Undergraduate nursing students require effective opportunities to gain, develop, and master the skills and knowledge required to be competent RNs (Beckham, 2013; Weiner et al., 2014). However, objective evaluation of clinical competence in nursing students remains a major challenge for nurse educators due to limited sites for clinical placements, varying clinical hours, and no consistent assessment of practice tools (Crookes & Brown, 2010; Walsh, Bailey, & Koren, 2009).
The use of Objective Structured Clinical Examinations (OSCEs) in preregistration nursing education can offer a consistent and reliable assessment approach to student clinical competencies (Jones, Pegram, & Fordham-Clarke, 2010; McWilliam & Botwinski, 2010). The OSCE enables nursing students to develop clinical competence that is based on theoretical knowledge and evidence-based nursing practices (Bradshaw & Merriman, 2008; Weiner et al., 2014). However, few studies have explored nursing students' perspectives of completing OSCEs (Nulty et al., 2011; Walsh et al., 2009), which is needed to inform the development of quality, student-centered assessment processes.
The purpose of this article is to provide an overview of the perspectives of nursing students undertaking an OSCE. This study was undertaken as part of a larger quantitative evaluation of the OSCE, which is to be reported elsewhere. In 2014, 278 final-year undergraduate nursing students completed an OSCE for the first time, which centered on the administration of a scheduled medication (i.e., controlled drug or drug of addiction, Schedule 8 of the New South Wales Poison List [New South Wales Parliamentary Counsel's Office, 2008]) to a simulated patient. The students completed the OSCE at four different sites; the curriculum is delivered at multiple campuses that form part of the school of nursing. Prior to undertaking the OSCE, students were asked to complete a survey centering on their thoughts and feelings about the impending OSCE, which also contained a section for qualitative comments. The students also completed a post-OSCE survey. This article will report on the qualitative analysis of the student comments, as their perspectives are needed so as to enhance the development of future OSCEs within the school.
The purpose of this research was to evaluate the first implementation of the OSCE from the perspectives of the involved students to enhance the quality of this style of assessment within the school.
Ethical approval for the project was gained from the human research ethics committee (HREC) within the university. Throughout the stages of the project, the purposes were outlined to participants. Issues relating to confidentiality, voluntary participation, and the option of withdrawing from the process at any time without incurring sanctions were made clear.
OSCE Development and Application
The OSCE development team was composed of the first three authors of this article (R.B., M.M., R.A.B.), with consultation undertaken with staff at other universities who had developed and conducted similar types of assessment. Six patient scenarios were developed with corresponding documentation and medication charts. The marking criteria and evaluation framework are based on Crookes' and Brown's (2010) nursing competency assessment schedule. This assessment and developmental framework was developed and validated through an Australian Learning and Teaching Council and is used by several Austrailian universities.
The students completing the OSCE were in the final session of their 3-year degree and were located at all four sites or campuses. Preparation for the OSCE included access to marking criteria, use of a dedicated online discussion space, and a laboratory session. In the laboratory session, students attended a mock OSCE, which broadly reflected the actual assessment without the standardized patient.
The assessors for the OSCE were RNs who worked within the school as clinical facilitators, laboratory teachers, and tutors. In November 2014, 278 students participated in the medication administration OSCE as their final assessment. For each student, the examination consisted of a 5-minute period to read his or her allocated case study and medication chart. Six different patient scenarios were included, and the students were randomly allocated to a station and a corresponding scenario. The student then had a further 25 minutes to introduce themselves to the standardized patient and obtain informed consent (including explanation of adverse effects), calculate the dose, prepare the medication, and then safely administer this to the patient using the five rights of safe medication administration.
While the examination took place, an RN (assessor) observed the student throughout all processes and evaluated the student's performance using the nursing competency assessment schedule employer competency document “Managing Medication Administration—the management of medicine administration for a single client/patient—oral administration” (Crookes & Brown, 2010).
This qualitative study is part of a larger mixed-methods investigation exploring the experiences of both the students and assessors who participated in the OSCE within the school. The addition of a qualitative component to a quantitative assessment can provide a vivid description of the intervention, adding insight into the quantitative results (Creswell & Plano Clark, 2007).
Participants who formed the convenience sample were those students from the third-year cohort undertaking the OSCE who expressed interest in participating. Of the original sample, 40% (n = 102) provided comments on both the pre- and postsurveys. The qualitative analysis of these comments from stage one and stage two of the study is the focus of this article. A two-stage data gathering strategy was undertaken. The first stage was to survey participants' pre-OSCE using a hard copy questionnaire that incorporated both Likert-scale questions and a section for comments. The second stage involved surveying the same participants' immediately post-OSCE with the use a Likert-scale questionnaire that also included a comments section.
All data was transcribed and analyzed by the two researchers using the open-coding method, whereby each assigned codes that highlighted the key points within the data. After initial coding sheets were completed, both researchers compared and merged their initial codes into more robust categories. Comparison and analysis continued until themes emerged and a level of saturation was identified (Corbin & Strauss, 1990).
