Nurse educators ’ perceptions of O S C E as a clinical evaluation method

The South African Qualifications Authority, and the South African Nursing Council are in pursuit of quality nursing education to enable the learners to practise as independ­ ent and autonomous practitioners. The educational pro­ gramme should focus on the facilitation of critical and reflective thinking skills that will help the learner to make rational decisions and solve problems. A way of achiev­ ing this level of functioning is the use of assessment and evaluation methods that measure the learners’ clinical competence holistically. This article is focused on the perceptions of twenty nurse educators, purposively selected from three Nursing Col­ leges affiliated to a university in Gauteng, regarding the use of OSCE (Objective Structured Clinical Examination) as a clinical evaluation method within a qualitative and descriptive research strategy. Three focus group inter­ views were conducted in different sessions. A descriptive content analysis was used. Trustworthiness was ensured by using Lincoln and Guba’s model (1985). The results revealed both positive and negative aspects of OSCE as a clinical evaluation method with regard to: administrative aspects; evaluators; learners; procedures/instruments and evaluation. The conclusion drawn from the related find­ ings is that OSCE does not measure the learners’ clinical competence holistically. It is therefore recommended that the identified negative perception be taken as challenges faced by nurse educators and that the positive aspects be strengthened. One way of meeting these recommenda­ tions is the use of varied alternative methods for clinical assessment and evaluation that focus on the holistic meas­ urement of the learners’ clinical competence.

This article is focused on the perceptions of twenty nurse educators, purposively selected from three Nursing Col leges affiliated to a university in Gauteng, regarding the use of OSCE (Objective Structured Clinical Examination) as a clinical evaluation method within a qualitative and descriptive research strategy.Three focus group inter views were conducted in different sessions.A descriptive content analysis was used.Trustworthiness was ensured by using Lincoln and Guba's model (1985).The results revealed both positive and negative aspects of OSCE as a clinical evaluation method with regard to: administrative aspects; evaluators; learners; procedures/instruments and evaluation.The conclusion drawn from the related find ings is that OSCE does not measure the learners' clinical competence holistically.It is therefore recommended that the identified negative perception be taken as challenges faced by nurse educators and that the positive aspects be strengthened.One way of meeting these recommenda tions is the use of varied alternative methods for clinical assessment and evaluation that focus on the holistic meas urement of the learners' clinical competence.llittreksel Die Suid-Afrikaanse Kwalifikasie Owerheid sowel as die Suid-Afrikaanse Raad op Verpleging strewe daama om gehalte verpleegonderwys daar te stel ten einde leerders instaat te stel om as onafhanklike en outonome praktisyns te praktiseer.Om die rede behoort opvoedkundige pro gramme op die fasilitering van kritiese en reflektiewe denke te fokus wat die leerder behulpsaam gaan wees om rasionele besluite te neem asook om probleme op te los.Een so d an ig e w yse w aardeur h ierd ie vlak van funksionering bereik kan word is deur die aanwending van assessering-en evalueringsmetodes wat die leerder se vaardigheid op 'n holistiese wyse meet.

