INTRODUCTION:

Clinical skills and practice play the main roles in training different fields including nursing. Evaluation of clinical skills has a central role in nursing education. The selection of suitable methods has been a matter of concern for teachers of nursing education and concerned others. Thus the assessment of clinical skills (clinical evaluation) is far more important and complex as it is directly linked with patient care.¹ Clinical evaluation, as a way of determining the clinical competence, is one of the fundamental principles of development and student achievement measurement in nursing education.²

Evaluation of students has a direct impact on nursing practice. Clinical evaluation has always been an integral part of nursing education.³Examining the presence of professional behavior, establishing an appropriate interaction with the patients, prioritizing the problems, possession of basic knowledge about clinical methods, correct performance of care procedures and application of critical thinking are components of clinical evaluation.⁴

When clinical performance is evaluated, students’ skills are judged as they relate to implementation of established standards of patient care. The ultimate outcome for clinical evaluation is safe and quality patient care.¹Practical evaluation stimulates students to use their critical thinking skills for problem solving and their future performance. Thus assessment techniques appear to have an impact on learning strategies and to influence the performance of students with the imperative need for basic mastery of clinical skills in students upon graduation. In order to achieve this aim, there is a need to improve the quality of clinical skills assessment.

For a long time, teachers of nursing in India have been using the traditional practical examinations for evaluating students' clinical performance. A student would be assigned to an examiner who would observe his/her performance of the students for the entire examination while providing nursing care to a patient in the clinical area, or performing one procedure in the skill lab.

This type of assessment program is problematic for many reasons and criticized by many researchers. Traditional practical examination does not cover the entire subject area and there is no uniformity in the assignment of patients. This method lacks in reliability and validity of evaluation. This approach also has the potential bias and subjectivity in the evaluation.^5-8There is very often a lack of transparency about the objective of the assessment and the competencies required to succeed using this method. The use of a single patient or small number of cases is linked to perceived unfairness.⁶

In addition, schools are under tremendous pressure to increase student achievement, employ higher order thinking skills and measure multiple abilities by using fair tests through strengthening classroom assessments. One method of improving student evaluation is by using alternative or authentic assessments that allows students to showcase their competence is an OSCE.⁸ OSCE is recommended as a powerful and effective tool for evaluating students' clinical performance. OSCE was first introduced in medical education by Ronald Harden in Scotland at the University of Dundee in 1975.^9,10Since then, it has been used worldwide to provide formative and summative assessment in medicine, dentistry, nursing and pharmacy.^11-16

OSCE is a method of Practical examination comprising a series of stations through which all candidates rotate on a timed basis. In each station, the candidate is faced with a client or task or problem to perform a specific function. The candidate is assessed by the examiners using predetermined check lists with set criteria and scoring key.^17,18

Over the past two decades, psychiatric education has seen dramatic changes including introduction of OSCE. Application of OSCE in psychiatric education, although theoretically very attractive, is witnessing slow usage.¹⁹Though the review of literature strongly supports the use OSCE as a valid method of clinical evaluation and currently practiced across the world, it is not explored much in the field of nursing education in India especially in psychiatric nursing where it is still in infancy stage. It is also not known how well the students will be able to perform in OSCE.

Considering the drawbacks of traditional clinical evaluation, higher demand of student achievement through competence, the need was felt by the researcher to improve student evaluation by using the alternative authentic assessment approach that allow students to showcase their knowledge, attitude and skills. Hence this study was undertaken to compare the nursing students’ performance in psychiatric nursing between Objective Structured Clinical Examination (OSCE) and Traditional Practical Examination (TPE) for supplementing the present system of clinical evaluation in order to increase the reliability, validity and objectivity in assessment.

STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of Objective Structured Clinical Examination (OSCE) over Traditional Practical Examination (TPE) in psychiatric nursing on the performance of nursing students in a selected nursing college, Chennai, Tamil Nadu, India.

HYPOTHESES:

There will be a significant difference between OSCE and TPE in the performance of students in selected clinical competencies in psychiatric Nursing.

