Nurse educators’ experiences of the use of Objective Structured Clinical Evaluation (OSCE) at a university in South Africa

Nurse educators’ experiences of the use of Objective Structured Clinical Evaluation (OSCE) at a university in South Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nurse educators’ experiences of the use of Objective Structured Clinical Evaluation (OSCE) at a university in South Africa Maserapelo G Serapelwane, Onchebile I Mokgaola This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5318877/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background There is an ongoing global debate on the reliability of Objective Structured Clinical Evaluation (OSCE) as an assessment method at nursing education institutions, and South Africa is not exempt. The purpose of this study was to explore and describe the experiences of nurse educators with the use of OSCE at a university in the North West province of South Africa. Design and Methods: The study applied a qualitative, explorative, descriptive, and contextual design. Purposive sampling was used to select nurse educators who were facilitating the teaching and learning of undergraduate nursing students. The study conducted two focus group interviews at two selected campuses. The Tesch’s eight steps of analysis were used to analyse the raw data. Trustworthiness was ensured by applying the principles of credibility, confirmability, dependability, and transferability. All ethics measures were upheld throughout the study. Results The themes that emerged from the findings include among others the perceived effect of OSCE on students. This was evident from the emotional and psychological distress and the challenges surrounding the implementation of OSCE. Conclusion It is clear from the findings that the use of OSCE should be improved at the university in the North West province of South Africa. nurse educators university nursing education institution Objective Structured Clinical Evaluation 1 Introduction Objective Structured Clinical Examination (OSCE) is an adaptable evaluation tool that can be used to evaluate students’ skills in a simulated or real clinical setting [1]. OSCE assesses competency using objective testing. Assessment relies on two examiners’ direct observation of students. The set-up involves numerous stations where students are expected to perform a variety of clinical skills within a specified time [1]. OSCE is used in both undergraduate and postgraduate settings to offer a standardised and objective evaluation of the clinical skills that form the outcomes of a specific educational programme [2–4]. OSCE helps the student to learn and to gain competence in the prescribed clinical skill [2–4]. It was first introduced in 1970 to assess the skills of medical students and is currently used globally to also assess the clinical competency of nursing students [2&4]. The findings of a study conducted at a universities in the north of India revealed that 27% of nurse educators and students experienced the use of OSCE in the simulation environment negatively [5]. This was evident from reports of anxiety and inability to complete skills because of the limited time at each station [5]. The same was reported in Saudi Arabia as the participants said that OSCEs are stressful compared to other examination methods due to factors like the complexity of tasks, the allocated time to perform the skill, and poorly designed stations [6]. Participants found the inability to communicate with dummies during practical examinations stressful [9]. Most of the participants were unsatisfied with OSCE [9]. The abovementioned studies reported on the negative effects of OSCE in the east and northern regions of Asia [5, 6 & 9]. It was therefore important for the current study to explore the use of OSCE at a university in the North West province of South Africa. The study in India relied on a systematic review and analysed quantitative research. It recommended a qualitative study to explore the broader view of the use of OSCE [5]. The recommendation of qualitative study bears evidence of a knowledge gap that could be addressed by a qualitative study that examines the experiences of nurse educators with the use of OSCE. A study conducted in Vietnam reported the benefits of OSCE and said that students are fully aware of the nature and method of the examination. The study found that OSCE exposes the student to wide range of skills and helps the student gain confidence in clinical practice [7]. Additionally, the tasks that are normally included in OSCE are found to be relevant to sustain clinical competency [7]. A study conducted in Korea revealed that after lectures on clinical skills and core nursing skills practice, OSCE improved the retention of nursing students’ knowledge [8]. Furthermore, the findings revealed that OSCE can strengthen student clinical competency. Another study reported that OSCE helped to identify the weakest areas of the students’ competency [9]. The current study considers the reported benefits of OSCE as important to sustain. It is therefore important to gauge the experiences of nurse educators with the use of OSCE, in this case at a university in the North West province of South Africa. Two studies have been conducted in South Africa in the Western Cape and the North West provinces respectively, but neither addressed the experiences of nurse educators with the use of OSCE [9 & 10]. The finding bears testimony to the lack of published evidence on nurse educators’ experiences with the use of OSCE [9 & 10]. The students who participated in the two mentioned studies revealed negative attitudes towards OSCE, with comments mentioning outdated mannequins, a lack of integration of theory and practice, and a need for OSCE with real-life patients [9&10]. The aim of the current study was therefore to explore and describe nurse educators’ experiences with the use of OSCE on the selected campuses of the North-West University in the North West province of South Africa. The study offers recommendations to improve the use of OSCE on the selected campuses [9]. 2 Design and methods The study adopted a qualitative, exploratory, descriptive and contextual research design. The qualitative, exploratory and descriptive study seeks to understand and describe the deeper meaning and the complexity of given phenomena or construct [11]. The chosen design was found to be most suited to a study that seeks to understand the experiences of nurse educators with the use of OSCE at two selected campuses of the university. 2.1 Study setting The study took place on two campuses of a university in the North West province of South Africa. The selected campuses both offer a basic nursing qualification and uses OSCE to assess the competence of nursing students. The two campuses have approximately 47 nurse educators who facilitate the teaching and learning, which includes the assessment of undergraduate nursing students. The two campuses are situated in the Ngaka Modiri Molema and Dr Kenneth Kaunda districts of the North West province of South Africa. The two campuses are denoted as Campus A and Campus B for the purpose of the discussion below. 2.2 Population and sampling The population for this study was the nurse educators on the two selected campuses. Site A has 21 and site B has 26 nurse educators who teach undergraduate students. A non-probability purposive sampling technique was used to select the participants. This purposive sampling technique is also called criterion-based sampling, as the researcher used set criteria to purposively select participants who are judged to have knowledge about the phenomenon that is under study [11]. The inclusion and exclusive criteria used to select the population of interest are listed below. 2.2.1 Inclusion criteria The following inclusion criteria were applied for the selection of nurse educators. Nurse educators had to: Be employed by the selected university to assess competency of students using OSCE; Be registered with South African Nursing Council (SANC) as nurse educators since they are then by law permitted to assess the practical skills of nursing students; Have participated in OSCE before as this would enable them to share their experiences and respond to the qualitative questions on their experiences with the use of OSCE; and Be willing and consent to participate in this study because it is an ethics requirement for everyone to sign an informed consent form before being interviewed. 2.2.2 Exclusion criteria The following exclusion criteria were applied to the nurse educators: Nurse educators who had never been involved in an OSCE were excluded. 2.2.3 Sample size and data saturation Two focus group interviews were conducted during the study. Fifteen nurse educators participated and data collection stopped once no new information emerged from each group. 2.3 Recruitment of participants and data collection Goodwill permission was obtained from the Research Data Gatekeeper Committee, which enabled the researchers to commence with the recruitment of prospective participants. The process started after getting approval from the following research committees: (1) Quality in Nursing and Midwifery; (2) the Faculty of Health Sciences Centre for Health Professions; and the final approval from (3) the Faculty of Health Research Ethics Committee. Goodwill permission to conduct this research was also granted by the director of the School of Nursing, who acted as a gatekeeper for Campus A and B. The role of the school director was to appoint mediators for both campuses. The role of the mediators was to introduce the study to the nurse educators by convening a meeting to explain the study, thus recruiting potential participants. Another role of the mediators was to print flyers and to post them on the notice boards in the school buildings. The mediators for Campus A and B were administration clerks who did not have any direct power relationships with the nurse educators. An honours degree student not involved in teaching the students, was appointed as an independent person responsible for facilitating the signing of consent forms. The mediators gave those nurse educators who were interested in participating in the study consent forms to sign over a two-week period to ensure voluntary participation. The independent person and the researcher acted as witnesses for the nurse educators who signed the consent form. The focus group interviews were conducted by a research assistant who holds a doctoral degree and who is an experienced qualitative researcher. The research assistant guided the discussions using an interview guide with the following two broad questions: What are your experiences with the use of OSCE at the North West University (NWU) ? What could be done to improve the use of OSCE at the NWU. Participants were asked to consent to the use of an audio recorder to capture the conversations and the interviews were conducted in English. The following communication techniques were used to get in-depth information: probing, reflection, paraphrasing and summarising [12]. The field notes that were taken during data collection include descriptive or observational, personal, methodological, and theoretical notes [12]. 