Introduction
Clinical nursing education lies at the heart of a nurse's profes sional practice and therefore a learner's competency in clinical nursing education is an important component of comprehen sive programmes leading to registration as a professional nurse with the South African Nursing Council.It has been estab lished beyond doubt that assessment and evaluation greatly influence learning and define the de facto curriculum (Ramsden, 1992).Much as the assessment and evaluation of a learner's clinical competency are of great importance, they are, however, unfortunately complex and present difficulties since there is a demand for accountability in the profession.To reiterate this point, Halloway (2000:2) asserts that beyond the profession there is certainly a demand in many countries for greater accountability.Government and employment au thorities have used legislative force to require better education and training standards.Employers complain of poor skills among graduates and hold educational institutions responsi ble for this.The move towards competency-based learning is further evidence of efforts within and beyond the profession to identify and find a means to improve teaching and learning.
South Africa is facing similar problems of equipping the learn ers with competencies that will help to make them active and valuable participants in creating a better country and a better future for all through education (Van der Horst & McDonald, 1997:5).An effective educational system is realised through effective assessment and evaluation methods as stated by Astin (in Gravett, 2000), "An institution !v assessment and evalu ation practices are a reflection o f its values".
Outcomes-based education system.Van der Horst & McDonald (1997:169) require learners to demonstrate what they really know, are able to do and appreciate.This shift in paradigm from a teacher-centred to a learner-centred model brought about fur ther scrutiny of the traditional assessment and evaluation meth ods.It is therefore important to utilise trustworthy assessment and evaluation methods in clinical nursing education.OSCE (Objective Structured Clinical Examination) as a method of clinical evaluation has dominated for years and has gained the status quo.It is, according to Harden & Gleeson (in Nicol & Freeth, 1998:602) the best known and most widely researched development in clinical competency assessment pioneered by the medical profession.Learners are expected to demonstrate their caring virtue and must therefore be able to define prob lems accurately, make the best choice from an array of possible alternative solutions, safely implement the care plans and evalu ate the effectiveness of their actions.Learners need critical and reflective thinking skills to be evaluated in order to be safe and competent practitioners of the profession (Jenkins, 1985;Malek, 1986 andMellish, Brink &Paton, 1998).The question, however, is whether OSCE is effective in view of the expecta tions of the nursing/midwifery profession and the demands placed by the transformation towards competency-based nurs ing education and the evidenced-based nursing practice.Does OSCE measure what it is supposed to measure?Its validity is questionable (Gillings & Davies 1998:8).
The assessment and evaluation of the learners' clinical compe tence traditionally takes place in the demonstration/practical rooms within colleges of nursing, mainly in the form of OSCE.This approach adds value to the traditional scientific authority and ensures adherence to well-established clinical protocols, routine practices and atomistic, specification assessment and evaluation systems characterized by a detailed list of skills (Nicol &Freeth, 1998:601 andHalloway, 2000:2).Such an ap proach to education has proved to be inadequate (Halloway, 2000:4) and does not adequately equip graduates for a future holistic practice in any discipline (Wallace, Shorten, Crooke, McGurk & Brewer, 1999:137).Concern has been expressed about the unrealistic and the artificial nature of the traditional system of clinical evaluation (Gillings & Davies, 1998:8).Be sides, state the authors, learners would pass the examination with high marks -up to 100%, but would not make any differ ence in the clinical practice with regard to improvement on clinical reasoning skills.This problem raises much concern and the research question that arises is "What is the percep tion o f clinical nurse educators with regard to the use o f OSCE as a method o f clinical evaluation o f learners under going a four-year comprehensive diploma course in Gauteng Province ?" The purpose of this article is to explore and describe the per ceptions of nurse educators with regard to the use of OSCE as a method of clinical evaluation of learners in Gauteng.

Nurse educator
A person registered with SANC as a nurse educator, who acts as a facilitator of the learning process through education and training of nurses and midwives to provide diversified compre hensive health care within the National Health System in a variety of settings, within and outside hospitals.Facilitation is achieved through active involvement and participation of nurses/midwives to enable them to change, analyse and solve problems, to develop analytical, critical, reflective and creative thinking skills, to communicate effectively, to adopt an ethos of caring and to have a positive attitude towards learning which will inspire them to become lifelong learners (SANC, 1999:2) The learner A person undergoing a basic comprehensive diploma in nurs ing (general, psychiatric and community health) and midwifery registered with the South African Nursing Council.The learner is prepared to render beginning professional nursing.A prac titioner and generalist nurse clinician and midwife is expected to practise professionally with independence in clinical decision-making and problem-solving, case management, commu nity empowerment, supervision of other staff and efficient use of resources (SANC 1999: Document A, 2; Document B,l).

Clinical assessm ent and evaluation methods
Clinical assessment methods are methods that utilise multiple indicators and resources of evidence as a process of gathering information about the learners' progress.These methods in volve a process of collecting, analysing and interpreting evi dence in learning achievement.Evaluation is the process whereby information obtained through assessment is inter preted to make judgements about the learners' competence.It is a process of determining the merit, worth or value of a proc ess or the product of that process (Mellish et al, 1998:224;Gravett. 2000;Van der Horst & McDonald, 1997:169).

