The International Council of Nurses (ICN) defines competence as the effective application of a combination of knowledge, skills, and judgment in practice.1 Nursing is a practice-based profession where clinical placement, teaching, and learning are essential for students to acquire the necessary competencies for professional practice.2,3,4 To ensure that only competent graduates are licensed to practice, nursing councils conduct licensing examinations, which may comprise clinical competency assessments.5,6,7
Assessment is the process of gathering and evaluating information on what an individual knows and he/she can do to make an informed decision about the next steps in the educational process or professional life.8,9 In Nursing Education Institutions (NEIs), students’ continuous and summative assessments in the three main domains of learning (cognitive, affective, and psychomotor) are conducted.10 Summative assessment in health profession educational programs aims to ensure that decisions such as progression and licensing, and prediction of future performance, are evidence-based.9 Assessment goes beyond an exercise that enables students to acquire a grade to pass a course; rather, a student may be required to use a combination of knowledge, skills, and attitudes that were learned in their theory and practice.11,12,13
The importance of quality clinical assessment in nursing cannot be overemphasized as a proper assessment of clinical competence has a positive influence on patient care.14 Assessment is said to be of good quality if it is valid, fair, transparent, reliable, feasible, and has an educational impact.11,15 An assessment system should have the ability to accurately differentiate competent students from incompetent ones.16
In a recent review of nursing competency assessment in general, Reljić et al.17 stated that there are three main types of clinical competency assessment: observation, self-assessment, and a combination of both – the most common of all being the structured observation using rubrics. Reljić et al.17 concluded that notwithstanding the system, approach, and model or framework used for clinical competency assessment, it should measure knowledge, clinical skills, and problem-solving skills. Lastly, the review proposed further research to develop and validate a reliable clinical competency assessment tool (system).17 The purpose of this study is to explore current practices in clinical competency assessment of nursing students globally. This review forms part of a larger study aimed at developing an evidence-based, context-specific framework for clinical competency assessment in a sub-Saharan African (SSA) country.
This scoping review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).18 Scoping reviews synthesize findings from empirical qualitative, quantitative and mixed-method studies. According to Christmals and Armstrong,19 scoping reviews are conducted either as pre-systematic or free-standing reviews to synthesize findings from empirical and gray literature on a complex concept. “Clinical competency assessment” is a complex concept, hence the choice of methodology.
Five databases, Scopus, PubMed, CINAHL, Wiley Online Library, and ProQuest, were searched using varying combinations of the keywords: (Nursing OR Clinical) AND (Competence OR skill OR performance) AND (assessment OR evaluation). Peer-reviewed literature published in English from 2014 to 2019 that meet the objective of the study were included. The studies identified were imported into the Mendeley reference manager group where all duplicates were removed.20,21 All titles were scanned, abstracts, where the study titles were related to the study objectives, were read, and full texts of the abstracts that met the inclusion criteria were retrieved by two independent reviewers. The two reviewers met and compared their list to reconcile their inclusion and exclusion decisions. There were no contentions on any study, hence there was no need for an adjudicator.
The search produced 1151 studies from the databases. Thirty-nine (39) duplicates were identified and merged, leaving 1112 studies. After screening the titles of the 1112 remaining studies, 1063 were excluded leaving 49 studies. The full articles of the 49 studies left were retrieved and critically evaluated. Twenty-eight (28) studies were finally included in this review, comprising 18 quantitative studies, 4 qualitative studies, 3 mixed-method, and 3 multimethod studies (Figure 1).
Of the studies included, 13 (46.4%) were conducted in Europe followed by the Middle East (5,17.9%), Americas (3,10.7%), Asia (3,10.7%), Australia (3,10.7%). Only one study (3.6%) included was from Africa (Figure 2). Of the 28 papers, 19 either developed or validated a clinical assessment tool or model. Participants were mostly nursing students, while other studies included qualified nurses. Two of the studies16,22 neither included input from nursing students nor did they use data collected from them.
