Teaching and Learning Forum 95 [ Contents ]

Assessing clinical competencies

Carol Piercey
School of Nursing
Curtin University
Professionals are people who problem solve for service in their particular discipline, through the use of technical or specialised knowledge and skills. If graduates from higher education are adequately prepared to perform their role as professionals, then the concept of competency comes to the forefront of the education charter. The literature reveals a variety of meanings concerning the concept of competency resulting in some academics adopting a narrow definition which focuses on psychomotor skills and vocational training. Competence, however, is a complex concept that encompasses such attributes as knowledge, skills and attitudes. It enables an individual/group, to perform a role or set of tasks, to an appropriate level, grade, quality or achievement, thus making the individual/group competent in that role. As competency is a complex concept, it follows that there should be multiple assessment strategies, to evaluate the effectiveness of student learning. Some of these include critical incidence, case studies, journal keeping, and self-evaluation.

Introduction

Generally, curricula are organised around different subjects in order for students to pass written tests. This subject centred curriculum whilst it is easily administered and controlled, may fall short of preparing students to practice at the beginning level of their chosen profession. This traditional system of education has been criticised by employers who complain that 'qualified' people, those who have completed a recognised program of learning in universities, only know what to do, they cannot actually do it (Fletcher, 1992). This challenges the responsible teacher who prepares students for professional practice, to develop appropriate assessment techniques, which judge whether an individual meets the criteria required to enter that profession. Competency-based assessment can meet this need, as it focuses on actual performance of what a person can do rather than what an individual knows.

Defining competency

A narrow concept of competency can be conceived as the discrete behaviours associated with the completion of a single task. In effect the task becomes the competency (Gonczi 1993). This interpretation negates the underlying complexities involved in the performance of roles in the real world of professionals (Preston and Walker, 1993) and it ignores group processes and their effect on performance (Ashworth and Saxton, 1990; Field, 1991; Collins, 1991).

A second and more generic interpretation of competency, can be found in the management literature (Boyatzis, 1982). This interpretation concentrates on the crucial general attributes of effective role performance that a practitioner demonstrates and which may be transferable to other roles (Gonczi, 1993). This model not only ignores the context in which the competency takes place, but also the literature on novice to expert, which suggests that expertise is domain specific (Benner, 1984; Mc Gaw, 1993).

A holistic perspective of competency marries both the above interpretations and considers the context in which the professional works. It allows for the incorporation of values, ethics and the need for reflective practice. This holistic interpretation of competency has been adopted by 19 professions, all of whom require specific standards of competency to be learnt at a university level of education.

The link between competencies and higher education

In fulfilling the goal of providing effective education, teachers in university have a responsibility to prepare practitioners according to the standards of that profession. Competency-based standards are basic statements of outcomes. They identify the major attributes which are required to ensure that a role can be fulfilled. These attributes reflect the knowledge, attitudes, values and skills associated with each aspect of performance in the workplace and are expressed in terms of professional practice.

A competency can be measured by using performance criteria that describe the processes, tasks and expectations of performance a competent professional will perform. That is the behaviour, the observable results and type of performance which would provide the evidence of competence. The nature of performance criteria for the professions can be complex and broad. They are not a check list of functions, but represent the complex attributes required to fulfil a professional role.

Competency-based assessment

Assessment is about the collection of evidence. Within the traditional educational system evidence of required learning is often in the form of written assignments and/or a final examination. This evidence may be matched with the unit objectives and influenced by a 'norm referencing' process which compares results of the learners within a group with each other. Objectives are clear precise statements of what students should be able to do when they complete their instruction and passing the assessment attests to them having met those objectives. Collectively, unit objectives should reflect the competencies the student will need to demonstrate on completion of the learning program. Norm referencing, however, provides little help for the assessor who has the responsibility of deeming the student competent to enter the profession as a novice practitioner. Conversely, 'criterion referenced' assessment is based on the specific criteria on which a performance can be judged acceptable. By breaking down the elements of competency into performance criteria sufficient evidence can be collected to demonstrate that an individual can perform to the specified standard in a specific role.

Competency-based assessment in Nursing

The most important aspect of an educational assessment is the ability of the test to measure what it is supposed to measure, that is its validity. It also needs to be reliable. The use of assessment techniques which are based on the representation of the real world enables one to increase the reliability and the validity (Hepworth, 1989). Clearly the use of direct observation would be ideal, however, nursing is based on the premise that each person is an individual and therefore no two patient situations are the same. The relationship between the nurse and the patient is constantly changing and is inextricably bound up in the differing perceptions of both parties. Additionally, reliability and validity is further compromised by the assessor's own perception of the nursing situation and their own nursing experiences.

