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Finding reality: the use of objective structured clinical examination (OSCE) in the assessment of mental health nursing students interpersonal skills
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Finding reality: the use of objective structured clinical examination (OSCE) in the assessment of mental health nursing students interpersonal skills Martin Anderson and Theodore Stickley
Martin Anderson PhD, MSc, BA(Hons), RN, (Mental Health) Dip HE Lecturer in Mental Health, Theodore Stickley MA, RMN, DipN, DipCouns, Teacher/ Practitioner – Mental Health, School of Nursing, Faculty of Medicine and Health Sciences, University of Nottingham, Room B50, Medical School, Queen’s Medical Centre, Nottingham, NG7 2UH. Tel./Fax: (0115) 9709955, (0115) 970 9265, Ext.: 42463; E-mail: martin. anderson@nottin gham.ac.uk (Requests for offprints to MA) Manuscript accepted: 11 April 2002
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Alice felt dreadfully puzzled. The Hatter’s remark seemed to her to have no sort of meaning in it, and yet it was certainly English. ‘I don’t quite understand you,’ she said, as politely she could (Lewis Carroll 1865). This paper presents the implementation of an objective structured clinical examination (OSCE) in the assessment of mental health nursing students’ interpersonal skills. It begins by providing a rationale for the use of this instrument to assess such skills and offers a brief discussion of the development of OSCEs. The preparation and implementation of the OSCE is explored and both students’ and tutors’ reflections of the process are highlighted. The strengths and problems, particularly the use of an actor and video tape recordings are examined, in the light of other studies. The paper concludes by advocating the use of such an assessment tool as a formative exercise. © 2002 Elsevier Science Ltd. All rights reserved.
Introduction The development of interpersonal skills is central to the education of mental health nurses in becoming capable practitioners in modern mental health services. Such skills continue to become ever more essential in the current climate of mental healthcare, and in particular, in the preparation of practitioners with the ability to implement the relevant components of the National Service Framework for Mental Health (SCMH 2001, DoH 1999). Therefore, there is a real need to develop a method of identifying student mental health nurse’s competency in this area.
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Assessing the range of skills nurses require for professional practice is regarded to be of great importance, yet the assessment of any clinical skill is complex and presents problems (Nicol & Freeth 1998, Clifford 1994). Assessing student mental health nurses’ ability to use effective interpersonal skills presents a number of difficulties for educators, particularly in terms of how to assess such skills. The use of the Objective Structured Clinical Examination (OSCE) is not a new method in the assessment of nursing and medical students skills acquisition (Nicol & Freeth 1998, Brewin & Cantwell 1997, O’Neill & McCall
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1996, Woodburn & Sutcliffe 1996). The OSCE was originally developed for use in medical education in 1975 by Harden et al. (1975) and was designed to test a broad spectrum of skills and knowledge. Harden regarded the OSCE to be: ‘an approach to the assessment of clinical competence in which the components of competence are assessed in a well planned or structured way with attention being paid to the objectivity’ (Harden 1988). p. 19 There is a significant amount of literature on the use of OSCEs within general nursing (Studdy et al. 1994, Bujack et al. 1991, Roberts & Brown 1990, Ross et al. 1988, Aggleton et al. 1987). This material raises some important issues in terms of the instrument as a form of assessment in nursing. There is a absence of literature on the use of OSCEs to assess interpersonal skills in nursing practice. This paper focuses on the use of a method of assessing the interpersonal skills of mental health nursing students undertaking a 4 year undergraduate pre-registration Master of Nursing degree course at the University of Nottingham. The paper is structured as follows. It begins by presenting a brief review of the relevant literature exploring the contemporary development and use of OCSEs for the assessment of practical skills in a range of healthcare professionals. This leads into a discussion surrounding the development of the OSCE for assessing mental health nursing student’s interpersonal skills. The preparation and implementation of the OSCE is examined covering the actual process of assessment and evaluation of the OSCE. Tutors and students reflective comments on the experience provide material for further discussion. The paper closes by highlighting the benefits and limitations of using the OSCE and drawing conclusions on the process.
The development of OSCEs for the assessment of clinical skills The literature presents a number of studies evaluating the efficacy of using an OSCE. Bujack & Little (1988) developed an OSCE that enabled students to work through a series of
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stations for students to work round. The usual format is that students rotate around these stations and spend 5–10 minutes on each station whilst they are assessed on the skill (Nicol & Freeth 1998). The aim of this is to facilitate the integration of their knowledge and skills of care surrounding one single patient. This process appeared to work well and was positively evaluated by the students. The validity of the OSCE is reliant upon the quality of the problems presented at each station, but also the design of the assessment schedule (Nicol & Freeth 1998). In contrast, Ross et al. (1988) felt that the OSCE format was inappropriate for assessing nursing skills and that it did not reflect the clinical reality of nursing practice. They continued to use the medical orientated approach to assessment, implying that the OSCE implemented was ridged and inflexible. From this, it is clear that despite the apparent success of the OSCE in medicine and other disciplines (occupational therapy, physiotherapy etc), the traditional medical OSCE has a number of limitations with respect to the assessment of nursing skills. Nicol & Freeth (1998) list the following:
Performing skills at stations poses the risk of perceiving nursing as a set of performed tasks. There is little scope for testing communication skills in an integrated way. Because of the time limit on each OSCE certain skills may be omitted.
