Measures Of Clinical Competence Research Articles

Clinical Evaluation of Competence in Nursing Education: What Do We Know?

The purpose of this article was to examine the research literature to identify objective, replicable measurement of clinical competence in undergraduate nursing education. Although a standardized licensure examination is used to determine minimal competence to practice, no consensus on the definition or components of competence exists in the research literature. A comprehensive search was conducted to locate studies that evaluated nursing students' general competence in the clinical setting. Twelve reports published from 2010 to 2021 were examined. Measures to evaluate competence were varied and contained multiple concepts including attributes of knowledge, attitudes and behaviors, ethics and values, personal attributes, and cognitive or psychomotor skills. Most studies used researcher-created instruments. Although essential to nursing education, competence in the clinical setting is not commonly defined or evaluated. The lack of standardized instruments has contributed to the use of varied methods and measures for evaluating competence in nursing education and research.

Assessment of diagnostic accuracy and adherence to maternal and child health guidelines as a measure of clinical competence of frontline healthcare workers in Nigeria.

Clinical competence of primary healthcare (PHC) workers is important in the delivery of maternal and child health care and services. In this cross-sectional study, we investigated the diagnostic accuracy and adherence to clinical guidelines for the management of some clinical conditions such as malaria, diarrhea, pneumonia, neonatal asphyxia and postpartum hemorrhage, as a proxy to measure the clinical competence of frontline health workers in PHCs in selected states in Nigeria. Ninety PHC facilities were randomly selected in each State and the FCT. Of the 3330 health workers, only 36.0% were able to correctly diagnose the five selected medical conditions. There was a significant difference in the diagnostic accuracy of the health workers with the doctors having highest diagnostic accuracy (65.5%) compared to other health workers (p <0.001). Adherence to the management guidelines was generally poor across all cadres of health workers and this pattern appear similar across the geopolitical regions in the country. The highest adherence to guidelines was observed among medical doctors (38.2%). The diagnostic accuracy and adherence to national guidelines for managing patients was poor among health workers, particularly, among other cadres except doctors. PHC workers in Nigeria need continuous training to enhance their clinical competence to improve quality of maternal and child health care.

One-Year Follow-Up of COVID-19 Impact on Surgical Education: Clinical Training Restored but Surgical Trainee Emotional Well-Being Still at Risk.

A previous survey documented the severe disruption of the coronavirus disease 2019 pandemic on surgical education and trainee well-being during the initial surge and systemic lockdowns. Herein, we report the results of a follow-up survey inclusive of the 2020 to 2021 academic year. A survey was distributed to education leaders across all surgical specialties in summer 2021. We compared the proportion of participants reporting severe disruption in key areas with those of the spring 2020 survey. Aggregated differences by year were assessed using chi-square analysis. In 2021, severe disruption of education programs was reported by 14% compared with 32% in 2020 (p < 0.0001). Severe reductions in nonemergency surgery were reported by 38% compared with 87% of respondents in 2020. Severe disruption of expected progression of surgical trainee autonomy by rank also significantly decreased to 5% to 8% in 2021 from 15% to 23% in 2020 among respondent programs (p < 0.001). In 2021 clinical remediation was reported for postgraduate year 1 to 2 and postgraduate year 3 to 4, typically through revised rotations (19% and 26%) and additional use of simulation (20% and 19%) maintaining trainee promotion and job placement. In 2021, surgical trainees' physical safety and health were reported as less severely impacted compared with 2020; however, negative effects of isolation (77%), burnout (75%), and the severe impact on emotional well-being (17%) were prevalent. One year after the initial coronavirus disease 2019 outbreak, clinical training and surgical trainee health were less negatively impacted. Disruption of emotional well-being remained high. Future needs include better objective measures of clinical competence beyond case numbers and the implementation of novel programs to promote surgical trainee health and well-being.

