Jönköping University, School of Health and Welfare
Ho
l
ist
ic
C
l
in
ica
l Assessment
for
Undergraduate
Nurs
ing
Students
V
iv
ien
X
i
WU
DISSERTATION SERIES NO. 69, 2016 JÖNKÖPING 2016
©
Vivien Xi WU, 2016Publisher: School of Health and Welfare Print: Ineko AB, Göteborg
ISSN 1654-3602
"The rea
l voyage of d
iscovery cons
ists of not
in seek
ing
new
landscapes but
in hav
ing new eyes."
Marcel Proust
Abstract
A major focus in nursing education is on the judgement of clinical performance, and it is a complex process due to the diverse nature of nursing practice. Difficultiesinthe development of valid and reliable assessment measures in nursing competency continueto pose a challengein nursing education. A holistic approach in the assessment of competency comprises knowledge, skills and professional attitudes, whereinthe notion of competency incorporates professional judgement and management skills in the clinical situation. Therefore, the thesis aims to develop a holistic clinical assessment tool with a reasonable level of validity and reliability to meetthe needs ofclinical education.
The conceptual framework underlying this research is formed by establishing a theoretical connection between the practice of learning, and of pedagogy and assessment. This research consists of five studies. In Study I, a systematic review was conducted to explorethe current assessment practices and tools for nursing undergraduates. In Studies II, III and IV, a qualitative approach with focus group discussions was adopted to explore the views of final-year undergraduate nursing students, preceptors, clinical nurse leaders and academics on the clinical assessment. Based on the multiple perspectives, it therefore addresses concerns in clinical assessment. In Study V, a holistic clinical assessmenttool was developed, for which a psychometrictesting was conducted.
The systematic reviewindicatedthatlimited studies adequately evaluatethe psychometric properties ofthe assessmentinstrument. The qualitative studies have raised an awareness of professional and educational issues in relation to clinical assessment. Workload, time, availability of resources, adequate preparation of preceptors, and availability of valid and reliable clinical assessment tools were deemed to influence the quality of students’ clinical learning and assessment. In addition, the presence of support systems and formal educational programs for preceptorsinfluencedtheir preparation and self-confidence. Nursingleadershipsin hospitals and educational institutions have a joint responsibility in shaping the holistic clinical learning environment and making holistic clinical assessment for students. The involvement of all stakeholders in the development of a valid and reliable assessmenttool for clinical competencyis alsoessentialtothe process. The Holistic Clinical Assessment Tool (HCAT) was developed bythe author based on the systematic review, qualitative findings andthe core competencies of registered nurse fromthe professional nursing boards. The HCAT consists of 4 domains and 36 assessmentitems. Furthermore,testing ofthe psychometric propertiesindicated
that the HCAT has satisfactory content validity, construct validity, internal consistency andtest-retest reliability.
In conclusion, the HCAT is meritorious in that it carries the potential to be used as a valid measure to evaluate clinical competency in nursing students, and provide specific and ongoing feedback to enhance the students’ holistic clinical learning experience. The HCAT not only functions as a tool for self-reflection for the students, but also guidesthe preceptorsin clinicalteaching and assessment. In addition,the HCAT can be used for peer-assessment and feedback. Itisimperative that the clinical and academic institutions establish various levels of ongoing support for both students and preceptorsinthe process of clinical assessment. Keywords
Clinical assessment;transitionto practice; clinical nursing education. clinical guidance; feedback; undergraduate nursing student; nurse preceptor; clinical nurse leader, academic, holistic clinical assessmenttool;tool development; psychometric testing.
Or
ig
ina
l
papers
Thisthesisis based onthe following papers, which are referredto bytheir Roman numeralsinthetext:
Paper I
Wu, X. V., Enskär, K., Lee, C. C. S., & Wang, W. (2015). A systematic review of clinical assessment for undergraduate nursing students. Nurse Education Today, 35(2), 347-359. doi: http://dx.doi.org/10.1016/j.nedt.2014.11.016
Paper II
Wu, X. V., Wang, W., Pua, L. H., Heng, G. N. D., & Enskär, K. (2016).
Undergraduate nursing students’ perspectives on clinical assessment attransitionto practice. Contemporary Nurse: A Journalforthe Australian Nursing Profession,00, 1-14. Published by Taylor & Francis. doi: 10.1080/10376178.2016.1163232
Paper III
Wu, X. V., Enskär, K., Heng, G. N. D., Pua, L. H., & Wang, W. (2016). The perspectives of preceptors regarding clinical assessment for undergraduate nursing students. International Nursing Review,00, 1-9. Published by Wiley. doi:
10.1111/inr.12272 Paper IV
Wu, X. V., Enskär, K., Heng, G. N. D., Pua, L. H., & Wang, W. Clinical nurse leaders’ and academics’ perspectives on clinical assessment: a qualitative study. Submittedto Nurse Education Today, on 8 March 2016.
Paper V
Wu, X. V., Enskär, K., Heng, G. N. D., Pua, L. H., & Wang, W. Development and psychometrictesting of Holistic Clinical Assessment Tool (HCAT) for
undergraduate nursing students. Submittedto BMC Medical Education, on 5 February 2016.
The articles have been reprinted withthe kind permission ofthe respectivejournals.
Table of Contents Acknowledgements ... 1 Abbreviations ... 4 Definitions of concepts ... 5 1.Introduction ... 7 2. Background ... 9 2.1 Holistic nursing ... 9
2.2 Clinical competencyin nursing education ... 9
2.3 Clinical assessment of nursing studentsin clinical practice ... 10
2.4 Generic and holistic assessmentinthe practice-disciplines ... 11
2.5 Context ofthe study ... 12
3. Conceptualframework - Holistic Clinical Assessment ... 14
3.1 Studentsin clinical practice ... 15
3.2 Preceptors and Clinical Nurse Leadersin clinical practice ... 16
3.3 Academicsin clinical practice ... 17
3.4 Nursing students, preceptors, Clinical Nurse Leaders and academics ... 18
3.5 Learning, pedagogy and assessment ... 18
3.5.1 Student’s self-assessment and preceptor’s assessment ... 19
3.5.2 Formativefeedback bythe preceptors ... 20
4. Rationaleforthethesis ... 21
5. Aims ofthethesis ... 23
6. Methodology ... 24
6.1 Study designs ... 24
6.2 Settings and participants ... 24
6.3 Estimation of sample size ... 32
6.4Instruments ... 32
6.5 Data collection ... 33
6.5.1 Literature search ... 33
6.5.2 Focus group discussions ... 33
6.5.3 Psychometrictest ... 34
6.6 Data analysis ... 35
6.7 Process of developmentforthe Holistic Clinical Assessment Tool ... 39
6.7.1 Development ofthe domains anditems ofthe HCAT ... 39
6.7.2 Development onthelevel of proficiency ... 40
6.8 Rigour ofthe study ... 41
6.9 Ethical considerations ... 42
7.1 The evidencefromthe systematic review (StudyI) ... 44
7.2 Findings ofthe qualitative studies (StudyII,III &IV) ... 44
7.2.1 The needfor a valid and reliable clinical assessmenttool ... 45
7.2.2 The needfor aflexible style of reflection and specificfeedback ... 46
7.2.3 Effortsinlearning/teaching and assessment ... 47
7.2.4 Challenges encounteredin clinical assessment ... 48
7.2.5 The needto enhancethe support systemfor preceptors and students ... 49
7.3 Results of psychometrictesting (Study V) ... 51
7.3.1 Assessment offace validity ... 51
7.3.2 Assessment of content validity ... 51
7.3.3 Pilottesting ... 52
7.3.4 Factor structure ... 52
7.3.5Internal consistency reliability andtest-retest reliability ... 53
7.3.6 Content analysis ofthe open-endedfeedback ... 53
8. Discussion ... 58
8.1 Whyisthere a needfor a newtool? ... 58
8.1.1 The needfor a valid and reliable clinical assessmenttool ... 58
8.1.2 Reflectionsfromthe students, preceptors, clinical nurseleaders and academics . 58 8.2 Contents ofthe Holistic Clinical Assessment Tool ... 61
8.2.1 Holistic approach ofthe HCAT ... 61
8.2.2 Development onthe critical elements ofthe HCAT ... 61
8.2.3 The needfor aflexible reflection style and specificformativefeedback ... 62
8.3 Scientific value ofthe Holistic Clinical Assessment Tool ... 62
8.3.1 Reliability and validity ofthe HCAT ... 62
8.3.2 Advantages and disadvantages ofthe HCAT ... 65
8.4 Clinical value ofthe Holistic Clinical Assessment Tool ... 65
8.4.1 Threefold use ofthe HCAT... 65
8.4.2 Process ofthe assessment practices ... 66
8.5 Discussion onthe methodology ... 66
9. Conclusion ... 68
10. Implicationsfor practice ... 69
11. Future research ... 72 12. References ... 73 Appendix 1 ... 84 Appendix 2 ... 89 Appendix 3 ... 94 Appendix 4 ... 97
Acknow
ledgements
The journey of being a doctoral student has been exciting, challenging, and fulfilling. Many people have supported me and made this research work possible, andto whom I wouldliketo express my sincere gratitude.