There are a number of more positive aspects of the OSCE which provide evidence of it’s efficacy as a method of assessing nursing practice. Harris & Miller (1990) piloted an OSCE with undergraduate medical students and found that the most beneficial aspect for their students of using the OSCE was the feed back post-examination. Students commented on the experience of being given formal and informal feedback. They valued the face to face feedback for helping them to identify their strengths, boost their confidence and identify their weaknesses. Harris & Miller (1990) also used video camera to record the stations used as part of the OSCE. Bujack et al. (1991) found that self-assessment is most effective when it combines the use of video playback to focus on specific competencies. Others have pointed out
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that, with adequate consent, video recordings can offer other practical factors such as external examining and further research (Nicol and Freeth 1998). Brewin & Cantwell (1997) developed a psychiatry based OSCE for the undergraduate medical programme in Nottingham. Similar OSCEs have also been developed for psychiatry (Famuyiwa et al. 1991). In particular, Brewin & Cantwell (1997) included some stations that were focused on assessing the quality of students’ interactions. Yet more recent work with undergraduate medical students using video-recorded scenarios to assess medical students of communication skills has raised a number issues. Humpris & Kaney (2000) designed a method of assessing cognitive aspects of students clinical communication skills, named the Objective Structured Video Exam (OSVE). In the study, the video-based written examination was found to be efficient and quick to administer, and demonstrated some evidence for validity. There are no reports providing evidence of the use of such an instrument in the development of mental health nursing student’s interpersonal skills. The UKCCs report on pre-registration education ‘Fitness for Practice’ highlights the need for a systematic, problem-based approach to assessing interpersonal skills (UKCC 1999). It is important to note that the pre-registration requirements for nurses include outcomes to be achieved for entry to the branch programme. These centre on ensuring that the student recognises the effect of their own values on interactions with patients and clients and their families, and friends; implement appropriate communication skills with patients and clients and understand the boundaries of a professional caring relationship (UKCC 2000a). As teachers of future mental health nurses we have been looking at ways in which we could enhance students’ ability to acquire core interpersonal skills essential for mental health nurse (MHN) practice. Within the current course (Master of Nursing) an OSCE has been used to assess a range of nursing skills such as eating and drinking, taking blood pressure, weighing patients. In essence the same kind of skills that have been assessed and described in
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the literature cited above. In the mental health branch we have been searching for a way of assessing students’ interpersonal skills. The OSCE offers a method of maintaining a student centred approach to learning. At the centre of our rationale for exploring the use on an OSCE in the education of mental health nurses is the point raised by Nicol & Freeth (1998) that this form of assessment leaves little scope for addressing communication skills. This was our challenge. We intended therefore, to develop a new form of OSCE for use in assessing our students’ competency in interacting with patients.
Developing the OSCE for assessing student mental health nurse interpersonal skills The interpersonal skills OSCE seeks to promote interventions, that are fundamental to mental health nurse practice. The skills we endeavour to teach and assess could be judged by some to be human qualities and not skills at all. Burnard (1999) asserts that the ability to listen well is the most helpful quality found in the sort of person you might go to see to talk about a personal or emotional problem. If mental health nurses are able to provide ‘good enough’ relationships with their clients by exercising ‘good enough’ interpersonal skills then they have successfully negotiated the first move to forming a therapeutic alliance. The ability to successfully listen is the first step of the first move (Rawlins et al. 1993, Wright & Giddey 1993, Stuart & Sundeen 1991). Listening may be differentiated from hearing. We can hear without synthesising or integrating information, in the same way that we may be seemingly oblivious to background music in a supermarket. The process of demonstrating active listening by reflecting feeling and content is a demonstration of basic empathy (Egan 1990). This ability is fundamental to the interpersonal skills required for building and maintaining therapeutic relationships. In the development of the interpersonal skills OSCE, we have made numerous assumptions. Firstly, the tutors implementing the instrument have assumed that the ability to
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listen can be a taught skill. It is acknowledge that this ability comes more naturally to some people than to others. It is also assumed that these skills can be objectively observed and, conversely, can also be detected when absent. There is inconclusive discussion whether effective listening is a skill or a quality. However, given the long history of the inclusion of listening skills training within mental health nursing education and given our own history in this area, we proceeded on the premise that effective listening can be taught and subsequently learnt by those with or without innate qualities.
Preparation for the OSCE The OSCE was part of the assessment process for an introductory module relating to mental health nursing practice. The OSCE (as with the physical OSCEs for the adult nursing students) would count for 20% of their overall marks for the module assessment. There is a requirement that parity is maintained across all branches using this form of assessment. As discussed above, the OSCE was focused on core, basic listening skills widely identified in the counselling, human relation and mental health nursing literature (Burnard 1999, Barker 1999). The skills were taught in a series of scheduled sessions. Given the constraints of the module, we were able to run only six one and a half an hour sessions, in consecutive weeks. The sessions were focused on specific skills, these included:
Non-verbal communication Open questions Clarifying Reflecting content Reflecting feeling Summarising The use of silence
In each session, students were encouraged to explore the theory underpinning the key practical skills being taught. These sessions were built around Rogers’ theory of personcentred therapy and Egan’s The Skilled Helper (Egan 1990, Rogers 1951). Each skill was firstly identified and described. Students were provided with practical examples, then had an opportunity to practice the skills in role-play
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situations. Group process time was included before, during, and at the end of each of the sessions. For the rest of the week students would be in allocated practice placements and were therefore encouraged to practice these interpersonal skills under the supervision of a mentor. Each week students returned to the sessions and shared with the group their experience of practising the skills and reflect on their successes and areas for improvement.
