Nursing Leadership and Management

Kepemimpinan dan Manajemen Keperawatan

Clinical Evaluation

Posted by Afandi on January 28, 2009

Clinical Evaluation
Moh. Afandi)*

Concep of Evaluation

Evaluation is the process of obtaining information for making judgments about learners. Evaluation as the systematic collection of evidence to determine wheter in fact certain change are taking place in the learner as well as to determine the amount or degree of change in individual students (Bloom, 19971 in Reilly, Dorothy E, 1985).

Evalution is a dynamic, continuous process intervowen with the teaching-learning process. This view of evaluation emphasizes its relationship to growth learner, for the judgment made facilitate the learners own further development of knowledge, skills, and potential essential for professional practice.

Evaluation serves three major purposes:
1. Selection of students for a given nursing program
2. Assessment of student learning in varied setting: classroom, learning laboratory and clinical field
3. Program revision and determination of program success.

Evans and Larson (1978) in Reilly, Dorothy E (1985) identified nine trends concerning evaluation of clinical skills:
1. Greater emphasis on relating objectives to evaluation
2. More focus on student learning as the function of clinical evaluation
3. Increased attention to the clinical evaluation process as a vehicle for instructional improvement.
4. More involvement of student in clinical evaluation
5. Provision for observer training to improve reliability among faculty evaluators
6. Increased use of simulation techniques
7. Use of patient records as instruments for clinical evaluation
8. Renewed efforts toward dealing effectively with the issue of grades and clinical evaluation
9. Combined clinical evaluation methods for more comprehensive evaluation

Purposes of Evaluation

Evaluation serves many purposes. The instructor needs to remain attuned to the purposes for which evaluation data are being collected so that the data are used appropriately. Assessment of individual learner is likely to involve
• Indentification of existin ability and aptitude, which provides a base upon which futher learning can be built
• Indentification of learning needs, or observed deficits or missed opportunities that should be addressed during the clinical experience
• Assessment of progress toward achievement of course objectives, and
• Judgment concerning students achievement of a satisfactory level of performance at the conclusion of the clinical experience

Types of Evaluation
There are two major types of evaluative processes:
1. Formative Evaluation
Formative evaluation represents feedback to the learner regarding the learner progress in meeting objectives.
Evaluation that is formative enables the teacher and student to identify areas in which further learning is needed and plan relevant learning experiences.
2. Summative Evaluation
Summative evaluation, end of instruction evaluation, provides information as to the extent to which the learner has achieved the behavioral objectives.
Summative evaluation is Final, stating what has been accomplished rather than what can be.

Nature of Clinical Evaluation Process
Clinical evaluation is a judgmental process, reflecting the values and beliefs of the participants. Value is part of the word and since values are personally chosen, there is subjective involvement in all aspect of the process.
Schweer and gebbie (1976) in Reilly (1985) write: The very nature of evaluating clinical nursing performance means that the evaluators, the students, and the setting in which the evaluation occurs deal with human being. As such, one can hardly eliminate subjectivity in evaluation.
Quality of Fairness in Clinical Evaluation
Whereas clinical evaluation cannot be objective, it can be fair, and this quality of fairness in the evaluative process should be the goal of the faculty.
Fairness has two requisites:
1. Clarity of objectives identified for the field practice experience
2. Supportive climate within which the evaluation take place
Clinical Objectives
The clinical objectives communicate to the learner the expected behaviors to be developed and in turn, the focus of evaluation. These behaviors need to be adhered to in the evaluation process so the learner is aware of the behavioral competencies to be evaluated and can be direct his or her own learning toward them.
The clinical objectives also direct the teacher as to the specific behaviors to be evaluated in the field, rather than allowing the teachers personal desires and beliefs to become the focus of the evaluation.
The clinical objectives represent a contract between learner and teacher.
Psychosocial Climate of Clinical Evaluation
The climate within which the evaluation takes place is critical determinant of the way the learner perceives the evaluation process. A supportive climate denoting trust and respect between teacher and student is essential if evaluation is to be viewed by the learner as a learning experience, providing needed feedback for improvement in learning.
Learning in the clinical field is a difficult process for it places students in vulnerable position. Learning, especially that which requires a demonstrated performance, occurs as a public event in front of the teacher, clients and sometimes even staff and peers, often resulting in the student experiencing feeling of anxiety and stress.

Relationship of Clinical Evaluation to Objectives
Clinical evaluation is based on the objectives established for field practice, which are those course objective and behaviors for which clinical practice is required for attainment.
These objectives address competencies in the cognitive, psychomotor and affective domains at different taxonomic level.
Cognitive Domain
Evaluation of cognitive learning relates to the learner’s acquisition of the knowledge base needed for problem solving and decision making and the ability to use these skill practice. Level of the coginitive taxonomy: Knowledge and understanding level, Application level, Analysis level, Synthesis level, Evaluation level.

Affective Domain
Evaluation of affective learning in the field relates to two aspect:
1. The experiencing behaviors of the learner which may be evidenced in practice
2. The Critical thinking behaviors vital to the element of choice in value development
Psychomotor Domain
Evaluation of psychomotor performance competency relates to judgements of the learner’s accuracy, coordination, and speed in performance. Evaluation of psychomotor learning at the upper level of taxonomy is intended to ascertain the integration of the act in nursing practice. Performance should be reflect a consistently high level of coordination and competence.
Multidomain Performance
This is evident in performance evaluation situations where the student is involved in administering care to a client, thus requiring an assessment of the integration of cognitive, psychomotor and affective skills. Criteria for assuring fairness are described by lenburg (1979):
1. The test must be uniform and equivalent for all students and judged by the same criteria, by all of the faculty
2. It must be administered at a designated time and place with specific and prescribed conditions that are known and accepted by both student and faculty
3. The expected performance behaviors are clearly and explicitly stated and known in advance by student and faculty
4. Students are responsible for learning the entire array of performance behaviors prior to the examination, but are tested on a sample of those that have been systematically derived according to stated criteria and are consistent with the program objectives.