2.4 Data analyses The eight steps of Tesch’s content analysis and open-coding process as outlined in Creswell were used for data analysis [13]. The steps were applied as follows: (1) the arrangement and preparation of data were accomplished through verbatim transcription of all interviews and typing of field notes; (2) researchers repeatedly read through the two transcripts and the field notes and focused on making a sense of the information by writing general thoughts on the data; (3) re-reading started with reading one interesting transcript and writing thoughts in the margin of the transcript; (4) all the topics that emerged from reading the transcripts were listed and similar topics were developed and grouped together and sorted into columns; (5) the topics were further narrowed into broad themes, categories and subcategories, and the codes were written next to the appropriate part of the text; (6) the researchers made a final decision about the main themes categories and subcategories; (7) the setting and the narrative of themes were described referring to educators and events during the use of OSCE; and (8) the researchers interpreted the research findings and compared the findings with the existing literature. 2.5 Trustworthiness The trustworthiness of this study was ensured by applying the four principles of Lincoln and Guba’s model (1981), which are credibility, confirmability, dependability and transferability [14]. The strategies that were used to apply these principles are truth value, applicability, consistency, and neutrality. To enhance the credibility of this study, the strategy of truth value was applied by allowing prolonged engagement with the participants. The interviews lasted between 60 and 90 minutes. Breaks were provided after every 30 minutes to avoid exhaustion in participants. The principle of conformability was achieved by using the strategy of neutrality. In this regard, data from the proposed study were validated by an independent co-coder. The mechanism of scientific peer review was used to ensure dependability and consistency. The principle and strategy of transferability and applicability was ensured by (1) sufficient description of the place where the study took place to enable the reader to establish how transferable the results could be to other settings; (2) clear description of the research questions, purpose of the study and the aims and objectives; (3) discussion of the research design and methods, sampling as well as data collection and analysis; and (4) reporting the findings in a table form and discussing themes to reveal the experiences of nurse educators. 2.6 Ethical considerations The principles of respect for persons, beneficence and justice were upheld in this study [16&17]. The decision of persons who were not willing to participate were respected. Additionally, an informed consent form was signed prior to participation and the researcher emphasised voluntary participation and provided complete information about the study. Confidentiality was ensured by setting the following ground rules for the focus group discussion: (1) Information said in the group should not be divulged to anyone; (2) Participants will be identified by codes instead of names; (3) Respect for individual points of view had to prevail throughout the discussions. The participants received assurance that any form of identifiable data will be kept safe and private and will not be exposed to unauthorised people. Beneficence entails that the participants should be protected from emotional and physical harm throughout the research process [16&17]. In this study, emotional harm was minimised by explaining to the participants that they are free to withdraw from the study if they feel uncomfortable. Physical and emotional fatigue was minimised by taking a 5–10 minute break to avoid prolonged interviews. The principle of justice refers to the participants’ right to fair recruitment, selection, and treatment throughout the research process [16]. The mediators of the study explained the aim of the study, the benefits and how any physical and emotional risks would be avoided. 3 Results Fifteen participants consented to take part in the study on the use of OSCE at a university in the North West province of South Africa. Fourteen of the participants were females and one was a male. One focus group interview was conducted on each campus. The total number of participants on Campus A was eight and on Campus B seven participated. The participants were representative of nurse educators across all year levels of the undergraduate nursing programme. Table 1.1 depicts the themes that emerged from raw data Four broad themes with categories and subcategories emerged from data. These were: (1) the perceived impact of OSCE on students; (2) poor integration of theory and practice, (3) the experiences of nurse educators with the planning and implementation of OSCE; and (4) strategies to improve the planning and implementation of OSCE. The themes divided into categories and subcategories as indicated in the table. Broad theme Category Subcategory 1. Perceived impact of OSCE on students 1.1. Emotional and psychological distress 1.1.1. Stressful environment 1.1.2. Fear of unknown and anxiety 1.1.3. Negative attitudes among the assessors 1.2. Challenges with the implementation of OSCE 1.2.1. The focus is on how the student performs a skill 1.2.2. Unclear instructions at the stations 3. Poor integration of theory and practice 2.1. Encourages route learning 2.1.1. Narrating versus demonstrating a skill 2.1.2. Cramming of the specific assessment tool 4. Experiences of nurse educators with the planning and implementation of OSCE 3.1. Physical and psychological strain 3.1.1. Examiner fatigue and frustrations on the day of OSCE 3.1.2. Disagreement about the tools 3.2. Systemic challenges 3.2.1. Lack of human and material resources 3.2.2. Pressure related to the alignment issues 3.2.3. Opposing views and ideas on planning, organising and implementation of OSCE 3.3. Advantages of OSCE 3.3.1. Promotes self-reflection and evaluation by nurse educators 3.3.2. Enables evaluation and improvement of clinical assessment tools 6. Strategies to improve the planning and implementation of OSCE 4.1. Management should provide more support 4.1.1. Management must ensure there are enough venues to house the OSCE 4.1.2. Management should increase the budget for the clinical materials needed for OSCE 4.1.3. Lecturers and clinical preceptors should be trained on clinical assessment 4.1.4. Train simulated/standardised patients 4.2. The manner of planning and implementing OSCE should improve 4.2.1. Conduct quality examiner calibration and piloting of stations before OSCE sessions 4.2.2. Ensure that station instructions are clear and specific to the type of skill being assessed 4.2.3. Feedback from student 4.2.4. Revision of academic rule 4.2.5 Avoid giving students clues 3.1 Theme 1: The perceived impact of OSCE on students During data analysis the perceived impact of OSCE on students emerged as a theme with the following categories: (1) emotional and psychological distress; (2) challenges with the implementation of OSCE. The categories of Theme 1 are supported by the subcategories and quotes below. 3.1.1 Emotional and psychological distress During the discussions, the nurse educators reported that students experience emotional and psychological distress during OSCE. The subcategories that support this category are the stressful environment; fear of the unknown and anxiety; and negative attitudes among the assessors. Stressful environment The nurse educators reported that OSCE creates a stressful environment for students. One of the participant said: They are really, really stressed out about the evaluations and it depends on how you handle them, if you lower the stress or if you increase the stress. Another participant said: They don't always know what to expect. And yes, I think the uncertainty makes it for them very stressful. Fear of the unknown and anxiety The participants indicated that the nursing students experience a fear of the unknown and anxiety. One participant remarked: I've noticed that most of them, they'll be haphazard and anxious, forgetting the important points. Another participant said: I think the other factor that the students experience, it might be anxiety. It's just the fear of unknown, even though they know the procedures. Negative attitudes among the assessors The participants reported negative attitudes among assessors and said: We need to talk about attitude as well. Because you will find that student that comes out crying out of the same station and it's attitude of the evaluator. Another participant put it in this way: When we do debrief with them, they talk about the assessors being sort of harsh towards them. Harshness through their looks, not only harsh words. 3.1.2 Challenges with the implementation of OSCE During data collection, the participants reported challenges with the implementation of OSCE. The challenges fall into two subcategories. The focus is on how the student performs a skill One participant commented as follows about the focus of a : We focus on how the student will demonstrate their skill, forgetting the emotional and psychological aspect of the student. Another participant put it in this manner: For the fact that we are not considering their emotional and psychological aspect brings a problem when it comes to OSCE. Unclear instructions at the station Participants reported unclear instructions as follows: Students, should be instructed clearly on what is being tested at the specific station. Another participant remarked: The outcome for your specific station should be stipulated clearly on what is actually being tested in that specific station. 3.2 Theme 2: Poor integration of theory and practice The poor integration of theory and practice emerged as a theme. Participants reported that this lack of integration encourages route learning. 3.2.1 Encourage route learning The subcategories that emerged from this category are: (1) narrating versus demonstrating the skill; and (3) cramming of the specific assessment tool. Narrating versus demonstrating the skill One participant commented as follows: You'll find that the student has a lot of information, but she wants to narrate the practical part. Another one explained: They just narrate what is on the tool and they want to get it over and done with. However, what we want to see is the skill. Cramming of the specific assessment tool One participant remarked: I've noticed that students have been told on what they're going to be assessed on, of which they cram that clinical assessment tool and come to the assessment. Another one put it in this way: To my view or experience is that the student will be cramming the specific clinical skills that will be OSCE, but not other skills. 