Process of implementing the OSCE For this particular assessment, we considered it inappropriate to include more than one station because this OSCE examines interpersonal skills which present as a constellation and are therefore inseparable. The assessment process for the OSCE was planned to be thirty minutes in duration. Students were given a scenario (Fig. 1) in advance and were told that they would need to conduct an assessment of the patient. The ‘patient’ was in fact a paid actor who we named ‘Janice’. It was made clear to the students that this was not an assessment of their nursing assessment skills per se but rather their interpersonal skills. However, students were advised to proceed by eliciting the patient’s story. The students were informed that their interview would be video recorded and the tutors would mark their work by watching the video recordings at a later date. Finally, for preparation purposes the students were shown a thirty-minute video of a tutor in action with ‘Janice’. This provided the students with a schematic representation of how the patient might present, together with a revision of the interpersonal skills taught in the previous sessions. Each student was also given a marking sheet to be used by the tutors during the assessment of the recorded video footage. On the day, the interviews were held in a small interview room within the School. The room selected reflected an environment that might be found on an acute admissions ward. Students were shown to the room and were offered a brief introduction to Janice and were then immediately left on their own with her. When the students had completed the
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The Scenario Janice was admitted to the acute ward yesterday evening following a serious overdose. She was transferred from the medical ward. Janice is now physically stable and slept throughout the night. The ward manager has asked you to assess her. You only know that she is 46 years old, married and a schoolteacher.
Figure 1
interview, a tutor met them outside of the interview room to ensure the session was successfully completed. Once all the students had finished the interview and a video recording of their intervention had been completed, the tutors set aside half a day to view and mark the video recordings. The marking sheet, presented to the students in the early stages of the OSCE, clearly identified the required skills in ten categories (see Appendix 1). For each skill the tutors awarded points out of ten (a higher score demonstrating more competency). The tutors discussed each skill, carried out in the interview by each student, before agreeing on a final score.
Evaluation The final part of the OSCE came when tutors had completed their examination of the video footage. Students were invited to watch a play back of the video recording and evaluate themselves and one another, without the tutors being present. Approximately two weeks later the students received their marks and tutors’ written feedback for their work. Subsequently, the students were asked to attend an evaluation meeting facilitated by the tutors. During this meeting students were encouraged to be open and honest about their whole experience of the interpersonal skills OSCE. All students attended and engaged fully with this process and gave extremely valuable feedback.
The tutors’ reflection on the process of implementing and evaluating the interpersonal skills OSCE Due to the close relationship between ‘listening skills’ and personality, the teaching of interpersonal skills is an intimate business and cannot be successfully negotiated with a large
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group. We are fortunate to be able to work with small groups on the degree programme. As with any teaching which involves and promotes personal development, it is important to allow time for the group to process the experience, where students may freely express thoughts and feelings in a supportive environment. During the teaching sessions which prepared them for the OSCE, individuals, at times, felt vulnerable and it was important for the tutors to be sensitive to the individuals’ emotional and psychological needs. The tutors were also able to spend maximum time with the students outside of the preparation sessions, e.g. running journal clubs, clinical seminars, other teaching sessions and visiting them on placement. The tutors and students were able therefore to build up a strong working relationship. It became very important to relate their classroom learning to clinical practice. Assessing the student’s work was a humbling process. The tutors witnessed a high degree of competency. Given the relative immaturity of the participants and the brevity of the teaching sessions, we considered this to be quite remarkable. The sessions appeared on video to be extremely realistic and all of the students exercised the listening skills that they were taught. One of the writers teaches therapeutic counselling at Diploma level in Further Education and observed that some of the work witnessed on the videos surpassed that which he would expect from his third year counselling students.
The students’ reflection on the process of implementing and evaluating the interpersonal skills OSCE Generally, the students were fairly negative about their experiences of OSCEs used earlier
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in their education. Knowing that OSCEs were originally used in medical education they perceived them as exercises which tend to medicalize nursing skills. The students expressed intense feelings when required to complete OSCEs for other parts of the course. The students all acknowledged feeling nervous whilst under scrutiny and claimed that OSCEs did not give a true reflection of practical skills whilst being conducted under such false conditions. It was suggested that OSCEs only tested the specific skills required and not the whole nurse-patient interaction. The students indicated that their previous experiences of OSCEs were not good. Therefore, their opinion of such a method of assessment was low, based on some of the assessment of clinical skills they had encountered in previous years of the course.
Students’ experience of the preparation for the OSCE The students thought that the teaching of the seven skills was a thorough process. They appreciated being taught the skills in the classroom, practising with each other and then being able to practice ‘live’ whilst on placement. They thought the skills were relevant to their work and that the allied theoretical component of the teaching was relevant. The students maintained that they would have benefited from greater opportunity to practice all of the skills together in role-play. The students reported that more practice using a camera would have been helpful. Observing a tutor on video practising the skills in advance was helpful. They also appreciated seeing the score sheets in advance so they knew what was expected of them.
Students’ experience of the implementation of the OSCE When the students entered the room, they said they felt nervous (one even ‘petrified’). This was largely to do with the presence of the camera and knowing that they were being examined on their skills. However, the students said that they preferred a camera to the possibility of being watched by tutors in
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the same room. All of the students thought that the actor was very realistic and effective. The students would have appreciated being able to talk to the actor once she had de-roled. It was thought that a half an hour interview was the right length of time.
Students’ experience of watching the video recording of themselves following the OSCE The most significant problem with the process of self-evaluation was the students’s embarrassment at watching themselves. They said it was easier to evaluate one another’s sessions for this reason. The students were glad that the tutors were not present for this session. One student said they would like to watch it again. One student said that the whole process made her feel as if she was being judged as a person. All of the students said that they thought the interpersonal skills OSCE should be a formative assessment and not summative as implemented. Nevertheless, in this informal feedback students concluded that the interpersonal skills OSCE was a useful way of helping the development of competency in these skills and that it was helpful to evaluate the whole process.
