It is the intention of this assignment to explore the application and use of Objective Structured Clinical Examination (OSCE) as an assessment tool for both formative learning on placement and as a synoptic process for the attainment of clinical competency.
The reason for choosing OSCE for analysis and further exploration has two main facets. Firstly, a recent development for the author as an Advanced Nurse Practitioner (ANP) is the role of teacher/mentor for Emergency Nurse Practitioner (ENP) and Emergency Care Practitioner (ECP) students. As part of their university based Minor Injury and Illness Management Course they are seconded to the Minor Injury Unit as a practice placement. The primary role and remit of which is to provide an eclectic mix of clinical teaching and learning opportunities and experiences, in-house assessment and evaluation in real life scenarios, and preparation for both mock and final OSCE. A high level of expectation is placed on both the student and the placement teacher/mentor at the onset to make ample opportunity to prepare for the OSCE.
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An in-depth study of OSCE, and an understanding of its assessment and evaluation benefit, ensues that the student centred teaching and learning is provided (Saunders et al 2004, Neary 2002). Further that the placement ‘nano’ curriculum is designed for a progression of learning (Akker 2008), fit for purpose and in harmony with sending HEI expectations (Ward & Willis 2006, Nicol & Freeth 1998).
Secondly, as part of the ANP professional ethos, the author is an OSCE examiner for the Degree and Masters level nurse practitioner students at a HEI. This is in keeping with meeting the RCN 2008 domains on advanced nursing practice students education and assessment, that they should be assessed by proficient advanced nurse practitioners (RCN 2008, pg 30). As an examiner a broader understanding of the history and purpose of OSCE can ensure parity and fairness, as well as the maintenance of high standards and uniformity (Byrne & Smyth 2008). Wilkinson et al (2003) go further, stating that examiner commitment produces ownership of the entire assessment process, thus creating a more holistic approach to evaluation.
The OSCE, as a method of assessing and evaluating clinical competency, has been utilised throughout an eclectic range of professional health related disciplines. It was instigated over 30 yrs ago by Dr. Roger Harden, who sought to find a more relevant and reliable assessment tool by which to evaluate the clinical competency of medical students. His main concerns were that traditional methods such as written exams, multiple choice questions, viva, and ward based ‘real patient scenario’ assessments, could not quite capture the complexity of clinical competency, but only demonstrate a limited dimension of the students’ knowledge and expertise (Harden et al 1975,Wass et al 2001). Many other authors agree, finding that clinical competency is a complex concept to grasp and evaluate (Abbey 2008, Carr 2004, Iliot & Murphy 1998). With attempts to clinically adjudicate academic, functional and personal abilities a challenging and seemingly impossible task (Rushforth 2007, Watson et al 2005). The OSCE however, after several decades of application in medicine and more recently in nursing, with an increasing amount of research supporting its reliability and validity, appears to more than fulfil the role of a ‘gold standard’ assessment tool (Ward & Willis 2005, David et al 2004, Wass et al 2001).
Beginning with medicine in the 70’s, a multitude of professions nationally and internationally has since adopted the OSCE as their preferred final assessment for clinical competency. Surgery (Zyromski 2003), Psychiatry (Hodges et al 2002), Dentistry (Holyfield et al 2005), Radiology (Sisley et al 1999), Pharmacology (Landford et al 2004), Physiotherapy (Nayer 1993), Occupational Therapy (Battles et al 2004), Osteopathy (Abbey 2008), Chiropractic (Kobressi & Schut 1987), have all successfully assimilated the OSCE into their organised educational programmes. In the last decade the nursing profession has embraced the OSCE for advanced practice (Khattab & Rawlings 2008, Mason et al 2005), and pre-registration students, finding it a valuable and integral component of the curriculum, fulfilling both formative and summative assessment criterion ( Rushforth 2007, Khattab & Rawlings 2008, Curraccio & Englander 2000).
