Wallace, Lynn

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Queen Margaret University eResearch

                                       eResearch: the open access repository of the research output of Queen Margaret University, Edinburgh   This is an author-formatted version of a presentation published as:    Wallace L (2009) Sharing experience of clinical skills assessment between Scottish and Egyptian Nursing degree programmes: introducing the Objective Structured Clinical examination (OSCE) into emergency and critical care modules at Alexandria University. RCN Joint Education Forum’s 2nd international Conference  Glasgow                             Accessed from:    http://eresearch.qmu.ac.uk/962/                Repository Use Policy  The full-text may be used and/or reproduced, and given to third parties for personal research or study, educational or not-for-profit purposes providing that:  • The full-text is not changed in any way • A full bibliographic reference is made • A hyperlink is given to the original metadata page in eResearch  eResearch policies on access and re-use can be viewed on our Policies page: http://eresearch.qmu.ac.uk/policies.html     Copyright © and Moral Rights for this article are retained  by the individual authors and/or other copyright owners.                                   http://eresearch.qmu.ac.ukSharing Experiences of Clinical Assessment between Scottish & Egyptian Nursing Degree Programmes:Introducing the OSCE into emergency & critical care modules at Alexandria UniversityLynn Wallace, Lecturer, QueenMargaret University, Scotland, UKDr. Eman Zahran, Lecturer,Alexandria University, EgyptOutline • Sharing experiences – how it started• Process of collaboration in developing OSCEs at Alexandria University• Different approaches to clinical skills assessment –Clinical exam & Objective Structured Clinical Exam (OSCE)• Issues and challenges along the way How it started• Eman studying at QMU (post graduate diploma Professional Education) in 2007/8• My role as Personal Academic Tutor • Eman assisted with QMU pre-reg. OSCEs• Shared background in critical care• Both co-ordinating acute/ critical care modules in our roles as Lecturers  and interested in OSCEsBachelor Nursing: AlexandriaEman co-ordinator for:• Year 2 – Emergency Nursing course• Year 3 – Critical Care I & II courses• Clinical assessment by practical & oral exams • Large cohorts (75-260) BSc (Hons) Nursing: QMUCo-ordinator of Year 3 Problem Based Learning module (WebCT, 6 week block)ACUTELY ILL ADULT• Trauma learning package• ICU learning package• Simulation skills labs (CVP monitoring, ET suctioning, chest drains, trauma care)• Small cohorts 45-55 students• Lack of time & specialised equipment for OSCEsEman back to Alexandria• Resume lecturer post• Wishing to maintain links with QMU nursing staff• Idea of collaborating on curriculum development to introduce OSCEs into Emergency & Critical Care coursesAlexandria University1st Egyptian University to establishNursing Department• ‘Higher Institute of Nursing’ set up in 1955 and more recently developed into ‘Faculty of Nursing’Drivers for change at Alexandria University • Ministry of Higher Education: government encouragement and funding for educational reform• Revised National Quality Assurance & Accreditation 2004 : includes curricular & assessment standards, quality of learning opportunities• Nursing Sector Committee of Supreme Council of Universities 2008 – developed National Academic Reference Standards (NARS) for Bachelor Degree NursingCollaboration for change• Alexandria Faculty of Nursing received substantial government funding to improve clinical assessment • Faculty OSCE lab established with High Fidelity Patient Simulators for adult, paediatric and maternity care• Action Research Project – introducing OSCEs into critical care & emergency modules• My role as ‘expert’ external advisor on OSCEsThe collaboration process“… through the process of collaboration, people with a variety of strengths & backgrounds can collectively address substantive issues in education and ensure that the results are disseminated over diverse educational cultures.”