METHODS AND MATERIALS:

The present study was carried out to assess the nursing students’ performance between Objective Structured Practical Examination (OSCE) versus Traditional Practical Examination (TPE) in psychiatric nursing at Apollo College of Nursing, Chennai, Tamil Nadu, South India.

The research design used for the study was randomized cross over research design with two groups. The study was conducted among 84 (42 students in each group) III year B.Sc. Nursing students. Approval of the study was obtained from the Institutional review board, and Principal of Apollo College Nursing. Permission was obtained from the concerned authorities of the Psychiatric Hospital. Setting was selected through purposive sampling technique.

The study samples were selected using the consecutive sampling technique. i.e. all the available students who met the inclusion criteria were selected. The students were ranked in the descending order according to the marks obtained in the II year final university examination. Students were marked with number 1 and 2 from 1 to 84 consecutively for the random assignment. Simple random assignment (lottery method) was used to assign the students with number 1 to Group II and students with number 2 to Group I. OSCE and TPE were conducted (100 marks each) with one-month washout period between these Examinations.

The study subjects were randomly allocated to two groups (Group I and Group II) and then sequentially received two phases of intervention of OSCE and TPE or vice versa. Hence there were 42 students in each group. Using simple random technique (lottery method), Group I was administered OSCE first, followed by TPE and Group II was administered TPE first, followed by OSCE. Each group was further divided into three subgroups - 14 students in each sub group for conducting both the examinations. Both the examinations, OSCE and TPE were conducted in the private psychiatric hospital.

Day 1: OSCE was conducted for Group I for all the students in three sessions.

Day 2 to 4: TPE was conducted for 3 consecutive days for Group II.

Written informed consent was obtained from the students. Assurance was given to all the students that confidentiality and anonymity would be maintained. Verbal consent was obtained from the patients and family members. Patients who were cooperative only were included in the study. Examiners were briefed about the whole process of OSCE and their role as the examiners in OSCE. Both, the OSCE and TPE were administered in English. The OSCE was conducted to cover all the aspects of nursing process as in TPE.

In OSCE, 17 stations (including one rest station) were used to assess the clinical competencies necessary to apply nursing process in psychiatric nursing which included the assessment (History collection, MSE-Mental Status Examination and process recording), formulation of nursing diagnosis, nursing intervention (planning and implementation), with total score of 100. The weight age of 30 % on viva voce in TPE evaluation was substituted by unmanned stations in OSCE.

Tab 1: Blue Print of OSCE Stations and TPE

S. No	Components	OSCE Stations	Scores	Weight age in %
1	Assessment 1. History Collection 2. MSE 3. Process Recording	1-2 3-4 5	14 14 6	34
2.	Nursing Diagnosis	6	6	6
2	Nursing interventions	7-12 (9-Rest Station)	30	30
3	Viva(Other) Aspects*	13-17	30	30
Total Scores		-	100	100%

*Viva in TPE was substituted with unmanned stations in OSPE.

Out of 17 stations, 8 were manned-Stations No 1-4,8, 10-12 and 8 were unmanned stations - Station No; 5-7, 13-17) and one was rest station- No - 9. In each station, six minutes was allotted. Hence 105 minutes was required to complete one session for one group of 14 students (including three minutes for changing the patients in between). Eight teachers were asked to evaluate the students by observing their performance using predetermined checklists with set criteria and scoring key. Students’ performance in unmanned stations was evaluated by the same examiners after the completion of OSCE. Only one station was changed for the Group II with similar task with same difficulty level. OSCE stations and evaluation checklists were developed by the researchers, based on the review of literature, and in consultation with experts and department faculties.

Among these stations, 10 stations required psychiatric patients for each session. These patients were changed once during the session, after completion of 8 stations to give them rest. These patients were once again involved for the second or third session in a same day after the rest for around one and half hour. These patients were replaced by other patients with similar conditions. Thus, a total of 30 patients were involved in one day OSCE. Each patient was involved in the OSCE twice a day (about one hour and 40 minutes / patient).