O S C E : description
OSCE is an acronym for Objective Structured Clinical Examina tion, which is popular as a means of summative (or final) evalu ation for clinical competence at a particular stage of a course to decide on promotion to a further course of study, to complete a definite section of a course, or at the end of a course (Mellish et al, 1998:252).The basic format is that learners rotate among a number of stations spending a shorter period (5 or 10 min utes) at each, during which they must perform a particular clini cal skill.Often, the required skill is set in the context to re spond to a short, written scenario in the presence of a simu lated patient.A learner's performance is assessed against a detailed checklist of the components of the skill.Some sta tions are manned, some are unmanned and some are resting stations provided in between.A bell-ringer is equipped with a second-hand watch to monitor and control time.The overall assessment is made by aggregating scores from the various stations (Nicol &Freeth, 1998:602 andMellish et al, 1998:252).

Research Design and Methods
A qualitative, contextual, exploratory and descriptive research strategy was utilised (Mouton & Marais 1994:43-44,51).Focus group interviews (Krueger 1994:6) were conducted in three nursing colleges affiliated to the Nursing Science Department at a university in Gauteng, to collect data from nurse educators who met the sample criteria for this research.The population consisted of nurse educators involved in a four-year compre hensive diploma course (general nursing, community health, psychiatry) and a midwife in the three nursing colleges affili ated to the Nursing Science Department at a university in Gauteng.The participants had to meet the sampling criteria based on five or more years of involvement with the learners' clinical evaluation using OSCE.Sampling was purposive in that all the participants volunteered with enthusiasm to take part in the research.There were six participants from two nurs ing colleges and eight participants from the third nursing col lege (N = 20).Written permission was obtained from the partisipants as well as from the relevant Department of Health and the various Assistant Directors of Nursing Colleges to conduct the focus group interview using a tape recorder.
According to Krueger (1994:6), a focus group interview is de fined as a carefully planned discussion conducted with seven to ten people.It is designed to obtain perceptions on a defined area of interest in a permissive, non-threatening environment.Focus group interviews were conducted in three nursing col leges on days that suited the colleges.An expert interviewer who holds a doctoral degree and is experienced in qualitative research was purposively selected to conduct the three focus group interviews, and the researcher collected field notes dur ing the interview by noting group dynamics and interaction.The research question asked was: What is your perception with regard to the use of OSCE as a method of clinical evaluation of learners following a basic nurs ing education programme?
The duration of the interviews was about one hour.The ques tion was thoroughly dealt with until the perceptions were satu rated.While tea was served to the participants, the researcher did a preliminary categorisation of the concepts, themes and patterns.A co-coder was purposively selected, based on ex tensive experience in qualitative research.The co-coder was given Tech's protocol for data analysis to be used.After one week, the researcher and the co-coder had a consensus dis cussion to arrive at common themes and sub-themes from the collected data.Follow-up interviews were conducted with two participants from each college to validate the findings.
Tesch 's protocol (in Cresswell 1994:155) was used for the de scriptive content analysis of the collected data, followed by a literature control.Lincoln and Guba's model (1985) was used to ensure trustworthiness throughout the study.Trustworthi ness was ensured according to the four principles related to credibility, transferability, dependability and confirmability.Credibility was ensured through prolonged engagement since the researcher and the participants are experienced clinical nurse educators.The researcher took field notes and follow-up in terviews were conducted to validate the categories deduced from the collected data.A literature control was conducted by using the findings of similar studies.To ensure transferability, the sampling method was purposive with no prior selection and a complete description of the design, methodology and literature control maintained transparency.A consensus dis cussion between the researcher and an independent coder as well as the description of the design and methodology en sured dependability.Confirmability was also ensured through the taking of field notes.

Findings
Five main categories pertaining to both positive and negative perceptions and their related themes emerged from the descrip tive content analysis of data collected with regard to: aspects concerning administration, evaluators, learners, procedures/ instruments and evaluation.Both the positive and negative results will be discussed simultaneously and controlled by lit erature in the order displayed in table 1.
Participants were of the opinion that as much as OSCE has been a traditional and dogmatic method of clinical examination for learners, it also has positive aspects that contribute to ef fective teaching and learning.However, the negative percep tions raise much concern regarding the development of the clinical reasoning skills of the learners who are expected to make rational clinical decisions and solve problems.This con cern poses a challenge to the nurse educators and all the stakeholders in the education and training of learners in nurs ing.

