Nurse Education in Practice 11 (2011) 64e69

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Implementing a clinical competency assessment model that promotes critical reection and ensures nursing graduates readiness for professional practice
Tracy Levett-Jones*, Jean Gersbach 1, Carol Arthur 2, Jan Roche 3
School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW 2308, Australia

a r t i c l e i n f o
Article history: Accepted 19 July 2010 Keywords: Nursing education Nursing student Clinical assessment Competence Critical reection Work readiness

a b s t r a c t
Aim: This paper describes the design, implementation and evaluation of the Structured Observation and Assessment of Practice (SOAP), a model used to assess third year undergraduate nursing students clinical competence. Background: Competence is a complex concept that is difcult to dene and measure. The assessment of nursing students clinical competence has confronted universities with problems of validity, reliability, subjectivity and bias for many years. This presents particular problems in nursing as patient outcomes may be compromised by incompetent practice. Too often assessments of nursing students competence comprise brief assessments of psychomotor skills, vague global assessment of generic skills/attributes or assessments undertaken in simulated laboratory settings rather than the real world of practice. Methods: The Structured Observation and Assessment of Practice (SOAP), is a full day holistic practicedriven clinical competence assessment approach that motivates nursing students learning, promotes critical reection and conrms graduates readiness for professional practice. This model was introduced in 2004 and since then 1031 students have been assessed. Quantitative and qualitative data has been collected via an anonymous online evaluation. Results: Survey results have been statistically analysed using The Statistical Package for the Social Sciences (SPSS) (Version 13) with exploratory factor analysis employed to ascertain construct validity. This paper will report on the four components that showed acceptable factor loadings and that together accounted for 77.65 per cent of the variance: perceived learning outcomes, consistency with general clinical performance, quality of assessors, and anxiety/stress impact. Conclusion: The results of the SOAP approach supports the premise that quality clinical assessment requires nursing students exposure to complex challenges undertaken in authentic clinical contexts, observed by registered nurses who are trained as assessors and have a strong educational and clinical background. 2010 Published by Elsevier Ltd.

Introduction Competence remains a complex concept that is difcult to dene and even more difcult to measure (FitzGerald et al., 2001; Watson et al., 2002). The assessment of nursing students clinical competence has confronted educationalists with problems of validity and reliability over an extended period of time (Girot, 1993, 2000). Assessors often give learners the benet of the doubt and

* Corresponding author. Tel.: 61 02 4921 6559; fax: 61 02 4921 6301. E-mail addresses: Tracy.Levett-jones@newcastle.edu.au (T. Levett-Jones), Jean. Gersbach@newcastle.edu.au (J. Gersbach), carol.arthur@newcastle.edu.au (C. Arthur), Jan.Roche@newcastle.edu.au (J. Roche). 1 Tel.: 0410 144 969. 2 Tel.: 61 02 4021 6339; fax: 61 02 4921 6301. 3 Tel.: 61 2 4921 6230; fax: 61 02 4921 6301. 1471-5953/$ e see front matter 2010 Published by Elsevier Ltd. doi:10.1016/j.nepr.2010.07.004

fail to fail incompetent learners, unless there is very clear evidence of unsafe practice (Lankshear, 1990; Watson et al., 2002). This presents particular problems for the nursing profession as patient outcomes may be compromised by poor practice. While universities aim to prepare nurses to work in complex, dynamic and unpredictable clinical environments, too often clinical assessments are focused on psychomotor skills and fail to take into account the multidimensional nature of competence and the range of attributes required for professional practice. In order to address these educational and professional concerns an innovative clinical assessment model has been implemented into the Bachelor of Nursing program at the authors university. This paper outlines the design, implementation and evaluation of the cornerstone of this model, the Structured Observation and Assessment of Practice (SOAP). It is a comprehensive and practice-driven clinical assessment that motivates student learning, promotes critical reection

