Assessing nursing clinical skills competence through Objective Structured Clinical Examination (OSCE) for open distance learning students in Open University Malaysia

Nelson Ositadimma Oranye
School of Medical Rehabilitation, University of Manitoba, Winnipeg, Manitoba, Canada

Che’an Ahmad
School of Nursing and Allied Health Sciences, Open University Malaysia, Kulala Lumpur, Malaysia

Nora Ahmad
School of Nursing and Allied Health Sciences, Open University Malaysia, Kuala Lumpur, Malaysia

Rosnida Abu Bakar
School of Nursing and Allied Health Sciences, Open University Malaysia, Kulala Lumpur, Malaysia

PP: 234 - 242

Abstract

Background: The objective structured clinical skills examination (OSCE) has over the years emerged as a method of evaluating clinical skills in most medical and allied professions. Although its validity and objectivity has evoked so much debate in the literature, little has been written about its application in non-traditional education systems such as in distance learning. This study examined clinical skills competence among practising nursing students who were enrolled in a distance learning programme. The study examined the effect of work and years of nursing practice on nurses' clinical skills competence.

Methodology: This study used observational design whereby nursing students' clinical skills were observed and scored in five OSCE stations. Two instruments were used for the data collection - A self-administered questionnaire on the students' bio-demographic data, and a check list on the clinical skills which the examiners rated on a four point scale.

Results: The findings revealed that 14% of the nurses had level four competence, which indicated that they could perform the tasks correctly and complete. However, 12% failed the OSCE, even though they had more than ten years experience in nursing and post basic qualifications. Inter-rater reliability was 0.92 for the five examiners. Factor analysis indicated that five participant factors accounted for 74.1% of the variations in clinical skills performance.

Conclusion: An Objective Structured Clinical Exam is a necessary assessment tool that should be continuously applied in nursing education, regardless of the mode of the education program, the student's years of experience or his/her clinical placement. This study validates the need for objective structured clinical examination in both the design of tertiary nursing degree programs and the assessment of nurses' clinical competency level.

Keywords

continuing nursing education, clinical skills competence, Objective Structured Clinical Examination (OSCE), nursing, open distance learning

Article Text

Objective Structured Clinical Examination (OSCE) has been described as 'a practical test to assess specific clinical skills' (Ahuja, 2009, p. 37). In 1975, Ronald Harden at the University of Dundee first introduced the OSCE into medical education (Furlong, 2008; Peeraer et al., 2008). The OSCE represents an approach to clinical skills assessment, the practice of which can enable the student to develop these skills further.  It is a well established method of assessing clinical competence among practitioners in the clinical field, with an enormous advantage for testing a number of skills in a limited time. Proficiencies assessed through the OSCE are presumed to be relevant to the safe practice of medicine (Peeraer et al., 2008).

The OSCE format consisted of a multi station arrangement in which students performed an assigned skill at each station using a standardized patient, while a faculty member/instructor watched and evaluated the student's performance (Robbin and Hoke, 2008; Kurz et al., 2009). In such examinations, the tasks were divided into various components such as history taking, nursing diagnoses, performance of a procedure, and the interpretation of clinical data with each component being assessed at a different station. Students rotated through a number of stations, spending a pre-specified equal amount of time at each station (Furlong, 2008; Munoz et al., 2005). The stations could be limited to as few as two or five stations or as many as 20 stations or more. Describing the nature of the OSCE examination, Ahuja (2009) stated that at the ring of a bell the students entered a station and performed the predefined timed task. At the end of the specified time, students left the station and moved to the next one. Hence, each student performed the same set of tasks and the examiner marked each student according to the same criteria, thereby making the examination structured and objective.

According to Franklin (2005, p. 14), 'the OSCE requires the student to actively demonstrate how he/she would apply acquired knowledge to a simulated 'real world' situation.' An assessor in each station provided real-time, direct observation and assessment of each candidate's performance (Munoz et al., 2005). The assessor rated each student's performance using the checklist or rating scale (Robbin and Hoke, 2008). The task at each station tested specific competencies that were marked using the mark sheet. The sheet could be checklist-based or a combination of a checklist and a global score. The examiner gave an overall score based on the overall performance of the student (Ahuja, 2009).

