Nigerian Journal of Paediatrics

Experiences with conducting the objective structured clinical examination OSCE as a formative tool at the end of Paediatric Posting in a new Medical School in Nigeria

Niger J Paediatr 2019; 46 (1):9 – 14

ORIGINAL

Musa S

CC – BY

Experiences with conducting the

Aliyu-Zubairu R

Haliru L

objective structured clinical

Andeyansto EA

examination (OSCE) as a

Dodo A

formative tool at the end of

Paediatric Posting in a new

Medical School in Nigeria

DOI:http://dx.doi.org/10.4314/njp.v46i1.3

Accepted: 16th February 2019

Abstract : Background: Medical

of the posting using standardized

schools use different evaluation

patients while scoring was done

Musa S (

)

methods after students undergo a

using task-specific and validated

Aliyu-Zubairu R, Haliru L

period of instruction for certifica-

checklists by the same assessors.

Andeyansto EA, Dodo A

tion of acquisition of requisite

Results: A range of clinical com-

Department of Paediatrics,

skills and competencies required

petencies in different clinical sce-

Barau Dikko Teaching Hospital,

for registration. Despite a global

narios, including history taking,

Kaduna. Nigeria

trend towards adoption of OSCE

physical examination and basic

Email: musa4all@gmail.com

format to test competencies, its

clinical skills was examined using

adoption in medical schools in

this format.

Nigeria has been relatively slow

The conduct was resource inten-

and local experiences with its use

sive with much time spent during

are limited. We describe the de-

the selection of the competencies

velopment and administration of

and appropriate standardized pa-

OSCE for the formative assess-

tients to be tested, standardization

ment of undergraduate medical

of checklists, briefing assessors

students of Kaduna state univer-

and choosing appropriate venue as

sity at the end of paediatrics clini-

well as preparation of stations.

cal rotation.

Unfamiliarity with OSCE by both

Methodology: OSCE was devel-

some students and assessors was a

oped and conducted to assess

major challenge.

clinical skills of 20 undergraduate

Conclusions: OSCE is a feasible

medical students at the end of

way of assessing a wide range of

clinical posting in paediatrics.

clinical competencies of medical

Students rotated through a series

students during paediatric rotation

of clinical encounters arranged in

in our setting.

ten stations in a circuit, each for a

short duration of five minutes.

Key words: OSCE, Evaluation,

Clinical tasks were carefully cho-

Assessment, Competencies, Skills

sen to reflect learning objectives

Introduction

with the right attitude to practice the profession are al-

lowed to eventually graduate. One way of ensuring that

Barau Dikko Teaching Hospital is the newly accredited

students have achieved the intended and expected learn-

Teaching Hospital for the training of clinical students of

ing outcomes is to put them to test in all the learning

domains of knowledge, skills, attitude and behaviours

the College of Medicine of the Kaduna State University.

Different departments are required to instruct potential

The evaluation of acquired clinical skills and attitudes is

doctors in their areas of expertise in rotation otherwise

therefore an essential component of this assessment of

clinical competency. The newly accredited Department

referred to as clinical postings or clerkship, and to ac-

cess them at the end of the period of posting in order to

of Paediatrics of the College of Medicine Kaduna State

certify that they have acquired the requisite knowledge,

University therefore needs to employ the most appropri-

skills and competencies required for registration as

ate assessment tools for this purpose.

medical doctors with the Medical and Dental Council of

Nigeria (MDCN).

The tools available for both training and assessment in

medical education are however continually changing,

The Department of Paediatrics plays a key role in ascer-

which makes it necessary for the trainers, the training

taining that only competent and knowledgeable students

institutions as well as the trainees to be up-to-date with

current trends in line with best practices globally.