3.3 Theme 3: The experiences of nurse educators with the planning and implementation of OSCE The categories that emerged from theme three are: (1) physical and psychological strain; (2) systemic challenges; and (3) the advantages of OSCE. 3.3.1 Physical and psychological strain During data collection the nurse educators reported that they experienced physical and psychological strain. This theme divided into two subcategories. Examiner fatigue and frustration on the day of OSCE The participants referred as follows to examiner fatigue: OSCE can be tiring at times. I mean, for the fact that we sometimes start OSCE from 8 o'clock until 7 o'clock in the evening. Another participant said: When I think of an OSCE it’s really a chaos, frustrations, because there’s so much planning that must go into it. Disagreement about the tools Participants highlighted that there is sometimes disagreement about the tools: It’s also stressing and then you get those people who would come and somehow critique your document on the day of the OSCE. Another one said: Someone who is not part of the module will come and say but this could have been done better this way or something like that. 3.3.2 Systemic challenges The systemic challenges are reported under the following subcategories: Lack of human and material resources One participant referred to the challenges with human resources: And someone will not pitch. Some of the evaluators. And you must restructure everything. Another one pointed out: The shortage of exam documents also put a stress on you. shortages of papers. Pressure related to the alignment issues One of the participants expressed frustration with the pressures to align assessment across campuses: With the new curriculum……. It's aligned on paper, some of the things are not aligned so there is that pressure in terms of working together. Another participant explained: The other campus will be relaxed because they don't have to do any paper translation and send things for moderation even after translation to see that everything is still fine. Opposing views and ideas on planning, organising and implementing OSCE Opposing views on planning, organising and implementing OSCEs emerged as follows: There must be at least three domains the cognitive, the affective and the psychomotor. But sometimes we find that this tool is focusing only on communication skill. Another participant said: Sometimes we give a mark for greeting the patient and identifying the patient but that is not actually the skills that actually need to be tested in that specific station . Another participant put it in this way: It doesn't feel humane because the student just goes straight into the implementation without greeting the patient and they don't see other aspect. This was contradicted by a participant who argued: What is identifying and greeting the patient actually having to do with the technical skill of actually being able to do an abdominal palpation? 3.3.3 The advantages of OSCE During the discussions with the participants, the advantages of OSCE were also addressed. Promotes self-reflection and evaluation among nurse educators One of the participants highlighted that: The OSCE is sort of self-reflect on what we are evaluating and what we taught the students yeah that’s my opinion. Another participant put it this way: I think with OSCE we do examine ourselves on the skills presented to the student. Enables evaluation and improvement of clinical assessment tools One participant remarked: It also gives us an opportunity to evaluate ourselves in terms of the very tools that we are using. Another participant reiterated: OSCE shows us whether the tools need some improvement or not. 3.4 Theme 4: Strategies to improve the planning and implementation of OSCE 3.4.1 Management should provide more support Participants’ need for more support from management is reported in the following subcategories: Management must ensure that there are enough venues to house the OSCE One of the participants said: We need more space. Another added: The space we have is limited to accommodate the number of students and stations. Increase the budget for the clinical materials needed for OSCE One participant pointed out: The budget must change the technology, please. We need more money. Another participant reiterated: If we could use technology when assessing, like using tablets. I know there's software available when you do your assessment of your patient on a tablet. It also calculates the marks for you. Training of lecturers and clinical preceptors on clinical assessment One participant highlighted the importance of training: “I think the best thing is to maybe go for, there should be workshops on clinical evaluation”. Another participant put it as follows: And if we all go through training regarding OSCE’s, the planning, preparation, implementation, and evaluation. Train simulated/standardised patients One of the participants made the following suggestion: I think it will be credible if we can train simulated patients. Another participant explained: If ever we can have standardised patients, it will be a little bit better so that the student does not speak to himself. 3.4.2 Improve the planning and implementing of OSCE Participants pointed to a need to improve the planning and implementation of OSCE. The subcategories discussed below address this matter. Conduct quality examiner calibration and piloting of stations before OSCE sessions One participant commented as follows: Examiner calibration, this is where you brief your examiners in the beginning and everyone must be briefed in the same way. Another participant put it in this way: The day before the OSCE when you set up your stations to not just set up, but actually pilot a station. Ensure that station instructions are clear and specific to type of skill assessed One participant indicated that: The instructions in the scenarios should be clear to student and lecturers. The same phenomenon was addressed differently as another participant said: The student should not stand without knowing what to do. I think the instruction must be very clear to them. Feedback from students Participants made the following suggestion for student feedback: Maybe we can have a survey or an evaluation tool that they can use to rate how was the OSCE, rating themselves, also rating the environment, rating even the assessors so that we can be able to improve. Revision of academic rule Participants identified the academic rules of the institution as being problematic: With A rule, if a student fails one station, they fail the whole OSCE which is unfair to students. Another participant emphasised the same view: Well, then the rules need to be revised because it's not fair. It's not right. Avoid giving students clues Participants identified clues to students as one of the problems: Sometimes even the assessors are leading the students, whereas we are there to assess, not to lead the student. Another one said: Lecturers should avoid giving clues to students during OSCE. 4 Discussion The study’s findings reveal that participants largely experience OSCE negatively. This became evident from the themes that emerged, including emotional and psychological distress, fear of the unknown and anxiety, and negative attitudes among the assessors. The negative attitude of assessors became evident during the use of OSCE, as some of the students would exit some of the stations crying. Furthermore, some assessors have been found to be harsh with students during OSCE. The findings of one study [18] reported that 65% of student participants revealed that the way in which the examiners looked at them during the exam could either increase or decrease their confidence during OSCE. They stated this as a so-called “negative”. The participants in this study revealed a need for training to address the attitude of assessors during the use of OSCE. Additionally, the participants perceived challenges with the implementation of OSCE, which in turn affect students. Participants reported that the assessors focus on the performance of the relevant skill during OSCE, which causes them to disregard the emotional and psychological aspects of the students. Furthermore, unclear instruction at the stations emerged as a challenge that affects the performance of students. Different to what was said by the participants of this study, one of the available studies reported that the students experience OSCE positively because it promotes self-assessment on the skills demonstrated to them [19]. Participants in this study commented on poor integration of theory and practice as a result of OSCE. They felt that the use of OSCE encourages route learning. This took the form of students narrating skills instead of demonstration them during OSCE. Some students crammed the specific assessment tool. The participants reported that students got into the habit of cramming a tool was because they were told what they will be assessed on. Another research discovered that there are a variety of factors that influence the integration of theory and practice in clinical skills attainment, such as a lack of suitable resources, lack of proper guidance, and inadequate time for practice [20]. The participants in this study reported physical and psychological strain due to examiner fatigue and frustrations on the day of OSCE. The fatigue and frustrations were caused by rigorous preparation before OSCE and at times assessing students from the morning until late in the evening. The participants reported that they sometimes disagreed on the tools on the day of OSCE, resulting in psychological strain. They also reported systemic challenges during the use of OSCE. This is evidenced by lack of human and material resources, pressure related to the alignment issues, and opposing views and ideas on planning, organising and implementing OSCE. One of the studies found that OSCE is physically demanding, and it is necessary to invest more time in the preparation and organisation of the exam. OSCE also creates a competitive atmosphere, and some educators find it stressful [21]. The participants in the current study did experience some advantages to OSCE. They pointed out that the use of OSCE promotes self- reflection and evaluation among nurse educators. Additionally, in their view, OSCE enables evaluation and the improvement of clinical assessment tools. The same was reported in a study [21] that reported OSCE as being a powerful tool to assess the adequacy and relevancy of the assessment instruments. The participants in the current study suggested strategies to improve the planning and implementation of OSCE. They suggested that management should give more support by ensuring that there are enough venues to house OSCE. They also made a case for the budget for the clinical materials needed for OSCE to be increased. Some participants called for the training of nurse educators and clinical preceptors on clinical assessment. Another recommendation centred on the use of simulated or standardised patients. The participants made an appeal for improved planning and implementation of OSCE. They pointed out that there is a need for quality examiner calibration and piloting of stations before OSCE. Additionally, the participant also reiterated that the instructions at stations should be clear and specific to the type of skill assessed. This theme was addressed by another study, which recommended that the management should develop a plan to enhance the implementation of OSCE [20]. The participants in this study suggested that student feedback could improve the use of OSCE. The same finding appears in literature as it is reported that students indicated that their feedback was valuable to nurse educators as it improved the implementation of OSCE [19]. The participants in this study also contended that the academic rule (A rule) should be revised. The participants felt it unfair that a student would fail if they failed one station of out of 6 stations. Lastly, participants warned that the assessors should avoid giving student clues when they have to perform the skill to ensure fairness across the board. 