(Elliot 2001 p1)Features of collaborating• Working equitably, commitment, respect• Not necessarily the same goals but compatible, clear & agreed• Sharing of prior experience, collective self-reflection, shared ‘language’(Elliot 2001)Recent experiences of international collaborationEstablishing BSC (Hons) Nursingprogrammes • Jeddah, Saudi Arabia• British University in Egypt, CairoApplying UK model of clinical assessment which includes OSCEsSecondment to Egypt: 2009• 4 months working in the new Nursing Faculty of BUE, Cairo • Need to find out more about Nursing & Higher Education in Egypt• Opportunity to link with established Nursing Faculty of Alexandria University Process of collaboration1. Together in Edinburgh 2. Keeping in touch: Edinburgh –Alexandria3. In Egypt4. Back in Scotland Process of collaboration 1In Edinburgh: • Eman observed and participated in pre-reg OSCEs• ‘Sharing stories’ - discussions between Eman & QMU Lecturers on our background knowledge and experiences of clinical assessment (clinical exams and OSCEs)• Eman - literature search on clinical examination & OSCE  Process of collaboration 2Keeping the links• Eman and team formulating plans for curriculum development • Action  Research Project:  Staff workshops, designing & testingOSCE stations, preparing students, preparing for and running OSCEs, student & staff evaluation with questionnaires and video analysis • Regular critical discussions (via email & Skype) as project evolved - delay in my secondment to BUE• Sharing documentation – exchanging examples of OSCE material and literature findingsAlexandria: problems with existing Clinical Exams • Increasing student numbers (e.g. 15:4 student: teacher ratio)• Time intensive 3 hour ‘long case’ style exam per student• Finding enough patients with the required conditions to match Intended Learning Outcomes (ILOs), permission to access• Uncontrolled environment: ensuring patient safety and rights, noise, interruptions• Examiner subjectivity Global problems? –shift from real to simulated assessment• All of the factors experienced in Alexandria PLUS• Shorter length of patients stay & higher acuity• Staffing shortages• Issues of standardisation, reliability & validity(Walder & Olson 2007, Rushforth 2006)Issues: ‘Long Case’ exam  • ‘real world’ clinical exam may have greater face validity than simulated or standardised OSCE situation• Inter-case reliability is more of a problem than inter-rater reliability – content specificity • Need broad sampling across cases to reliably assess clinical competence – number needed may be unachievable given limited clinical resources• Greater ‘depth’ of assessment than OSCE• Lacks standardisation – but is this a problem?(Wass & Van Der Vleuten 2004)Adapting the Long Case?• Improvements which incorporate some direct observation– the Objective Structured Long Examination Record (OSLER) or mini-Clinical Evaluation Exercise (mini-CEX)• Further research:  impact of inter-case, inter-examiner & real patient variance, construct & consequential validity• Argument for retaining use in formative capacity or combine long cases with OSCE stations (achieve depth & breadth)(Wass & Van Der Vleuten 2004, Fernando et al 2008, Donato et al 2008, McCrorie & Boursicot 2009)OSCE: the ‘gold standard’• Scotland home of the OSCE (Harden et al 1975)• Introduced to Egyptian medical education in line with 2004 proposed higher education reforms• Small number of Egyptian Nursing Faculties now using OSCEsIssues: choosing OSCEs for Nursing?• Student’s stress: but enhances validity of ‘real world’• Risk of fragmentation: skills as tasks, not holistic• Complex to organise (time, staff, cost)(Rushforth 2008)• Greater Objectivity: reduces bias with wider range of examiners• High level of validity & reliability• Cover broad range of skills• Students and staff value, motivatesNursing OSCEs: innovations• Holistic patient centred designs• Small number of stations or only 1• Allocated more time e.g. 30min stations• Incorporating ‘reflection’ / video analysis• Global ratings(Nicol & Freeth 1998, Major 2005, Joy & Nickless 2007, Byrne & Smyth 2008)Value of OSCEs: learning and assessment Hodges (2003) suggests OSCE• Powerful transformative tool• An instrument of change • Contextual fidelity (content validity)• Role representation (predictive validity)  Integrative OSCE approach Alinier et al (2003)• OSCE is integrated way of measuring learning outcomes in skills based learning• Encourages deep learning by testing higher cognitive functionsIntegrative OSCE approachDickieson, Carter & Walsh (2008) - factor analysis of 20min OSCE with simulated patient• safety: fundamental tenet of clinical competence• anticipation (pre-thinking & pre-planning): characterizes higher order concepts of critical & integrative thinking, evidence of mental processingProcess of collaboration 3In Egypt:• Continue with regular communication (phone calls, email, Skype)• April visit to Alexandria University Nursing Faculty, Critical Care & Emergency Nursing Department¾ Observe and review summative OSCE¾ Visit hospital setting where clinical exams take place¾ International Guest speaker at dept.’s Critical Care Conference: Revamping Clinical Evaluation in Acute Care Nursing – paper on developing OSCEs: the QMU experience¾ Report on findings from visit and make suggestions for continuing the development of OSCEsIssues : different educational language & norms• Course = module• Grading = marking• Formative assessment = mid term summative assessment• Heavy assessment schedule in comparison to UK for equivalent study• Student HE culture – expect & want lots of assessment to motivate study, won’t see value in formative assessment unless gradedQMU: programme pattern of Clinical AssessmentWork –Based ‘Clinical Practice’modulesPractice Record• Learning activities mapped with NMC proficiencies –complete and discuss in reflective tutorials with lecturer• Professional assessment by mentorUniversity based modules• Year 1 Skills module – Multi station OSCE incorporating ‘reflection’, e-OSCEs• Year 2 & 3 Enquiry/Problem Based modules – Integrated OSCE• OSCEs conducted inSimulation SuiteQMU Clinical Simulation SuiteQMU: Simulated patients• Bank of Volunteers from local community and Edinburgh area• Year 4 student nurses act as simulated staff nurses for Integrated OSCEsAlexandria:  revised pattern of Emergency / Critical Care assessment• Portfolio (includes assignment activities, some of which graded)• Mid semester & Final exams• Continuous clinical assessment• 2 OSCEs incorporating oral exam (in university skills labs)• Final Clinical evaluation (exam in clinical setting)Alexandria Skills labsRange of rooms andequipment includingHigh Fidelity Patient (HFP) Simulators OSCE : Emergency nursingFIRST • Pre-hospital CPR• Recovery Position & Log Roll• Written (MCQ)• Written (Audio-visual/ computer based)SECOND• Acute coronary syndrome (cardiac monitoring)• Inhalation therapy (Nebulisers)• N/G insertion & lavage• Trauma (problem solving) OSCE: Critical Care I & II FIRST• CVP measurement• N/G feeding• Written (MCQ)• Written (Audio-visual/ computer based)SECOND• Endo-tracheal suction (ventilated patient)• Ventilated patient (Communication with family)• Respiratory Assessment: intubated SIM MAN (critical thinking)Issues & ChallengesWhat are the priorities?• OSCE results revealed areas of  teaching weaknesses – how to address once identified? (e.g. increase teaching & learning  in skills labs)• Interpreting ILOs - choosing priority & range of skills (emergency/critical, common or rare) and deciding feasible number of stations• Balanced assessment strategy -holding onto the old ways as well as introducing new approaches could lead to over assessmentCreativity v Resources?  • Create realistic station design to enhance holism and clinical complexity while giving consideration to resource limitations (expanding time allocation and integrating several skills e.g. the way that assessment skills, communication, problem solving are included)• Maximise use of HFS / patient simulators and consider ways of developing simulated patients Issues & Challenges: students• Unhappy about long waits between stations• Not enough time at stations to complete skills • Rooms very noisy• Grading mid-semester formative OSCE: what effect does this have on students’ learning? • Concerns about opportunity for collusion over station information / answers between sets of students Issues & Challenges: staffEnhancing preparation of teachers in role as OSCE examiners• Realistic time commitment (attending ahead of start time to prepare stations, sticking to starting & finishing  times of stations, how many hours contribute to timetable)• Consistency (involve markers in preparation of check lists to increase familiarity and enhance reliable marking, students prompts during stations, when to give and nature of feedback, tracks of same station match same standards of set up and running)Issues & Challenges: staffSpreading the organisational load• Take forward excellent staff suggestion of OSCE Committee in order to distribute responsibilities across team but retain designated person as overall OSCE Co-ordinator.