Description of OSCE stations

Generally, several assessment tools of medical trainees’

competencies exist. The choice of a method to assess

Sixteen students who received clinical training at the

performance-based learning must necessarily be one that

Department of Paediatrics as part of their first clinical

is potentially very good in the assessment of profes-

rotation for eight weeks and four undergraduate medical

sional competence, including communication skills,

students (three from Chinese medical schools and one

clinical reasoning, judgement, attitudes, emotions, val-

from a Sudanese medical school) who were on elective

ues and reflection. This is the value of the Objective

postings in the department at the time participated in the

Structured Clinical Examination (OSCE), which objec-

OSCE.

tively assesses these domains and thus rectifies the limi-

tations associated with the traditional assessment meth-

The OSCE consisted of a single carousel with seven

ods of clinical skills using the long case-short cases

clinical stations comprising of ten clinical encounters

model. Besides assessing the competency and perform-

including three rest stations. Students were introduced in

ance of the candidates, OSCE is said to have further

groups starting at any one of the stations and rotated

benefits over traditional methods of assessment such as

round the carousel of stations until they have completed

the conventional bedside examination methods.

the cycle as shown in figure 1. Each station was for a

short duration of five minutes. The clinical tasks for the

OSCE has been in use in many medical schools across

OSCE were carefully chosen to reflect the learning ob-

the globe since its introduction and is now well estab-

jectives of the posting. Standardized patients were pur-

lished as effective assessment tools for clinical compe-

posively recruited and used for the manned stations.

tence. Along with its numerous variants and adaptations,

Scoring was done by Faculty members, using task-

it is increasingly becoming an important part of the

specific and validated checklists. In that way, all candi-

medical assessment process in many medical schools

dates were objectively made to perform the same tasks

throughout the world.

3,6-10

The widespread adoption of

in the same setting and were scored by the same examin-

this examination method is based on decades of research

ers using the same structured scoring scheme.

and use across the globe. Its flexibility renders it a rea-

sonable method of assessment of clinical competence

Prior to the day of the OSCE, a suitable venue was iden-

which has been found useful in different cultural and

tified and the assessors to man different stations as re-

geographical settings to assess a wide range of learning

quired were identified and assigned. All the required

outcomes, in different specialties and disciplines for

instruments to be used were assembled. Stations were

both formative and summative purposes. It can further

clearly set up and clearly marked. Instructions and tasks

be used to assess students in the different phases of edu-

to be carried out for each station were developed and

cation including the early and later years of the under-

printed. The sequence and flow of the students during

graduate curriculum.

the OSCE were determined and agreed on. Appropriate

signage was placed to direct the students. Finally, check-

However, in spite of the general trend towards adoption

lists were developed by the examiners and standardized.

of the OSCE format elsewhere, especially in the UK and

On the day of the OSCE, the candidates, assessors and

the USA, its adoption and use in medical schools in

the standardized patients were further briefed separately.

Nigeria and postgraduate medical colleges in the assess-

There were other support staffs, including a timekeeper

ment of both undergraduate and postgraduate students

with reliable stop clock and a bell, to further direct the

respectively has relatively been slow with less than 30%

students and ensure a smooth flow.

of medical schools in Nigeria currently using this format

of assessment.

Station 1 was a manned station designed to test history

In this paper, we describe the development and admini-

taking skills. It aimed at assessing the candidates’ ability

stration of OSCE for the formative assessment of under-

to take focused history under observation from an 18-

graduate medical students of a state university at the end

month old girl presenting with fever and rash. (Box 1)

of the first paediatric clinical rotation, and share our

This was followed by a rest station, during which no

experiences with the conduct of the OSCE.

clinical encounter took place.

Station 2 was also a manned station consisting of two

coupled clinical encounters. In the first encounter of this

station, the students’ ability to obtain a focused history

Subjects and methods

of convulsions from a boy was assessed. In the second

Study area

clinical encounter of the station, the ability to carry out a

motor neurologic physical examination of the lower

The study was conducted at the Paediatrics Department

limbs was tested. (Box 1)

of Barau Dikko Teaching Hospital, a tertiary referral

hospital, newly accredited training centre for the training

Station 3 was an unmanned written station that was to

of medical students of a new state university. The de-

test the ability of the students to make accurate diagno-

partment was receiving its first batch of 16 undergradu-

sis, outline management plans and write an appropriate

ate medical students for their clinical posting together

prescription. (Box 2) This was then followed by another

with four other foreign-based medical students on elec-

rest station devoid of any clinical encounter.

tive posting.

