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DEVELOPMENT AND VALIDATION OF A STRUCTURED
CLINICAL ASSESSMENT TOOL FOR ASSESSING STUDENT NURSES’ CLINICAL COMPETENCE
ABSTRACT
Assessment of clinical performance
contributes to academic qualifications that incorporate professional awards.
The administrators of Nursing Schools are facing the problem of subjectivity in
practical examination of student nurses. This is evident in examination
situations in which the examiner assigns any task of choice to the student and
scores the student based on his/her perception of the student’s competence in
performing the task. By this, some students are exposed to more difficult tasks
than others and subjective scoring, all depending on the inclination of the
examiner. In response to this problem, the study developed and validated a
Structured Clinical Assessment Tool (SCAT) that will make it possible for all
the students to be examined on the same tasks for any examination episode and
judged on the same premise. Instrumentation research design was used. One
hundred and thirty seven student nurses from three Schools of Nursing in the
South East Zone of Nigeria formed the sample for the study. Prior to developing
the tool, a competency assessment framework was developed based on the nursing
process model with the five steps of the process being the core competencies
and sub skills identified for each of the core competencies. The appropriateness
of the sub-skills was verified using 52 nurse educators. The care sub-skills
were pooled to form the model for SCAT. The model consists of twelve activity
stations which are examination points where students perform specified nursing
tasks and are scored using a predetermined standard. Initially 48 items (four per station) and
their scoring guide were generated and four experienced nurse educator/managers
were used to verify their appropriateness. Thirty six items survived the
validation exercise using average congruency percentage. Data collected were
analysed using alpha coefficient, t-test and analysis of variance. The results
of the analysis confirmed the validity of the 36 items and showed that the
items were able to discriminate between the high and low achievers. The high
reliability index (0.84-0.99) for most of the procedure station items and
moderate reliability index (0.69-0.78) for others confirm that the instrument
has a good inter-scorer consistency and therefore is reliable. Based on these
findings, the SCAT is a tool that has the potentials for reducing the
subjectivity that is inherent in clinical assessments that are based on
observation and is therefore recommended for assessing clinical competence of
student nurses.
Chapter One
Introduction
Background to the Study
Effective administration requires
rational decision making which will lead to the selection of the way to reach
the anticipated goal. The educational administrator in trying to achieve the
ultimate goal of improving learning and learning opportunities to ensure
competent products is faced with the responsibility to make decision on such
issues as selecting appropriate curriculum, selecting appropriate teaching
methods, and selecting appropriate methods for assessing the student’s
progress. If appropriate decisions are made on these issues, appropriate
educational policies will be made and the goals of education will be met. However,
if inappropriate decisions are made, particularly on methods of assessing
students, the society will be exposed to the danger of incompetent practice.
This is so because learners who have not acquired the necessary knowledge and
skills for competent practice may be certified to be qualified to practice and
may not give quality and safe care. Generally, the school curriculum is
organized to expose students to subjects that provide opportunity for them to
acquire the knowledge and skills that should help them practice. Sometimes
students who have passed written examination and certified fit to practice fail
to do so. Considering the legal and
financial implications of employee performance and safe practice in a rapidly
changing environment, a major concern of an educational administrator of an
institution should be to produce manpower that is competent. It is therefore
important in assessing students for certification to practice, in this case, in
a health care institution, to generate appropriate data that will help in
making decision on whether they are able to perform tasks that the knowledge
they have acquired should help them to accomplish. This can be done if an
appropriate assessment tool is in place.
Stressing the importance of assessing what nursing care providers can
do, not what they know, Del Bueno (1990) cited situations in which people who
had performed excellently well in examination had difficulty performing a
procedure or recognizing warning signs in patients experiencing difficulty.
This kind of situation is unacceptable and informed the reforms in nursing
education which led to calls for assessment of clinical performance to
contribute to academic qualifications that incorporate professional awards. In
response to this call, training institutions have developed clinical assessment
tools. However, Redfern, Norman, Calman, Watson & Murrels, (2002) expressed
some concern about the psychometric quality of the tools that are available and
the ability of the tools to distinguish between different levels of practice.
They analyzed some tools of assessing competence to practice in nursing, while
Norman, Watson, Murrels, Calman, and Redfern (2002) tested selected nursing and
midwifery competence assessment tools for reliability and validity. Both team
of researchers concluded that a multi-method approach which enhances validity
and ensures comprehensive assessment is needed for clinical competence
assessment for nursing and midwifery.
In order to ensure such a tool, Lenburg (2006) created a constellation
of ten basic concepts and suggested that they should be adapted for developing
and implementing objective performance examination. They include:
• Concept
of examination
• Dimensions
of practice
• Required
critical elements
• Objectivity
of the assessment process
• Sampling
critical skills for the testing period
• Level
of acceptability
• Comparability
in extent, difficulty and requirements
• Consistency
in implementation • Flexibility in actual clinical environment • Systematized
conditions.
These concepts are very useful to the
development of accurate assessment instruments. Thus far in the nursing context
in Nigeria, such tool does not exist. The administrators of nursing schools are
facing the problem of subjectivity in practical examination of student nurses.
This is evident in situations where students are given different tasks to
perform during clinical examination and awarded grades based on the tasks they
perform. By this some students are exposed to more difficult tasks than others,
all depending on the inclination of the examiner and yet judged on the same
maximum score. This is unfair. It is therefore necessary to develop an
assessment tool that will examine the students on the same tasks for a
particular examination episode.