Data were extracted from studies using an adapted extraction sheet (Table 1) from De Souza and Carvalho.23 Author and setting, the aim of the study, methodology, data collection and analysis, and key findings were extracted. All the quantitative results were qualitized and synthesized with the qualitative data, using a convergent integrated approach.24 Data were synthesized using the five-stage data analysis method outlined by Whittemore and Knafl25: reduction, data display, data comparison, drawing of conclusions, and verification.2
Data matrix.
Author, country and region | Aim of the study | Design | Data analysis, outcomes, instruments | Key findings |
---|---|---|---|---|
Quantitative studies included in the review | ||||
1. Ahn and Hyun-Young, |
To implement two high-fidelity simulations to help nursing students integrate their cognitive and psychomotor skills to evaluate the students’ simulation experience using the Simulation Design Scale and learning outcomes. |
Quasi-experimental post-test design. | Five nursing experts and 69 nursing students ANCOVA was used to compare the experimental and control groups, and correlation coefficient analysis was used to determine the correlation among them. | Students rated guided reflection and fidelity highly in the designed simulations. |
2. Oetker-Black et al., |
To psychometrically evaluate the Clinical Skills Self-Efficacy Scale in a population of nursing students in Tanzania. | Psychometric evaluation. | 287 nursing students enrolled in the preservice or in-service nursing programs at two schools |
Evidence of construct validity. |
3. Teixeira et al., |
To compare the level of anxiety and performance of nursing students when performing a clinical simulation through the traditional method of assessment with the presence of an evaluator and a filmed assessment without the presence of an evaluator. | Randomized control trial. | 20 nursing students were randomly assigned to one of two groups. |
The final scores of the two groups correspond to mild anxiety. |
4. Alamri and Almazan, |
To examine the barriers to physical assessment skills among nursing students in a government university in the Arab Peninsula. | A cross-sectional research survey. | 206 nursing students participated. |
Physical assessment is not often practiced in clinical settings. |
5. Alquwez et al., |
To assess the perceived patient safety competence during clinical training of Saudi nursing students. | Descriptive, cross-sectional design. | 829 nursing students. |
Students expressed positive perceptions toward their patient safety competencies. |
6. Arbabshastan et al., |
To determine the status of clinical competencies nurse practitioner students – self and instructor assessment. | Analytical cross-sectional study. | All senior nurse students ( |
The lowest scores of competencies were from communication and hygiene |
7. Daly et al., |
To determine the extent of assessor variability in clinical skills assessments in an undergraduate nursing program. | Prospective follow-up study design | The results of students’ clinical skills assessments in three clinical units were extracted from an administrative database. |
Overseas-born students had lower pass grades than Australian-born students. |
8. Gurkova et al., |
To investigate the use and effectiveness of a valid and reliable rating scale for summative clinical evaluation of student performance. | Descriptive cross-sectional study | 82 students participated in the study. |
A valid and reliable tool may allow an objective evaluation of nursing student performance in clinical settings. The Nursing Student Clinical Performance Evaluation Scale is useful for summative evaluation of student performance. Teachers and clinical mentors can rate students’ performance over time and note patterns of performance. |
9. Iglesias-Parra et al., |
To develop an evaluation system of clinical competencies for the practicum of nursing students based on the NIC. | Psychometric validation study a cross-sectional study. | Reliability and construct validity, as well as responsiveness, were tested by the evaluations performed by clinical mentors on 107 students over two consecutive years. |
A competency system for the nursing practicum, structured on the NIC, is a reliable method for assessing and evaluating clinical competencies. |
10. Kajander et al., |
To assess the congruence between graduating nursing students’ self-assessment and their mentors’ assessments concerning nurse competence with a particular focus on nursing skills. | Cross-sectional study | Completed questionnaires were received from 60 students and 50 mentors. |
Students’ rated their performance higher than the mentors. |
11. Langari et al. |
To examine and compare the self-assessment of patient safety competence between British and Finnish nursing students. | Cross-sectional study. | The PaSNEQ, 502 surveys to the final year nursing students |