Many authors agreed the OSCE was a valid and reliable method of assessing clinical competence objectively, in various settings (Kurz et al., 2009; Elder et al., 2009; Robbin and Hoke, 2008). The findings of later researches on the applications of the OSCE in assessing clinical skills showed obvious improvement from earlier knowledge and application of OSCE as reported in Watson et al., (2002) and Ross et al., (1988). Perhaps, knowledge and experience related to the OSCE have progressed over the years, and the methodology has been enhanced to the extent that it is currently adopted for professional entry examinations (Austin et al., 2003). Robbin and Hoke (2008) proposed three components for a valid clinical competency evaluation system: validity, reliability and practicality. OSCEs provided a valid means to evaluate a student's performance in a holistic manner. Specifically, the exercises were designed to allow student evaluation through the entire patient encounter, including history taking, physical examination, identification of initial problems, selection of necessary tests needed, interpretation of the results of the encounter, and recommendation of appropriate treatment. Reliability of the OSCE was based on the interaction among the standardized patient, the student, and the evaluator. Robbin and Hoke (2008) opined that increasing the number of evaluators could increase the OSCE reliability.

One of the early studies that examined the application of OSCE in clinical skills evaluation for nursing was conducted by Ross et al., (1988). Although the OSCE assessment had yet to be widely embraced in the field of nursing, it was becoming increasing popular as a tool for assessing clinical competency in nursing (Anderson and Stickley, 2002). Also, the OSCE had found wide application in different fields and situations. Elder Jr. et al., (2009) applied the OSCE in the assessment of the impact of internet based knowledge on the doctor-patient relationship. As well, other schools in the field of health sciences were beginning to implement the OSCE method. In the 1970s, the College of Pharmacists of British Columbia introduced the OSCE as a method of evaluating entry-to-practice and continuing competence of its members (Austin et al., 2003; Fielding et al., reported in Munoz et al., 2005). In medical schools, OSCEs have been used more commonly to validate clinical skills/competencies at various points in the curriculum, for both formative and summative evaluations, through the use of standardized patients (Hall et al., 2009). The use of actual patients for such exercise has been noted to present several barriers to objective evaluation (McDowell et al., 1984 cited in Kurz et al., 2009).

The OSCE as an assessment method, which was mainly performance-based, had numerous advantages and had proven a useful complement to the traditional paper-based or computer-based assessment methods. Very importantly, the method not only assessed knowledge but also skills which were demonstrated by doing. 'OSCEs demonstrate particular advantages over traditional forms of testing such as multiple choice tests, in assessing communication and interpersonal skills, professional judgement and moral/ethical reasoning' (Munoz et al., 2005, p. 33).   

The question of validity and reliability of the OSCE as an objective system for assessing clinical skills competence among clinical practitioners and students was widely discussed in the literature (Jones et al., 2009; Peeraer et al., 2008; Watson et al., 2002). In addition, the OSCE also complemented traditional methods of short answer questions (SAQ) and multiple choice questions (MCQ), and led to improvements in skills assessment. This study looked at a unique category of students - practising nurses who were enrolled in an open distance learning programme. Despite the enormous interest in the OSCE, attempts to examine factors that affect students' clinical skills performance were still limited. This study therefore moved beyond the issues of reliability and validity, to determining the factors that could determine competency in clinical skills performance, and how such knowledge could be useful in curriculum planning, implementation, and hospital policy formulations.

Aims and objectives

The aim of this study was to assess the clinical competence of practising nursing students' through OSCE. The specific objectives were (1) to determine the levels of clinical skills competence among practising nursing students; (2) to assess the impact of years of clinical practice and the educational training through distance learning on nursing students' clinical competence; (3) to determine what individual/group characteristics affect clinical skills competence among practising nursing student.

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