By:- firoz qureshiDept. psychiatric nursing

OSPE

OSCEAssessment of clinical practice skills in health profession’s

education poses several challenges in terms of its objectivity.

• Objective Structured Clinical Examination (OSCE) is one form of objective evaluation method that is gaining more importance and is being adopted by educators of various disciplines

OSCE -OBJECTIVE

• All the candidates are presented with the same test

• Specific skill modalities are tested at each station

• History taking• Explanation• Clinical examination• Procedures

OSCE - Structured

• The marking scheme for each station is structured

• Structured interaction between examiner and student

OSCE-Clinical examination

Advantage-OSCE• Wider sampling than traditional methods• Every candidate does same examination• Greater opportunity for objectivity• OSCE Stations are re-useable• Better psychometrics than traditional methods

Focus

• It involves use of cognitive skills like critical thinking and problem solving. OSCE also enhances good interaction between the teacher and the student .Although OSCE is practiced worldwide in nursing education, its practice in India and other developing countries is scarce.

• The nurse educators from India and other developing countries should be encouraged to utilize this form of evaluation.

Core Assessment area

OSCE is an approach to the assessment of clinical competence in which the components of the competence are assessed in a planned or structured way, with attention being paid to the objectivity of the examination (Harden, 1988).

OSPE

In a non clinical area e.g. Biochemistry/Anatomy Physiology lab setting), a similar approach may be adopted and in this context, it is referred to as an OSPE (Objective Structured Practical Examination)

PURPOSES OF OSCE

According to Boursicot, Ware, and Hazllet (2011), the purposes of OSCE are to

– Measure clinical skills – Match assessment to intended constructs – Promote structured interaction between student and

examiner – Make structured marking scheme possible – Present all candidates with the same test – Promote objectivity

COMPONENTS ASSESSED IN OSCE

Various components of clinical competence are assessed using OSCE, – For example, the components of advance clinical nursing practice skills typically assessed by OSCE are…

1. Interpersonal and communication skills 2. History taking skills 3. Physical examination of specific body system 4. Mental health assessment 5. Clinical decision making including the information of

differential diagnosis

CONT

6. Interpretation of clinical findings and investigations ,management of a clinical situation including treatment and referral

7. Patient education 8. Health promotion 9. Clinical problem solving skills 10.Acting safely and appropriately in an urgent

clinical situation 11.Critical thinking in therapeutic management

Quality of Assessment

Reliability of a test

• measure reproducibility of scores across raters, questions, cases, occasions

• capability to differentiate consistently between good & poor students

Reliability

Validity of a test

• MeasureContent is deemed appropriate by relevant experts

• Test measures the characteristic (e.g. knowledge, skills) that it is intended to measure

• Performance of a particular task predicts future performance

Feasibility

• Is it a reasonable task to expect the candidates to perform? Is it authentic?

• Can the task be examined at an OSCE station? Match clinical situations as closely as possible

• Some tasks may require simulated patients• Some tasks may require manikins• Some tasks simply cannot be examined in this format

congruence

• Is the station testing what you want it to test?• Station construct: describe what station is

testing

cont

• Ensure that all parts of station coordinate Candidate instructions

• Marking schedule• Examiner instructions• Simulated patient instructions• Equipment

Train the examiner

THE COMPONENTS OF THE OSCE

The OSCE (Objective Structured Clinical Examination) has reached a stage of development that allows clear recognition of key components that bring structure and organization to its construction, implementation and assessment of its performance

Blueprinting

• Content of the assessment should align with the learning objectives of the course

• Blueprinting allows mapping of test items to specific learning outcomes

• ensures adequate sampling across subject area and skill domains

Bp-System based

BP-Discipline based

Possible station

• Communication – a telephone conversation• Counseling – a trained SP• Reading a CVP – special equipment• Intubation – anaesthetic manikin• Excision biopsy – a pig skin and equipment• Breast palpation – silicon simulations• Form completion – a collection of forms• CPR – Resus Annie• Suturing – RCS suture jig• Assembling equipment – IV infusion set• Traction – SP and equipment• Bandaging – masses of crepe bandage