The OSCE, is defined by Harden (1988) as ‘an approach to the assessment of clinical competence in which the components of competence are assessed in a well planned of structured way with attention being paid to objectivity’ or Ward & Willis (2006) as ‘assessment of well defined clinical skills’. This type of format is generally utilised for students, to evaluate both fundamental and advanced skills and competencies, dependent on who, and what competencies are being assessed. Traditionally, students will rotate through between 3 and 10 ‘stations’ each lasting between 5-10mins long, which include practical, academic and communicative skills demonstration (Alinier et al 2006, Schoonheim-Klein et al 2005, Pender & de Looy 2004),using standardised patients (Battles et al 2004). A predetermined marking gird ensures objectivity, promoting inter-rater reliability and avoiding the risk of bias (Major 2005, Calman et al 2002).
For ENP/ANP students the OSCE stations are designed to echo the RCN domains for advanced practice role requirements, such as history taking, decision making, physical examination, health education and autonomous practice (RCN 2008, Mason et al 2005). Both the RCN and HEI regard this type of assessment and evaluation as a vital tool in demonstrating both clinical competence and fitness for practice (Mason et al 2005, Rushforth 2007, Ward & Willis 2006, Wass et al 2001). With this in mind, it is vital that the teaching aims and objectives of the placement should reflect and match these domains and those of HEI guidelines (RCN 2008 pg. 32, QAA 2006).
Nationally and internationally, healthcare educators and evaluators have sought to incorporate reliable and valid assessment tools within their curricula (Mitchell et al 2008, Neary 2002). Innovative and well researched methods of assessing clinical competence, knowledge acquisition and application in and to practice, have been identified as vital in recognising and maintaining professional skills, protecting standards, patient safety, and evaluating educational benchmarks (Rushforth 2007, Ward & Willis 2005, Mason et al 2004, Wass et al 2001, Jarvis & Gibson1985).
While it could be argued that no one assessment tool should be depended on as a foolproof method of measuring competency, the OSCE has a culminating element of a wider assessment process, being viewed as the gatekeeper for fitness to practice, and safe to practice (Delisa 2000, McCormick 2000). With OSCE seen as an innovative tool as part of a holistic process of assessment, with portfolios, reflective practice, learning objective etc, also playing an important role alongside the OSCE in adjudicating clinical competency. Innovation has been defined as the catalyst that makes a difference either by conceiving new ideas or enhancing and adapting the old, with the OSCE clearly fulfilling a much needed fresh approach to clinical competency assessment (DH 2009, Joy & Nickless 2008, Bryan & Clegg 2006)
Competence, skills, skills maintenance, education, assessment, and evaluation of the educational process are all both directly and indirectly affected by the use of OSCE as a finale to the assessment process. (Brosnan et al 2006, Rushforth 2006) David et al (2004) support this view, stating that OSCE should be regarded as a gold standard of evaluating clinical competence as it enables students to demonstrate far more than just knowledge acquisition.
While the OSCE seeks to assess medical knowledge and clinical skills, demonstrate clinical reasoning and data gathering ability, other more subtle attributes are enhanced. Communicative skills, clinician to patient interaction, ethical and professional behaviour, integrative thinking, autonomous behaviour and confidence are all incidental benefits of this process (Mitchell et al 2009, Major 2005, Mason et al 2004).
Assessment tools need to provide educationalists, curriculum designers and HEI with reliable and proven mechanisms with regards to passing students fit for practice and safe to practice (Rushforth 2007, Wass et al 2000, Nicol & Freeth 1998). Furthermore, a highly developed method such as the OSCE, while providing prognostic values for clinical competence, offers a much wider remit by way of formative and educational enhancement (Wass et al 2001, Ward & Willis 2005.
The overall purposes and intentions of the OSCE assessment process – to evaluate basic and advanced skills, measure base line competency, provide feedback, an educational tool, a structure to appraise safe practice for safe practice, are all commiserate with the aims and ethos of the clinical placement. That is to equip and enable the student in advanced practice competency, to journey from advanced beginner to competent and proficient practitioner (Benner 1994).