4.1 Limitations The study was conducted on the two campuses of the North-West University in South Africa using a qualitative explorative and descriptive design. The study can therefore not be generalised to the other institution of higher learning. One of the campuses of the North-West University in South Africa does not offer an undergraduate nursing programme, so the findings are limited to the two campuses involved in the study. 4.2 Conclusions Based on the findings of the study, the management of the nursing schools on the two campuses should ensure that the clinical budget is increased and that there is transparency. This could help with the provision of standardised patients and adequate facilities during OSCE. The increased budget could also be used to train nurse educators and preceptors on the planning and implementation of OSCE. The budget should leave room for the use of improved technology, with specific reference to a tablet. This could reduce the extra work of manual calculation of marks by nurse educators after OSCE. The quality of OSCE can be improved by considering student feedback on the experience. For further improvement, the nurse educators responsible for each clinical module must ensure that the stations are piloted, and examiner calibration is done before assessments. The management of the nursing schools on both campuses should advocate for the revision of the academic rule that governs the practical examination of nursing students. Abbreviations NWU North West University OSCE Objective Structured Clinical Evaluation SANC South African Nursing Council Declarations Author contributions Drafting and writing of the whole manuscript: MG Serapelwane, OI Mokgaola. MG Serapelwane is the corresponding author. Funding The study was funded by theNorth-West University under Scholarship of Teaching and Learning. Data availability statement The original data is available upon request from the corresponding author. Ethical approval and consent to participate The study was approved by theHealth Research Ethics Committee (NWU-00015-23-A1) and Research Data Gatekeeper Committee (NWU-GK-23-146).All the participants we informed about the purpose of the study and signed the consent form to show voluntary participation. Consent for publication Consent for publication was gained from the study participants, who offered their consent for publication when they signed the informed consent for participation in the study. Competing interest The authors declare no competing interests. References Zayyan N. Objective structured clinical examination: The assessment of choice. Oman Medical Journal. 2011 , 26: 219–222. Rao P. Objective structured clinical examination (OSCE) nursing teacher and student perception: A systemic review. Journal of Nursing and Health Science (IOSR-JNHS). 2021 , 10: 2320–1940. Gawade S. Students’ evaluation of an observed structured clinical evaluation (OSCE) in community health nursing clinical practice. Asian Journal of Nursing Education and Research. 2018, 8: 278–281. https://doi.org/10.5958/2349-2996.2018.00054.X Marcyjanik L. Senior baccalaureate nursing students' clinical competence and objective structured clinical examination. Ph.D. dissertation, 2016. Capella University, Minneapolis, USA. Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. British Medical Journal. 1975 . 1:447–451. https://doi.org/10.1136/bmj.1.5955.447 PMid:1115966 PMCid:PMC1672423 Llaguno, M.B.B.; Ablao, J.N.; Domantay, A.; Cancino, E.C. Evaluation of the objective structured clinical examination by the nursing students. International Journal of Advanced and Applied Sciences. 2023. 11: 1. http://www.science-gate.com/IJAAS,html Anh NTL. Linhi BK. The perception and satisfaction of final-year nursing students with objective structured clinical examination (OSCE) . https://vame.org.vn/Images/Content/6.Phien%201_Fulltext_Nguyen_Thi_Lan_Anh_OSCE_HMU Ha EH, Lim E. The effect of objective structured clinical examinations for nursing students. PLoS ONE. 2023, 18:6. e028678 https://doi.org/10.1371/journal.pone.0286787 Kattil S, Manju SS, Varkey E. OSCE: Nursing students’ perception, satisfaction and feedback. The Nursing Journal of India, 2022. https://www.tnaijournal-nji.com Mongale RS, Rakhudu M A, Matsipane MJ. Perceptions of nursing students on clinical assessment in the selected nursing education institutions of the North-West province. MA dissertation, 2023. North-West University, South Africa. Brink H, Van der Walt C, Van Rensburg Fundamentals of Research Methodology for Health Care Professionals. 4 th ed. Juta, 2018. Polit D F, Beck BT. Essentials of nursing research. Appraising evidence for nursing. 9th ed. Wolters Kluwer 2018 . Creswell JW. Research design: Qualitative, quantitative and mixed methods approaches. 3rd ed. Sage 2014. Krefting L. Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy. 1991, 45: 214–222. Johnson, S.; Rasulova, S. Qualitative impact evaluation: Incorporating authenticity into the assessment of rigour. 2016, University of Bath. Klopper, H. The qualitative research proposal. Curationis. 2008, 31:62–72. doi: https://doi.org/10.4102/curationis.v31i4.1062 Grove S, Gray S, Burns N. Building an evidence-based practice. 6 th Saunders 2016. Raziani Y, Nazari A, Raziani S. Nursing students’ experiences with the objective structured clinical examination (OSCE): A qualitative study. International Journal of Africa Nursing Sciences . 2022, 16: 100433. Sola-Pola M, Morin-Fraile V, Fabrellas-Pasres N, Raurell-Torreda M, Raurell-Torreda M, Guanter-Peris M, Guix-Comellas E, Pulpon-Segura E. The usefulness and acceptance of the OSCE in nursing schools. Nurse Education in Practice. 2020, 43: 102736. Fathi KY, Ibrahim RH, Factors influencing integration of theory into practice in clinical skills acquisition among nursing students. Informatics in Medicine Unlocked. 2023, 37:101181. Smrekar M, Ficko SL, Honsnjak AM, IIic, B. Use of the objective structured clinical examination in undergraduate nursing education. Croatian Nursing Journal. 2017, 1: 91–102. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 28 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 26 Oct, 2024 First submitted to journal 23 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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OSCE assesses competency using objective testing. Assessment relies on two examiners\u0026rsquo; direct observation of students. The set-up involves numerous stations where students are expected to perform a variety of clinical skills within a specified time [1]. OSCE is used in both undergraduate and postgraduate settings to offer a standardised and objective evaluation of the clinical skills that form the outcomes of a specific educational programme [2\u0026ndash;4]. OSCE helps the student to learn and to gain competence in the prescribed clinical skill [2\u0026ndash;4]. It was first introduced in 1970 to assess the skills of medical students and is currently used globally to also assess the clinical competency of nursing students [2\u0026amp;4].\u003c/p\u003e \u003cp\u003eThe findings of a study conducted at a universities in the north of India revealed that 27% of nurse educators and students experienced the use of OSCE in the simulation environment negatively [5]. This was evident from reports of anxiety and inability to complete skills because of the limited time at each station [5]. The same was reported in Saudi Arabia as the participants said that OSCEs are stressful compared to other examination methods due to factors like the complexity of tasks, the allocated time to perform the skill, and poorly designed stations [6]. Participants found the inability to communicate with dummies during practical examinations stressful [9]. Most of the participants were unsatisfied with OSCE [9]. The abovementioned studies reported on the negative effects of OSCE in the east and northern regions of Asia [5, 6 \u0026amp; 9]. It was therefore important for the current study to explore the use of OSCE at a university in the North West province of South Africa. The study in India relied on a systematic review and analysed quantitative research. It recommended a qualitative study to explore the broader view of the use of OSCE [5]. The recommendation of qualitative study bears evidence of a knowledge gap that could be addressed by a qualitative study that examines the experiences of nurse educators with the use of OSCE.\u003c/p\u003e \u003cp\u003eA study conducted in Vietnam reported the benefits of OSCE and said that students are fully aware of the nature and method of the examination. The study found that OSCE exposes the student to wide range of skills and helps the student gain confidence in clinical practice [7]. Additionally, the tasks that are normally included in OSCE are found to be relevant to sustain clinical competency [7]. A study conducted in Korea revealed that after lectures on clinical skills and core nursing skills practice, OSCE improved the retention of nursing students\u0026rsquo; knowledge [8]. Furthermore, the findings revealed that OSCE can strengthen student clinical competency. Another study reported that OSCE helped to identify the weakest areas of the students\u0026rsquo; competency [9]. The current study considers the reported benefits of OSCE as important to sustain. It is therefore important to gauge the experiences of nurse educators with the use of OSCE, in this case at a university in the North West province of South Africa. Two studies have been conducted in South Africa in the Western Cape and the North West provinces respectively, but neither addressed the experiences of nurse educators with the use of OSCE [9 \u0026amp; 10]. The finding bears testimony to the lack of published evidence on nurse educators\u0026rsquo; experiences with the use of OSCE [9 \u0026amp; 10]. The students who participated in the two mentioned studies revealed negative attitudes towards OSCE, with comments mentioning outdated mannequins, a lack of integration of theory and practice, and a need for OSCE with real-life patients [9\u0026amp;10]. The aim of the current study was therefore to explore and describe nurse educators\u0026rsquo; experiences with the use of OSCE on the selected campuses of the North-West University in the North West province of South Africa. The study offers recommendations to improve the use of OSCE on the selected campuses [9].\u003c/p\u003e"},{"header":"2 Design and methods","content":"\u003cp\u003eThe study adopted a qualitative, exploratory, descriptive and contextual research design. The qualitative, exploratory and descriptive study seeks to understand and describe the deeper meaning and the complexity of given phenomena or construct [11]. The chosen design was found to be most suited to a study that seeks to understand the experiences of nurse educators with the use of OSCE at two selected campuses of the university.