Findings and Discussion
With the findings from the first stage data analysis (the pre-surveys), three main themes emerged from the study: (a) Student Anxiety, (b) Student Preparedness, and (c) The Effectiveness of This Style of Assessment. It is important to mention that no disparities were noted in the analysis when considering the data were collected across four different sites.
Anxiety. A key theme that became obvious early on in the analysis was centered on Student Anxiety. Over half of the sample (n = 69) documented feeling “nervous” or “anxious” regarding the impending OSCE. This perception could be due to the fact that this was the first OSCE experience for participants. One student commented:
It's extremely stressful and confronting, it's the first time we have to do this. People will find their nerves contribute to worry, stress, and their performance .
Conversely, the current study found that the thought of the OSCE evoked strong senses of anxiety and stress, although the students still thought that the OSCE would be beneficial. Another student commented:
It's a very nerve wracking process. It's an extremely stressful process but I believe that it's an effective assessment tool and will help me in the near future when I'm [an] RN.
Preparedness. The way in which the students were prepared for the OSCE also featured strongly in the analysis, with 55 participants mentioning OSCE preparation in their responses. Preparation and familiarization with the OSCE process is recognized as a significant issue within the literature (Brand & Schoonheim-Klein, 2009; Brooks, 2007; Furlong, Fox, Lavin, & Collins, 2005). Comments related to preparation by the participants in the current study centred on the online availability of assessment information in the form of a step-by-step guide to OSCE processes, as well as the presentation of the marking criteria. Participants also positively mentioned the preparatory laboratory sessions, as reflected in this comment:
I feel the preparation class simulation was good to prepare for the OSCE. It really helped test my practical skills and things I have learnt throughout the 3 years.
However, not all participants agreed they felt appropriately prepared, which contributed to feelings of anxiety and stress. Thirteen students expressed dissatisfaction with preparation processes, which were mostly specific to the skill being assessed. Medication administration is deemed by students and experienced nurses alike as being one of the most anxiety-provoking, high-risk tasks performed as part of regular nursing responsibilities (Coyne, Needham, & Rands, 2013), which may have contributed to the negative feelings felt by participants.
Effectiveness. More than one fourth of the sample (n = 31) expressed their views whether they felt that this type of assessment was an effective way of assessing students. A number of students discussed this in terms of their future practices as RNs. One student stated: “I believe the OSCE is an effective way to gain knowledge and skills in medication administration.”
Conversely, 22 participants in the current study did not believe that the OSCE would be of benefit to them or their future practices, with one stating: “I don't think it's an effective assessment—maybe I'll change my mind when I've finished it.”
With the post-OSCE findings, the second stage in the study, the three key themes that emerged from the data were: (a) Feelings Toward the OSCE, (b) Assessor Interaction, and (c) The OSCE Environment.
Feelings. The subjective experiences of completing the OSCE and their feelings toward this style of assessment were mentioned by 88 participants. Students expressed both positive and negative feelings toward the OSCE. One student stated: “[From a] student point of view, OSCE should be done more often in order for [students to] feel confident in [the] procedure of medication administration.”
The majority (77%) of comments about their feelings, however, were positive. These positive feelings were largely compared to participants' less-than positive ones prior to completing the OSCE. Participants documented feeling “much more positive” and “happy” about this style of assessment after they had completed it, they felt it was “fair” and they had “achieved” something.
Assessor Interaction. More than two thirds of the sample (n = 82) commented positively on the interactions between themselves and the RN assessing them. Words such as “supportive,” “kind,” and “understanding” were frequently mentioned in participant comments. However, not all assessor interactions were viewed in a positive way. Ten participants' comments were negative in terms of their allocated assessor, as they felt the attitude of the assessor resulted in them becoming more “nervous” and “stressed.”
Environment. The environment in which the OSCE took place was mentioned by more than one third of the sample (n = 42). The OSCE development team went to great lengths to ensure a realistic environment in terms of the clinical space, the medications being administered, and the documentation provided.
A limitation for this research was that it was undertaken in one university in a regional area of New South Wales, Australia. This was the first time these groups of students were exposed to an OSCE, allowing for a rich source of data; however, it contributed to the students' feelings of anxiety. The OSCE was the final examination for this group of students in a 3-year degree, and this may have influenced their responses and anxiety related to their performance in the OSCE.
In general, the student voice was clear in that the OSCE was valued, albeit stressful. The OSCE gave the students confidence in their capabilities with medication management. Students will find this form of assessment stressful, but implementing additional opportunity to use OSCEs within the curriculum and enabling greater frequency of exposure is important and will reduce the stress that students perceive. This strategy will be used in the course pedagogy in the future. Further research from the perspectives of nursing students should be undertaken to explore how increasing opportunities to undertake OSCEs affects students' capability and confidence in their future practices as RNs.
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