Article type: Systematic review or other type of review paper

· Short informative title

ASSESSMENT OF NURSING STUDENTS´ COMPETENCE IN CLINICAL PRACTICE: A SYSTEMATIC REVIEW OF

REVIEWS

· Short running title

ASSESSEMENT OF STUDENTS COMPETENCE IN CLINICAL PRACTICE

Kati IMMONEN¹, Ashlee OIKARAINEN¹, Marco TOMIETTO¹, Maria KÄÄRIÄINEN¹, Anna-Maria

TUOMIKOSKI¹, Boris Miha KAUČIČ2, Bojana FILEJ2, Olga RIKLIKIENE3, M. Flores VIZCAYA-MORENO4, Rosa
M. PEREZ-CAÑAVERAS4, Paul DE RAEVE5, Kristina MIKKONEN¹

· List of all authors

1. Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
2. College of Nursing in Celje, Slovenia
3. Faculty of Nursing, Lithuanian University of Health Sciences, Kaunas, Lithuania
4. Nursing Department, Clinical Nursing Research Group, University of Alicante, Spain
5. European Federation of Nurses Associations, Belgium

· Acknowledgment

We would like to acknowledge European Commission, Erasmus+, KA2: Strategic partnership for
providing funding for the project Quality mentorship for developing competent nursing students
(QualMent).

· Funding Statement
European Commission, Erasmus+, KA2: Strategic partnership for providing funding.
· Corresponding author:

Dr. Kristina MIKKONEN (Orcid ID: 0000-0002-4355-3428; Scopus ID: 56373805200)

Research Unit of Nursing Science and Health Management

University of Oulu

P.B. 5000

FI-90014, University of Oulu, Finland

e-mail: [email protected]

Twitter: @Kristinamikkon
 1

1 Article type: Systematic review or other type of review paper

2 ABSTRACT
3 Background: The assessment of nursing students’ nursing competence is a matter of concern
4 worldwide and the complexity of assessing students’ clinical competence has challenged educators
5 for decades. It has been recognized that there is inconsistency among assessment methods and
6 tools between countries and institutions.
7 Objective: To identify the current best evidence on the assessment of nursing students’
8 competence in clinical practice.
9 Design: Systematic review of reviews.
10 Data sources: The electronic databases CINAHL, PubMed, Eric, Medic and the JBI Database of
11 Systematic Reviews and Implementation Reports were searched in autumn 2018.
12 Review methods: Two researchers independently assessed the eligibility of the studies by title,
13 abstract and full-text, and then assessed the methodological quality of the included studies.
14 Analysis of study findings was conducted using the thematic synthesis approach.
15 Results: Six reviews were included following critical appraisal. Assessment tools used to assess
16 students’ nursing competence commonly focus on the domains of professional attributes, ethical
17 practices, communication and interpersonal relationships, nursing processes, critical thinking and
18 reason. Clinical learning environments and mentoring provide important support structures and
19 guide the learning of students. The availability of assessment tools and criteria along with
20 providing individualized feedback and time for reflection strengthen the objectivity and reliability
21 of assessment.
22 Conclusions: There continues to be a need to develop consistent and systematic approaches in
23 assessment, and to use reliable and valid instruments in assessment. Mentors find assessment of
24 students’ competence to be particularly challenging and emphasize the importance of clear
25 assessment criteria, support from nurse educators and further education on assessment. Further
26 development in feedback practices and providing students with opportunities for reflection are
27 important in supporting the continuous learning process of students.
28 Key words: assessment, clinical practice, evaluation, nursing student, systematic review.
29
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1 What is already known about the topic?

2 - The assessment of nursing students’ competence in nursing is a matter of concern
3 worldwide and the complexity of assessment has challenged educators for decades.
4 - Inconsistency exists among assessment methods and tools between countries and higher
5 education institutions.
6 - Clinical competence assessment is challenging for both mentors and nurse educators,
7 and agreement must be achieved on assessment content and processes at the beginning
8 of clinical practice.
9 What this paper adds
10 - It is important to strengthen collaboration between healthcare organizations and higher
11 education institutions and to involve all stakeholders in designing assessment
12 strategies.
13 - There continues to be a need to develop consistent and systematic approaches in
14 assessment along with reliable and valid assessment tools.
15 - Several assessment methods and tools exist, but it is imperative that the language used
16 is clear and that mentors’ have competence to interpret and use these.
17 - The focus of assessment is to encourage the continuous learning process of students
18 which requires constructive feedback and opportunities for reflection between the
19 student, mentor and educator.
20

21 1. Introduction
22 The aim of nursing education is to educate students so that they achieve the necessary professional
23 level of nursing competence before entering the nursing profession. According to the World Health
24 Organization (WHO, 2013), it is imperative to not only increase the number of health
25 professionals, but to ensure that they have the appropriate knowledge, skills and competencies
26 relevant to the needs of the population. Quality education is the foundation for developing
27 competent health professionals capable of delivering safe, quality care (WHO, 2016). Patient
28 safety is a core value of nursing. Professional nurses have the ethical responsibility to safeguard
29 individuals when care is endangered by health care personnel or any other person, while educators
30 are responsible in promoting students’ understanding for the importance of patient safety
31 (International Council of Nurses, 2012).
32
33 Both theoretical and practical preparation are key components of nursing curricula, which are
34 needed in order for nursing students to achieve a professional level of nursing competence. In the
35 European Union countries, the duration of clinical training should account for at least one half of
36 the minimum duration of the nursing program (Directive 2013/55/EU). Even though higher
37 education institutions are responsible for providing nursing education, nurses who work as mentors
38 in clinical practice have a pivotal role in fostering students’ clinical learning (Directive
 3

