Assessing Australian undergraduate clinical Learning

[REFEREED ARTICLE]

AssessincjN^rStralian undergraduateMinical

LEARNING Determining the clinical preparedness of undergraduate nursing students is vital in

developing graduates who are ready to assume the roles of registered nurses. This paper reports findings relating to clinical assessment in Australian undergraduate nursing programs. Using data collected in a national survey and selected case studies, current assessment practices are described. Although students were increasingly exposed to a narrower range of clinical experiences, claims to comprehensive preparation of nurses remain prominent. Issues in the congruity between assessment methods and purported outcomes of clinical learning programs are discussed. By Allison Williams, Sally J Wellard and Elizabeth Bethune. Introduction nurses are

prospect of increased f u n d i n g in the

expected to demonstrate clinical compe-

luture which has implications for the edu-

tencies across a range of health care

cator attempting lo maintain standards in

UPON

GRADUATION,

specialties. Nursing curricula are designed

undergraduate nurse education (Crealish

to prepare graduates w i t h the necessary

& Caroll 1998, Worrall-Carter 1998).

nursing knowledge and skills leading to

This paper reports on a pari of a larger

competency to practice in a wide variety

study e x p l o r i n g the organisation and

of health care settings. I hese '... should

implementation of clinical learning pro-

include but not be limited lo basic strands

grams in Australian undergraduate nursing

in medical/surgical nursing, community

courses (Bethune et al I 999). The relation-

and mental health nursing for individuals

ship between the clinical learning pro-

across the life span in institutional and

grams and the t h e o r e t i c a l c o n t e n t of

non-institutional sellings' (SCNRNF

undergraduate

1994 pi70).

remained a contentious issue since nurse

Undergraduate nursing education is

n u r s i n g courses

has

education moved into the tertiary sector.

located within a system ol tertiary educa-

Issues relating to the assessment of clinical

tion which has experienced reduced fund-

learning, such as high variability within

ing over the past decade and can barely

and across courses in assessment practices,

subsist on the present level of Common-

assessment lools, and staffing ratios were

wealth funding (Rcid 1996). I here is no

examined and are the focus of this paper.

Allison F Williams Grad Dip Adv Nsg BAppSc (Nsg) MNSt RN, Lecturer, School of Nursing, Deakin University. Email: [email protected] Sally J Wellard BA fSoc Sc) MN PhD RN, Senior Lecturer, School of Nursing, Deakin University. Elizabeth Bethune BEcon DipEd BEd Grad Dip Eval RN RM, Senior Lecturer, School of Nursing, Deakin University. Collegian Vol S No4 2001 9

[REFEREED ARTICLE]

Clinical learning

priate clinical learning e x p e r i e n c e s for

quality of experience has been argued as

Clinical experience, while an expensive

students w h e r e they will be exposed to

more important than quantity (Battersby

c o m p o n e n t of undergraduate education,

experiences that draw on the appropriate

& 1 l e m m i n g s 1991, Redfern 1999) a n d

is considered to be the core of nursing

stage of their theoretical learning. How-

the o u t c o m e s of u n d e r g r a d u a t e clinical

education ( C a r p e n i t o & Duesphol 1985,

ever, studies indicate that there has been

learning experiences have been chal-

Conrick 1996). Curricular goals, teacher

little attempt to address the lack of under-

lenged (Monahan

expertise, the learning environment and

pinning nursing theory to clinical experi-

Indeed, major problems relating to under-

characteristics ol the learner (Fothcrgill-

ence (Smilhcrs & Bircumshaw 1988,

graduate clinical learning in Australia are

H o u r o o n n a i s & H i g u c h i 1995) ideally

bowler 1996, Cassner et al 1999) or the

the cost (Ferguson 1996, Crealish & Car-

determine the selection of clinical learn-

p r e p a r a t i o n and skills of clinical nurse

roll 1998), the availability of appropriate

1 9 9 1 , Brans 1 9 9 7 ) .