I am honoured to have two outstanding supervisors guiding me throughout thisjourney. My main supervisor, Professor Karin Enskär, has showed methe path, and providedthe opportunity for meto explore variousoptions. Being a nurturing and flexible supervisor, she has empowered me to exercise my decision-making skills in the research work. She believed in me and was confident that I would develop into an independent researcher. She took me under her wings graciously and always reassured me onthe efforts and quality of my work. Assistant Professor Wang Wenru, my co-supervisor, has always inspired me to move to the new heights. She nudged me gently when Itook alittletoolong. She encouraged meto preserve and supported me alongthe process. She helpedto rebuild my confidence when I faced challenges. I am grateful for both of my supervisors, who have showed methe wide possiblitiesinthe academic world, developed my capablities, and streched my potential.
I would like to express my sincerethankstothereviewers for my half-time seminar, Associate Professor Jonas Sandberg, Associate Professor Elisabeth Carlson, and Mr Tomas Dalteg. I truly appreciate the thought-provoking dialogue session which set meto reflect on my research process and make refinement on my work.
I would like to thank the reviewers for my final seminar, Professor Violeta Lopez, Associate Professor Evalotte Mörelius, and Associate Professor Karina Huus for their constructive feedback and criticisms. Their valuable comments helpedto build on mythesis.
I really appreciatethetime and effort ofthe academicjournal reviewers and editors. Their advice helped me to further enhance the quality of the manuscripts, and eventuallyledtothe publication ofthe manuscripts.
I have met many friends at Jönköping, Sweden. Professor Mats Granlund, Professor Bengt Fridlund, Professor Jan Mårtensson, thanks for sharing your experiences andthe wise advicesinthe research process. Assistant Professor Maria Björk, Assistant Professor Susanne Knutsson, Assistant Professor Ingalill Gimbler Berglund, and Ms KajsaLinnarsson. Their hospitality made me feellike home each time I visited Jönköping University. Thank you for the warm welcome in the
Swedish way. I hadthe opportunitytojoin Dr Laura Darcy’s public defencein June 2015, and experienced a Swedish style of doctoral defence. She inspired me and gave methe confidencethat I could makeittoo.
I wouldliketo express my sincere gratitudeto Professor Emily Ang, (Head of Alice Lee Centre for Nursing Studies), who always encouraged me to work on my research and supported me in this journey. Her guidance motivated me to preserve and maintain a good balance between full-time work, part-time study and family commitment. I wouldliketothank Professor Karis Cheng (Acting Head of Alice Lee Centre for Nursing Studies), who has approvedthe research project.
Specialthanksto Ms Pua Lay Hoon (Deputy Director of Nursing, Tan Tock Seng Hospital) and Ms Doreen Heng (Assistant Director of Nursing, National University Hospital), who are the collaborators of the research project, and the gatekeepers of the hospitals. Thanks for believing in me and provided the opportunitiesto startthe research project.
Thanks to the nursing students, preceptors, nurse managers, clinical nurse educators, and academics who voluntarily participatedinthe study. Theirinputs are most valuableinthe research work.
I am fortunateto have many good friends who encouraged me and supported me along the way. Professor Sally Chan, Associate Professor Chow Yeow Leng, Associate Professor He Honggu, Associate Professor Piyanee Yobas, Dr Liaw Sok Ying, Dr Yanika Kowitlawakul, Dr Cherry Lau, Dr Wilson Tam, Ms Lydia Lau, Ms Lim Fui Ping, Ms Zhou Wen Tao, Ms Cindy Lee, Ms Kamala Devi, Dr Jeanette Ignacio, Ms Siriwan Lim, Ms Chen Hui Chen, Dr Shawn Goh, Ms Rosalind Siah, Ms Chan Yah Shih, Mr Sam Goh, Ms Yvonne Zhang, Ms Joyce Lim, Associate Professor Quan Chengen, Mr Alan Soong, Dr Betsy Ng, Dr Tan Khoon Kiat, Mr Tay Wei Sern, Mdm Tan Wee King, Ms Mae Tang, Dr Tan Siok Bee, Ms Kathleen Low, and many others. Theintellectual conversations withthem have nurtured me to be a reflective thinker. Their words of encouragement always kept me in high spirits, and allthese years of friendship madethisjourney more pleasant.
I express my appreciation to Ms Sim Soo Kheng (Director, Research and Innovation), Professor Johnny Sung (Head, Centre for Skills, Performance and Productivity), Mr Eric Lee (Principal Manager, Centre for Innovation and Development), and Mr Zach Aw (Manager, Research Management and Administration) atthe Institute of Adult Learning, Singapore. Thank you for giving me the opportunity for the interview and the trust in me. I was awarded with the Research Grant for Doctoral Studies bythe Institute of Adult Learning. In addition, the research was funded with Teaching and Enhancement Grant, bythe Centre for
Development of Teaching and Learning, National University of Singapore; and International Research Grant, by Sigma Theta Tau International Honor Society of Nursing, Singapore, Upsilon Eta Chapter. The funding organisations not only providedthe financial support, but also gave me reasonsto believethat my research work worththetime and efforts.
This journey will not be possible without the support of my family, my parents, my husband Roger, my son Alexander, and my sister Vicky. The unconditional love and support that you have provided all these years made the journey to be a success. Especially, I thank my husband who encouraged me to beginthejourney, and supported methroughoutthe good and badtimes. Thethesis is dedicatedto all of you.