• Making timetables work ?Experiment with other methods of processing large cohort numbers to prevent student and examiner fatigue.Process of collaboration 4Back in Scotland:• Reflection on experience of nursing culture where clinical examsassessed by university teachers in practice setting are still the norm.  What are the issues? Has UK lost something valuable? • Differences in  roles and responsibilities of university (Teaching Assistants/ Lecturers) and clinical (nursing) staff between the two countries.  Does this impact on quality of clinical assessment?• Forthcoming curriculum review: Should there be changes made to include OSCEs in Year 3 Acutely Ill Adult module (as formative simulated learning experience or summative assessment).  Has theEgyptian experience demonstrated value of using OSCEs in specialist areas of pre-registration programme?• Eman completing Action Research    AcknowledgementParticular thanks to Alexandria University• Professor Nahed El Sebai (Dean of Faculty of Nursing)• Professor Azza El Soussi ( Head of Critical Care & Emergency Nursing Dept.)References• Alinier, G. 2003. Nursing students’ and lecturers’ perspectives of objective structured clinical examination incorporating simulation.  Nurse Education Today, 23 pp.419-426.• Byrne, E. and Smyth. S. 2008. Lecturers’ experiences and perspectives of using an objective structured clinical examination.  Nurse Education in Practice, 8 pp. 283-289.• Dickieson, P., Carter, L. M. and Walsh, M. 2008.  Integrative thinking and learning in undergraduate nursing education: three strategies. International Journal of Nursing Education Scholarship, 5 (1) article 39. pp1-15.• Donato, A., Pangaro, L., Smith, C., Rencic, J. Diaz, Y. and Mensinger, J.  2008.  Evaluation of a novel assessment form for observing medical residents: a randomised, controlled trial.  Medical Education, 42 (1) pp. 1234-1242. • Fernando, N., Cleland, J., McKenzie, H. and Cassar, K. 2008. Identifying the factors that determine feedback given to undergraduate medical students following formative mini-CEX assessments. Medical Education, 42 (1) pp. 89-95.• Harden, R., Stevenson, M., Wilson Downie, W. and Wilson, G. M. 1975. Assessment of clinical competence using objective structured exam. British Medical Journal, 1 pp. 447-451.• Hodges, B. 2003. Validity and the OSCE. Medical Teacher, 25 (3) pp. 250-254.• Joy, R. and Nickless, L. J. 2008. Revolutionising assessment in a clinical skills environment – A global approach: The recorded assessment. Nurse Education in Practice, 8 (5) pp. 352-358.References (cont.)• Major, D. A. 2005.  OSCEs – seven years on the bandwagon: The progress of an objective structured clinical evaluation programme.  Nurse Education Today, 25 (6) pp. 442-454.• McCrorie, P. and Boursicot, K.A.M 2009.  Variation in medical school graduating examinations in the United Kingdom: Are clinical competence standards comparable? Medical Teacher, 31 (3) pp. 223-229.• Nicol, M. and Freeth, D. 1998. Assessment of clinical skills: a new approach to an old problem. Nurse Education Today, 18  pp. 601-609. • Rushforth, H. E. 2007 Objective Structured Clinical Examination (OSCE): Review of literature and implications for nursing education.  Nurse Education Today, 27 pp. 481-490.• Walder, M. H. and Olson, J.K. 2007. Taking the patient to the classroom: applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship, 4 (1) Article 18.  pp.1-13.• Wass, V. and Van Der Vleuten, C. 2004. The long case. Medical Education, 38 pp. 1176-1180.

Sharing experience of clinical skills assessment between Scottish and Egyptian Nursing degree programmes: introducing the Objective Structured Clinical examination (OSCE) into emergency and critical care modules at Alexandria University.

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Sharing experience of clinical skills assessment between Scottish and Egyptian Nursing degree programmes: introducing the Objective Structured Clinical examination (OSCE) into emergency and critical care modules at Alexandria University.

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