placements, and student supervision and assessment (Duke 1996, N a p t h i n e 1996, Yong 1996). T h i s study

specifically

sought to examine issues pertaining to t h e assessment ol the student's clinical experience and the p u r p o r t e d c o m p r e h e n s i v e p r e p a r a t i o n of t h e n e w g r a d u a t e . I his r e s e a r c h was c o n s i d e r e d i m p o r t a n t by p r o v i d i n g data to inform

decisions

regarding clinical practicums a n d to enable t h e profession to review c u r r e n t ing experiences. However, clinical educa-

educators to evaluate student competency

t i o n in A u s t r a l i a h a s b e e n

(Myrick 1991, Wcllard et al 1995, Duke

arguably

l o u n d e d upon prior e x p e r i e n c e , educa-

1996, N a p t h i n e 1996, M c K e n n a 1996,

tional supposition, and cost of implemen-

Wellard et al in press).

tation (Barnard & Dunn 1994).

practices that s u r r o u n d t h e e x p e r i e n c e and

make

appropriate

changes

to

s t r e n g t h e n this essential c o m p o n e n t of undergraduate nurse education.

Registering authorities in each Aus-

Clinical nurse educators facilitate stu-

tralian state have m a n d a t e d the A N C I

METHODS

d e n t transferral of k n o w l e d g e i n t o t h e

national c o m p e t e n c y s t a t e m e n t s (Aus-

T h e data were collected by survey methodology and individual case studies.

clinical arena ( W h i t e & Hwan 1991). A

tralian Nursing Council 1994) for prac-

v a r i e t y of different m o d e l s of clinical

tice as a registered nurse a n d provided

facilitation operate in Australia, including

guidelines that inform university curricula

Sample

casual clinical educators, registered nurses

lor a s s e s s i n g c l i n i c a l c o m p e t e n c e of

All forty-live universities across Australia

seconded from the clinical field, academic

undergraduate nursing students. Various

offering nursing pre-regislralion courses

staff, preceptors and mentors. N o matter

tools have been devised to assess compe-

were invited to participate in t h e study

which model is utilised, the clinical facili-

tence. These include the Student C o m p e -

irrespective of how long each school had

tator 'teaches, observes and evaluates the

tence Profile (Yuen et al 1987), variations

been offering t h e course. T h e response

student in the clinical area where the stu-

ol t h e O b j e c t i v e S t r u c t u r e d C l i n i c a l

rate was 66.6% [n = 30] with 27 sufficient-

dent is given a specific patient assignment

Assessment ( O S C A ) (Fahy & Lumby

ly c o m p l e t e to include in data analysis.

to p r o v i d e p a t i e n t care' ( C r a i g & Page

1988, Bujack et al 1991a, 1991b, Nicol &

F o l l o w i n g t h e a n a l y s i s of s u r v e y d a t a

1981 p 19).

Freeth 1998, Stroud el al 1999), adapta-

three distinctly different universities were

Clinical competence

tions of Hondy's (1983) clinical perfor-

selected for in-depth case study to devel-

mance assessment tool (Fisher & Parolin

op an understanding of contextual issues

Clinical c o m p e t e n c e is u n d o u b t e d l y a

2000), and other written

major aim of undergraduate nurse educa-

instruments (Cormley 1997, I,of mark et

assessment

tion. Dreyfus and Dreyfus (1996) identi-

al 1999, T h o m p s o n & Farrow 1999).

influencing t h e delivery of t h e clinical learning programs.

Data collection

fied c o m p e t e n c y as t h e third stage in

I he amount of time students need in

nursing skill acquisition, w h e r e the stu-

clinical environments remains a contested

A letter ol invitation was sent to the head

dent nurse with experience is able to pri-

issue. lensions exist between the limited

of the nursing education division request-

oritise and devise a specific plan for each

f u n d i n g a v a i l a b l e to s u p p o r t c l i n i c a l

ing the accompanying survey be forward-

clinical encounter. The d e v e l o p m e n t of

learning programs and the m a i n t e n a n c e

ed to the staff member responsible for t h e

c o m p e t e n c y involves the integration of

of acceptable standards of practice. T h e

organisation of clinical learning. Partici-

nursing theory into nursing practice

number' of hours in clinical learning has

pants were requested to sign a c o n s e n t

(Nicol et al 1996, Conrick 1996), which

frequently been used as an indicator ol

form prior to c o m p l e t i n g and r e t u r n i n g the questionnaire by post.

