Historically, educators from a variety of disciplines struggled with questions relating to evaluation or assessment of student learning. In practice disciplines such as nursing, evaluation of student learning is complicated by the need to accurately and objectively judge the performance of students in the clinical setting. The problems associated with the development of objective clinical evaluation tools are not new to nurse educators. Woolley (1977) and Battenfield (1986), among others, have well documented what Woolley describes as "the long and tortured history of clinical evaluation" (Woolley, 1977, p.308). The goal among nurse educators has been to devise a method that provides students with an objective evaluation of their clinical performances. The emphasis in recent years moved towards developing a more comprehensive formative evaluation in addition to the usual summative evaluation completed at the end of each clinical rotation or semester.
From the turn of the century until the 1940s and 1950s, nurse educators relied heavily on "efficiency reports," checklists, and a variety of less sophisticated evaluation methods often completed by the head nurse of the ward or unit in which the student was placed. In the 1950s, the anecdotal record, developed by Duke University, gained favor among nurse educators and continues to be used in some form today.
In 1963, Rine advocated the use of a criteria-referenced format over the more traditional normative method in clinical evaluation. She thought that clinical grading should be a bipolar or pass/fail system and that evaluation criteria should be based on course objectives. Also, in 1963, Flanagan and colleagues pioneered the critical incident report. Analysis of a student's competence was to be based on observed behaviors that were classified as either effective or ineffective (Battenfield, 1986). These methods, in addition to others such as self-evaluation, continue to go through many adaptations and transformations by nurse educators. Additional clinical evaluation methods, such as Bondy's (1983) extensive and much-cited work on criterion-referenced rating scales and Lenburg"s (1979) work on clinical performance nursing examinations, have added to the body of literature and sophistication of clinical evaluation methods in recent years.
These newer clinical evaluation methods as well as the more dated methods have consistently addressed similar issues such as objectivity vs. subjectivity, teaching separate from evaluation, grading vs. pass/fail systems, the validity and reliability of evaluation tools, and others. As nurse educators, we have often looked to our colleagues in educational research and evaluation for assistance with some of these issues. An example of this partnership between nursing education and the broader field of education has led to the development of clinical co-assessment at Alverno College (Alverno College Nursing Faculty, 1979).
At Alverno College, a liberal arts women's college, student learning is outcome-oriented and designed to foster development of eight broad-based abilities representing characteristics of an educated person (Alverno College Faculty, 1981). To facilitate and validate development of these abilities, faculty use an assessment process (Alverno College Faculty, 1985 p.l) defined as "a multidimensional attempt to observe and, on the basis of criteria, to judge the individual learner in action." Assessments are designed by faculty consensus to validate a student's ability and to diagnose areas in which the student can continue to develop. Assessments provide behavioral data indicating a learner's ability at a specific point and occur several times each semester either inside or outside of the classroom.
Elements critical to the process of assessment are criteria, feedback, and self-assessment. Developmental criteria are made explicit to the student at the beginning of each course, which assist the student in designing personal learning goals and are used during assessments to judge the student's performance. After each assessment, specific feedback is provided to the student by the assessor. Although formal teaching is not a part of the assessment, learning is inherent in the process as students are given specific behavioral evidence of how they met criteria and how they might be able to develop their abilities to a higher level. As students engage in self-assessment, using the same behavioral criteria as the assessors, they are actively involved in the evaluation process.
Clinical co-assessment, a process used by the nursing faculty as one of several evaluative methods, is so named because the student is assessed in the clinical setting by two assessors. Abilities assessed are the use of the nursing procees, effective interaction, and formation of value judgments that reflect a respect for the dignity of others.
Occurring near the end of each semester of the junior and senior year, clinical coassessment lasts for 3 to 4 hours on specific clinical days and is conducted by two practicing nurses from the community. Minimally prepared at the baccalaureate level, assessors hold a variety of professional positions including, but not limited to, staff nurse, director of nursing, nurse practitioner, and nurse educator. Assessors attend training workshops each semester to provide comparability and consistency in observing and judging clinical behaviors.