Conducting TPE: TPE was conducted in the same Hospital for 3 consecutive days, one day for each sub group. As per the university norms, maximum number of students examined per day is 20. TPE was conducted in the morning from 8 am. Patients were allotted to the students through a lottery method using bed number and patient name. Each student was assigned one patient to give total patient care using nursing process steps. The time allotted for total patient care was 4 hours. TPE was followed by the viva voce in the afternoon from 2-4 pm (after the lunch break) and it was conducted in a separate room in the hospital. TPE was evaluated by the two examiners (internal and external) using the prescribed evaluation format which was developed by the researchers, based on the review of literature, and in consultation with experts and department faculties.The entire process of administration of OSCE and TPE was repeated for different groups after a one-month washout period between two interventions to eliminate the residual effects of the intervention by the former phase. The collected data were organized, tabulated and statistically analyzed using SPSS software statistical computer package version 16. Descriptive statistics - frequency, percentage, mean, standard deviation and range were used to summarize the data on students’ baseline characteristics, clinical performance. Chi Square test was used to test the homogeneity of the students’ baseline characteristics between Group I and Group II. Paired t-test was used to find out the difference between OSCE and TPE in the Group I and Group II on students’ performance. Independent t-test was used to find out the difference between Group I and Group II on students’ performance in OSCE and TPE. All hypotheses were tested at p<.05 level.

RESULTS:

Table 2: Frequency and Percentage wise Distribution of Baseline Characteristics of the Students(N=84)

Characteristics

Total( N= 84)

Group I( n= 42)

Group II( n= 42)

χ²value anddf

p - value

Age in years

· 20

· 21

· 22 and above

28.57

58.33

13.10

35.71

52.38

11.90

21.43

64.29

14.29

2.10

df=2

0.35

Medium of Instruction inHr Secondary

· English

· Tamil

· Others

73.81

26.19

0.00

71.43

28.57

0.00

76.19

23.81

0.00

0.25

df=1

0.80

Native State

· Tamil Nadu

· Kerala

· Other States

48.80

2.38

50.00

47.62

2.38

47.62

50.00

2.38

0.48

df=1

1.00

Domicile

· Rural

· Urban

44.05

32.14

42.85

57.14

45.24

54.76

1.71

df=1

0.28

Table 2 indicates that, there was no significant difference between Group I and Group II on the basis of age, medium of instruction, native state and domicile (p > .05).

Table 3 : Level of Students’ Performance in OSCE and TPE in Group I and Group II (N= 84)

Level of performance	Group I( n= 42)				Group II( n= 42)
	OSCE		TPE		OSCE		TPE
	f	%	F	%	f	%	f	%
Very Good (75-100)	29	69.0	11	26.2	29	69	13	31.0
Good ( 60-74)	12	28.6	28	66.7	13	31	28	66.7
Average ( 50-59)	1	2.4	3	7.1	-	-	1	2.4
Poor ( Below 50)	-	-	-	-	-	-	-	-

Table 3 shows that, in OSCE, 69% of the students’ performance was very good in Group I and Group II, whereas in TPE, 26.2 and 31% of students’ performance was very good in Group I and Group II respectively.

Table 3: Comparison of Students’ Performance Scores between OSCE and TPE in Group I (n= 42)

Clinical Competencies and Possible Score Range	OSCE		TPE		Mean difference and SD	Paired t-value	p - value
Clinical Competencies and Possible Score Range	Mean(SD)	Range	Mean(SD)	Range	Mean difference and SD	Paired t-value	p - value
Assessment
History Collection 0-14	11.51 (1.25)	8.5-13.5	9.86 (0.80)	8-11	1.65 (0.97)	11.03***	0.000
MSE 0-14	10.02 (1.70)	7-13	8.99 (1.91)	7-11	1.04 (1.14)	5.87***	0.000
Process Recording 0-6	5.01 (0.60)	4-5.5	4.23 (0.39)	4-5.5	0.79 (0.69)	7.37***	0.000
Nursing Diagnosis 0-6	4.93 (1.01)	3.5-6	4.07 (0.74)	3.5-5.5	0.86 (1.22)	4.55***	0.000
NursingIntervention 0-30	24.77 (1.94)	18.5-28.5	22.65 (1.34)	18.5-26.5	2.12 (1.23)	11.18***	0.000
Viva aspects 0-30	21.86 (3.38)	14-28	20.37 (3.35)	12.5-26.5	1.49 (0.08)	125.00***	0.000
Total Score 0-100	78.10 (6.95)	58.5-93.5	70.17 (5.92)	56.5-84	7.94 (2.60)	19.83***	0.000