Discussion Examining the use of the OSCE with the mental health students in light of previous work illustrates some positive and negative characteristics. This paper presents a new approach to assessing mental health nursing students’ interpersonal skills. The experience of using the OSCE has been interesting because of the innovative nature of its implementation and informative because of the collaboration of the students. It has not been possible to check for validity or to actually measure the extent to which the students retain competency in using the interpersonal skills. Yet, while it has been a generally worthwhile exercise for assessing students’ interpersonal skills, it is really one of the only possible ways of getting close to the students’ human relationships skills in order to assess them. It is clear from the students’ reflection that it is much better carried out as
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formative rather than a summative exercise. This requires further investigation in a planned study. This paper has not presented empirical research evidence arising from a study into the use of the OSCE. We have therefore not addressed issues relating to methodology, validity or reliability. The use of the video recording as described above, raised a number of issues. In particular, the students reflected on the use of the camera and on being videotaped. The students were unsure and felt that the presence of the camera created anxiety. Yet this was much better than actually being watched by two human assessors. Nicol & Freeth (1998) found that in fact, students quickly forget the presence of a camera in a room. So despite some reservations, the use of video playback was a very powerful form of learning. Asking the students to go and watch themselves interact and internally evaluate their interactions with Janice was perhaps the most powerful and meaningful exercise in the whole experience of using the OSCE. The effect of the process upon the tutors watching the students also has to be noted. As mentioned – this experience has been humbling – the students were clearly capable and had the human abilities to conduct an effective interview in spite of such minimal preparation. Brewin & Canterill (1997) reported a similar experience in that they observed the variety and flexibility the OSCE can provide in assessing students. This is despite the inherent rigidity in being objectively led. It is acknowledged that it is impossible for us to be truly objective about assessing another’s interpersonal skills. Like everybody else, we have our own culture, preconceived ideas and stereotypes that inevitably prejudice our judgement. Whilst attempting objectivity, we accept the subjective element to every form of assessment. In this process, the tutors acknowledged that they are both white, educated males, both considerably older than the students. Acknowledging these issues appears to have been missed in more recent attempts to assess medical student’s skill in communicating with other people. Humpris & Kaney (2000) appear to be suggesting that they need to ‘get through’ lots of medical students and assess their communication skills quickly and efficiently. This paper presents the view
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that interpersonal skills (in any profession) need to be assessed carefully and with awareness. Therefore, Humpris & Kaney’s OSVE suffers a major flaw in that the assessor never actually observes the student carrying out the intervention. How can they pass a judgement on a student’s ability to communicate if this is the case? This is the point at which role-play has great value. Historically, listening skills courses include the use of role-play in order to help practice taught skills (Burnard 1999). The use of role-play for practice purposes is encouraged but the use of a professional actor for assessment purposes provides an extremely realistic challenge for the students. The UKCC (2000b) may be correct in maintaining that the Thorn programme and other programmes are grounded in evidence supporting their efficacy. But as Barker et al. (1999) suggests the need for psychiatric nurses is clear but complex. Instead of looking to develop new skills or fashion new roles, psychiatric nurses might focus on new ways of developing and enhancing traditional functions – human caring – in a complex, growing technological healthcare arena that threatens the human factor at the heart of all care. The introduction of an OSCE for the assessment of interpersonal skills is designed as an aid for mental health nurse teachers who are involved with interpersonal skills training. Hopefully, this approach will help focus the minds of teachers and students in enhancing the basic listening skills each mental health nurse needs in order to develop meaningful relationships with clients. In doing so, it may be possible to move closer to developing future practitioners capable of delivering the services set out in current mental health polices (DoH 1999). What we have presented is not only innovative but also assists in promoting and determining core skills, which are fundamental to mental health nursing practice. It is beyond the scope of this paper to explore the literature and research relating to empathy, however, the authors acknowledge its relevance to this work.
Conclusion This paper has highlighted the value of implementing an OSCE to assess interpersonal
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skills in the education of pre-registration mental health nurses. Mental health nurses need to feel competent in the skills forming the fundamental basis of their practice. Recognising the centrality of interpersonal skills in the mental health nurses role, this work has been an exploration attempting to put real meaning in student mental health
nurses’ development of these skills and finding out what they can really do. Acknowledgements
We would like to thank all of the 1998–2002 mental health branch Master of Nursing degree for their contribution in this work.
