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PubMed2006

Evaluating clinical competence of distant nurse practitioner students.

Developing and evaluating core clinical competencies of nurse practitioner students at distant clinical sites requires dialog among the student, the clinical preceptor and University faculty. Students enter our program with diverse backgrounds, experience and interests. Here we demonstrate an innovative online Clinical Development Scale (CDS) that gathers self assessment data from each student, analyzes, organizes and prioritizes competencies to be accomplished in a clinical practicum, produces midterm and final evaluation summaries from data contributed by both student and preceptor and displays action plans developed by students, for meeting deficient competencies for preceptor and faculty approval.

Clinical Competence↗
PubMed1992

Clinical competence of family physicians. The patient perspective.

OBJECTIVE: This study examines the attitudes and perceptions of patients regarding the clinical competence of family physicians. DESIGN: Telephone survey employing probability sampling (random-digit dialing). SETTING: A sample of adults living in Kentucky. PARTICIPANTS: Data come from a sample of 650 completed calls (64% response rate). MEASUREMENTS/MAIN RESULTS: Ninety-three percent of the patients reported having a physician who provides primary health care. Only 1% of those with a physician listed a specialist as their source of care. Patients generally agree that family physicians are clinically competent to handle common medical problems. Of 11 investigated conditions, depression and heart disease were the conditions with the lowest reported patient confidence. A stepwise logistic regression model indicated that the quality of care provided by one's primary care physician was the only significant predictor of patient confidence in the competence of family physicians. CONCLUSIONS: These results suggest that patients believe family physicians are competent to treat a wide variety of common medical problems.

Aged↗
PubMed1999

The relative contributions of interpersonal and specific clinical skills to the perception of global clinical competence.

BACKGROUND: The objective structured clinical examination (OSCE), an established instrument for evaluating resident competence, was used to test the hypothesis that faculty assessment of clinical competence in residents at various levels of training may be influenced more by general skills as a physician and less by competency in the actual skills being specifically tested. In this study, advantage was taken of the anticipated observation that general surgery residents did not demonstrate improvement in their ability to perform a focused neurological assessment over time. METHODS: An OSCE, which was administered to 56 general surgery residents at all levels of training, included the assessment of a specific clinical neurosurgical problem (sciatica). Univariate and multivariate analyses were used to evaluate the relationship between the global faculty judgment of competent or noncompetent and the other performance measures that were applied. RESULTS: At different levels of training, there was no observed difference in the specific skills being tested; nevertheless, junior and senior residents were more likely than incoming interns to be judged "competent" and received better evaluations of how well they introduced themselves to the patient. The competence judgment correlated significantly with all of the other performance measures, including the skills being tested. CONCLUSIONS: The perception of competence is not solely dependent upon the particular skills under scrutiny. General competence does not guarantee competence in each specific skill set of a medical specialty.

Clinical Competence↗
PubMed1998

Self-assessment of clinical competence by general practitioner trainees before and after a six-month psychiatric placement.

BACKGROUND: General practitioners (GPs) are responsible for managing the majority of mental health problems. There is evidence that the recognition and management of mental disorders could be improved. Vocational training schemes including a placement in psychiatry should be a prime opportunity to develop the requisite skills. AIM: To determine whether GP trainees thought that a six-month psychiatric placement had improved their clinical competence. METHOD: Questionnaires were sent to 18 junior doctors in the south-west region entering a senior house officer placement in psychiatry. Trainees rated their perceived competency in 20 skill areas at the beginning and at the end of six months. Comparisons between matched trainees were made using ranking techniques. RESULTS: There was a statistically significant improvement (P < 0.05) in perceived efficacy for matched trainees in 19 of the 20 areas of clinical competency appraised. The exception was in the confidence to identify different types of eating disorders. On completion of training, ability to diagnose depression, take a psychiatric history, and examine mental state were ranked most highly. However, skill levels in dealing with problems such as prescribing in acute psychosis and managing psychiatric emergencies were generally ranked above those dealing with neurotic and psychological problems. Most trainees indicated a favourable impression of their training experience. CONCLUSIONS: Clinical competency appeared to improve in all but one of the areas appraised. However, skills were ranked more highly in dealing with hospital-based problems than those likely to be encountered in primary care. This may have implications for the focus of psychiatric training currently received.

Adult↗
PubMed1998

[Assessment of clinical competence of medical school graduates in Italy with standardized patients. The opinion of the examinees].