Adm inistration
All the participants acknowledged the fact that good adminis tration of OSCE can lead to effective learning.They indicated that the selection of an effective committee and a co-ordinator to plan the entire examination plays an integral part as evi denced by: "Every examination needs a committee and a leader to co-ordinate the planning, execution and control o f the entire examination, or else there will be confusion through out".
However, the participants felt that a well-organised OSCE could accommodate a large group of learners smoothly as cited: "An effective committee that plans well in advance can evaluate a large number o f learners simultaneously and timeously with out causing confusion".
Yet, on the negative aspect, most participants emphasised the fact that most of the time, the tutors are not clear about the principles guiding the management, execution, monitoring and evaluation of OSCE, as quoted: "It is a fa ct that most tutors are just followers in as fa r as the running o f OSCE is con cerned.We have not been adequately prepared about the management and execution o f OSCE.We learn on the job ".Some participants also stated: "Without the theoretical base, OSCE becomes a nightmare fo r both students and tutors, and this contributes to the lack o f co-operation and a genuine commitment o f tutors to the entire examination.Where there is lack o f knowledge, negative attitudes and feelings build up".Another aspect that was raised was the composition of the elected committee and co-ordinator.In this aspect, the partici pant stated: "The co-ordinator and the committee usually do not have expert clinical knowledge, skills and values result ing in the examination not being goal-directed" other partici pants stated: "Without the expert knowledge and vision, OSCE is viewed as part and not a whole activity.It becomes difficult to handle a large group, the organisation o f staff and re sources, venues and time schedule become a confusion ".At this point, the participants were demonstrating their anger and dissatisfaction.They were expressing themselves with emo tions in order to make their point.
It must be realised that clinical assessment and evaluation are actually the 'life blood' of professional learning and must there fore be taken seriously (Gravett, 2000:2).Every clinical exami nation needs good administration with careful planning.The selection o f a com m ittee is m andatory.M ellish et al (1998:244,251) stated that all forms of assessment and evalua tion require careful planning, with consultation, testing, a re view of the previous examinations from time to time and altera tions made according to the changing needs.The authors acknowledged the fact that assessing clinical competence is a difficult task, which is nevertheless absolutely vital.Collabo rative consultation with other interdisciplinary health teams is essential for the evaluation to be holistic and goal-directed.Major and Pines (1999:122) assert that collaboration and infor mation sharing plays an integral part in decision-making since the decisions made will influence the way things are done.The authors maintain that collaboration drives change.It allows teachers to engage, reflect and collaboratively agree on solu tions to problems.
The following authors (in Major and Pines 1999:76,79) state categorically that the purpose of the examination committee and a co-ordinator is as follows: to clarify ideas and establish direction for the working group (Senge 1990), to foster commit ment from individuals and groups (Conger 1992), to motivate others to achieve agreed-upon objectives (Conger 1992) and to develop a culture that reinforces individual performance (Cunningham & Gresso 1993).The authors suggest that the selection of a committee should include people who are willing to create a bridge between the traditional leaders who must satisfy rigorous canons and norms, and others who respect the realities of clinical practice and honour service to the com munity.
The selection should include people who are willing to create an atmosphere of guidance, mentorship, facilitation, staff de velopment and peer leadership.People who are open to learn new clinical skills, demonstrate respect for others, value a flat tened hierarchy and committee, and who are open to the cur rent wave of reform and restructuring that is challenging these traditional roles and recognise new forms of leadership are imperative.People who will look at life from a different angle Bennis (in Major & Pines 1999:79) and make their colleagues do things they would not ordinarily do on their own to improve their quality of professional practise should be included (Wasky in Major & Pines 1999:79).It is also imperative for the criteria against which the learners will be judged to be compiled by a group of experts most concerned with the technique.These criteria should be reviewed from time to time and revised as necessary (Mellish et al, 1998:248;Boud 1995;Van der Horst & McDonald 1997).
The administrative aspect of the clinical assessment and evalu ation is important and requires commitment and a mind-shift of the committee members from individual to participatory deci sion-m aking.Solar and C onejeros (2000:8) assert that participative decision-making produces good quality, but warn that the practice of quality is not a straight line but a spiral.Every new planning should generate a new process, but will have to start from the revision of previous assessment and evaluation experiences, followed by careful planning, perform ance, revision and readjustment proposals.
With reference to nurse educators' lack of expertise in OSCE, Major and Pines (1999:78) are of the opinion that it is no sur prise that many teachers lack confidence in the ability to evalu ate positively, and Mellish et al (1998:253) urge that the teacher training programme should prepare teacher learners to meet the needs of the community.Teachers need an ongoing up date of clinical competence.They need enough support in order to play a meaningful role in clinical teaching.The au thors encourage nurse educators to attend in-service educa tion, or other updating offered in both the theoretical and clini cal aspects of nursing as well as new advances in educational technology.Nurse educators are encouraged to undertake self-evaluation to identify their strengths and weaknesses.
A lack of human and material resources was perceived as a limitation of OSCE as this adds stress and strain to the tutors and learners.Going from one department to another request ing necessary equipment or seeking staff to be evaluators is rather absurd.Mellish et al (1998:254) argue that OSCE can be very frustrating and stressful for learners and examiners, and suggest therefore that in all evaluations, care should be taken to eliminate stress in learners as far as possible.Thoughtful planning and organisation of any assessment and evaluation are imperative (Mellish & Johnston, 1986).In the same vein, Nicol and Freeth (1998:603) are of the same opinion that the traditional OSCE has severe limitations that have an impact on the assessment of clinical nursing skills.These entail limited time for each situation, handling large numbers of learners, small venues and lack of equipment.Gillings and Davies (1998:8) maintain that because of these constraints, vital as pects of clinical competence may be omitted, resulting in the credibility of OSCE as a method of clinical evaluation being questioned.