Appendix 1 OSCE – Assessment Guidelines Interpersonal Skills Name:
PIN Number:
Outline: Time: 30 mins Situation: (scenario)
Intervention
Rating
Introduces themselves to the client appropriately, gives outline of what they are going to do Gives client broad openings, open questions Responds to clients NVC, makes adequate notes & interpretation Clarifies issues with client Uses appropriate NVC, eye contact, body language Listens to client, demonstrates understanding of clients verbal communication by reflecting & restating content and feeling Uses silence appropriately Offers acknowledgement for the clients contribution to the interaction Ends interaction appropriately by offering a summary and giving information on future plans Total Rating
Rating: Marks out of ten Signed Student:
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Signed Assessor:
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Humpris GM, Kaney S 2000 The Objective Structured Video Exam for assessment of communication skills. Medical Education 34:939–945 Nicol M, Freeth D, 1998 Assessment of clinical skills: a new approach to an old problem. Nurse Education Today 18:601–609 O’Neill A, McCall J 1996 Objectively assessing practices: A curricular document. Nurse Education Today 16:121–126 Rawlins RP, Williams SR, Beck CK 1993 Mental Health – Psychiatric Nursing – a Holistic Life-Cycle Approach (3rd Ed.), Mosby Yearbook St. Louis Roberts J, Brown B 1990 Testing the OSCE: a reliable measurement of clinical nursing skills. Canadian Journal of Nursing Research 22(1):51–59 Rogers CR (1951) Client Centered Therapy. Constable, London Ross M, Carroll G, Knight J, Chamberlain M, FothergillBourbonnais F, Linton J, 1988 Using the OSCE to measure clinical skills performance in nursing. Journal of Advanced Nursing 13:45–46 Sainsbury Centre for Mental Health 2001 The Capable Practitioner. Report written by The Sainsbury Centre for Mental Health for the National Service Framework Action Team. SCMH, London Stuart GW, Sundeen SJ 1991 Principles and Practice of Psychiatric Nursing. Mosby Year Book St Louis Studdy SJ, Nicol MJ, Fox-Hiley A 1994 Teaching and learning clinical skills. Part 1: Development of a multidisciplinary skills centre. Nurse Education Today 14:177–185 Woodburn J, Sutcliffe N 1996 The Reliability, Validity and Evaluation of the Objective Structured Examination in Podiatry (Chiropody). Assessment and Evaluation in Higher Education 21(2):131–145 Wright H, Giddey M, 1993 Mental Health Nursing. From first principles to professional practice. Chapman & Hall, London UKCC 1999 Fitness for Practice: The Report. UKCC, London UKCC 2000a The nursing, midwifery and health visiting contribution to the continuing care of people with mental health problems. UKCC, London UKCC 2000b Requirements for pre-registration nursing. UKCC, London
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Finding reality: the use of objective structured clinical examination (OSCE) in the assessment of mental health nursing students interpersonal skills Martin Anderson and Theodore Stickley
Martin Anderson PhD, MSc, BA(Hons), RN, (Mental Health) Dip HE Lecturer in Mental Health, Theodore Stickley MA, RMN, DipN, DipCouns, Teacher/ Practitioner – Mental Health, School of Nursing, Faculty of Medicine and Health Sciences, University of Nottingham, Room B50, Medical School, Queen’s Medical Centre, Nottingham, NG7 2UH. Tel./Fax: (0115) 9709955, (0115) 970 9265, Ext.: 42463; E-mail: martin. anderson@nottin gham.ac.uk (Requests for offprints to MA) Manuscript accepted: 11 April 2002
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Alice felt dreadfully puzzled. The Hatter’s remark seemed to her to have no sort of meaning in it, and yet it was certainly English. ‘I don’t quite understand you,’ she said, as politely she could (Lewis Carroll 1865). This paper presents the implementation of an objective structured clinical examination (OSCE) in the assessment of mental health nursing students’ interpersonal skills. It begins by providing a rationale for the use of this instrument to assess such skills and offers a brief discussion of the development of OSCEs. The preparation and implementation of the OSCE is explored and both students’ and tutors’ reflections of the process are highlighted. The strengths and problems, particularly the use of an actor and video tape recordings are examined, in the light of other studies. The paper concludes by advocating the use of such an assessment tool as a formative exercise. © 2002 Elsevier Science Ltd. All rights reserved.
Introduction The development of interpersonal skills is central to the education of mental health nurses in becoming capable practitioners in modern mental health services. Such skills continue to become ever more essential in the current climate of mental healthcare, and in particular, in the preparation of practitioners with the ability to implement the relevant components of the National Service Framework for Mental Health (SCMH 2001, DoH 1999). Therefore, there is a real need to develop a method of identifying student mental health nurse’s competency in this area.
Nurse Education in Practice (2002) 2, 160–168
Assessing the range of skills nurses require for professional practice is regarded to be of great importance, yet the assessment of any clinical skill is complex and presents problems (Nicol & Freeth 1998, Clifford 1994). Assessing student mental health nurses’ ability to use effective interpersonal skills presents a number of difficulties for educators, particularly in terms of how to assess such skills. The use of the Objective Structured Clinical Examination (OSCE) is not a new method in the assessment of nursing and medical students skills acquisition (Nicol & Freeth 1998, Brewin & Cantwell 1997, O’Neill & McCall
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1996, Woodburn & Sutcliffe 1996). The OSCE was originally developed for use in medical education in 1975 by Harden et al. (1975) and was designed to test a broad spectrum of skills and knowledge. Harden regarded the OSCE to be: ‘an approach to the assessment of clinical competence in which the components of competence are assessed in a well planned or structured way with attention being paid to the objectivity’ (Harden 1988). p. 19 There is a significant amount of literature on the use of OSCEs within general nursing (Studdy et al. 1994, Bujack et al. 1991, Roberts & Brown 1990, Ross et al. 1988, Aggleton et al. 1987). This material raises some important issues in terms of the instrument as a form of assessment in nursing. There is a absence of literature on the use of OSCEs to assess interpersonal skills in nursing practice. This paper focuses on the use of a method of assessing the interpersonal skills of mental health nursing students undertaking a 4 year undergraduate pre-registration Master of Nursing degree course at the University of Nottingham. The paper is structured as follows. It begins by presenting a brief review of the relevant literature exploring the contemporary development and use of OCSEs for the assessment of practical skills in a range of healthcare professionals. This leads into a discussion surrounding the development of the OSCE for assessing mental health nursing student’s interpersonal skills. The preparation and implementation of the OSCE is examined covering the actual process of assessment and evaluation of the OSCE. Tutors and students reflective comments on the experience provide material for further discussion. The paper closes by highlighting the benefits and limitations of using the OSCE and drawing conclusions on the process.
The development of OSCEs for the assessment of clinical skills The literature presents a number of studies evaluating the efficacy of using an OSCE. Bujack & Little (1988) developed an OSCE that enabled students to work through a series of
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stations for students to work round. The usual format is that students rotate around these stations and spend 5–10 minutes on each station whilst they are assessed on the skill (Nicol & Freeth 1998). The aim of this is to facilitate the integration of their knowledge and skills of care surrounding one single patient. This process appeared to work well and was positively evaluated by the students. The validity of the OSCE is reliant upon the quality of the problems presented at each station, but also the design of the assessment schedule (Nicol & Freeth 1998). In contrast, Ross et al. (1988) felt that the OSCE format was inappropriate for assessing nursing skills and that it did not reflect the clinical reality of nursing practice. They continued to use the medical orientated approach to assessment, implying that the OSCE implemented was ridged and inflexible. From this, it is clear that despite the apparent success of the OSCE in medicine and other disciplines (occupational therapy, physiotherapy etc), the traditional medical OSCE has a number of limitations with respect to the assessment of nursing skills. Nicol & Freeth (1998) list the following:
Performing skills at stations poses the risk of perceiving nursing as a set of performed tasks. There is little scope for testing communication skills in an integrated way. Because of the time limit on each OSCE certain skills may be omitted.
