Clinical Assessment of Learners Clinical assessment involves the evaluation of technical skills, communication skills, professionalism, knowledge base, and teaching skills, where applicable, of students who are about to enter independent practice. Technological changes have made it possible to assess clinical performance in ways that are far more advanced than pencil and paper tests relied on in the past (Dauphinee, 1995). In the late 1970s, clinical training programs utilized continuous practical assessments to evaluate learner competencies and as means of providing formative assessment feedback. These continuous practical assessments were considered to be "a much more valid, reliable, and realistic method of assessment" (Quinn, 1989). As clinical placements grew shorter and the number of staff, including those with "supernumerary status" grew larger, the quality of continuous practical assessments was substantively impaired (Girot, 1993). The goal of assessment has always been to identify a "competent practitioner" and to support the educational efforts required to develop clinicians who meet the standards associated with that designation (Quinn, 1989). What then "is meant by the term competence and how can it be assessed, especially at different levels of development"? (Girot, 1993).

Clinical Assessment Definitions

The level of quality and reliance that is demanded of clinical assessment requires the use of assessment tools that tend to be based on quantitative measures and which rely on professional judgments (Harris & Bell, 1997). The validity and reliability of these measures must come from evidence-based multiple measures and the triangulation of data (Harris & Bell, 1997).

Research in the area of poorly performing physicians may help inform the task of developing valid and reliable measures of assessing clinical performance (Southgate, et al. 2000). The definitions of the ratings acceptable, cause for concern, and unacceptable are based on the judgments of professional assessors and lay people, and they are determined according to the commonly accepted standards of any reasonably competent professional. The measures make up a broad portfolio -- as well they should, with the stakes so high -- and include the following approaches: "Examination of medical record; case-based discussions; observation of consultations; tour of the doctors working environment; up to 20 structured interviews with third parties, including patients, colleagues, health service managers, and nurses; and an interview with the doctor under review" (Southgate, et al. 2000: 152). The point of this discussion is that the validity and reliability of this constellation of performance procedures and measures is sufficiently robust to withstand legal challenge. These procedures are typically reserved for use with doctors who are at high-risk of failure due to poor performance. Less intrusive, rigorous, and costly data collection is used for marginally performing professionals.

Assessment criteria. Assessment strategies must meet a number of key criteria in order to be considered effective assessment methods (Harris & Bell, 1997). Assessment must be valid, which at its most fundamental level means that the assessment actually measures what it was intended to measure (Harris & Bell, 1997). To ensure validity, a first step is to match the assessment to the pre-determined learning outcomes (Harris & Bell, 1997). Assessment must be reliable according to certain standards -- absolute reliability is generally not achievable because there are so many variables that are not under the control of the learner or the assessor (Harris & Bell, 1997). An assessment of clinical performance should yield the same fundamental results if the assessment was repeated at another time with the same learner and under the same conditions (Harris & Bell, 1997). Assessment must be feasible (Harris & Bell, 1997). This means that the assessment can be accomplished with the available resources and in the allotted time frame (Harris & Bell, 1997). Feasibility applies to the learning environment, the learner, and to the clinical practice assessor (Harris & Bell, 1997). Finally, an assessment must demonstrate that it has adequate power to discriminate among learners (Harris & Bell, 1997). Discriminating power is important in both formative if there is to be any remediation or prescriptive instruction as a result of the formative assessment (Harris & Bell, 1997). It is also important for an assessment to demonstrate the power to discriminate in the summative evaluation process (Harris & Bell, 1997).

Assuring Assessment Validity

Accountability in assessment cannot be accomplished without a wide battery of evaluation tools that measure a broad range of outcomes and attributes. Those attributes must be gauged at the level of the individual and at the level of the group in order to develop accurate quality indices.

Assessment strategies used today are capable of predicting clinical competence...

Newer approaches to clinical assessment include the capability to administer large-scale performance tests across multicenter locations (Dauphinee, 1995). In addition, improvement in the measurement quality of performance-based tests has been substantive (Dauphinee, 1995). One approach -- that exemplifies the higher standards now feasible -- is the Objective Structured Clinical Examination (OSCE) (Dauphinee, 1995). The Objective Structured Clinical Examination consists of multiple independent stations through which students proceed in a timed, serial assessment format (Dauphinee, 1995). The Objective Structured Clinical Examination system is designed to assess predetermined clinical skills and typically utilizes standardized patients (SPs) (Dauphinee, 1995).
Standardized patients are lay people who are trained to role-play and simulate a range of medical problems (Dauphinee, 1995). The primary benefit of using Standardized patients is that the simulations are conducted in a reliable, consistent, and wholly realistic manner (Dauphinee, 1995). A strength of simulation training is that it is highly suitable for the training of multidisciplinary teams (Nishisaki, et al., 2007). The competence, self-efficacy, and overall performance of individuals and the performance of the multidisciplinary teams have been show to improve with training and assessment on standardized patients (Nishisaki, et al., 2007). There is reliable evidence that the actual operational performance of trainees improves in clinical settings through the use of procedural simulation (Nishisaki, et al., 2007).

Self-Reflection - Assessor Skills

The mentor's role is critical to the facilitation of the development of future clinicians (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). It is both a responsibility and a privilege to assist students in their efforts to bring the classroom into the real world, to translate theory into practice, and to bring about the transfer of training that makes for a professional clinician (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). A mentor is entrusted with this important role by the patients who will be and are being treated, by the corpus of colleagues whose reputations hinge on the strength and health of the field, and by the students, for whom a mentor is a pivotal link between what they have studied to become and who they will be professionally (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). The passing on of skills and knowledge is an ancient and essential role in society -- it can be at once the most challenging and rewarding role that a professional assumes (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007).

A mentor must have achieved the same level of competence, knowledge, and skills of those who will be mentored and assessed (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). This means that the mentor must have met the outcomes defined for that stage of the educational developmental framework that support the learning and the assessment of the clinician in practice (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). The skills that an assessor needs -- beyond the basic professional training they will have demonstrated -- create quite a broad menu (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). The mentor must be able to assist the student to make sense of their training and their practice through "the application of theory; assessing, evaluating, and giving constructive feedback; facilitating reflection on practice, performance, and experiences" (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). Assessors must ensure that they are able to function effectively in practice, that they can fulfill the needs of the field, and that they have the depth and breadth of knowledge and skills to warrant the awarding of the appropriate diploma, degree, or certification" (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a; Price, 2004b; "RCN, 2007). In addition to the solid and extensive base of knowledge, a mentor must function as a positive role model for student (Andrews & Chilton, 2000; Atkins & Williams, 1995; Cahill, 1996; Darling, 1984; Gray & Smith, 2000; Price, 2004a;…