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study setting\u003c/h2\u003e \u003cp\u003eThe study took place on two campuses of a university in the North West province of South Africa. The selected campuses both offer a basic nursing qualification and uses OSCE to assess the competence of nursing students. The two campuses have approximately 47 nurse educators who facilitate the teaching and learning, which includes the assessment of undergraduate nursing students. The two campuses are situated in the Ngaka Modiri Molema and Dr Kenneth Kaunda districts of the North West province of South Africa. The two campuses are denoted as Campus A and Campus B for the purpose of the discussion below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Population and sampling\u003c/h2\u003e \u003cp\u003eThe population for this study was the nurse educators on the two selected campuses. Site A has 21 and site B has 26 nurse educators who teach undergraduate students. A non-probability purposive sampling technique was used to select the participants. This purposive sampling technique is also called criterion-based sampling, as the researcher used set criteria to purposively select participants who are judged to have knowledge about the phenomenon that is under study [11]. The inclusion and exclusive criteria used to select the population of interest are listed below.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Inclusion criteria\u003c/h2\u003e \u003cp\u003eThe following inclusion criteria were applied for the selection of nurse educators.\u003c/p\u003e \u003cp\u003eNurse educators had to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eBe employed by the selected university to assess competency of students using OSCE;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBe registered with South African Nursing Council (SANC) as nurse educators since they are then by law permitted to assess the practical skills of nursing students;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHave participated in OSCE before as this would enable them to share their experiences and respond to the qualitative questions on their experiences with the use of OSCE; and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBe willing and consent to participate in this study because it is an ethics requirement for everyone to sign an informed consent form before being interviewed.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Exclusion criteria\u003c/h2\u003e \u003cp\u003eThe following exclusion criteria were applied to the nurse educators:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNurse educators who had never been involved in an OSCE were excluded.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Sample size and data saturation\u003c/h2\u003e \u003cp\u003eTwo focus group interviews were conducted during the study. Fifteen nurse educators participated and data collection stopped once no new information emerged from each group.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Recruitment of participants and data collection\u003c/h2\u003e \u003cp\u003e Goodwill permission was obtained from the Research Data Gatekeeper Committee, which enabled the researchers to commence with the recruitment of prospective participants. The process started after getting approval from the following research committees: (1) Quality in Nursing and Midwifery; (2) the Faculty of Health Sciences Centre for Health Professions; and the final approval from (3) the Faculty of Health Research Ethics Committee. Goodwill permission to conduct this research was also granted by the director of the School of Nursing, who acted as a gatekeeper for Campus A and B. The role of the school director was to appoint mediators for both campuses. The role of the mediators was to introduce the study to the nurse educators by convening a meeting to explain the study, thus recruiting potential participants. Another role of the mediators was to print flyers and to post them on the notice boards in the school buildings. The mediators for Campus A and B were administration clerks who did not have any direct power relationships with the nurse educators. An honours degree student not involved in teaching the students, was appointed as an independent person responsible for facilitating the signing of consent forms. The mediators gave those nurse educators who were interested in participating in the study consent forms to sign over a two-week period to ensure voluntary participation. The independent person and the researcher acted as witnesses for the nurse educators who signed the consent form.\u003c/p\u003e \u003cp\u003eThe focus group interviews were conducted by a research assistant who holds a doctoral degree and who is an experienced qualitative researcher. The research assistant guided the discussions using an interview guide with the following two broad questions: What are your experiences with the use of OSCE at the North West University (NWU) ? What could be done to improve the use of OSCE at the NWU.\u003c/p\u003e \u003cp\u003e Participants were asked to consent to the use of an audio recorder to capture the conversations and the interviews were conducted in English. The following communication techniques were used to get in-depth information: probing, reflection, paraphrasing and summarising [12]. The field notes that were taken during data collection include descriptive or observational, personal, methodological, and theoretical notes [12].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analyses\u003c/h2\u003e \u003cp\u003eThe eight steps of Tesch\u0026rsquo;s content analysis and open-coding process as outlined in Creswell were used for data analysis [13]. The steps were applied as follows: (1) the arrangement and preparation of data were accomplished through verbatim transcription of all interviews and typing of field notes; (2) researchers repeatedly read through the two transcripts and the field notes and focused on making a sense of the information by writing general thoughts on the data; (3) re-reading started with reading one interesting transcript and writing thoughts in the margin of the transcript; (4) all the topics that emerged from reading the transcripts were listed and similar topics were developed and grouped together and sorted into columns; (5) the topics were further narrowed into broad themes, categories and subcategories, and the codes were written next to the appropriate part of the text; (6) the researchers made a final decision about the main themes categories and subcategories; (7) the setting and the narrative of themes were described referring to educators and events during the use of OSCE; and (8) the researchers interpreted the research findings and compared the findings with the existing literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Trustworthiness\u003c/h2\u003e \u003cp\u003eThe trustworthiness of this study was ensured by applying the four principles of Lincoln and Guba\u0026rsquo;s model (1981), which are credibility, confirmability, dependability and transferability [14]. The strategies that were used to apply these principles are truth value, applicability, consistency, and neutrality. To enhance the credibility of this study, the strategy of truth value was applied by allowing prolonged engagement with the participants. The interviews lasted between 60 and 90 minutes. Breaks were provided after every 30 minutes to avoid exhaustion in participants. The principle of conformability was achieved by using the strategy of neutrality. In this regard, data from the proposed study were validated by an independent co-coder. The mechanism of scientific peer review was used to ensure dependability and consistency. The principle and strategy of transferability and applicability was ensured by (1) sufficient description of the place where the study took place to enable the reader to establish how transferable the results could be to other settings; (2) clear description of the research questions, purpose of the study and the aims and objectives; (3) discussion of the research design and methods, sampling as well as data collection and analysis; and (4) reporting the findings in a table form and discussing themes to reveal the experiences of nurse educators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e \u003cp\u003eThe principles of respect for persons, beneficence and justice were upheld in this study [16\u0026amp;17]. The decision of persons who were not willing to participate were respected. Additionally, an informed consent form was signed prior to participation and the researcher emphasised voluntary participation and provided complete information about the study. Confidentiality was ensured by setting the following ground rules for the focus group discussion: (1) Information said in the group should not be divulged to anyone; (2) Participants will be identified by codes instead of names; (3) Respect for individual points of view had to prevail throughout the discussions. The participants received assurance that any form of identifiable data will be kept safe and private and will not be exposed to unauthorised people. Beneficence entails that the participants should be protected from emotional and physical harm throughout the research process [16\u0026amp;17]. In this study, emotional harm was minimised by explaining to the participants that they are free to withdraw from the study if they feel uncomfortable. Physical and emotional fatigue was minimised by taking a 5\u0026ndash;10 minute break to avoid prolonged interviews. The principle of justice refers to the participants\u0026rsquo; right to fair recruitment, selection, and treatment throughout the research process [16]. The mediators of the study explained the aim of the study, the benefits and how any physical and emotional risks would be avoided.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eFifteen participants consented to take part in the study on the use of OSCE at a university in the North West province of South Africa. Fourteen of the participants were females and one was a male. One focus group interview was conducted on each campus. The total number of participants on Campus A was eight and on Campus B seven participated. The participants were representative of nurse educators across all year levels of the undergraduate nursing programme. Table\u0026nbsp;1.1 depicts the themes that emerged from raw data\u003c/p\u003e \u003cp\u003eFour broad themes with categories and subcategories emerged from data. These were: (1) the perceived impact of OSCE on students; (2) poor integration of theory and practice, (3) the experiences of nurse educators with the planning and implementation of OSCE; and (4) strategies to improve the planning and implementation of OSCE. The themes divided into categories and subcategories as indicated in the table.