1 2013/55/EU; Warne et al., 2010). Clinical learning environments have an essential role in the
2 development of students’ professional competencies and identity (Pitkänen et al., 2018; Tomietto,
3 2018; Vizcaya-Moreno et al., 2018). Well-designed and organized clinical placements are
4 important in ensuring that students receive appropriate support and learning experiences needed
5 to develop their competence and knowledge, skills, and attitudes required in their future
6 professional careers (Vizcaya-Moreno et al., 2018; Lovecchio et al., 2015).
7
8 The assessment of nursing students’ competence in nursing is a matter of concern worldwide and
9 the complexity of assessment has challenged educators for decades. Assessment of students’
10 competence during clinical practice is especially challenged for mentors and nurse educators
11 (Helminen et al., 2017). It has been recognized that there is inconsistency among assessment
12 methods and tools between countries and higher education institutions (Cant et al., 2013), and
13 there continues to be a lack of reliability and validity in the assessment of nursing students’
14 competence during clinical practice (Helminen et al., 2017). Assessment of students’ competence
15 according to clear professional standards is core in ensuring that students deliver safe nursing care
16 (Trede and Smith, 2012).
17
18 According to Oermann (2018), assessment involves gathering information about student learning
19 and performance, which can be used to determine further learning needs of the student and to plan
20 activities that will assist students to meet these needs. Assessment is used to confirm the outcomes
21 and competences met by the student, and can be conducted using diagnostic, formative or
22 summative approaches (Oermann, 2018). Although many good practices related to the assessment
23 of nursing students' clinical competence exist, assessment remains a challenging issue (Helminen
24 et al., 2014). For example, various assessment tools have been developed to improve the
25 assessment of clinical competence and that aim to enhance clear assessment of students’ clinical
26 competence according to safety and quality standards of nursing care (Ulfvarson and Oxelmark,
27 2012).
28
29 An essential component of competence assessment is the setting of learning goals (Clements and
30 Kamau, 2018). According to Oermann (2018), learning goals represent the level of nursing
31 competence that the student is required to achieve and may be written in the three domains of
32 learning: cognitive, affective, and psychomotor. Prior to entering clinical practice, students need
33 to be familiar with what they are expected to learn and of the clinical competences they are required
34 to develop. Learning goals need to be clearly defined and measurable, as they guide students in
35 their learning and also guide those involved in assessment in developing instruction and planning
36 the assessment (Oermann, 2018). Learning goals should be written clear enough so that they are
37 easy to follow and transparent assessment criteria should be made available (Hilli et al., 2014).
38
39 Successful completion of clinical practice requires the implementation of supportive and
40 continuous assessment within safe clinical learning environments and mentoring relationships
 4

1 (Norton, 2008). Effective mentoring in clinical environments supports development of students’

2 competence in nursing and promotes integration of theory into practice (Mikkonen et al., 2016).
3 Mentors have the responsibility to assess the learning outcomes achieved by students
4 (Dobrowolska et al., 2016), to provide students with continuous, tailored, and constructive
5 feedback on their performance and skills, to provide students with learning situations and to
6 increase their responsibility to work independently (Jokelainen et al., 2011). Mentors need to
7 develop and maintain adequate communication and assessment skills in order to effectively
8 support the learning process of students (Jokelainen et al., 2013). A study by Tuomikoski et al.
9 (2018) found that mentors need to further develop their competence in mentoring, for example on
10 how to support reflective discussion with students (Tuomikoski et al., 2018). It is important that
11 further continuing education is provided to mentors to enhance their competence in mentoring,
12 however a study by Oikarainen et al. (2018) reported that over half of mentors had not previously
13 attended further education.
14
15 The World Health Organization (2016) defines the core competencies of nurse educators which
16 includes, among other things, the ability to adapt, design and use tools for assessing and
17 documenting clinical practice. Educators ensure that appropriate methods of assessment are used
18 and that the learning outcomes of the curriculum are achieved, foster students’ reflection and self-
19 assessment skills, and provide students with timely and constructive feedback (WHO, 2016). The
20 role that nurse educators have in the assessment of nursing students’ competence in clinical
21 practice varies significantly internationally. In some countries, nurse educators from higher
22 education institutions take the role of clinical facilitators and actively guide students during
23 completion of their clinical practice (Dimitriadou et al., 2015). In several European countries,
24 however, the role of nurse educators in clinical practice has decreased and at times nurse educators
25 visit students only once, often during clinical competence assessment (Warne et al., 2010). For
26 example, the role of nurse educators has been reduced in Finland to the extent that nurse educators
27 do not always attend the clinical practice of students (Pitkänen et al., 2018). Therefore, registered
28 nurses who mentor students during their clinical practice have an increasingly significant role in
29 guiding students in their learning process and supporting development of their professional nursing
30 competence (Jokelainen et al., 2013; Rahnavard et al., 2013).
31
32 Due to the diminishing role of nurse educators in the clinical practice of nursing students (Warne
33 et al., 2010), it is essential that mentors have a clear understanding of strategies and processes
34 designed to facilitate students’ clinical competence assessment, and that they receive the necessary
35 support from higher education institutions (Helminen et al., 2017). Mentors and nurse educators
36 must work together and achieve agreement on assessment content and processes (Helminen et al.,
37 2017). It has been found that different expectations between students, mentors and nurse educators
38 generate situations where it is unrealistic or even impossible for students to achieve their goals in
39 clinical practice (Huston et al., 2018). The aim of this systematic review of reviews was to identify
40 the current best evidence on the assessment of nursing students’ competence in clinical practice.
 5

1 The following research questions guided the review: What kind of aspects are included in the
2 assessment of nursing students’ competence during their clinical practice? What kind of tools and
3 approaches have been used during the assessment of nursing students’ competence in clinical
4 practice?
5

6 2. METHODS
7
8 2.1. Design
9 A systematic review of reviews was conducted to compile evidence regarding the assessment of
10 nursing students’ competence in clinical practice from multiple reviews into one useful, accessible
11 document. The guidelines published by the Joanna Briggs Institute (JBI) (Aromataris et al., 2017)
12 and the Centre for Review and Dissemination (CRD, 2009) were used to guide each phase of the
13 systematic review of reviews. An evaluation of this review was performed using the PRISMA
14 checklist of items to include when reporting a systematic review (Moher et al., 2009).
15
16 Although both guidelines by JBI (Aromataris et al., 2017) and CRD (2009) recommend that only
17 systematic reviews be included in systematic reviews of reviews, we included other types of
18 reviews in addition to systematic reviews because of the lack of systematic reviews on this topic.
19 A systematic review is a rigorous research method used to identify, evaluate, and summarize
20 findings from relevant individual studies (CRD, 2009). The systematic review differs from other
21 types of reviews such as literature, scoping or integrative reviews through its systematic and
22 comprehensive approach in study selection, critical appraisal and data extraction (Aromataris and
23 Pearson, 2014).
24
25 2.2. Search methods
26 The electronic databases CINAHL, PubMed, Eric, Medic and the JBI Database of Systematic
27 Reviews and Implementation Reports were searched in autumn 2018 by two researchers (KI, AO).
28 Prior to conducting database searches, three researchers (KI, AO, KM) defined the search strategy
29 after consultation with an library information specialist. The keywords used in the search are listed
30 in figure 1 and supplementary file 1. Selection of the reviews was conducted based on precise
31 inclusion and exclusion criteria, which were set according to the research question in the PICoS
32 format (see Table 1; Aromataris et al., 2017; CRD 2009). This systematic review of reviews
33 included published, peer-reviewed systematic, integrative, narrative, scoping and literature
34 reviews. No time or language limitations were set. A search for the grey literature was not
35 conducted, however additional relevant evidence was searched for by screening the reference lists
36 of all of the articles included in the full-text review phase.
 6