No separate module for patient safety was included in the curriculum. Both groups of students ranked their competence to prevent patient safety incidents (attitude) the highest and their competence to act after errors (skill) relatively low. |
12. Macia-Soler et al., |
To determine the level of involvement of clinical nurses accredited by the Universitat Jaume I (Spain) as mentors of practice (Reference Nurses) in the evaluation of competence of nursing students. | Cross-sectional study | 200 clinical nurses completed the CPAM tool. | 63% of CPAM were completed correctly, without reaching the quality threshold established (80%). Nurses’ performance on the CPAM tool was determined by their respective clinical units There are significant differences according to clinical units. Collaboration and training of clinical nurses was recommended. |
13. Murray et al., |
An evaluation of a NTS framework that could potentially be used to measure ward round skills of student nurses. | Observation (cohort) study. | Development of NTS framework |
The proposed NTS framework included seven categories which were rated as important and relevant to practice and could be used as a means of evaluating student nurse competencies in respect of many NTS required for a successful ward round. |
14. Numminen et al., |
To evaluate whether educational outcomes of nurse education meet the requirements of nursing practice by exploring the correspondence between nurse educators’ and nurse managers’ assessments of novice nurses’ professional competence. | A cross-sectional, comparative design using the Nurse Competence Scale. | 86 Nurse educators and 141 nurse managers. |
Examiners who are educators rate novice nurses’ competence higher than examiners who are managers in all competence areas. Differences between educators’ and managers’ assessments scores were strongly associated with their age and work experience. |
15. Meskell et al., |
To explore electronic OSCE delivery and evaluate the benefits of using an electronic OSCE management system. |
A descriptive survey. | An electronic software in the management of a four-station OSCE assessment with first-year nursing students over two consecutive years ( |
Electronic software facilitated the storage and analysis of overall group and individual results thereby offering considerable time savings. |
16. Oermann et al., |
To explore the feasibility of developing scenarios for high-stakes evaluation of students’ clinical performance. | Video recordings of students performing in standardized scenarios. |
Most of the nursing students were able to competently perform most of the skills assessed on the CCEI. There was some inconsistency in the inter-rater agreement. |
|
17. Ossenberg et al., |
To advance the assessment properties of a new instrument, the ANSAT, and investigate the acceptability of this instrument when applied to the evaluation of the professional competence of nursing students in authentic practice settings. | Cross-section survey study | A validation study of ANSAT was conducted by 23 clinical assessors from two universities, completing 220 instruments for nursing students. |
The instrument is sensitive to different levels of performance across different year levels. |
18. Solheim et al., Norway41 | To develop and evaluate a new reflection and feedback tool for formative assessment. | Descriptive design | 129 nursing students participated in the study. After high fidelity simulation, data were collected using a questionnaire with 19 closed-ended and 2 open-ended questions. | The tool provided a structure for self-assessment and made visible items that are important to be aware of in clinical skills. The tool has the potential for enabling students to learn about reflection and developing skills for guiding others in practice after they have graduated. |
Qualitative studies | ||||
19. Cassidy et al., |
To develop a theoretical explanation of how mentors experience borderline competency achievement of nursing students in clinical practice. | Grounded theory study. | Interviews and focus group discussions with Registered Nurse mentors and practice educators. |
There were conflicts regarding mentors’ assessment decision-making where students were on the borderline of achievement of competence in clinical practice. |
20. Meier et al., |
To examine how the ISP was used to assess interpersonal skills in a university pre-registration nursing program. | Realistic evaluation approach | Interviews with clinical nursing mentors, practice education facilitators, and education champions. Documentary analysis of student assessment booklets was also done. | The ISP tool is used for formative and summative assessment. It supports the overt assessment of interpersonal skills, support to mentors, and provides feedback and “feed-forward” to students. |
21. Ochylski et al., |