The central focus of the placement teaching aims and learning objectives is the attainment of competent clinical skills. As Teacher/mentor for the ECP and ENP students the challange is twofold, firstly to ensure clinical competency is actually achieved, culminating in the OSCE. Secondly, that it is not merely a ‘performance’ of passing an OSCE successfully, but rather an integrative demonstration of knowledge, understanding and skills mastery that developed as the result of a synoptic process that has occurred during the preceding months (Barman 2005, Jain et al 1997). Gardener et al (2008) expound this idea further, with the view that not only should competency be demonstrated, but also capability in all manner of serendipitous situations.
How this is achieved as placement educator is multifaceted and has theoretical, educational and practical elements. A deeper understanding of what clinical competency is, and the competency theory that guides it, is vital in undergirding the actual process of the learning and development of competent clinical skills (Watson et al 2002). This then enables a structured and clear plan of teaching and learning to take place (Stuart 2003). Assessment focused strategies promotes both a formative and summative educational environment, which helps to motivate and encourage the student to achieve primary goals (Wass et al 2001). Conversely, poorly structured learning opportunities and assessment methods can lead to passive or rote learning, which will enable a student to pass an exam, but result in an inability to apply it to real life scenarios (Brown and Doshi 2006).
Clinical competency is a nebulous term which has engendered much discussion and debate over a number of years (Carr 2003). It has a high profile, especially in the risk adverse arena of health care, with both public protection and confidence in the legislature of competency a high priority (Tee & Jowett 2009, Pearson et al 2002). Both HEI and nursing organisations have strived to meet the challenges of ensuring clinical competency is at the forefront of nurse training and education (Piercey 1995). Indeed, a central tenet of the RCN advanced practice document is the emphasis on achieving a high level of competency with regard to advance practice (RCN 2008).
Defining competence has proven to be an elusive task, with no single definition or dimension being captured (Cowen et al 2005, Eraut 1998). Historically, competence sought to distinguish between intellectual prowess and not performance (Eraut 1998). At present the reverse is found, with an approach underlining performance and a demonstration of capabilities as of greater importance, thus a competence -based education is now firmly entrenched in nursing, medicine and teaching higher education (Watson et al 2002, Neary 2000).
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Illiot and Murphy (1998) hold the view that competence is not merely a series of separate elements to be judged, but that ‘integrated competence is holistic’ (pg 32). They further contend that competence to practice is a tacitly understood term, which sees the practitioner integrating a wide ranging spectrum of skills both intellectually and practically, using autonomous thinking and actions, in a safe and appropriate manner. The UKCC (2001) Fitness for Practice document also picks up this theme defining competence as the ability to practice independently, skilfully, safely and effectively without supervision, in a legally and responsible way.
Conceptualizing competency enables the educationalist to grasp both the different approaches to teaching competency, and the students understanding of what is being assessed. There appears to be three main approaches to competency that brings insight to its elusive character: Behaviourist, Attributional and Integrated (Illiot & Murphy 1998).
The Behavourist approach, a model favoured by the NVQ forum, (ref), is a task based view of competence, which evaluates attainment of a series or set of technical tasks that are easily measured. However, this approach fails to include the finer attributes of professional practice which the OSCE seeks to appraise, such as complex thinking processes, autonomy and clinical analysis (Mitchell et al 2009, O’Connor et al 2009, Illiot & Murphy 1998).
The Attributional or generic approach is focused on a collective of abilities and attitudes which support an effective performance, which may include critical thinking, problem solving and self-confidence (O’Connor et al 2009, Illiot & Murphy 1998). This approach assumes these personal skills can be transposed into a multitude of different situations and contexts. However the main criticism of this approach is the assumption that an individual has the ability to be expert in different situations, as expertise can be very context sensitive (O’Connor et al 2009, Iliot & Murphy 1998).
