A child health nursingobjective structured clinicalexamination (OSCE)Joan Walters and June Adams

The UK has been experiencing an increasing focus on the assessment of clinical competencein nurse education. In response, an Objective Structured Clinical Examination (OSCE) was

introduced into the assessment strategy of a core course within a Diploma in Nursing Studiesfor Child Branch students at an English University. This paper focuses on the use ofprofessional role players to simulate user involvement in the assessment of competence. It

also describes the development of objective checklists for each scenario within theOSCE, which contributed to the overall reliability of the marking process, as well as being a

step-by-step guide to administering an OSCE. �c 2002 Published by Elsevier Science Ltd.

Introduction

Assessment of student nurses’ clinicalcompetence has been an integral part of theoverall assessment strategy since formalnursing assessment began (Hill 1998). In thepast decade there has been an increasing levelof concern that newly qualified staff nurses donot posses the skills expected of them byemployers and the public perceptions aboutlevel of preparedness for practice aresometimes negative. The UKCC document‘Fitness for Practice’(1999) recommended are-focusing of pre-registration training onoutcome-based competencies. Workingtowards a curriculum that ensure that studentsdevelop higher order intellectual skills andabilities and the practice knowledge and skillsto the art and science of nursing. Thecombination of theoretical and practicalassessment should overcome the problem ofthe apparently knowledgeable nurse whopractices unsafely (While 1994).Within the United Kingdom (UK) there are

currently four pathways to first levelregistration. These are known as branches:adult, mental health, learning disabilities, andchildren’s nursing. The two key issues that ledto the development of this branch structure

were: first, whether a generic practitionerwould be competent across a range of settings,and second, concerns around a lack ofprofessional development for generic nurses,particularly in mental health, learningdisabilities, and children’s nursing, (UKCC1999). Having four branches leading to one‘end point’ qualification has implications forassessment of competence.

Competence and the OSCE

One of the fundamental problems faced byassessors is defining competence. As Hill(1998) observes definitions of competence areoften inadequate in explaining what is requiredwhen assessing others. The definition mostcommonly used describes competency as ‘theknowledge skills and attitudes required toperform a given task or act’ (Tuxwoth 1982). Infact there exists confusion between the terms‘competence’ and ‘performance’ (While 1994).The two are often seen as diametricallyopposed, instead of being seen aspects of oneanother. However, if viewed holistically,competence can be seen to combine two formsof assessment. One that is based on theobservation of performance or inspections ofproducts of performance; the other is based on

224 Nurse Education in Practice (2002) 2, 224–229 1471-5953/02/$ - see front matter �c 2002 Published by Elsevier Science Ltd.doi:10.1016/S1471-5953(02)00024-0, available online at http://www.idealibrary.com on

Focus

Joan WaltersMSc, BSc (Hons),RSCN, RGN,LecturerPractitioner,FlorenceNightingaleSchool of Nursingand Midwifery,King’s College,London, JamesClerk MaxwellBuilding, 57Waterloo Road,London SE1 8WA,UK. Variety ClubChildren’sHospital, King’sCollege Hospital,Denmark Hill,London SE5 9RS,UK. Tel.: +44-20-7848-3510; fax:+44-20-7848-3555.

June AdamsMSc, BA (Hons),RGN, HV cert,Lecturer, FlorenceNightingaleSchool of Nursingand Midwifery,King’s College,London, JamesClerk MaxwellBuilding, 57Waterloo Road,London SE1 8WA,UK.

(Requests foroffprints to JW)

Manuscriptaccepted:8 May 2002

the accounts of practice, reports on aspects ofpractice or discussion on practice. The latterprovides evidence of knowledge needed forpractice and evidence of professional thinking.These two kinds of assessment can increase theassessor’s confidence that performances seen inone context can be transferable to another(Eraut 1998).The objective structured clinical examination

(OSCE) has been in use in the assessment ofmedical students for over 20 years. In the last10 years there has been increasing interest inthis form of assessment in other healthprofessional disciplines, such as nursing andphysiotherapy (Bujack et al. 1991, Ross et al.1988). However, there remains a paucity ofliterature on the use of the OSCE in theassessment of nursing students. Mcknight et al.(1988) confirmed the benefits of this type ofassessment as the opportunity to observeclinical competence, whereas Bramble (1994)stressed its objectivity. Bujack et al. (1991)suggested that the difficulty that the OSCEpresents for nursing was that it may not be ableto simulate the nature of nursing. Its mainadvantage, however, is the potential to test awide range of knowledge and skills as opposedto sampling a narrow range of the examinee’sperformance, as well as been able toaccommodate a large number of examinees inone examination period (Ross et al. 1988).During an OSCE the clinical competence to

