• Assessment of clinical practice skills in health
profession’s education poses several
challenges in terms of its objectivity.
• Objective Structured Clinical Examination
(OSCE) is one form of objective evaluation
method that is gaining more importance and
is being adopted by educators of various
• It involves use of cognitive skills like critical
thinking and problem solving. OSCE also
enhances good interaction between the teacher
and the student Although OSCE is practiced
worldwide in nursing education, its practice in
India and other developing countries is scarce.
• The nurse educators from India and other
developing countries should be encouraged to
utilize this form of evaluation.
• OSCE is an approach to the assessment of
clinical competence in which the components
of the competence are assessed in a planned
or structured way, with attention being paid to
the objectivity of the examination
• In a non clinical area e.g. Biochemistry/Anatomy
Physiology lab setting), a similar approach may
be adopted and in this context, it is referred to
as an OSPE (Objective Structured Practical
PURPOSES OF OSCE
According to Boursicot, Ware, and Hazllet
(2011), the purposes of OSCE are to
– Measure clinical skills
– Match assessment to intended constructs
– Promote structured interaction between student
– Make structured marking scheme possible
– Present all candidates with the same test
– Promote objectivity
COMPONENTS ASSESSED IN OSCE
• Various components of clinical competence are
assessed using OSCE,
– For example, the components of advance clinical
nursing practice skills typically assessed by OSCE
1. Interpersonal and communication skills
2. History taking skills
3. Physical examination of specific body system
4. Mental health assessment
5. Clinical decision making including the informationof
6. Interpretation of clinical findings and
investigations Management of a clinical
situation including treatment and referral
7. Patient education
8. Health promotion
9. Clinical problem solving skills
10.Acting safely and appropriately in an urgent
11.Critical thinking in therapeutic management
THE COMPONENTS OF THE OSCE
• The OSCE (Objective Structured Clinical
Examination) has reached a stage of development
that allows clear recognition of key components
that bring structure and organization to its
construction, implementation and assessment of
The major components are:
1. The (examination) coordinating committee
2. The examination coordinator
3. Lists of skills, behaviors and attitudes to be
4. Criteria for scoring the assessment (marking
scheme of checklist)
5. The examinees
6. The examiners
7. Examination site
8. Examination stations
– 8.1 Time and time allocation between stations
– 8.2 Anatomic models for repetitive examinations
– 8.3 Couplet Station
– 8.4 Examination Questions
– 8.5 Environment of Exam Station
– 8.6 Examination Station Circuit
1. The Examination Coordinating
• An examination coordinating committee is made up
of members who are committed to the evaluative
and educational process and whether appointed or
volunteered must give this effort high priority in
order for the OSCE to be developed and
• It is the responsibility of the examination committee
to determine the content of the examination,
development and implementation.
2. The Examination Coordinator
• The functions of the examination coordinator
(M.D. or Ph.D. educator) are the catalyst that
facilitates the smooth working of the
committee in developing, implementing and
assessing the performance of the OSCE.
3. Lists of Skills, Behaviors and
Attitudes to be Assessed
• The examination will measure objectively the
competencies in specific areas of behavior,
techniques, attitudes and decision-making
strategies based on the objectives of the course
or the requirement of the licensing body.
• The OSCE should be able to reliably assess
clinical competence in history taking, physical
examination, laboratory, radiographic and other
data interpretation, technical and procedural
skills as well as counseling and attitudinal
4. Criteria for Scoring the Assessment
(Marking Scheme or Checklist)
• A marking scheme or checklist is prepared for
each station. Preparation of the checklist
requires predetermined objective criteria that
are agreed upon by the examination committee,
based on faculty input.
• Marking scheme/checklist should be concise,
unambiguous and written to contribute to the
reliability of the station.
5. The Examinees
• The examinee is the student, resident, or fellow
in training or at the end of training of a
prescribed course designed to teach certain
clinical competencies that the examinee can use
in a clinical situation to make an assessment and
develop a diagnostic formulation that culminates
in a therapeutic plan.
6. The Examiners
• Most stations will require an examiner, although
some stations do not. The examiner at the
station where clinical skills (history-taking,
physical examination, interviewing and
communication) are assessed, may be either a
physician or a standardized patient
7. The Examination Site
• The examination site is part of a special teaching
facility in some institutions. When such facilities
are not available, the examination may be
conducted in an outpatient facility or other
space where offices are available in close
proximity to each other.
