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Assessment of Learners in the Clinical Setting

Introduction

In the present competitive environment of health care, a student graduating needs to be ready to knockout the racing world. As the ultimate objective of nursing is to provide an adequate health care with high quality, therefore, a student must be able to manage his clients’ demand in an effective way in order to achieve the desired outcome of the patients. Hence, the nursing students, who are considered future care providers, must be assessed in such a way that their provided health care is reliable and effective. Generally, most of the students are assessed against a standard of competent professionals. Similarly, nursing students are assessed against benchmarks set in the clinical care. This particular paper deals with the assessment of learners in the clinical setting or nursing education. In this particular study, the academic literature pertaining to the assessment criteria of nursing learners will be examined in detail. 

Assessment Process

Assessment is considered to a significant part of medical education. The basic objective of making assessment is to assess an individual’s competencies, capabilities and abilities in that specific area. Six possible purposes of assessment have been suggested by Taylor and Weir (2009) which mainly include diagnosis, grading, evaluation, prediction and selection.  Whereas Ratnapalan and Hilliard (2002) demonstrate that in medical education, assessment can be of two types including formative assessment and summative assessment. Formative assessment supports students in developing skills and encouraging learning. However, its disadvantage is that it is not taken seriously by all students. On the other hand, summative assessment is being utilised to evaluate an individual in determining whether he is good enough to move to the next level. Students take this assessment seriously because of the fact that it is threatening and no feedback is provided in this assessment type.  As opposed to deep learning that occurs with the formative type of assessment, this specific assessment stimulates last minute superficial learning. It is observed by Anderson (2012) that there is no single specific assessment technique or tool that can be used reliably to assess medical students and a number of different methods are available and being used to assess the skills, knowledge, attitudes and professionalism of nursing learners.

The assessment of clinical competencies of health care students is considered to be more important in the nursing education process. Although, the assessment of clinical competencies appears to be straightforward, but, from its history, it appears as a complex procedure that has undergone with many modifications. As a consequence of these modifications, numerous assessment tools have been introduced that resulted in continuous change of the role of tutors, preceptors and professionals. According to Connolly and DeYoung (2004), in Ryles tube insertion, patient management and professional behaviour are used as assessment tool for assessing the nursing students for both personal and professional development. The nursing students are evaluated for their professional behaviours in such a way that the existence of the proper behaviour is rated against 0% as never, 50% as rarely or sometimes and 100% is rated as most of the time or always. The roles of tutors, in this regard, are to enable nursing students to provide their“Always” professional behaviour in the clinical setting (Connoly and DeYoung, 2004). On the other hand, the nursing students are evaluated on their patient management skill, as“well below” that demonstrates that they require a gigantic deal of guidance,“below” that explains that nursing students require a least amount of guidance.“At average level” demonstrates that students can perform themselves and can achieve effective outcome,“above” is described as the students accessibility is massively helpful and“well above” demonstrates that nursing students have achieved masters in patient management skills. Such assessment is rated in the rating scale as 1 and 2 for well above, 3 and 4 for above, 6 and 6 stands for at average level, 7 and 8 for above level and 9 and 10 stands for well above level (Lawson and Hennefer, 2010).

A pyramidal framework for assessment of nursing learners was proposed by Scott (2001). The base of this pyramidal framework presents a knowledge factor (Knows). The above of this factor is the application of knowledge component (Knows how), followed by performance components (Shows how), whereas the apex of the pyramidal framework represents action (Does). By utilising this pyramidal assessment process, the nursing students are evaluated on their knowledge and application of knowledge during their studies, whereas performance is assessed as work bases assessment in vitro performance and the final step is assessed after their graduation in vivo performance (Scott, 2001). Hire best assignment writer

The assessment of nursing students is also tested by written essays and this is highly prioritised in the clinical setting, but unfortunately this assessment process is considered to be subjective. Whereas the objective approach that includes the Multiple Choice Questions and Extended Matching Questions are highly effective for assessing the knowledge of nursing learners. Long case examination and oral examination are also widely used for assessing clinical skills of nursing learners, however, this assessment process was highly criticised because of its subjective and unstructured nature. Currently, throughout the United Kingdom and many other countries, Objective Structured Clinical Examinations (OSCE) is being used in medical schools forming the backbone of performance assessment of nursing students in clinical settings (Casey and Clark 2014).