To demonstrate the use of a multidimensional evaluation method as applied to a new simulation-based remediation course to enhance the clinical skills of prelicensure nursing students. | Seven who participated in a variety of simulation scenarios and skill-building activities were interviewed on the last day using 12 open-ended questions. | Student scores reflected positive skill performance 2 months after participating in the course. Some students expressed concern over a potential negative stigma among peers for needing and participating in a skills enhancement course. | |
22. Tommasini et al. |
To compare the clinical competence assessment processes and instruments adopted for nursing students during their clinical placement abroad. | A case study design | Tools for evaluating competences and written procedures were scrutinized through a content analysis method. Seven European countries participated in the study. | Great variability emerged in the tools, with between five and 88 items included. Twelve different core competence categories were identified. |
Mixed method | ||||
23. Burke et al., |
To explore Irish preceptors’ experience of using a competence tool to assess undergraduate nursing students’ clinical competence. | Six focus group interviews to explore preceptor's experience of using an assessment tool to assess clinical competence. |
Preceptors had difficulty understanding the content of the tool as it was too academic. Challenges of using the assessment tool include difficulty understanding the content, negotiating complex repetitive language, time constraints and the need to facilitate qualitative commentary. | |
24. Zasadny et al., |
To develop a model in response to the inadequacies of existing tools to assess competence. | The ASAP tool was trialed in three public tertiary hospitals and four private hospitals. Quantitative and qualitative feedback was collected from students and clinical facilitators. | The ASAP model can be used as a focused diagnostic tool, removal from PEP support tool, and a framework for documenting evidence. |
|
25. Lai, |
To implement an online video peer assessment system to scaffold their communication skills and examine the effects and validity of the peer assessment. | Expert evaluation scores showed that peer assessments led to significant improvement in students’ communication performance. | Online peer assessment could be perceived as a valid assessment method for nursing communication skills training. Communication became more patient-centered gradually due to peer assessments. Peer assessment activities contributed to the improvement of the communication skills of students | |
Multimethod | ||||
26. Marquez-Henandez et al., |
To design, develop, and implement a tool to evaluate the clinical skills of nursing students. | 250 Nursing students were randomly placed in an experimental group and a control group. |
The web-based tool designed is an effective strategy to evaluate clinical skills. The need for innovative strategies that can determine the development and acquisition of the skills required for future nursing professional | |
27. Imanipour and Jalili, |
To develop a comprehensive assessment system for nursing students in their critical care rotation based on a programmatic approach | -Expert review |
38 nursing students in their critical care course. |
The new assessment system had high validity, reliability, and a positive impact on learning. |
28. Wu et al., |
To develop and test psychometric properties of a holistic clinical assessment | -Systematic review |
Synthesis of the literature, exploratory and confirmatory factor analysis, Content Validity Index | HCAT was developed and validated through psychometric testing. The tool was internally consistent and reliable. |
ASAP, Australian amalgamated student assessment in practice; ANSAT, Australian Nursing Standards Assessment Tool; CPAM, Clinical Practice Assessment Manual; CCEI, Creighton Competency Evaluation Instruments; HCAT, Holistic Clinical Assessment Tool; ISP, Interpersonal Skills Profile; NTS, Non-Technical Skills; NIC, Nursing Interventions Classification; PaSNEQ, Patient Safety in Nursing Education Questionnaire; PEP, Professional Experience Placement.
The Joanna Briggs Institute (JBI) Critical Appraisal tools were used to evaluate the studies included in this study. The reviewers agreed that a study would be included if it met 80% of the criteria set in each of the JBI Critical Appraisal tools.50 All the included studies met the quality criteria for inclusion.
Data were synthesized into five categories namely: clinical competency systems and tools; qualities of the assessment Systems/Tools/Frameworks/Models; strengths and weaknesses of the assessment process; management of assessment process; and quality improvement of the examination system. Sub-categories were also presented below.
