ABSTRACT
Assessment of clinical performance contributes to academic qualifications that
incorporate professional awards. The administrators of Nursing Schools are
facing the problem of subjectivity in practical examination of student nurses.
This is evident in examination situations in which the examiner assigns any
task of choice to the student and scores the student based on his/her perception
of the student’s competence in performing the task. By this, some students are
exposed to more difficult tasks than others and subjective scoring, all
depending on the inclination of the examiner. In response to this problem, the
study developed and validated a Structured Clinical Assessment Tool (SCAT)
that will make it possible for all the students to be examined on the same tasks
for any examination episode and judged on the same premise. Instrumentation
research design was used. One hundred and thirty seven student nurses from
three Schools of Nursing in the South East Zone of Nigeria formed the sample
for the study. Prior to developing the tool, a competency assessment framework
was developed based on the nursing process model with the five steps of the
process being the core competencies and sub skills identified for each of the
core competencies. The appropriateness of the sub-skills was verified using 52
nurse educators. The care sub-skills were pooled to form the model for SCAT.
The model consists of twelve activity stations which are examination points
where students perform specified nursing tasks and are scored using a
predetermined standard. Initially 48 items (four per station) and their scoring
guide were generated and four experienced nurse educator/managers were used
to verify their appropriateness. Thirty six items survived the validation exercise
using average congruency percentage. Data collected were analysed using
alpha coefficient, t-test and analysis of variance. The results of the analysis
confirmed the validity of the 36 items and showed that the items were able to
discriminate between the high and low achievers. The high reliability index
(0.84-0.99) for most of the procedure station items and moderate reliability
index (0.69-0.78) for others confirm that the instrument has a good inter-scorer
consistency and therefore is reliable. Based on these findings, the SCAT is a
tool that has the potentials for reducing the subjectivity that is inherent in
clinical assessments that are based on observation and is therefore
recommended for assessing clinical competence of student nurses.
8
TABLE OF CONTENTS
TITLE PAGE ii
APPROVAL iii
CERTIFICATION iv
DEDICATION v
ACKNOWLEDGEMENT vi
ABSTRACT vii
TABLE OF CONTENTS viii
LIST OF TABLES xi
CHAPTER ONE: INTRODUCTION
Background to the study 1
Statement of the problem 8
Purpose of the study 11
Significance of the study 12
Scope of the study 14
Research questions 15
Research hypothesis 16
CHAPTER TWO: REVIEW OF RELATED LITERATURE
Introduction 17
Conceptual framework 18
– Definition of Nursing 18
– Clinical competence in nursing 24
– Nursing process 24
– Competency outcome performance assessment 32
– Competency assessment framework 34
Theoretical framework 36
Organizational theories 36
-Max Weber theory of bureaucracy 36
-Getzel and Guba theory of organizational behaviour 38
Developing criterion-referenced measures 41
-Determining conceptual framework 43
-Explicating objectives or domain definition 44
9
-Preparing of test specifications 46
Validating clinical competency assessment tool 50
Empirical studies on instrumentation 63
Summary of reviewed literature 74
CHAPTER THREE: RESEARCH METHODOLOGY
Introduction
Research Design 77
Area of the Study 78
Population of the Study 78
Sample and Sampling Procedure 80
Instrument for Data Collection 81
Development of SCAT 84
Validity of the Instrument 100
Trial testing of the Instrument 101
Reliability testing of the Instrument 103
Method for Data Collection 104
Method of Analysis of Data 106
CHAPTER 4: PRESENTATION AND ANALYSIS OF DATA
Presentation of Data 109
Research Question 1 109
Research Question 2 118
Research Question 3 121
Research Question 4 125
Hypothesis 1 127
Hypothesis 2 128
Summary of findings 132
10
CHAPTER FIVE: DISCUSSION OF RESULTS, CONCLUSION AND
RECOMMENDATION
Introduction 134
Appropriateness of Tasks and the Activities for Assessing
Competence 134
Validity of SCAT 135
Reliability of SCAT 136
Hypotheses testing 136
Conclusion 138
Educational Implication of the Study 138
Recommendations 140
Limitations of the Study 140
Summary 141
REFERENCES 145
APPENDICES 150
11
LIST OF TABLES
Table 1: Distribution of student population. 79
Table 2: Ratings of the appropriateness of sub skills of assessment. 109
Table 3: Ratings of the appropriateness of sub skills of diagnosing. 110
Table 4: Ratings of the appropriateness of sub skills of planning 110
Table 5: Ratings of the appropriateness of sub skills of evaluation. 111
Table 6: Ratings of the appropriateness of sub skills of
implementation. 111
Table 7: Ratings of the appropriateness of the items of SCAT. 113
Table 8: Mean scores of ratings of the appropriateness of activities
for determining competence. 119
Table 9: Average congruency percentage of the ratings of the
four raters. 121
Table 10: Alpha coefficient values for School 1 125
Table 11: Alpha coefficient values for School 2 126
Table 12: Alpha coefficient values for School 3 127
Table 13: t- test values for high and low achievers on SCAT. 128
Table 14: F- ratio for students’ performance for School 1. 129
Table 15: F- ratio for students’ performance for School 2. 130
Table 16: F- ratio for students’ performance for School 3. 131