‘Wherethere's a will,there's a way!’
Abbrev
iat
ions
AACN – American Association of College of Nursing AHNA – American Holistic Nurses Association CCER – Continuous Clinical Education Record CNE – Clinical Nurse Educator
CNL – Clinical Nurse Leader CVI – Content Validity Index EFA – Exploratory Factor Analysis HCAT – Holistic Clinical Assessment Tool ICC – Intraclass correlation coefficient I-CVI – Item Content Validity Index IRB – Institutional Review Board
JBI-MAStARI – Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument
KMO – Kaiser-Meyer-Olkin coefficient NM – Nurse Manager
NMBA – Nursing and Midwifery Board of Australia PCA – Principal components analysis
QARI – Qualitative Assessment and Review Instrument RN – Registered Nurse
SCAT – Student Clinical Assessment Tool S-CVI – Scale Content Validity Index SNB – Singapore Nursing Board TTP – Transitionto Practice
Def
in
it
ions
of
concepts
Nurse preceptor
The nurse preceptor is a registered nurse who provides direct care to patients and conducts clinical teaching for students. Such preceptors guide students to integrate theory into practice, teach them clinical skills, assess their clinical competency, and enhancetheir criticalthinking and problem-solving skills; in addition, preceptors are seen asthe students’ role models and pivotalin shaping their nursingidentityin clinicalsettings (Cant et al., 2013).
Nurse Manager (NM)
The nurse manager is responsible for nursing practice and quality of care among nursesin a single unit, he or she not only oversees all personnel and budget matters, but also creates an environment that supports professional practice and employee engagement (Cipriano, 2011). Most nurse managers play the role of central command, such as providing support, recognition, just-in-timeinformation, a calm hand and cool headin emergencies, and advocacy for patients, families, and staff. They also encourage personal and professional development amongthe staff.
Clinical Nurse Educator (CNE)
The clinical nurse educator focuses on the professional development of the nurses and students. In addition, such educators assist nurse managers with the operationalissues.
Clinical Nurse Leader (CNL)
The nurse manager and clinical nurse educator are clinical nurseleaders, and they setthe stage and expectations for excellencein caring and optimising quality of care. Such clinical nurse leaders may not provide direct clinical facilitation and assessmenttothe students, butthey provide encouragement and supportto boththe students and preceptors.
Student Clinical Assessment Tool (SCAT)
The SCATis an assessmenttool developed by academics, of whichthe face validity and content validity are achieved by consensus after discussion among nursing experts. It consists of four broad domains: management of client care; professional accountability and ethical practice; communication and team work; and clinical decision making (Alice Lee Centre for Nursing Studies [ALCNS], 2011). Each domain consists of fiveto seven sub-domains with further descriptions.
Holistic Clinical Assessment Tool (HCAT)
The HCAT is developed based on the systematic review, the results of the qualitative studies which provide critical perspectives of the key players (students, preceptors, clinical nurse leaders and academics), and the competency standards stated bythe national andinternational boards of nursing. Thetool aimsto employ a holistic approachto assess student’s clinical competencyin knowledge, attitudes, values and skills used to function in various clinical situations (Bradshaw et al., 2012; Eraut, 1994; Gonczi, 1994; Watson et al., 2002). Thetesting of psychometric properties ofthe HCAT ensures its validity and reliability.
Transition to Practice (TTP)
Transition to Practice is a consolidated clinical practicum for pre-registered nursing studentsinthe university at Singapore. It prepares studentsto developthe requiredlevel of competencyto functionas beginning practitioners uponlicensure registration (ALCNS, 2014).
1
.
Introduct
ion
One major focus in nursing education is on the judgement of clinical performance, and it is a complex process due to the diverse nature of nursing practice (Dolan, 2003). Assessment of clinical competency requires explicitly defined standards meeting national standards of the nursing profession (Garrett, MacPhee, & Jackson, 2013). At the same time, the standards should be easily understood and interpreted unequivocally by the preceptors, should provide a guideline for the nursing students, and can practically be applied in the clinical setting.
On the part of the nursing students, despite their being equipped with theoretical knowledge and beginners’ skill competency throughout the undergraduate study, they may lack confidence and clinical experiences. Some preceptors have reported that new graduate nurses were lacking in psychomotor and assessment skills, critical thinking, time management, communication and teamwork (Hickey, 2009). In addition, Hengstberger-Sims, Eagar, Gregory, and Andrew (2008) suggestedthatthe new graduate nurses’ confidence depends onthe time spent during undergraduate clinical placements and on the provision of workload of patients in conjunction with a preceptor to consistently improve time management, competency and confidence. On the part of the preceptors and academics, the common challenge faced by the former is their unfamiliarity with the pedagogy and assessment system, and that by the latter is their unfamiliarity withthe hospital policies and clinical environment. Indeed,the academics develop the assessment system whereas the preceptors implement the assessment system. Clinical assessment is thus a robust, dynamic activity that requires collaboration between the clinical partners and academia to optimise the clinical experiences of students,the professional development of preceptors, andthe clinical credibility of academics.
The author currently teaches the undergraduate nursing program in the university, and is involved in the clinical liaison for nursing students’ clinical practice. The students would be visited by the author at the clinical setting to understandtheirlearning experiences and provide guidance. In addition,the author communicated with the preceptors and clinical nurse leaders (CNLs) to gain insights into the clinical situation and to provide support to the students and preceptors where necessary. Over the years, we have received feedback from our clinical partners about the clinical assessment tool and practice. It is against this
backdrop that we review the clinical assessment tool and practices to enhance the clinicallearning forthe students.
2
.
Background
2
.1
Ho
l
ist
ic
nurs
ing
Holistic nursing is the art and science of caring for the whole person. It is based on the belief that dynamic mind-body-spirit interactions are ongoing and impact a person's ability to grow and heal. Holistic nurses aim to promote health and wellness asthey facilitate the patient’s growth and healing (American Holistic Nurses Association [AHNA], 2015). Holistic assessment and care are inseparable from the nursing process. The practice of holistic nursing requires nurses to integrate self-care, self-responsibility, spirituality and reflectionintheirlives. This may lead nurses to greater awareness of the interconnectedness with self, others, nature, and spirit. Furthermore, this awareness may serve the twofold purposes of enhancingthe nurses’ understanding of allindividuals andtheir relationshipstothe human and global community, and of permittingthe nursesto usethis awarenessto facilitate the healing process (AHNA, 2015). Gonczi (1994) advocated a holistic approachinthe assessment of competency whereinthe knowledge, skills, attitudes of the professionals in clinical situations is combined; this notion of competency incorporates professionaljudgement, whichinvolves complex structuring, bringing together disparate attributes and tasks required for intelligent performance in a particular clinical situation.
2
.2
C
l
in
ica
l
competency
in
nurs
ing
educat
ion
Nursing education aimsto preparethe studentsto engagein criticalthinking willingly and skilfully (Facione & Facione, 1996). In other words, nursing students will be ableto usetheir criticalthinking skillsto make purposefuljudgments about the beliefsto adopt andthe actionstotake. Clinical practice provides opportunities for the students to learn in multiple patient care settings, receive appropriate guidance, and foster the development of clinical competency and professionalism (American Association of College of Nursing [AACN], 2008). Competency is defined as behaviours that reveal mastery at work and can be applied in the determination of work standards, formulation of strategies to describe individuals and teams, formation of power and responsibility, and extension of decision making (Hsieh & Chihuikao, 2003). Clinical competence is described by the theoretical and clinical knowledge used inthe practice of nursing, incorporating
psychomotor skills and problem-solving abilities withthe goal of safely providing care for patients (Hickey, 2010). Nevertheless, Benner (1982) emphasized that clinical competence develops over time as the nurses progresses through the variouslevels of proficiency.
