Mitchell, Marion PhD, RN; Strube, Petra M Adv Prac, RN; Vaux, Amanda M Adv Prac Critical Care, RN; West, Nicky GCert Hlth Mment, RN; Auditore, Anthony MNSt, RN
As a practice profession, nursing requires safe and efficient delivery of care. Assessing safe practice, competence, and professional attributes is challenging when appointing nurses into new positions, particularly in the case of advancing to senior clinical positions entailing advanced responsibility and expectations. In 2003, the health district in which this practice innovation was set introduced behavioral-based recruitment1 using past or observed behaviors as the predictors of candidates’ future performance, instead of recruiting nurses for clinical advancement opportunities based on skills alone.2 The hospital, which is accredited by the American Nurses Credentialing Center with Magnet® status, strives for excellence in nursing using structural empowerment to promote leaders to initiate innovation and change.
This article reports on a recruitment process undertaken as a quality improvement initiative in an intensive care unit (ICU) to appoint existing staff to clinical nurse (CN) positions. A CN in this ICU is described as a clinician who provides expert clinical care and supports the general function of the ICU through the application of the principles of evidence-based practice (EBP), leadership, and education. In previous recruitment processes, nurses who exhibited desirable practices and behaviors were not always able to demonstrate these attributes in a traditional interview. Consequently, an innovative recruitment process was developed to better meet the needs of the ICU. The new method required candidates to submit the usual written application addressing key selection criteria for short-listing, and rather than progressing to interview, candidates were required to demonstrate their abilities in a simulated clinical scenario or objective structured clinical examination (OSCE).3,4
Objective structured clinical examinations are designed to reflect a real patient situation, allowing for the assessment of an integration of skills rather than a set of tasks.5 This is particularly relevant for the advanced practitioner,6,7 as in the current situation with ICU CN positions. Objective structured clinical examinations are used extensively in nursing4 and medical curricula competency-based assessments and have successfully been used in recruitment for healthcare positions.8,9 No literature has been found that describes their use for the selection of nurses advancing to higher level clinical positions; thus, this innovation adds to the existing body of literature.
The aim of this innovation was to determine the effectiveness of OSCEs in the recruitment process for CN positions in an ICU from the perspective of the selection panel and the candidates. The following sections outline the method, process, and results of implementing OSCEs as a structure for clinical advancement in a 25-bed ICU at a tertiary referral teaching hospital in Australia.
An OSCE was developed and implemented by the ICU interview team members using best practice guidelines (BPGs) (Table 1) that were developed and tested for undergraduate educational purposes.10 Each guideline was examined for appropriateness, suitability, and applicability for the positions open in the unit. Table 1 outlines the BPGs and the manner in which they were used or adapted for this purpose. It became evident that each of the BPG provided guidance to support the development and assessment of the candidates.
Information Given to Candidates
Candidates were instructed to attend the interview dressed as though they were coming to work a clinical shift. They were told they would be expected to engage in a clinical situation in a clinical skills room. Candidates were given background patient information as outlined in Figure 1 and were taken into the prepared simulation skills room by the role-playing bedside nurse who requested their assistance and support with a deteriorating patient (a high-fidelity mannequin).
How OSCE Was Conducted
Experienced clinical staff undertook various roles in the simulation to add authenticity and an ability to provide support to the candidate during the scenario (as would occur in a real-life situation in the ICU). Each role player was prepared for his/her role and understood the need for consistency for all candidates. The entire interview/scenario and scoring process was piloted with a staff member not otherwise involved in the recruitment process. Minor changes were made as a result of this trial; for example, an additional role of a medical staff member was introduced into the scenario for authenticity.
The person acting as the bedside ICU nurse was able to provide additional clinical information regarding the patient’s condition as requested by the candidate. Additional clinical support was introduced to the scenario at the candidate’s request (ie, role-playing senior nursing colleague or medical staff were available to assist in the scenario upon request). The clinical scenario progressed with the eventual need for the initiation of advanced life support (ALS).