Methods of Evaluation Clinical Practice
Clinical practice is complex and as such cannot be evaluated by one method. Since nursing practice encompasses behaviors in the cognitive, psychomotor and affective domain, it requires an evaluation protocol that contains multiple strategies for appraising the learner’s practice competence in all three domains as appropriate.
Reilly (1980) identifies five reasons for providing diversity in evaluation strategies:
1. Complexity of human behavior
2. Individual differences in responses to learning
3. Suitability of specific evaluation approaches to specific types of learning behavior
4. Motivational factor of evaluation
5. Creative dimension to the evaluation process

Evaluation strategies applicable for use in the clinical field may be classified:
1. Observation
Observation of learner performance is a major means of evaluating student in clinical practice. Through observation, judgments may be made regarding cognitive, psychomotor, and affective performance behaviors.
Difficulties in the use of observation methods lie with:
– The influence of teacher variables on the observation and resulting judgments
– Focus of observation
– Sampling of behaviors observed which may or may not be representative of the usual level performance of the student.
Anecdotal Note is narrative description of an observed behavior recorded in relation to a specified clinical objectives. Effective use of anecdotal notes can be increased by devoleloping a systematic approach to their collection. Reilly (1980) recommends that at the times certain clinical behaviors are identified for evaluation by anecdotal note, the number of notes to be recorded for each also be specified and the student so notified.
Critical Incident. Schweer and Gebbi (1976) define critical incident as “ ..a sample of observable human behavior in a given situation that clearly demonstrates either positive or negative factors contributing to the effective or ineffective completion of the activity.
Critical incidents are an effective strategy for formative evaluation since they include a record of observations made regarding performance in the field and allow for analysis of behavior in terms of its influence on the outcomes of the activity.
Rating Scale, used to a great extent for evaluation in the clinical field, provide a means of recording qualitative and quantitative judgement regarding the learner’s performance in practice.
Rating scale contains two major parts: (1) a set of defined clinical behaviors on which students are judged. (2) an accompanying graduated scale to rate the degree of competence with which the behavior has been performed.
Most of the rating scales used in nursing programs represent five point scales: Letter A, B, C, D, E or number 5, 4, 3, 2, 1; qualitative label, such as excellent, very good, good, fair nad poor.
Videotape, one additional means of recording observation of learner performance is trough videotape.
2. Written communication methods
Evaluation strategies classified as written communication methods provide data on the ability of the learner to communicate in writing and on quality of the content communicated.
Evaluation of the substance of the written material provides data relevant to the objectives. Strategies for clinical evaluation include:
a. Nursing care plan
b. Case study
c. Teaching plan
d. Process recording
e. Log
f. Nursing notes
g. Other written assignment

3. Oral communication methods
– Clinical conference
– Issue conference
– Nursing and multidisciplinary conference

4. Simulation
Simulations are a valuable strategy for clinical evaluation, offering a readily available means of judging performance. Simulation is a new method of performance testing for the cognitive, affective and psychomotor domains.

5. Self-evaluation
Fuhrmann and weissburg (1978) emphazise that “ just as skill in evaluation are not inherent in human beings but must be learned, so too must self evaluation skills be learned.
The focus of self evaluation in clinical practice is determined by the objectives of the experience and individual learner goals.

Evaluation Strategies for The Laboratory and Clinical Practice Settings
Nursing educators recognize that not all experience are educative, and that not all learning requires practical experience with its subject matter. But sometimes student identify their clinical experience as a major contributor to their eventual success in the profession. Given the difficulty in articulating how learning occurs, in the clinical practice setting.
Offering the student opportunities to improve performance (the goal of clinical instruction) must be balanced with the need to remove the student from the clinical area if her performance continues to jeopardize patient safety.
Diagnostic evaluation also is essential to ensuring due process in evaluation practices. Providing guidelines for improvement gives the student a chance to overcome deficits. While feedback is essential, the instructor should avoid labeling a student’s performance with an interim grade, unless this required by nursing program policies at a point midway through the experience.
Grading is the final outcome of the evaluation process, and represents the results of summative evaluation.

Clarifying the Standards for Evaluation
There are two professional judgments about the students performance: whether the student has met course objectives and whether the student can safely provide care. While students can not expect equivalency of evaluation procedures across clinical areas and with different instructors, they should know the “ground” below which problems occur, as well as what marks a superior level of performance.
Reliability in the application of standards is facilitated by the use of rating scales. Certain elements critical to minimally safe practice may be identified as overriders. These are elements that must be present whenever a skill is performed.

Evaluation in the clinical field provides data for making judgments of the learner’s performance in all domains of learning.
There is no such process as objective evaluation. Evaluation is always subjective, fo it is influenced by the values and beliefs of the participants.
Clinical practice is complex and as such, cannot be evaluated by one method alone. Multiple strategies are needed for appraising the learner’s performance in practice.

O’Connor, Andrea B (2001). Clinical Instruction and Evaluation: Teaching Resource. United State of America. Jones and Bartlett Publishers
Reilly, Dorothy E (1985). The Clinical Field: Its use in Nursing Education. United States of Amerika, prentice-Hall


6 Responses to “Clinical Evaluation”

  1. Anonymous said

    many thanks for this timely article which I will use as a nurse educator.

  2. Anonymous said

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  4. mary said

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  5. Mas Afan said

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    […]Clinical Evaluation « Nursing Leadership and Management[…]…

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