Nursing has been recognised as a reputable profession worldwide. Professional bodies are established in many countries to provide guidelines for nursing practice and education. Comparison studies are done to examine the core competencies as required by most nursing regulatory bodies. The Nursing and Midwifery Board of Australia (NMBA, 2006) defines competency standards for RNs as the combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performancein a professional/occupational area. The Singapore Nursing Board reinforces that the core competencies set the foundation for RNs to maintain their competence and to acquire additional competencies or advanced clinical skills to deliver safe client care in response to changing healthcare needs and advancement in technology (Singapore Nursing Board [SNB], 2012a). According to the Board (SNB, 2012b), clinical nursing education allows students to learn from experience and role models to prepare for entry-level practiceinthe complex and diverse healthcare environment. Achieving clinical competency in the final year of nursing education is a key element in the development of professional standards and patient safety (Kim, 2007). In this regard,the assessment of clinical competencyis a crucialtask for nursing educators and administrators.
2
.3
C
l
in
ica
l
assessment
of
nurs
ing
students
in
c
l
in
ica
l
pract
ice
According to Bloom's Taxonomy (1956), learners should demonstrate cognitive, psychomotor and affective domains of learning. Firstly, the cognitive domain revolves around knowledge, comprehension and critical thinking of a particular topic (Nitko & Brookhart, 2011). Secondly, the psychomotor domain describesthe abilityto physically manipulate atool or instrumentlike a hand or a hammer (Nitko & Brookhart, 2011). Psychomotor objectives usually focus on change and development in behaviour and skills; therefore, such skills must be demonstrated. Ideally,the demonstrationrequiresthe studentsto showthatthey can usethe skillin as realistic a situation as possible (Pratt, 1994). Thirdly,the affective domain relatestothe way people react emotionally andtheir abilityto feel another livingthing's pain orjoy (Nitko & Brookhart, 2011). Affective objectivestypically
target the awareness and growth in attitudes, emotion and feelings. Ideally, a holistic assessment should reflect the development of all three domains for the students.
Accordingto Quellmalz (1991), performance assessment can be developedto measure depth across domains by tracking the development of higher order skills, such as analysis, comparison, interpretation and evaluation. Moreover, Torrance (1996) has opined that the quality of teaching will be improved if higher-order skills and competencies such as problem-solving, investigation and analysis are included in the assessment. How does a preceptor know that the students really understand? McTighe and Emberger (2006) argued that this is only evidenced when the students can apply what they have learnt to new situations. Nursing students need to explain their responses, show their work, support their reasoning and justify their answers. Clinical situations present students with real-world challengesthat requirethemto synthesise and applythe concepts and strategiesthat they have developedthrough classroominstructionto authentic situations (Luongo-Orlando, 2003). Therefore, a holistic assessment satisfies the demands of nursing education which requires nursing studentsto apply knowledge and skillstothe real clinical situation and solvethe problems.
2
.4
Gener
ic
and
ho
l
ist
ic
assessment
in
the
pract
ice-d
isc
ip
l
ines
Generic skill assessment tends to focus on the psychomotor domain (Eraut, 1994). Ideally, a holistic assessment should reflect the development of cognitive, psychomotor and affective domains for the nursing students, as the work of a professional nurse requires substantiate level of nursing knowledge, competent performance of nursing skills and caring attitudetowards patients.
Facione and Facione (1996) have suggested that the nursing education aims to preparethe studentsto engagein criticalthinking willingly and skilfully. In order to preparethe studentsto handletheincreased patient acuity andthe ever-changing clinical situations, nurse educators need to nurture the students to develop critical thinking skills, through which the students can make purposeful judgments about the course of actions to take in clinical practice. Moreover, Torrance (1996) expressedthatthe quality ofinstruction will beimprovedif higher-order skills and competencies such as problem-solving, investigation and analysis are included in
the assessment. Nurse educators need to facilitate students to learn to apply knowledge and skillsto solve problemsinthe real situation.
In fact, educational assessment applies to other professions which are practice-disciplines. Educational assessment isthe process of documenting, usually in measurableterms, knowledge, skills,attitudes and beliefs. Assessment can focus ontheindividuallearner,thelearning community,theinstitution, orthe educational system as a whole (Nitko & Brookhart, 2011). Holistic assessment is designed to measure students’ ability in applying the knowledge they acquire to their real-life experiences (Henson, 2010). Favourably, it gives teachers the opportunity to introduce new instructional methods that encourage investigation, exploration and students’ creation of knowledge (McNeil, 1996). Luongo-Orlando (2003) further emphasised that assessment must focus on problem solving, critical thinking, comprehension, reasoning, meta-cognition and self-reflection.
2
.5
Context
of
the
study
In Singapore, undergraduate nursing students are required to complete Transition to Practice (TTP) which is a consolidated 9-week clinical practicum module prior to graduation. This module aims to enable the students to integrate theory and clinical knowledge through experience in a clinical placement attachment oftheir choice (Alice Lee Centre for Nursing Studies [ALCNS], 2014). The students consolidate the necessary clinical experiences and develop the requiredlevel of competencyto enablethemto function as registered nurses (RNs) on the completion of the module. In this regard, a student is attached to a nurse preceptor with a minimum oftwo years of working experiencesinthe unit, whois responsible for conducting the assessment ofthe student and providing feedback onthe clinical performance at various clinical settings.
Currently,the nursing students are assessed by preceptors usingthe Student Clinical Assessment Tool (SCAT) and Continuous Clinical Education Record (CCER). They are required to demonstrate competency in knowledge, skills and attitudesin orderto achieve a ‘pass’ of the TTP. The SCAT is an assessment tool developed by academics, the face validity and content validity of which are achieved by consensus after discussion among nursing experts. The SCAT consists of four broad domains: management of client care; professional accountability and ethical practice; communication and team work; and clinical decision making (ALCNS, 2011). Each domain consists of five to seven sub-domains with further
descriptions. The preceptor assessesthe competency of the students based ontheir clinical performance, and indicates ‘achieved’ or ‘not achieved’ for each sub-domain. The CCER is a checklist of skills that are aligned with the university curriculum, based on whichthe students must demonstratethatthey have achieved the required level of competency. In addition, they are required to reflect on their learning experiences and submittheir reflectionstothe preceptor on a weekly basis.
The preceptors are recommended by the nurse manager (NM). The preceptorship courseis conducted bythe hospital as atwo-day program. In general, the course covers the topics on basic concepts of clinical teaching, guidance and principles of assessment. Different academic institutions use different assessment forms,therefore,itisimpossible forthe hospitalto explainin detailsthe assessment practices andtools within thetwo-day program.