recent developments in partnership mod-

the adequacy of a clinical learning pro-

els between academics and clinicians has

gram. T h e average n u m b e r of hours in

facilitated (Cassner et al 1999, M a n n &

clinical e n v i r o n m e n t s in 1992 was 894

Data collection instrument

Byrnes 2009). This c o m p e t e n c y premise

h o u r s (Australian C o u n c i l of D e a n s of

Survey data were collected using a ques-

arguably underlies the selection of appro-

H e a l t h S c i e n c e s 1992). H o w e v e r , t h e

tionnaire developed by the researchers and

10

Collegian Vol 8 N o 4 200 I

consisted ol both multiple choice and

81.4%) were indicated as the predomi-

open-ended questions. Questions explored

nant teaching strategics supporting clini-

tive assessment throughout the clinical placement (n = 25, 92.5%) and summalive

the range and loci ol clinical experiences

cal learning. Other teaching strategies are

evaluation at the end of the placement

offered, the relationship of theory to this

incorporated at students' request and with

In 22, 81.4%). Some universities relied

experience and broad questions relating to

the cooperation of the clinical agency.

solely on one or the other method to

assessment and competence. I he ques-

The ratio of clinical educator to stu-

determine student progress. Assessment ol

tionnaire was piloted for face and content

dent was variable within each university

specific clinical skills prior to the clinical

validity prior to distribution.

and across universities. I he reported

placement was undertaken at 21 universi-

Data in the case studies were collected

range was I mm I stall member to between

ties. Nineteen universities (70%) indicated

through interview and document review.

5-36 students at different times during the

the use of written work together with clin-

The same research assistant visited each

clinical learning program. I he student to

ical skill assessments as part of the process

of the three universities, spending two to

educator ratio was greater in community

of assessing clinical learning. Several uni-

three days meeting with relevant staff and

health nursing and mental health place-

versities noted the use of reflective jour-

reviewing documents relating to the con-

ments, and in the first and final years of

nalling and Objective Structure Clinical

duct of the clinical learning programs All

the program ( W c l l a r d el al in press).

Assessments (OSCAs) as other strategics

interviews were audio-taped with partici-

When relatively inexperienced students

used to assess student progress.

pants' consent and later transcribed ver-

were in environments with higher patient

The responsibility for the assessment

batim to assist in data analysis.

dependency, the ratio of student and edu-

ol student progress most commonly was

cator would be lower. I his suggests the

shared between academic staff and clini-

Data analysis

perceived importance ol clinical skills

cal educators (n \tt, 66%), with six uni-

The Statistical Package (or Social Sci-

required for nursing acutely ill patients.

versities reporting it as the sole activity of

ences (SPSS version 8.0) was used to

Additionally, a case study interview

an academic staff member. One university

analyse the survey data. Descriptive sta-

reported that il the health care agency

created a leaching fellow position lo co-

tistics and correlation analysis were per-

were small and not able to accommodate

o r d i n a t e the c l i n i c a l p r o g r a m , being

formed.

the full quota of students (usually 8 stu-

employed by the hospital and paid by the

Interview data were analysed themali-

dents), the clinical educator would work

university. Assessment ol the student in

cally. T h r e e members of the research

for fewer hours to avoid increasing the

this context was combined between the

team individually listened to the inter-

cost per student. 1 herefore, assessment of

fellow, student 'buddy', unit manager and

view tapes and read and reread the tran-

competency was influenced by the num-

ward staff, providing a comprehensive

scripts to decide on broad themes.

ber of hours available to gather the data

picture ol the student's capabilities. Clini-

on student performance. In larger settings

cal assessment was sometimes graded, and

it was reported that many nurse unit man-

sometimes accounted for 50 per cent of

the final grade of the particular unit. In

FINDINGS The questions regarding the number of hours allocated to clinical learning experiences and the breakdown of these hours to specific strands in the course were poorly answered. However, it was clear that community health and mental health areas ol practice were a minor feature of clinical learning programs in Australia. 1 he dominant area of clinical practice was medical/surgical nursing in hospital settings. Table 1 demonstrates the proportion of the clinical learning program in these areas. Medical/surgical nursing occupies an average ol 60% (SO 17) of the total clinical experience of undergrad-

agers would only allow a small number of

uate students, w i t h c o m m u n i t y health

students in their wards to avoid disrupt-

these cases all but one university translat-

nursing receiving 13% (SI.) 4.6) and mental

ing ward routine. Frequently students

ed a failure in the clinical component to a

h e a l t h n u r s i n g 30% ( S D 6.1). T h e

were dispersed over several wards making

fail grade for the whole unit. The clinical

remaining time was allocated to other

teaching and assessment more difficult.

componcnl was graded separately from

experiences, which included maternity,

academic course work in 14 universities

paediatrics, and outback 'bush' practice.

