Students in a Clinical Setting

Evaluating student performance of any kind is always a controversial issue. However, assessing nursing skills is a particularly serious and controversial subject, given that if assessment is inadequate, the consequences for patients can be dire. It is essential that the evaluation of new nurses be accurate, particularly given the hope that many new nurses will be entering the profession, the result of new initiatives designed to cope with the pending nursing shortage due to the retirement of the current generation of older nurses. A review of existing literature indicates that the evaluation of nurses’ competency is deemed to be problematic world-wide. Various strategies to remedy this have been suggested, including more rigorous training of and support for mentors who grade student nurses as well as the use of more objective assessment instruments.

According to Gopee (2008) in her article “Assessing student nurses’ clinical skills: the ethical competence of mentors” from the International Journal of Therapy & Rehabilitation, there is troubling evidence in the United Kingdom that nurse-mentors are simply ‘signing off’ in a pro forma fashion to evidence of new nurse’s demonstration of clinical competence. Mentors are not requiring that students fully perform the actions they are required to perform before becoming fully licensed healthcare professionals. This is not only a violation of their employment agreement but also a violation of their ethical obligation as healthcare mentors. Mentors must uphold the ethical values that support “the value of life; goodness and rightness; justice and fairness; truth telling and honesty;” and “individual freedom” (Gopee 2008: 402).

However, there are a number of barriers which can impede the full implementation of an effective mentorship role. The first is the mentor’s other duties: mentors are required to keep up with their other clinical demands as they mentor a nurse, and naturally the health of their own patients comes first, rather than the hypothetical implications for the mentee’s future patients. This is a normal human response to immediacy, but it can have grave consequences if mentees are insufficiently prepared. Another human response is the unwillingness to fail another person, particularly someone one has a relationship with, like a mentee nurse. It is very tempting for mentor nurses to excuse evidence of incompetence simply because it is emotionally and logistically easier to do so (Gopee 2008: 403).

Thus, according to Gopee (2008), it is necessary to support assessment methods which work to counter such natural tendencies. Having multiple assessment methods for different skills other than direct reports from the mentor is one method of doing so. For example, these can include “direct observation of skill performance; questions and answers sessions; reflective write-up of a learning ‘incident;’ consulting associate mentors and team members; feedback from the patient/service user” all in conjunction (Gopee 2008: 404). Institutions can likewise support more effective mentorship by giving mentors additional time to perform duties as part of their ‘job’ as teachers, rather than simply expecting them to fit in their new roles on top of their professional responsibilities. Mentors themselves need to be adequately supported and trained — if institutions do not take their roles seriously, they will not take them seriously either, and additional support should be given to mentors dealing with struggling students, as this can cause additional stress for the mentor. Ultimately, if difficulties are spotted early on during the mentorship, life will be easier for both the student and the mentor (Gopee 2008: 405-406).

Gopee’s findings about the accuracy and reliability of clinical evaluation practices are not limited to the United Kingdom but seem epidemic in the nursing profession as a whole world-wide. According to Oermann (et al. 2009) in her analysis based upon the Schools of Nursing: National Survey Findings Part II published in Nursing Education Perspectives, the much-discussed nursing shortage in the United States is one of the root causes of inadequate clinical assessment. “The obligation to move more students into and through nursing programs must be balanced against the obligation to assure the public that nursing graduates are safe and competent to enter practice… Generally in a clinical course, students are evaluated on their cognitive abilities, communication skills, psychomotor and technological competencies, and values and professional behaviors” (Oermann et al. 2009: 353-354). Evaluation must make use of multiple formats — not solely rely upon the observation of one person — and both summative and formative assessment strategies are required for maximum efficacy.

In other words, it is not enough to merely assess the nurse at the end of the practicum (which can create an unintentional incentive to pass marginal candidates, to avoid ‘failing’ them completely): ongoing feedback must be given in the form of short-term, formative assessments. This can then affect the trajectory of the preparation program with important ‘correctives’ at critical junctures for candidates, better ensuring a truly effective completion. There has been criticism that nursing programs only use pass/fail grades for clinical practice, which can place additional stress upon the graders: a nurse is either judged ‘competent’ or ‘incompetent’ with little shades of grey in-between (Oermann et al. 2009: 354).