We have received feedback from the clinical counterparts that there are multiple challenges with the SCAT: it was not user-friendly; the preceptors often had difficulties in understanding the SCAT; and the ‘achieved’ or ‘not achieved’ optionslimitedthe preceptors’ grading choices. It may not reflect accurately onthe various level of performance of the students. Hence, it is necessary to develop a holistic clinical assessmenttool with reasonable validity and reliabilityto measure the gains from learning. Although the SCAT was developed by academics, it is implemented bythe nurse preceptors, who assessthe students;thus, itis crucialto take into account the perspectives of the nursing students, preceptors, CNLs and academics regardingthe clinical assessment to develop a holisticassessmenttool.
3
.
Conceptua
l
framework
-
Ho
l
ist
ic
C
l
in
ica
l
Assessment
The project’s conceptual framework (Figure 1) was developed based on the cognitivelearningtheory, social developmenttheory andliterature reviews (Benner, Tanner, & Chesla, 2009; O'Connor, Pearce, Smith, Voegeli, & Walton, 2001; Shepard, 2000). The cognitive learning theory (Bransford, Brown, & Cocking, 1999) states that existing knowledge, structures and beliefs work to impede new learning. That intelligent thought involves self-monitoring and awareness of when and howto use skills andthat expertise developsin a field of study as a principled and coherent way ofthinking and representing problems. Vygotsky’s (1978) social development theory illustrates that cognitive abilities, expertise in academic disciplines, metacognitive skills and formation of identity are developed through socially supported interactions. Indeed, both learning and development are primarily social processes. Schoollearning should be more authentic and connected to the real-world. Thus, the content of assessments should match challenging subject matter standards. A broad range of assessment tools is needed to capture important learning goals and processes, and to more directly connect assessment with ongoinglearning (Shepard, 2000). The assessment should ensurethat students are ableto reason critically, solve complex problems, and apply their knowledgein real-world contexts.
Inthe conceptual framework, atheoretical connection oflearning, pedagogy and assessment is formed as advocated by Shepard’s (2000) emergent paradigm (Figure 2). Sherpard (2000) elaboratedthat curriculum,learning and assessment are developed in parallel. The interlocking circles indicate the coherence and in ter-relatedness of the three ideas. In other words, any change proposed in assessment need to consider the curriculum and learning concurrently. In the conceptual framework underlying a holistic clinical assessment model (Figure 1), the inner circle consists of nursing students, preceptors/CNLs, and academics. The outer circle comprises of learning outcomes, pedagogical approaches and assessment system. The double-sided arrows indicate the inter-connections of the concepts. The following section explainsthe conceptual frameworkin further details.
Figure 1: Conceptual Framework – Holistic Clinical Assessment Model
3
.1
Students
in
c
l
in
ica
l
pract
ice
Throughout the undergraduate study, nursing students are equipped with theoretical knowledge and beginners’ skill competency. However, they may lack confidence and clinical experiences. A meta-summary oftheliterature on students’ clinical experiences has identified four major themes: fear of harming patients, desire to help people, need to integrate theory and clinical practice, and desire to master psychomotor skills (O’Connor, 2006). Moreover, it has been reported that preceptors opined that new graduate nurses were lacking in psychomotor and assessment skills, critical thinking, time management, communication and teamwork (Hickey, 2009). Infact, Hengstberger-Sims et al. (2008) have suggested that new graduate nurses’ confidence depends on the time spent during
undergraduate clinical placements and the provision of workload of patients in conjunction with a preceptor to consistently improve time management, competence and confidence with nursingtasks.
Figure 2: Sherpard’s Emergent Paradigm (Sherpard, 2000)
3
.2
Preceptors
and
C
l
in
ica
l
Nurse
Leaders
in
c
l
in
ica
l
pract
ice
The student works alongside a preceptor on shift duties and engages in direct care of the patients under the guidance from the preceptor. The preceptor model, commonly used in nursing programmes, allows the student to experience the realities of the nurse’s role while practising the skills (Hickey, 2010). A comparison study has demonstrated that preceptorship was an important criteria for improving the competency of new graduate nurses (Bartlett, Simonite, Westcott, & Taylor, 2000). The preceptor’s roleisto facilitatethelearning, build a supportive clinical learning environment, assess the clinical competency of the
nursing students, review the progress and provide effective feedback to the students. Preceptors need to possess a strong familiarity with the principles of teaching and learning to effectively help students reach their learning goals (O’Connor, 2006). The meta-review by Tang, Chou, and Chiang (2005) highlighted four categories of effective clinical teaching behaviours: professional competence, interpersonal relationship skills, personality characteristics and teaching ability.
The preceptors are appointed bythe NM. The selection criteria are minimum of two to three years of clinical experiences, satisfactory job performance and willingnesstoteach. The NMis responsible forthe nursing practice and quality of care among nurses in a single unit, he or she not only oversees all personnel and budget matters, but also creats an environment that supports professional practice and employee engagement (Cipriano, 2011). Most NMs playthe role of command central, such as providing support, recognition, just-in-time information, a calm hand and cool head in emergencies, and advocacy for patients, families, and staff. They also encourage personal and professional development among the staff. Furthermore, NMs evaluate the impact of the care that the nurses provide and its effect on patients and families. The clinical nurse educator (CNE) focuses on the professional development of the nurses and students. In addition, the CNE assists the NM with the operational issues. In fact, the NM and CNE are CNLs, both of whom set the stage and expectations for excellence in caring for patients and optimising quality of care.
3
.3
Academ
ics
in
c
l
in
ica
l
pract
ice
The role of the academics is to visit the students and preceptors at the hospital regularly, discuss their learning goals, review their progress, and provide supportto both preceptors and studentsin the clinical practice (McSharry, McGloin, Frizzell, & Winters-O’Donnell, 2010). In the university where the study was conducted,the academics functions as ‘Clinical Liaison’inthe clinical practice. As is suggested by McSharry et al (2012), duringthe regularvisitstothe hospital,the faculty members would discuss with both students and preceptors the learning goals, reviewthe progress, and providethem support. However, researchers pointed outthatthe role ofthe academicsin clinical practiceis not well-defined. In fact,it varies amonginstitutions and countries (McSharry et al., 2010).
3
.4
Nurs
ing
students
,
preceptors
,
C
l
in
ica
l
Nurse
Leaders
and
academ
ics
The many hours spent by the preceptor with the student in the clinical settings providethe opportunity for aninteractive andcollaborative relationshipto develop. Clinicalimmersion happens rapidly asthe student moves from shadowing the preceptor to performing nursing activities at a pace set by the students themselves (O'Connor et al., 2001). The student and the preceptor are encouraged to meet daily for both discussing on the opportunities of achieving learning objectives and reflecting on the learning experience. In fact, students and preceptors often develop a mentoring relationship. The CNLs may not provide direct clinical facilitation and assessment to the students, but they do provide encouragement and supportto both students and preceptors.
On the part of the academics, they are experienced in clinical teaching and have existing rapport with the students in the campus. While visiting the hospital, they could assess the student-preceptor relationship for learning, provide support for the preceptor in terms of pedagogical approaches, motivate and encourage the student to maximise the learning opportunitiesin clinical setting, and evaluate the student’s capability of achievingthe required learning objectives. Onthe part ofthe students,they are familiar with academics asthey engageinthelearning activities with the academics. Meeting the academics in the clinical area provides another platform for the students to share their learning experiences. In fact, this regular visit promotes the dialogue among students, preceptors, CNLs and academics, thereby providingthe opportunitiesto discuss clinicalteaching pedagogy, concerns in clinical practice and area for professional growth.