Introduction of Direct Observation of Procedural Skills as Workplace-Based Assessment Tool in Department of Anesthesiology

Abstract Background: The direct observation of procedural skills (DOPS) was introduced for the workplace-based assessment of procedural skills. It offers an opportunity to provide feedback to trainees. This makes DOPS an authentic measure of clinical competence in anesthesiology training. The goal of this study was to assess the perceptions of both trainees and consultants regarding the use of DOPS and to evaluate the performance of anesthesia postgraduate (PG) trainees over consecutive assessments. Materials and Methods: After approval from the ethical committee and sensitization workshop, two exposures of DOPS per trainee were given for three common anesthesia skills as per their years in training. Thereafter anonymous feedback was collected from faculty and trainees to gather their perception regarding DOPS. Consecutive DOPS scores for trainees were analyzed. Data were presented in terms of percentages, mean, and standard deviation. A P value of &lt;0.05 was considered significant. Results: More than 50% of participants were satisfied with the way DOPS was conducted and thought it was feasible for formative assessment. About 80% of participants were of the view that DOPS is helpful for anesthesia training and improving anesthesia procedural skills. Yet only 40%–50% favored the addition of DOPS to the departmental assessment plan. Significant improvement was observed in DOPS scores of PG trainees. Mean DOPS scores of postgraduate trainee year 1, 2, and 3 (JR 1, JR 2, and JR 3) increased from 2.6 to 4.8, 4 to 5.7, and 5.6 to 7, respectively (P &lt; 0.05). Conclusions: DOPS may be considered as a useful tool for workplace-based assessment for anesthesia PG training.

Establishing Objective Measures of Clinical Competence in Undergraduate Medical Education Through Immersive Virtual Reality

ObjectiveThe Association of American Medical Colleges defines recognition of the need for urgent or emergent escalation of care as a key Entrustable Professional Activity (EPA) for entering residency (EPA#10). This study pilots the use of an immersive virtual reality (VR) platform for defining objective observable behaviors as standards for evaluation of medical student recognition of impending respiratory failure.MethodsA cross-sectional observational study was conducted from July 2018 to December 2019, evaluating student performance during a VR scenario of an infant in impending respiratory failure using the OculusRift VR platform. Video recordings were rated by 2 pair of physician reviewers blinded to student identity. One pair provided a consensus global assessment of performance (not competent, borderline, or competent) while the other used a checklist of observable behaviors to rate performance. Binary discriminant analysis was used to identify the observable behaviors that predicted the global assessment rating.ResultsTwenty-six fourth year medical students participated. Student performance of 8 observable behaviors was found to be most predictive of a rating of competent, with a 91% probability. Correctly stating that the patient required an escalation of care had the largest contribution toward predicting a rating of competent, followed by commenting on the patient's increased heart rate, low oxygen saturation, increased respiratory rate, and stating that the patient was in respiratory distress.ConclusionsThis study demonstrates that VR can be used to establish objective and observable performance standards for assessment of EPA attainment – a key step in moving towards competency based medical education.

Development of a Mental Health Objective Structured Clinical Examination (OSCE): A Pilot Study

Background.An Objective Structured Clinical Examination (OSCE) is an effective means for clinical evaluation related to clinical competence. Historically, clinical assessment is based on direct observation which can be rooted in subjectivity. Evidence is minimal regarding psychometric properties of an OSCE in undergraduate mental health nursing education, although established as a valid measure of clinical competence. Method.A pilot study was conducted with a convenience sample of 13 sixth semester nursing students to evaluate the validity and reliability of an OSCE framework designed to assess undergraduate mental health nursing students’ clinical competence. The research questions asked: What are the psychometric properties of a mental health OSCE developed for undergraduate nursing education? How do students perceive the OSCE? Results.Preliminary validity and reliability measures were established, including content and criterion validities and inter-rater reliability. Students perceived the OSCE as both a beneficial and challenging learning experience. Conclusion.The OSCE was initially established as a valid, reliable tool for the assessment of clinical competence in undergraduate mental health nursing education. This evaluation method may be used to objectively assess mental health nursing knowledge, skills, and attitudes in conjunction with existing clinical assessment methods to provide a valid, reliable measure of clinical competence. More testing is needed.

Preliminary piloting and validation of a questionnaire identifying basic clinical skills practised by research nurses.

Clinical research nurses (CRNs) need to be competent in both clinical and research skills. In the past 10 years there has been increasing focus on developing the research competencies of CRNs. Employers, however, use the nurses' registered status as a proxy measure of clinical competence to perform their duties. The true extent of what clinical skills are practised by CRNs in a large NHS trust is unclear and there is a lack of validated measures to obtain this information. By using a mixed-methods approach of questionnaire and semi-structured interview, we aimed to pilot and validate a questionnaire to identify CRNs' self-reported confidence with clinical skills.