The tools used in the included studies were developed either to assess technical skills or non-technical skills (NTS). Technical skills include: patient assessment13; nursing care process31,44; managing patient care and education44; wound dressing48,51; catheterization41,47,48,51; inserting feeding tube41; inserting a nasogastric tube51; preparation and administration of parenteral medication41,47; handwashing38; documentation38; blood sampling48; inserting peripheral lines41 and management of care.49
NTS that were assessed included: self-learning and critical thinking44; interpersonal skills22; ethical behavior44; nurse-patient communication36,44; risk prevention44; nursing students’ communication performance on advocacy, the therapeutic use of self and validation to patients and family46; and ethical principles and professionalism.31
The studies presenting the tools in Table 2 were mainly focused on the assessment of clinical competency skills29; preceptor experience of using competency tools45; anxiety level of students during the assessment28; assessment practices of nurse educators and managers37; involvement of clinical nurses as mentors35; mentors experiences when nursing students are on the borderline of achievement of competence in clinical practice.42 Other areas included comparing nursing students’ self-assessment and mentors’ assessments on competency skills33; and influence of assessors,16 professional, legal and ethical nursing practice, leadership and nursing management and professional development.49
Clinical competency assessment systems/tools/frameworks/models.
Tools | Purpose | Development | Validated | Publicly available | Remarks |
---|---|---|---|---|---|
The ISP22 | To assess students interpersonal and professional skills | It comprises 40 statements about interpersonal skills, professionalism, and engagement with the learning process, against which students’ performance in practice may be graded | Yes | Yes | Can be used for both formative and summative assessment |
QLCCT27 | To assess formative and summative competency skills of students based on Tanners (2006) model. | The tool, which is grounded in the seminal work of Tanner,52 consists of 8 items on which students are rated either as a novice, progressing, advancing, or a graduate nurse. Psychometric properties of the tool were reported as interrater reliability (0.87), content validity index (0.72), and alpha coefficient (0.83) | Yes | Yes | The tool provides a clear and reliable way of measuring the clinical competency of students at various stages of training |
ENS Assessment tools ENS44 | To compare the clinical competence assessment processes and instruments adopted for nursing students during their clinical placement abroad | The tool composes 196 items which were categorized into 12: “Technical skills competence; Self-learning and critical thinking; Nursing care process; Ethical behavior; Patient communication; Risk prevention’ competence category; Self-adaptation; Clinical documentation; Managing nursing care; Patient/family education; and Theory and practice integration” | Yes | Not applicable | Increases transparency in learning expectations and evaluation |
ASAP tool amalgamated student assessment in practice model13 | The ASAP model functioned effectively as an assessment tool, focused diagnostic tool, removal from PEP support tool, and a framework for documenting evidence | The model comprises an assessment tool, a clinical reasoning framework and a negotiated learning contract. |
Yes | Yes | It is useful for both formative and summative assessment |
ICAS tool53 | To assess the communication competencies of students in undergraduate programs | This tool is a 23 items tool. |
Yes | Yes | Used for summative and formative assessment clinical performance |
H-PEPSS54 | To assess patient safety competencies of students | Six domains of the safety competencies: “Contribute to a culture of patient safety; Work in teams for patient safety; |
Yes | Yes | It is an effective tool in assessing summative clinical performance |
NSCPES31 | To assess the summative clinical performance of nursing students | Instrument development consists of 77 items of clinical responsibilities of nursing students. | Yes | Yes | A valid and reliable tool may allow an objective evaluation of Nursing students’ performance in clinical settings. |
DOPS55 | To assess students clinical performance through direct observation | Many variant forms of tools are in use. Khanghahi and Azar (2018) presented a systematic review of the DOPS used. | Not applicable | Not applicable | Insufficient training, poor feedback, time constraints. Attention needs to be paid to the quality of the tests |