Station 4 was yet another manned, coupled station with

two clinical encounters. It assessed the students’ skills in

Box 2: Structure of OSCE Stations

respiratory system examination in the first encounter

Station 3: Clinical Case Management

and skill in measuring the blood pressure of a child in

the second clinical encounter of the station. (Box 2)

This station tests your ability to properly manage a

case of Malaria

Box 1: Structure of OSCE Stations

Clinical Scenario: Tolu Alade is a four-year old boy

Station 1: History Taking

who was brought into the EPU in coma, having been

This station tests your ability to take a focused history from

unarousable for the past one hour. Examination re-

a patient presenting with fever and rash

vealed a pale and febrile child weighing 15kg. His

Clinical Scenario: Lami Tanko is an 18-month old child

temperature was 39.5 C. Side Lab blood film result

presenting at the EPU with fever and rash of one week dura-

tion.

showed mps ++ and a Hb = 4.1g/l.

Instruction: Take a focused history of her complaints.

Instruction: Please write on the sheet of paper pro-

Station 2A: History Taking

vided:

This station tests your ability to take a focused history from



What is the most likely diagnosis?

a patient presenting with convulsions



List four other possible presentations of your di-

Clinical Scenario: You are seeing Tunde Olowu, a five-

agnosis and the parameter for its definition

year old boy in the outpatient department today. His mother

states that he has had convulsions on their way to the hospi-



Outline your management plan for Tolu Alade

tal.



Write an appropriate prescription for Tolu Alade..

Instruction: Take a focused history of this complaint.

Station 4A: Skill – Respiratory System Examina-

Station 2B: Examination

tion

This station tests your ability to examine the Central Nerv-

This station tests your skills in the examination of the

ous System in the lower limbs

respiratory system

Clinical Scenario: Bala is a five-year old boy who com-

plains of lower limb weakness

Clinical Scenario: Chidi Nwosu is a ten-year old boy

Instruction: Carry out a motor neurologic examination of

who complains of cough

the lower limbs.

Instruction: Carry out a complete examination of the

respiratory system

Box 3: Structure of OSCE Stations

Station 4B: Skill – Blood Pressure Measurement in

Station 6A: History Taking

Children

This station tests your ability to take a focused history from

a patient presenting with diarrhoea

This station tests your skills in measuring the blood

Clinical Scenario: Ademola Wasiu is a 2-year old child

pressure of a child.

presenting at the DTU with diarrhoea.

Clinical Scenario: Nsikan Udo is a ten-year old boy

Instruction: Take a focused history of his diarrhoea.

who complains of cough and left-sided chest pain.

Instruction: Measure the blood pressure of Nsikan.

Station 6B: Laboratory Result Interpretation

This station tests your ability to interpret a result of Urea &

Station 5: Skill – Abdominal Examination

Electrolytes

This station tests your skills in the examination of the

Clinical Scenario: The following is the U & E result of

Abdomen

Ademola

Urea

4.3 mmol/L

Clinical Scenario: Ayuba Nda is a ten-year old boy

Sodium

139 mmol/L

who presents with a 2-day history of abdominal pains

Potassium

2.1 mmol/L

Instruction: Carry out a thorough abdominal exami-

Chloride

102 mmol/L

nation of Ayuba

Bicarbonate

24 mmol/L

Creatinine

30 umol/L

Station 5 was also a manned station that aimed at assess-

Instruction: Answer the following questions in the sheet of

ing the students’ skills in abdominal examination as the

paper provided

sole encounter. (Box 2) There was a rest station follow-



What abnormalities can you identify?

ing this in which no clinical encounter took place.



List four signs that could be picked in Ademola

Station 6 was a manned station and consisted of two



How would you correct the abnormalities?.

clinical encounters. In the first clinical encounter of this

Station 7: Skill – Use of Pulse Oximetry

station, the students’ ability to obtain a detailed history

This station tests your skills in the ability to use a pulse

Oximeter

of diarrhoea was assessed, while their ability to accu-

Clinical Scenario: Benjamin Tukura is a 2-year old boy

rately interpret urea and electrolytes laboratory results

who complains of cough, fever and fast breathing. He has a

was tested as well as the ability to associate clinical

respiratory rate of 40 cycles per minute and SPO2 of 84%.

signs with the electrolytes abnormality detected and the

Instruction: Answer the following questions in the sheet of

ability to correct the abnormalities. (Box 3)

paper provided

Station 7 was another unmanned written station that



What is your most likely diagnosis?

assessed the students’ ability to recognize the need for



Assuming that his SPO2 remains at 84%, what will be

oxygen therapy in a child and the ability to appropriately

your next line of action?