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBroad theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1. Perceived impact of OSCE on students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1. Emotional and psychological distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1.1. Stressful environment\u003c/p\u003e \u003cp\u003e1.1.2. Fear of unknown and anxiety\u003c/p\u003e \u003cp\u003e1.1.3. Negative attitudes among the assessors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2. Challenges with the implementation of OSCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2.1. The focus is on how the student performs a skill\u003c/p\u003e \u003cp\u003e1.2.2. Unclear instructions at the stations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Poor integration of theory and practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1. Encourages route learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1.1. Narrating versus demonstrating a skill\u003c/p\u003e \u003cp\u003e2.1.2. Cramming of the specific assessment tool\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4. Experiences of nurse educators with the planning and implementation of OSCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1. Physical and psychological strain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1.1. Examiner fatigue and frustrations on the day of OSCE\u003c/p\u003e \u003cp\u003e3.1.2. Disagreement about the tools\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2. Systemic challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2.1. Lack of human and material resources\u003c/p\u003e \u003cp\u003e3.2.2. Pressure related to the alignment issues\u003c/p\u003e \u003cp\u003e3.2.3. Opposing views and ideas on planning, organising and implementation of OSCE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3. Advantages of OSCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3.1. Promotes self-reflection and evaluation by nurse educators\u003c/p\u003e \u003cp\u003e3.3.2. Enables evaluation and improvement of clinical assessment tools\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6. Strategies to improve the planning and implementation of OSCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1. Management should provide more support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1.1. Management must ensure there are enough venues to house the OSCE\u003c/p\u003e \u003cp\u003e4.1.2. Management should increase the budget for the clinical materials needed for OSCE\u003c/p\u003e \u003cp\u003e4.1.3. Lecturers and clinical preceptors should be trained on clinical assessment\u003c/p\u003e \u003cp\u003e4.1.4. Train simulated/standardised patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2. The manner of planning and implementing OSCE should improve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2.1. Conduct quality examiner calibration and piloting of stations before OSCE sessions\u003c/p\u003e \u003cp\u003e4.2.2. Ensure that station instructions are clear and specific to the type of skill being assessed\u003c/p\u003e \u003cp\u003e4.2.3. Feedback from student\u003c/p\u003e \u003cp\u003e4.2.4. Revision of academic rule\u003c/p\u003e \u003cp\u003e4.2.5 Avoid giving students clues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Theme 1: The perceived impact of OSCE on students\u003c/h2\u003e \u003cp\u003eDuring data analysis the perceived impact of OSCE on students emerged as a theme with the following categories: (1) emotional and psychological distress; (2) challenges with the implementation of OSCE. The categories of Theme 1 are supported by the subcategories and quotes below.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Emotional and psychological distress\u003c/h2\u003e \u003cp\u003eDuring the discussions, the nurse educators reported that students experience emotional and psychological distress during OSCE. The subcategories that support this category are the stressful environment; fear of the unknown and anxiety; and negative attitudes among the assessors.\u003c/p\u003e \u003cp\u003eStressful environment\u003c/p\u003e \u003cp\u003eThe nurse educators reported that OSCE creates a stressful environment for students. One of the participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThey are really, really stressed out about the evaluations and it depends on how you handle them, if you lower the stress or if you increase the stress.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThey don't always know what to expect. And yes, I think the uncertainty makes it for them very stressful.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFear of the unknown and anxiety\u003c/p\u003e \u003cp\u003eThe participants indicated that the nursing students experience a fear of the unknown and anxiety. One participant remarked:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI've noticed that most of them, they'll be haphazard and anxious, forgetting the important points.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think the other factor that the students experience, it might be anxiety. It's just the fear of unknown, even though they know the procedures.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNegative attitudes among the assessors\u003c/p\u003e \u003cp\u003eThe participants reported negative attitudes among assessors and said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe need to talk about attitude as well. Because you will find that student that comes out crying out of the same station and it's attitude of the evaluator.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant put it in this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we do debrief with them, they talk about the assessors being sort of harsh towards them.\u003c/p\u003e\u003cp\u003eHarshness through their looks, not only harsh words.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Challenges with the implementation of OSCE\u003c/h2\u003e \u003cp\u003eDuring data collection, the participants reported challenges with the implementation of OSCE. The challenges fall into two subcategories.\u003c/p\u003e \u003cp\u003eThe focus is on how the student performs a skill\u003c/p\u003e \u003cp\u003eOne participant commented as follows about the focus of a :\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe focus on how the student will demonstrate their skill, forgetting the emotional and psychological aspect of the student.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant put it in this manner:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor the fact that we are not considering their emotional and psychological aspect brings a problem when it comes to OSCE.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnclear instructions at the station\u003c/p\u003e \u003cp\u003eParticipants reported unclear instructions as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStudents, should be instructed clearly on what is being tested at the specific station.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant remarked:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe outcome for your specific station should be stipulated clearly on what is actually being tested in that specific station.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Theme 2: Poor integration of theory and practice\u003c/h2\u003e \u003cp\u003eThe poor integration of theory and practice emerged as a theme. Participants reported that this lack of integration encourages route learning.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Encourage route learning\u003c/h2\u003e \u003cp\u003eThe subcategories that emerged from this category are: (1) narrating versus demonstrating the skill; and (3) cramming of the specific assessment tool.\u003c/p\u003e \u003cp\u003eNarrating versus demonstrating the skill\u003c/p\u003e \u003cp\u003eOne participant commented as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYou'll find that the student has a lot of information, but she wants to narrate the practical part.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother one explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey just narrate what is on the tool and they want to get it over and done with. However, what we want to see is the skill.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCramming of the specific assessment tool\u003c/p\u003e \u003cp\u003eOne participant remarked:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI've noticed that students have been told on what they're going to be assessed on, of which they cram that clinical assessment tool and come to the assessment.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother one put it in this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTo my view or experience is that the student will be cramming the specific clinical skills that will be OSCE, but not other skills.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Theme 3: The experiences of nurse educators with the planning and implementation of OSCE\u003c/h2\u003e \u003cp\u003eThe categories that emerged from theme three are: (1) physical and psychological strain; (2) systemic challenges; and (3) the advantages of OSCE.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Physical and psychological strain\u003c/h2\u003e \u003cp\u003eDuring data collection the nurse educators reported that they experienced physical and psychological strain. This theme divided into two subcategories.\u003c/p\u003e \u003cp\u003eExaminer fatigue and frustration on the day of OSCE\u003c/p\u003e \u003cp\u003eThe participants referred as follows to examiner fatigue:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOSCE can be tiring at times. I mean, for the fact that we sometimes start OSCE from 8 o'clock until 7 o'clock in the evening.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I think of an OSCE it\u0026rsquo;s really a chaos, frustrations, because there\u0026rsquo;s so much planning that must go into it.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDisagreement about the tools\u003c/p\u003e \u003cp\u003eParticipants highlighted that there is sometimes disagreement about the tools:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt\u0026rsquo;s also stressing and then you get those people who would come and somehow critique your document on the day of the OSCE.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother one said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSomeone who is not part of the module will come and say but this could have been done better this way or something like that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Systemic challenges\u003c/h2\u003e \u003cp\u003eThe systemic challenges are reported under the following subcategories:\u003c/p\u003e \u003cp\u003eLack of human and material resources\u003c/p\u003e \u003cp\u003eOne participant referred to the challenges with human resources:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd someone will not pitch. Some of the evaluators. And you must restructure everything.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother one pointed out:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe shortage of exam documents also put a stress on you. shortages of papers.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePressure related to the alignment issues\u003c/p\u003e \u003cp\u003eOne of the participants expressed frustration with the pressures to align assessment across campuses:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWith the new curriculum\u0026hellip;\u0026hellip;. It's aligned on paper, some of the things are not aligned so there is that pressure in terms of working together.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe other campus will be relaxed because they don't have to do any paper translation and send things for moderation even after translation to see that everything is still fine.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOpposing views and ideas on planning, organising and implementing OSCE\u003c/p\u003e \u003cp\u003eOpposing views on planning, organising and implementing OSCEs emerged as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere must be at least three domains the cognitive, the affective and the psychomotor. But sometimes we find that this tool is focusing only on communication skill.