An international collaborative project for the evaluation of clinical competence at the end of the Medical School curriculum using the ECFMG-CSA (Educational Commission for Foreign Medical Graduates--Clinical Skills Assessment) prototype was started in Italy in April 1996. Faculty representatives from Italian Medical Schools and experts from the ECFMG in Philadelphia participated in the Project. The CSA consists of integrated clinical encounters with 10 standardized patients during which the examinee is asked to obtain a focused history, perform a relevant physical examination and communicate initial diagnoses and management plan to the Standardized Patient (SP). The SP then completes checklists that are scored by Faculty members. The project was concluded in Spring 1998 and a total of 173 new graduates were examined. The data elaborated by the primary site in Chieti University will be available in the Fall 1998 by the ECFMG in Philadelphia. This preliminary communication reports the opinions of the examinees on the ECFMG-CSA, contained in the questionnaires administered after the test. Most of the examinees considered this new methodology as a valid tool for the assessment of clinical competence, especially history-taking and interpersonal skills and stated that the SP simulations were realistic. The 72% of examinees indicated that the Medical School curriculum does not adequately prepare for the CSA examination. Lastly, 68% was in favour of including the SP in the Medical Licensing Examination.

Clinical Competence↗
PubMed2000

The development of clinical competencies for use on a paediatric oncology nursing course using a nominal group technique.

This paper outlines the development of a competency model to be used to assess clinical competence during a post-registration specialist course. A nominal group technique was used to gather data about the detailed practice of paediatric oncology nurses. The nominal group technique was chosen to achieve consultation and consensus with a professional group. The six steps from undertaking the nominal group technique to implementation are described in detail. Some reflections on the use of competency statements are offered.

Child↗
PubMed2006

Medical students' clinical reasoning skills as a function of basic science achievement and clinical competency measures: a structural equation model.

BACKGROUND: The purpose of this study was to investigate the fit of a hypothesized model of medical students' diagnostic or clinical reasoning skills based on their aptitude for medical school, basic science achievement, and clinical competency measures. METHOD: A total of 589 medical students who received their MD from 1994 to 2002 participated in this study. Confirmatory factor analysis was used to evaluate the fit of theoretical models of clinical reasoning using measures of basic science and clinical knowledge. RESULTS: The results provided support for a three-factor model of medical student performance (Bentler's Comparative Fit Index = .905, standardized root mean squared residual = .054, root mean squared error of approximation = .105). The clinical reasoning skills of medical students were influenced by an independent relationship between latent variables of basic science achievement and clinical competency. CONCLUSION: The findings support a theoretical model of diagnostic or clinical reasoning that treats the basic science and clinical knowledge of medical students as distinct domains.

Aptitude Tests↗
PubMed1994

Do ratings on the American Board of Internal Medicine Resident Evaluation Form detect differences in clinical competence?

OBJECTIVE: To determine whether raters using the American Board of Internal Medicine (ABIM) Resident Evaluation Form can detect differences among residents in clinical competence. DESIGN: Cross-sectional study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: University-based internal medicine (UCIM) residents (ABIM certifying examination pass rate, 91%; mean score, 95th percentile), community hospital-based internal medicine (CHIM) residents (ABIM examination pass rate, 68%; mean score, 42nd percentile), and residents from three university-based non-internal medicine (UC non-IM) programs all assigned to the same inpatient general medicine service over a three-year period. Four hundred eighty-nine evaluations of 110 postgraduate-year-one residents were analyzed. MEASUREMENTS AND MAIN RESULTS: Mean ratings for the UCIM residents were significantly higher than those for the CHIM or UC non-IM residents (analysis of variance [ANOVA], p < 0.05). Variance was smallest for the UCIM residents (F test, p < 0.01), and only the UCIM residents' mean scores were in the "superior" range (7-9) in all evaluated categories. The mean ratings for the CHIM residents while at the university-affiliated hospital were not significantly different from the ratings of the same residents at their home hospital. The ratings for the CHIM residents at either site were significantly lower than those for the UCIM residents in all categories (ANOVA, p < 0.05). Factor analysis revealed a single factor accounting for 76% of the variance among the ratings with all dimensions loading high on that factor (0.75-0.95), providing evidence for a "halo" effect. Mean interrater agreement over all variables was 0.87, indicating good consistency among raters. CONCLUSIONS: Ratings on the ABIM Resident Evaluation Form detect global differences among residents in clinical competence in the expected direction based on type of training program and performance on the ABIM certification examination, but fail to differentiate among the nine evaluated dimensions of clinical care. This rating method may be valid for assessing overall clinical performance, but is less useful for providing feedback in specific areas to individual residents.