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and conrms graduates readiness for professional practice. For an outline of the other components of the clinical assessment model, including self-assessment of competence using narrative reection and core skills assessment, the reader is referred to: Levett-Jones (2007), Levett-Jones and Bourgeois (2007) and Levett-Jones et al. (2006). Review of the literature Dening competence One of the challenges underpinning clinical assessment is dening the term competence. Watson et al. (2002, p. 422) suggests that competence is a nebulous concept dened in different ways by different people. Its relationship to other concepts such as capability, performance and expertise is also unclear (Eraut, 1994). Gonzi (1994) describes three ways of understanding competence: (a) task related skills; (b) pertaining to generic attributes essential to effective performance; and (c) the bringing together of a range of general attributes such as knowledge, skills and attitudes appropriate for professional practice. This integrated and holistic approach aligns with the denition of competence provided by the Australian Nursing and Midwifery Council Competency Standards for the Registered Nurse (ANMC, 2005): The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area. It is this denition of competence that has been adopted for the SOAP model. Assessment of competence An additional challenge is that of measuring clinical competence. Reliability (the extent to which an instrument measures consistently) and validity (the extent to which an instrument measures the construct of interest) are fundamental to the assessment of competence. However, Norman et al. (2000) claims that these issues are rarely taken into account in the clinical assessment process. There is also the contentious issue of the level of performance that is indicative of competence and consequently at what level a student can be deemed incompetent (Watson et al., 2002). Lankshear (1990) and Eraut (1998) are in agreement that incompetence is easier to identify than competence. Watson et al. (2002, p. 423) adds to the debate by asking If someone is 90% competent, as judged by a series of tasks or observations, are they competent to practise or do they have to receive 100%? Similarly, are there some areas of practice more important that others and who decides? Messick (1994) adds to this discussion by questioning whether clinical competence can truly be assessed through addressing several discrete tasks or competencies, each of which may be performed well, or whether it is the interaction between the competencies that is of greater importance. The role of assessors The next issue to arise is the identication of the most appropriate person to assess nursing students clinical competence, as well as the likelihood of bias and subjectivity. Howard (1990, p. 31) asserts that one persons judgement, without explicit criteria and training, is likely to be biased and that the judgement may be biased even further e in either direction e by the assessor getting to know the student. Toohey et al. (1996) add that if the assessment is carried out by a preceptor or mentor who has worked with the student for an extended period of time a socialization process will occur which may inuence the assessors judgement. Conversely, an assessor unknown to the student may need to base their decision regarding

the competence of a student, on a very short period of observation that may not be representative of the students overall performance (Watson et al., 2002). Indeed, the students performance during this brief period of observation may be adversely inuenced by intrinsic factors (for example, anxiety) or external factors (such as patient acuity on a particular day), and these factors need to be taken into account during the assessment. Assessment of competence using simulation To counteract some of the issues raised above and in light of the unpredictable, dynamic and sometimes chaotic nature of clinical environments, many nursing programs have adopted simulated assessment approaches using standardised patients (actors) or human patient simulation manikins. Assessments such as objective structured clinical examination (OSCE) have advantages such as objectivity, the capacity for video analysis and the ability to recreate the same or similar scenarios for multiple assessments. Although simulated experiences are effective learning opportunities (Bremner et al., 2006), they often lack authenticity, are not contextual and, according to Eraut (1994), are second-best. McKinley et al. (2001) strongly advocate that nursing students competence should be assessed by direct observation of practice in a real clinical context. Background to the SOAP Prior to the introduction of the SOAP, registered nurses that mentored students, academics and students themselves had expressed reservations about the authenticity and relevance of the clinical assessment practices in use (Levett-Jones et al., 2006); there had been concerns expressed about the capacity of clinical assessments to promote student development and ensure safe practice. Boud (1995, p. 38) suggests that quality assessment practices require contextualised, complex challenges, not fragmented tasks. He adds, It is the use of more naturalistic in situ, multifaceted forms of assessment which provides the new challenge (Boud, 1995, p. 39). We were determined to create an authentic, meaningful assessment process that not only measured students clinical competence but also caused them to critically reect on their practice and to learn from that experience. We were mindful that good assessment is that in which the process of assessment has a directly benecial inuence on the learning process (Boud, 1995, p. 39). Thus, our goals were to address the professional and educational issues that had been identied and to improve the quality of clinical assessment practices by implementing a contextually based clinical assessment. Our challenge was to develop and implement a model that would be sustainable with a student cohort of over 1900 Bachelor of Nursing students, and to harness the collective support and enthusiasm of students, academic and clinical staff, for a radically different approach to the assessment of competence. The SOAP model was developed with regards to the literature (previously discussed) and in consultation with educational and clinical experts. It was piloted and initially evaluated with a group of sixty students in early 2004. The SOAP process The SOAP model is a 6 hour holistic assessment of nursing students clinical knowledge, skills, behaviours, attitudes and values, undertaken in a clinical context. The SOAP is an integral component of third year nursing students nal semester course work. It is a hurdle requirement; students are required to achieve a competent rating in the SOAP in order to complete their program and to graduate.

