Development of a Geriatric Nursing-Specific Mini-CEX and Evaluation of the Professional Competence of Nursing Students: A Novel Approach to Clinical Evaluation in Implementing Case Study

Concerning the growing population of geriatric patients, worldwide, the academic and clinical preparation of nursing students as future health professionals is critical to improving general and geriatric competencies through the development of professional competence. (1). The word “competence” is a complex and multidimensional concept, a set of attributes that underlies the desirable performance of the person (2). Nursing is one of the leading professions in the healthcare system (3). Three issues need to be considered to equip internship nursing students to develop the necessary competencies: the core competencies should be defined based on established definitions, and effective methods should be developed to bridge the gap between academic knowledge and professional clinical practice and effective performance evaluations should be implemented (4). A core competency of nursing is the ability to practice nursing which fulfills the needs of clients cared for using logical and critical thinking and accurate nursing skills based on the model of nursing care process (5). Cultivation of core competencies has recently become a key global issue in developing nursing education (6). A gap exists between the expected competence of nursing staff employed to provide care; the call for the need to measure clinical competence among nurses remains a debatable issue in nursing education (4). Besides, the current treatments and care programs should focus on modifying the quality of life of patients (7). Therefore, the professional competence of nursing students in all specialties and specifically in geriatrics requires the development of core competencies and awareness of the specific needs of patients and relevant caring for patients (8-10).

Geriatric nursing is professional holistic care that needs special attention (8). The main objective of geriatric nursing education is to train competent nursing professionals who possess the knowledge, skills, and attitudes appropriate to the needs of the elderly, the ability to solve problems and exhibit clinical geriatric competence (11). Aging causes various health problems, such as physical, mental, social, and intellectual weakness, diseases, syndromes, and issues that reduce the quality of life, and also increase the need for attention and assessment of functional status (8). Concerning about 60% of medical-surgical patients are geriatric patients, therefore, non-geriatric nursing students need to assess their competence and be educated in minimum geriatrics competencies (12). Therefore, competent nursing students must be optimally equipped with core geriatric competencies through training and implementing Comprehensive Geriatric Assessment (CGA) to fulfill the unique needs of older adults (1).

Accordingly, professional competence in geriatric care refers to a set of attitudes, knowledge, behaviors, and skills that nurses use in the process of the clinical nursing of geriatric patients. Evaluating PGC in internship nursing students during professional practice is essential since it provides a vital understanding for the development of strategies to enhance competence, particularly among non-geriatric nursing students (12). Considering that the number of elderly people in Iran has reached 10 million in 2021, which constitutes about 10% of the total population, meanwhile (13), the definition of knowledge and geriatric competence contents are limited in the undergraduate curriculum of nursing education in Iran, particularly in the internship training program. Recently, Bahrami et al. (2019) conducted a study on the components of geriatric nursing competencies in caring for older people in hospitals which included three fundamental geriatric core competencies of patient and family-centered care, process-oriented care, and self-care and continuing professional development (11). However, to the best of our knowledge, limited information exists on the components of geriatric competencies of nursing students in internship practice and evaluation of professional geriatric competence through specific measurement tools among nursing students in Iran.

Assessment of professional practice in undergraduate nursing programs entails designing tools that can be reliably assessed against a broad set of national competence standards. The substantial instrument for measuring competence or professional competence is using self-report or self-assessment tools to measure the level of competence among nursing students, as it can stimulate deep-level learning in the students (14). Many clinical assessment methods are available in a nursing internship program such as objective structured clinical examination (OSCE) and direct observation of procedural skills (DOPS) (15). The validity of these clinical evaluation methods is still under consideration, attitude is difficult to be evaluated, more time is needed which causes the patients to be inconvenient, totality fails to be reflected, the assessment is only performed once by an assessor, no observation and feedback are directly provided so that clinical preceptor fails to recognize the strengths and weaknesses of students (16). New methods of assessment focus on the dimensions of clinical work and competence skills such as communicative skills, clinical skills assessment, nursing diagnostic and professional actions. Additionally, professional clinical competence is not knowledge or practical ability; therefore, it incorporates other components such as professionalism, impersonal skills, self-assessment, decision making, and clinical judgment to progress nursing intervention. Accordingly, conventional knowledge-based assessment methods failed to assess these areas (17).