use a pulse oximeter. (Box 3)



List 3 other indications for oxygen therapy

At the end of the OSCE session, assessors, support staff

Time spent

and the standardized patients received light refreshments

as a token of appreciation for the contribution each gave

A lot of time was spent during the planning stage of the

towards the success of the examination. Scores were

OSCE, including the time for meticulous planning of the

compiled by all the examiners and the results were sub-

OSCE session. Further time was spent in the selection of

sequently displayed. Experiences and observations were

the competencies and skills to be tested, the recruitment

shared among the academic staff members of the depart-

of appropriate standardized patients (SPs), formation

ment.

and standardization of the checklists, briefing the asses-

Fig 1: Schematic diagram of OSCE carousel

sors and the SPs. Time was additionally required for the

selection of an appropriate venue that will allow for free

flow of the examination without interruption. Prepara-

tion and labelling of each station to avoid ambiguities

also required time of its own.

The actual conduct of the OSCE sessions was conducted

in over two hours for the two rounds required to com-

plete.

Staff and other resources needed

Conduct of OSCE was also found to be resource inten-

sive – human and material. For the eight manned sta-

tions used in this examination, there was the need for at

least sixteen different assessors, two for each station as

per standard practice. This was in addition to the other

support staff that took care of students’ registration,

attendance, as well as general invigilation for good con-

duct of the students during the sessions and time

keeping.

Results

Besides the examination staff, the other resources that

were required include stationary used as answer sheets

OSCE format was successfully used to examine a range

for the written stations, a stop clock, a bell and other

of clinical competence in different clinical scenarios,

miscellaneous items required for the examination sta-

including interviewing, physical examination skills,

tions.

critical thinking, clinical judgments, and technical skills.

Standardised Patients (SP)

Scope of clinical competencies assessed

These were used for the OSCE session rather than real

Overall, some of the competencies assessed in this

patients partly because of the stress to which the later

OSCE included; history taking, physical examination,

would have been subjected. These SPs were made to

data interpretation, diagnosing, management options and

play roles simulating a clinical scenario desired for the

prescribing. Some other competencies that were indi-

station.

rectly assessed include communication and interpersonal

skills and professional attitude. Table 1

Challenges

Table 1: Scope of competencies assessed at various clinical

encounters station

In the absence of mannequins, the use of children as

standardized patients was found to be particularly chal-

Station/Clinical

Competencies tested/Assessed

lenging. Briefing these SPs to give consistent history or

Encounter

to endure the rigours of the OSCE was another chal-

Station one

History taking, Communication and

lenge. Another major challenge that limited the number

interpersonal skills, professionalism

Two

History taking, Physical examination,

of carousels used in this OSCE was that of finding pa-

Communication and interpersonal skills,

tients with similar features for use across multiple carou-

professionalism

sels to further save time.

Three

Diagnosing, Management plan options,

Finally, unfamiliarity with the OSCE format by both

Prescribing

students and some assessors was another major chal-

Four

Physical examination, Communication

lenge witnessed in the course of the OSCE.

and interpersonal skills, professionalism

Five

Physical examination, Communication

Limitation

and interpersonal skills, professionalism

Six

History taking, Data interpretation,

Management plan options,

The present study is a descriptive narrative of experi-

Communication and interpersonal skills,

ences with the conduct of OSCE as a tool for assessing

professionalism

undergraduate medical students in a new medical school.

Seven

Data interpretation, Diagnosing,

It did not attempt to determine the reliability or validity of

Management plan options

OSCE as an evaluation tool.

Discussion

ray and 2 slides), five for lab reports, one for problem

solving and four for questions related to the tasks per-

formed on various stations. We designed OSCE stations

This report has clearly shown that use of OSCE is feasi-

ble for the formative assessment of medical students

that didn’t only assess psychomotor skills but other do-

during their paediatric postings in our setting. A 13-

mains of learning as well. That was possible by design-

station OSCE comprising ten clinical encounters and

ing written stations for clinical reasoning, data interpre-

three rest stations set up assessed twenty medical stu-

tation and diagnosis. Similar designs were shown to be

viable in some OSCEs.

6,7

dents at the end of their first clinical posting rotation in

paediatrics.

