovi Clinical competence of nursing students


No specific funding was received for this study. Competing interests: none to declare

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South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 1, May 2013

Klinike kompetencije studenata sestrinstva i mogunosti

njihove procene pomou objektivnog strukturisanog ispita

Dragana Milutinovi,

Katedra za zdravstvenu negu, Medicinski fakultet, Univerzitet u Novom Sadu, Srbija

Cilj Ispitati mogunosti procene klinikih kompetencija studenata sestrinstva koristei objektivni
strukturisani kliniki ispit (OSCE).
Metode Za pronalaenje empirijskih radova o proceni klinikih kompetencija studenata sestrin-
stva koriena je elektronska baza SCOPUS. Strategija pretraivanja ukljuivala je primenu dve ili
tri kljune rei po MeSH-u (OSCE, nursing student i clinical competence). Analizom su obuhvaeni
radovi na engleskom jeziku publikovani u poslednjih deset godina. Bibliografija odabranih radova
takoe je koriena za pronalaenje dodatnih empirijskih radova.
Rezultati Pregledom literature je utvreno da je od 1975. godine, od kada je prvi put uveden
objektivni strukturisani kliniki ispit, postojao sve vei interes za njegovu primenu u proceni kli-
nikih kompetencija studenata sestrinstva. Ovaj metod procene ukljuivao je direktnu procenu
klinikih vetina u uionici ili u bolesnikoj sobi. Primena objektivnog strukturisanog ispita za-
htevala je dobru organizaciju, pripremljene kontrolne liste, vei broj ispitivaa, vreme i novac.
Analizirajui efikasnost ove metode pojedini autori ukazivali su na to kako upotreba ovog metoda
moe dovesti do toga da se zdravstvena nega smatra jednostavnim skupom zadataka koje treba
izvriti, dok su drugi ukazivali na to kako se prilagoenom primenom ove metode mogu proceniti
i druge komponente klinike kompetencije studenata sestrinstva. Miljenja studenata o ovom na-
inu ocenjivanja su razliita.
Zakljuak iroka upotreba OSCE-a za procenu klinikih vetina namee i veliki broj pitanja za
one koji uestvuju u njegovom planiranju, implementaciji i evaluaciji.
Kljune rei: obrazovanje medicinskih sestara, kontrolne liste vetina, veba, standardizovani pa-
cijent, pedagoka merenja, evaluacija.