The use of OSCE is being described by Zabar, (2013). However, this assessment process changed the clinical competence assessment due to the fact that it used scenarios and actors. The clinical competence of nursing students is assessed by OSCE in a planned and structured way, aiming at the objectivity of the examination. It is considered a“focused” examination and assessment process with each component emphasising on one of more areas of competence. However, this is regarded as performance assessment that evaluated the performance of nursing students rather than their knowledge. The objectivity of OSCE, unlike traditional clinical assessment, is ensured by students being examined through more than 8 examiners where assessment criteria are decided before by examiners and all students have to face the same task, trained examiners and standardised patients. This assessment and examination process focus on evaluation of what students can do rather than what they know (Jeffreys, 2010). 

Assessment Tools

Competence is referred as the combined skills, knowledge, attitudes and judgment essential to deliver professional nursing services (Byram, Nichols and Stevens 2001). The competence self-assessment tool is considered as an organised and systematic method to identify learning requirement of a nursing student (Keller 2005). The students can use the data to plan a professional and continuing education development program in order to remain competent in clinical profession. This assessment tool helps the nursing students to assess their nursing competencies in a comprehensive manner. Competence self-assessment tool is categorised into two groups: basic self-assessment tool and advanced self-assessment tool. 4 points scale is being used in Basic self-assessment tool and a more complex 5-point scale is used in advanced self-assessment tool for assessing the rate of competencies, a nursing student has achieved during his studies (Baxter and Norman 2011). However, it must be noted that this is self-assessment tool and students need to be honest in the identification of their learning needs and assessing their competencies towards their profession. 

Whitenton and Walker (2010) mention another beneficial assessment tool for nursing students and that is regarded as Self-Assessment Readiness Tool or widely known as SART. This assessment tool is specifically intended and designed to help Internationally Educated Nurses in understanding nursing profession. This assessment tool gives information to registered as well as licensed practical nurses about what they are expected to know and do. This specific assessment tool helps the nursing students to outline their competencies, knowledge, abilities and skills that nurses must require to apply for clinical settings (Jeffreys, 2010). 

Although, competence self-assessment is widely practiced in medical schools, however, considerable research evidence has been observed that indicates that self-assessment of knowledge, competencies and skills of nursing students do not provide reliable and accurate results. Therefore, students need to be evaluated with their self-assessment combined with assessment tools being utilised by supervisors, tutors and professionals. The use of multiple sources of data for planning and implementing professional development programs and activities can help the nursing educators to assess their competencies in clinical settings (Chong, 2002).

Nursing educators intending to experience their first clinical practices are observed to be stressed inherently. Their exposure to physiology, pathophysiology and anatomy are appeared to be completely academic and their prospect of transforming their academic knowledge into patient care can be present as well as intimidating. The anxiety of learners might be so acute that it obstructs the application of newly acquired clinical abilities in the clinical setting. In this regard, Connolly and DeYoung (2004) demonstrate that the human patient simulators are considered to be a useful assessment tool that bridge classroom learning and actual patient care. The simulation assessment tool is being used to reinforce basic assessment skills, providing nursing learners an opportunity to make diagnostic and treatment errors in a controlled and safe clinical setting. This assessment tool is also utilised to assess nursing students using a“standardised patient” that is observed to be closely impossible in a clinical setting. It is reported by most of the students that simulation assessment tool supports in codifying instructional knowledge and in making it achievable to actual patient situations, whereas research study of Thoureen and Scoutt (2013) reports that student-centered and active learning experienced is allowed by simulation assessment. Although, practice is considered a significant component of skill acquisition, therefore, only a small number of nursing learners feel really comfortable in head-to-toe assessment in simulation assessment tool. However, it is suggested by Henneman et al (2010) that student comfort is usually increased by early exposure to simulation assessment tool. 