1 2.3. Search outcomes

2 A total of 1464 publications were retrieved from the database searches (Figure 1). Duplicate
3 publications (n=101) were removed and two researchers (KI, AO) independently screened and
4 assessed the title (n=1363), abstract (n=688) and full text (n=25) of each publication against the
5 inclusion criteria (CRD, 2009). The researchers discussed results of the screening process and
6 agreement was reached on the inclusion of eligible studies. A third researcher (KM) was consulted
7 in situations where there was uncertainty regarding the eligibility of studies. Seventeen out of the
8 25 reviews included in the full-text phase did not meet the inclusion criteria and were excluded.
9 No additional reviews were identified following screening of the reference lists of all of the
10 reviews included in the full-text screening phase. The remaining eight reviews met the inclusion
11 criteria and were assessed for methodological quality.

12

13 2.4. Quality appraisal

14 The eight reviews that met inclusion criteria were assessed for methodological quality by two
15 researchers (KI, AO) independently using the JBI Critical Appraisal Checklist for Systematic
16 Reviews and Research Syntheses (Aromataris et al., 2015). The checklist contains a total of 11
17 assessment criteria. Every criterion was given a rating of ‘yes’, ‘no’, ‘unclear’ or ‘not applicable’,
18 and one point was given to every criterion rated ‘yes’. Following this, a total score was calculated
19 for each study. Reviews were not included into this systematic review of reviews if they failed to
20 reach a score of at least 50% on critical appraisal, the predetermined cut-off score agreed upon by
21 the researchers. Following critical appraisal, both researchers reached agreement on the
22 methodological quality of the studies. The total scores ranged from 0 (Wells and McLoughlin,
23 2014) to 11 (Suikkala et al., 2018) points (see Table 2). Two reviews (Lejonqvist et al., 2016;
24 Wells and McLoughlin, 2014) were excluded due to poor methodological quality in order to avoid
25 compromising the validity of the results and recommendations of this systematic review of reviews
26 (Poritt et al., 2014).
27
28 2.5. Data extraction and synthesis

29 Data relevant to the review question were extracted including: authors, year, country of
30 publication, journal type, type of analysis, study objectives, characteristics of participants,
31 characteristics of primary studies included in the review, databases searched, methods for quality
32 assessment of primary studies, number of primary studies included, and review findings (see Table
33 3).

34 Thematic synthesis was used to synthesize the data and to facilitate interpretation of the results.
35 This is a method used in the synthesizing of data from a focused research topic, and an approach
36 often used in identifying, analyzing, and reporting found themes (Nicholson et al., 2016;
 7

1 Whittemore and Knafl, 2005). During thematic synthesis, one researcher (KI) carefully identified
2 and analyzed the results from the included reviews. Following this, frequently recurring themes
3 and issues were identified, which were given categorical, aggregating or explanatory names. These
4 were used to search for combining or interpreting themes. Researchers (KI, AO, KM) identified
5 five themes that explained the studied phenomenon (see Figure 2).

6 3. Results

7 3.1. Study characteristics

8 This systematic review of reviews included one integrative review (Almalkawi et al., 2018), one
9 narrative review (Helminen et al., 2016), one scoping review (Suikkala et al., 2018), one literature
10 review (Yanhua and Watson, 2011), and two systematic reviews (Yepes-Rios et al., 2016; Wu et
11 al., 2015). The reviews were published between the years 2011 and 2018, and included original
12 studies published between the years 1985 and 2016. The original studies included in the reviews
13 were conducted in the United Kingdom (n=48), United States (n=20), Ireland (n=15), Canada
14 (n=10), Australia (n=9), Sweden (n=7), Finland (n=3), Taiwan (n=3), South Africa (n=2), Belgium
15 (n=1), China (n=1), Denmark (n=1), Nepal (n=1), New Zealand (n=1), Norway (n=1), Thailand
16 (n=1), Turkey (n=1), Scotland (n=1), and jointly in Canada and USA (n=1).

17

18 The reviews included qualitative and quantitative studies, mixed methods studies and reviews (see
19 Table 3). In addition to including reviews, qualitative and quantitative studies, Yepes-Rios et al.
20 (2016) reported also including a newspaper report, editorial and teaching points. In four of the
21 included reviews, standardized critical appraisal tools were used to assess the methodological
22 quality of original studies (Almalkawi et al., 2018; Suikkala et al., 2018; Yepes- Rios et al., 2016;
23 Wu et al., 2015). Critical appraisal was not reported in two of the included reviews (Helminen et
24 al. 2016; Yanhua and Watson, 2011).

25 The assessment of nursing students’ competence in clinical practice was divided into five themes
26 ‘nursing competence assessed during clinical practice’, ‘clinical learning environment’,
27 ‘mentoring’, ‘approaches in assessment’ and ‘assessment instruments’.

28

29 3.2. Nursing competence assessed during clinical practice

30 Clinical competence of students has frequently been assessed in various clinical environments and
31 during completion of different clinical nursing tasks (Almalkawi et al., 2018; Helminen et al.,
32 2016; Wu et al., 2015). The domains of professional attributes, ethical practices, communication
33 and interpersonal relationships, nursing processes, critical thinking and reason are often included
 8