History taking station

Procedure station

Physical examination station

Major components

The major components are 1.The (examination) coordinating committee2. The examination coordinator 3. Lists of skills, behaviors and attitudes to be assessed 4. Criteria for scoring the assessment (marking scheme

of checklist)5. The examinees 6. The examiners 7. Examination site

THE COMPONENTS OF THE OSCE

Examination stations 8.1 Time and time allocation between stations8.2 Anatomic models for repetitive examinations

(Breast, Pelvic/Rectum)8.3 Couplet Station 8.4 Examination Questions 8.5 Environment of Exam Station8.6 Examination Station Circuit

The Examination Coordinating Committee

The Examination Coordinating Committee • An examination coordinating committee is made up

of members who are committed to the evaluative and educational process and whether appointed or volunteered must give this effort high priority in order for the OSCE to be developed and implemented.

• It is the responsibility of the examinationcommittee to determine the content of the examination, development and implementation

The Examination Coordinator

• The functions of the examination coordinator (M.D. or Ph.D. educator) are the catalyst that facilitates the smooth working of the committee in developing, implementing and assessing the performance of the OSCE

Lists of Skills, Behaviors and Attitudes to be Assessed

• The examination will measure objectively the competencies in specific areas of behavior, techniques, attitudes and decision-making strategies based on the objectives of the course or the requirement of the licensing body.

• The OSCE should be able to reliably assess clinical competence in history taking, physical examination, laboratory, radiographic and other data interpretation, technical and procedural skills as well as counseling and attitudinal behaviors

Criteria for Scoring the Assessment (Marking Scheme or Checklist)

• A marking scheme or checklist is prepared for each station. Preparation of the checklist requires predetermined objective criteria that are agreed upon by the examination committee, based on faculty input.

• Marking scheme/checklist should be concise, unambiguous and written to contribute to the reliability of the station.

Rating

Likert scale

The Examinees

• The examinee is the student, resident, or fellow in training or at the end of training of a prescribed course designed to teach certain clinical competencies that the examinee can use in a clinical situation to make an assessment and develop a diagnostic formulation that culminates in a therapeutic plan.

The Examiners

• Most stations will require an examiner, although some stations do not. The examiner at the station where clinical skills (history-taking, physical examination, interviewing and communication) are assessed, may be either a physician or a standardized patient

The Examination Site

• The examination site is part of a special teaching facility in some institutions. When such facilities are not available, the examination may be conducted in an outpatient facility or other space where offices are available in close proximity to each other.

Examinations Station

• The total number of stations will vary based on a function of the number of skills, behaviors and attitudinal items to be tested.

8.1 .Time Allocation and Time between Stations – The competency being assessed in particular station will

define how much time should be allotted per station. The length of time will range from 5-20 minutes.

– The time allocated per station should be as uniform as possible thus facilitating the smooth movement of examinees from station to station

OSCE DESIGN

e.g., a 10 minute station, 9 minutes is allocated for the task and one minute transit time to the next station.

The examiner can complete the checklist prior to the entry of the next examinee.

8.2 Anatomic Models for Repetitive Examinations (Breast, Pelvic/Rectum)

• The skill, behavior or attitude to be tested in a station determines whether the station requires a real patient, simulated patient Chronic patients (stable) may serve well in this situation with proper training.

• Simulated patients who are well-trained offer reliability and consistency in the quality of their presentations.

8.3.Couplet Station

• Some competencies may best be assessed by coupled or linked stations. For example, a couplet station may consist of a history-physical examination combined with a problem-solving station.

8.4.Examination Questions

• Examination questions are designed to assess the ability to interpret information and critical thinking. The questions deal with diagnostic investigations, differential diagnostic and management plans.

8.5.Examination Station environment

The Examination Station environment should be conducive to the competency to be tested, including adjustable lighting for fundoscopic examinations and appropriate examination tables for focused physical skills assessment.

• Stations where auscultatory skills are being assessed should be either well insulated or in appropriately quiet areas of the examination site. Clearly marked directions leading from one station to the next should be displayed.

8.6.Examination Stations Circuit Stations

• The Examination stations should be clearly marked in a logical sequence that allows easy, unimpeded transit from one station to the next.