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Preparation of assessors One of the key elements in the success of the SOAP is the quality and commitment of the assessors and their capacity to turn, what has the potential to be a stressful experience, into one that is productive and afrming. Assessors are university employed registered nurses selected because of their clinical experience, highly developed interviewing skills, and demonstrated ability in observation, analysis, interpretation and evaluation of assessment data. Many of the assessors have worked as clinical educators previously and some undertake part time academic work when they are not in the assessor role. Assessors attend a two-day training workshop where they are introduced to the purpose and process of the SOAP and provided with opportunities to practice the assessment using videos of students with standardised patients (actors). Hypothetical situations are presented to promote dialogue and problem solving. Discussion topics include professional judgement, ensuring the rigour of the process and fairness. Prior to undertaking their rst assessment peer review is undertaken: new assessors observe an experienced assessor and then they are observed as they undertake their rst student assessment. This process enhances inter-rater reliability. Assessors attend debrieng sessions during the semester, and have access to an online discussion forum. This provides ongoing opportunities for questions and the provision of support. Less experienced assessors are sometimes concerned about achieving consistent standards in the summative judgements made about student performance. Dialogue with other assessors and with the course coordinator provides the opportunity for them to review and validate their professional judgement and their application of the specied criteria. The SOAP is conducted in the following order: Observation During a two-three hour observation period where students are engaged in their usual patient care activities, each of the students discrete nursing behaviours are documented in sequence by their assessor using a situation, action, outcome (SAO) format. Examples of two SAOs are provided below. Outcomes refer to the response to or following from the students action as well as the assessors assessment of the implications for the clients care: SAO Number: 1 Situation: Student enters Mrs Browns (pseudonym) room, a 67 year old client with rheumatoid arthritis. Action: Student asks How are you, did you sleep well? Outcome 1. Client responds, I had a terrible night with the pain and only slept on and off . I still have a lot of pain. Outcome 2. Clients condition/pain not assessed appropriately SAO Number: 2 Situation: Client (Mrs Brown) experiencing pain. Action: Student responds: Oh youll feel better when youve had a shower. Come on. up you get. Outcome 1. Client assisted to the shower. Outcome 2. Communication inadequate; clients pain not managed appropriately. VIVA The SOAP is different to many assessment models; there is no check list; it is contextually responsive; it seeks to understand more than the students observed behaviours; it also examines the knowledge, values and attitudes that inform the students practice. Following the observation period a VIVA is conducted. The Oxford English dictionary (2006) denes a VIVA as an examination conducted in the form of an interview using a set of questions or exercises

to evaluate skill or knowledge. In the VIVA conducted as part of the SOAP assessment probing and open ended questions are used to elicit the intentions, knowledge, rationales, attitudes and values underpinning a range of the most signicant student behaviours observed by the assessor. In the VIVA assessors are also looking for evidence of critical thinking and clinical reasoning, key attributes of a professional nurse. This approach ensures that the assessment is not just one dimensional. The assessor examines the students performance from different perspectives; the VIVA is an opportunity for the assessor to understand and document the students behaviours and interactions through a different lens as students are called on to explain and sometimes defend their actions: VIVA Question: Can you tell me about your reason for prompting Mrs Brown to have a shower even though she had stated that she was in pain? Response: I have cared for Mrs Brown for the past three days and I know that after she has a shower her pain is much improved. She had analgesics and anti-inammatory medications at 0800 and following her shower Ill rub Voltaren into her knees. Perhaps my communication with her was not appropriate though? Mapping Trends or patterns in the students cumulative behaviours are identied by mapping their behaviours and responses against the ANMC Competency Standards for the Registered Nurse (2005). The SOAP approach removes ambivalence by providing evidence for assessors to discriminate areas of performance and to make a valid and reliable judgement of competence. A result is determined by comparing the evidence gathered during the observation and VIVA with the ANMC Competency Standards (2005), taking into account the following criteria:
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Provision of safe and effective nursing care consistent with client needs and plan of care Demonstration of effective oral communication skills Demonstration of appropriate professional documentation skills Practice within ethical and legal boundaries.

