CONTINUAL ASSESSMENT OF STUDENT NURSES

M has been written about the continual assessment of clinical practice and the theoretical aspects of the general science and art o f nursing. This article aims to clarify the practical aspects o f assessment rather than to discuss the numerous theories. Firstly, we need to define that we mean by evaluation or assessment. According to Reilly, “ Evaluation is a positive process whose primary purpose is to assess growth” . (6, P .93). The process should therefore facilitate learning. This means that the person evaluating the student should act as a counsellor rather than a judge. Evaluation may be summative i.e. it occurs at the end of a course or year and refers to the extent to which a student has realised the specific objectives laid down. In nursing, summative evaluation consists o f the written examinations set by the South African Nursing Council and the oral examinations in clinical practice set by the hospital. Alternatively evaluation may be formative i.e. it oc­ curs throughout the program and refers to the students’ PROGRESS towards realising the objectives set. This is what is aimed at with continual assessment. An impor­ tant aspect o f formative evaluation concerns feedback on performance from the evaluator to the student which in turn assists in improving the student’s performance. (6,P .92). The purpose of evaluation can be summarised as follows: — creating and maintaining satisfactory standards of performance — highlighting the needs and opportunities for growth and development — validating training programs i.e. if the laid-down objectives are not being met the course and its presentation should be reviewed. Possible reasons for objectives not being met may include unrealistically high standards or goals and faulty methods of teaching. (1, P .311). A brief discussion of the abovementioned purposes of evaluation follows: Creating and maintaining satisfactory standards of performance

M uch has been written about the continual assessment of clinical practice and the theoretical aspects of the general science and art of nursing.This article aims to clarify the practical aspects of assessment rather than to discuss the numerous theories.
Firstly, we need to define that we mean by evaluation or assessment.According to Reilly, " Evaluation is a positive process whose primary purpose is to assess growth" .(6, P .93).The process should therefore facilitate learning.This means that the person evaluating the student should act as a counsellor rather than a judge.
Evaluation may be summative i.e. it occurs at the end of a course or year and refers to the extent to which a student has realised the specific objectives laid down.In nursing, summative evaluation consists of the written examinations set by the South African Nursing Council and the oral examinations in clinical practice set by the hospital.
Alternatively evaluation may be formative i.e. it oc curs throughout the program and refers to the students' PROGRESS towards realising the objectives set.This is what is aimed at with continual assessment.An impor tant aspect of formative evaluation concerns feedback on performance from the evaluator to the student which in turn assists in improving the student's performance.(6,P.92).
The purpose of evaluation can be summarised as follows: -creating and maintaining satisfactory standards of performance -highlighting the needs and opportunities for growth and development -validating training programs i.e. if the laid-down objectives are not being met the course and its presentation should be reviewed.Possible reasons for objectives not being met may include unrealistically high standards or goals and faulty methods of teaching.(1, P.311).A brief discussion of the abovementioned purposes of evaluation follows:

Creating and maintaining satisfactory standards of performance
In order to assess whether satisfactory standards of performance are being achieved, objectives must be set against which performance may be measured.Having set objectives, which shall be discussed in more detail later, the student is assessed on her/his ability to achieve these objectives.The pass mark is arbitrarily set at 50% thereby implying that the student who has passed has achieved 50% of the objectives.Fifty percent is general ly regarded as the minimum level of competency re quired to ensure safe performance.A student scoring below 50% is regarded as lacking certain essential elements of the desired level of knowledge.Such a stu dent should be assisted by the evaluation to improve her/his performance and thereby achieve the required levels of patient safety and care.Students must know what is expected of them and how they are going to be evaluated.Time should be set aside for discussion of performance with individual students especially with regard to assessment in clinical practice.In this way a student is made aware of her/his shortcomings and if handled correctly and tactfully the discussion should lead to the student being motivated to improve her/his performance.

According to
In discussions of performance, the procedures ensur ing satisfactory performance should be emphasised rather than those aspects of a student's performance which have been found to be unsatisfactory.At this point it would be as well to give some thought to what we mean by the word " objectives" .Objectives concern the levels of performance students should be able to attain during the various stages of their training.An objective must be: -relevant i.e. it must be based on specific educa tional needs -measurable -clearly stated (8, pp 152-160) For example, all students must be able to bedbath a patient.During the first few months of training the ob jective may be that the student should be able to bed bath the patient within an hour.However, by the end of the first year the objective would be adjusted in accor dance with the greater proficiency now expected of the student -the objective may now be that the student should complete a bedbath within half an hour.
Objectives are set in both the theoretical and practical fields for example: Theoretically a student is expected to be able to list and explain the following steps in the nursing process: 1 Assessing the patient's needs 2 Planning nursing intervention 3 Implementing the planned intervention 4 Evaluating the results of the intervention However, practically, the student must not only be able to list and explain the abovementioned steps, she/he must also be able to put them into practice.The following is an example of how each of the steps are put into practice: 1 Assessing the p a tie n t's needs 1.1 the patient appears flushed (observation) 1.2 the patient complains of feeling hot (com munication) 1.3 a temperature of 40°C is recorded (physical ex amination) In this case lowering the patient's temperature is a primary need.