Furthermore, the nursing professional competence structure consists of four capacities include understanding the needs, providing care, collaborating, and bolstering decision-making (5). Therefore, professional clinical competence assessment should be performed through the indirect observation method in practical and real situations. A wide range of competencies of nursing staff is required to fulfill the needs of older patients in hospital care. Geriatric competence assessments can help examine geriatric competence concerning competence development (18). Therefore, using evidence-based methods, such as case studies in the evaluation of professional geriatric competence is suitable in the real world for adequate comprehensive assessment and complex care for the aging population. A nursing case study is an in-depth study of a patient encountered during the student's daily practice in a practicum (19). The literature indicates that work-based formative assessments can have a substantial impact on the behavior of learners. In this regard, Mini-CEX is one of the best measurements for evaluating workplace assessment among students. The American Board of Internal Medicine (ABIM) developed a quality assessment tool, for the first time in 1972 (20), the Mini-Clinical Evaluation Exercise (Mini-CEX), which is internationally used to assess the clinical competencies of trainees in various subspecialties in a wide variety of clinical settings. It is a cost-effective way of assessing and providing constructive feedback to the students in a structured manner. By using this method the professional clinical skills of students are evaluated through direct observation and provide constructive feedback. However, little is known about nursing education. Recently, Liu et al. in 2019 developed a valuable specific nursing-mini clinical evaluation exercise (Mini-CEX) for nursing students and defined core competencies of nurses such as the attitudes, skills, abilities, knowledge, and behaviors necessary for safe and independent practice with high standards of patient care in a clinical setting  (6). The validity and reliability calculations of mini-CEX have been conducted in some studies (6,21). The reliability and validity of the Persian version of Mini-CEX were assessed for nursing students in Iran and test stability was measured (17). The need for a specific geriatric tool to evaluate these competencies is increasing among nursing students since the quality of geriatric care and competence developments are considered. Meanwhile, no evidence is available for the development of specific professional geriatric nursing measurements in nursing students (6). No study has examined the geriatric competence of internship nursing students based on existing demands, and no instrument exists for this purpose. To the best of our knowledge, this issue has not been studied in nursing education in Iran. Therefore, the present study is crucial to fill data scarcity.

The present study aimed to develop a geriatric nursing-specific Mini-Clinical Evaluation Exercise (Mini-CEX) tool and evaluate the professional competence of internship nursing students.

3.3. Phase 2- Evaluation of validity and reliability of the Geriatric Nursing-Specific Mini-CEX Tool

The face validity and the allocation of sample behavior items were evaluated to the appropriate dimensions using the Delphi method. The present study aimed to reach a consensus regarding which geriatric competence of nursing students and related descriptive items are more relevant to meet the current needs of geriatric patients. In this light, the instrument was validated by ten experts:  three academic specialists in the field of geriatric nursing, three academic specialists in the field of educational measurement and evaluation, and four academic professors of nursing education. They evaluated the feasibility and wording of the items and detailed descriptions in the expert opinion form. The Delphi stages were consistent. In the first round, experts modified the wording of items and descriptions according to the definitions used in the study. The authors referred to the comments and observations from the first-round experts to validate the items and descriptions in the second-round Delphi. Three ratings were adopted to decide on the inclusion of dimensions: dimension is important and should be retained (3 points), dimension is important but needs to be reconsidered (2 points), and dimension is not important and should be removed (1 point). The wording of items and descriptions was modified and reexamined if experts granted 2 points. The experts demonstrated a clear consensus regarding the most relevant and current geriatric core competencies for internship nursing students in professional clinical practice. Therefore, a new competence measurement instrument was specifically developed and validated as a Geriatric Nursing-Specific Mini-CEX Tool (GN-Specific Mini-CEX).