On the day of the scheduled assessment, the assessors arrive on the unit an hour after students receive the reports on their clients. Although students frequently have multiple client assignments, during co-assessment the student provides care to only one client. Assessors have equal responsibilities in observing and collecting data, making judgments, and providing written feedback to the student. Using a co-assessment form identifying specific behavioral criteria, the assessor collects data on the student's ability to provide therapeutic client care; to interact effectively with the client, nursing staff, and medical staff; and to act on value judgments that reflect their respect for others. For example, a criterion identified in the course syllabus for a senior student measuring her ability to effectively solve problems states the student "develops a comprehensive client care plan consistent with the nursing diagnosis."
The depth of the care plan varies depending on when the student began caring for the client. For example, a student placed in a long-term care setting would develop an in-depth written care plan. In an acute care setting, the student may be caring for the client for the first time, hence the care plan would be verbal and preliminary. However, in both cases, the assessor should observe a plan of care reflecting analytical use of the nursing process. Assessors also document the absence of behaviors related to specific criteria. As in the previous example, it would be noteworthy if the student feiled to collect data from the client prior to formulating a nursing diagnosis.
When the assessors have collected sufficient data on which to base their judgments, they collaborate to draft an extensive descriptive statement of the student's clinical nursing abilities. The assessors also make a collaborative decision as to whether or not the student is "successful" in this assessment. At that tune, verbal and written feedback is given to the student.
Success in the nursing course is not dependent on the student's performance during clinical co-assessment, as this is one of many assessments used to judge a student's abilities.
The role of the clinical instructor during co-assessment is twofold. She continues to function as a nurse educator facilitating the experience for all the students, including those who are being assessed. In addition, as assessment facilitator, the instructor assigns assessors to students, provides an area for privacy during assessorstudent interviews, and provides appropriate explanations to clients, families, and professional staff.
Although clinical co-assessment is a unique clinical nursing evaluation process, perhaps the most beneficial aspect is that of having practicing professional nurses function as assessors. This process incorporates several evaluation principles identified in the nursing education literature, foremost of which is objectivity. These assessors have not had contact with the students prior to the day of coassessment and, therefore, are unbiased. Judgments are based solely on observed behavior and specified criteria, not on prior clinical performance. These objective judgments enhance the clinical nursing faculty's ability to direct the individual student's learning experiences for the remainder of the semester. Although assessors frequently provide judgments that support those of the instructor, they also might identify areas of strength or areas needing further development that the instructor had not identified.
The formative evaluation process of clinical co-assessment is further enhanced by having practicing professional nurses as assessors, as this creates a separation of teaching and evaluation. Although the process itself provides learning for the student, assessors do not teach clinical content or process. Instead, the process of co-assessment facilitates the development of self-directed !earning. Students learn to set personal criteria and to assess their own performance; hence, they are able to identify knowledge deficits, use appropriate resources, and judge their own professional abilities. This may, in part, explain the response of students to co-assessment.
Students understandably experience a degree of anxiety at the prospect of having two unfamiliar professional nurses observe their interactions, clinical skills, and discuss the clients' plans of care. However, after receiving feedback from practicing professional nurses, students report they have a stronger feeling of competence. It is common to hear students exclaim that they "forgot" they were being assessed and simply provided client care to the best of their ability. Experiencing this intense focus on their client, followed by objective external feedback, provides students with the opportunity to envision themselves as competent practitioners in the professional nursing world beyond college.
- Alverno College Faculty. (1981). Liberal learning at Alverno College (2nd ed.). Milwaukee. WI: Alverno Productions.
- Alverno College faculty. (1985). Assessment at Alverno College (2nd ed.). Milwaukee, WI: Alverno Productions.
- Alverno College Nursing Faculty. (1979). Nursing education at Afaerno College: A liberal arta model. Milwaukee, WI: Alverno Productions.
- Battenfield, B. f L986). Designing clinical evaluation tools: The state of the art. New York: National League for Nursing.
- Bondy, K. (1983). Criterion-referenced definitions for rating scales in clinical evaluation. Journal of Nursing Education, 22(9), 376382.
- Lenburg, C. (19791. The clinical performance examination. New York: Apple-CenturyCrofts.
- Woolley, A- (1977). The long and tortured history of clinical evaluation. Nursing Outlook, 25(5), 308-315.