Conductas y comportamientos.

Clinical competence assessment approaches are strategies used for assessing learning outcomes in clinical practice. Despite the need to facilitate students’ professional development, there is no uniform or systematic approach to assessment of clinical competence, making it a challenge to measure all the attributes of clinical competence (O’Connor et al., 2009:493). Previously in the 1960s, assessment was based on a list of the student characteristics and behaviours thought to influence performance (Kirschbaum et al., 1994, cited in Oermann & Gaberson, 2009:372). Using this approach, judgements were made against course objectives which were measurable and observable. Recently, researchers have utilised various approaches to distinguish students’ level of performance. Anema and McCoy (2010:40) suggest that assessment can either be objective or performance related. According to Anema and McCoy objective assessment focuses on what learners know and comprises predetermined correct responses; for example, oral responses to questions. The focus of objective assessment is on knowledge, concepts, and basic skills in the cognitive domain. Palomba (2001:18) observes that the objective approach to assessment focuses on factual knowledge rather than higher-order thinking skills hence learners lack the ability to apply such knowledge to the real world.

On the other hand, performance related assessment focuses on what learners can do with their knowledge. It involves the assessment of critical thinking, synthesis, affective domains, and

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psychomotor skills. Examples include simulations, portfolios, essays, journals and skills demonstrations and direct observations (Anema & McCoy, 2010:41). The assessments aim at evaluating the learners’ ability to demonstrate foundation knowledge in relation to concepts and basic skills. For example, learners will need to have foundational competency in maternal conditions affecting neonatal development in order to make clinical decisions related to providing care to neonates with congenital anomalies. This will allow the learner to rethink, revise and reflect on their work. It also provides choices for the learner in how the competence would be demonstrated. In turn, the learner can advance his/her level of competency to critically analyse what he knows, synthesise the information and apply it to different situations in the clinical setting.

An example of a performance related approach commonly used in nursing practice is objective structured clinical evaluation (OSCE) (Oranye Ahmad, Ahmad & Bakar, 2012:233-241; El- Nemer & Kandeel, 2009:1265-127). Jahan et al. (2013:94) describe OSCE as an approach to student assessment in which the clinical competence is evaluated in a comprehensive, consistent and structured manner. During OSCE students are exposed to different clinical scenarios specifically designed in a structured environment, and are expected to demonstrate their competence under these simulated conditions (Einion, 2013:893; Sharma, Chandra & Chaturvedi, 2013:299). In OSCE, teachers use direct observation to assess the students’ performance. The OSCE provides the students with opportunities to demonstrate interpersonal skills, problem solving abilities and application of basic clinical knowledge (McWilliam & Botwinski, 2012:38-39) while the teacher observes performance and records the observed skills and behaviours. OSCE has been perceived as a useful and effective method for assessing clinical competence as well as for enhancing the knowledge required for clinical work when compared to

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other assessment approaches (Noonan, Bradshaw & Murphy-Tighe 2012:690). In addition, the approach has been effectively used in undergraduate nurse curricula to assess safe practice in terms of performance of psychomotor skills as well as the declarative and schematic knowledge associated with their application (Mitchell et al., 2009:398).

However, the approach is not as comprehensive as has been thought in assessing students’ level of clinical competence in all the domains. The approach is a form of performance-based assessment (Rouse, 2010:26-30; McWilliam & Botwinski, 2012:35-39) as well as a means for summative assessment (Einion, 2013:893) focusing more on objective assessment of knowledge and skills than most practice-based assessments. Fastre et al. (2010:518) argue that the performance-based assessment approach is task dependent and focuses on the learner’s current behaviour; what the learner can do. Student desired performance tasks are specified in advance, step by step and chronologically, describing what needs to be done to fulfill the requirements. This limits the focus and content for targeted skills as only certain components of the total skills are included for assessment. As such, not all domains may be assessed using this approach. In addition, students memorise the steps without applying critical thinking (Rouse, 2010:26-30; McWilliam & Botwinski, 2012: 35-39) making it a challenge for them to transfer the skills in diverse situations. Furthermore, the approach has been reported to generate uncertainty and stress among students with regards to objectivity (Muldoon, Biesty & Smith, 2014:468; Einion, 2013:896; Rouse, 2010:27; El-Nemer & Kandeel, 2009:1272; McWilliam & Botwinski, 2012:38). This can negatively affect the students’ performance as they may not demonstrate their capability because of the stressful environment.

In addition to OSCE, nurse educators have used the students as assessors of their own performance through self- and peer assessments. Student self-assessment refers to the process by

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which the student gathers information about and reflects on his or her own learning in relation to personal progress in knowledge, skills, and/or attitudes (Andrade, 2008:60). During self- assessment, the student reflects on the quality of his/her work and judge the degree to which it reflects the stated goals or criteria. Self-assessment approaches include reflective diaries and portfolios which encourage the student to reflect upon and judge his/her own performance and abilities. On the other hand, peer assessment is an arrangement, by the teacher, in which individuals consider the amount, quality, level of success or outcomes of learning of peers of similar status (Taylor, Grey & Satterthwaite, 2013:26). It involves groups of students assessing their colleague’s achievements. Taylor et al. (2013:27) observe that both self- and peer assessment promote active learning as the students get motivated and are involved in the learning process. In addition, there is an increased amount of feedback and reflection enabling the students to identify their own limitations and strategies to improve their knowledge and skills. However, using students as assessors may sometimes be challenging as students may either underscore or over score their performance or that of a colleague because of fear of failure.

Despite having a number of approaches, McCready (2007:147) observes that there is no comprehensive and effective approach to assess clinical competence. McCready argues that most of the competence assessment approaches measure only a quarter of the nurses’ clinical competence because they focus on technical skills. But the integration of cognitive, psychomotor and affective skills is paramount to the development of a safe and competent practitioner. Nicholson et al. (2013:1093) observe that assessment of clinical competence becomes more challenging because of the complexity of nursing practice and human interaction which requires sufficient evidence to make a sound judgement about an individual’s level of clinical competence. As such, the assessment of clinical competence requires a constant monitoring of

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the student’s professional development in all the domains, throughout the course of training. McMullan et al. (2003:288) suggest an assessment approach that integrates knowledge, understanding, problem solving, technical skills, attitudes and ethics with clear criteria to interpret the judgement. The integrative assessment influences students’ learning by providing activities that define and track strategies that the students use to assess their own learning abilities and problem-solving capabilities. Fordham (2005:42) recommends a competency-based approach which takes into account the students’ capacity to integrate knowledge, values, attitudes and skills in the practice setting. Competency-based assessment links knowledge and practice by creating a correspondence between what students know or are expected to learn, thereby simulating them to develop relevant professional skills and thinking processes (Gullikers et al., 2008:173). To achieve this, competency assessment approaches should be comprehensive enough to capture all the aspects of competent performance, integrate cognitive, psychomotor and affective skills while providing clear and specific guidance on performance criteria. This assists the students to visualise the skilled performance expected of them, thereby enhancing opportunities for the students to develop skills of self- and peer-evaluation. There is a dearth of literature on the assessment approaches used in Malawi but undocumented information indicates that most of the training institutions use OSCE for assessment of clinical competence.