12
LIST OF FIGURES Page
Figure 1: Process in developing criterion-referenced measure 85
Figure 2: Model for the structured clinical assessment tool. 90
13
LIST OF APPENDICES
Appendix 1: Core competencies of the Nursing process. 150
Appendix 2: Core competencies of the Nursing process and
their care sub-skills 151
Appendix 3: Structure clinical assessment model. 152
Appendix 4: The Structure Clinical Assessment Tool 153
Appendix 5: Ratings of items of SCAT and the scoring
guide 203
Appendix 6: Selected items of SCAT after preliminary
validation. 207
Appendix 7: Scoring guide for the selected items. 222
Appendix 8: Students’ scores as determined by the three
scorers that scored each student in the six
procedure stations (for trial test). 250
Appendix 9: Mean scores of the ratings of the students and
scorers on the adequacy of instructions, time
allotted and ease of scoring. 251
Appendix 10: Students’ scores as determined by the three
scorers that scored each student in the six
procedure station (for the three schools used
in the study) 252
Appendix 11: Letter of permission to institutions. 256
Appendix 12: Consent form. 257
14
CHAPTER ONE
INTRODUCTION
Background to the Study
Effective administration requires rational decision making which will
lead to the selection of the way to reach the anticipated goal. The
educational administrator in trying to achieve the ultimate goal of
improving learning and learning opportunities to ensure competent
products is faced with the responsibility to make decision on such issues
as selecting appropriate curriculum, selecting appropriate teaching
methods, and selecting appropriate methods for assessing the student’s
progress. If appropriate decisions are made on these issues, appropriate
educational policies will be made and the goals of education will be met.
However if inappropriate decisions are made, particularly on methods of
assessing students, the society will be exposed to the danger of
incompetent practice. This is so because learners who have not acquired
the necessary knowledge and skills for competent practice may be
certified to be qualified to practice and may not give quality and safe
care.
15
Generally the school curriculum is organized to expose students to
subjects that provide opportunity for them to acquire the knowledge and
skills that should help them practice. Sometimes students who have
passed written examination and certified fit to practice fail to do so.
Considering the legal and financial implications of employee
performance and safe practice in a rapidly changing environment, a major
concern of an educational administrator of an institution should be to
produce manpower that is competent. It is therefore important in
assessing students for certification to practice, in this case, in a health
care institution, to generate appropriate data that will help in making
decision on whether they are able to perform tasks that the knowledge
they have acquired should help them to accomplish. This can be done if
an appropriate assessment tool is in place.
Stressing the importance of assessing what nursing care providers can
do, not what they know, Del Bueno (1990) cited situations in which
people who had performed excellently well in examination had difficulty
performing a procedure or recognizing warning signs in patients
experiencing difficulty. This kind of situation is unacceptable and
16
informed the reforms in nursing education which led to calls for
assessment of clinical performance to contribute to academic
qualifications that incorporate professional awards. In response to this
call, training institutions have developed clinical assessment tools.
However, Redfern, Norman, Calman, Watson & Murrels, (2002)
expressed some concern about the psychometric quality of the tools that
are available and the ability of the tools to distinguish between different
levels of practice. They analyzed some tools of assessing competence to
practice in nursing, while Norman, Watson, Murrels, Calman, and
Redfern (2002) tested selected nursing and midwifery competence
assessment tools for reliability and validity. Both team of researchers
concluded that a multi-method approach which enhances validity and
ensures comprehensive assessment is needed for clinical competence
assessment for nursing and midwifery.
In order to ensure such a tool, Lenburg (2006) created a constellation
of ten basic concepts and suggested that they should be adapted for
developing and implementing objective performance examination. They
include:
17
Concept of examination
Dimensions of practice
Required critical elements
Objectivity of the assessment process
Sampling critical skills for the testing period
Level of acceptability
Comparability in extent, difficulty and requirements
Consistency in implementation
Flexibility in actual clinical environment
Systematized conditions.
These concepts are very useful to the development of accurate
assessment instruments. Thus far in the nursing context in Nigeria, such
tool does not exist. The administrators of nursing schools are facing the
problem of subjectivity in practical examination of student nurses. This is
evident in situations where students are given different tasks to perform
during clinical examination and awarded grades based on the tasks they
perform. By this some students are exposed to more difficult tasks than
others, all depending on the inclination of the examiner and yet judged on
the same maximum score. This is unfair. It is therefore necessary to
develop an assessment tool that will examine the students on the same
tasks for a particular examination episode.