D e t e r m i n i n g student progress

(52%). Most universities (n = 22, 81.5%)

Student progress in the clinical learning

provided supplementary clinical learning

Teaching methods and staff

program was guided by A N C I competen-

experiences for students who were suc-

Nationally, pre- and post-clinical briefin-

cies (1994) in 96% ( n - 26) ol the respon-

cessful in the academic component but

gs (n = 26, 96%), journalling (n = 26, 96%)

dent schools. Mechanisms for assessing

had failed the clinical component of the

and the use ol case presentation (n = 22,

student competence included both forma-

unit of study. Collegian Vol 8 No4 2001

11

[REFEREED ARTICLE]

Difficulties clinical competencies in 96% ol sites sur-

TABLE 1: SUMMARY OF THE DISTRIBUTION OF CLINICAL HOURS IN PRE-REGISTRATION UNDERGRADUATE PROGRAMS Mean Max % Min %

SD

veyed, despite published findings of its

Medical/surgical nursing

17

The Bondy (1983) tool was used to assess

30

85

60

poor inter-rater reliability (Donoghue &

Community health nursing

5

20

13

4.6

Pelletier 1991, Fisher & Paroiin 2000),

Mental Health nursing

6

30

14

6.1

and validity (Donoghue & I'elletier 1991).

Other

10

47

23

13

I his tool consists of a numerical five point rating scale for evaluation ol stu-

in assessment. Ibis occurred where one

registered nurses in competency assess-

dent perlormance. The generic rating sys-

educator supervised students across sever-

ment, and students dispersed over a num-

tem has been applied to any professional

al wards in the one institution.

ber of wards challenges the effectiveness

behaviour and provides students w i t h diagnostic feedback as well as assessment of their performance (Bondy 1983). It also provided a record that could be used as evidence lo support the grade given in the event of student appeal and/or failure. Case study participants said the tool privileged objective assessment whilst affective domains, such as confidence, were not assessed. The scale also created difficulties because a student could obtain an

The timing of assessment was also a

of clinical supervision and inler-rater reli-

problem. Often students were given too

ability. This is compounded by the ques-

little feedback, loo late in the clinical

t i o n a b l e c l i n i c a l c r e d i b i l i t y of some

placement to be able to modify their

academics (Hindley 1997).

practice. Therefore they had little oppor-

Pre- and post-clinical briefings, reflec-

tunity to improve their clinical perfor-

tive journalling, and case presentations

the

were the dominant teaching strategies

placement. Yet the data revealed very few

s u r r o u n d i n g the c l i n i c a l e x p e r i e n c e .

mance

during

the

period

of

students failed the clinical component of

Horsfall (1990) has reported the value of

the course, raising concerns about the

pre- and post-clinical briefings in Aus-

standards ol clinical education.

'independent' grade if working in a nonchallenging placement.

tralia, yet a recent study found a lack of concordant understanding of the need for

DISCUSSION

the pie-clinical visit between hospital and

Participants described a range of prob-

Our findings demonstrate that there was a

university staff (Forbes et al 1998).