8. Examinations Station
• The total number of stations will vary based on
a function of the number of skills, behaviors and
attitudinal items to be tested.
8.1 Time Allocation and Time between Stations
– The competency being assessed in particular station
will define how much time should be allotted per
station. The length of time will range from 5-20
– The time allocated per station should be as uniform
as possible thus facilitating the smooth movement
of examinees from station to station.
e.g., a 10 minute station, 9 minutes is allocated
for the task and one minute transit time to the
next station. The examiner can complete the
checklist prior to the entry of the next examinee.
8.2 Anatomic Models for Repetitive
Examinations (Breast, Pelvic/Rectum
• The skill, behavior or attitude to be tested in a
station determines whether the station requires
a real patient, simulated patient Chronic patients
(stable) may serve well in this situation with
• Simulated patients who are well-trained offer
reliability and consistency in the quality of their
8.3 Couplet Station
• Some competencies may best be assessed by
coupled or linked stations. For example, a
couplet station may consist of a history-physical
examination combined with a problem-solving
8.4 Examination Questions
• Examination questions are designed to assess the
ability to interpret information and critical
thinking. The questions deal with diagnostic
investigations, differential diagnostic and
8.5 Environment of Exam Station
• The Examination Station environment should
be conducive to the competency to be tested,
including adjustable lighting for fundoscopic
examinations and appropriate examination
tables for focused physical skills assessment.
• Stations where auscultatory skills are being
assessed should be either well insulated or in
appropriately quiet areas of the examination
site. Clearly marked directions leading from
one station to the next should be displayed.
8.6 Examination Stations Circuit
• The Examination stations should be clearly
marked in a logical sequence that allows easy,
unimpeded transit from one station to the
S.No Station Task/Question
1. I Check and record Blood Pressure
2. II List five factors which helps in maintaining
3. III Take oral temperature and record it
4. IV Rest station
5. V Using the formula, convert 39 °C into
6. VI Test the urine for sugar and albumin
7. VII List five causes of albuminuria
9. Patient (Real) or Simulated
• A standardized patient is an individual with a
health problem that is in a chronic but stable
condition. Standardized or simulated patient
may be used when properly trained for history
and physical assessments.
• Simulated patients may come from the ranks
of volunteers, or acting guilds.
• Detailed instruction package is provided for
both the standardized and simulated patient.
The instructions describe how the patient
responds to historical questions and physical
exam, as well as how the patient should dress
10. Timekeeper, Time Clock and Time
• Appropriate personnel for the position of official
timekeeper and exam facilitators need to be
identified and properly instructed. A well
functioning time clock and time signal are
• One support person per three stations is
11. Contingency Plans
• A contingency plan includes reserve standardized
patients who are trained to assume a number of
roles, and a patient trainer who circulates to deal
with any patient problems that arise.
• A number of reserve stations should be available.
A contingency plan must be developed for
students who must leave the exam when the
12.Assessment of the Performance of
• The OSCE should be tested for appropriate
measurement characteristics such as validity,
reliability, feasibility and credibility.
• A valid OSCE station measures what it was
designed to measure. A reliable station measures it
• Grading can be based on a criterion-referenced
system, norm-referenced system, or a combination
of both. The Examination committee needs to
decide in advance which system best meets its
fundamental purposes for the exam.
The advantages of OSCE outweigh other traditional methods of
clinical evaluation. The main advantages of OSCE listed by
Wikidot (2011) are as follows:
– The whole examination is objective
– It ensures integration of teaching and evaluation
– Variety inbuilt in OSCE maintains student's interest
– It helps in the development of critical thinking and
problem solving skills
– There is increased faculty and student interaction
– It is adaptable to local needs
– A large number of students can be tested within a
– Subjective bias is minimized
• As components of clinical competence are
broken down for examination at different
stations, it leads to the following limitations
• Inability to assess simple and specific skills
• Discomfort to patient
• Artificial setup
• Fatigue of examiners
Viva Voice/Oral Examination
• Knowledge is tested in theory examination
and skills are evaluated in clinical/practical
examination and oral examination is meant to
evaluate the following qualities: depth of
knowledge, ability to discuss and defend one's
decisions,' attitudes, alertness, ability to
perform under stress and professional
• Oral examination should primarily aim at
testing, problem-solving, alertness, ability to
develop and answer and come decisions
• It allows a direct contact between the
examiner and the examinee, it provides an
opportunity for studying personal
characteristics and permits flexibility in
• There is less scope for cheating or unfair
practice by the examinee.