*** p< .001 MSE- Mental Status Examination

Table 3 shows a significant difference in the mean scores between OSCE and TPE on overall performance and all the clinical competencies (p < .001). Mean scores obtained by the students in OSCE was higher than TPE.

Table 4: Comparison of Students’ Performance between OSCE and TPE in Group II (n= 42)

Clinical Competencies and Possible Score Range	OSCE		TPE		Mean difference and SD	Paired t-value	p - value
Clinical Competencies and Possible Score Range	Mean(SD)	Range	Mean(SD)	Range	Mean difference and SD	Paired t-value	p - value
Assessment History Collection 0-14	11.44 (1.27)	8.5-13.5	10.10 (0.83)	8-11.5	1.35 (0.70)	12.41***	0.000
MSE 0-14	10.56 (1.70)	7-13.5	9.18 (0.78)	8-11	1.38 (1.55)	5.78***	0.000
ProcessRecording 0-6	4.93 (0.18)	4.5-5	4.12 (0.48)	3.5-5	0.81 (0.49)	10.64***	0.000
NursingDiagnosis 0-6	4.93 (0.93)	3.5-6	4.33 (0.50)	3.5-5	0.60 (0.98)	3.92***	0.000
NursingIntervention 0-30	24.88 (1.73)	21-28	18.29 (1.69)	17.5- 26	6.60 (1.79)	23.87***	0.000
Viva aspects 0-30	21.77 (2.65)	16-27	20.12 (2.92)	16-25	1.65 (2.77)	3.87***	0.000
Total Score 0-100	78.29 (5.97)	64.25-89.3	70.81 (5.88)	59-81	7.48 (4.49)	10.79***	0.000

***p <.001 MSE - Mental Status Examination

Table 4 shows that in the group II there was a significant difference in mean scores between OSCE and TPE on overall performance scores and all the clinical competencies (p <.001). Mean scores obtained by the students in OSCE was higher than TPE.

Table 5: Comparison of Students’ Average (mean) Performance Scores of Group I and Group II in OSCE and TPE (N= 84)

Clinical Competencies and Possible Score Range	OSCE		TPE		Mean Difference and SD	Paired t-value	P - value
Clinical Competencies and Possible Score Range	Mean(SD)	Range	Mean(SD)	Range	Mean Difference and SD	Paired t-value	P - value
Assessment HistoryCollection 0-14	11.23 (1.27)	8-13.5	9.98 (0.82)	8-11.5	1.25 (0.85)	13.50***	0.000
MSE 0-14	10.29 (1.71)	7-13.5	9.08 (1.01)	7-11	1.21 (1.36)	8.11***	0.000
Process Recording 0-6	4.97 (0.44)	4-5.5	4.17 (0.44)	3.5-5.5	0.80 (0.60)	12.25***	0.000
Nursing Diagnosis 0-6	4.93 (0.64)	3.5-6	4.20 (0.64)	3.5-5.5	0.73 (1.11)	6.00***	0.000
NursingIntervention 0-30	24.83 (1.83)	14.5-23.5	22.81 (1.76)	17.5-26.5	2.02 (1.61)	11.48***	0.000
Viva aspects 0-30	21.82 (3.02)	14-28	20.24 (3.13)	12.5-26.5	1.58 (1.95)	7.39***	0.000
Total Score 0-100	77.95 (6.45)	58-93	70.49 (5.87)	56.5-84	7.46 (3.65)	18.75***	0.000

*** p< .001 MSE - Mental Status Examination

Table 5 shows that there was a significant difference (p< .001) between OSCE and TPE on the average (mean) scores of overall performance and all the clinical competencies of Group I and Group II. Mean scores obtained by the students in OSCE was higher than TPE.

