A Short Commentary about Benefits and Drawbacks of Osces in the Nursing Education

Determining the clinical competency of nursing students before graduation involves many challenges. Recently in Taiwan, objective structure clinical examinations have been promoted for evaluating the clinical competence of nursing graduates. Objective structure clinical examination remained controversial, despite many studies having demonstrated the benefits of such examinations and their extensive use in nursing education. In this commentary, we discuss the benefits and drawbacks of using objective structure clinical examination in the nursing education to provide reference for their application.


Introduction
Traditional nursing education typically emphasizes the reasoning and application of the nursing theory as well as mastering of clinical skills; however, such theories do not assist in evaluating nursing students' clinical competency and practice. In contrast to traditional examinations, OSCEs initially involved well-trained standardized patients following clinical scripts to evaluate the clinical performance of the medical students through simulated scenarios. In the standard protocol, examinees rotate in a series of stations and are tested for a certain period, during which examiners use structured checklists to evaluate the students. However, discussing the appropriateness of OSCE implementation in nursing education is essential because of considerable discrepancies in the nature of practice between medicine and nursing.

Benefits of OSCEs
The literature indicates the following benefits of OSCEs:

Improvement of clinical skills
OSCEs involve a series of stations, thus assisting students in integrating professional knowledge and clinical skills through designing various scenarios associated with clinical knowledge and attitudes. Students have more opportunities to apply skills to develop various clinical competencies [1].

A safe learning context and assessment environment
Possible hazards or injuries to real patients are not a concern because OSCEs are conducted in simulated clinical contexts. OSCEs provide students with a safe learning environment, facilitate the transfer of learning, and enable the secure evaluation of clinical skills [1,2].

Opportunity for self-learning
Instead of exerting efforts to recall self-performance, students can interact with the instructor after OSCE during the instructor feedback time or directly observe themselves through video debriefing to improve their self-reflection and learning [3,4].

Gaining confidence in preparation for the career in nursing
Students not only gain experience through OSCEs and reduce their anxiety by practicing clinical skills in a bed-side context, but they also cultivate their abilities of on-sight observation and problem-solving. Therefore, they gain more confidence in becoming competent nurses in the nursing career [5].

Improvement of teaching
Students' performance reflects the appropriateness of teaching. Therefore, results from OSCEs provide a reference for teachers to rectify their teaching and instruction [6].

Drawbacks of OSCEs
Although OSCE seemingly possesses some advantages, many obstacles must be overcome. These challenges are as follows:

High ongoing costs
Organizing and conducting OSCEs constitute a complex procedure that requires a considerable amount of resources including adequate infrastructure, teaching personnel, materials, and finances, etc.. Furthermore, teachers must be updated continually on new knowledge and training methods. This procedure is time-consuming and exhausting. In addition, compared with medical departments, more resources are required because of the high number of nursing students graduating every year [2,7].

Controversy in validity and reliability
Multiplicity is involved in the planning and implementing OSCEs. Testing the validity and reliability of the evaluation processes and outcomes is challenging. The involved challenges include determining the relationship between stations, ensuring that standardized patients act appropriately and consistently, confirming that the assessment content reflects the real-life situations, examining clinical professional competencies that are essential in nursing, ensuring examiners' consistency in conducting and grading the OSCEs, building test-retest reliability in evaluation, and establishing the validity and reliability of grading checklists and passing criteria, etc.. Any one of these items being poorly organized could affect the fairness and objectivity of an assessment outcome [2,8,9].

Lack of a holistic nursing evaluation mechanism
Most OSCEs designed enable only a partial evaluation of nursing competencies and are usually lacking of mechanism and tools to measure patient-centered and holistic care-based nursing abilities. Competencies such as clinical decision making, caring, and ethics, etc.. are either being overlooked or are simply unable to be tested in OSCEs. This shortfall is the result of OSCEs being conducted involving too many short stations. Methods for rectifying the mechanism used require further discussion [10].

Student stress
The literature suggests that student stress is another limitation of OSCEs. Most studies have indicated that majority of students experience high level of stress during an OSCE, which might negatively affect the performance of students. Consequently, this might undermine the validity and reliability of OSCEs [11].

Conclusion
Teachers must employ various teaching strategies, such as OSCE, to miss the need of diversified students learning. Competencies such as providing holistic care, caring (the core nature of nursing), and making sound clinical decisions (a survival tactic in clinical practice) can rarely be validated through OSCEs. The cost-effectiveness of OSCEs is another issue. Discreetly advocating OSCEs for evaluating the competencies of nursing students is recommended.