The Objective Structured Clinical Evaluation (OSCE) allows nursing students to practice acquired knowledge and skills in a controlled risk-free environment before entering the high stakes of professional nursing practice (Redfern, Norman, Calman, Watson, & Murrells, 2002; Ward & Willis, 2006). The OSCE challenges students to think on their feet, incorporate prior learning, use critical thinking, and demonstrate clinical reasoning and judgment (Rentschler, Eaton, Cappiello, McNally, & McWilliams, 2007). Quantitative assessments of clinical skills performed during OSCEs usually address two of the three domains of learning: cognitive (knowledge) and psychomotor skills (Jeffries & Norton, 2005). The affective domain, encompassing students’ attitudes, beliefs, values, and feelings (Krathwohl, Bloom, & Masia, 1964), is infrequently assessed with student OSCE performances. This qualitative research study explored the feelings, beliefs, and attitudes of senior-level undergraduate pediatric nursing students upon completion of a pediatric medication administration OSCE.
The affective domain is concerned with the emotional components of student behaviors, such as feelings, beliefs, attitudes, values, and motivation or engagement in the learning process (Krathwohl et al., 1964; Ringness, 1975; Savickiene, 2010; Stenzel, 2006). Although educators express that teaching from the affective domain directly impacts students’ values, attitudes, and beliefs (Brien, Legault, & Tremblay, 2008), clinical evaluation tools in nursing do not include objectives relating to the affective domain (Miller, 2010). Nurse educators are challenged to develop OSCEs that objectively assess essential nursing skills, knowledge, and attitudes relating to clinical competence in practice (Redfern et al., 2002; Rushforth, 2007; Walsh, Bailey, & Koren, 2009).
Few studies have examined nursing student beliefs and attitudes from participation in OSCEs (Walsh et al., 2009). After completion of a 10-station patient safety OSCE, 227 first-year medical residents expressed confusion, poor knowledge and skills, lack of realism, and need for immediate feedback (Wagner, Hoppe, & Lee, 2009). In Ireland, 90% of 185 registered nurses in oncology reported high levels of stress and discomfort during the completion of five OSCE stations even though all were provided checklists of learning outcomes in advance (Furlong, Fox, Lavin, & Collins, 2005). The aim of this current study was to examine nursing student feelings, beliefs, and attitudes after completion of a solo videotaped pediatric medication administration OSCE.
An exploratory focus group design was used to obtain qualitative data on nursing student feelings, beliefs, and attitudes after participation in a pediatric medication administration OSCE. The focus group facilitator (A.R.) was a senior undergraduate nursing student who had also completed the OSCE in the same semester (fall 2010) as the study participants. Approval was obtained from the institutional review board at a large university in the southwestern United States. Twenty students, 1 man and 19 women ranging in age from 20 to 46 years (mean = 24.4 years), were recruited through word of mouth. In February 2011, two 30-minute focus group sessions involving 10 nursing students each were conducted.
The facilitator asked three questions from the affective domain, in the same order, during each of the focus groups:
- How would you describe the OSCE experience you completed? [feelings]
- What did you learn about yourself during this OSCE experience? [beliefs]
- What does this OSCE experience mean for you as you begin your Capstone experience and your nursing career? [attitudes]
All audiotapes were transcribed verbatim; the facilitator reviewed the transcripts word-for-word with the audiotapes for accuracy. The student facilitator (A.R.) and a doctorally prepared nurse researcher (M.C.) analyzed responses line-by-line for common themes; however, differing or opposing responses were also noted. The facilitator verified the common themes with 14 of the 20 participants who supported the qualitative findings.