lems surrounding assessment ol student

great deal of variability in the way student

Clearly the number of hours allocated

clinical learning. Consistency of grading

competency was assessed. Clearly, assess-

to medical/surgical strands dominated

student performance was a major prob-

ing student nurse clinical competency in a

other areas of practice. The dominance of

lem. Inler-rater reliability between clinical

variety of health care organisations across

medical/surgical nursing suggests that clin-

educators across Australia was difficult to

Australia is complex. The Australian nurs-

ical competency is equated with skill per-

ensure. Some assessors reportedly had

ing profession has chosen to utilise the

formance and was driven by the number of

trouble informing the student of negative

A N C I competencies to guide undergradu-

hours the student completed, rather than

feedback, s u p p o r t i n g the f i n d i n g s of

ate clinical nurse education. However, this

the quality of this experience, as raised by

Duke (1996). It was noted that few stu-

study demonstrated a plethora ol teaching

Redfern (1999). It is questionable whether

dents failed the clinical component. This

methods and assessment tools that have

predominant medical/surgical c l i n i c a l

was attributed lo non-academic staff and

been uncritically adopted for widespread

experience will prepare graduates to prac-

novice clinical educators being unable to

use in determining learning outcomes.

divorce themselves from a nurturing role, 'pushing the struggling student through'.

It was evident that the Bondy (1983) tool was the most commonly utilised tool

tice effectively in a changing health care system requiring specialised skills for home health nursing, public health and community nursing (jamieson 1998).

Additionally, concerns were expressed

in undergraduate clinical assessment. It

that some clinical educators assessed stu-

was used across domains other than med-

Collaborative relationships between

dents' potential rather than their actual

ical/surgical nursing, questioning the

universities and the providers of health

ability. Some participants argued that

specificity of the tool and il i l has the

care has been seen as helpful lo bridge the

these problems occurred with inexperi-

capabilities and robustness for assessment

financial constraints on clinical learning

enced clinical educators who were not

in alternate situations, such as community

programs in this study. Yet difficulties

familiar with the expected curricula out-

and menial health. Additionally, there is

remain. Research into educational prac-

comes and the aims of the associated clin-

limited empirical evidence regarding the

tices does not attract funding. Utilisation

ical e x p e r i e n c e . As a consequence,

learning outcomes of nursing students

of educational research was the least ciled

students tended lo be assessed against the

using the Bondy and OSCA tools (Fahy &

reason for the organisation and implemen-

Lumby 1988, Bujackelal 1991a, 1991b).

tation of clinical learning programs. There

clinical educator's own set of norms and expectations or they compared student

F.ven if the assessment tools had been

is a clear need lor research and identifica-

performance against that ol a practicing

validated, inler-rater reliability was diffi-

tion of pedagogies for clinical education.

registered nurse. Some clinical educators

cult to achieve. Some placements were

Additionally, developing reliable and valid

reportedly experienced difficulty in allo-

hundreds of kilometres from the universi-

measures lor assessing student learning is

cating an 'independent' grade to a second

ty making it difficult to provide the clini-

vital lor the profession if we are to guaran-

year student when using the Bondy (I 983)

cal educator with the appropriate advice

tee the public that newly registered nurses

tool. Others found that limited exposure

and support. W i t h differing educator/stu-

have the appropriate knowledge and skills

to observing students created difficulties

dent ratios, the assumed skill of seconded

to supporl their health and well being.

12

Collegian Vol H No4 2001

Conclusion Developing clinical competence in new graduates is an imperative of undergraduate nurse education. Issues and difficulties surrounding assessment of competency, such as the use of empirically untested tools and teaching methods, and problems of interrater reliability, have been highlighted. This study documents the current practices in undergraduate clinical assessment in Australia and clearly raises questions about the need for a l t e r n a t i v e models lor assessing student learning. The d i v e r s i t y of c l i n i c a l preparation offered by schools ol nursing in Australia has signilicance for both the education and practice settings in preparing new

9( 1,1:30-4 B c t h u n e L, W e l l a r d S I, W i l l i a m s A . M i s c h k u l n i g D , Rushton C 1999 Air e\ploratiou- clinical learning programs in undergraduate pre registration liacbclor of Nursing coursa Report to the Nurses Board of Victoria

H o r s l a l l J 1990 Clinical placement: pre-brieting and d c - b r i c t i n g teaching strategies. Australian Journal of Advanced Nursing 8( I) 3-7

B o n d y K 1983 C r i t e r i o n - r e f e r e n c e d d e f i n i tions lor r a t i n g scales in clinical supervision. Journal ojNursing Education 22(91:376-382

L o f m a r k A , H a n n e r s j o S, W i k b i a d K 1999 A stimulative evaluation o l clinical competence students' and nurses' perceptions of patients' individual physical and e m o t i o n a l needs Journal of Advanced Nursing 29 l 4 h 942-949