There are a number of more positive aspects of the OSCE which provide evidence of it’s efficacy as a method of assessing nursing practice. Harris & Miller (1990) piloted an OSCE with undergraduate medical students and found that the most beneficial aspect for their students of using the OSCE was the feed back post-examination. Students commented on the experience of being given formal and informal feedback. They valued the face to face feedback for helping them to identify their strengths, boost their confidence and identify their weaknesses. Harris & Miller (1990) also used video camera to record the stations used as part of the OSCE. Bujack et al. (1991) found that self-assessment is most effective when it combines the use of video playback to focus on specific competencies. Others have pointed out
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that, with adequate consent, video recordings can offer other practical factors such as external examining and further research (Nicol and Freeth 1998). Brewin & Cantwell (1997) developed a psychiatry based OSCE for the undergraduate medical programme in Nottingham. Similar OSCEs have also been developed for psychiatry (Famuyiwa et al. 1991). In particular, Brewin & Cantwell (1997) included some stations that were focused on assessing the quality of students’ interactions. Yet more recent work with undergraduate medical students using video-recorded scenarios to assess medical students of communication skills has raised a number issues. Humpris & Kaney (2000) designed a method of assessing cognitive aspects of students clinical communication skills, named the Objective Structured Video Exam (OSVE). In the study, the video-based written examination was found to be efficient and quick to administer, and demonstrated some evidence for validity. There are no reports providing evidence of the use of such an instrument in the development of mental health nursing student’s interpersonal skills. The UKCCs report on pre-registration education ‘Fitness for Practice’ highlights the need for a systematic, problem-based approach to assessing interpersonal skills (UKCC 1999). It is important to note that the pre-registration requirements for nurses include outcomes to be achieved for entry to the branch programme. These centre on ensuring that the student recognises the effect of their own values on interactions with patients and clients and their families, and friends; implement appropriate communication skills with patients and clients and understand the boundaries of a professional caring relationship (UKCC 2000a). As teachers of future mental health nurses we have been looking at ways in which we could enhance students’ ability to acquire core interpersonal skills essential for mental health nurse (MHN) practice. Within the current course (Master of Nursing) an OSCE has been used to assess a range of nursing skills such as eating and drinking, taking blood pressure, weighing patients. In essence the same kind of skills that have been assessed and described in
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the literature cited above. In the mental health branch we have been searching for a way of assessing students’ interpersonal skills. The OSCE offers a method of maintaining a student centred approach to learning. At the centre of our rationale for exploring the use on an OSCE in the education of mental health nurses is the point raised by Nicol & Freeth (1998) that this form of assessment leaves little scope for addressing communication skills. This was our challenge. We intended therefore, to develop a new form of OSCE for use in assessing our students’ competency in interacting with patients.
Developing the OSCE for assessing student mental health nurse interpersonal skills The interpersonal skills OSCE seeks to promote interventions, that are fundamental to mental health nurse practice. The skills we endeavour to teach and assess could be judged by some to be human qualities and not skills at all. Burnard (1999) asserts that the ability to listen well is the most helpful quality found in the sort of person you might go to see to talk about a personal or emotional problem. If mental health nurses are able to provide ‘good enough’ relationships with their clients by exercising ‘good enough’ interpersonal skills then they have successfully negotiated the first move to forming a therapeutic alliance. The ability to successfully listen is the first step of the first move (Rawlins et al. 1993, Wright & Giddey 1993, Stuart & Sundeen 1991). Listening may be differentiated from hearing. We can hear without synthesising or integrating information, in the same way that we may be seemingly oblivious to background music in a supermarket. The process of demonstrating active listening by reflecting feeling and content is a demonstration of basic empathy (Egan 1990). This ability is fundamental to the interpersonal skills required for building and maintaining therapeutic relationships. In the development of the interpersonal skills OSCE, we have made numerous assumptions. Firstly, the tutors implementing the instrument have assumed that the ability to
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listen can be a taught skill. It is acknowledge that this ability comes more naturally to some people than to others. It is also assumed that these skills can be objectively observed and, conversely, can also be detected when absent. There is inconclusive discussion whether effective listening is a skill or a quality. However, given the long history of the inclusion of listening skills training within mental health nursing education and given our own history in this area, we proceeded on the premise that effective listening can be taught and subsequently learnt by those with or without innate qualities.
Preparation for the OSCE The OSCE was part of the assessment process for an introductory module relating to mental health nursing practice. The OSCE (as with the physical OSCEs for the adult nursing students) would count for 20% of their overall marks for the module assessment. There is a requirement that parity is maintained across all branches using this form of assessment. As discussed above, the OSCE was focused on core, basic listening skills widely identified in the counselling, human relation and mental health nursing literature (Burnard 1999, Barker 1999). The skills were taught in a series of scheduled sessions. Given the constraints of the module, we were able to run only six one and a half an hour sessions, in consecutive weeks. The sessions were focused on specific skills, these included:
Non-verbal communication Open questions Clarifying Reflecting content Reflecting feeling Summarising The use of silence
In each session, students were encouraged to explore the theory underpinning the key practical skills being taught. These sessions were built around Rogers’ theory of personcentred therapy and Egan’s The Skilled Helper (Egan 1990, Rogers 1951). Each skill was firstly identified and described. Students were provided with practical examples, then had an opportunity to practice the skills in role-play
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situations. Group process time was included before, during, and at the end of each of the sessions. For the rest of the week students would be in allocated practice placements and were therefore encouraged to practice these interpersonal skills under the supervision of a mentor. Each week students returned to the sessions and shared with the group their experience of practising the skills and reflect on their successes and areas for improvement.