At the conclusion of the simulation, candidates were invited to discuss with the panel any additional information and reflections they wanted to share. To conclude the interview process, each candidate was asked a question in relation to an aspect of practice not covered by the scenario. This involved their knowledge and involvement in quality improvement initiatives.
Assessment of Candidates
The BPGs supported the development of the scenario, the scoring guide, and assessment. An outline of the clinical scenario used in the position selection can be seen in Figure 1. The scoring guide had 2 components (Table 1, BPG 3) and was developed by the 4 interview panel members. One panel member was drawn from outside the ICU and was a senior clinician in an acute care area; both genders were represented, and 3 of the 4 were competent in assessing ALS. The 4th panel member was briefed on what was expected of a CN in such a scenario, and key elements were highlighted and discussed until the external interview panel member was confident that they understood the expectations for consistency and performance.
Candidates were scored out of 10 possible points on 3 broad areas (patient focus, team focus, and clinical expertise; Table 2). That is, they were not scored against individual tasks performed in the scenario but rather in a broad holistic manner (Table 1, BPG 3). An a priori score of higher than 5 of 10 was required in all 3 areas for the candidate to be considered a desirable candidate for advancement. The panel made notes and ranked the candidates independently, and their collective average score was the final data considered in the decision. The quality improvement question remained unchanged from previous recruitment and required candidates to speak to a quality project in which they had led a change within their unit. Their responses were scored out of 10, and for consistency, a result of 5 or higher was required. This score was then added to an individual’s overall OSCE numeric. Additional feedback was sought by the panel from the role player participants regarding their perception of the candidate’s teamwork and general communication skills. Individuals involved in role playing were not included in the panel deliberations or rating of candidates.
Evaluation of New Recruitment Strategies
Both the selection panel and candidates evaluated the new recruitment strategies. The selection panel met on more than 1 occasion after the completion of the recruitment period to reflect and discuss all aspects of the new selection process. This included an assessment of the appointed candidates’ clinical practice 6 months after appointment. Candidates were asked their perceptions and reflections on the OSCE process as a selection method for a CN position. This evaluation occurred 1 week after the interviews yet before candidates were notified of the outcome of the process.
There were 5 positions available at the time, and 11 candidates were shortlisted from 23 and progressed through the OSCE and interview process. Each scenario took approximately 30 minutes to complete. Three candidates successfully achieved the required cutoff scores as outlined earlier and were offered and accepted appointments in the ICU.
Evaluation of the New Recruitment Process by the Selection Panel
The selection panel considered that the scenario was sufficiently demanding of candidates and allowed them to demonstrate their ability. Successful candidates demonstrated knowledge, skills, teamwork, professionalism, and accountability by way of the scenario. The panel’s preparation with orientation to the scenario, the clinical expectations, and development of the scoring criteria proved effective. In fact, when panel members compared their scores at the conclusion of each candidate’s OSCE, they found that there was minimal variation in their scores, thus indicating the reliability of the ranking criteria. The external panel member was equally able to assess the candidates due to the preparatory work undertaken and the instructive scoring criteria.
The panel reconvened 6 months after the interviews to further evaluate the clinical progress of the selected candidates in their new roles. Senior ICU colleagues were asked to provide an assessment of the successful candidates’ overall performances. Universally, it was reported that they were performing at a high standard and were not requiring additional support to meet the requirements and expectations of the CN role.
Evaluation of the New Recruitment Process by Candidates
Feedback from the candidates (who were existing staff members in the ICU) occurred before the conclusion of the formal human resources process. All 11 candidates were invited to a group discussion; of these 11 candidates, 7 attended. (Note: candidates were unaware of the outcome of the process at this time). They stated that all forms of interviews induce stress. Overall, they indicated that they considered the OSCE format a valid and fair way to assess suitability for advancement positions because it replicated a real-life ICU situation in which they would need to be clinically proficient. It was acknowledged that with the same scenario, the degree of difficulty was uniform for all candidates.