As early as 1980 in Britain, it was shown that a solely

Another aspect of some difficulties when conducting

paediatric-dedicated OSCE was possible, when an 18-

OSCE in paediatrics is the use of standardized patients,

which is a distinguishing feature of all OSCEs.

1,13

station OSCE was reported. Prior to that OSCEs were

Stan-

done mostly in adult medicine or just establishing a few

dardized patients would require special training of chil-

paediatric cases stations within OSCEs.

dren to act or simulate the feature that the examiners

desired to be assessed. The consistency and reliability of

The initial preparation for the OSCE was quite daunting

a child simulator cannot be guaranteed, and that can

and time consuming. The course coordinator had to as-

compromise the objectivity of the exam. This difficulty

sume the role of the departmental OSCE coordinator and

was recognized early, which made OSCEs in paediatrics

thereby take full responsibility for the smooth organiza-

not to be as common as in adult medicine, until paediat-

tion of the OSCE. These included advanced practical

ric OSCEs or paediatric cases within OSCEs increas-

steps, including identifying the most appropriate venue,

ingly used both children and parents as standardized

patients.

setting up the various stations after the determination of

In the present OSCE, this was overcome by

the number and nature of the stations, numbering and

the use of parents as informants for stations that in-

labelling the stations, identifying and assigning asses-

volved history taking and real patients for physical ex-

sors to the various stations, recruiting and briefing the

amination stations. Similarly, some OSCEs also used

either the parents at history taking stations

14, 15

standardized patients or parents and checking the equip-

or real

patients

8-10, 12

ment to be used in all stations. Other initial steps taken

as a way of overcoming the difficulties

faced in the use of children as standardized patients.

prior to the conduct of the OSCE are preparing and vali-

dating checklists and other sundry printing work.

It has been reported that unfamiliarity with OSCE for-

mat could interfere with the performance of students and

staff. This has been seen to be the major challenge fac-

The actual conduct of the OSCE took a total of 130 min-

utes for the 20 students to complete the circuit unlike the

ing young or new medical schools and training institu-

much shorter time of 80 minutes used to assess same 20

tions like ours. It is hoped that with the introduction of

students in another setting. This was because of having

the OSCE as an assessment tool in paediatric postings,

fewer carousels in our case. Setting up more carousels

students will pay greater attention to learn the necessary

would have shortened the time for the entire OSCE, but

skills and staff will also adapt the OSCE methods to

would have required us to have more examiners to man

appropriately teach to reflect the real-life tasks of the

the stations in the additional carousels. Some other pae-

doctor.

diatric OSCEs had overcome this limitation by increas-

ing the number of stations in a single carousel, using

The Faculty of Clinical Sciences should also consider

between 10 and 34 stations,

5-6,11

making up for the extra

sourcing for some of the resources needed for a success-

manpower needed with the addition of unmanned writ-

ful conduct of the OSCE by the department, such as

ten assessment stations.

mannequins to obviate the short-comings inherent in the

use of children as standardised patients. The administra-

Traditionally, educators face difficulties attempting to

tion of formative and summative OSCEs in teaching

a s s e s s

c l i n i c a l

q u a l i t i e s

s u c h

a s

programs has been shown to improve final-year medical

professionalism, teamwork, and expertise that have been

school student’s examination performance.

difficult to define and quantify. With the use of OSCE

Although the present study did not venture into assess-

however, we were able to test a wide range of skills and

ing the reliability and validity of OSCE as an evaluation

competencies including three clinical encounter stations

tool, the importance of paying attention to test content,

for history taking, three for physical examinations

test design, as well as implementation factors for guar-

(general and focused), three for data interpretation, three

anteeing OSCE is used in a valid and reliable way was

previously highlighted. This article shares experiences

for management plan, one for laboratory report (urea &

electrolytes), one for prescribing and five clinical en-

about the design and implementation of OSCE for un-

counters tested communication skills, interpersonal rela-

dergraduate medical students to be considered by medi-

tionship and professionalism. This was similar to a 10-

cal educators when planning to use OSCE in similar

station OSCE used to assess four domains of compe-

settings as they may impact on both reliability and

tence; clinical skills, problem-solving, knowledge and

validity.