All Fall 2010 pediatric nursing students (N = 105) participated in a 7-hour Pediatric Medication Administration, Assessment, and Skills Simulation Lab on the first day of the course. The simulation consisted of four medication administration scenarios on developmentally different simulated patients (infant, preschool, school age, and teenager). All students performed medication calculations to assess for the safety of ordered medication dosages, learned about developmentally age-specific considerations of medication administration, administered medications via various routes (oral, nasogastric, inhalation, intravenous, intramuscular, subcutaneous, and intradermal) to their “patients,” and participated in an intensive instructor-led debriefing at the end of the day. Within 1 to 3 weeks after simulation, each student completed a solo videotaped OSCE; students were instructed to administer the oral and intravenous medications due at 2100 to their infant patient. The OSCE was developed to evaluate the effectiveness of the 7-hour simulation on student learning and for clinical instructors to offer reinforcement or remediation during their pediatric clinical rotations.
Question One: Feelings
Feelings expressed from students’ OSCE experiences were loss of control and anxiety. Students described a loss of control related to inconsistencies with instructions, simulation staff involvement, and organization of room set up. These students were the first class to experience the medication administration OSCE.
I wasn’t sure what exactly I was supposed to be doing. I came in and I was like, am I just supposed to give her the [medication], am I supposed to do an assessment, am I supposed to do a focused assessment? So I didn’t really know what they wanted.
Many students agreed that anxiety was intense during the OSCE. Some described “video stress.” Many attributed their nerves to a perceived lack of knowledge or competence in medication administration during the OSCE.
- Yeah, you could be more comfortable if you felt like you knew what you were doing.
- I stupidly left out flushing because I was so flustered by that point that I just didn’t.
- I was more nervous about being recorded and making sure I was looking at the camera than actually looking at the patient.
Some students denied feeling anxious during the OSCE because they knew that no course grade (only pass/remediate) was involved: “I wasn’t that nervous because I knew it wasn’t [for] a grade.”
Question Two: Beliefs
Students identified two common beliefs about their OSCE performance: need for feedback and reaction under pressure. All students received feedback after their clinical instructors viewed the videotapes, from 1 to 3 weeks after student performances. Most of the students believed that immediate instructor feedback would have been more beneficial.
After I got done, I thought...I should not be out there doing this. I really felt bad. So, I agree that [it would be beneficial] having an instructor sit there with you afterwards to remediate with you and say “okay hey, you did this really good, but you need to do this, this, [and] this.”
Students believed that their reaction under pressure negatively affected their OSCE performance, not allowing for an accurate assessment of their clinical competence in medication administration, communication, or patient care. Several students believed that real practice settings such as hospitals provide less pressure when performing clinical skills.
- I don’t know if I washed my hands or not. I didn’t [identify] my patient and at the end, I told the camera I would have done it before giving [medications].
- I don’t think it was a good assessment of our medication abilities.... When, in a real hospital, we know what we’re doing and we’re fine, but this just didn’t measure our skills well.
Question Three: Attitudes
The students identified their attitudes derived from the OSCE as safety first and no connection. Students said they would need to be careful and make safety a priority as they integrate this OSCE experience into their future medication administration practices.
- I think one big thing we could take from the OSCE is some people mistook the oral [medications] for the [intravenous medications because] they were both in syringes. I heard that many others screwed up.... So just double check the order and the route.
- So, I think that’s what I took from it that I’m never gonna let a [medication] start if I’m not positive that it’s the right rate….
Many of the students stated that they could make no significant connections between their medication administration OSCE and their upcoming Capstone experience, future nursing practice, or their previous simulation. Again, students blamed lack of immediate feedback for lack of connection:
I didn’t really feel like I could take very much from it because there wasn’t any sort of feedback afterwards. It makes me nervous to think, like, oh my gosh, I’m going to take care of real patients all by myself.
Students confirmed both the positive and negative effects of the affective domain. The comments by students who felt a loss of control and anxiety during the OSCE, who believed no immediate feedback and their reaction under pressure affected OSCE performance, and who developed attitudes of safety first without a connection to future practice have both course and curricular impact in OSCE development, modification, and implementation.
Ringness (1975), an early advocate of affective domain learning, stressed that all behavior is associated with feelings and emotions, but feelings are rarely considered in curriculum development. Students described a loss of control related to perceived inconsistencies, lack of preparation, and unrealistic setting. Walsh et al. (2009) advised that the task of OSCE developers is to maintain control of environmental variables. To address these student concerns, the following changes have been made: (1) written and specific OSCE set-up protocols for simulation facility personnel, (2) staff posted outside OSCE rooms as student resources, and (3) instructor-modeled medication administration skills during simulation laboratory.