What Matters More About the Interpersonal Reactivity Index and the Jefferson Scale of Empathy? Their Underlying Constructs or Their Relationships With Pertinent Measures of Clinical Competence and Patient Outcomes?

In their study published in this issue of Academic Medicine, Costa and colleagues confirmed the underlying constructs of the Interpersonal Reactivity Index (IRI) and the Jefferson Scale of Empathy (JSE) in medical students. The authors of this Commentary propose that in comparing two instruments that both purport to measure empathy, researchers or test users must pay close attention to the target populations, the conceptualizations of empathy, and the validity evidence in relation to pertinent criterion measures. The Commentary's authors draw attention to the fact that the IRI was developed for administration to the general population, whereas the JSE was developed specifically for administration to students and practitioners of health professions. Also, the author of the IRI conceptualized empathy as a combination of cognitive and emotional attributes, whereas the authors of the JSE defined empathy as a predominantly cognitive attribute. These differences are reflected in the content of the items, which determines the underlying constructs of the two instruments. The Commentary authors suggest that any empathy-measuring instrument in the context of health professions education and patient care requires the crucial evidence of significant relationships with indicators of clinical competence and positive patient outcomes. Such validity evidence is readily available for the JSE, and the Commentary authors recommend that researchers make efforts to provide pertinent validity support for any other instrument measuring empathy in health professionals-in-training and in-practice.

Objective Structured Clinical Examination in Undergraduate Pharmacy Students: Time to Switching to an Alternative Exam for Clerkship Courses

Abstract: Background: Significant changes in the clinical context of health professional education and impressive body of research on the measurement of clinical competence support the use of the Objective Structured Clinical Exam (OSCE) as the preferred means of performance-based assessment to current teaching and evaluation method. The objective of this paper is to describe how the OSCE method was developed and applied to an undergraduate community pharmacy clerkship course, as a pilot for assessing clinical competence and skills of these students. Methods: A seven-station OSCE was designed and implemented to assess the learning objectives of community pharmacy clerkship course(s) in the Pharmacy Doctorate program of pharmacy curriculum of the Isfahan University of Medical Sciences. The key process in designing and implementing the OSCE includes: development and face-validation of seven stations in accordance with our learning objectives of the course; designing of dichotomous performance checklists or suitable assessment instruments for individual stations; and conducting of the final examination. The broad competencies tested in the OSCE included: drug labeling, patient education and counseling, drug usage instruction, reading and evaluating prescriptions and use of drug information resources (electronic or hard copy texts) for determining probable drug interactions. Results: The students scored the highest marks in use of drug information resources for determining probable drug interactions (mean ± SD: 5.6 ± 0.68) and the lowest marks in drug usage instruction (mean ± SD: 4.8 ± 0.56). Most of the students (84%) found OSCE as an appealing and useful method of assessment. Conclusion: The assessment methods and educational objectives should be aligned with each other. Although OSCE is not commonly used in Iranian pharmacy schools, however, due to the practical nature of clerkship courses of the pharmacy doctorate program, OSCE seems to be a more suitable and relevant method to evaluate the community pharmacy clerkship course compared to conventional written exams. Key words: Educational Assessment, Pharmacy Students, Pharmacy Education, Clinical Clerkships, Educational Measurements.

Does Step 3 of the United States Medical Licensing Exam Measure Clinical Competence? A Predictive Validity Study

The main purpose of the present study was to evaluate the predictive validity of medical school admissions data, preclinical and clinical achievement data, postgraduate evaluations, and the United States Medical Licensing Exam Step 1 and 2 data for performance on Step 3. A total of 321 physicians (178 men, 55.4 %; 143 women, 44.6 %) participated. Admissions data, medical school preclinical achievement data, medical school clerkship clinical performance data, postgraduate clinical performance data, and USMLE Step 1 and 2 data were independent variables. Step 3 was the dependent variable in a backwards multiple regression. An analysis of covariance with Step 3 scores as the dependent variable, Step 2 scores as the covariate, and residency program (narrowly focused vs. broadly focused two levels) as the independent variable was conducted. The regression analyses resulted in an optimal model fit with the most parsimonious combination of independent variables (multiple R = 0.686, R 2 = 0.470, p < 0.001): Step 2 (β = 0.606) + verbal reasoning (β = 0.125) + PGY1 (β = 0.161) + Year 3 (β = 0.157). Candidates in broadly focused residencies scored higher on Step 3 compared to those in narrowly focused residencies (F = 5.17, p < 0.05). The predictive validity of Step 2, verbal reasoning, PGY1 assessment, Year 3 average for Step 3 performance is supported by the optimal regression model. Candidates in broadly focused residencies scored higher on Step 3 compared to those in narrowly focused residencies. The results are evidence for the validity of Step 3 as a measure of clinical competence.