3
.5
Learn
ing
,
pedagogy
and
assessment
A holistic clinical assessment model promotes an assessment forlearning, instead of an assessment of learning, especially in nursing education. A model of holistic competencein clinical practice consists of a combination ofthese domains: knowledge and understanding, clinical skills, interpersonal skills, problem-solving skills, clinical judgment and management skills (Hanley & Higgins, 2005). However, change in assessment is never a stand-alone initiative, it has to be integrated with curriculum, pedagogy and learning, as rightfully pointed out by Shepard (2000).
Assessmentis more useful in helping studentstolearnifitis ongoing rather than atthe end-point ofinstruction;theinteractive, ongoing assessments allowthe teachers to gain more insights about understanding and provide the means to scaffold subsequent steps (Shepard, 2000). Nevertheless, Tomlinson (2003) has suggestedthat assessmentis ongoing and diagnostic,the goal of whichisto provide the teachers day-to-day data on the students’ readiness for particular ideas and skills, their interests and learning profiles. Therefore, the formative assessment of today can be used as a meansto modifytheinstruction forthe next dayin orderto best meetthelearning needs ofthe students.
In addition, the holistic assessment provides students a real situation to enrich their learning experience. Dewey (1998/1938) argued that an organic connection exists between experience and education, with experience being defined as the engagement of the individual with their environment. In fact, Nightingale (1860) described the critical role of experiential learning in nursing education and practice: ‘Itis asimpossible in a booktoteach a personin charge ofthe sick howto manage, as it is to teach her how to nurse. Circumstances must vary with each different case’. Experiential learning requires focused attention on the part of the learner, a recognition that the practice itself is a continuous source of knowledge development and skill acquisition, and an environment where reflecting on the experience is deliberately planned (Benner et al., 2009). Therefore, the students’ learning, pedagogical approaches and assessment systems could be integrated to promote holisticlearning experiences forthem, whichinturn will contributetothe enhanced quality of care forthe patients.
3.5.1 Student’s self-assessment and preceptor’s assessment
Frederiksen and Collins (1989) advocated the idea of transparency, arguing that students must have a clear understanding of the criteria by which their work will be assessed. Moreover, Shepard (2000) stated that the features of excellent performance should be sotransparentthat students canlearnto evaluatetheir own work in the same way that their teacher would. Furthermore, Tombari and Borich (1999) recommendedthatthe criteria of successthat eachlearneris expectedtolive up to should be openly shared. Thus, students would be able to better relate suggestions for self-improvement based on the standards made available for all to see.
Self-assessment plays an important role in clinical setting. A major goal of assessment is to help students to develop the capacity to evaluate their own work andtakeinitiativeto assess their own progress (Wiggins, 1989). Consequently,the
assessment can be designedto provide ongoing feedbacktothe nursing students. In the clinical context,the preceptors would assessthe students’ competency, provide continuous feedback, and encourage the students to continuously refine and improve on their learning. This allows them to develop competencies of se lf-evaluation, self-improvement and the opportunity to see their own growth in their competencies.
3.5.2 Formative feedback by the preceptors
Posner (2001) has opined that the basic aim of assessment is to improve teaching and learning. Thus, it is meaningful to provide students with formative feedback throughout the clinical practice, which helps to enrich their learning experiences and enhancetheirlearning outcomes. Onthe other hand,the preceptors may usethe formative feedbackto evaluatetheteaching process andto modifythe teaching strategies based ontheresults ofthe assessment.
In a review onthe research on assessment, Marzano (2006) has summarised effective assessmentinto four generalisations: feedback from assessments should (a) give students a clear picture oftheir progress onlearning goals and potential areas for improvement; (b) encourage students to improve; (c) be formative in nature; and (d) be frequent in providing feedback. Marzano’s (2006) work provides insightsinto effective assessment and reminds educators on matters such as guiding nursing studentsin setting clearlearning goals, providingtimely feedback based on the results of assessment and encouragingthemtotakethe feedback positively and to reflect on how to improve. Popham (2005) highlighted that students’ performances on assessments should form ateacher’sinstructional decisions. Ifthe assessment results show that the students are weak in one area, the preceptor may accordingly adjusttheinstructional strategy.
In summary,the ultimate goal of holistic clinical assessmentisto developthe students’ clinical competencies holistically through enhancing the collaboration between academics and clinical partners. Eventually, the students will be able to achieve clinical competencies holistically andtransfertheirlearninginto providing better quality of care forthe patients.
4
.
Rat
iona
le
for
the
thes
is
A major focus in nursing education is on the judgement of clinical performance, a complex process due to the diverse nature of nursing practice (Dolan, 2003). Difficulties in the development of valid and reliable assessment measures in nursing competency have resulted in the development of assessment instruments with an increase in face validity, but with less focus on reliability (Nicholson, Griffin, Gillis, Wu & Dunning, 2013). Literature reviews suggest that there is no ‘gold standard’ for measuring clinical competence; thus, assessing nurses’ competency continues to pose a challenge in nursing education (Redfern, Norman, Calman, Watson, & Murrells, 2002; Watson, Stimpson, Topping, & Porock, 2002).
Thereis a rising demand on clinical nursesto mentor and assess studentsin clinical practice, as supported bythe preceptorship model. A comprehension ofthe perspectives from the students, preceptors, CNLs and academics on clinical assessment contributes to the big picture of what more could be done in clinical education and assessment. The fact that both preceptors and students require support and guidance from CNLs and academics in the assessment process underlies the need for the clinical and academic institutions to collaborate and provide continuous support.
The common challenge faced by the preceptors is their lack of familiarity withthetheoretical knowledge and skillstaughtinthe academic setting. This may influence the preceptors’ ability to helpthe students bridge the gap between theoretical foundation and clinical practice. In addition,the preceptors may not be familiar withthe pedagogyand assessment system which designed bythe academic setting. Further compounding the situation is the presence of numerous nursing institutions, both nationally and internationally, with their diverse assessment systems. Allthese give additional stressto the preceptors who needto be competent with the assessment system. Only when the preceptors who function as assessors are competent in assessment system will unbiased and objective assessment for students be achieved.
As the assessment system is developed by the faculty members, it is the academics’ responsibility to ensure the reliability and validity of the assessment. Unfortunately, the faculty members may not be familiar with the hospital policies and clinical environment. Indeed, the academics are the designers who plan the assessment system whereas the preceptors are the assessors who implement the assessment. There should be a strong collaboration between the preceptors in the
clinical settings and the faculty members in the academic institutions. However, academics, preceptors and nursing students often have different interpretations of the system or process ofassessment (Neary, 2001).
The assessment of nursing students’ clinical competency has been an ongoing challenge for educators. Researchers have noted that clinical assessments often focus on psychomotor skills and that more consideration should be given to the multidimensional nature of competency and the attributes required for the nursing profession (Levett-Jones, Gersbach, Arthur, & Roche, 2011). The assessment of clinical competency requires explicitly defined standards that meet the national standards ofthe nursing profession (Garrett et al., 2013). Atthe same time, the standards should provide a guideline for the nursing students, could be easily understood andinterpretedinthe same manner bythe preceptors, and could be practically appliedinthe clinical setting. However, few studies have adequately evaluatedthe psychometric properties ofthe assessmentinstrument. Therefore,itis essential to develop a holistic assessment tool with reasonable validity and reliabilityto meetthe needs ofthe clinical education.