1 in assessment tools used to assess nursing students’ nursing competence during clinical practice
2 (Wu et al., 2015). According to Wu et al. (2015) the majority of assessment tools used to assess
3 nursing students’ nursing competence are developed with reference to competency standards stated
4 by national boards of nursing. The authors list three broad conceptualizations of competence
5 models in nursing: 1) the behavioral approach, 2) identification of general attributes of the student
6 (knowledge, critical thinking skills), and 3) the holistic approach that addresses knowledge,
7 attitudes, values and skills used to function in clinical situations (Wu et al., 2015).
8
9 Studies have shown that there are significant problems associated with the language used to
10 describe competencies (Almalkawi et al., 2018; Helminen et al., 2016). Assessment may not
11 consider students’ performance or competence and may not give a clear enough picture of what is
12 required of the student (Almalkawi et al., 2018). Written examinations have been proven to be an
13 efficient way to describe students’ theoretical knowledge rather than their clinical practice skills
14 (Helminen et al., 2016). Wu et al. (2015) recommend the use of predefined standards to measure
15 the competence of students, for criterion-referenced assessment may facilitate reliable assessment.
16 Fair and clear assessment of students is impeded by the lack of appropriate and unambiguous
17 assessment systems and criteria (Almalkawi et al., 2018; Helminen et al., 2016). It has been shown
18 that students may feel that they are assessed according to personal characteristics rather than their
19 developing professional competence (Helminen et al., 2016). Assessment has also been found to
20 be inconsistent when evaluating students’ competence in situations where they have failed clinical
21 practice (Suikkala et al., 2018; Helminen et al., 2016).
22
23 3.3. Learning environment
24 Clinical assessment can be a very stressful event for students (Wu et al., 2015) and the personal
25 characteristics of students may influence the entire assessment process (Helminen et al., 2016). It
26 is necessary to promote an understanding that assessment can be helpful in facilitating learning
27 rather than a process that highlights incompetence (Almalkawi et al., 2018). The provision of
28 formal, constructive and development feedback in supporting clinical learning environment is an
29 essential element in the development of students’ competence (Almalkawi et al., 2018). Although
30 the role of patients in the assessment of students continues to be quite passive, it has been found
31 that patients’ active participation in students’ learning process and assessment is a valuable asset
32 in clinical assessment. Patients’ contribution can also improve the effectiveness of the assessment
33 of students´ competence (Suikkala et al., 2018).
34
35 3.4. Mentoring
36 The majority of clinical assessment focuses on collaboration between mentors, nursing students
37 and nurse teachers (Almalkawi et al., 2018; Helminen et al., 2016; Wu et al., 2015). Nurse
38 educators play an important role in ensuring that the mentor and student understand the use of
39 assessment criteria before the clinical practice begins (Helminen et al., 2016). They should also
40 clarify how the student can meet these criteria and to highlight that assessment aims to support
 9

1 students’ achievement of competences rather than to assess their personality (Helminen et al.,
2 2016). Helminen et al. (2016) emphasize the importance of a meeting between the nurse teachers,
3 mentor and student at the beginning of clinical practice and to provide opportunity for
4 familiarization with assessment processes and forms. These meetings can promote students’
5 understanding as to how they can overcome weaknesses (Almalkawi et al., 2018). Furthermore,
6 nurse teachers are recommended to include mentors in curriculum planning in nursing education
7 and to adopt assessment tools in line with educational standards (Helminen et al., 2016).
8 Mentors who are responsible for assessing students have expressed concern for their lack of
9 mentoring competence to assess students’ performance, which is also challenged by the limited
10 exposure they have with students (Yepes-Rios et al., 2016). The assessment process of nursing
11 students’ clinical competence is multifactorial and includes several elements. Clinical mentors are
12 required to be aware of the variety of approaches and strategies, but this is difficult when they
13 work as healthcare professionals full time and lack knowledge and skills on these methods
14 (Jokelainen et al., 2011).
15
16 A competent mentor has the capability to build a supportive clinical learning environment,
17 facilitate learning, monitor progress made by the student, assess the clinical competence of nursing
18 students, and give effective feedback to students (Wu et al., 2015). According to students, a good
19 mentor provides constructive feedback during the clinical practice rather than allowing poor
20 practices to continue. Assessment is considered to be of high quality when mentors are well
21 prepared to conduct assessment and when mentors have worked to create an effective mentor-
22 student relationship (Wu et al., 2015). Studies have shown that mentors do not always have a
23 sufficient amount of time to work together with students during clinical practice, which can affect
24 the reliability of their final assessment (Helminen et al., 2016). Also, a close relationship between
25 the mentor and student can hinder assessment (Helminen et al., 2016; Yepes-Rios et al., 2016).
26 Mentors’ ability to conduct quality assessment needs to be strengthened (Yepes-Rios et al., 2016;
27 Wu et al., 2015) and issues that hinder mentors’ interpretation of assessment documents need to
28 be addressed. Mentoring education has a significant influence on the assessment process and has
29 been recommended to be further developed (Almalkawi et al., 2018; Helminen et al., 2016; Yepes-
30 Rios et al., 2016; Wu et al., 2015). Lack of mentoring education may hinder mentors’
31 understanding of assessment criteria and the language used in these (Wu et al., 2015). Well-
32 executed use of positive and negative feedback makes assessment more effective (Helminen et al.,
33 2016), but it can be manifested in completely different ways in clinical settings than in mentoring
34 education.
35
36 3.5. Approaches of assessment
37 According to the included reviews, a variety of assessment approaches are utilized during clinical
38 practice (Helminen et al., 2016; Wu et al., 2015; Yanhua and Watson, 2011), but these are mainly
39 developed to meet the assessment needs of individual organizations. Some organizations use the
40 same assessment practices irrespective of the context of the clinical practice, even in situations
 10

1 where other assessment practices could better fit the context. This situation can make comparison
2 of assessment approaches more difficult (Helminen et al., 2016).
3
4 The assessment process needs to be objective (Yanhua and Watson, 2011), repeatable, and a
5 combination of different forms and tools should be used. Assessment should be conducted in close
6 collaboration between the mentor, student, and nurse teacher (Almalkawi et al., 2018; Helminen
7 et al., 2016; Wu et al., 2015) and support learning and the relationship between different roles
8 during assessment. Educators need to provide support to mentors and nursing students and an
9 orientation to the assessment process (Helminen et al., 2016; Wu et al., 2015).
10
11 The assessment of students' competences can be based on a performance-based system, which
12 includes a variety of tools and provides an opportunity for students to reach a certain level
13 (Almalkawi et al., 2018; Helminen et al., 2016). The dimensions of clinical competence can be
14 roughly divided into formal, objective and subjectively experienced competence. Formal
15 competence is achieved by education and gives a certificate regulated by guidelines and law,
16 objective knowledge is demonstrable competence, and subjective competence expresses the
17 experiences of students. Knowledge and skills can be measured between these three dimensions,
18 but this is challenging to review and value, which makes it less common to achieve coverage.
19 When formative assessment is used in the assessment of learning upon competence development,
20 it is carried out by giving students individual feedback on their performance in clinical practice
21 (Almalkawi et al., 2018). Objective assessment provides a cross-section of the students'
22 competence, but it is often limited to measure specific skills and uses only certain assessment
23 protocols.
24
25 Mentors play a substantial role in giving assessment feedback to students. Students desire that
26 mentors allocate more time to reflective discussion and to providing feedback (Almalkawi et al.,
27 2018). Feedback needs to be timely, coherent and individualized in order to foster effective
28 assessment. The review by Suikkala et al. (2018) identified studies that emphasize the usefulness
29 of feedback from patients in supporting the learning process of students. Effective approaches that
30 can be used to involve patients during the assessment process include allowing patients to provide
31 students with direct feedback, to participate in confidential assessment discussions or to fill in
32 assessment questionnaires (Suikkala et al., 2018).
33
34 3.6. Assessment instruments
35 Various different assessment tools have been used to assess students’ competence and to support
36 the learning process of students. Students are commonly assessed by being asked to answer
37 questions, through observation, completion of written exercises and self-assessment, through
38 feedback from mentors, staff, or patients, and through discussions between the student and the
39 mentor (Almalkawi et al., 2018; Suikkala et al., 2018; Helminen et al., 2016; Wu et al., 2015). In
40 addition, different scales, portfolios, formal documents, videos, skills laboratories, and learning
 11