Clinical Competence↗
PubMed1985

Clinical competence of paediatric primary health care nurses in Soweto.

Primary health care (PHC) nurses provide care at polyclinics in Soweto. Our study assessed nurse competence in the clinical detection of important respiratory signs in 337 consecutive paediatric patients with respiratory complaints. The patients were then independently re-examined by two paediatricians, one of whom was arbitrarily chosen as a 'standard doctor'. The standard doctor found 95 patients with important respiratory signs; nurses detected the same signs in 45 and the other doctor in 44 patients. Therefore nurses detected important signs as well as could be expected, considering the inter-observer variation between doctors. The nurses did, however, significantly overdiagnose one condition, follicular tonsillitis. Our results suggest that the Soweto paediatric PHC nurses detect clinical signs with as much accuracy as doctors. This study adds to the available evidence that adequately trained and supervised nurse practitioners can provide high-quality health care.

Clinical Competence↗
PubMed1991

Reliability and efficiency of components of clinical competence assessed with five performance-based examinations using standardized patients.

The present study was conducted to provide in-depth information on the reliabilities of measures of the separate components of clinical competence (e.g. data collection, test interpretation, diagnosis, etc.) assessed by a performance-based examination consisting of standardized-patient cases administered to five classes of senior medical students at Southern Illinois University School of Medicine. In general, the reliabilities of the competencies as they were actually measured on the examination (using the number of cases on which each competency was actually measured) were small, with 54% less than 0.30 and 75% less than 0.40. For generalizability coefficients pooled across the five classes and projected to a common number of k = 10 cases, two of the nine competencies had reliabilities in the 40s, a third was close to 0.40, and the remaining six were in the low 20s. The number of cases needed for the competencies to achieve the recommended reliability of 0.80 ranged from 45 to 170 cases, with six of the nine competencies requiring over 100 cases to reach the 0.80 level. The low reliabilities of these measures of the components of clinical competence raise serious questions about using the scores as indicators of student performance.

Clinical Clerkship↗
PubMed2002

[Clinical competence evaluation in undergraduate gynecology and obstetrics].

OBJECTIVE: Assess the clinical competence in Gynecology and obstetrics to the Internship students of the Faculty of Medicine, UNAM. METHOD: The study design was descriptive, transverse type. We assessed 64 students, which had finished their gynecology field rotation with the objective structured clinical examination. The criteria to consider a competent performance level, was arbitrarily set up in 60%, both for individual problems and for the exam's global result. RESULTS: In 15 stations, the result was a 56.2 global average. The best performances were achieved in the following stations: take the pap smear (74.7), Pregnancy diagnostic (67.9), history of Gynecology and obstetrics (67.1), self examination of breast explanation (62.2) preclampsia (61.7) and cervicovaginitis (60). All the rest got a mark lower than 60. DISCUSSION: The results are lower than the ones obtained in written exams, because these cannot assess clinical skills. It could be observed that a student's performance in a clinical problem does not certainly predict his performance in other, so it seems to be determined more by the specific knowledge and the student's experience related to the case, than by a general problem-solving skill. CONCLUSIONS: The results show the advantages of this instrument to assess clinical skills, that justify its application in the formative process. This work evidences that its necessary to improve the acquisition of basic clinical skills trough systematic instructionals strategies and greater opportunities of learning.

Clinical Competence↗
PubMed1993

Beyond multiple-choice questions and essays: the need for a new way to assess clinical competence.

This essay reviews the influence that research on psychological processes in clinical reasoning has had upon the characteristics and formats of licensing examinations such as the new United States Medical Licensing Examination (USMLE) and its predecessors, emphasizes the implications of such research for the assessment of clinical competence at all levels of medical education, and proposes a challenging new direction for educational research that could make clinical assessment more effective. Specifically, (1) factors are discussed that support the continued judicious use of multiple-choice questions (MCQs); and (2) emphasis is given to the need to assess the clinician's ability to analyze controversial clinical situations, where no single answer is agreed upon as "most nearly correct," for even though essay questions and oral examinations are better suited than MCQs to assess such questions, they have been replaced by MCQs largely because of problems of consistency in grading, breadth of domain sampling, and cost. Because of these limits on essays and oral examinations, a program of educational research is advocated to develop a test format that can effectively assess the clinician's abilities to deliberate among alternatives, to recognize the role of values and preferences in decisions, and to weigh risks and benefits. Just how much this new tool could be used for national certification and licensing examinations would have to be determined, but it is important that some component be included to signal to educators and new physicians that medical practice is, at least in part, concerned with matters for which final answers are not available.