5
.
A
ims
of
the
thes
is
The overall aims of the thesis were to explore the various perspectives on clinical assessment, develop a new holistic clinical assessmenttool and evaluatethe psychometric properties ofthetool.
The specific aims wereto:
1. explorethe current assessment practices andtools for nursing undergraduates intheliteratures (Paper I).
2. explore the perceptions of the final-year undergraduate nursing students, preceptors, clinical nurse leaders and academics on the clinical assessment tool and practices (Papers II, III and IV).
3. develop a Holistic Clinical Assessment Tool (HCAT) which facilitates and consolidates the learning experiences for final-year nursing undergraduates in clinical practice (Paper V).
4. perform the psychometric test to ensure the validity and reliability of the HCAT (Paper V).
6
. Methodo
logy
6
.1
Study
des
igns
To answer the overall aims of the thesis, studies with a number of research questions and various research designs were considered necessary (Table 1). The first studyis a systematic review guided bythe Cochrane Handbook for Systematic Reviews of Interventions. The designsin Studies II, III and IV are exploratory and qualitativein natureto explorethe perspectives of final-year undergraduate nursing students, preceptors, CNLs and academics on the clinical assessment during TTP. Based on the multiple perspectives, it therefore then addressed issues, concerns about learning and assessment in TTP. In Study V, a prospective quantitative approachis adoptedto develop a holistic clinical assessmenttool,the psychometric properties of which are evaluated.
An exploratory qualitative approach which values respondents’ views and seeks to understand the world in which they live (Parahoo, 1997) - using focus group discussion was adopted in Studies II, III and IV. Boyd (1993) emphasized that the focus of the qualitative approach is on “achieving understanding and opening new perspectives that can change people’s worlds” (p. 69). Such an approach was therefore adopted to understand the learning and assessment experiences of nursing students, preceptors, CNLs and academics in TTP. According to Gerrish and Lacey (2010), focused group discussion is a useful method for data collection which aims to clarify, explore or confirm ideas with a range of participants on a predefined set of issues. Various focused group discussions were conducted based onthe categories ofthe participants. In Study V, a prospective quantitative approach was employed to develop and test the psychometric properties of the HCAT, since the various relationships among the items are required to establish the psychometric properties of the instrument (DeVellis, 2012).
6
.2
Sett
ings
and
part
ic
ipants
A multi-centre study was conducted at one university and two tertiary hospitalsin metropolitan areasin Singapore. In Studies II, III, and IV, a purposive sample was usedtojustifytheinclusion of rich sources of datathat could be usedto
Table 1. Study designs
Paper/
Study Aims Participants Design Methods Analysis
I
To explore the current
assessment practices and tools for nursing undergraduates in the literature
– Systematic
review PreReportferred ing Items for Systematic Reviews and Meta‐ Analyses (PRISMA)
Critical appraisal using the Qualitative Assessment and Review
Instrument (QARI) and the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI‐MAStARI)
I
I
To explore the final‐year undergraduate nursing students’ perceptions of clinical assessment at transition to practice
24 final‐year
undergraduate nursing students from a university
Exploratory
qualitative Three group focus discussions
Qualitative thematic analysis
I
I
I
To explore the perspectives of preceptors on clinical assessment for undergraduate nursing students in the transition to practice
17 preceptors from
two tertiary hospitals quaExploratory litative Three group focus discussions
Qualitative thematic analysis
IV
To explore the perspectives of clinical nurse leaders and academics on clinical assessment for undergraduate nursing students in the transition to practice
8 nurse managers and 6 clinical nurse educators from two tertiary hospitals, 8 academics from a university
Exploratory
qualitative Four group focus discussions
Qualitative thematic analysis
V
To develop the holistic clinical assessment tool and conductpsychometric testing of the tool
14 content experts for content validity testing, 20 final‐year
undergraduate nursing students for pilot test, 130 final‐year undergraduate nursing students for
psychometric testing
Prospective quantitative approach
Self‐reported
questionnaire QuantDescriptitative ive data: statistics, factor analysis, internal consistency reliability, test‐ retest reliability Qualitative content analysis
generate explanatory frameworks (Gerrish & Lacey, 2010). Final-year undergraduate nursing students, preceptors, CNLs and academics were invited to participate in the focus group discussions. Permission to approach preceptors and CNLs was secured from the appropriate nursing managerial personnel in the two tertiary hospitals. Permission to approach the final-year undergraduate nursing students and academics was obtained from the head ofthe schoolinthe university. A recruitment email was sent to the students, academics, and various clinical departments to which any potential participants could respond to express their interestto participateinthe study.
Inclusion criteria:
Final-year undergraduate nursing students who have completedthe TTP, age ranging from 21to 40 years old
Preceptors who are guidingthe undergraduate nursing students forthe TTP, age ranging from 21to 65 years old
Nurse manager, clinical nurse educator and academics who are guiding the nursing students forthe TTP, age ranging from 21to 65 years old
Exclusion criteria:
Participants who do not agree to allow audio recording of the focus group discussions.
In Study II, a purposive sample of 24 final-year nursing students was recruited from a university.Students who did not consent to audio recording during the focus group discussionswere excluded. Three focus groups discussions (7+8+9) were conducted forthe students from Marchto June 2014. A total of 7 male and 17 female students participatedinthethree focus group discussions. Their age ranged from 21 to 25 years (mean age of 22.5 years). All the participants had completed nine weeks of TTP in different clinical settings at various tertiary hospitals in Singapore prior to their participation in the discussions. The demographic data of the participantsisillustratedin Table 2.
In Study III, a purposive sample of 17 preceptors was recruited from two tertiary hospitals. Preceptors who did not consent to audio recording during the focus group discussion were excluded. Three focus groups discussions (5+6+6) were conducted forthe preceptors from Marchto July 2014. The participants were RNs with 2to 32 years of working experiences andthe average experience of being a preceptor was 21 months. The demographic data ofthe participantsisillustrated
in Table 3. Allthe participants had been preceptors guidingundergraduate nursing studentsthroughthe TTP at various clinical settings, for example, medical, surgical, and geriatric care settings.
In Study IV, 8 NMs, 6 CNEs and 8 academics were from two tertiary hospitals and one university. Two focus groups discussions (7+7) were conducted for the NMs and CNEs, and two for the academics (4+4) from March to August 2014. The majority of them were female and one academic was male. Most of them had education up to the level of a bachelor degree and one had a PhD. The participants’ age ranged from 29to 53 years (mean age of 38.7 years), and had 10 to 30 years of experiences as an RN. The demographic data of the participants is illustratedin Table 4.
In Study V, a purposive sample was usedto achieve the specific objective of the study. For the testing of the content validity, a panel of content experts were invitedto evaluatethe developed HCAT. Theseincluded 4 preceptors, 2 NMs and 2 CNEs from two hospitals, and 3 academics, 3 nursing graduates from the university. For the pilot test, a group of 20 final-year undergraduate nursing students were recruited.