1 contracts are commonly used (Helminen et al., 2016; Wu et al., 2015; Yanhua and Watson, 2011).
2 Students’ self-assessment has been seen as an important part of the assessment process, however
3 the reliability of self-assessment remains unclear (Helminen et al., 2016). The use of portfolios has
4 been proven to be an effective way to describe students’ development in clinical competence,
5 knowledge and actions in clinical practice (Helminen et al., 2016; Wu et al., 2015; Yanhua and
6 Watson, 2011), especially in clinical placements that are longer in length. Portfolios have been
7 shown to promote students’ active learning and their individual accountability in the development
8 of clinical skills (Yanhua and Watson, 2011).
9
10 A wide range of instruments and checklists have been used during assessment. These provide a
11 means to assess students’ clinical competence especially in quantitative ways. Different kinds of
12 assessment instruments enable reliable assessment of the level of competence that the student has
13 achieved, along with clear direction for students on their opportunities for making progress (Wu
14 et al., 2015). The majority of educational institutions use a pass or fail grading scale instead of
15 verbal or numerical grading scales (Helminen et al., 2016).
16
17 Examples of assessment instruments include: the Objective Structured Clinical Assessment Tool
18 (OSCE) (Yanhua and Watson 2011), the Shared Specialist Document; the Competency Inventory;
19 the Nursing Student Core Competencies Scale; the Self-Evaluated Core Competencies Scale;
20 Nurse Competence scale; Structured Observation and Assessment of Practice (SOAP), the
21 Competency Assessment Tool (CAT); Assessment of Clinical Education (AssCE); Competency
22 Inventory of Nursing Studies (CINS) (Wu et al., 2015); Generic Assessment Tool (SSPD) (Wu et
23 al., 2015, Yanhua and Watson, 2011); and the Six Dimension Scale of Nurse Performance (Yanhua
24 and Watson, 2011). In the reviews, it was emphasized that assessment instruments should be
25 effectively evaluated (Wu et al., 2015; Yanhua and Watson, 2011) and the reliability and validity
26 ensured (Wu et al., 2015). The reviews commonly did not report the reliability and validity of the
27 instruments.
28

29 4. Discussion
30 This systematic review of reviews identified the current best evidence on the assessment of nursing
31 students’ competence in clinical practice. Key developmental issues arose in this systematic review
32 of reviews including the need for enhancing assessment that supports the development of students’
33 professional competencies and the development of mentors’ competence in assessing students, in
34 addition to the need for development of objective assessment methods.

35 Nursing competence assessed during clinical practice focused on clinical competence in nursing,
36 communication, ethical decision-making, collaboration and critical thinking. Previously, it has
37 been found that students focus more on learning subjects they know will be assessed (Helminen et
 12

1 al., 2014). For this reason, the content of assessment should be clearly emphasized before students
2 enter clinical practice. The results of this review have further shown that nursing competence is
3 not the only learning outcomes that is being assessed during clinical practice. Students also need
4 to develop critical thinking, ethical decision making and multi-professional collaboration.

5 In our review, we found that the supportive clinical learning environments are needed with mentors
6 that are competent and educated in mentoring and in assessment practices. Mentors’ positive
7 attitude towards the students’ individual learning needs and the development of a good student-
8 mentor relationship remain important in enhancing students’ learning (Wu et al., 2015). When
9 trustworthiness has been established, students adopt self-assessment and self-regulation behaviors
10 in the assessment process. A good mentor-student relationship improves students’ confidence in
11 sharing feedback (Allen and Molloy, 2017) and it influences students´ learning outcomes upon
12 their competence development (Mikkonen et al., 2016).

13 The role of nurse educators in the assessment of students’ competence in clinical practice was
14 minimally emphasized in the results of the included reviews. This may indicate that the role of
15 nurse teachers is not considered to be a central part of the entire assessment process since
16 internationally the role of nurse teachers has been reduced or has diminished completely from
17 clinical practice educators (Warne et al., 2010). However, active participation of nurse educators
18 in the clinical assessment process is particularly important (Helminen et al., 2014; Hovland, 2011).
19 Nurse educators could share their pedagogical and methodological competence to support the
20 assessment process. Students have also expressed the need for nurse educators to take an active
21 role in clinical practice especially when challenging situations are faced (Arkan et al., 2018;
22 Pitkänen et al., 2018; Mikkonen et al., 2017). Support from nurse educators as well as their ability
23 to explain unclear issues to students can enhance students’ learning (Juntunen et al., 2016;
24 Helminen et al., 2014; Hovland, 2011).

25 Even when mentors have access to versatile assessment methods, the effective use of these may
26 be hindered when consistent and common guidelines are not available. Education has been
27 provided to those responsible for assessing students during clinical practice. Despite this, the
28 subjective views of the evaluator may affect the outcome of the assessment itself when assessment
29 forms are not properly used (Arkan et al., 2018; Helminen et al., 2014). In this systematic review,
30 assessment has been seen as challenging because the environment and the people involved in
31 assessment varied. Mentors are required to carry out a detailed assessment of students’ learning in
32 clinical practice, but at the same time assessment greatly influences students’ experiences of
33 clinical practice and the students’ professional identity (Pitkänen et al., 2018; Tuomikoski et al.,
34 2018). According to the results of this systematic review, the established relationship between the
35 mentor and the student strengthens successful assessment and contributes to successful clinical
36 learning and the development of professional identity.
37
 13