Measuring competence in healthcare learners and healthcare professionals by comparing self-assessment with objective structured clinical examinations: a systematic review

Executive summary Background The measure of clinical competence is an important aspect in the education of healthcare professionals. Two methods of assessment are typically described; an objective structured clinical examination and self-assessment. Objectives To compare the accuracy of self-assessed competence of healthcare learners and healthcare professionals with the assessment of competence using an objective structured clinical examination. Inclusion criteria Types of participants All healthcare learners and healthcare professionals including physicians, nurses, dentists, occupational therapists, physiotherapists, social workers and respiratory therapists. Types of intervention Studies in which participants were first administered a self-assessment (related to competence), followed by an objective structured clinical examination; the results of which were then compared. Types of outcomes Competence, confidence, performance, self-efficacy, knowledge and empathy. Types of studies Randomized controlled trials, non-randomized controlled trials, controlled before and after studies, cohort, case control studies and descriptive studies. Search strategy A three-step search strategy was utilized to locate both published and unpublished studies. Databases searched were: Medline, CINAHL, Embase, ERIC, Education Research Complete, Education Full Text, CBCA Education, GlobalHealth, Sociological Abstracts, Cochrane, PsycInfo, Mosby's Nursing Consult and Google Scholar. No date limit was used. Methodological quality Full papers were assessed for methodological quality by two reviewers working independently using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data collection Details of each study included in the review were extracted independently by two reviewers using an adaptation of the standardized data extraction tool from JBI-MAStARI. Data synthesis Meta-analysis was not possible due to methodological and statistical heterogeneity of the included studies. Hence study findings are presented in narrative form. The data was also analyzed using 'The Four Stages of Learning' model by Noel Burch. Results The search strategy located a total of 2831 citations and 18 studies were included in the final review. No articles were removed based on the critical appraisal process. For both competence and confidence, the majority of studies did not support a positive relationship between self-assessed performance and performance on an OSCE. Conclusions Study participants' self-assessed competence or confidence was not confirmed by performance on an objective structured clinical examination. An accurate self-assessment may be threatened by over confidence and high performers tend to underestimate their ability. It is theorized that this disparity may in part be due to the stage that the learner or professional is in, with regard to knowledge and skill acquisition. Educators need to examine their evaluation methods to ensure that they are offering a varied and valid approach to assessment and evaluation. Notably, if self-assessment is to be used within programs, then learners need to be taught how to perform consistent and accurate self-assessments. Implications for practice It is important that educators understand the limitations within the evaluation of competence. Key aspects are the recognition of the stage that the learner is in with regard to skill acquisition and equipping both learners and professionals with the ability to perform consistent and accurate self-assessments. Implications for research There is a need for standardization on how outcomes are identified and measured in the area of competence. Further, identifying the leveling of an OSCE and the appropriate number of stations is required.

Validity and Reliability of the Standardized Orthopedic Assessment Tool (SOAT): A Variation of the Traditional Objective Structured Clinical Examination

Health care professions have replaced traditional multiple choice tests or essays with structured and practical, performance-based examinations with the hope of eliminating rater bias and measuring clinical competence. To establish the validity and reliability of the Standardized Orthopedic Assessment Tool (SOAT) as a measure of clinical competence of orthopaedic injury evaluation. Descriptive laboratory study. University. A total of 60 undergraduate students and 11 raters from 3 Canadian universities and 1 standardized patient. Students were required to complete a 30-minute musculoskeletal evaluation in 1 of 2 randomly assigned mock scenarios involving the knee (second-degree medial collateral ligament sprain) or the shoulder (third-degree supraspinatus muscle strain). We measured interreliability with an intraclass correlation coefficient (ICC) (2,k) and stability of the tool with standard error of measurement and confidence intervals. Agreement was measured using Bland-Altman plots. Concurrent validity was measured using a Pearson product moment correlation coefficient whereby the raters' global rating of a student was matched to the cumulative mean grade score. The ICCs were 0.75 and 0.82 for the shoulder and knee cases, respectively. Bland-Altman plots indicated no systematic bias between raters. In addition, Pearson product moment correlation analysis demonstrated a strong relationship between the overall cumulative mean grade score and the global rating score of the examinees' performances. This study demonstrated good interrater reliability of the SOAT with a standard error of measurement that indicated very modest stability, strong agreement between raters, and correlation indicative of concurrent validity.