Specic, clear and unambiguous feedback is documented and a detailed performance prole created. Formative and summative feedback During a oneetwo hour debrieng session immediately following the assessment formative and summative feedback are provided by the assessor to the student. The students clinical strengths and areas requiring further development are clearly identied. This approach provides a mechanism to give students individualised, detailed and non-threatening feedback which promotes critical self-reection and enables them to respond in a positive way when the need for improvement is identied. Summative results are recorded as either: competent on this occasion; competent pending completion of specied remediation, or not competent on this occasion and requiring remediation and reassessment. The performance prole that is documented and discussed with the student is easily understood and readily accepted as a way to extend learning and understanding. It clearly details the ways in which they have met professional and educational expectations; it describes their strengths and the particular areas where they excel. It also details areas in which improvement is required. For each identied limitation one or more explicit strategies for improvement are documented. Students are required

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to reect on the feedback provided. Strategies for improvement are negotiated with the student and their mentor and learning contracts are developed. Targeted remediation is designed to address clinical performance limitations. Remediation may include additional practice in a particular nursing skill or set of skills, writing a reective narrative about a critical incident, searching for the evidence that underpins a particular aspect of practice, additional supervised clinical placement hours, or spending time with a specialist nurse, for example, a pain consultant. Students are offered one opportunity for reassessment following remediation. Evaluation of the SOAP Since the implementation of the SOAP model in 2004 1031 students have been assessed. As part of the usual course evaluation process students have the opportunity to complete an anonymous online evaluation of the SOAP via the web platform Blackboard. The evaluation instrument was developed following review of the relevant literature and consultation with an expert panel to ensure face and content validity. The instrument consists of ve open ended questions and 46 closed questions with answer choices based on a ve-point Likert scale ranging from 1 strongly agree to 5 strongly disagree. Since the introduction of the SOAP 654 students have completed the evaluation survey giving a response rate of 63.4 per cent. Ethics approval was not required for data collection because this was an educational evaluation and a quality improvement project; however ethical principles underpinned the entire process. Survey results were statistically analysed using The Statistical Package for the Social Sciences (SPSS) (Version 13) with exploratory factor analysis employed to ascertain construct validity. Principal components analysis with varimax rotation was performed on the 46 variables. Six components with eigen values greater than one were extracted. This paper will report on the four that showed acceptable factor loadings and that together accounted for 77.65 per cent of the variance: perceived learning outcomes, consistency with general clinical performance, quality of assessors, and anxiety/ stress impact. Cronbachs alpha was used to measure the internal consistency reliability of the subscales; reliability coefcients were excellent: perceived learning outcomes 0.96; consistency with general clinical performance 0.92; quality of assessors 0.98; and anxiety/stress impact 0.90. Perceived learning outcomes Students evaluative feedback each semester has been consistently positive. The assessment process motivates students and causes them to critically reect on their practice. Its capacity to foster independent learning is evidenced by the quantitative data which demonstrate that the majority of students either agreed or strongly agreed with the following statements:
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clinical competence and readiness for practice 80 per cent agreed or strongly agreed. Students feel that the assessment is authentic, comprehensive, clinically relevant and contextually appropriate, as indicated by the following qualitative data from the open ended questions: We were assessed in a real working environment unlike the lab assessments where everything is make-believe. When you have the patients wellbeing in your hands, it makes you think more carefully about the what, why, and how of everything you do. The clinical assessment is the culmination of all that theory and practice and a thousand times better than any exam. When an experienced nurse assesses you in a real clinical environment and then says you are O.K. then that is really the icing on the cake. I was assessed on my whole approach, as opposed to individual clinical skills, and all aspects of my nursing were taken into consideration. The assessment tests the abilities of nursing students to see whether or not theyre ready to begin working as an RN. It also gives students the chance to put into practice everything theyve learnt at uni. And with remediation you can learn from any mistakes youve made. Quality of assessors Quantitative student feedback attests to the positive impact of the assessors of the students learning. The majority of students either agreed or strongly agreed with the following statements:
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The assessor was willing to assist me to learn and improve (89 per cent) The assessors feedback and advice were clear (96 per cent) The assessor spent sufcient time in providing feedback following the assessment (96 per cent).