be tested is broken down into its variouscomponents. For example the acquisition ofclinical data (history taking, physicalassessment), the interpretation of clinical data(problem identification, nurse diagnosis), orthe use of clinical data (decision making)supportive, educative, or therapeuticinterventions (Ross et al. 1988). The basicstructure of an OSCE is a circuit of assessmentstations where a range of practical clinical skillsare assessed by an examiner using a previouslydetermined objective marking scheme (Harden& Gleeson 1979). The tasks to be assessed are ofdifferent types and of varying difficulties toprovide a mixed assessment circuit. This is lessdemanding for the students and also helps todiscriminate between students of varyingability. The length of an assessment isdetermined by the number of assessmentstations and the time each candidate will spend

at each station. To accommodate the requirednumber of candidates the examination may berepeated or held at different sites at the sametime (Selby et al. 1995). Stations can be mannedwhere the student is expected to perform anobservable clinical task, usually presented in atwo or three sentence scenario and a requestfor the appropriate action to be demonstrated,and are called examiner stations. Otherwise,stations are unmanned where the student maybe asked to answer short questions, to interpretdata, or record findings, these are calledmarker stations (Mcknight et al. 1987, Ross et al.1988). For such an assessment real patients,staff volunteers, or professional model patientscan be used.

Method

Concerns from managers and practitioners thatProject 2000 programmes, although stronger ontheoretical content, were demonstrating somedeficits in the acquisition of practical skills(Macleod Clarke et al., 1997) prompted aninvestigation of strategies to ensure skillcompetency. The child health forum forlecturers in the School of Nursing set up astrategy group to explore the implementationof the OSCE for the Assessment andInterventions course. The intention was thatthe OSCE would facilitate learning through theprocess whilst still assessing the knowledgeskills and attitudes of students.Prior to the first meeting literature was

disseminated for pre-reading to lend a focusto the discussions (Bujack et al. 1991, Rosset al. 1988). There was strong debate abouttwo major issues. The first issue pertained tothe value of an OSCE, given that the essenceof children’s nursing is flexibility andadaptability and concerns were raised thatthis form of assessment could not adequatelyevaluate these characteristics. The second areaof concern was the use of children, sick orotherwise to facilitate this process and theappropriateness of a child to encounter 20–30students in eight-minute cycles. The ethics ofgaining informed assent from the child is akey issue in children’s nursing to preventelements of coercion (Alderson 1990).Although proxy consent might be obtainedfrom a parent it was considered, important

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that the assessment modelled best practice.This was resolved by the introduction ofprofessional role players, that is parents andchildren to bring reality to the scenarios and,emphasise user involvement. This was a clearattempt to involve the user in the decisionmaking process which is in line with currentgovernment policy (Kelson 1997). Therefore,children of eight years and above wererequested because by this stage it isconsidered that they are able to makedecisions that take account of choices andconsequences (Bird & Dearmun 1995). It wasessential that the students were able todemonstrate the ability to adapt each activitywithin the OSCE to the developmental stageof the child and to deliver non-discriminatorypractice.

Developing the OSCE

The theoretical content of the course beingassessed focused on student’s ability to assessand select the appropriate interventions for avariety of children between the ages of 0–16years, taking into account the physical,cognitive, social, emotional, and cultural needsof the child. So as not to disadvantage studentsin relation to the variability of their clinicalexperiences it was agreed that students couldonly be tested in areas covered on theAssessment and Interventions course. It wasrecognised that one station would notnecessarily meet all the criteria but the sumtotal of the stations would cover all theexpected areas. The total marks allocated to theOSCE was 100%, but each station was equallyweighted, at 20%.Lecturers worked on developing the

scenarios such as holistic patient assessment(see Fig. 1), feed calculation, neurologicalobservation, patient teaching, and painassessment in their acknowledged areas ofexpertise. Each scenario was brought tosubsequent meetings with objective checklistsfor marking. These were written in clearconcise and simple language and agreed levelof competence to ensure that each marker usethe same criteria as a contribution to reliabilityof scoring. A sufficient number of scenarioshad to be created to accommodate studentswho might need to resit the examination.

Students also needed to gain a pass mark inthree of the five activity stations to pass theoverall OSCE. The length of the assessmentwas one hour and the number of stations wassix, including one rest station. The time spentby the candidate at a station was eight minutesand the timekeeper indicated the requiredchange over between each station.To accommodate the 60 students required to

take the OSCE and to ensure that it was apositive experience, some practical issues wereconsidered:

1. Students were informed of the assessmentprocess at the start of the course andguidelines were included in the coursehandbook. Within the course timetable weresessions facilitated by the lecturers allowingthe students to role-play similar scenariosand obtain feed back.