EXAMPLE S . No Station Task/Question

1. I Check and record Blood Pressure 2. II List five factors which helps in maintaining

Blood Pressure 3. III Take oral temperature and record it 4. IV Rest station 5. V Using the formula, convert 39 °C into Farenheit 6. VI Test the urine for sugar and albumin 7. VII List five causes of albuminuria

As number of stations affects reliability, often overall OSCE’s reliability is quite low

because often can’t practically run more than 20 stations

9.Patient (Real) or Simulated

• A standardized patient is an individual with a health problem that is in a chronic but stable condition. Standardized or simulated patient may be used when properly trained for history and physical assessments.

• Simulated patients may come from the ranks of volunteers, or acting guilds.

cont

• Detailed instruction package is provided for both the standardized and simulated patient. The instructions describe how the patient responds to history questions and physical exam, as well as how the patient should dress.

10.Timekeeper, Time Clock and Time Signal

• Appropriate personnel for the position of official timekeeper and exam facilitators need to be identified and properly instructed. A well functioning time clock and time signal are critical.

• One support person per three stations is recommended.

11.Contingency Plans

• A contingency plan includes reserve standardized patients who are trained to assume a number of roles, and a patient trainer who circulates to deal with any patient problems that arise.

• A number of reserve stations should be available. A contingency plan must be developed for students who must leave the exam when the situation arises.

12.Assessment of the Performance of the OSCE

• The OSCE should be tested for appropriate measurement characteristics such as validity, reliability, feasibility and credibility.

• A valid OSCE station measures what it was designed to measure. A reliable station measures it consistently.

• Grading can be based on a criterion-referenced system, norm-referenced system, or a combination of both. The Examination committee needs to decide in advance which system best meets its fundamental purposes for the exam.

Objective Structured Practical Examination (OSPE)

• Objective structured practical examination (OSPE) is a new pattern of practical examination, in which each component of clinical competence is tested uniformly and objectively for all the students who are taking up a practical examination at a given place.

Steps of OSPE

• In order to organize an OSPE successfully, one has to spell out the objectives of practical experiences in a given discipline related to a particular subject.

1. Demonstrate Practical Skills. For example, for demonstration of practical skills, monitoring and recording oral temperature, blood pressure, converting 39.4 degree centigrade to Fahrenheit and testing urine for sugar, etc. can be given

cont

2. Make Accurate-Observations Differentiate between the normal and abnormal ECG, identify the type of arrhythmias from the ECG.

3.Analyze and Interpret Data Hemogram report, liver function report, urine or blood sugar report and other laboratory reports.

4. Identify the Patient's Problems • The student has to identify the patient's problem in

order to organize her work. • Problems such as Dyspnea, • Rigor following blood

transfusion and • CSF rhinorrhea following head injury.

5. Plan Alternative Nursing Interventions • In case of airway obstruction, the student is expected to

keep the patient in side lying position. • Do Oro pharyngeal suction. • Start O2 inhalation if required

Types of Stations

• Procedure station: It requires a student to perform a task, e.g. monitoring of oral temperature. When a student performs the task, simultaneously she is observed and marked against the checklist being prepared in advance, by a silent but vigilant examiner.

The question station/the response station

• The student answers the question being asked on the answer sheet provided and leaves it in the place specified

Scoring Students in OSPE

• For each specific skill, a checklist is prepared by breaking the skill being tested into essential steps and score is assigned to each step which is proportional to the importance of the step related a particular procedure.

Procedure of Conducting OSPE

• Examiners A, B, C stand in a place from where they can have a good view of what a candidate is doing at a particular station. They have a checklist on which they tick as they observe. The score of each student is entered separately and confidentially.

• The students are given clear instructions regarding how they will rotate around the stations and the time limit in each station and what they are supposed to do in each station (demonstrate a skill, make observation, make calculation from the data provided or answer the question asked).

Conclusion

The OSCE has several distinct advantages. In view of these, the nurse educators can adopt it as an objective method for clinical evaluation. This will help the students to improve their clinical competence. The emphasis is on assessing what students can do rather than what they know. Therefore, OSCE gives direction for attaining the ultimate aim of the teaching- learning process.

Thank you