Table 6: Students’ Performance Scores by Group I in OSCE and Group II in TPE (N = 84)

Clinical Competencies and Possible

Score Range

Group I( n=42)OSCE

Group II( n=42)TPE

Independentt-value

p - value

Mean(SD)

Assessment

History Collection

0-14

11.51

(1.25)

10.10

(0.83)

3.96***

0.000

MSE

0-14

10.02

(1.70)

9.18

(0.78)

2.92**

0.004

Process Recording

0-6

5.01

(0.60)

4.12

(0.48)

7.54***

0.000

Nursing Diagnosis

0-6

4.93

(1.01)

4.33

(0.50)

3.42**

0.001

Nursing Intervention

0-30

24.77

(1.94)

22.96

(2.10)

4.11***

0.000

Viva aspects

0-30

21.86

(3.35)

20.12

(2.92)

2.52*

0.014

Total Score

0-100

78.10

(6.95)

70.81

(5.88

4.84***

0.000

*p< 0.05, ** p < 0.01, *** p < 0.001 MSE - Mental Status Examination

Table 6 shows that there was a significant difference in the mean scores between the performance by Group I in OSCE and Group II in TPE on overall performance (p < 0.05) and all the clinical competencies. Mean scores obtained by the Group I in OSCE was higher than Group II in TPE.

Table 7: Students’ Performance Scores by Group I in TPE and Group II in OSCE (N=84)

Clinical Competencies

and PossibleScore Range

Group I(n= 42)TPE

Group I(n= 42OSCE

Independent

t-value

p– value

Mean(SD)

Mean( SD)

Assessment

History Collection

0-14

9.86

(0.80)

11.44

(1.27)

6.82***

0.000

MSE

0-14

8.99

(1.19)

10.56

(1.70)

4.92***

0.000

Process Recording

0-6

4.22

(0.39)

4.93

(0.18)

10.72***

0.000

Nursing Diagnosis

0-6

4.07

(0.74)

4.93

(0.93)

4.69***

0.000

Nursing Intervention

0-30

17.96

(1.28)

24.88

(1.73)

6.08***

0.000

Viva aspects

0-30

20.37

(3.35)

21.77

(2.65)

2.13*

0.036

Total Score

0-100

70.17

(5.92)

78.29

(5.97)

6.53***

0.000

*p<.05 ***p<.001 MSE - Mental Status Examination

Table 7, shows that there was a significant difference in the mean performance scores between Group I in TPE and Group II in OSCE on overall scores (p<.001) as well as all the competencies ( p<.05). Mean scores obtained by the students in OSCE was higher than TPE.

Since there is significant difference (p <001) in students’ performance scores between OSCE and TPEwithin and between the groups,(Table 3, 4, 5, 8 and 9 ), H₀1- ‘There will not be any significant difference between OSCE and TPE in the performance of students in selected clinical competencies in psychiatric Nursing’ is rejected.

DISCUSSION:

The study findings show that there was no significant difference between Group I and Group II in terms of baseline characteristics such as age, medium of instruction, religion, and native state of the students, indicating the homogeneity of the groups (Table 1).

With regard to age, 52.4 and 64.29%of the students in Group I and Group II respectively were in the age of 21 years. Nearly half of the students in Group I (47.62 %) and Group II (50%) were from Kerala state. Most of the students’ medium of instruction in the higher secondary education in Group I ((71.43 %) and Group II (76.13%) was English. By domicile, 57.14 % and 57.76% of the students in Group I and Group II respectively were from urban areas (Table 1).

With regard to academic performance of the students in II year final university examination, 66.67 % of the students in Group I and Group II obtained marks in the range 60-74. 30.95 % and 33.33% of the students in Group I and Group II respectively, obtained distinction (75-100%) reflecting the good academic performance of the students in general.

With regard to difference in performance between OSCE and TPE, the study findings revealed that there was a highly significant difference between OSCE and TPE (p < .001) in Group I and Group II on overall performance scores and the performance in all the clinical competencies assessed ( Table 3 and Table 4). The mean scores of overall performance were higher in OSCE (Group I = 78.10 and Group II = 78.29) than TPE (Group I = 70.17 and Group II= 70.81) in both the groups.