Another assessment tool is a 10-minute assessment tool that provides a simple benchmark to conceptualise that the nursing students take their initial contact with patients in an acute care environment (Goldon Joughin., Ngar-Fun Liu. and Associates. 2006). This assessment tool provides step-by-step guidance on approaching the immediate patient care environment. The important elements of 10-minute assessment tool are shown in following figure:

In its preliminary arrangement for new nursing learners, the 10-minute assessment tool requires the students to perform a timely, concise and realistic head to toe assessment. This assessment initiates with the learners entering a room, washing their hands, provide their introduction and identifying the standardised patient with their name band, date of birth and medical record number. The entire patient–picture is then observed by the novice student that includes the level of consciousness, the breathing pattern, physical pain and mental status and equipment utilised for treating the patient. The next step in this assessment is to integrate the significant medical history of the patient and to admit diagnoses for identifying and problem solving any instantaneous requirements of the patient. For novice nursing learners, the assessment findings of 10-minute assessment tool is as normal, as the student evaluates the cardiac and respiratory system, abdomen, skin, extremities, intravenous catheter placement, and running fluids. Therefore, it helps the novice students in identifying what normal is before and what they have identified abnormal (Tuttle, 2013). 

Importance of Assessment in Clinical Setting

Assessment is a significant process in nursing education and is regarded as the first part of the nursing process (Taylor and Weir, 2009). Its importance can be judged by the fact that it forms the basis of the care plan. The important prerequisite of precise assessment is to view patients holistically and thus identifying their real requirements. According to Elrington (2015), as many fields of health care are undergoing essential transformations in recent years, in order to meet the demands of a rapidly changing society, the nursing education is also changed accordingly. Such changes demand the adaptation new roles for all those, who are vigorously involved in nursing education, such as tutors, teachers, practitioners as well as those, who act as preceptors and mentors for nursing students in clinical practice. The application of different teaching theories in nursing education is significantly influenced by such changes. In this regard, the Carl Roger’s humanistic theory has been particularly initiated as a new approach to learning and teaching. Being widely used by many teachers, this has been adopted as a learning philosophy by many academic institutions across the globe. Kanchana and Sangamesh (2016) believes in the importance of nursing education, whereas Oreck, Baum and Owen (2004) states that the distinctive potential for growth and development of each assessment process provide support to the notion that the role of teachers should be concerned with the facilitation of the learning experience and should be in the best assessment criteria towards nursing learners. 

According to Luxford (2012), a comprehensive and holistic assessment nursing process provides informing decisions on nursing diagnosis, planning, implementation and evaluation. Therefore, assessment of nursing educators is vital steps as the collected information from the assessment determines the competencies of students and the initial phases of nursing care to be required in a clinical setting. Luxford (2012) also suggests five aspects of general assessment that includes psychological aspects, sociological aspects, developmental aspects, spiritual and cultural assessment aspects.