Comparison of Student Self-Assessment with Faculty Assessment of Clinical Competence

At the University of Minnesota, fourth-year veterinary students assessed their clinical competence after completion of a small-animal, internal-medicine clinical rotation using the same rotation assessment form used by supervising faculty. Grades were compared between the two groups. Students identified by faculty as low-performing were more likely to overestimate their competence in the areas of knowledge, clinical skill, and professionalism than were students identified by faculty as higher performing. This finding mirrors research results in human health professional training. Self-assessment should not be used as the primary or sole measure of clinical competence in veterinary medical training without the introduction of measures to ensure the accuracy of student self-assessment, measures that include active faculty mentoring of student self-assessment, student goal-setting and reflection, and availability of subsequent opportunities to practice additional self-assessment.

Assessing Trainee Clinical Psychologists' Clinical Competence

Within UK clinical psychology training, traditionally used methods for assessing the development of trainees' clinical competence have taken the form of evaluations of trainee knowledge regarding their clinical practice, either in the form of written assignments or via discussion in the supervisory relationship. Whilst direct observation of trainees is expected and required by supervisors on practice placements, frequency of observation varies, and supervisors can experience difficulties occupying both supervisory and evaluatory roles. In addition, calls from within the clinical psychology training community have expressed a need for a consistent and formalised in vivo assessment of trainees' clinical competency (Gallichan &amp; Mitchell, 2008). This article reports on a psychometric evaluation of the Clinical Skills Assessment Rating Form (CSA-RF), a seven domain measure of clinical competence developed at the University of Leicester Doctoral Programme in Clinical Psychology for use with live or videotaped clinical material. Results suggest that the CSA-RF has acceptable levels of internal consistency, although interrater reliability requires further investigation. Factor analysis revealed a five domain structure. From this, a revised CSA-RF has been developed which aims to be a valid and practicable initial means by which trainees' clinical competence can be assessed.

Challenges in multisource feedback: intended and unintended outcomes

Multisource feedback (MSF) is a type of formative assessment intended to guide learning and performance change. However, in earlier research, some doctors questioned its validity and did not use it for improvement, raising questions about its consequential validity (i.e. its ability to produce intended outcomes related to learning and change). The purpose of this qualitative study was to increase understanding of the consequential validity of MSF by exploring how doctors used their feedback and the conditions influencing this use. We used interviews with open-ended questions. We purposefully recruited volunteer participants from 2 groups of family doctors who participated in a pilot assessment of MSF: those who received high (n = 25) and those who received average/lower (n = 44) scores. Respondents included 12 in the higher- and 16 in the average/lower-scoring groups. Fifteen interpreted their feedback as positive (i.e. confirming current practice) and did not make changes. Thirteen interpreted feedback as negative in 1 or more domains (i.e. not confirming their practice and indicating need for change). Seven reported making changes. The most common changes were in patient and team communication; the least common were in clinical competence. Positive influences upon change included receiving specific feedback consistent with other sources of feedback from credible reviewers who were able to observe the subjects. These reviewers were most frequently patients. Findings suggest circumstances that may contribute to low consequential validity of MSF for doctors. Implications for practice include enhancing procedural credibility by ensuring reviewers' ability to observe respective behaviours, enhancing feedback usefulness by increasing its specificity, and considering the use of more objective measures of clinical competence.