1 Studies included in this review have shown that students perceive the final assessment as
2 inconsistent when feedback is provided solely on how poor clinical performance was (Suikkala et
3 al., 2018; Helminen et al., 2016). Students have experienced mentors who have the tendency to
4 focus on shortcomings in their competence and who place too high expectations on the level of
5 competence the student is to achieve, or that mentors are not aware of the actual knowledge that
6 students have achieved (Arkan et al., 2018; Vae et al., 2018). This causes increased anxiety in
7 students and affects the overall effectiveness of clinical learning. Assessment needs to be clear and
8 systematic, encouraging students’ continuous learning process. Mentors need to develop an open
9 attitude towards providing constructive feedback that leads to the development of students’
10 competence, even in situations where the student fails to achieve the set learning outcomes. During
11 assessment, there is a need to foster open discussion on how to make progress in clinical learning
12 and competence development. This provides the opportunity to set clear learning goals and it helps
13 students to take responsibility of their own learning (Vae et al., 2018). Assessment of students
14 needs to focus on objective criteria, and it is important to avoid the impact of personal factors
15 (Helminen et al., 2016).
16
17 Assessment is conducted using a wide range of methods and tools, depending on the specific issue
18 being measured in each situation. Studies have shown that there continues to be variability in
19 mentors’ competence in assessing students’ learning, despite the fact that methods and tools are
20 available. In this review, it was found that the objectivity can be increased by using validated
21 instruments to assess students’ development of their competence in clinical practice. Mentors have
22 experienced uncertainty about what is expected in assessment and therefore they need clear
23 guidelines and support (Kälkäjä et al., 2016). The individual needs of students must to be taken
24 into account to provide comprehensive guidelines on how to assess students’ competence
25 (Hovland, 2011).
26
27 No one single correct approach exists to performing assessment of nursing students’ competence,
28 which is suitable in all different contexts. A study by Flott and Linden (2015) has shown that
29 educational and healthcare organizations need to invest in cooperation and to create appropriate
30 learning experiences for students that ultimately have a positive impact on students’ professional
31 development and on the realization of safe patient care.

32 Feedback should be focused on the issues that students need to focus on in their learning (Vae et
33 al., 2018). Students appreciate being treated equally, and that their opinion is valued and listened
34 to during the final assessment (Helminen et al., 2014). Also, it is imperative that students have a
35 clear understanding of what is needed to reach the desired level of competence, and that students
36 can identify their personal weaknesses and strengths (Wu et al., 2015). In this way, students are
37 better able to develop specific areas of competence during completion of their clinical practice and
38 to focus less on the issues that they have already mastered (Helminen et al., 2016).
 14

1 4.1. Strengths and limitations

2 To the best of the authors’ knowledge, this is the first systematic review of reviews conducted to
3 identify the evidence on current best practices on the assessment of nursing students’ competence.
4 The phases of this systematic review of reviews were conducted following rigid systematic review
5 methodology and guidelines. A systematic, comprehensive electronic database search was
6 conducted without use of time or language restrictions in order to ensure as comprehensive a search
7 as possible. Also, the reference lists of the studies included in the full-text review phase were
8 screened for additional eligible studies.
9
10 The search of this systematic review of reviews was limited to nursing education and not
11 broadened to cover education in other health professions. With increasing emphasis on the
12 importance of multidisciplinary collaboration and interprofessional education during clinical
13 practice, we recognize this as a potential limitation of our review. However, during the screening
14 process, we came across a review by Jepes-Rios et al. (2016) that included original studies from
15 the fields of dentistry, medicine and nursing. We decided not to exclude this review as the majority
16 of included original studies were from nursing, and the authors did not find differences in the
17 results between the different fields in regards to assessment.

18 5. Conclusion
19 According to our findings presented in discussion we suggest that nursing students’ competence
20 is not limited to the procedures of nursing care, but also their competence in becoming critical
21 thinkers, ethical decisionmakers and great collaborators. Students need to enter clinical practice
22 where learning environment is permissive and open for their continuous learning and professional
23 development. Moreover, the mentor-student relationship is an essential premise to achieve
24 openness and mutual understanding in the assessment process, together with a clinical learning
25 environment in which this relationship is embedded. Interaction between the mentor, student and
26 nurse teacher in the clinical learning environment enhances the professional growth and learning
27 of the student. Mentors need to be provided with further education to enhance their competence in
28 the assessment of students’ competence. The setting of goals prior to the beginning of clinical
29 practice is essential when designing effective assessment and in order to enhance constructive
30 feedback during clinical learning and competence development. Further studies could be
31 developed to detect which educational interventions could improve mentors’ competences in
32 clinical assessment and in fostering students’ achievement of learning outcomes in nursing
33 competence development.
34
35 Declaration of Competing Interest
36 No conflict of interest has been declared by the authors.
 15

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Table 3. Characteristics of included studies (n=6).
Authors Design Objectives Participants Search strategy Type of studies Critical Methods Key findings
(Year) included appraisal used in
Country used in analysis
review
Almalkawi, Integrative To evaluate the Mentors, Databases: Total studies Mixed Whittemore · Difficulties in the
Jester and review empirical and nursing Medline, CINAHL, included: n=8 Methods and Knafl's interpretation of language
Terry theoretical students, PsycINFO, ERIC, Appraisal (2005) used to describe
(2018) literature on the tutors ERC, AMED, Range in years Tool integrative competencies to be
challenges EMBASE, British of included (MMAT) review assessed
mentors face in Nursing Index, studies: framework · Challenges were
interpreting and DARE, Cochrane 2000-2012 experienced in
assessing levels of Library, Joanna distinguishing between
competence of Briggs Institute, Qualitative different levels of nursing
student nurses in EThOS, along with (n=1), competence
clinical practice search for grey quantitative · Challenges associated with
literature (n=1), mixed giving clear and constructive
(Department of method feedback to students
Health databases, studies (n=5), regarding developmental
Google Scholar, literature needs
Science direct) review (n=1) · Lack of availability of
appropriate tools and
Time period for Country of taxonomies to assist in
search: 1986- origin of assessing performance of
2016 included the student
studies: · Lack of transparent and
Ireland (n=4), explicit criteria impedes
United accurate and fair
Kingdom (n=4) assessment
Helminen, Narrative To provide an Nursing Databases: Total studies Not reported Inductive Practices before final assessment:
Coco, review overview of students, CINAHL, PubMed, included: n=23 content
Johnson, summative preceptors, Medic, ISI Web of analysis · It is important to organize
Turunen assessment of mentors, Science, Range in years orientation and opportunity
and student nurses’ tutors, Cochrane, ERIC of included for familiarization with
Tossavaine practice currently lecturers, studies: 2000- assessment process and
n (2016) in use educators, Time period for 2014 forms at beginning of clinical
nurses, search: 2000- practice
faculty 2014 Qualitative · Mentors find the
members (n=5), terminology of evaluation
quantitative forms hard to understand
(n=6), mixed · Lack of consistency in
method assessment process exists
studies (n=6), · Students conduct clinical
literature practice in different
reviews (n=6) environments making
assessment of all
Country of competence areas
origin of challenging
included · Mentors’ attitudes,
studies: qualifications, poor timing of
Australia assessment, or the mentors’
(n=2), Canada lack of time with the student
(n=1), Ireland can impact assessment
(n=6), Sweden
(n=1), United Performance of final assessment
Kingdom
(n=9), United
· The educator, mentor and
States (n=4)
student should participate in
final assessment and
conduct reciprocal
discussion of achieved
competencies
· Role of educators is to
support mentors and
students in appropriate
assessment
 · All actors must have
consistent understanding of
assessment criteria
· Situations where students
fail to pass are challenging
for the mentor

