Application of Objective Structured Clinical Examination in Community Health Nursing Course : Experience of Staff Members and Students

Objective Structured Clinical Examination (OSCE) is the most valid and reliable tool for evaluation of performance competency. There are different formats of OSCE to assess the cognitive and psychomotor skills as well as the knowledge recall and communication skills in an objective and consistent manner. It is important to involve students and examiners in changing or innovating of evaluation pattern. The present study aimed to investigate the perception and experience of staff members and students toward introducing OSCE as a new approach of assessment in community health nursing course. In addition to compare the applicability of using three different structured methods of simulated patient (Lay person with staff members, Staff members play double roles and two staff members), in order to find out the most appropriate simulated patient method. The study is a mix of quantitative and qualitative design. It was carried out at the fourth year community health-nursing students, totaling 160 students. All examiners (n= 16) and only 60 students participated at the focus group sessions. Results revealed that most of students and examiners were satisfied with the objectivity of OSCE and the variety of questions that increase the chance of gaining marks. The students' level of performance ranged from good to excellent in all stations for most of students. The study recommends introducing OSCE into the curriculum of community health nursing course and holding comprehensive training for staff members on being a simulated patient and examiner at the same time.


INTRODUCTION:
The Objective Structured Clinical Examination (OSCE) is one form of performance-based assessments; this assessment was first introduced into medical education by Harden in Scotland 1975 (1,2) .OSCE has proven to become the gold standard allover the world as a tool for evaluating the clinical competency in view of the fact that it fulfill all the criteria of an ideal method of assessment, which Bull High Inst Public Health Vol.39 No.2 [2009]   includes comprising validity, reliability, objectivity and practicability or feasibility (3) .

Objective Structured Clinical
Examination (OSCE) is an assessment approach that is used to evaluate clinical competence of health science undergraduate students in a comprehensive, consistent, and structured manner, putting into consideration the objectivity process by using an examination format that instructs students to rotate through a circuit of stations of clinical tasks to increase the test reliability (2,9,10) .In addition, it addresses the assessment of the three domains cognitive, affective, and psychomotor at one point (11) .Currently OSCE becomes a popular tool for assessing clinical competency in nursing, for the reason of its main objective is to evaluate students' skills and attitudes at a higher level of integrated learning, which is not possible with traditional evaluation approaches.Studies have shown that OSCE objectively evaluates various skills including the ability to elicit vital information, analyze and synthesize it, apply knowledge, make sound clinical decisions, and communicate effectively (12)(13)(14) .
There are different formats of OSCE that have been used for health sciences students including nursing students.These formats include anatomical models to enable students demonstrate practical tasks, computer images to evaluate students abilities to utilize information regarding identification of certain health conditions, risk factors or proper intervention (15) .In addition, standardized patient/ stimulated patient (SP) which is a simulation of a patient by an actor or other layperson who is trained to present the specified history and physical findings in a standardized particular manner.Students, faculty staff, or physicians could be trained to act as SP (16,17) .This performance is repeated uniformly and consistently.The advantage of standardized patients in evaluation is presenting different students with a similar challenge, thus it reduces one important source of variability (18) .
Furthermore, SP incorporates a wide range of options resembling reality that allow students to work out through a clinical problem with little or no mistakes, permit students to make life-threatening errors without hurting a real patient, and provide instant feedback so students that can correct a mistaken action (17) .
In nursing education it was approved that OSCE can be used most effectively to assess safe practice in terms of performance of psychomotor skills, as well as the communication and schematic knowledge associated with their application (19) .
While using non-standardized patients  Bull High Inst Public Health Vol.39 No.2 [2009]   Staff members play double roles and two staff members), in order to find out the most appropriate simulated patient structure method.

Methodology:
Study design: The study is a mix of quantitative and qualitative designs.The qualitative design was used to portray the students and examiners' experience with OSCE by using focus group discussion (FGD) (20) .According to Barrour 2005, The FGD is appropriate to draw-out the voice of students in relation to introducing a new method of evaluation. (21).
The study included research questions, which are: 1 -What is the experience of students and examiners with the application of OSCE?
2-What are the challenges that face students and examiners in OSCE?
3-What are the views of students and examiners about using different three structure methods in simulated patient stations?
4-What is the most applicable structure method of simulated patient station?

Setting:
The study was carried out at Community

Methods:
The study carried out through two main phases:

1-Preparation Phase included two parts:
The first part included negotiation and discussion with staff members of community health nursing department.students were asked to record their findings in a certain sheet that used to confirm the observation scale marks.

Exam's scores:
Researchers used the gained scores to compare the level of performance of students at the different stations, in order to predict its appropriateness for students.
Level of performance of students rated as following: Poor less than 50%, fair from 50% up to < 65%, good from 65% to < 75%, very good from 75% to < 85% and excellent from 85% and more.

2-Data collection: Data was collected by using:
-Focus Group Discussion (FGD) was used to obtain the views of students and examiners regarding the different examination methods of OSCE.
Focus group discussion included two groups: The first group is "Group (A) students FGD", and the second group is "Group (B) examiners FGD".To

Data analysis:
Quantitative data analysis The quantitative data was analyzed by using SPSS package, ONE-WAY ANOVA was used to compare the mean difference of students' scores at multiple simulated patient stations.

Qualitative data analysis:
Thematic categories and agreed themes (21) .

Ethical consideration:
All participants informed about the study, and consents were obtained from them.
Students informed that there is no any obligation to participate in the study and they have the right to refuse to participate without any affection on their formal assessment.All data was anonymised, and names were replaced with a participant number.

