Assessing competence to practise in nursing: a review of the literature

Recent reforms of nursing education have led to calls for assessment of clinical performance to contribute to academic qualifications that incorporate professional awards. Questions then follow concerning the psychometric quality of methods available for assessing competence and performance and the ability of the methods to distinguish between different levels of practice. The purpose of this review of the literature is to analyse methods of assessing competence to practise in nursing and draw conclusions on their reliability and validity. The methods reviewed include questionnaire rating scales, ratings by observation, criterion-referenced rating scales, simulations including the objective structured clinical examination (OSCE), Benner's model of skill acquisition, reflection in and on practice, self-assessment and multi-method approaches. Methodological challenges to competence assessment are raised. Findings of the review are as follows. Questionnaire rating scales used to assess competence in nursing have not been rigorously tested for reliability and validity. The methodological limitations of observation can be overcome with use of criterion-referenced scales or simulations such as the OSCE or its variations, as has been found in research on competence assessment in medicine. The Bart's Nursing OSCE, designed for the end of the common foundation programme of the nursing diploma course, has promise because it provides a close simulation to real life and is grounded in an interpretive approach to skill acquisition. Reflection on practice using portfolios, learning contracts and self-assessment is valid if based on rigorous analysis of critical incidents rather than simple description. Reflective approaches have the advantage of being located in real-life settings and can integrate theory with practice but they need skilled collaboration between teachers, employers and practitioners. The conclusion is that a multimethod approach enhances validity and ensures comprehensive assessment of the complex repertoire of skills required of students in nursing.