Planning nursing intervention
The following steps may be planned: 2.1 to report the patient's condition to the sister or doctor 2.2 to remove the extra bedclothes 2.3

to tepid sponge the patient 3 Im plem enting the planned intervention
The steps mentioned under planned intervention are carried out.

Evaluating the results o f the intervention
The results of the abovementioned steps are evaluated and, if successful, should lead to a reduction in temperature; the patient is no longer flushed and feels cooler.
Taking time to sit down and work out objectives for each section of the course is a long process, but is necessary to ensure that standardised methods of evaluation are used i.e. all students are measured against the same yardstick.

Evaluation
Having set objectives, the next problem is to decide how often and at what stages in the student's training evaluation is to take place.The term continual assess ment implies that evaluation is an ongoing process.The actual intervals between evaluations depend on the number of students to be evaluated and the number of people available to carry out the evaluations.
Some hospitals attempt to assess their students every week, but this places an almost impossible burden on the people who are doing the evaluating.In hospitals where students are normally rotated on a monthly basis, it is advisable to train the ward sisters to evaluate the students so that each student can be evaluated at least once a month.While the clinical tutors must also assess the students on a regular basis, with a large number of students it may only be possible to assess each one every two to three months.
It is important that the clinical tutor should ask the ward sister or the registered nurse responsible for clinical teaching on the ward to accompany her when she is assessing students -this allows them to compare their assessment methods and to modify them where necessary.
Although the student is being assessed by a number of people, the use of the same evaluation methods helps to ensure that each evaluation is fair and therefore assists in motivating the student to improve her/his perfor mance.In view of the fact that students are regularly rotated between wards, it becomes impossible for the ward sister to carry out more than one or two evalua tions of a specific student.Therefore, in addition to the evaluations carried out by the various ward sisters, evaluations of the same students should also be carried out by clinical tutors.This system allows the clinical tutor to gauge the degree of improvement shown by a particular student.
The tutoring staff of the hospital or college are responsible for evaluating the theoretical aspects of the general science and art of nursing.This evaluation is achieved mainly through the tests written by the students while they are in college and may be sup plemented by tests given at intervals while the students are working in the wards.

Evaluation of Theory
Although there is a degree of overlap between theoretical and practical assessment, we will discuss these aspects as separate entities.The systems for evaluating the theoretical aspects are many and varied and the following are a few examples: 1 THE UNSTRUCTURED OR SHORT QUESTION -the student's answers the questions may be given full sentences or in point form.Corrections of the answers is simple since the answers have been predetermined 2 ESSAY QUESTIONS -this type of question tests the student's knowledge of the subject matter as well as her ability to com municate ideas in a logical and coherent manner.However, the essay-type question severely limits the extent to which the student's knowledge can be tested.Furthermore, essay-type questions are often very difficult to mark objectively P .lll)Note that it is advisable to list more items to column B than responses required, in order to minimise the chance of correct answers being given as a result of the student resorting to the process of elimination.

PROBLEM-SOLVING
This method is designed to assess the student's ability to think critically.She/he is presented with a written description of a nursing problem and is then asked to respond to questions relative to the situation.This form of evaluation also lends itself to group discus sion although then it is sometimes difficult to assess each student's contribution.It may also be used in clinical practice.

CLINICAL EVALUATION
According to Litwack: " Clinical evaluation is the process of assessing student progress in all educa tional experiences outside the formal classroom.It refers to the student's ability to provide competent nursing care under supervision" .(3, P. 141)-The methods which are used for assessment in clinical practice include the following:

Anecdotal notes
This is a brief description of observed behaviour that appears significant for evaluation purposes, sometimes referred to as critical incident recording.Anecdotal records are recorded on a separate sheet and resemble progress notes.These notes cannot be used for marking or grading the student, but are useful in formative A evaluation, planning, assesment, intervention B intervention , planning, evaluation, assesment C assessment, planning, intervention, evaluation D assessment, intervention, planning, evaluation evaluation to help a student improve her/his perfor mance.They are used mainly by clinical tutors when do ing " follow up" visits to their students in the wards.The disadvantages of this method are that neither the notes nor the observations are standardised and there is a strong element of subjectivity.Many of the problems encountered can be overcome by adopting a more systematic approach to the collection of anecdotal notes.
Evaluation of how a student attains the objective of recognising and treating respiratory arrest The checklist This is a prepared list of statements related to the per formance of actions.Each statement is ticked to in dicate whether the action was performed or not and if so in what sequence.For example, if the tutor wishes to evaluate a student's ability to recognise and manage a respiratory arrest, the following checklist would be us ed.The example gives the type of evaluation that might be obtained and the student's actions can be discussed with recommendations being made for improvement.