patient management, and the range of skills tested in the

first solely paediatrics OSCE that had one station for

history taking, three for physical examinations (general

and focused), four for laboratory examinations (urine, x-

Conclusion

Acknowledgement

In conclusion, OSCE was found to objectively assess

We thank all colleagues, nurses and other staff of the

clinical skills of medical students on paediatric rotation

paediatric wards of Barau Dikko Teaching Hospital,

in our setting including in domains not well assessed

Kaduna for their assistance with the conduct of the

using the traditional examination methods. The design

OSCE, as technical support staff. We particularly thank

and conduct of the OSCE however is both time consum-

Mr Sunday Ashel, whose timekeeping was invaluable in

ing and resource intensive. OSCE, which is used exten-

the smooth flow of the OSCE. Finally, we most sin-

sively globally, should be a more frequent evaluation

cerely thank all the children and their caregivers for their

method, and when well designed, may improve teaching

cooperation as standardized patients. Without them, this

and learning of the desired competencies and appropri-

OSCE could not have been successfully done.

ate behaviour and skills to ensure a more professional

Conflict of interest: None

doctor.

Funding: None

References

1. Ohwovoriole A. OSCE Skills

9. Smith LJ, Price DA, Houston

15. Hilliard RL, Tallett SE: The

for Trainees in Medicine: Au-

IB: Objective structured clini-

use of an objective structured

thor House, 2015.

cal examination compared with

clinical examination with

2. Epstein R. Assessment in

other forms of student assess-

postgraduate residents in pae-

Medical Education. N Eng J

ment. Archives of Disease in

diatrics. Archives of Paediat-

Med 2007;356:387 – 396.

Childhood , 1984;59:1173-

rics and Adolescent Medicine ,

3. Waterston T, Cater JI, Mitchell

1176.

1998;152:74-78.

RG: An objective undergradu-

10. Frost GJ, Cater JI, Forsyth: The

16. Lane JL, Boulet JR: A paediat-

ate clinical examination in

use of objective structured

ric clinical skills assessment

child health. Archives of Dis-

clinical examination (OSCE) in

using children as standardized

ease in Childhood , 1980;

paediatrics. Medical Teacher ,

patients. Archives of Paediat-

55:917-922.

1986; 8:261- 269.

ric and Adolescent Medicine ,

4. Abo-Bakr AM. What makes

11. Verhoeven BH, Hamers JGHC,

1999; 153:637-644.

OSCE a good adjunct to the

Scherpbier AJJA, Hoogenboom

17. Townsend AH, McLlvenny S,

conventional methods of as-

RJI, van der Vleuten CPM: The

Miller CJ, Dunn EV. The use

sessing clinical competence?

effect on reliability of adding a

of an objective structured

Ann Saudi Med 1991 Jan;11

separate written assessment

clinical examination (OSCE)

(1):87-89.

component to an objective

for formative and summative

Matsell DG, Wolfish NM, Hsu

structured clinical examination.

assessment in a general prac-

E: Reliability and validity of

Medical Education , 2000;

tice clinical attachment and its

the objective structured clinical

34:525-529

relationship to final medical

examinations in paediatrics.

12. Malloy MH, Perkowski L,

school examination perform-

Medical Education , 1991;

Callaway M, Speer A: The

ance. Med Educ 2001;35

25:293-299

relationship between preceptor

(9):841-846.

6. Joorabchi B: Objective struc-

expectations and student per-

18. Turner JL, Dankoski ME. Ob-

tured clinical examination in a

formance on 2 paediatric objec-

jective structured clinical ex-

paediatric residency program.

tive structured clinical exami-

ams: a critical review. Fam

American Journal of Diseases

nation stations. Archives of

Med . 2008;40(8):574-8.

in Children , 1991; 145:757-

Paediatric and Adolescent

762.

Medicine , 1998; 152:806-811.

7. Verma M, Singh T: Experi-

13. Boursicot K, Roberts T. How to

ences with objective structure

set up an OSCE. Clin Teach

clinical examination (OSCE) as

2005;2:16-20.

a tool for formative evaluation

14. Lane LJ, Ziv A, Boulet JR: A

in paediatrics. Indian Paediat-

paediatric clinical skills assess-

rics , 1993; 30:699-702.

ment using children as stan-

8. Watson AR, Houston IB, Close

dardized patients. Archives of

GC: Evaluation of an objective

Paediatrics and Adolescent

structured clinical examination.

Medicine , 1999; 153:637-644.

Archives of Disease in Child-

hood , 1982; 57:390-398.