Following final assessment

· Appropriate documentation
of assessment is necessary
to conduct
· It may be necessary to
organize extra time in
clinical practice for failing
students

Suikkala, Scoping To review and Patients, Databases: Total studies Criteria by Inductive · Patient involvement in the
Koskinen review summarize the service CINAHL, Medline, included: n=32 Reilly et al. content learning process and
and Leino- existing empirical users, PsycINFO, ERIC, (2008) analysis assessment of students
Kilpi (2018) literature clients, along with manual Range in years varied from active to passive
regarding students, search of included participation
patients’ nurses, studies: 1985- · Patients were supportive
involvement in teachers, Time period for 2016 towards students and some
nursing students’ faculty search: no time felt positive about giving
clinical education members, limitation set Qualitative, feedback on students’
other quantitative, performance
stakeholders and mixed · Giving critical feedback was
methods experienced as difficult
approaches · Some patients preferred
direct feedback or
Country of confidential assessment
origin of discussions. Others
included preferred using an
studies: assessment questionnaire.
Australia · Students’ interpersonal
(n=2), Belgium competence was important
 (n=1), Canada in building relationships with
(n=2), Finland patients
(n=3), Nepal · Students’ professional
(n=1), New attitudes and attributes
Zealand (n=1), related to knowledge and
South Africa skills were important to
(n=2), Sweden patients
(n=3), United · The presence of the mentor
Kingdom was appreciated by patients
(n=9), United
States (n=8)
Wu, Systematic To explore the Nursing Databases: Total studies Qualitative Not specified Current assessment practices and
Enskär, Lee review clinical students, PubMed, CINAHL, included: n=14 Assessment processes
and Wang competency midwifery ScienceDirect, and Review
(2015) assessment for students, Web of Science, Range in years Instrument · Clinical assessment focuses
undergraduate preceptors, EBSCO of included (QARI), on collaboration among
nursing students clinical studies: 2002- Joanna academics, nursing
placement Time period for 2014 Briggs students, preceptors and
coordinators search: 2000- Institute hospitals
, clinical 2013 Qualitative Meta · The use of validated
nurse (n=8) and Analysis of assessment tools enables
managers, quantitative Statistics objective and fair
lecturers, studies (n=6) Assessment assessment of students
nurses, and Review
educators Country of Instrument Issues with learning and assessment
origin of (JBI-
included MAStARI),
· Assessment, receiving
studies: Joanna
negative feedback and
Australia Briggs
insufficient guidance by
(n=1), Institute
mentors causes anxiety in
Denmark Critical
students
(n=1), Ireland Appraisal
(n=4), Norway Criteria for · Mentors monitor students’
(n=1), Descriptive/ progress, facilitate learning,
Scotland Case Series provide feedback and assess
(n=1), Sweden Studies students’ clinical
(n=3), Turkey competency
(n=1), Taiwan · The role of educators is to
(n=2) visit and provide support to
 students and mentors on a
regular basis, discuss
learning goals and review
progress

Development of assessment tools

· Assessment tools generally

include the domains of
professional attributes,
ethical practices,
communication and
interpersonal relationships,
nursing processes, critical
thinking and reasoning
· The majority of assessment
tools are developed with
reference to competency
standards stated by national
boards of nursing

Reliability and validity of assessment

tools

· Reliability of assessment
tools reported in 3 of the
included studies, construct
validity reported in 2 studies
· Instruments should be
further evaluated to verify
validity and reliability

Yanhua Literature To investigate Nursing Databases: Total studies Not reported Not specified Instrument development and testing
and review trends in the students, Cochrane, included: n=
Watson evaluation of newly Medline, CINAHL 23 · Instruments have been
(2011) clinical graduated increasingly developed and
competence in nurses Range in years tested using rigorous
nursing students
 and newly Time period for of included methods for ensuring
qualified nurses search: 2001- studies: 2001- reliability and validity
2010 2009 · National and international
cooperation exists in
Qualitative instrument development
(n=5) and
quantitative Approaches to testing competence
studies (n=13),
reviews (n=5) · Portfolios have gained
popularity as a tool to
Country of evaluate nursing students'
origin of clinical competences
included
· Objective structured clinical
studies:
examinations are valid and
Australia
reliable methods of
(n=3), China
assessment
(n=1), Ireland
(n=1), South
Africa (n=1)
Taiwan (n=1),
Thailand
(n=1), United
Kingdom
(n=11), USA
(n=4)
Yepes-Rios, Systematic To consolidate Focus on Databases: Total studies Qualitative Thematic Barriers to failing underperforming
Dudek, review and analyze medical CINAHL, EMBASE, included: n=28 studies analysis students
Duboyce, knowledge from students, and MEDLINE appraised
Curtis, medical, dental dental Range in years using Critical · Failing a student has a
Allard and and nursing students, Time period for of included Appraisal strong impact on the
Varpio literature relating nursing search: 2005- studies: 2005- Skills assessor professionally and
(2016) to assessor’s students 2015 2014 Program – it can be easier to pass than
ability and UK tool to go through process of
willingness to Specific Qualitative checklist failing a student
report poor participants (n=15) and (CASP-UK) · Assessors felt personal
clinical academic of original quantitative failure, guilt and emotional
and professional studies not studies (n=3), toll involved with failing a
performance specified reviews (n=7), trainee
teaching
points (n=1), · Assessors considered the
editorial (n=1), emotional reaction and
newspaper distress along with the
report (n=1) impact that failure would
have on the students’ career
Country of · Assessors felt unprepared in
origin of their evaluation role, with
included little formal training and lack
studies: of assessment tools
Australia · Lack of support from
(n=1), Canada institutions or pressure to
(n=7), United pass underperforming
Kingdom students was experienced
(n=15), USA
(n=4), jointly Enablers supporting assessors’
in USA and willingness to fail a failing student
Canada (n=1)
· Responsibility to patients, to
society and to the
profession
· Strong assessment systems
along with institution
support helped assessors
recognize poor performance
· Opportunities for students
after failing enabled
assessors to accept their
decision to fail student
 Table 1. Inclusion and exclusion criteria using PICoS format