Validation of the Clinical Internship Evaluation Tool

Graduates of physical therapist education programs should be expected to function as competent clinicians. Instead, the benchmark for many clinical performance assessment tools has been "as good as an entry-level graduate." The authors developed the Clinical Internship Evaluation Tool (CIET), which measures clinical performance of the student relative to a "competent clinician." The purpose of this study was to provide evidence for validity of the tool. The CIET was used to evaluate physical therapist student clinical performance from 1999 to 2003. Data from 228 student evaluations, a survey of 26 clinical instructors (CIs), and an item review by 7 faculty members were used to collect validity evidence. The relevance of items on the CIET was examined by the survey and the item review. Coefficient alpha was calculated to estimate internal consistency among the items. A Spearman correlation was used to examine the relationship between 2 measures of clinical competence. A repeated-measures analysis of variance (ANOVA) compared the student scores at each clinical time frame to confirm expected improvements in performance longitudinally. Evidence for practicality was collected by the CI survey. Based on the faculty item review and the CI survey, all items were representative of skills and behaviors considered important for a clinically competent physical therapist. The internal consistency (alpha) was .98 for the patient management items. The average correlation of the 2 measures of clinical competence was .76. The repeated-measures ANOVA was significant and demonstrated improved patient management scores as the student progressed through the program. The CI survey results indicated that 96% of respondents agreed or strongly agreed that the instrument was short and easy to use. The results of the study suggest that the CIET is representative of skills and behaviors necessary for students to perform at the level of a competent therapist and that the instrument is practical to use for busy clinicians. The CIET appears to be a valid tool for measuring student clinical performance and can be a time-efficient alternative for CIs in today's demanding clinical environment.

Trainee psychiatrists' assessment outcomes

Aims and MethodThe Record of In-Training Assessment grades of all registrars in the psychiatric specialties in the UK were analysed for each of three successive years, specialty by specialty, and compared with the average outcome for registrars in all disciplines over the same period.ResultsOver 98% of psychiatry registrars were assessed as satisfactory, 1.2% needed targeted training and 0.7% were graded as unsatisfactory, requiring repeat training. Targeted training and repeat training led to a satisfactory outcome in the majority of cases.Clinical ImplicationsThe process of assessment needs to become more objective, and should do so as the Royal Colleges develop better measures of clinical competence.

Outcomes of assessments of registrars in the medical specialties

The Records of In-training Assessment (RITAs) of all registrars in the medical specialties in the UK were analysed in three successive years, specialty by specialty, and compared with the average outcome for registrars in all disciplines over the same three-year period. Over 97% of medical registrars were assessed as satisfactory, 1.5% needed targeted training and 1.0% were graded unsatisfactory, requiring repeat training. Targeted training and repeat training led to a satisfactory outcome in the majority of cases. The process of assessment needs to be more objective and should become so as the medical Royal Colleges develop better measures of clinical competence.

Clinical competence: Starship Enterprise or straitjacket?

Clinical competence assessment has been a feature of nurse education in the United Kingdom for about 20 years but has really moved to centre-stage since the nurse education reforms of 1999. Clinical competence is a controversial issue and there are problems with assessment and the relationship between the practical and educational aspects of nurse education programmes. The present paper explores the origins of clinical competence assessment, presents some of the problems associated with the adoption of clinical competence in nurse education and reviews some literature in this area. In so doing the paper refers to two research studies commissioned in the United Kingdom into the educational preparation of nurses in which the measurement of clinical competence has been an issue. This paper is based on the Winifred Raphael Memorial Lecture delivered by the author on behalf of the Royal College of Nursing Research Society at the Royal College of Nursing Congress in Harrogate, England on 23 May 2001. The views expressed are those of the author and not necessarily, those of the Royal College of Nursing or the Royal College of Nursing Research Society.

Measurement of clinical performance of nurses: a literature review

Despite a 40-year history of researching and developing an instrument for measurement of clinical competence in nursing, there are none that are universally accepted for this purpose. This article presents a critical review of the research, which has been carried out to explore the measurement of nurses' clinical performance. To search the literature in a systematic manner, the criteria stipulated by the Cochrane Research Database were applied. The review showed that assessment tools have been developed using a variety of different methods and several instruments were found to have been developed but nothing that is universally accepted. However, the authors found that the pathway for instrument generation suggested by Smith and Kendall (1963) offers a robust approach to the generation of such a tool regardless of the practice setting. Other methods identified in this literature review also offer interested researchers an opportunity to explore the current role of the nurse, as well as the possibility of developing tools for assessing the performance of students at various stages in their education and nurses at various times after qualification.