Evaluators
The participants, as evaluators themselves, expressed their genuine perspective in this regard.They indicated that OSCE encourages team spirit as they all actively participate in the preparing, executing and evaluating the examination as evi denced by the following citation: "OSCE actually fosters a collaborative and co-operative spirit amongst tutors.We work together and share ideas and therefore learn from each other." Furthermore, some participants indicated that OSCE improves their observation skills, as cited: "When you are an evaluator, you have to stay alert throughout, lest you miss out on some steps performed by the student.Your observation skills are sharpened." Yet, on the negative aspect, the participants also provided their genuine perspective in this regard.They indicated that sub jectivity, inconsistency and incompetence among tutors exist as quoted: "You sometimes become subjective since a student can impress you at face value and you just allocate high marks on impression.Sometimes you lose concentration and on realising that the student is already performing other steps, xou simply tick in the middle to play it safe.Sometimes you are not sure about the performance o f certain aspects o f the procedure and you fin d yourself marking in the middle or lower simply because there is no time to verify with the other tutor." Participants also indicated that: "That is why you find that the two evaluators in the same station have a wide dis crepancy in marks such as a 30% discrepancy.Many factors have an impact on the tutor' s evaluation process ".
Again, most of the participants expressed their frustration due to the lack of interaction and time to think during an evalua tion, as cited: "It is frustrating to see the student performing in a certain way, but you cannot ask the reasoning behind her action because 'silence' is the order o f the day".
The participants also expressed their concern about the use of professional nurses as evaluators in OSCE, as quoted: "The use o f professional nurses in OSCE is minimal and this makes the sisters lose their credibility as having a role in clinical teaching ".Compounding the problem is that: "Even when it is decided to involve the ward sisters, they are never briefed or prepared in the use o f the instruments and how OSCE is run.The whole situation is frustrating ".
The notion of OSCE encouraging active tutor participation, sharpening their observation skills and encouraging teamspirit is reiterated by Major and Pines (1999:78,122) who state that interactive collaboration and information-sharing play an inte gral part in decision-making as those decisions have an influ ence on the way things are done.They maintain that collabo ration drives change, allows teachers to engage, reflects and collaboratively agrees on solutions to problems.It is impor tant for tutors to develop a positive attitude, an attitude of receptivity, empathy and openness to sharing ideas with oth ers in order to acquire knowledge.Team spirit or partnership in clinical assessment and evaluation involves all the stakeholders in the education and training of learners, such as, unit nurse managers, ward sisters, central sterilising department staff, in fection control officers, clinical nurse educators, preceptors or mentors and learners.This integrated collaborative approach to clinical assessment and evaluation is in keeping with the contemporary requirements of the outcomes-based education and is greatly encouraged.
Concerning the problem of subjectivity, inconsistency and in competence among some nurse educators, Boud (1995:169) has attributed these problems to systematic bias, which leads to giving higher and lower marks.Of concern is whether this is a conscious act or not.In this regard, the author states that the question of the reliability of the evaluators is subject to scru tiny (Andursyszn, 1990:411).Rowntree (in Boud, 1995:158)has identified the unreliability of teacher marking.Studies have demonstrated that there are discrepancies between evaluators, with the same evaluation overtime, even when there is appar ent agreement of what is being assessed.They maintain that different perspectives can give rise to different interpretations and ideas about what is important, which may lead to lack of interrater reliability of evaluators.
Holzbach and Kegel-Flom (in Boud 1995:159) suggest the fol lowing considerations of how to improve maker reliability: • Establish explicit criteria for satisfactory and unsatis factory performance.