The use of OSCEs can assist in the assessment of candidates’ clinical competence in an ICU.11-14 It was important that the OSCE provided the opportunity for candidates to demonstrate an integration of knowledge, skills, attitudes, and values that are reflective of a real-life situation. In addition, when the 1 OSCE was used exclusively, it facilitated consistency of assessment.4,5,15 It was important to achieve a fair, equitable, and transparent process for credibility of the internal clinical advancement opportunities.
Although developed for undergraduate nursing student assessment and learning,10 the OSCE BPGs provided a theoretical foundation and direction for the development of scenarios for simulation and the assessment of practicing nurses as candidates for CN positions. It is argued that in nursing education programs, authentic and clearly defined outcomes are important to students.10 This is also the case when recruiting and advancing staff into clinical positions where context-related competence is under examination.11-14
The purpose of this innovation was to assess whether OSCEs would provide a valid method to assess candidates for the role of a CN in an ICU. The site hospital strives to demonstrate the Magnet components: (1) including transformational leadership, (2) structural empowerment, (3) exemplary professional practice, (4) and new knowledge, innovations, and improvements.16 The OSCE-based selection technique aligned with each of these components. A major constituent of transformational leadership emphasizes the need for mechanisms to be implemented for BPGs to evolve and for innovation to flourish.16 The scenario-based interview technique significantly enhanced the behavioral-based interview technique used to recruit senior nursing staff into positions of leadership and advanced clinical care delivery at the site.
This interview technique also aligned with exemplary professional practice, as it allowed the candidate to demonstrate competence in a realistic situation. Furthermore, the element of structural empowerment was achieved through the organization using multiple strategies to establish structures, systematic and equitable processes, and expectations that support lifelong professional learning, role development, and career advancement.16 The candidates were able to put into practice the skills that they had developed over their time in the clinical setting to demonstrate their knowledge and understanding of the CN role and expectations. Moreover, they had the ability to attain career advancement through a successful and equitable recruitment process.
The OSCE developed using the BPGs was effective in identifying clinically advanced practitioners who were able to demonstrate their abilities in core elements, patient focus, clinical expertise, teamwork, and leadership. The BPGs provided clear direction and structure in preparing and conducting the OSCEs. The selection method clearly identified those candidates with the desired abilities and those who did not meet the required clinical standard. This same technique has been successfully implemented in a study where OSCEs were used as a selection tool for admission to a nurse anesthesia program.17
The validity of the OSCE process was confirmed by a 6-month review of appointed candidates’ clinical performances, where they were found to be achieving at a high level in the new roles. In another setting, the OSCE component in a longitudinal predictive study demonstrated a significant positive association with job performance 3 months into practice. In fact, those who were selected using the OSCE results performed significantly better than did those selected through traditional (non-OSCE) procedures.8 The candidates’ feedback for the current innovation indicated that they considered the OSCE method of selection for appointment to be fair, equitable, and appropriate to assess suitability for appointment.
This innovation was conducted at a single ICU in Australia. Magnet accredited hospitals may have more resources and support for innovation than would be found in other organizations. Not all hospitals have access to simulation environments, as was used in this process, which supported the real-life aspects of the OSCE. The process may be difficult to implement with large numbers of short-listed candidates.
Objective structured clinical examinations grounded in BPGs10 have been found to be an innovative, valid, and reliable way to identify suitably competent senior nurses for advancement in an ICU environment in a Magnet hospital. The new selection process aligned with the Magnet philosophy, promoting excellence in nursing care. The OSCE provided a relevant and appropriate simulated real-life situation where candidates displayed their ability to provide the skills, knowledge, and attitudes in patient focus, clinical expertise, teamwork, and leadership, all crucial elements of a senior clinical role. The BPGs provided a framework for OSCE development and assessment and supported the panel’s ability to discriminate between candidates in an objective manner. The successful candidates proved able and competent 6 months later, and the panel was confident that the new interview process helped with the selection of the right person with the right skills for the right job. Objective structured clinical examinations grounded in BPGs are recommended for wider application in the selection of candidates in health related clinical roles and settings.
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