Thirdly, the Integrated approach is both holistic and inclusive in its ethos, and one which aligns itself well with the OSCE values. This concept seeks to amalgamate the two approaches, thus representing a much more rounded understanding of competency (Illiot & Murphy 1998). Gonczi (1994) describes this view of integrated competency as a homogenous interdependent mixture of attitudes, knowledge, values and skills, which undergirds and directs safe, autonomous professional practice. With Stephenson (1994) adding that this type of assimilated capability when used effectively, can be utilised safely in a variety of both familiar and unfamiliar situations. Iliot (1996) supports this view, finding that junior doctors are a stereotypical example of this concept, with advanced nurse practitioners also demonstrating the same integrative qualities (Gardner et al 2004, Pearson 2002).
In applying this understanding of competence to practice to the practice setting, an application of Miller’s (1990) framework for the development of clinical competence is invaluable. His triangular model outlines four levels by which the learner can be evaluated: knows, knows how, shows how, does, which conforms well to the preparation and taking of OSCE’s. Knows – represents the basic facts – knows how to applied knowledge, shows how – the OSCE, and does – competent real life practice (Mitchell et al 2009).
Using Miller’s (1990) framework enabled me as the placement teacher/mentor to instigate a plan of teaching and learning that was harmonised with the both the students needs of attaining clinical competency, and to successfully demonstrate this by passing an OSCE.
A synthesis of different methods was utilised to give the students every opportunity to learn and develop clinical skills and competence (Stuart 2003). This type of Action Planning facilitates the transfer of knowledge and skills, bridging the gap between theory and practice, so what is learnt in the practice placement can be applied to actual practice (Field 2004, Watson et al 2002, Foxton 1994).
Demonstration, role play, role modelling (Phillips et al 2000), simulation (Alinier et al 2006), feedback (Ginnis 2002), peer assessment (Donnelly 2007), mock OSCE practice and scenarios (Khattab & Rawlings 2008, Brosnan et al 2006), all provided an authentic learning environment (McKinley et al 2001). These lived experiences are found to support learning in practice and enable the student to broaden their knowledge and understanding (Phillips et al 2000).
Although simulated conditions are viewed as artificial and may be, according to Eraut (1994) ‘second best’, this is not the case with OSCE. Both on placement and post OSCE, researchers have consistently found that it provides reliable real life scenarios, without the vagaries and uncertainties of ward round type assessments (Battles et al 2004, Harden et al 1975).
Conversely, in the clinical setting using ‘real’ time patients with their consent, also gave the ENP/ECP students a more realistic opportunity to be assessed clinically, as it helped overcome the anxieties and stresses often found surrounding assessments such as OSCE (Brosnan et al 2006).
Undertaking mock OSCE at university and on placement provided a positive source of learning and development by identifying gaps in both education and learning, and weaknesses in their clinical skills attainment (Khattab & Rawlings 2008). It is this factor, they argue, demonstrates that the OSCE has a product and process advantage over other single means of assessment. This proved true for one of the students, who failed the mock OCSE, using the feedback sheets as a guide we were able to successfully readdress areas of weakness.
As an educator in the clinical environment, an in-depth study of OSCE as an innovative and holistic assessment tool, has led to a creative and student-centred approach to teaching and learning. Using the OSCE as a foundational goal has provided the student placement with a credible ‘nano’ curriculum by which clinical competency can be thoroughly tested and attained. This transfer of learning from one context to another is vital, as it demonstrates that a mastery of relevant knowledge, skills and competency has taken place (Newble 1992, Ellis 1965). Fitness to Practice is a key component of advanced practice, and the OSCE centred learning programme clearly provides a structured approach to the appraisal of ‘safe practice’ for safe practice (NMC 2008, RCN 2008, UKCC 2001).
As a student teacher, this understanding and incorporation of the OSCE as an assessment process within the clinical placement, embraced many of the domains found in the NMC (2008) Standards to support learning and assessment in Practice. An effective leadership role provided the students on placement with an environment of creative, facilitated learning, raised awareness of accountability in the context of clinical competency, and provided a means of evaluation and feedback which enabled the students to experience both a formative and summative education.
Objective Structured Clinical Examination: an innovative tool for assessment and evaluation
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