NTS-NAS56 | To assess the not technical skills of nursing students | NTS-NAS resulted in a list of 63 items that are assessed on a 5-point Likert scale: “totally disagree to totally agree” with intermediaries. A “non-applicable” option was also added. | Yes | Yes | This tool could be used in teaching and assessment in undergraduate and postgraduate programs |
CCEI57 | To assess clinical competency of nursing students in simulation or traditional clinical settings | The tool focuses on 22 general nursing behaviors which were divided into four categories: “assessment, communication, clinical judgment, and patient safety”. | Yes | Yes | This tool has been validated and is used in many countries |
ANSAT40 | The instrument tested contained 17 items spread across 4 domains of practice used to assess the student's level of ability. The items are rated using a | A 17 item tool which is rated on a 1–4 scale. The tool is categorized into 4 domains: “professional practice; critical thinking and analysis; provision and coordination of care; and collaborative and therapeutic practice”. The scale is calibrated as: “1 = minimum standards not met, 2 = minimum standards met, 3 = performs above minimum standards in some areas, 4 = performs above minimum standards in most areas”. | Yes | Yes | It allows for clarity, reliability, and collaboration in clinical competency assessment |
COPP41 | It is intended to help students in their formative assessment and reflection on themselves and their peers before, during, and after learning clinical skills. | Measures five main areas: “Preparation and planning, Performance |
Yes | Yes | The tool provided a structure for self-assessment indicates essential components of skills for students |
ASAP, Australian amalgamated student assessment in practice; ANSAT, Australian Nursing Standards Assessment Tool; COPP, Competence-development of Practical Procedures; CEEI, Creighton Competency Evaluation Instruments; DOPS, Direct observation of procedural skills; ENS, Erasmus Nursing Students; H-PEPSS, Health Professional Education in Patient Safety Survey; ICAS, Interpersonal Communication Assessment Scale; ISP, Interpersonal Skills Profile; NTS-NAS, Non-Technical Skills - Nursing Assessment Scale; NSCPES, Nursing Students Clinical Performance Evaluation Scale; PEP, Professional Experience Placement; QLCCT, Quint Leveled Clinical Competency Tool.
Quality assessment tools/systems/frameworks should have the following features: objectivity and feasibility22,48; educational impact45,48; validity and reliability22,26,31,32,38,40,49,51; defined scope13; defined procedures44; measuring dimensionality of the tool51; utility of the tool22,40; transparency and clarity22,44,49; relevance40,49; efficient/timely to complete40; data storage38; support reflection41,49 and provide feedback (Figure 3).13,22,31,39,41,45,46,48,49
Strengths and weaknesses were identified in the clinical competency assessment systems. The authors identified improved self-confidence26; critical thinking26 and good communication34,43,46; collaboration and teamwork43,46; effective remediation35; quality nursing care29 and monitoring students’ progress49 as strengths of assessment systems. Using different evaluation forms44; incongruence between teaching and assessment22; no module on patient safety in the curriculum34; overwhelming clinical scenarios39; and difficulty with face-to-face interaction22 and lengthy assessment tool49 were identified as weaknesses in clinical competency assessment.
Findings from the synthesis outlined some aspects (sub-categories) of managing the assessment processes, such as testing assessment tools, examiner-related factors, supporting students, scoring performances, and educational effects that are critical for a quality clinical competency assessment.
Before commencing a clinical competency examination, there is a need to conduct a pilot test of the assessment tools and scenarios in the examination setting. Pilot testing helps correct any errors regarding scenarios39 and ensures clarity and transparency in selecting items for the assessment process.22,49 Also, using manikins’ functionality and other instruments such as cameras and microphones helps to capture relevant data for storage and reference.39 Testing instruments ensures that students and examiners are familiar with the assessment tools before examination45 as evident in all the tools that were described in Table 1.