In order to accomplish this, consideration should be given to the
concepts proposed by Lenburg (2006) which were mentioned earlier. To
18
achieve objectivity in an assessment process two components must be
considered. First the content (skills and critical elements) for the
particular assessment should be specified in writing and second, there
should be a consensual agreement of everyone directly involved in any
aspects of the examination process. When individual examiners begin to
digress from the established standards and protocols, objectivity erodes
back into subjectivity and inconsistency. This regression destroys the
process and the purpose.
To prevent this from occurring, the educational administrator
should ensure that the content of the examination is specified by the list
of the dimensions of practice, that is, the skills and competencies and
their required critical elements that determine the extent and conditions of
competence.
The use of a conceptual framework to systematically guide the
assessment process increases the likelihood that concepts and variables
universally salient to nursing and health care practice will be identified
and explicated (Waltz, Strickland & Lenz, 2005).
19
Concepts of interest to nurses and other health professionals are
usually difficult to operationalise, that is to render measurable. This is
partly because nurses and other health professionals deal with a
multiplicity of complex variables in diverse settings, employing a myriad
of roles as they collaborate with a variety of others to attain their own and
others goals. Hence, the dilemma that they are apt to encounter in
measuring concepts is two fold; first; the significant variables to be
measured must, by any means, be isolated, and second, very ambiguous
and abstract notions must be reduced to a set of concrete behavioural
indicators. It is therefore the responsibility of the educational
administrator who knows the goals that are intended and that selected the
content that should help in the achievement of the goal to select the
variables that must be measured and to reduce them to concrete
behavioural indicators of competence. These should be incorporated into
a protocol that will guide the assessor.
Protocols ensure that each test episode for a given group is
comparable in extent, difficulty and requirements. Protocol also ensures
that the process is implemented consistently, regardless of who
20
administers the examination or when it was conducted. When
performance examinations are administered in actual clinical
environment, not simulation, the concept of flexibility is essential as each
client is different. The responsible educational administrator, who
prepares students for professional practice is therefore challenged to
develop appropriate competency-based assessment tools for use in the
assessment of students’ clinical competence.
Competency-based assessment tool focuses on measuring the
actual performance of what a person can do rather than what the person
knows. It is based on criterion-referenced assessment methods where the
learner’s performance is assessed against a set of criteria provided so that
both the learner and assessor are clear on what performance is required.
Competency-based assessment technique addresses psychomotor,
cognitive and affective domains of learning and its goal is to assess
performance for the effective application of knowledge and skill in
practice setting. The competencies can be generic to clinical practice in
any setting, specific to a clinical specialty, basic or advanced (Benner,
1982; Gurvis & Grey, 1995).
21
Criterion-referenced measures are particularly useful in the clinical
area when the concern is the measurement of process and outcome
variables as applies in nursing. A criterion-referenced measure of process
according to Waltz, Strickland & Lenz (2005), requires that one identifies
standards or the client care intervention and compares the subjects’
clinical performance with the standard of performance which is the
predetermined target behaviour. When all these are taken into
consideration in developing a clinical assessment tool, the tool is bound
to be authentic.
Statement of Problem
In Nigeria, assessment of clinical performance contributes to the
academic qualification for professional award. The Nursing and
Midwifery Council of Nigeria (NMCN) has adopted the Objective
Structured Clinical Examination (OSCE) for midwifery but has not done
the same for general nursing examination. The tool that is currently in use
for clinical assessment for the general nursing examination leaves a lot to
be desired. It lacks the comparability and consistency that are required to
22
make an assessment tool objective and fair hence the need for a structured
clinical assessment tool. Some of the pitfalls of the tool include;
The tool makes allowance for the selection of the procedure to
be performed by the candidate to be made by the assessor and
this is varied from one candidate to another. The implication is
that all the candidates do not perform the same tasks and the
tasks they perform are not comparable and since the task
difficulty is not the same for all tasks, the candidates are not
examined nor judged on the same premise. This is unfair.
Another problem that is closely linked with not specifying tasks
that all candidates must perform is that the mark allotted to the
item, “procedure” is the same for all procedures whether simple
or complex and since some candidates are assigned simpler
tasks than those assigned to others and are judged on the same
optimal score for less work, the tool is unfair. Again, because
the activities expected to be carried out for each procedure is
not specified, the scoring of the candidates’ performance is
based on what the scorer thinks is right and this may vary from
23
one scorer to another. The implication is that most times, the
scoring is subjective.
