This study aimed to explore the challenges encountered by nursing students regarding OSCE in Malawi. The study found that OSCEs caused emotional and psychological problems among nursing students. The participants also reported experiencing administrative and academic challenges with the OSCEs.
Participants in the present study, reported that OSCE induced unbearable stress and nervousness, leaving the students mentally paralyzed and unable to think clearly. Applying theoretical knowledge to practical situations and the pressure to perform perfectly under observation contributed to the anxiety and stress. Likewise, a study conducted in Malawi by Msiska et al. [10] found that OSCEs, as high-stakes examinations, were associated with increased levels of stress and anxiety. These findings aligned with numerous studies in healthcare disciplines, such as dental, medical, and nursing fields which showed that OSCEs were more anxiety-inducing, intimidating and stressful than other assessment formats [3, 13, 15]. The studies agreed that anxiety and stress are linked to the OSCE’s structured format and its direct evaluation [14, 15]. High levels of stress and anxiety negatively affect students’ satisfaction and undermine the validity and reliability of the exam [11, 16]. Moreover, anxiety and stress may impair students’ performance and contribute to health problems, which can hinder their professional growth and development [3, 16, 17].Conversely, a study by Ferreira et al. [18] in Brazil, found that students reported a significant reduction in anxiety and stress during subsequent OSCEs compared to their first experience. The improvement was attributed to increased confidence from familiarity with the assessment structure and having acquired the necessary knowledge and skills for making appropriate judgments and actions [10, 18]. To mitigate the effects of intense anxiety and stress, a study by Mojarrab et al. [19] in Iran, introduced a pre- and post-exam anxiety coping program which included relaxation techniques, diaphragmatic breathing training, progressive muscle relaxation, and light instrumental music. The coping program positively affected students and helped improve their final exam results [19].
The present study found that majority of participants reported experiencing administrative problems related to OSCE, with most students expressing concerns about inadequate time allocation for each station. This resulted in students rushing through the process, leading to feelings of overwhelm, anxiety, reduced performance, and a failure to effectively showcase their skills. These findings are consistent with other studies from Oman by Alamri et al. [13] and India by Chongloi et al. [20], which indicated that most students required more time to complete each OSCE station and some even reported having insufficient time to read and complete the OSCE scenarios [5, 16, 21]. Time constraints lead to rushed decisions that may not fully engage critical thinking and problem-solving processes which are essential for effective learning among nursing students [22]. Moreover, due to elevated stress levels, the OSCE may not accurately reflect students' competence under less pressured conditions [23]. However, some participants’ in the current study regarded the issue of inadequate time as a factor that improved their competence and confidence. Similarly, Kattil et al. [24] in India, found that timed scenarios enhanced students' speed in performing tasks, allowing them to demonstrate their abilities and work efficiently under time pressures. Therefore, reviewing and adjusting time allocations for each station based on task complexity can help address the issue.
Additionally, participants complained about the absence of well-equipped skills laboratories and the lack of well-trained assessors, particularly, the nursing officers from the hospitals who were invited to assist in OSCE assessments. A similarly study conducted in Ethiopia found that a significant percentage of both examiners and students reported inadequate equipment for conducting OSCEs [27]. Another study by John [28] in the Kingdom of Bahrain, also reported that the OSCE stations were poorly arranged and equipment were not functioning well. Lack of adequate and necessary resources negatively impacts assessment and students' learning [27] as it hampers students' ability to practice and perform clinical skills effectively [25, 26]. In agreement, Alkhateeb et al. [29] in Iraq, reported that medical schools with dedicated simulation laboratories and well-designed examination spaces were able to conduct OSCEs more effectively. These facilities provide a controlled environment that enhance the reliability and validity of the examinations. To address these problem, school authorities should ensure adequate funding for OSCEs. The aim is to improve resource allocation, including purchasing up-to-date equipment and materials, although OSCE is a resource-intensive technique [38]. The financial support will also facilitate the training of assessors, contributing to the overall success of the examinations [30].
However, on inexperienced assessors, Chen et al. [26] in Taiwan, found that less experienced examiners are more likely to be unfair and judge harshly compared to their more experienced counterparts. A study by Schleicher et al. [32] in Germany, observed that assessors lacking necessary training often conduct OSCEs ineffectively, leading to variability in scoring and feedback. The lack of adequate training and standardization among assessors is a critical issue, as subjectivity can undermine the objectivity that OSCE aims to achieve. In agreement, Guerrero et al. [25], found that inadequate training and orientation of both raters and examiners were significant challenges in the OSCE process. Therefore, it is necessary for assessors to receive comprehensive orientation and preparation in standardization and situation-based trainings for positive student experiences and improved performance, thus enhancing OSCE effectiveness [25, 32] as consistent and fair evaluations help maintain the integrity of the OSCE process [33]. According to Guerrero et al. [25], assessors frequently face time constraints and heavy workloads which impact their performance during OSCEs. Time pressure and the need to assess multiple candidates in a short period can lead to fatigue and reduced attention, compromising the quality of the assessments [25].