•
Use scales in which the categories are unambiguously defined.• Do not use scales that are more sensitive than the fineness of discrimination allows.

•
Train evaluators by applying accepted criteria to typical examples of work to be evaluated and by resolving differences through discussions between evaluators to reach consensus on the interpretation of the criteria.
Ward sisters should not be excluded in this worthwhile exer cise, but should be empowered with the necessary knowledge and skills of clinical assessment and evaluation.

Learners
Participants acknowledged the fact that OSCE contributes posi tively to learning and enhances the learners' confidence and self-esteem, as cited: "During OSCE students are actively in volved and demonstrate confidence as they use all their senses to collect data and make quick decisions.Even a shy student who is an introvert plays her part that day".
The aspect on the validity of OSCE was raised and some par ticipants felt that a well-planned OSCE could evaluate the cognitive, affective and psychomotor skills of the learner, but there was some debate on this issue, as cited: "I f OSCE is well planned, all the three domains, that is, the cognitive, affective and psychomotor skills can be evaluated, but the levels o f the thinking skills are to be considered, especially the affective domain." On the other hand, participants stated categorically that some learners do not take OSCE seriously, as cited: "Some students do not take OSCE seriously and would actually joke about it.To them, clinical examination is not meaningful but rigid and suppressive to their individuality".Besides, stated some participants: "OSCE expects students to perform uni form ly according to the checklist.It does not allow fo r crea tivity and flexibility o f individual students.In a relaxed sup porting environment, even a nervous student can perform to his or her maximum potential".
Participants further stated that: "There is no time fo r students to reflect on their experience.The scenarios written on little papers and instructions do not provide adequate informa tion to make decisions.Whilst they still read the scenarios, the bell rings fo r them to start.The student then acts quickly like a robot without any thinking.It is crazy and very fru s trating to both the student and the tutor".
Participant added: "Interpersonal skills and the affective com ponent are not adequately evaluated as the whole exercise is sterile".What is even more frustrating to the learners is the use of their peer group as patients, as quoted: "The negative reaction o f a student can be easily displayed especially if the 'said patient' is not her friend.It puts the student o ff com pletely".
To overcome some of the problems created by OSCE, Nicol and Freeth (1998:601) assert that the validity of an OSCE is reliant upon the quality of the problems posed at each station and, most importantly, the agreement of assessment checklists Large numbers of learners can be evaluated simultaneously and timeously.

1.
Tutors not clear about the guiding principles of OSCE. 2.
Planning is haphazard.

3.
Committee members lack expertise in OSCE.

4.
Lack of human and material resources.5.
Time constraint.
Improves observation skills of evaluators.
There is no interrater reliability 3.
No interaction with learners 4.
Less involvement of ward sisters -if involved, no debriefing in the use of instrument.
Active involvement using all senses.2.
Evaluate the cognitive, affective and psychomotor skills.
1. Some learners do not take OSCE seriously.

2.
Principle of individuality not considered.

3.
No time to reflect on their experiences.4.
Insufficient knowledge base acquired from written scenarios -no time for proper history taking.5.
Interpersonal and affective skills are not evaluated effectively.6.
Use of peer group as patients has a negative impact on learners' perform ance.7.
Learners become very nervous and feel threatened.
Procedures/ Instruments 1. Simulated procedures -patients lives and their privacy is not at risk. 2.
Less threatening.