Sometimes, the length of time required to accomplish a certain
task the assessor assigned to a candidate to perform may not
allow the assessor opportunity to assess the candidate on all the
areas that are listed on the clinical performance assessment
guide. Since all the items sum up to give the maximum score, it
creates the difficulty of determining what to do about scoring
those items particularly as it was not the fault of the candidate
that he was not examined in those areas by the particular
assessor.
Again, some of the criteria on which the candidates are judged
are not stated in specific terms. For example such statements as
“handles patients gently and skillfully” and “adapts the
environment for the patient’s comfort” are not specific enough
as to what the candidate is expected to do and therefore leaves
room for assessor’s subjective conclusions. The implication of
all these is that some of the results of assessments using this
24
kind of tool are not valid and may have negative impact on the
candidate who failed when actually he/she should have passed
and on the consumers of nursing care where a candidate who
had not acquired the necessary skills for competent and safe
practice passed when he/she should have failed.
In view of this problem, there is the need to develop a clinical
assessment tool that is objective and fair. This is the intent in this
study.
Purpose of the Study
The main purpose of the study is to develop and validate a
structured Clinical Assessment Tool which will provide opportunity for
all the students to be examined on the same tasks for a particular
examination period and be scored based on predetermined performance
criteria. This will ensure a fair, objective and valid assessment of student
nurses’ clinical performance.
Specifically the objectives are to:
1. develop appropriate tasks for assessing student nurses’ clinical
competence.
25
2. develop appropriate activities for determining competency in
the tasks
3. determine the content validity of the Structured Clinical
Assessment Tool (SCAT) that was developed
4. determine the construct validity of the Structured Clinical
Assessment Tool (SCAT).
5. determine the inter-rater reliability of the SCAT.
Significance of the Study
The study will result in the availability of an instrument for a more
comprehensive and objective clinical assessment of student nurses.
Because the instrument will cover the core practice competency areas in
nursing, it will be useful in determining whether or not student nurses
have acquired the complex repertoire of knowledge, skills and attitudes
required for competent practice before they enter the profession. The
instrument will be useful to nurse educators and clinical
supervisors/managers of health care institutions who are preparing
students for practice because it will show them the core elements of
competence in nursing and thus help them to guide the students
26
appropriately to acquire the skills necessary to become competent and
safe. It will also be useful to the students because they will know from the
start what is expected of them, and being focused, they will work toward
success.
The instrument will eliminate the problem of leaving the
candidates to the whims and caprices of their assessors which results in
some candidates carrying out more complex tasks than others and yet
judged on equal score. Instead, the candidates will perform the same and
specified tasks. This way, the candidates will be examined on the same
premise and any judgment made on the results that are generated by the
instrument will be worthy and valid.
Again, because the instrument has broken down the elements of
competence into performance criteria on which the performance can be
judged acceptable, scoring of students’ performance during assessment
will be easier and will be devoid of subjectivity and therefore will make
the result more authentic. The tool will serve as an impetus for the
Nursing and Midwifery Council of Nigeria (NMCN) to revise the tool
that is currently in use for the final qualifying examination to become
27
more objective and fair. If this is done only those who have acquired the
necessary knowledge and skill will be certified competent and licensed to
practice and the consumers of nursing care will be sure to receive quality
and safe care. The tool will also be a reference for other researchers who
will want to develop tools that will address procedures that are not
accommodated in the present study.
The Scope of the Study
The study is delimited to developing a structured clinical
assessment tool, developing a scoring scheme for the tool, establishing
the content and construct validity of the tool and determining the internal
consistency reliability of the tool. Only the average congruency
percentage for determining content validity; mean and standard deviation
of contrasted groups for determining the construct validity, as well as the
internal consistency reliability using index of inter-rater agreement were
determined.
The clinical events that were assessed were limited to procedures that
would be completed within 5 minutes. This was to ensure that the
students are assessed on a good variety of events within the one hour they
28
are normally assessed during practical exams. Exposing them to
procedures that take longer will limit the number of events that they will
be assessed on. The tool however presupposes that the students would
have been assessed (using a structured assessment tool) on those
procedures that take longer time to accomplish prior to this final
assessment.
Though the tool is developed for assessing clinical competence of
student nurses in Nigeria, the validation of the instrument was conducted
in the South East zone of Nigeria using three randomly selected Schools
of Nursing.
Research Questions
The study is guided by the following Research Questions
1. How appropriate are the tasks of SCAT for assessing student
nurses’ clinical competence?
2. How appropriate are the activities for determining competence
in the selected items?
3. How valid is the content of SCAT?
4. What is the inter-rater reliability coefficient of SCAT?
29
Hypotheses
The following hypotheses were tested at an alpha of 0.05
Ho1: There is no significant difference in the mean scores on SCAT
of high and low achievers.
Ho2: There will be no significant difference in the scores of the
students on any of the procedure stations of SCAT as determined
by the three assessors
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