Lack of training of examiners, workload, and lack of time makes assessment challenging.22 Some examiners also complained about the assessment tools’ language being too academic and complicated, lengthy and time-consuming, so they end up skipping some of the problematic sections.45 Some examiners have challenges with awarding “excellent” and excellent grades in some of the higher items, such as confidence in decision-making and being innovative, as they believe that may be difficult to achieve in specialist areas.22 Some examiners also struggle when they are not well trained, not familiar with the practice setting, not experienced, not confident, and not competent in what is being assessed.22,38,39 Therefore, preceptors, mostly examiners, felt prepared and fulfilled after going through a training course.45 Nurse educators and nurse clinicians appointed as examiners need to be well trained to assess students.22,45 Training also prepared examiners to cope with the fear of failing non-performing students.22
To support students, examinations must be done in a safe environment to reduce anxiety,43 and must provide timely support to students when a concern is identified.45 In assessing interpersonal skills profiles (ISPs), examiners may need to create an enabling environment such as engagement, confidence in judgment, and welcoming students.22,39 Students are believed to be motivated when their good practice is rewarded.22 Competence-development Practical Procedures (COPP) helped clarify what to focus on when giving feedback and is used to raise awareness among students on quality in skills training.41 Essential areas such as hygiene principles, preparing equipment, being more thorough in what to assess as an observer, and information given to the patient and completing work and documentation were identified.
According to examiners, tools aid in assessing in a safe, effective and proficient manner.13 Tools allow the collection of data that can be disseminated later to students and faculty13 and can be used as a guide or framework to support examiners’ judgments.45 The clinical examination results are expressed in different formats such as dichotomous (pass/fail) measurement to an ordinal scale using a five to 20 Likert scale score.44 It was reported that students assessed by the most lenient assessors were over seven times more likely to pass than students assessed by the most stringent assessors.16 Although language affects performance, for example, indigenous students performed better than international students, the strongest predictor of a student passing their clinical skills assessment was the leniency (doves) and stringency (hawks) of the examiner.16
There are other variabilities in the assessment of clinical competence by nurse educators and nurse managers. The age difference between educators and managers also influences the award of marks to students. Numminen37 discovered that educators and nurse managers who were <50 years of age award lower marks than those over the age of 50. The finding calls for an investigation of the association between age, expertise groups, and student assessment. Also Oermann et al.39 discovered inter-rater disagreement in the assessment of administering medication, managing technology, and equipment. It was found that the inconsistent use of “not applicable” resulted in the inability to judge the performance of students.39 In some instances, the software is embedded to forecast a new pass mark to control stringent and lenient examiners.38 Fatigue also affects the award of marks. Evaluators needed to break and rest after viewing four videos of students performing clinical competence due to fatigue, indicating there may be the need to extend the duration of the examination.39 Novice examiners’ rating skills improved after examining eight videos. Also, it was easier to rate outstanding and poor performance than average.39 In clinical assessment, students must be allowed to evaluate the examination system, tools, and examiners.47,48
Assessment of clinical competency skills of students, using various assessment tools, leads to skills improvement. Some students expressed concern over a potential negative stigma among peers for needing and participating in a skills enhancement course.43 During peer assessment, students were able to provide feedback to their peers.46 Students identified the importance of patient safety and were confident that they could respond to adverse effects toward patients,34 while most students were able to competently perform most of the skills assessed on the Creighton Competency Evaluation Instruments (CCEI).39 There was no difference in anxiety level when examined using the traditional method or video method on performance.28 Formative clinical competency assessment creates an awareness among students to improve their clinical skills.41 In effect, examination helps to provide feedback to students and identify their learning needs, towards the provision of remedial activities to enhance learning.45,49
Although most of the articles showed that the current assessment systems were effective (Table 1), there is a need for improvement in some areas. The need for more collaboration between nurse educators and managers could reduce the inter-rater variability and bridge the theory-practice gap.37,45 Some competency skills, such as handwashing and communication, need to be assessed exclusively to ensure that students are competent in those areas.30 Students must be exposed to skills continuously to improve clinical competency performance,29 identifying their learning needs and styles,45 increase collaboration, and continuously develop professionally.49 Additionally, continuous review of assessment tools, providing space on the sheet for examiners’ comments, and including the assessment of ISP in all assessment systems improve the assessment system.22,45
The results highlighted various aspects of assessment of clinical competency: research output on clinical competency assessment; clinical competency assessment tools in use; criteria for quality clinical competency assessment; the management of clinical competency assessment system; and quality improvement of the examination system.