Process of implementing the OSCE For this particular assessment, we considered it inappropriate to include more than one station because this OSCE examines interpersonal skills which present as a constellation and are therefore inseparable. The assessment process for the OSCE was planned to be thirty minutes in duration. Students were given a scenario (Fig. 1) in advance and were told that they would need to conduct an assessment of the patient. The ‘patient’ was in fact a paid actor who we named ‘Janice’. It was made clear to the students that this was not an assessment of their nursing assessment skills per se but rather their interpersonal skills. However, students were advised to proceed by eliciting the patient’s story. The students were informed that their interview would be video recorded and the tutors would mark their work by watching the video recordings at a later date. Finally, for preparation purposes the students were shown a thirty-minute video of a tutor in action with ‘Janice’. This provided the students with a schematic representation of how the patient might present, together with a revision of the interpersonal skills taught in the previous sessions. Each student was also given a marking sheet to be used by the tutors during the assessment of the recorded video footage. On the day, the interviews were held in a small interview room within the School. The room selected reflected an environment that might be found on an acute admissions ward. Students were shown to the room and were offered a brief introduction to Janice and were then immediately left on their own with her. When the students had completed the
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The Scenario Janice was admitted to the acute ward yesterday evening following a serious overdose. She was transferred from the medical ward. Janice is now physically stable and slept throughout the night. The ward manager has asked you to assess her. You only know that she is 46 years old, married and a schoolteacher.
Figure 1
interview, a tutor met them outside of the interview room to ensure the session was successfully completed. Once all the students had finished the interview and a video recording of their intervention had been completed, the tutors set aside half a day to view and mark the video recordings. The marking sheet, presented to the students in the early stages of the OSCE, clearly identified the required skills in ten categories (see Appendix 1). For each skill the tutors awarded points out of ten (a higher score demonstrating more competency). The tutors discussed each skill, carried out in the interview by each student, before agreeing on a final score.
Evaluation The final part of the OSCE came when tutors had completed their examination of the video footage. Students were invited to watch a play back of the video recording and evaluate themselves and one another, without the tutors being present. Approximately two weeks later the students received their marks and tutors’ written feedback for their work. Subsequently, the students were asked to attend an evaluation meeting facilitated by the tutors. During this meeting students were encouraged to be open and honest about their whole experience of the interpersonal skills OSCE. All students attended and engaged fully with this process and gave extremely valuable feedback.
The tutors’ reflection on the process of implementing and evaluating the interpersonal skills OSCE Due to the close relationship between ‘listening skills’ and personality, the teaching of interpersonal skills is an intimate business and cannot be successfully negotiated with a large
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group. We are fortunate to be able to work with small groups on the degree programme. As with any teaching which involves and promotes personal development, it is important to allow time for the group to process the experience, where students may freely express thoughts and feelings in a supportive environment. During the teaching sessions which prepared them for the OSCE, individuals, at times, felt vulnerable and it was important for the tutors to be sensitive to the individuals’ emotional and psychological needs. The tutors were also able to spend maximum time with the students outside of the preparation sessions, e.g. running journal clubs, clinical seminars, other teaching sessions and visiting them on placement. The tutors and students were able therefore to build up a strong working relationship. It became very important to relate their classroom learning to clinical practice. Assessing the student’s work was a humbling process. The tutors witnessed a high degree of competency. Given the relative immaturity of the participants and the brevity of the teaching sessions, we considered this to be quite remarkable. The sessions appeared on video to be extremely realistic and all of the students exercised the listening skills that they were taught. One of the writers teaches therapeutic counselling at Diploma level in Further Education and observed that some of the work witnessed on the videos surpassed that which he would expect from his third year counselling students.
The students’ reflection on the process of implementing and evaluating the interpersonal skills OSCE Generally, the students were fairly negative about their experiences of OSCEs used earlier
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in their education. Knowing that OSCEs were originally used in medical education they perceived them as exercises which tend to medicalize nursing skills. The students expressed intense feelings when required to complete OSCEs for other parts of the course. The students all acknowledged feeling nervous whilst under scrutiny and claimed that OSCEs did not give a true reflection of practical skills whilst being conducted under such false conditions. It was suggested that OSCEs only tested the specific skills required and not the whole nurse-patient interaction. The students indicated that their previous experiences of OSCEs were not good. Therefore, their opinion of such a method of assessment was low, based on some of the assessment of clinical skills they had encountered in previous years of the course.
Students’ experience of the preparation for the OSCE The students thought that the teaching of the seven skills was a thorough process. They appreciated being taught the skills in the classroom, practising with each other and then being able to practice ‘live’ whilst on placement. They thought the skills were relevant to their work and that the allied theoretical component of the teaching was relevant. The students maintained that they would have benefited from greater opportunity to practice all of the skills together in role-play. The students reported that more practice using a camera would have been helpful. Observing a tutor on video practising the skills in advance was helpful. They also appreciated seeing the score sheets in advance so they knew what was expected of them.
Students’ experience of the implementation of the OSCE When the students entered the room, they said they felt nervous (one even ‘petrified’). This was largely to do with the presence of the camera and knowing that they were being examined on their skills. However, the students said that they preferred a camera to the possibility of being watched by tutors in
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the same room. All of the students thought that the actor was very realistic and effective. The students would have appreciated being able to talk to the actor once she had de-roled. It was thought that a half an hour interview was the right length of time.