Given the need for objective student evaluations, Oermann (et al. 2009) suggests the use of “standardized, systematized, well-known in advance, and objective” performance measures such as the Objective Structured Clinical Examinations (OSCE), noting that students themselves tend to be more appreciative and receptive to these measures although most prelicensure nursing programs, presumably because of the instrument’s greater expense, tend to shy away from using them (Oermann et al. 2009: 356). A survey of nursing candidates revealed that one of the most common complaints of students was the perceived lack of objectivity of the judgments of their performance, not the fact that they were judged too harshly. This is an argument for the justifiability of the added expense of purchasing an objective measurable instrument, combined with the fact that any additional cost must be weighed against the even greater expense of poorly-trained nurses to the healthcare system.

Karayurt, Mert, & Beser (2009) concur with this need for objective measures of performance, as detailed their article “A study on development of a scale to assess nursing students’ performance in clinical settings” from the Journal Of Clinical Nursing. They apply their concerns about clinical evaluation to a specifically Turkish context. In their article, after assessing the clinical performance of nurses, they attempted to construct an instrument that satisfied standards of objectivity and clinical performance required by the nursing profession. To do so, they collected data for the 2002 — 2003 and 2003 — 2004 academic years and performed 350 evaluations of third and fourth year students. “In the light of the literature and our experiences, we determined clinical responsibilities of nursing students and wrote 77 items accordingly. These items were discussed twice by 17 teachers at a University School of Nursing and then the items were decreased to 28. Each item was scored between 1 and 10. The structure validity of the scale was evaluated with factor analyses and reliability of the scale with Cronbach’s alpha and item-to-total correlation” and thus suggested that this tool would be useful in assessing nursing students’ performance in clinical settings throughout Turkey (Karayurt, Mert, & Beser 2009: 1123). Having an ‘objective’ scale takes the ‘subjective’ element out of observation.

According to Oranye (et al. 2012), the use of such objective structured clinical examination (OSCE) methods that are tested for both validity and reliability can be useful in distance learning as well. Distance learning is commonly deployed in continuing professional education settings for nurses, and in the case of the Malaysian context in which the Oranye (et al. 2012) study was conducted, distance learning can even offer nurses the potential for an upgrade from a diploma to a degree. In the study, although the curriculum was distance-based, a traditional OSCE format was deployed, which meant students had to “actively demonstrate how he/she would apply acquired knowledge to a simulated ‘real world’ situation” before an assessor who would then rate student performance according to a checklist or rating scale (Oranye et al. 2012: 233).

Based on the results of the findings, it was noted that “11.6% of the participants failed the OSCE meant that they operated at level 1 competence; while only 13.8% were in the level 4 competency. This finding has serious implications for nursing practice, considering that the participants were practising nurses, with several years of experience,” including some specialists (Oranye et al. 2012: 2). The rate of failure was highest for clinical instructors, a particularly troubling finding given that these persons are responsible for teaching new students (Oranye et al. 2012: 239).

Thus, the overwhelming evidence indicates that far from being dangerously rigid, objective measures of nurse performance in educational contexts is useful internationally as well as nationally. In fact, given the literature supporting such evidence around the world, it is likely to become standard operating procedures within many healthcare systems in coming decades. Although such objective formats may take additional expense to train evaluators to execute and implement, in the long run it is likely to be money well spent in terms of its potential to reduce medical errors. Evaluators must be better prepared to make use of such instruments and institutions must allocate more time for evaluators to be fully involved in the grading process. Students as well must be willing to accept not ‘passing’ immediately, with an eye upon developing a more secure skill set in the long run.

References

Gopee, N. (2008). Assessing student nurses’ clinical skills: the ethical competence of mentors. International Journal of Therapy & Rehabilitation, 15(9), 401-407.

Karayurt, O., Mert, H., & Beser, A. (2009). A study on development of a scale to assess nursing students’ performance in clinical settings. Journal of Clinical Nursing, 18(8), 1123-1130. doi:10.1111/j.1365-2702.2008.02417.x

Oermann, M. (2009 et al.). Clinical evaluation and grading practices. Schools of Nursing:

National Survey Findings Part II. Nursing Education Perspectives, 30(6), 352-357.

Oranye, N., Ahmad, C., Ahmad, N., & Bakar, R. (2012). Assessing nursing clinical skills competence through objective structured clinical examination (OSCE) for open distance

learning students in Open University Malaysia. Contemporary Nurse: A journal for the Australian Nursing profession, 41(2), 233-241.