Several researchers argue that student anxiety may actually increase the validity of OSCEs by reflecting real-world stressful clinical situations (Bartfay, Rombough, Howse, & Leblanc, 2004; Bujack, McMillan, Dwyer, & Hazleton, 1991). Students reported less disabling anxiety when they focused on the OSCE for clinical hours rather than a course grade. To prevent or minimize anxiety, students will be given copies of the evaluation rubric prior to the OSCE so expectations are known and all staff will be removed from the room during student performance. Video stress, a curricular issue, could be alleviated with an earlier introduction of OSCEs prior to the senior level.
Students believed that immediate feedback was necessary to reinforce learning and improve perceived weaknesses. Literature reinforces the importance of immediate feedback for increased clinical confidence (Dickieson, Carter, & Walsh, 2008; Dreifuerst, 2009; Wagner et al., 2009). Students who experienced end-of-life care education found that reflective journals were the most appreciated learning activity—offering students opportunities to immediately debrief their emotional experiences until meeting with their instructors (Brien et al., 2008). To better address students’ concerns, half of our clinical instructors will watch student OSCE performances in real time and immediately debrief students. The remaining students will immediately self-reflect post-OSCE by writing down their answers to the same three questions used in focus groups; these reflections will be reviewed by their clinical instructors within 1 to 2 days of completion. Future research will evaluate differences in affective, cognitive, and psychomotor domains between immediate instructor feedback and immediate self-reflection.
Students’ beliefs that their OSCE performances were affected by their reaction under pressure are supported in the literature (El-Nemer & Kandeel, 2009; Mitchell, Henderson, Groves, Dalton, & Nulty, 2009). According to Griffith & Nguyen (2006), “If one feels threatened, sad, stressed, etc., the learning process can break down” (p. 2). Registered nurses identified similar barriers to performance in simulated environments: (1) “being videotaped,” (2) “unfamiliar with equipment,” (3) “stressful environment,” (4) “not the real thing,” and (5) “inaccurate reflection of skills” (DeCarlo, Collingridge, Grant, & Ventre, 2008, p. 92). To minimize student concerns, development of video exemplars are planned for the students to view role-modeled examples of medication administration prior to the OSCE.
The students expressed a favorable attitude of safety first, but judged unfavorably the role of the OSCE’s connection to future practice. Benner, Sutphen, Leonard, and Day (2009) explained that not all aspects of the complex practice of nursing are transferable: “If evidence or feedback from a situation does not mesh with their understanding of the situation or interpretation of information, the student must consider new interpretation” (p. 42). Improvements in attitudes may occur with immediate instructor feedback, post-OSCE self-reflections, and pre-OSCE viewing of video exemplars. Safety first, fundamental to clinical competence and a commendable outcome for this OSCE, reflects a connection to future practice.
The study findings may reflect female feelings, beliefs, and attitudes more because only one male student participated. Focus group methodology has the potential for “power differentiation”; the discussions may have been guided by more powerful voices and a consensus may have been a false representation of the group (Happell, 2007). The peer facilitator was instructed to encourage across-the-board participation to limit this phenomenon. These students represent the first groups to participate in this OSCE, a new experience as well for the simulation facility, the staff, and the pediatric faculty.
Although focus in nursing education has been on the cognitive and psychomotor domains of learning, the students’ feelings, beliefs, and attitudes affirmed the importance of including the affective domain into the development of experiential teaching strategies such as OSCEs. Students integrated the attitude of safety first into future practice but felt that anxiety, loss of personal control, reacting under pressure, and no feedback affected their ability to connect the OSCE performance with future clinical practice beyond safety first. Future nursing education research should develop quantitative OSCE assessment rubrics that include measurable affective domain components along with those from the cognitive and psychomotor domains.
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