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSometimes we give a mark for greeting the patient and identifying the patient but that is not actually the skills that actually need to be tested in that specific station\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant put it in this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt doesn't feel humane because the student just goes straight into the implementation without greeting the patient and they don't see other aspect.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis was contradicted by a participant who argued:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhat is identifying and greeting the patient actually having to do with the technical skill of actually being able to do an abdominal palpation?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 The advantages of OSCE\u003c/h2\u003e \u003cp\u003eDuring the discussions with the participants, the advantages of OSCE were also addressed.\u003c/p\u003e \u003cp\u003ePromotes self-reflection and evaluation among nurse educators\u003c/p\u003e \u003cp\u003eOne of the participants highlighted that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe OSCE is sort of self-reflect on what we are evaluating and what we taught the students yeah that\u0026rsquo;s my opinion.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant put it this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think with OSCE we do examine ourselves on the skills presented to the student.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEnables evaluation and improvement of clinical assessment tools\u003c/p\u003e \u003cp\u003eOne participant remarked:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt also gives us an opportunity to evaluate ourselves in terms of the very tools that we are using.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant reiterated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOSCE shows us whether the tools need some improvement or not.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Theme 4: Strategies to improve the planning and implementation of OSCE\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Management should provide more support\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; need for more support from management is reported in the following subcategories:\u003c/p\u003e \u003cp\u003eManagement must ensure that there are enough venues to house the OSCE\u003c/p\u003e \u003cp\u003eOne of the participants said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe need more space.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother added:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe space we have is limited to accommodate the number of students and stations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIncrease the budget for the clinical materials needed for OSCE\u003c/p\u003e \u003cp\u003eOne participant pointed out:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe budget must change the technology, please. We need more money.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant reiterated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf we could use technology when assessing, like using tablets. I know there's software available when you do your assessment of your patient on a tablet. It also calculates the marks for you.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTraining of lecturers and clinical preceptors on clinical assessment\u003c/p\u003e \u003cp\u003eOne participant highlighted the importance of training:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think the best thing is to maybe go for, there should be workshops on clinical evaluation\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother participant put it as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd if we all go through training regarding OSCE\u0026rsquo;s, the planning, preparation, implementation, and evaluation.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTrain simulated/standardised patients\u003c/p\u003e \u003cp\u003eOne of the participants made the following suggestion:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think it will be credible if we can train simulated patients.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf ever we can have standardised patients, it will be a little bit better so that the student does not speak to himself.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Improve the planning and implementing of OSCE\u003c/h2\u003e \u003cp\u003eParticipants pointed to a need to improve the planning and implementation of OSCE. The subcategories discussed below address this matter.\u003c/p\u003e \u003cp\u003eConduct quality examiner calibration and piloting of stations before OSCE sessions\u003c/p\u003e \u003cp\u003eOne participant commented as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eExaminer calibration, this is where you brief your examiners in the beginning and everyone must be briefed in the same way.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant put it in this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe day before the OSCE when you set up your stations to not just set up, but actually pilot a station.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEnsure that station instructions are clear and specific to type of skill assessed\u003c/p\u003e \u003cp\u003eOne participant indicated that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe instructions in the scenarios should be clear to student and lecturers.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe same phenomenon was addressed differently as another participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe student should not stand without knowing what to do. I think the instruction must be very clear to them.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFeedback from students\u003c/p\u003e \u003cp\u003eParticipants made the following suggestion for student feedback:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMaybe we can have a survey or an evaluation tool that they can use to rate how was the OSCE, rating themselves, also rating the environment, rating even the assessors so that we can be able to improve.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRevision of academic rule\u003c/p\u003e \u003cp\u003eParticipants identified the academic rules of the institution as being problematic:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWith A rule, if a student fails one station, they fail the whole OSCE which is unfair to students.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant emphasised the same view:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWell, then the rules need to be revised because it's not fair. It's not right.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAvoid giving students clues\u003c/p\u003e \u003cp\u003eParticipants identified clues to students as one of the problems:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSometimes even the assessors are leading the students, whereas we are there to assess, not to lead the student.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother one said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLecturers should avoid giving clues to students during OSCE.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe study\u0026rsquo;s findings reveal that participants largely experience OSCE negatively. This became evident from the themes that emerged, including emotional and psychological distress, fear of the unknown and anxiety, and negative attitudes among the assessors. The negative attitude of assessors became evident during the use of OSCE, as some of the students would exit some of the stations crying. Furthermore, some assessors have been found to be harsh with students during OSCE. The findings of one study [18] reported that 65% of student participants revealed that the way in which the examiners looked at them during the exam could either increase or decrease their confidence during OSCE. They stated this as a so-called \u0026ldquo;negative\u0026rdquo;. The participants in this study revealed a need for training to address the attitude of assessors during the use of OSCE. Additionally, the participants perceived challenges with the implementation of OSCE, which in turn affect students. Participants reported that the assessors focus on the performance of the relevant skill during OSCE, which causes them to disregard the emotional and psychological aspects of the students. Furthermore, unclear instruction at the stations emerged as a challenge that affects the performance of students. Different to what was said by the participants of this study, one of the available studies reported that the students experience OSCE positively because it promotes self-assessment on the skills demonstrated to them [19].\u003c/p\u003e \u003cp\u003eParticipants in this study commented on poor integration of theory and practice as a result of OSCE. They felt that the use of OSCE encourages route learning. This took the form of students narrating skills instead of demonstration them during OSCE. Some students crammed the specific assessment tool. The participants reported that students got into the habit of cramming a tool was because they were told what they will be assessed on. Another research discovered that there are a variety of factors that influence the integration of theory and practice in clinical skills attainment, such as a lack of suitable resources, lack of proper guidance, and inadequate time for practice [20].\u003c/p\u003e \u003cp\u003eThe participants in this study reported physical and psychological strain due to examiner fatigue and frustrations on the day of OSCE. The fatigue and frustrations were caused by rigorous preparation before OSCE and at times assessing students from the morning until late in the evening. The participants reported that they sometimes disagreed on the tools on the day of OSCE, resulting in psychological strain. They also reported systemic challenges during the use of OSCE. This is evidenced by lack of human and material resources, pressure related to the alignment issues, and opposing views and ideas on planning, organising and implementing OSCE. One of the studies found that OSCE is physically demanding, and it is necessary to invest more time in the preparation and organisation of the exam. OSCE also creates a competitive atmosphere, and some educators find it stressful [21]. The participants in the current study did experience some advantages to OSCE. They pointed out that the use of OSCE promotes self- reflection and evaluation among nurse educators. Additionally, in their view, OSCE enables evaluation and the improvement of clinical assessment tools. The same was reported in a study [21] that reported OSCE as being a powerful tool to assess the adequacy and relevancy of the assessment instruments.