3.
Some stations do not require an evaluator.
1. Simulated procedures are not realistic.

2.
Not holistic but atomistic and superficial.

3.
Certain procedures are not easy to simulate.4.
Manner of improvising is not realistic and is confusing.5.
Instruments not properly developed.6.
Criteria for evaluation and critical points are not clearly defined.
More procedures can be evaluated.

2.
Learners express their anger through evaluation.
by means of a panel of expert opinions.Authentic problems are encouraged through which learners are given enough time to reflect and make their own interpretations and decisions.It is advisable rather to have less stations where learners would have time to apply their own clinical reasoning and prioritise actions appropriately in a realistic manner than to have many stations that encourage superficial thinking actions rushing to complete the procedure.In this way, the communication skills and the affective components could be evaluated adequately.
The learners are advised to use the teacher as a resource per son if necessary.This will, according to Nicol and Freeth (1998:603) reduce the nervousness and the feeling of being watched.
Fahy and Lumby (in Nicol and Freeth, 1998:603) assert that OSCE should aim to integrate and contextualise the skills, modify the number of stations and length of time at each station, some stations could take up to 45 minutes.This was found to im prove the validity and reliability of the examination, to reduce learner stress and to encourage learners to reflect upon and evaluate their own experiences.
Concerning the use of the peer group as patients, Nicol and Freeth (1998:604) suggest that university staff or ex-nurses who do not make regular contact with the learners under ex amination could be used.This makes the assessment authen tic by removing prior knowledge and expectations.Learners are not distracted by the 'simulated patients' having precon ceived ideas about the behaviour of individual learners.The authors maintain that it is important for the simulated patients to be primed to ask questions that would enable the learners to demonstrate their communication and affective skills.

Procedures/Instrum ents
All the participants acknowledged the fact that since OSCE mostly involves simulated procedures, the patients' lives are not at risk, as cited: "OSCE is ideal because the lives o f pa tients are not put at risk, their privacy is not invaded and dolls do not get tired.It is also less threatening and the inclusion o f unmanned and resting stations is desirable to students ".
On the other hand the participants expressed their dissatisfac tion in that simulated procedures are unrealistic and not holis tic.Certain procedures cannot be evaluated as it may be diffi cult to simulate them, as cited: "Simulated procedures are not realistic and holistic.Students cannot get the human feeling o f the procedure.They perceive the procedure as parts and thus the holistic nature o f the performance cannot be devel oped.Simulation can be confusing since it is done in an unrealistic manner, such as sterile packs are packed differ ently, yet when the procedure was demonstrated, correctly packed packs were used.This causes the student to be devas tated and confused".
Again, participants indicated the problems of the evaluation instrument, as stated: "Evaluation instruments are not prop erly developed.They do not provide a wide range o f evalua tions especially when a checklist with YES or NO is used.The instrument does not allow fo r justification and reasoning.Instead, instruments are developed in such a way that a stu dent with poor performance would get a high mark and a gifted student would have + 100% pass.Even the critical points are not clearly defined, they do not allow fo r creativity' and are not realistic.Allocation o f marks fo r these critical points is not consistent according to the weight o f the item Nicol and Freeth (1998:604) assert that OSCE suffers from the characteristic problem of the quest for objectivity, which leads to the lengthy and atomistic specification of content and stand ards such as a 20 or more item checklist used for 5 minutes at single-task stations.The emphasis on measurable parts can miss the essence of the whole (Wolf 1993).There is much concern about the distorting effects of checklists, resulting in learners having a tendency to learn these skills in a fragmented way (Nicol and Freeth, 1998:458).The authors suggest the development of 'global rating' when the overall performance of learners at a station is graded on a scale with descriptors.It has been suggested that global rating should allow for the discriminating reasoning, which is thought to be the hallmark of clinical competence.The authors suggest the use of guided framework proposed by Benner (1984), which has been elabo rated on to consider the attainment of specified learning out comes with reference to standards of safety, accuracy, effec tiveness and affective component (Parker 1995).To increase the validity and reliability of the examination, it is advisable to include self-evaluation of the learner during discussion with the assessor.Mellish et al (1988:248) assert that provided that the learners are subjected to such 'proficiency' testing frequently and are judged by more than one person, rating scales can provide a very accurate picture of the learners' competency and other characteristics.Learners must be aware of the criteria against which they are being assessed.Critical points must be clearly described and the authors suggest that instead of using the concept critical, rather use safe patient care.