Students’ experience of watching the video recording of themselves following the OSCE The most significant problem with the process of self-evaluation was the students’s embarrassment at watching themselves. They said it was easier to evaluate one another’s sessions for this reason. The students were glad that the tutors were not present for this session. One student said they would like to watch it again. One student said that the whole process made her feel as if she was being judged as a person. All of the students said that they thought the interpersonal skills OSCE should be a formative assessment and not summative as implemented. Nevertheless, in this informal feedback students concluded that the interpersonal skills OSCE was a useful way of helping the development of competency in these skills and that it was helpful to evaluate the whole process.
Discussion Examining the use of the OSCE with the mental health students in light of previous work illustrates some positive and negative characteristics. This paper presents a new approach to assessing mental health nursing students’ interpersonal skills. The experience of using the OSCE has been interesting because of the innovative nature of its implementation and informative because of the collaboration of the students. It has not been possible to check for validity or to actually measure the extent to which the students retain competency in using the interpersonal skills. Yet, while it has been a generally worthwhile exercise for assessing students’ interpersonal skills, it is really one of the only possible ways of getting close to the students’ human relationships skills in order to assess them. It is clear from the students’ reflection that it is much better carried out as
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formative rather than a summative exercise. This requires further investigation in a planned study. This paper has not presented empirical research evidence arising from a study into the use of the OSCE. We have therefore not addressed issues relating to methodology, validity or reliability. The use of the video recording as described above, raised a number of issues. In particular, the students reflected on the use of the camera and on being videotaped. The students were unsure and felt that the presence of the camera created anxiety. Yet this was much better than actually being watched by two human assessors. Nicol & Freeth (1998) found that in fact, students quickly forget the presence of a camera in a room. So despite some reservations, the use of video playback was a very powerful form of learning. Asking the students to go and watch themselves interact and internally evaluate their interactions with Janice was perhaps the most powerful and meaningful exercise in the whole experience of using the OSCE. The effect of the process upon the tutors watching the students also has to be noted. As mentioned – this experience has been humbling – the students were clearly capable and had the human abilities to conduct an effective interview in spite of such minimal preparation. Brewin & Canterill (1997) reported a similar experience in that they observed the variety and flexibility the OSCE can provide in assessing students. This is despite the inherent rigidity in being objectively led. It is acknowledged that it is impossible for us to be truly objective about assessing another’s interpersonal skills. Like everybody else, we have our own culture, preconceived ideas and stereotypes that inevitably prejudice our judgement. Whilst attempting objectivity, we accept the subjective element to every form of assessment. In this process, the tutors acknowledged that they are both white, educated males, both considerably older than the students. Acknowledging these issues appears to have been missed in more recent attempts to assess medical student’s skill in communicating with other people. Humpris & Kaney (2000) appear to be suggesting that they need to ‘get through’ lots of medical students and assess their communication skills quickly and efficiently. This paper presents the view
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that interpersonal skills (in any profession) need to be assessed carefully and with awareness. Therefore, Humpris & Kaney’s OSVE suffers a major flaw in that the assessor never actually observes the student carrying out the intervention. How can they pass a judgement on a student’s ability to communicate if this is the case? This is the point at which role-play has great value. Historically, listening skills courses include the use of role-play in order to help practice taught skills (Burnard 1999). The use of role-play for practice purposes is encouraged but the use of a professional actor for assessment purposes provides an extremely realistic challenge for the students. The UKCC (2000b) may be correct in maintaining that the Thorn programme and other programmes are grounded in evidence supporting their efficacy. But as Barker et al. (1999) suggests the need for psychiatric nurses is clear but complex. Instead of looking to develop new skills or fashion new roles, psychiatric nurses might focus on new ways of developing and enhancing traditional functions – human caring – in a complex, growing technological healthcare arena that threatens the human factor at the heart of all care. The introduction of an OSCE for the assessment of interpersonal skills is designed as an aid for mental health nurse teachers who are involved with interpersonal skills training. Hopefully, this approach will help focus the minds of teachers and students in enhancing the basic listening skills each mental health nurse needs in order to develop meaningful relationships with clients. In doing so, it may be possible to move closer to developing future practitioners capable of delivering the services set out in current mental health polices (DoH 1999). What we have presented is not only innovative but also assists in promoting and determining core skills, which are fundamental to mental health nursing practice. It is beyond the scope of this paper to explore the literature and research relating to empathy, however, the authors acknowledge its relevance to this work.
Conclusion This paper has highlighted the value of implementing an OSCE to assess interpersonal
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skills in the education of pre-registration mental health nurses. Mental health nurses need to feel competent in the skills forming the fundamental basis of their practice. Recognising the centrality of interpersonal skills in the mental health nurses role, this work has been an exploration attempting to put real meaning in student mental health
nurses’ development of these skills and finding out what they can really do. Acknowledgements
We would like to thank all of the 1998–2002 mental health branch Master of Nursing degree for their contribution in this work.
Appendix 1 OSCE – Assessment Guidelines Interpersonal Skills Name:
PIN Number:
Outline: Time: 30 mins Situation: (scenario)
Intervention
Rating
Introduces themselves to the client appropriately, gives outline of what they are going to do Gives client broad openings, open questions Responds to clients NVC, makes adequate notes & interpretation Clarifies issues with client Uses appropriate NVC, eye contact, body language Listens to client, demonstrates understanding of clients verbal communication by reflecting & restating content and feeling Uses silence appropriately Offers acknowledgement for the clients contribution to the interaction Ends interaction appropriately by offering a summary and giving information on future plans Total Rating
Rating: Marks out of ten Signed Student:
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Signed Assessor:
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