\u003c/p\u003e \u003cp\u003eThe participants in the current study suggested strategies to improve the planning and implementation of OSCE. They suggested that management should give more support by ensuring that there are enough venues to house OSCE. They also made a case for the budget for the clinical materials needed for OSCE to be increased. Some participants called for the training of nurse educators and clinical preceptors on clinical assessment. Another recommendation centred on the use of simulated or standardised patients. The participants made an appeal for improved planning and implementation of OSCE. They pointed out that there is a need for quality examiner calibration and piloting of stations before OSCE. Additionally, the participant also reiterated that the instructions at stations should be clear and specific to the type of skill assessed. This theme was addressed by another study, which recommended that the management should develop a plan to enhance the implementation of OSCE [20]. The participants in this study suggested that student feedback could improve the use of OSCE. The same finding appears in literature as it is reported that students indicated that their feedback was valuable to nurse educators as it improved the implementation of OSCE [19]. The participants in this study also contended that the academic rule (A rule) should be revised. The participants felt it unfair that a student would fail if they failed one station of out of 6 stations. Lastly, participants warned that the assessors should avoid giving student clues when they have to perform the skill to ensure fairness across the board.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eThe study was conducted on the two campuses of the North-West University in South Africa using a qualitative explorative and descriptive design. The study can therefore not be generalised to the other institution of higher learning. One of the campuses of the North-West University in South Africa does not offer an undergraduate nursing programme, so the findings are limited to the two campuses involved in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Conclusions\u003c/h2\u003e \u003cp\u003eBased on the findings of the study, the management of the nursing schools on the two campuses should ensure that the clinical budget is increased and that there is transparency. This could help with the provision of standardised patients and adequate facilities during OSCE. The increased budget could also be used to train nurse educators and preceptors on the planning and implementation of OSCE. The budget should leave room for the use of improved technology, with specific reference to a tablet. This could reduce the extra work of manual calculation of marks by nurse educators after OSCE. The quality of OSCE can be improved by considering student feedback on the experience. For further improvement, the nurse educators responsible for each clinical module must ensure that the stations are piloted, and examiner calibration is done before assessments. The management of the nursing schools on both campuses should advocate for the revision of the academic rule that governs the practical examination of nursing students.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNWU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNorth West University\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOSCE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObjective Structured Clinical Evaluation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouth African Nursing Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Drafting and writing of the whole manuscript: MG Serapelwane, OI Mokgaola. MG Serapelwane is the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by theNorth-West University under Scholarship of Teaching and Learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original data is available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by theHealth Research Ethics Committee (NWU-00015-23-A1) and Research Data Gatekeeper Committee (NWU-GK-23-146).All the participants we informed about the purpose of the study and signed the consent form to show voluntary participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was gained from the study participants, who offered their consent for publication when they signed the informed consent for participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZayyan N. Objective structured clinical examination: The assessment of choice. Oman Medical Journal. 2011\u003cstrong\u003e,\u003c/strong\u003e 26: 219\u0026ndash;222.\u003c/li\u003e\n\u003cli\u003eRao P. Objective structured clinical examination (OSCE) nursing teacher and student perception: A systemic review. Journal of Nursing and Health Science (IOSR-JNHS). 2021\u003cstrong\u003e,\u003c/strong\u003e 10: 2320\u0026ndash;1940.\u003c/li\u003e\n\u003cli\u003eGawade S. Students\u0026rsquo; evaluation of an observed structured clinical evaluation (OSCE) in community health nursing clinical practice. Asian Journal of Nursing Education and Research. 2018, 8: 278\u0026ndash;281. https://doi.org/10.5958/2349-2996.2018.00054.X\u003c/li\u003e\n\u003cli\u003eMarcyjanik L. Senior baccalaureate nursing students' clinical competence and objective structured clinical examination. Ph.D. dissertation, 2016. Capella University, Minneapolis, USA.\u003c/li\u003e\n\u003cli\u003eHarden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. British Medical Journal. 1975\u003cstrong\u003e.\u003c/strong\u003e1:447\u0026ndash;451. https://doi.org/10.1136/bmj.1.5955.447 PMid:1115966 PMCid:PMC1672423\u003c/li\u003e\n\u003cli\u003eLlaguno, M.B.B.; Ablao, J.N.; Domantay, A.; Cancino, E.C. Evaluation of the objective structured clinical examination by the nursing students. International Journal of Advanced and Applied Sciences. 2023. 11: 1. http://www.science-gate.com/IJAAS,html\u003c/li\u003e\n\u003cli\u003eAnh NTL. Linhi BK. The perception and satisfaction of final-year nursing students with objective structured clinical examination (OSCE)\u003cstrong\u003e.\u003c/strong\u003ehttps://vame.org.vn/Images/Content/6.Phien%201_Fulltext_Nguyen_Thi_Lan_Anh_OSCE_HMU\u003c/li\u003e\n\u003cli\u003eHa EH, Lim E. The effect of objective structured clinical examinations for nursing students. PLoS ONE. 2023, 18:6. e028678 https://doi.org/10.1371/journal.pone.0286787\u003c/li\u003e\n\u003cli\u003eKattil S, Manju SS, Varkey E. OSCE: Nursing students\u0026rsquo; perception, satisfaction and feedback. The Nursing Journal of India, 2022. https://www.tnaijournal-nji.com\u003c/li\u003e\n\u003cli\u003eMongale RS, Rakhudu M A, Matsipane MJ. Perceptions of nursing students on clinical assessment in the selected nursing education institutions of the North-West province. MA dissertation, 2023. North-West University, South Africa. \u003c/li\u003e\n\u003cli\u003eBrink H, Van der Walt C, Van Rensburg Fundamentals of Research Methodology for Health Care Professionals. 4\u003csup\u003eth \u003c/sup\u003eed. Juta, \u003cstrong\u003e2018.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003ePolit D F, Beck BT. Essentials of nursing research. Appraising evidence for nursing. 9th ed. Wolters Kluwer 2018\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eCreswell JW. Research design: Qualitative, quantitative and mixed methods approaches. 3rd ed. Sage 2014.\u003c/li\u003e\n\u003cli\u003eKrefting L. Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy. 1991, 45: 214\u0026ndash;222.\u003c/li\u003e\n\u003cli\u003eJohnson, S.; Rasulova, S. Qualitative impact evaluation: Incorporating authenticity into the assessment of rigour. 2016, University of Bath.\u003c/li\u003e\n\u003cli\u003eKlopper, H. The qualitative research proposal. Curationis. 2008, 31:62\u0026ndash;72. doi: https://doi.org/10.4102/curationis.v31i4.1062\u003c/li\u003e\n\u003cli\u003eGrove S, Gray S, Burns N. Building an evidence-based practice. 6\u003csup\u003eth\u003c/sup\u003e Saunders 2016.\u003c/li\u003e\n\u003cli\u003eRaziani Y, Nazari A, Raziani S. Nursing students\u0026rsquo; experiences with the objective structured clinical examination (OSCE): A qualitative study. International Journal of Africa Nursing Sciences\u003cstrong\u003e. \u003c/strong\u003e2022, 16: 100433.\u003c/li\u003e\n\u003cli\u003eSola-Pola M, Morin-Fraile V, Fabrellas-Pasres N, Raurell-Torreda M, Raurell-Torreda M, Guanter-Peris M, Guix-Comellas E, Pulpon-Segura E. The usefulness and acceptance of the OSCE in nursing schools. Nurse Education in Practice. 2020, 43: 102736.\u003c/li\u003e\n\u003cli\u003eFathi KY, Ibrahim RH, Factors influencing integration of theory into practice in clinical skills acquisition among nursing students. Informatics in Medicine Unlocked. 2023, 37:101181.\u003c/li\u003e\n\u003cli\u003eSmrekar M, Ficko SL, Honsnjak AM, IIic, B. Use of the objective structured clinical examination in undergraduate nursing education. Croatian Nursing Journal. 2017, 1: 91\u0026ndash;102.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"nurse educators, university, nursing education institution, Objective Structured Clinical Evaluation","lastPublishedDoi":"10.21203/rs.3.rs-5318877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5318877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThere is an ongoing global debate on the reliability of Objective Structured Clinical Evaluation (OSCE) as an assessment method at nursing education institutions, and South Africa is not exempt. The purpose of this study was to explore and describe the experiences of nurse educators with the use of OSCE at a university in the North West province of South Africa.\u003c/p\u003e\u003ch2\u003eDesign and Methods:\u003c/h2\u003e \u003cp\u003eThe study applied a qualitative, explorative, descriptive, and contextual design. Purposive sampling was used to select nurse educators who were facilitating the teaching and learning of undergraduate nursing students. The study conducted two focus group interviews at two selected campuses. The Tesch\u0026rsquo;s eight steps of analysis were used to analyse the raw data. Trustworthiness was ensured by applying the principles of credibility, confirmability, dependability, and transferability. All ethics measures were upheld throughout the study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe themes that emerged from the findings include among others the perceived effect of OSCE on students. This was evident from the emotional and psychological distress and the challenges surrounding the implementation of OSCE.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIt is clear from the findings that the use of OSCE should be improved at the university in the North West province of South Africa.\u003c/p\u003e","manuscriptTitle":"Nurse educators’ experiences of the use of Objective Structured Clinical Evaluation (OSCE) at a university in South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 17:26:49","doi":"10.21203/rs.3.rs-5318877/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-28T08:34:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T06:18:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-26T06:42:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-10-23T12:17:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a13581d-c083-4de0-b6ba-075fce87f9b8","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T08:26:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-06 17:26:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5318877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5318877","identity":"rs-5318877","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}