In order to accomplish this,
consideration should be given to the concepts proposed by Lenburg (2006) which
were mentioned earlier. To achieve objectivity in an assessment process two
components must be considered. First the content (skills and critical elements)
for the particular assessment should be specified in writing and second, there
should be a consensual agreement of everyone directly involved in any aspects
of the examination process. When individual examiners begin to digress from the
established standards and protocols, objectivity erodes back into subjectivity
and inconsistency. This regression destroys the process and the purpose.
To prevent this from occurring, the
educational administrator should ensure that the content of the examination is
specified by the list of the dimensions of practice, that is, the skills and
competencies and their required critical elements that determine the extent and
conditions of competence. The use of a conceptual framework to systematically
guide the assessment process increases the likelihood that concepts and
variables universally salient to nursing and health care practice will be
identified and explicated (Waltz, Strickland & Lenz, 2005).
Concepts of interest to nurses and other
health professionals are usually difficult to operationalize, that is to render
measurable. This is partly because nurses and other health professionals deal
with a multiplicity of complex variables in diverse settings, employing a
myriad of roles as they collaborate with a variety of others to attain their
own and others goals. Hence, the dilemma that they are apt to encounter in
measuring concepts is twofold; first; the significant variables to be measured
must, by any means, be isolated, and second, very ambiguous and abstract
notions must be reduced to a set of concrete behavioural indicators. It is
therefore the responsibility of the educational administrator who knows the
goals that are intended and that selected the content that should help in the
achievement of the goal to select the variables that must be measured and to
reduce them to concrete behavioural indicators of competence. These should be
incorporated into a protocol that will guide the assessor. Protocols ensure
that each test episode for a given group is comparable in extent, difficulty
and requirements. Protocol also ensures that the process is implemented
consistently, regardless of who administers the examination or when it was
conducted. When performance examinations are administered in actual clinical environment,
not simulation, the concept of flexibility is essential as each client is
different. The responsible educational administrator, who prepares students for
professional practice is therefore challenged to develop appropriate
competency-based assessment tools for use in the assessment of students’
clinical competence.
Competency-based assessment tool focuses
on measuring the actual performance of what a person can do rather than what
the person knows. It is based on criterion-referenced assessment methods where
the learner’s performance is assessed against a set of criteria provided so
that both the learner and assessor are clear on what performance is required.
Competency-based assessment technique addresses psychomotor, cognitive and
affective domains of learning and its goal is to assess performance for the
effective application of knowledge and skill in practice setting. The
competencies can be generic to clinical practice in any setting, specific to a
clinical specialty, basic or advanced (Benner, 1982; Gurvis & Grey, 1995).
Criterion-referenced measures are particularly
useful in the clinical area when the concern is the measurement of process and
outcome variables as applies in nursing. A criterion-referenced measure of
process according to Waltz, Strickland & Lenz (2005), requires that one
identifies standards or the client care intervention and compares the subjects’
clinical performance with the standard of performance which is the
predetermined target behaviour. When all these are taken into consideration in
developing a clinical assessment tool, the tool is bound to be authentic.
Statement
of Problem
In Nigeria, assessment of clinical performance
contributes to the academic qualification for professional award. The Nursing
and Midwifery Council of Nigeria (NMCN) has adopted the Objective Structured
Clinical Examination (OSCE) for midwifery but has not done the same for general
nursing examination. The tool that is currently in use for clinical assessment
for the general nursing examination leaves a lot to be desired. It lacks the
comparability and consistency that are required to make an assessment tool
objective and fair hence the need for a structured clinical assessment tool.
Some of the pitfalls of the tool include;
• The
tool makes allowance for the selection of the procedure to be performed by the
candidate to be made by the assessor and this is varied from one candidate to
another. The implication is that all the candidates do not perform the same
tasks and the tasks they perform are not comparable and since the task
difficulty is not the same for all tasks, the candidates are not examined nor
judged on the same premise. This is unfair.
• Another
problem that is closely linked with not specifying tasks that all candidates
must perform is that the mark allotted to the item, “procedure” is the same for
all procedures whether simple or complex and since some candidates are assigned
simpler tasks than those assigned to others and are judged on the same optimal
score for less work, the tool is unfair. Again, because the activities expected
to be carried out for each procedure is not specified, the scoring of the
candidates’ performance is based on what the scorer thinks is right and this
may vary from one scorer to another. The implication is that most times, the
scoring is subjective.
• Sometimes,
the length of time required to accomplish a certain task the assessor assigned
to a candidate to perform may not allow the assessor opportunity to assess the
candidate on all the areas that are listed on the clinical performance
assessment guide. Since all the items sum up to give the maximum score, it
creates the difficulty of determining what to do about scoring those items
particularly as it was not the fault of the candidate that he was not examined
in those areas by the particular assessor.
• Again,
some of the criteria on which the candidates are judged are not stated in
specific terms. For example such statements as “handles patients gently and
skillfully” and “adapts the environment for the patient’s comfort” are not
specific enough as to what the candidate is expected to do and therefore leaves
room for assessor’s subjective conclusions. The implication of all these is
that some of the results of assessments using this kind of tool are not valid
and may have negative impact on the candidate who failed when actually he/she
should have passed and on the consumers of nursing care where a candidate who
had not acquired the necessary skills for competent and safe practice passed
when he/she should have failed.
In view of this problem, there is the
need to develop a clinical assessment tool that is objective and fair. This is
the intent in this study.
DEVELOPMENT AND VALIDATION OF A STRUCTURED CLINICAL ASSESSMENT TOOL FOR ASSESSING STUDENT NURSES’ CLINICAL COMPETENCE
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