The use of skills inventories to assess and grade practice: Part 1 – Design and implementation

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Abstract

Employers increasingly require evidence of competent practice and cost-effective education that is fit for purpose. Historically, universities providing nurse education have been more concerned with the testing and grading of theory at undergraduate level which ultimately defines degree classification. This may be at the expense of recognising excellence in clinical practice which should be the ultimate goal of any nurse education programme.

This paper reviews the development and introduction of an assessment tool to grade clinical competence in higher education level 6 post-registration critical care courses using a skills-based assessment strategy. The knowledge and practice components for each skill are defined within a standardised template. A number of skills pertinent to the area of practice and academic module are then collected in a skills inventory for assessment and grading which contribute to degree classification.

Introduction

The reliability and validity of tools for assessing skills and clinical competence have attracted discussion by academics and practitioners alike (Nicol and Freeth, 1998, Ashworth et al., 1999, Robb et al., 2002, Dolan, 2003, Gill et al., 2006). In the United Kingdom, the relevance of practice-based assessment is not in dispute since the professional regulatory body, the Nursing & Midwifery Council (NMC), stipulates students must attain proficiency at the required standard in the context of practice (NMC, 2004: 22). This is unchanged with the new standards published by the NMC in September 2010 (standard 8, requirement 8.1.5). The measurement of competence in practice, however, is challenging (Quinn and Hughes, 2007, Murrells et al., 2009, Gray and Donaldson, 2009). This can be even more problematic when the assessment strategy attempts to differentiate between academic levels such as diploma or degree level practice, or grade clinical performance.

Smith (2007) noted inflation of practice grades in midwifery degrees skewed the overall classification and called into question the reliability and validity of the assessment process. Pre-registration midwifery programmes in the United Kingdom are now all graduate programmes and required to grade practice. Practice grades achieved must contribute to the final academic award and classification (Nursing & Midwifery Council, 2007a, Nursing & Midwifery Council, 2007b, Nursing & Midwifery Council, 2009). The move to an all graduate nursing profession from September 2011 requires equal weighting in the assessment of theory and practice in contributing to the final award (NMC, 2010). This may require the creation of tools for grading practice at different academic levels comparable with midwifery pre-registration programmes.

Ashworth et al. (1999) reported in their study that differentiating between levels of practice was problematic for nurse educators. Assessment tools which attempted to distinguish between diploma and degree level practice were unreliable as the language used was not sufficiently precise. In addition, language was not commonly shared by nurse educators when specifying academic level. Watson et al. (2002) in their systematic review of the literature also questioned the reliability of the assessor highlighting the risk of subjectivity and socialisation. In particular, they identified the risk of bias if the assessor becomes familiar with the work of the student if assessed over time. Alternatively, if assessment is conducted as a snapshot observation, competence may be affected by ‘stage fright’, local circumstances and resource deficiencies (p. 424 Watson et al., 2002). Similar concerns have been highlighted by Hanley and Higgins, 2005a, Hanley and Higgins, 2005b in their literature review and qualitative study on students’ perceptions of a clinical competence assessment tool in the intensive care environment. A further challenge for nurse educators is deciding which skills to assess to establish competence; a problem emphasised by Bradshaw and Merriman (2008). Hanley and Higgins (2005b) found an assessment tool can lack context and culture. Skills were not sufficiently specific for the clinical speciality. More recently Murrells et al. (2009) have argued that if the NMC approach of assessing individual competences is adopted it may detract from more holistic skills.

Against the backdrop of this debate, this paper is the first of two recounting the creation and implementation of a tool to assess and grade nursing practice in critical care settings at post-registration degree level. It describes the process of designing skills with practice-based assessment criteria and a tool to grade the knowledge and performance assessed.

Section snippets

Skills inventories as an assessment strategy

Healthcare is changing on a global scale. It is more complex and resource-intensive to manage diverse provision. Living with long term conditions such as heart failure at one end of the spectrum and survival of the neonate at the other, results in the need for a broad range of specialist skills. Nursing is not exempt and the skills agenda is now a significant driver for providers of education in the United Kingdom. The modern nursing career is increasingly constructed around patient pathways

Design of grading tool

Having defined the knowledge and skills to be assessed the course team considered the design of a tool to grade clinical practice. One style of grading tool was required for use across all post-registration courses to ensure parity in degree classification. As clinical staff were to be the assessors, the grading tool also had to, be ‘user friendly’ (Pfeil, 2003), and incorporate clinical language. Hanley and Higgins (2005b) found assessment was impeded if students could not interpret language

Implementing the grading tool

Clinical staff responsible for assessing practice were familiar with the style of the skills inventories and were confident in awarding a pass or fail grade. The introduction of the grading tool made a new demand on assessors to examine practice beyond pass/fail.

Each student was allocated a work-based clinical mentor who held a mentor qualification. In the United Kingdom, a mentor is someone who has undertaken a mentor preparation programme approved by the regulatory professional body the

Discussion

Recurring criticisms within the literature relate to assessment instruments which need to be objective, reliable and valid (Coates and Chambers, 1992, Bradshaw, 2000, Pfeil, 2003, Bradshaw and Merriman, 2008, Murrells et al., 2009). Critics of the performance outcomes model of competence complain of a reductionist approach with an emphasis on behaviour change (Milligan, 1998, Watson, 2002, Scholes, 2006). Others argue that assessment of competence and skills could potentially improve fitness

Conclusion

The ascendancy of the skills agenda is a significant driver with the implementation of the NHS Knowledge and Skills Framework (DH, 2004b) to address competence in practice. Increasingly employers require evidence of competent practice and cost-effective education that is fit for purpose. The modern nursing career is now constructed around patient pathways and a competency-based work system (Skills for Health, 2006, Department of Health, 2008). The skills inventory offers a valid solution for

Acknowledgements

The authors wish to acknowledge the contribution of the critical care course leaders at the School of Nursing and Midwifery, and clinical staff in the local NHS Trusts who assisted in the design of the skills inventories and grading tool. Also Pam Pooley and Lorelei Blackburn who prepared the skills templates and grading tool.

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