Evaluation
With reference to the evaluation of OSCE by the learners, the participants felt that it is an important aspect of the examina tion and allows for more learners to be evaluated simultane ously, as cited: "The feedback we get from students is invalu able because they indicate the strengths and weaknesses o f the examination and also where improvement has to be made ", and "OSCE can accommodate many students if well planned".
Yet, on the negative aspect, the participants stated: "Truly speaking, students wait fo r a long time before the results are published.Station and item analyses are not made.Modera tion is not effective and even when they get results there is no positive feedback given".
With reference to the evaluation written by the learners imme diately after OSCE, some participants stated that: "Some evalu ations are positive but mostly students find this exercise a way o f expressing their anger, and the comments can even be insulting at times ".
On the whole, the participants felt that the evaluation was not done properly to benefit the learner and the tutor.It is noted that post-evaluation conferences held by both learners and evaluators to discuss the strengths and weaknesses of the examination and how to improve the standard are invaluable (Chabeli 1995).This notion is supported by Mellish et al (1998:248) and Nicol and Freeth (1998:605) who maintain that the learners' results should be discussed with them after com pletion of the evaluation as a learning process.

Conclusion
Participants perceived the use of OSCE as a method of clinical evaluation in both positive and negative ways.Five themes were identified as aspects concerning the administrative as pects; evaluators, learners; procedures/instruments and the evaluation of OSCE.
The positive aspects with regard to administration are that OSCE requires an effective committee and a co-ordinator to ensure smooth running of the entire examination.O f utmost importance is collaborative and co-operative planning, execu tion and control of the examination.Nurse educators need to be empowered with the necessary competencies in order to conduct OSCE successfully.Proper administration of OSCE would allow large numbers of learners to be evaluated simulta neously and timeously.On the other hand, poor and ineffec tive administration results in the lack of human and material resources as well as time constraints causing stress for both the learner and the evaluator.What compounds the problem is the committee members and evaluators who lack expertise and guiding principles for OSCE to be conducted effectively.
The positive perceptions about the evaluators are that OSCE encourages team spirit and improves the evaluator's observa tion skills.The negative perceptions indicated the subjective, inconsistent and incompetent tendencies of the evaluators.Lack of interrater reliability, lack of interaction with learners during the examination and less involvement of ward sisters in OSCE were also posed as negative.
The positive perceptions of the participants with regard to the learners are that OSCE encourages active involvement of learn ers by using all the senses.It also enables the evaluation of the cognitive, affective and psychomotor skills.The negative perceptions described are that some learners do not take OSCE seriously.Learners become nervous, especially when fellow learners are used as patients.The time provided for learners to reflect on the procedure in relation to previous experience is limited.The written scenarios provide insufficient information to enable the learner to analyse, interpret and reflect on the activity to be performed.
With regard to the procedures and instruments, the positive perceptions are that OSCE constitute mostly simulated proce dures and are therefore less threatening to the learners, and the patients' lives and privacy are not at risk.Negative percep tions are that the simulated procedures are not realistic and holistic.Certain procedures are not easy to simulate since im provisation makes the procedures become unrealistic and mean ingless, causing confusion for learners.Evaluation instruments and the criteria for evaluation are not well developed and they lack clarity.
The positive perceptions on the evaluation of OSCE are that the feedback from learners is invaluable.More procedures could be evaluated in a single examination.The negative as pects are that no immediate feedback is provided to the learn ers.There is no station and item analyses to determine the strengths and weaknesses of the stations or the items for fu ture improvement.Some learners regard OSCE evaluation as an opportunity to express their anger and some comments could sometimes be insulting to the evaluators.

Recom mendations
In the quest to improve clinical evaluation, nurse educators need to strive towards improving and turning the negative aspects into challenges, and strengthening the positive as pects of OSCE.It is, however, recommended that further re search be undertaken to explore and describe the use of alter native, authentic methods of assessment and evaluation to measure the learners' comprehensive and holistic clinical com petence.
sr Curationis M a rch 2001

Table 1 :
Nurse educators' perceptions regarding the use of OSC E as a method of clinical evaluation