The number of tools available to measure man's products far outstrip man's ability to measure man. The educator's measurement of the growth of students rests largely on the results of paper and pencil tests. In professions where judgment and critical thinking must be developed, and where actions of the practitioner are to be evaluated, the measurement of the complex aspects of human behavior is difficult. The nurse educator is faced with the responsibility of measuring the quality of performance of the student nurse in the clinical areas with techniques which tend to be more subjective and less reliable than paper and pencil tests. The following discussion focuses on the process used by faculty members at the University of Hawaii in developing a scale for rating student performance in clinical practice as a means of measuring student nurse growth.
When the task of developing an evaluative device was begun, two questions seemed to need immediate consideration:
1. What are faculty expectations of clinical performance of the beginning student nurse?
2. What are the expectations of colleagues for students entering advanced courses in nursing?
Each faculty member was asked to submit a list of her expectations of students during the students' first year in nursing. Over two hundred expected behaviors were submitted and classified according to a nursing standardzation method suggested by Goodrich and Gray two decades ago: (1) behaviors which would assure the safety of the patient, and (2) behaviors conducive to patient welfare and comfort. In addition to safety and comfort, a third classification was chosen to include some measure of what the faculty called, "the professional mode of operation." A sample classification of expected behaviors encompassed the following items:
a. Uses principles of asepsis.
b. Protects patients from environmental hazards.
a. Provides for privacy of the patient
b. Gives baths and oral hygiene according to individual patient's needs.
3. Professional operation
a. Uses problem-solving method while giving care.
b. Teaches patients specific health information.
By using the convenient headings of Safety, Comfort, and Professional Operation it became possible to categorize the faculty's statements of behavior expectation. Some of the statements were developed into objectives and others were listed as characteristics which the student should exhibit in fulfilling these objectives. This portion of the task answered the question: What is to be evaluated in the clinical performance? The following ten objectives were identified and defined behavior ally:
1. Uses clean and contaminated areas and articles appropriately.
2. Prepares, administers, and records medications accurately.
3. Reports and records physical and behavioral deviations.
4. Controls environmental hazards.
5. Uses measures conducive to physical and mental rest.
6. Uses interviewing techniques in nurse role.
7. Develops skill and dexterity.
8. Uses principles of learning when teaching patients (or families).
9. Uses problem-solving method in nursing situations.
10. Coordinates services to the patient of some members of the health team.
Each nurse educator, on the basis of her own education and experience, establishes standards with respect to performance. These standards vary from educator to educator and may not always be explicit or shared by other faculty members or by the students being evaluated. In an attempt to reach agreement about such standards the faculty developed descriptions of merit to correspond with each objective. This portion of the process answered the question: How do we evaluate?
Descriptions of Merit and Rating
The descriptions of merit were made explicit as faculty discussed what they individually considered Good, Satisfactory, and Poor performance by a student. A statement described each level of performance and the degrees of merit applicable to each characteristic. The value judgments, missing in the behaviorally defined objectives, were agreed upon through discussion of the objectives by the faculty. Using objective number 1 as a sample, the objective with rating implications was:
Uses clean and contaminated areas and articles appropriately. Although "appropriately" is a qualifying term, behavioral characteristics were identified by faculty to specify what was appropriate, for example: (a) Washes hands "between" patients, and (b) Holds contaminated articles away from self. The faculty then outlined characteristics of performance which would apply to all objectives:
1. The good performer knows why and can devise the how; has a greater awareness, has depth of knowledge and displays initiative.
2. The satisfactory performer knows how but lacks depth of understanding; a safe but perfunctory practitioner.
3. The poor performer knows neither why nor how; an unsafe practitioner.
For each objective a description of merit of Good, Satisfactory, and Poor was included on the rating scale. The sample rating format, using the above objective, concerned the use of clean and contaminated areas. An attempt was made to define actions on the rating scale in observable terms.
1. Good rating: able to state rationale of use, and consistently uses clean and contaminated areas and articles appropriately.
2. Satisfactory rating: states rationale of use when asked; actual behavior indicates need for increased perception and follow through in use of clean and contaminated areas and articles.
3. Poor rating: able or unable to state rationale of use, but continues misuse of clean and dirty areas after specific reinstruction.
Although only three descriptions of behavior were included on the rating scale, a five-point scale was used to allow for the selection of intermediate positions on the continuum. For example, Good became 5; Satisfactory, 3; and Poor, 1. The inclusion of 2 and 4 allowed the use of a scale comparable to letter grades of A through F.
In order to use the objectives, the behavioral characteristics, and the rating scale meaningfully, the faculty met to revise sections and to discuss their expectations. The objectives, the behaviors, and the rating scale were then shared with the students so that they would understand this aspect of evaluation.
Student performance is not always successfully sampled. Neither are the observers always in agreement about what is to be observed. Since the faculty evaluating clinical performance were directly involved in the development of the rating scale, the tool has face validity. The reliability of the rating scale has been demonstrated with repeated independent observations made by several clinical instructors. The rating form provides ample space for supportive statements of an anecdotal nature. It is assumed that anecdotes would enhance the value of the rating scale
The process of developing the clinical performance rating scale involved:
1. Learning and categorizing faculty expectations
2. Developing objectives and descriptive behaviors
3. Developing the rating scale from the stated objectives
Although precise measurement still is not possible, there have been rewards for both faculty and students in the development and use of the rating scale
The faculty have agreed upon desired levels of achievement and have identified specifically what should be accomplished by the beginning student in nursing. The student has knowledge of what is expected of her, and what will determine her level of achievement in clinical performance With the additional use of anecdotal records there has been better counseling of the student.