The qualitative student evaluation data are also testament to the quality of the assessors: My assessor made me feel completely at ease from the moment that she arrived at the ward. She is fair and genuinely cared about how I was feeling. Even though there were a few areas where I needed remediation, which made me feel a bit inadequate, she turned them around and made me understand how important these things were at the same time praising me for my exemplary nursing care. Although I was pretty anxious to start with I tried to be positive and remember that the assessor was there to identify my strengths and weaknesses. The assessors attitude and approach were extremely positive, enthusiastic and encouraging. She documented a range of areas that I am competent in and I received lots of positive feedback. She clearly identied some areas that I need to improve on and provided strategies for me to achieve this. There is some remediation that I need to do but it was great to get this feedback now and to know that Im on the right track. I now feel more condent in becoming a Registered Nurse. Personally I feel this clinical assessment has been the most benecial and meaningful aspect of my clinical learning to date. Consistency with general clinical performance When students were asked whether they believed that the results of this clinical assessment were consistent with their general clinical performance 86 per cent of students agreed or strongly agreed. The overall consistency between the results of the SOAP and

The assessment allowed me to critically examine and reect on my clinical practice (90 per cent) I received feedback that helped me examine and develop my clinical skills and knowledge (90 per cent) I have developed my clinical ability as a result of this assessment (93 per cent) The assessor motivated me to follow up on important issues that were raised during the assessment (85 per cent).

As a result of the detailed and carefully considered feedback students receive, their condence has been enhanced. When asked whether the assessment increased their level of condence in their

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the weekly clinical appraisals completed by the students mentors attests to the validity of the process. However, when contradictions between SOAP results and weekly appraisals were identied clinicians often rationalised their decisions by explaining how they were reluctant to provide negative feedback to students they have worked alongside for a number of weeks. This phenomenon is similar to that described by Howard (1990) and Toohey et al. (1996) who assert that, due to the socialization process, the judgement of preceptors or mentors who have worked with the student for an extended period may be awed. Over the years since the SOAP has been conducted and because of the dialogue between assessors and clinicians, a gradual improvement in the quality, consistency and accuracy of the weekly appraisals has been observed. Of particular interest is the strong correlation between SOAP results and academic results. Over the three years it has been consistently identied that students who perform well in the SOAP almost invariably have a strong academic background. Conversely, those who perform poorly in their assessment have often struggled academically. This is particularly evident in the VIVA; students without a strong theoretical basis for their practice nd it difcult to provide rationales for care or to think critically about their actions. Anxiety/stress impact Undoubtedly, for many students the SOAP process provokes anxiety and stress. Sixty-three per cent of students agreed that the pressure caused by the assessment made them feel anxious; and 48 per cent felt that the SOAP was more stressful than exams. The qualitative results supported these ndings but indicated that most students were able overcome their anxiety quite quickly and to perform well despite their feelings. Students comments in regard to this included: Like any situation where you are being watched so closely, it unsettles the nerves a bit. I was anxious and stressed prior to the assessment as you never really have a complete understanding of what is going to happen and events that may arise during the course of the assessment. I liked the y on the wall style used by the assessor. It was quite easy to forget they were there and to treat the assessment like any other day out on clinical. After 15 minutes or so I went about my duties as I would normally, not even aware of the assessor, which helped me showcase my practice in a comfortable manner. My assessor was really great, it didnt feel like she was assessing me the whole time, she stood back and let me do my job, so I forgot about her.