There was only one study included from the African context. The lack of research on clinical competency assessment in the sub-region may lead to practitioners using evidence from a different context to guide their assessment systems. This phenomenon, if not handled cautiously, may result in ineffective, Eurocentric systems that are not responsive to the SSA context. Previous reviews2,58 found that there is a paucity of nursing and midwifery education research in SSA. It is therefore essential for research on clinical competency assessment from Europe and other regions to be contextualized before guiding practice in SSA.19
There are several tools for the assessment of various aspects of clinical competency. Almost all the tools that were used in the studies were validated (Table 2). They are publicly available to guide teaching and practice, which is important in summative assessment as the students and the educators can identify the expectations of the assessment system and prepare accordingly.44,45 This helps to bridge the theory-practice gap. Available tools allow students to engage in peer assessment, which is beneficial to them.46
A good assessment system must meet some quality criteria. It must: be fairly objective, measure what it is set to measure; produce the same result if it is conducted under similar conditions; be applicable within the context for which it is developed; be acceptable to the stakeholders within the context; be transparent and clear; result in improvement in teaching, learning and practice; and provide feedback to the stakeholders for quality improvement purpose. Any assessment system that is devoid of these qualities will be fraught with biases and unfairness, which will, in turn, lead to licensing of incompetent practitioners or denying competent practitioners license to practice with its associated risk to society.15
Just like every functional and effective system, clinical competency assessment systems must be thoroughly planned, developed, and pilot tested before implementation. This ensures that the recipients of the products or outcomes of the system are satisfied with it. The tools used for every assessment system must be validated. Validation of tools gives students confidence in the assessment system. It also ensures the validity and reliability of the assessment. Training of the examiners is essential in ensuring the applicability and reliability of the assessment system and should include the award of marks and the provision of a safe and conducive examination environment. This is observed through their confidence, good inter-rater reliability, and the students’ satisfaction. An incompetent examiner risks the introduction of bias which hampers the quality of the assessment system.16 In selecting examiners, consideration must be given to the age category and competency skills to be assessed as it affects the outcomes of the examination.37
Feedback is essential in the continuous improvement of an examination system. Students, examiners, and educators must be allowed to evaluate the examination system and the tools used to provide empirical evidence on which quality improvement could be based. Feedback from the examination body in terms of publishing anonymized examination results also provides the institutions and students data for quality improvement. Feedback on various aspects of the care provided by students during formative clinical competency assessment provides data on learning needs, remediation, and improvement in clinical competency.
A good assessment system must be valid, reliable, transparent, feasible, must provide feedback, continually improve, must be fair, must be objective, and have an educational impact. Clinical competency assessment systems must be developed on sound empirical evidence, pilot tested, and involve thorough training and evaluation of the examiners. Continuous evaluation of the assessment system is also essential in ensuring the quality and relevance of an assessment system. The paucity of clinical competency assessment research in sub-Saharan Africa may lead to benchmarking assessment systems on research conducted outside the context. Sub-Saharan Africa has a set of circumstances that demand a context-specific clinical competency assessment framework to guide clinical competency assessment in the sub-region.
The study presents a review and synthesis of empirical evidence on clinical nursing competency assessment globally. The findings highlighted critical areas that need attention in designing and improving clinical competency assessments systems especially in licensing examinations, which serve as the bridge between training and qualification as a nurse in many countries globally. The findings in this study, if applied, will assist in ensuring that only competent nurses are license to practice nursing, thereby protecting the public against malpractices.