Results:
The study results are presented by qualitative and quantitative data.These results were divided into two main parts; the first part describes the performance and experience of students with Objective

Structured Clinical Examination (OSCE).
The second part illustrates experience of examiners with OSCE.

Students' performance and experience with OSCE:
he study findings present important perspectives of admitted students to OSCE at community health nursing course.A student's view about OSCE is approximately similar in several studies.They view OSCE as helpful in identifying areas of weakness; it is a comprehensive, fair, and objective evaluation method (3,10,24) .The present study showed general positive views of students toward OSCE in terms of proper organization, objectivity, and fairness.In This negative view reported in other studies to be intimidating and more stressful than other assessment format (3,10,24) .Specifically, when OSCE introduced to nursing students in Ireland, it was perceived to be a meaningful and fair form of assessment, although they acknowledge the OSCE as a stressful experience (26,27) .
Results of examiners' experience with OSCE approved the positive and negative views of students about OSCE in terms of objectivity, comprehensiveness, and wide range of evaluated skills.This findings in agreement with Iqbal et al 2009, who reported that all staff members who participated in their study perceived OSCE to be an excellent tool for summative assessment that portray the level of different skills of each examinee (24) .In performance in OSCE (25,28) .Examiners declared that they found difficulty to train laypersons and they did not demonstrate enough cooperation during exam.These findings are confirmed by a study conducted at Michigan University which revealed that lay persons did not portray the patient in the manner expected (29) .
Furthermore, examiners pointed out that students tried hardly to pull out the correct answer from them.
There was variability in students' views understood the purpose of simulation and medical condition portrayed (29) .Students have a suspicion that the objectivity of the evaluation will be reduced when staff member acting as simulated patient, especially when playing double role.reliable and valid means of assessment (30)(31)(32) .

Conclusion:
In conclusion, all the academic staff as an assessment of clinical skills for students reduces the reliability and validity of exam.In community health nursing, patients or clients may complaint of manifestations that beyond the students abilities or out of the learned objectives.In addition, the turn over of clients and patients in community health settings is high, which results in absence of desired health conditions for students evaluation and inconsistent chances for students to be examined in an objective manner.In this highlight of finding of Pierre et al 2004, which indicated the necessity of using new assessment tools with student and the impact of OSCE in reducing injustice and inconsistency of clinical evaluation (3) , it was necessary to introduce OSCE approach in the community health nursing course as evaluation methods.Accordingly, the present study aimed to investigate the experience of staff member/ examiners and students toward OSCE as a new approach of assessment.Furthermore, the study compared the applicability of using three different structured methods of simulated patient (Lay person with staff members, the student challenges at each station and how you overcome?Q4-How do you think about fairness and objectivity of each station?Q5-How do you describe the statements, questions and scenarios of OSCE?Q6-Describe your experince as regarding simulated patients' station?Q7-What do you suggest to use OSCE effectively in the future?Q8-What are the challenges that you found in OSCE?
to search for common themes and similarities, and also variations among participants' views.Data was coded and similar codes were identified and grouped together under categories and subcategories.Similar categories were organized together under common themes.To check the validity of the findings, the three researchers reviewed the raw data and clarity of analysis in relation to the emerging
addition, they described it as a comprehensive either for covering most of Bull High Inst Public Health Vol.39 No.2 [2009] learned topics and course objectives, or the scope of measured skills especially intellectual skills.One benefit of this comprehensive evaluation method is collection of marks as mentioned by one third of participants.These results are confirmed by the quantitative marks of the registered students (table1), as nearly half of them demonstrate excellent scores and a minimal percentage had a fair scores, although the variation of performance level within the three types of examination that used in OSCE.The present study is in agreement with several studies that used OSCE for students in different health sciences.Health sciences' students approved that OSCE covers a wide range of clinical skills, competencies and, knowledge; in addition, chance of failing was minimal, as reported byAwaisu et al 2007 and Pierre et al 2004   (3, 10) .Furthermore, the present study in agreement with Khursheed et al 2007 who mentioned that the majority of students agreed that the given tasks of OSCE were clear and easily understood.(25)On the other hand, some participants of the present study had negative perspectives regarding to OSCE.These negative perspectives were expressed in terms of limited allocated time in some stations that provoke feeling of stress among students.
addition, they discussed that time limitation, uncomfortable environment at some stations, waiting for long time due to large number of students and shortage of staff members are the reasons of students' anxiety.This in agreement with Barman 2005 who recommended triplications of OSCE circuits was to reduce time and subsequently students' anxiety will be reduced (4) .Nowadays, simulation is taking an important place in training and evaluation of healthcare professionals.As regarding to multiple simulated patient exam, students found it the most difficult and stressful one.They referred feeling of stress to the presence of observer, level of cooperation and uncontrolled facial expression of simulated patients.Stress was decreased at Layperson with staff member as they felt more comfort to obtain health history, performing assessment and giving health education.Feeling of stress and difficulty was provoked at stations where staff members playing double roles, but it extremely exceeded at two Staff member's station.The uncooperative simulated patients viewed by students to be lay person who have limited information about the condition that they are acting, or staff members who disappoint their trails in obtaining a direct answer about the condition that mentioned in the scenario.Findings of Khursheed et al 2007 and Peckler et al 2009 confirmed the present study in relation to effect of simulator's response or behavior on students' about objectivity and fairness of multiple simulated patient exam.Some students referred objectivity and fairness to the reality in simulation that they felt in layperson with staff examiner station.While others found staff stations is more objective due to the understanding of staff members to the health condition when they acting as simulated patient.So it could be an advantage of using staff members to act as simulated patient in the highlight of the findings of Lovell et al 1998 who stated that medical student-simulated patient