Journal of Advanced Nursing

Brans 1. 1997 I l i t t h e g r o u n d r u n n i n g . 1 be graduate year issues for the musinit ptofessiou. Proceedings of the Royal College of Nursing Conference, Melbourne Bujack L, M c M i l l a n M . D w y e r J, H a z e l l o n M 1991 Assessing c o m p r e h e n s i v e m u s i n g p e r t o i mance the O b j e c t i v e Structured Clinical Assessm e n t ( O S C A ) - d e v e l o p m e n t ot t h e assessment strategy - part I. Nurse Education Today 1 1(3) 179-8-1 Bujack I., M c M i l l a n M , D w y e r J. H a z c l t o n M 1991 Assessing c o m p r e h e n s i v e n u r s i n g p e r f o r mance: the O b j e c t i v e Structured C l i n i c a l Assessment ( O S C A j - report of the evaluation projectpart 2. Nurse Education Today I 1(4,1:248-55

graduates, and warrants focus at relevant

C a r p c n i t o I., Duesphol T 1985 A Guide for EffecIwe ( linical Instruction Aspen, Rockland M a r y l a n d

nursing bodies, such as the Australian

C o n r i c k M 1996 C l i n i c a l d e c i s i o n - m a k i n g : issues in teaching. I he Australian Electrons .Journal of Nursing Education 2 ( 1 ! : no pagination

Council of Deans ol Nursing. Given the diminishing number of hours of clinical experience available to students for l e a r n i n g , a national strategy for strengthening the reliability and validity ol assessing student learning is needed. Further work is required to identify what a pedagogy of undergraduate clinical education is, and therefore inlorm innovation in the area ol assessment. Recent developments between schools of nursing and clinicians w i t h i n the agency offer promise (Gassner ct al 1999, Mann & Byrnes 2000), and re-focussing on skill attainment in the laboratory setting (Ncary 1997) w i t h a clinician using a validated common assessment tool may also prove useful.

Acknowledgements We acknowledge the financial support of the Nurses Board of Victoria, Australia, l o r this p r o j e c t and t h a t the views expressed within the paper do not necessarily represent those of the Nurses Board ol Victoria. We thank Carole Rushton for her role in data collection and Dallas

Craig J, Page G 1981 T h e questioning skills ol c l i n i c a l i n s t r u c t o r s . Journal o) Nursing Education 20(5):l8-23 D o n o g h u e I, Pellelier S 1991 A n e m p i r i c a l analysis of a clinical assessment tool. Nurse Education Today I 11 51:354-62 Dreyfus H , D i e y l u s S 1996 T h e relationship of theory and practice in the acquisition of skill. In Expeilisc in Nuising Practice- Caring, Clinical Judgment and Ethics (Benner P, T a n n e r C , Chesla C ( c d s i Springer N e w York: 29-17 D u k e M 1996 Clinical evaluation- difficulties experienced by sessional clinical teachers of nursing: a qualitative study. Journal of Advanced Nursing 23(2): 108-4 l-l Fahy K. L u m b y I 1988 Clinical assessment in a c o l l e g e p r o g r a m . Australian Journal o) Advanced Nuisnnj 5 (4): 5-9 Ferguson D S 1996 T h e lived experience o l clinical educators. Journal oj Advanced Nursing 23 {4}. 835-841 Fisher M . Parol in M 2000 T h e r e l i a b i l i t y ol measuring clinical performance using a competency based assessment t o o l : a p i l o t study Collegian 7(31:21-27 Forbes I, Jones I , James P, G r a h a m B 1998 Examination of the pie-clinical visit in a Bachelor of N u r s i n g program, Contemporary Nurse 71 3 I 125130 P o l h e r g i l l - B o u r b o n n a i s F, H i g u c h i K 1995 Selecting clinical learning experiences: an analysis of the factors involved. Journal of Nursing Education 34 ! 11:37-41

ment ol the project.

F o w l e r I 1996 T h e o r g a n i s a t i o n of c l i n i c a l supervision w i t h i n the nursing profession- a review of t h e l i t e r a t u r e . Journal oj Advanced Nursing 23I3M7I-478

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