Considering the importance of the assessment process, Scott (2001) demonstrates that assessment of nursing students has always been an arrangement of teaching as evaluating and teaching are considered to be crucial parts of one learning process. She characterises learning as a sophisticated as well as a complex activity. On the other hand, Wood (2010) demonstrates that assessment of nursing learners consists of a stubborn process that always represents a number of difficulties for assessors.  Wood (2010) explains that the complexity of nursing assessment is magnified in nursing education theory as well as in clinical practices. According to Anderson (2012) the assessment of nursing learners is three dimensional in a clinical setting. The three dimensions mentioned by Anderson (2012) that ought to be assessed are consisted of the psychomotor, cognitive and affective domain of learning. He suggests that the assessment of all three domains simultaneously provides a general and more holistic picture of performance of nursing students and their abilities upon particular competencies. However, it is claimed by Anderson (2012) that certain challenges are posed by the evaluation process that offers a marvelous degree of responsibilities for all those involved in the education of nursing students. Ulfvarson and Oxelmark (2012) demonstrate that clinical assessment procedures pose certain challenges for nurse educationalists, whereas Silivia, Valerio and Lorenza (2012) argued that many factors affect the validity of evaluation procedures in clinical settings. Moreover, alterations to the environment where students’ assessments take place must be deliberated. Whitenton and Walker (2010)emphasises the significance of the alteration process that the nursing students have to undertake as they are allotted to every clinical setting.

Practical utility of Assessment Methods

Van der Vleuten (2008) has explained five standards to evaluate the practical utility of assessment tools. Those five standards are validity, reliability, acceptability, educational impact and feasibility. There is no assessment tool that is considered to be high on all above mentioned standards. The consistency of the assessment test is measured by its reliability and it is often explained as reliability per hour of testing time because of the fact that time is a limiting factor during exams. Therefore, essays are regarded less reliable than Multiple Choice Questions because they demand longer time to answer (Anderson, 2012). It is examined by Thoureen and Scott (2013) that essay scoring is a multifaceted procedure as many variables are associated with it such as writer, essay content, rater and other colleague’s variability with their important writing impacts. However, Hodges (2008) recognized that OSCE stations can evaluate communication and history taking skills with acceptable reliability. While explaining the obstacles to reliability, Hodges (2008) explains that they could be relevant to the standardized patient, examiner or student. However, Byram, Nichols and Stevens (2001) suggest possible solution and might include structured guidelines to examiners, training of examiners, and description of the clinical setting to standardised patient.

Considering validity, it is referred as the ability of an assessment method to evaluate the supposed things, or, in other words, to which extent the result findings of the evaluation method are nearer to the real world. Validity is considered a conceptual terminology and four types of validity can be examined that may include face validity, construct validity, content validity and predictive validity. Byram, Nichols and Stevens (2001) suggest using a large number of short essays for improving the validity and reliability and for reducing the sampling errors. However, this has been argued by Casey and Clark (2014) by exploring that this might cause consuming more time to mark. Whereas, Connolly and DeYoung (2014) contend that a lack of validity is found in other OSCE scenario questions by healthcare professional, and this is due to the particular importance on multi-professional health care delivery.

The educational impact is one that reflects what the student has attained from learning objectives of the course. It is advised by Chong (2002) that educational impact is quite important, as it ensures what the student has achieved and how much his skills have improved.

Acceptability is also another significant consideration in practical utility of an assessment tool. Traditionally, the process of assessment was led by the examiner where they were allowed to use their capabilities. Unfortunately, the acceptability of the assessment process proves to be highly subjective in such scenarios. Another aspect of practical implication of the assessment tool is feasibility that is decided by the cost, time and other resources required to do assessment of nursing students. According to Elrington (2015), the recruitment of many examiners and highly standardised patients include a considerable amount of feasibility aspect such as cost. Costs can be decreased by running examinations on a continual basis. However, this might cause fatigue for examiners and can badly affect the validity and reliability.

Conclusion

From the above discussion, it is concluded that in order to compete the racing world, the competencies of a novice nursing learner need to be assessed appropriately. The role of examiners, tutors and professors is significantly important in enabling nursing learners to provide health care service reliably and effectively.  As, most of the students are assessed against a standard of competent professionals, similarly, nursing students are assessed against benchmarks set in the clinical care. Different assessment tools used for assessing nursing students include competence, self-assessment tool, self-assessment readiness tool, simulation assessment and 20-minute assessment tool. The practical utility of all above mentioned assessment tools is based on five criteria that determine how effective a learner is competitively assessed.


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