Thus the nature of nursing is dynamic. It changes in response to a variety of social/political, economic, cultural, religious and health factors. Professional nurses address these complex influences and the uniqueness of caring for the individual, by using knowledge, intuitiveness and logical thought. Mindful of this constantly changing nature of nursing, nurses have developed competency-based standards which make explicit the complex attributes of a novice practitioner. Nurse educators have sought and implemented a variety of strategies to assess a student's clinical competence based on these competency standards. These strategies of assessment are integrated, combining knowledge, comprehension, problem solving, technical skills, attitudes and ethics. By using multiple assessment techniques, the amount of evidence increases providing a more solid foundation on which to make a judgement about a students competence. Some strategies for assessing clinical competencies include: observation, written communication and self-evaluation.

Strategies in assessing clinical competence

Observation
In many instances competence cannot be observed directly, it can only be inferred from assessment techniques which reflect competence. Whilst it is important to observe performance, it is dangerous to infer competency of a student from one setting, since professionals work in a variety of contexts. Observations are generally based on one sample of the student's performance, because it is impossible for the teacher to be present in all clinical situations. Since inference on the student's competence cannot be made from one situation, an adequate number of observations need to be recorded by a variety of assessors. Observing and judging a student's behaviour based on specific performance criteria derived from the profession's competency statements, can potentially make the assessment more valid and reliable, and also allows different assessors to assess students performance.

Critical incidents
One method of recording student performance in the clinical environment is the critical incident. This method not only records a learner's performance but can also be used to assess a student's problem solving and analytical abilities. In this strategy the clinical teacher records some aspect of the student's behaviour, to be evaluated according to specific performance criteria. Critical implies that the behaviour has a significant impact, either positive or negative, on the outcome of the activity. Before this technique for competency assessment is implemented, there must be agreement between clinical teachers as to the specific competencies to be assessed. The record of critical incidents can also provide a basis for student teacher discussion helping the student to visualise their own behaviours identifying both strengths and weaknesses. In nursing, questions posed concerning the critical incident usually relate to nursing judgements and/or actions such as those involved in the nursing process (Schweer and Gebbie 1976).

Written communication methods

Case studies
Professionals communicate amongst themselves to promote continuity of practice with written notes often forming the basis for such communication. Written communication such as case studies can be used not only as a teaching tool, but also to assess clinical competencies. In nursing this is a problem solving activity whereby a student undertakes a comprehensive physical and psychosocial assessment of a client and documents the findings using the nursing process. (Schweer, 1972). Teachers using this method of evaluation, not only assess a student's ability to communicate in a logical clear and concise manner, but also assess the student's ability to present a holistic perspective of client care. The teacher can also draw conclusions about the cognitive and affective domains and the ability to establish a rapport with clients. Case studies are beneficial in providing an opportunity for students to identify what they would do in a particular situation, making explicit the underlying tacit knowledge they bring to problem solving and decision making (Schon, 1990).

As with other forms of evaluation strategies, evaluation criteria should be set before the case study is written. These should be based on the students educational level, practice experience and competencies to be achieved. Students should be informed of these details so that they clearly understand what is expected. For example, at the comprehension level the student should include interpretive and extrapolative behaviours is whilst at the analytical and synthesis level the student would be expected to draw upon relevant theories (Reilly, 1980).

Journaling
A further method of evaluating clinical practice by written work, is journal writing. 'Journals are written dialogues between the self and the chosen audience' (Strackbein and Tillman, 1987). The value of journals lies in the ability to actively engage the student in transferring classroom discussions to clinical experience and allowing the evaluator to participate in the learner's experience from the learner's perspective. Using a triangular approach, whereby the student links personal and professional experiences with theory from the classroom and the literature, prevents students from writing what they think the teachers want to read. Teachers must, however, clarify from the outset the guidelines for journal entries. These include the purpose and criteria for evaluation, which should be based on the clinical competency being assessed. It is important to inform the students if journals are to be used for peer evaluation since students need to know how much they can self-disclose.

Criteria for marking, using the triangulation approach, is based on determining the level of analysis and synthesis in the entries which reflect the students reading, classroom and life experiences. Using this method of journal keeping will foster the development of skills in introspection, reflection, and dialogue and provides an avenue for students to make sense of and to learn from their mistakes. For this to occur, however, teachers need to build a trusting relationship with the student. This can be achieved by responding in a sensitive manner to personal disclosures and providing constructive written feedback on specific aspects of content rather, than global references to 'good work' (Heinrich, 1992).