Rating scale
The scale has two major components -a set of defined traits or levels of performance on which the students are judged -a scale associated with each trait or performance which qualifies the extent to which a trait is possessed by a student or how well the perfor mance is carried out.These scales are particularly useful in assessing interpersonal skills, com munication skills, attitudes, interests and even job skills.The rating scale may be graphic where a tick is placed in the box best describing the student's performance.This rating does not result in a score being obtained for each student.
e.g." middle" score shown on this scale as people then tend to simply take the You will note that there is not an average or easy way out by marking the student as " average" .

PRACTICAL EXAMINATIONS
These provide the opportunity to test, in a realistic setting, skills involving all the senses while the ex aminer observes and checks performance.We at the University of Pretoria have continued to use practical examinations in addition to our con tinuous evaluation, as we feel it provides additional motivation for the students to maintain high stan dards. 1 he format for marking the practical examina tion is the same as that used for the continual evalua tion of students although the former situation is a pre-arranged one, whereas continual evaluation is done in the wards where the students are assessed while they are working.The form we use is based on the nursing process and the marks for each section are weighted according to their importance, e.g.Aseplic Procedure (1) Assessing the patient's needs, which includes knowledge of the patient's history, is marked out of 4 4 (2) Planning the nursing intervention, which includes all preparations both in dressing room and at the patient's bedside, is marked out of 8 8 (3) Implementing the planned intervention is divided into two sections: (i) The student's interpersonal relations with the patient including communication skills and concern for the comfort and dignity of the patient -marked out of 18 (ii) The procedure or performance itself marked out of 53 and made up of the following components 18 -The aseptic technique of the student is marked out of 25 25 -Competence and manual skill are marked out of 20 20 -Rounding off and tidying up marked out of 3.
-A five-point scale for the degree of difficulty of a particular procedure e.g.
Renewing a simple dressing -rates 1-2 Removing sutures -rates 2-3 Irrigation of a wound -rates 4-5 Catheterisation -rates 5 5 (4) The evaluation of the results of the procedure and the recording of both the procedure and the results are marked out of 5 5 (5) The examination is followed by a short 10-minute oral examination in order to obtain further information on the student's knowledge of certain aspects of the practical examination.This oral is marked out of 10 10 (6) The student's appearance, neatness, etc., is marked out of 2 2 The total score is therefore marked out of a possible 100 marks 100

Nurses' notes
Nurses' notes, problem-oriented records and other written reports can be used for evaluating purposes.Not only is content-knowledge assessed, but also the student's communicating skills.A rating scale or check list may be used as the actual assessment instru ment and the assessment should be repeated at inter vals throughout the student's training.Evaluation criteria in nurses' records should include the follow ing: -the appropriateness of what is said -the comprehensiveness of significant facts -the accuracy of data collection and interpretation -the consistency with which reported plans and actions agree with assessment data (6, P. 153) As patient's charts are legal records of the care pro vided it is essential that the student's ability to com plete them accurately is developed by continual assessment.

Nursing Care Studies
Although there are various ways of doing nursing care studies, including the workbook method, they are all basically individualised learning processes.Each study must be adapted to the student's level of training.They can then be used to evaluate the stu dent's understanding and implementation of the nurs ing process.

ORAL COMMUNICATION
Appraisal interviews conducted after the completion of evaluations present the ideal opportunity for feed back for both student and evaluator.Conferences which are problem-solving experiences can be organised either among peer groups, where the teacher rates individual participation, or they may be nursing team conferences in the ward where the ward sister assesses the student participation and their understanding of problem solving techniques.

CONCLUSION
We have discussed a few of the aspects of evaluation and different methods which may be used in the assess ment process.I do hope this will help to clarify the pro cess of continual assessment.However, as all our needs and circumstances differ, it is not possible to lay down hard-and-fast rules.The South African Nursing Council leaves it to the individual nursing schools to decide what methods of evaluation they wish to use.The Council merely demands that the methods must be quantitative assessments (i.e.measurable), so that the person in charge of the nursing school can submit a certificate stating that the student obtained at least an average mark of 50% in these continual assessments.This cer tificate is submitted 3 months prior to the month of ex amination.This aggregate mark is made up of both the tests on theoretical aspects as well as assessments in clinical practice.It is advisable, however, for each school to insist that the student obtains at least 50% in theoretical evaluations as well as clinical assessments.The oral examination in clinical practice set by the hospital as part of the Nursing Council's examination is a completely separate matter, and does not concern us here.
Litwack, " Students need to know what they are doing well, where they can improve and in what ways they can change their behaviour" .(3, P .145).
determining the effectiveness of her instruction.Con sistently poor results very often indicate poor teaching methods.
3 ALTERNATIVE RESPONSE/FORCED CHOICE e.g.True -False -this method is useful in covering an extensive field in a short period of time.e.g. if the objective is to define the terminology of heart disease, the student is required to circle the letter T if the statement is true or the letter F if the statement is false: The valve between the left atrium and ventricle is called.....................