Furthermore, most participants expressed concerns about being poorly treated by some assessors during the OSCE. Some even did not pay adequate attention to students during the tasks; instead they often appeared busy on their phones, marking the checklist only after the student had completed the procedure. Consistent with studies by Majumder et al. [5], Msiska et al. [10] and Alamri et al. [13], most nursing students reported experiencing difficult examiners during OSCEs. This suggests reasons for the heightened anxiety and lack of confidence among the nursing students, which may compromise the fairness and effectiveness of the assessment process. Contrary to this, some nursing students reported that certain assessors had a positive attitude towards them and played a crucial role in promoting a favorable learning environment. A study by Chong et al. [31] highlighted that assessors who create a conducive environment during OSCEs can reduce students' stress and anxiety, leading to a more precise evaluation of their clinical abilities as it enables them to feel more composed and confident during the OSCE [31, 37].
In the current study, participants reported that they faced significant academic challenges with the OSCE. Most participants reported feeling inadequately prepared for the OSCE leading to a sense of unequipped and uncertainty when tackling the scenarios. As a result they merely memorized the checklists to pass the OSCE without understanding. A similar study by Emebigwine et al. [22] in South Africa found that students felt inadequately prepared for the OSCE due to insufficient practice and lack of guidelines. Another study by Lim et al. [37] in Melbourne, Australia, pharmacy students commented that during OSCE they would memorize the products recommendations without understanding the concepts and principles in order to pass the exam. The high-stress environment of the OSCE, exacerbated by inadequate preparation, resources, and time constraints, can negatively affect students’ performance and overall learning experience [30]. Therefore, it is essential for educators to prioritize OSCE preparation to mitigate these risks and ensure students are well-prepared for the examination. A study conducted by Bevan et al. [34] in the United Kingdom explored a new approach to OSCE preparation through peer-led, multi-role practice OSCEs (PrOSCEs). They found that regular participation in PrOSCEs significantly improved students’ confidence and performance [34]. Consequently, this method helped in merging knowledge and skills, boosting confidence and enabling the students to face the exam in a better way.
Additionally, the current study revealed that immediate and constructive feedback was not provided to the students; instead, they received general feedback that lacked specific insights into their strengths and weaknesses which are essential in guiding individual improvement. The finding is consistent with the study by Emebigwine et al. [22] which noted that untimely and limited feedback from lecturers and clinical staff resulted in difficulties in preparing for exams. Immediate and constructive feedback corrects errors, promotes learning, and fosters growth [21, 28]. An Indian study by Dewan et al. [35] highlighted that following the examination, a thorough review of each student’s performance is conducted where they receive feedback from observers at every station. Furthermore, the students were informed about the ideal responses and the specific questions asked at each station. This aligns with the principles of formative assessment, where feedback is not just evaluative but also educational, helping students develop their clinical skills [5]. This type of feedback allows students to understand and reflect on their performance, identify strengths, and recognize areas for improvement while the experience is still fresh [35].
The participants in the current study revealed that English proficiency lead to difficulties in understanding exam instructions, communicating effectively with patients and interpreting and responding to cues. Notably, the students preferred using the vernacular language, as patient interaction in clinical settings is typically conducted in the local language. A similar study conducted in Netherlands by Schoonheim-Klein et al. [36] on Dutch native and non-native dental students found that non-native dental students performed worse in OSCEs compared to the native students, particularly in stations requiring patient education. To address this, non-native students were encouraged to take language lessons to improve their language skills [36]. Another study by Lim et al. [37] compared OSCE and Work Based Assessment using mystery shopping found that complex language used in competency based assessments was difficult for the students to understand making it hard to apply in practice. Therefore, proactive measures that provide fluent language support materials or offering language proficiency workshops can enhance students’ comprehension and ensure equitable assessment opportunities [36].
Limitations of the study
The study was conducted at three nursing colleges, therefore findings may not apply to other colleges because of differences in context. Additionally, exclusion of first and second year students, might have limited some nursing students in the study. However, some of their contributions have been captured since the study used senior students who have passed in all the years of study. Despite these limitations, the findings have significant implications for nursing education and development of a competent healthcare workforce in Malawi and other developing countries