The final modified tool consisted of 40 items in seven components for geriatric skills necessary to care for elderly patients in medical-surgical wards match with seven domains of the Mini-CEX questionnaire that scored between 1 to 9 in each question of skill parts (1–3 was “unsatisfactory,” 4–6 were “moderately satisfactory,” and 7–9 were “satisfactory”), with a total score from 40 to 360. A higher score means a higher PGC for nursing students. A test and retest design were conducted to assess the consistency among 20 students using Interclass Correlation  Coefficient (ICC) to evaluate the reliability of this geriatric nursing-specific mini-CEX, through a pilot test (Table 1). The computed Cronbach’s alpha for the 40-item of seven domains instrument indicates high internal consistency. Therefore, the instrument is reliable for measuring the PGC of nursing students.

 

 

 

practice. Also, it is recognized as a practical standard for assessing nurses' professional competencies by enhancing critical thinking skills and clinical judgment. Accordingly, the nursing case study consists of several sections that can be organized into three categories: the patient status, the nursing assessment of the patient, the current care plan, and possible recommendations (19). In the present study, the patient status and nursing assessment of geriatric patients were performed with a comprehensive geriatric care assessment (CGA) for identifying geriatric syndromes such as falls and diabetes in geriatric patients. CGA is a multi-disciplinary exercise that tests mental, physical, emotional, and psychological health, as well as assesses functionality, living conditions, socio-economic environment, social circles, family involvement, and anything else that determines the quality of life (18). The central philosophy in CGA should be holistic care using a person-centered approach that unites the various aspects of specialist care. The next steps of the case study were the current care plan, and possible recommendations were consistent with other steps of the nursing process such as analyzing data and formulating nursing diagnoses, planning nursing care, and implementing proper intervention and evaluation. The Geriatric Nursing-Specific Mini-CEX Tool provided a 15-minute snapshot of the way students interact with patients in a placement. The  Behavioral competencies of nursing students were rated by evaluators based on observed bedside practices for the selected case of geriatric patients in medical-surgical wards and finally provided them with constructive feedback.

3.6. Data Collection
A cross‐sectional observational study was conducted in January 2020. The study population was entire senior nursing students of the school of nursing from Mashhad University of Medical Sciences (MUMS) one of the major medical sciences universities in Iran, in 2020. A total of 160 nursing students were selected by a convenience sampling method from senior nursing students in the seventh semester. The calculation of sample size (n=160) was based on the effect size of a similar study the calculated which was d=0.694 by (22). The minimum sample size was calculated from the formula of effect size and the results were 124. The adjusted total sample size was 160 considering an attrition rate of 20%.

The recruitment process of participants began after the permission and the ethical approval were granted. All students volunteered to participate in the study. The inclusion criteria included being in the seventh semester of nursing and willingness to participate in the study. The exclusion criteria were a history of being active in other internship courses or educational background in other paramedical disciplines except nursing before entering this study. Therefore, all 160 eligible participants agreed to involve in the study. A written consent form was given to ensure the protection of human rights, their participation was voluntary, and the participant could withdraw whenever they wished, no coercion was imposed and no impact on their grade, and finally data was kept anonymous and confidential. Data collection instruments include a demographic information questionnaire with five items including age, gender, marital status, the experience of clinical student work, interest in nursing, and academic achievement in form of Grade Point Average (GPA) and Geriatric Nursing-Specific Mini-CEX Tool. In the briefing session, the students were fully acquainted with the study process and the way to measure geriatric professional competence by this developed instrument and through implementing a case study and similar the evaluators a video of performing a standard geriatric case study scenario of a geriatric nursing-specific Mini-CEX encounter was shown to the students. Clinical evaluators conducted the PGC evaluation by Geriatric Nursing-Specific Mini-CEX among nursing internship students by observing students for about 15 minutes while interacting with geriatric patients in medical-surgical wards. After that, the clinical evaluator gave constructive feedback to the students on their achievement for about 5 minutes. The results of this examination were entered in the assessment sheet containing seven assessment geriatric skills domains competencies. In this study, feedback was not a result to be measured.

3.7. Data Analysis

Data were examined using SPSS software (version 23.0; SPSS, Chicago, IL). Descriptive and inferential statistics were operated to respond to the research questions that guided this study. Descriptive statistics, such as mean (M), standard deviation (SD), and range were used to calculate the level of PGC of patients. A p-value less than 0.05 is statistically significant.

 

4.Results

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5.Discussion

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6.Conclusion

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Acknowledgments

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Footnotes

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References