Self-evaluation
A further method of assessing clinical competencies is by self-evaluation. Self-evaluation is useful in formative evaluation of clinical practice as students can identify their progress towards meeting specific goals. Techniques include journaling, videotape and self-rating scales. Self-evaluation requires skill and practice and for this reason the process needs to be taught in systematic manner at the beginning of the instructional period and implemented on a continuous basis. The literature describes the process of self-evaluation as the learner taking the responsibility to set goals and to determine achievement of those goals (Schweer, 1976; Best, Carswell and Abbott, 1990; Reilly and Oermann, 1992). In nursing, however, where there is an expectation of adherence to standards for safe practice, the process of self-evaluation can be learnt by working collaboratively with an experienced nurse educator, in setting appropriate learning goals based on the specific clinical competencies and performance criteria (Best, Carswell and Abbott, 1990). This collaborative approach allows the student to gain the confidence to self-evaluate and allows time for the student be socialised into the profession. It will only be successful, however, if the teacher is willing to act as a mentor and facilitator. Feelings of anxiety and negativity can be reduced by building a trusting relationship and creating a climate where the student feels free to take risks. The locus of control will eventually shift from teacher to learner as the learner gains more confidence in self-evaluation.

The focus of self-evaluation is to assist the student to confidently make independent judgements about her/his own practice in accordance with the values of the profession and it offers students the opportunity to express opinions about their performances. Thus, the goal of self-evaluation is to have students work towards an independent state where they will eventually be able to judge and act upon their own behaviours. This is based on studies which suggest that a person who participates in self-evaluation and creates their own learning objectives and solves their own problems, ultimately controls their own life (Best, Carswell and Abbott, 1990).

Conclusions

The traditional system of assessing students for professional practice has been criticised by potential employers as being ineffective. This challenges the university teacher to seek more appropriate techniques. Competency-based assessment may not be the panacea for this problem. However, it does measure the real world of clinical practice. Competency-based standards are basic statements of outcomes, they are the attributes required to fulfil the professional role at the beginning level. In nursing, they are complex and reflect the holistic nature of nursing practice.

There are a variety of competency-based assessment strategies which can be used to assess competency in clinical practice, these include observations such as critical incidents, written communication such as case studies and journaling and, finally, self evaluation. The degree of success, however, with these strategies depends on the teacher developing a trusting relationship with the learner and treating the learner as an adult, letting them take responsibility for their own learning. Vested interests and hidden agendas have to be dealt with if competency-based assessment is to function effectively. The change in assessment techniques means renouncing old habits, which is possible if university teachers are committed to preparing the graduate to the best of their ability. In the words of John Dewey 'We are free, not because of what we statically are, but as far as we are committed to becoming different from what we are' (Dewey, 1963 p291).

References

Ashworth, P. and Saxton, J. (1990).On competence. Journal of Further and Higher Education, 14, 3-25.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addition Wesley.

Best, M., Carswell, R. and Abbott, S. (1990). Self-evaluation for nursing students. Nursing Outlook, 38(4), 172-177.

Boyatzis, R. (1982). The competent manager. New York: Wiley.

Collins, M. (1991). Adult education as vocation. London: Routledge.

Dewey, J. (1963). Philisophy and civilisation. New York: Capricorn Books.

Field, J. (1991). Competency and pedagogy of labour. Studies in Education of Adults, 33(1), 41-52.

Fletcher, S. (1992). Competence-based assessment techniques. London: Kogan Page.

Gonczi, A. (1993). Competence and competencies: A global perspective. Paper presented at the First National Conference on Competencies in Nursing Adelaide: Australian Nursing Federation (SA Branch)

Heinrich, K. (1992). The intimate dialogue: Journal writing by students. Nurse Educator, 17(6), 17-21.

Hepworth, S. (1989). Professional judgement and nurse education. Nurse Education Today, 9, 408-412.

McGaw, B. (1993). Competence-based assessment: Measurement issues. National Assessment Research Forum. Sydney:TAFE Commission.

Preston, B. and Walker, J. (1993). Competency based standards in the professions and higher education: A holistic approach. Australia: University of Canberra.

Reilly, D. (1980). Behavioural objectives-evaluation in nursing. New York: Appleton, Century,and Crofts.

Reilly, D. and Oermann, M. (1992). Clinical teaching in nurse education. New York: National League for Nursing.

Schon, D. (1990). Educating the reflective practitioner. San Fransisco: Jossey-Bass.

Schweer, J. and Gebbie, K. (1976). Creative teaching in clinical nursing. Saint Louis: Mosby.

Strackbein, D. Tillman, M. (1987). The joy of journals-with reservations. Journal of Readings, 131(1), 28-31.

Please cite as: Piercey, C. (1995). Assessing clinical competencies. In Summers, L. (Ed), A Focus on Learning, p206-211. Proceedings of the 4th Annual Teaching Learning Forum, Edith Cowan University, February 1995. Perth: Edith Cowan University. http://lsn.curtin.edu.au/tlf/tlf1995/piercey.html


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