In the psychometric testing of the HCAT, a purposive sample was obtained from final-year undergraduate nursing students. A population-based sample including atotal of 130 final-year nursing students who have completedtheir TTP was recruited. The nursing students were aged between 21 and 24 years (mean =22.83). Eighty-three percent (n = 108) were females. The students’ clinical practice settings varied widely in the major tertiary hospitals in Singapore, including medical/surgical wards (42%, n = 55); cardiology/respiratory wards (11%, n = 14); oncology and palliative wards (12%, n = 12); geriatric wards (8%, n = 10); orthopedic wards (6%, n = 8); paediatric wards (6%, n = 8); obstetrics/gynaecology wards (6%, n = 8); emergency departments (6%, n = 8); and neurology wards (5%, n = 7). The characteristics and clinical placement settings of the participants are presentedin Table 5.
Inclusion criteria:
Final-year undergraduate nursing students who have completedthe TTP Age ranges from 21to 40 years old
Exclusion criteria:
Participants who do not agree to collection oftheir data
Table 2. Demographics of nursing students in Study II
Focus group discussions
(n = 24)
f (%) Gender Female
17 70.8 Male 7 29.2 Age 21–22 15 62.5 23–24 8 33.3 25–26 1 4.2 Ethnic group Chinese
18 75.0 Malay
3 12.5 Indian 3 12.5
Highest Educational
level obtained Degree 0 0 Diploma 4 16.7
GCE ‘A’ Level 20 83.3
Table 3. Demographics of preceptors in Study III
Focus group discussions
(n = 17)
F (%) Gender Female
15 88.0 Male 2 12.0 Age 25–30 8 47.1 31–40 6 35.4 41–50 2 11.8 51–60 1 5.9 Ethnic group Chinese
3 17.6 Malay 4 23.5 Indian Filipino 3 6 17.6 35.3 Sikh 1 5.9
Years of experiences as
RN 2–5 years 8 47 6–10 years 3 17.7 11–20 years 4 23.6 21–32 years 2 11.8
Years of experiences as
preceptor Less than 1 year 10 58.8 1–3 years
4 23.5
More than 3 years 3 17.6
Table 4. Demographics of clinical nurse leaders and academics in Study IV
Focus group discussions
(n = 22)
f (%) Job title Nurse manager
8 36.4
Clinical nurse educator 6 27.2
Academic
8 36.4
Gender Female
21 95.5 Male 1 4.5 Age 25–30 3 13.6 31–40 12 54.5 41–50 5 22.8 51–60 2 9.1 Ethnic group Chinese
17 77.4 Malay 2 9.1 Indian Filipino 1 1 4.5 4.5 Sikh 1 4.5
Years of experiences as RN 6–10 years 7 31.8
11–20 years 11 50.0 21–30 years 4 18.2
Educational background PhD
1 4.5
Master
8 36.4
Bachelor degree 11 50.0
Diploma 2 9.1
Table 5. Demographics of nursing students in Study V
N = 130 F (%) Gender Female
108 83.0 Male 22 17.0 Age 21–22 68 52.3 23–24 44 33.9 25–26 15 11.5 27–29 3 2.3 Ethnic group Chinese
101 77.7 Malay 11 8.5 Indian Others 15 3 11.5 2.3
Clinical practice setting Medical/surgical wards
55 42
Cardiology/respiratory wards 14 11
Oncology and palliative wards 12 12
Geriatric wards
10 8
Orthopaedic wards
8 6
Paediatric wards
8 6
Obstetrics/gynaecology wards 8 6
Emergency departments
8 6
Neurology wards 7 5
6
.3
Est
imat
ion
of
samp
le
s
ize
In Studies II, III and IV,the proposed number of participants was governed by both the project time frame and in-depth nature of the qualitative approach. Sandelowski (1995) emphasized that an adequate sample size in qualitative research permits the deep, case-oriented analysis that results in a new and richly textured understanding of experience. Thedecision onthe number of focus groups depends on whether data saturation has been achieved (Gerrish & Lacey, 2010), and, atthe end oftheten focus groups, rich andin-depth discussionsindicatedthat the focus group discussions were consideredsufficient. Asitis essentialto ensure maximum variation in the focus groups (Webb & Kevern, 2001) to deepen the understanding of participants’ perspectives on clinical assessment, a total of ten focus groups were conducted. Twenty-four final-year undergraduate nursing students, 17 preceptors, 14 CNLs and 8 academics participated.
In Study V, an instrument is considered to have construct validity if it accurately measures a theoretical, non-observable construct or trait. Therefore, exploratory factor analysis was conducted to determine the items that fall into the same subcategories. In fact, it provides an empirical test for the construct validity ofthe multidimensional assessmentinstrument (Stommel & Wills, 2004). In factor analysis, the number of subjects needed is usually assessed in relation to the number of variables being measured, and it is recommended that a sample size of 100 is fully adequate for exploratory factor analysis for purposes related to measurement (Sapnas & Zeller, 2002). Alternatively, researchers have suggested an item-to-subject ratio of 1:5 for a psychometrictest (Kellar & Kelvin, 2013). In our context,the cohort size of final-year nursing studentsis 130. Therefore,the sample size is targeted at the maximum number of students. Based on the literatures, a sample size of 100 is adequate for testing the psychometric properties of the instrument (Kline, 1997).
6
.4
Instruments
A semi-structuredinterview guideline was usedto facilitatethe focus group discussions. It was developed based on literature reviews and consultation with expertsinthe nursing education. The guideline covered the following areas during TTP:
learning/facilitation experiencesin clinical education preparation and support provided bythe preceptors preparation and support provided bythe hospital and support provided bythe university.
The semi-structured interview guideline was pilot-tested with a group of final-year nursing students, a group of preceptors and a group of CNLs and academics respectively with regard to the clarity of the questions. All the groups agreed that the interview guidelines were clear, and therefore, no changes were made.
The ‘Rating Form for Content Validity of the Holistic Clinical Assessment Tool’ was used for data collection for content validity testing (Appendix 1). The instrument used for the pilot test and for the psychometric testing was the ‘Questionnaire for the Holistic Clinical Assessment Tool’ and ‘Behavioural Cues forthe Holistic Clinical Assessment Tool’ (Appendix 2 & 3).
6
.5
Data
co
l
lect
ion
6.5.1 Literature search
The search of the literature was based on the relevant criteria from the PRISMA checklist (Moher et al., 2009) andthe Cochrane Handbookfor Systematic Reviews of Interventions. A total of five electronic databases were searched, including PubMed, CINAHL, ScienceDirect, Web of Science, and EBSCO from 2000to 2015. A systematic search strategy was formed,including key searchterms and related text words. ‘Clinical assessment’, ‘clinical evaluation’, ‘clinical measurement’, ‘clinical competence’, ‘clinical standards’, ‘assessment tool’, ‘assessment standard’, ‘educational measurement’, ‘undergraduate nursing students’, ‘preceptorship’, ‘clinical nurse leaders’, ‘academics’, ‘competence-based education’, ‘tool development’, and ‘psychometric testing’. The search was conducted using combinations of exact keywords on the title and abstract. The search was confinedto articlesinthe Englishlanguage.
6.5.2 Focus group discussions
The focus group discussions were conductedin a seminar room from March to August 2014, each session of whichlasted about 80to 100 minutes. Upon giving their consent,the participants were requiredto fillinthe demographic questionnaire