Academic Medical Centers↗
PubMed2006

Influence of clerkship experiences on clinical competence.

BACKGROUND: Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear. OBJECTIVES: This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence. METHODS: Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software. RESULTS: Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters. CONCLUSION: Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.

Clinical Clerkship↗
PubMed1993

Is the glass half full or half empty? A reexamination of the associations between assessment measures during medical school and clinical competence after graduation.

The purpose of this study was to investigate the associations between performances during medical school and in the first year of residency. It was hypothesized that the strength of such associations is a function of several variables, including similarities of the measured concepts, the formats of the assessments, the time interval between the assessments, performance levels, and specialty areas. The total sample consisted of 2,368 graduates of Jefferson Medical College between 1980 through 1990. The performance measures in medical school were grades on objective examinations in basic and clinical sciences, global ratings of clinical competence in junior core clerkships, and scores on the Part I and Part II examinations of the National Board of Medical Examiners (NBME). The postgraduate performance measures were scores on the Part III NBME examination, postgraduate competence ratings, and board certification. The ratings of postgraduate clinical competence (available for 73% of graduates) were made by residency directors at the end of the first year of residency in the areas of data-gathering and processing skills, interpersonal skills and attitudes, and socioeconomic aspects of patient care. Results supported the research hypotheses. It was found that the associations varied for different measures, at different levels of performance, and in different specialties. The authors conclude that the glass is "half full" regarding the associations between assessment measures before and after graduation from medical school.

Achievement↗
PubMed2005

The effect of preceptorship rurality on students' self-perceived clinical competency.

OBJECTIVE: This study's objective was to determine whether students' learning experiences, as measured by the improvement in students' perceived competence in several clinical areas, varied by the preceptorship county's rurality. METHODS: Rural preceptorship experiences from 1990 to 2003 were assessed using pre- and post-preceptorship questionnaires regarding students' perceived levels of competence. Questionnaires addressed basic clinical skills, common diagnoses, and advanced clinical skills. Rurality was measured both as population density and using the Rural-Urban Continuum (RUC) codes. RESULTS: Primary analysis was completed using 1,037 sets of questionnaires; 231 questionnaires were unsuitable for analysis due to missing information. Mean perceived competency improved for all items. Students in rural locations, regardless of operationalization, had no statistically significant differences from students in urban locations in perceptions of their clinical skill or comfort with basic diagnoses. Individual item analyses revealed a gendered pattern. Women improved more than men on the technical skills; men improved more on women's health and psychosocial items. CONCLUSIONS: There were no differences in medical students' perceived competence based on the rurality of their family medicine preceptorship site. The preceptorship experience provides both women and men with a variety of experiences that lead to increased confidence in areas where they were least confident prior to the preceptorship.

Clinical Competence↗
PubMed1984

Clinical competence certification: a critical appraisal.

The American Board of Internal Medicine has requested that residency program directors certify the clinical competence of their candidates. The clinical evaluation exercise (CEX) is one component of the overall certification process. During 1980-1982, 120 residents at the University of Michigan Hospitals participated in a CEX. The results show recurrent inadequacies among the residents in eliciting the social and family histories and performing the mental status and neurologic examinations. The ability to elicit a complete medical history correlated (p less than .01) with communication skills. In three of four specific organ examinations, the ability to perform a technically correct and complete physical examination correlated with the accuracy of the residents' findings (p less than .05). Separate evaluations by senior faculty members generally did not correlate with the residents' performance on the CEX. Analysis of the program described here showed that it requires considerable faculty time, requires training of evaluators to develop interrater reliability, and raises questions as to the validity of the CEX. As national certification boards integrate a formal clinical component into the certification process, such problems need to be addressed and rectified.

Certification↗
PubMedDate not supplied

Implementing continued clinical competency evaluation in the emergency department.

Nurse educators are challenged with the task of assuring that those who practice emergency nursing do so with competence. Yet beyond entry level competency verification, few nurse educators have implemented programs documenting continued clinical competence. In this article, the authors describe a cost-effective, practical approach to designing a competency verification program.

Clinical Competence↗