response to the clear and unequivocal data from the SOAP assessment. One example of this is the unsafe practices related to medication administration that were identied as a serious and recurring problem in over 50 per cent of the students assessed during 2004e2005. As a result a new rst year foundation course was developed to specically target this issue by focusing on the quality use of medicines. Medication skills assessments and knowledge tests have also been introduced into rst, second and third year clinical courses. Medication administration practices have improved considerably; this is evident in the 2008 SOAP assessment data where only 16 per cent of students required remediation in this area. The second factor that has contributed to overall student performance is the manner in which students have become active participants in their own learning. Students claim that they feel a strong sense of purpose and are cognisant of the importance of developing their competence and readiness for professional practice, as evident in this example: I tend to ask more questions because I know my clinical learning has meaning and purpose and Im motivated to take responsibility for my learning. I have to do this to become a safe nurse but I also need to prepare for my competency assessment in third year. Clinical reasoning While signicant improvements have been identied in students overall performance the SOAP approach has also uncovered a decit in the learning outcomes of some students. Results collated over the three year period (2005e2007) indicate that only 15 per cent of students demonstrated high level clinical reasoning and critical thinking skills during their assessment. Although most students had good content knowledge and adequate procedural skills, they frequently lacked the clinical judgement and decision making skills needed to respond appropriately in unpredictable or complex situations. Viewed against the background of increasing numbers of adverse patient outcomes (Aiken et al., 2003) and escalating healthcare complaints (NSW Health, 2006), this is an important nding. Research indicates that nurses with effective clinical reasoning skills have a positive impact on patient outcomes (Hoffman, 2007); conversely, those with poor clinical reasoning skills often fail to detect impending patient deterioration resulting in a failure-to-rescue (Aiken et al., 2003). In response to these concerns, a funded research project on clinical reasoning is currently in progress at the authors university. Potential of SOAP for performance assessment of qualied nurses The rigour and applicability of this assessment approach has been recognised by industry partners and nurse regulatory authorities. Performance assessors appointed by the NSW Nurses and Midwives Board have used this approach in the assessment of registered nurses with consistently positive feedback. For example: In my assessment I used the SOAP model and found it to meet the requirements of the assessment process as well as the legislative requirements of Board. The instrument provided clarity for what was an extremely complex performance issue which had been extant for over two years. Conclusion This paper has described the implementation and evaluation of SOAP, an innovative, practice-driven clinical learning and competency assessment model that motivates student learning and conrms their readiness for professional practice. Without doubt

Analysis of trends in student performance over time The SOAP mapping process not only identies trends and patterns in the students individual cumulative behaviours but also allows an analysis of trends and patterns in the performance of the entire student cohort over time. During the period 2004e2008 there has been a gradual but ongoing improvement in overall student performance as indicated by the results of the SOAP assessments. The percentage of students who have been identied as competent on this occasion has risen from 35 per cent in 2004 to 50 per cent in 2009; the percentage identied as competent pending completion of remediation has risen from 39 to 45 per cent; and the percentage identied as not competent on this occasion has decreased from 26 to ve per cent. The improvement trends can be attributed to two main factors. The rst is the curricula initiatives that have been introduced in

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the SOAP model represents a substantial nancial investment in development and implementation and some may consider the resourcing to be impractical. However, contemporary clinical practice environments are dynamic and challenging; patient acuity and throughput continue to rise; universities, working in partnership with healthcare organisations, have a responsibility to ensure that graduates are well prepared for the demands and challenges they will encounter in practice. The SOAP model is one way of ensuring that graduates meet the requisite standards of clinical competence and it gives them condence in their ability to practice as a beginning registered nurse. Just as importantly the SOAP helps to reinforce students accountability and responsibility in the provision of safe and effective patient care: The assessment made sure that I am a safe nurse and that I am person-centred rather then purely task orientated. But really, the assessment was not just for me but also the patients that I will be caring for in the future.

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