2. The briefing of students and familiarisationof examination procedure.

3. The environment—as well as allowing forspace between the stations, sound in termsof interviewing to avoid students beingoverhead by their peers, and to avoid thestudent being distracted by the otheractivities.

4. The distances between rooms in terms ofallowing sufficient time for changeoverbetween stations (2 min) and being able tohear the bell.

5. The number of lecturers required to assessthe students at each station, collectexamination paper, and to ensure studentswere in the right place at any given time.

6. A floor plan was developed that at any stagein the day it could be seen where staffand students were during the process (seeFig. 2).

7. Sufficient equipment was needed to allowthe same scenarios to be performed.concurrently and to meet health and safetyregulations.

8. Cost included the use of professional roleplayers and acquiring additional equipmentthat was age appropriate.

9. Preparation for the examination includedletters to the students stating the date, timeof arrival at the examination site, and theneed to bring identification. Students weregiven plagiarism forms to sign agreeing not

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to discuss the content of the assessment untilthe last circuit had been completed.

Evaluation

The OSCE provided a learning opportunity forthe nursing students, lecturers, and theinstitution. First the students stated that theexperience of doing the OSCE gave them asense of achievement. They learnt that they hadconsolidated previous nursing knowledge. It

demonstrated their ability to apply principles,to interpret data, to respond to clinicalsituations, and, effective time management(Kolb 1984). They reiterated that theopportunity to prepare through role-play hadcontributed to their understanding of theprocess. The briefing before the OSCE allowedstudents time to become orientated to theprocess whereas debriefing offered theopportunity to discuss personal issues andanxieties.

Fig. 1 Sample of student question and marker checklist.

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Lecturers involved in the administration ofthe OSCE felt that the planning hadcontributed to a good learning experience forthe students. However, several practical issueswere identified such as the need for anadditional examiner to be available throughoutthe day in case of illness of either students orstaff. It was found that due to the time limitsinherent within the design of the scenarios therearrangement of equipment between eachstudent was difficult both for manned stationsand unmanned stations (e.g. calculation of feedfor dehydrated baby where a student sat in adesk and did the paper). The marking of themanned stations (see Fig. 1) was easier thanexpected and the collation of results was lesstime consuming than marking traditionalscripts because of the pre-determinedchecklists. These checklists also ensuredobjectivity in the marking process. Studentswho were assessed to be less competent inparticular areas of the OSCE were found tohave also failed the equivalent assessments inpractice. Those whose practice was shown tobe unsafe at any of the stations had ten marksdeducted from the allocated score for thatstation.The marking of the interview station allowed

for the professional role playing child andparent to allocate marks on student’sperformance, this influenced the overall gradethat student gained and was another exampleof user collaboration (see Fig. 1). Moreover, theparents who accompanied the childrenrecognised this process as valuing the child’sperspective. One parent discussed a recent visit

to an Accident and Emergency departmentwhere she felt that the interpersonal skills usedwith her child during the encounter to beunsatisfactory. She commented that she waspleased that these skills were being tested withcurrent child branch students. This furtherdemonstrated the need for user involvement inthe monitoring, evaluation, and audit ofservices and their outcome at every level in theNHS. It is the client who has to live with theshort and long term consequences of theircondition and treatment and, the impact ofsuch encounters within the services (Kelson1997).The implications for the Institution is that an

OSCE is labour intensive on the day in terms ofhuman resources but reduced time is requiredfor marking of scripts. Accommodating theassessment of 60 child branch students usingOSCE requires several clinical skills rooms forconcurrent sessions as well as additionalequipment. The employing of the role-playersfor the planning meetings, the development ofthe scenarios and their attendance on the dayof implementation has financial implications.However, using OSCE greatly enhanced theapplication of theoretical principles to practice.It appears to mirror practice because implicitwithin the examination students are asked toassess care needs and demonstrate decisionmaking skills.

Conclusion

Objective Structured Clinical Examinationscan be part of an effective assessment

Fig. 2 Sample of an OSCE circuit for six child branch students.

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strategy of nursing competencies in childbranch students and provide a positivelearning experience. The development andthe execution of the OSCE also becomes avehicle for involving current practitioners e.g.lecturer practitioners, thereby facilitating jointownership of the assessment process andpotentially reducing the theory-practice gap.Whilst the day may be labour intensiveit is an objective measure of studentcompetence that should have immense valueto NHS Trusts and other health careproviders, knowing that standards are beingmet. The development of the OSCE alsodemonstrated the potential for userinvolvement in the children’s nursingcurriculum and could be adapted for use bythe other branches of nursing and the otherhealth care professions.

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