PICoS criteria Inclusion Exclusion

Participants Nursing students Students studying in healthcare fields
other than nursing
Phenomenon of Assessment Not focusing on assessment
Interest/Outcomes

Context Clinical practice/ training Settings other than clinical practice

Study design and Published, peer-reviewed Not reviews, not peer-reviewed, not
publication type systematic, integrative, narrative, published
scoping and literature reviews

Publication years No limitations No limitations

Language No limitations No limitations

Table 2. Analysis of the included studies using the JBI Critical Appraisal Checklist for Systematic
Reviews and Research Syntheses (Aromataris et al., 2015)

Almankawi Helminen et Lejonqvist et Suikkala et al. Wells & Wu et al. Yanhua & Yepes-
et al. (2018) al. (2016) al. (2016) (2018) McLoughlin (2014) (2015) Watson Rios et
(2011) al.
(2016)
1. Is the review Yes Yes Yes Yes Unclear Yes Yes Unclear
question clearly and
explicitly stated?

2. Were the inclusion Yes Yes Yes Yes Unclear Yes Yes Yes
criteria appropriate
for the review
question?

3. Was the search Yes Yes Unclear Yes No Yes Yes Yes
strategy
appropriate?

4. Were the sources Yes Yes Yes Yes No Yes Yes Yes
and resources used
to search for studies
adequate?

5. Were the criteria Unclear No Yes Yes No Unclear No Yes

for appraising studies
appropriate?

6. Was critical No No No Yes No Yes No No

appraisal conducted
by two or more
reviewers
independently?

7. Were there Unclear Unclear Unclear Yes No Yes No Unclear

methods to minimize
errors in data
extraction?

8. Were the methods Yes Yes Unclear Yes No Unclear Unclear Yes
used to combine
studies appropriate?
9. Was the likelihood No Yes No Yes No Yes No No
of publication bias
assessed?

10. Were Yes Yes Yes Yes No Yes Yes Yes

recommendations
for policy and/or
practice supported
by the reported
data?

11. Were the specific No Yes Unclear Yes No Yes Yes No

directives for new
research
appropriate?

Total points 6 8 5 11 0 9 6 6
 Search keywords group 1: nurs* and student*
Search keywords group 2: evaluat* or assess* or measure* or reflect* or grade or grading

Search keywords group 3: clinical AND

(practice or setting* or placement* or “learning environment” or education
or training)
Search keywords group 4: review or “meta-analysis” or “meta-review”
Identification

Records identified through Additional records identified

database searching through other sources
(n = 1464) (n = 0)

Records after duplicates removed

(n = 1363)
Screening

Records screened Records excluded

(n = 1363) (n = 1338)

Full-text articles assessed

for eligibility Full-text articles excluded, with
Eligibility

(n = 25) reasons
(n = 16)
- Not relevant participants:
(n=2)
Studies included in quality - Not relevant
assessment outcome/phenomenon of
(n = 8 ) interest:
(n=6)
- Not relevant context:
Included

(n=3)
Studies included in - Not relevant type of study:
Studies excluded thematic synthesis (n=5)
after critical (n = 6)
appraisal
(n=2)

Figure 1. PRISMA flow diagram of study (Moher et al., 2009)

 NURSING COMPETENCE ASSESSED DURING CLINICAL PRACTICE

The behavioral approach

Identification of general attributes of the student (knowledge, critical
thinking skills)
The holistic approach that addresses knowledge, attitudes, values and
skills used to function in clinical situations

MENTORING LEARNING ENVIRONMENT

Collaboration between mentor, student, and educators Facilitates learning
Mentor involvement in curriculum of a student Supports student progress
Mentor competence in assessment Providing constructive feedback
Mentor-student relationship Interaction with patients
Mentor education

APPROACHES OF ASSESSMENT ASSESSMENT INSTRUMENTS

Learning contract OSCE

Clear learning process (supportive, collaborative, objective) The Shared Specialist Document
Assessment criteria (objective, clear language, pedagogical) The Competency Inventory
Reflection discussion
The Nursing Student Core Competencies Scale
Feedback (timely, constructive, coherent, individualized)
Tools supporting learning: portfolios, scales, formal documents, The Self-Evaluated Core Competencies Scale
videos, skill laboratories, learning contracts Nurse Competence scale
Structured Observation and Assessment of Practice (SOAP)
The Competency Assessment Tool (CAT)
Assessment of Clinical Education (AssCE)
Competency Inventory of Nursing Studies (CINS)
Generic Assessment Tool (SSPD)
The Six Dimension Scale of Nurse Performance

Figure 2. Outcomes of thematic synthesis.

Supplementary File 1. Terms used to search the electronic databases.

Search terms
CINAHL (nurs* AND student*)
AND (evaluat* OR assess* OR measure* OR reflect* OR grade OR grading)
AND ((clinical) AND (practice OR setting* OR placement* OR “learning environment” OR education
OR training))
AND (review OR “meta-analysis” OR “meta-review”)
Filters: Exclude MEDLINE records, Human
Eric (nurs* AND student*)
AND (evaluat* OR assess* OR measure* OR reflect* OR grade OR grading)
AND ((clinical) AND (practice OR setting* OR placement* OR “learning environment” OR education
OR training))
AND (review OR “meta-analysis” OR “meta-review”)
No filters applied
JBI Database of (nurs* AND student*)
Systematic AND (evaluat* OR assess* OR measure* OR reflect* OR grade OR grading)
Reviews and AND (clinical)
Implementation AND (review OR “meta-analysis” OR “meta-review”)
Reports No filters applied

Medic (student*(in Finnish)) AND (evaluat* OR reflect* (in Finnish)) AND (clinical (in Finnish))
No filters applied

PubMed ("nurs*"[All Fields] AND "student*"[All Fields]) AND ("evaluat*"[All Fields] OR “assess*”[All Fields]
OR “measure*”[All Fields] OR “reflect*”[All Fields] OR “grade”[All Fields] OR “grading”[All Fields])
AND ((“clinical”[All Fields]) AND (“practice”[All Fields] OR “setting*”[All Fields] OR
“placement*”[All Fields] OR “learning environment”[All Fields] OR “education”[All Fields] OR
“training”[All Fields])) AND (“review”[All Fields] OR “meta-analysis”[All Fields] OR “meta-
review”[All Fields])
Filters: Humans