• It can be a good learning experience as there
is scope for an immediate feedback.
Objective Structured Practical
• Objective structured practical examination
(OSPE) is a new pattern of practical
examination, in which each component of
clinical competence is tested uniformly and
objectively for all the students who are taking
up a practical examination at a given place.
Steps of OSPE
• In order to organize an OSPE successfully, one
has to spell out the objectives of practical
experiences in a given discipline related to a
1. Demonstrate Practical Skills.
For example, for demonstration of practical skills,
monitoring and recording oral temperature, blood
pressure, converting 39.4 degree centigrade to
Fahrenheit and testing urine for sugar, etc. can be
2. Make Accurate-Observations
Differentiate between the normal and
abnormal ECG, identify the type of
arrhythmias from the ECG.
3.Analyze and Interpret Data
Hemogram report, liver function report,
urine or blood sugar report and other
4. Identify the Patient's Problems
• The student has to identify the patient's problem in
order to organize her work.
• Problems such as Dyspnea,
• Rieor following blood transfusion and
• CSF rhinorrhea following head injury.
5. Plan Alternative Nursing Interventions
• In case of airway obstruction, the student is expected
to keep the patient in side lying position.
• Do Oro pharyngeal suction.
• Start O2 inhalation if required.
Types of Stations
• Procedure station: It requires a student to
perform a task, e.g. monitoring of oral
temperature. When a student performs the
task, simultaneously she is observed and
marked against the checklist being prepared in
advance, by a silent but vigilant examiner.
• The question station/the response station:
The student answers the question being asked
on the answer sheet provided and leaves it in
the place specified.
Scoring Students in OSPE
• For each specific skill, a checklist is prepared
by breaking the skill being tested into essential
steps and score is assigned to each step which
is proportional to the importance of the step
related a particular procedure.
Procedure of Conducting OSPE
• Examiners A, B, C stand in a place from where
they can have a good view of what a
candidate is doing at a particular station. They
have a checklist on which they tick as they
observe. The score of each student is entered
separately and confidentially.
• The students are given clear instructions
regarding how they will rotate around the
stations and the time limit in each station and
what they are supposed to do in each station
(demonstrate a skill, make observation, make
calculation from the data provided or answer
the question asked).
Limitations of OSPE
• OSPE is used only in simulated situations due to non-
availability of patients for the same procedure.
• The simulated situation may not reflect the real life
• Students cannot be assessed for different skills, such as
IPR, communication skills and dexterity in handling
• Empathy towards the patients cannot be evaluated.
• The skill of the student in providing holistic nursing
care cannot be assessed.
• It may be time consuming to construct an OSPE.
• It cannot be used by a single person, it needs
resources in terms of manpower, time and
• There is no interaction between the examiner
• There is a risk of fatigue.
• The OSCE has several distinct advantages. In
view of these, the nurse educators can adopt
it as an objective method for clinical
evaluation. This will help the students to
improve their clinical competence. The
emphasis is on assessing what students can do
rather than what they know. Therefore, OSCE
gives direction for attaining the ultimate aim
of the teaching- learning process.
• Agarwal A., Batra, B., Sood, A. K., Ramakrishnan, R., Bhargava, S. K.,
Chidambaranathan, N., & Indrajit, I. K. (2010). Objective structured
clinical examination in radiology. Indian Journal of Radiology and
Imaging, 20 (2), 83-88.
• Boursicot, K., Ware, J., & Hazlett, C. (2011). Objective structured
clinical examination and objective structured practical examination.
Retrieved from http://www.oes.cuhk.edu.hk/Archives/01d%20
• Harden, R. M. (1988). What is an OSCE? Medical Teacher, 70(1), 19-
• Sturpe, D.A. (2010). Objective Structured
Clinical Examinations in Doctor of Pharmacy
Programs in the United States. American
Journal of Pharmaceutical Education, 74 (8),
• Wikidot (2011). Objective structured clinical
examination in otolaryngology. Retrieved from
http.V/oscenotesent. wikidot .com/