Further, the study findings found a highly significant difference (p < .001) between the mean performance scores obtained by the students in Group I in OSCE (M= 78.10) and Group II in TPE (M = 70.81) (Table 6). Similarly there was also a highly significant difference (p < .001) between performance scores of Group I in TPE (M= 70.17) and Group II in OSCE (M = 78.29) (Table 7). Therefore, the hypothesis was supported by the study findings and the hypothesis was accepted.

Similar findings are reported in a study conducted by Mirfeizi et al ²⁰ in Iran to compare the knowledge and clinical practices of midwifery students on OSCE method, traditional method and with the final clinical traineeship score. The mean scores of OSCE, traditional, and clinical traineeship were 85.29, 62.76 and 81.50 respectively which indicated that students performed better in OSCE than traditional methods of evaluation. The findings of this study are consistent with a study conducted by Nigam and Mahawar²¹ to compare OSCE and TPE in community medicine at Indore, India among medical students. Out of 20 marks, the mean marks obtained by the students in OSCE (13.75) was significantly (p <.001) higher than TPE (9.13).

Similar findings are also reported in a study conducted by Zahid et al²²on the effect of OSCE on the students’ performance among medical students in psychiatry in Kuwait University by comparing students’ performance between OSCE and TPE. Results revealed that students obtained higher scores in OSCE than TPE. Rahmanet al²³have conducted a study to evaluate the competency of medical students in OSCE compared to TPE in physiology among 400 medical students at Bangladesh. Mean score obtained by the students in OSCE was 77.72 and found significantly higher than TPE (64.44). These findings are also in agreement of the statement made by Jaywant and Pai²⁴ that, students perform better in OSCE than in TPE as the breaking of various tasks helps the students understand the problem better which facilitatesbetter performance.²⁵

In the present study, minimum and maximum marks obtained by the students in both groups in TPE was 57 and 84 respectively (maximum marks = 100) and in OSCE it was 58 and 93 respectively (Table 5). Ravichandran²⁶states that examiners on most occasions tend to give average scores, rather than very high or low scores which are reflected through narrow range of scores in TPE. Very rarely students score more than 90% in TPE. In the current study, 69% of the students in Group I and Group II scored more than 75% in OSCE, whereas in TPE, only 26.2 % and 31% of the students in Group I and Group II respectively scored more than 75%. 66.7% of the students in Group I and Group II scored between 60-74% in TPE (Table 2).

It is true that, in OSCE, students score higher than TPE and it is also possible to score even 100%, though never achieved in TPE. Another advantage of this method is that overall students perform better in OSCE by compensating in some stations, even if their performance is not satisfactory in other stations, whereas in traditional or conventional examination, they are likely to fail or score very less, if their performance is poor with one patient.

Assessment plays a major role in influencing students’ learning styles, success and their future performance. Thus it is important to ensure that methods used for assessment meet the educational goals and have the ability to evaluate competence levels of the students. Emphasis should be given more to the nursing curriculum, supporting the need for introducing OSCE as a part of formative and summative evaluation. Steps must be taken at the college and the university levels to introduce and implement OSCE as a routine evaluation method in addition to the existing method, TPE in the clinical area. In both formative and summative evaluation equal weight age in marks must be given to OSCE.

Since the present study shows a better performance among nursing students in OSCE when compared to TPE and accepted by a majority of the students as well, the nursing faculty members should pay attention to implement OSCE wherever possible in the clinical posting to test the wide range of clinical skills and competencies and also to reduce subjectivity and bias in evaluation.

Well organized OSCE needs sound knowledge on the subject and OSCE, good planning and mobilization of resources which include examiners, patients or simulated patients, arrangement of venue etc. Hence the nursing faculty members must be trained and prepared suitably to conduct the OSCE with greater emphasis on preparation of OSCE stations and check lists. Preparation of OSCE bank in all the subjects based on the significance of the subject matter and requirement is essential, as it is a laborious task to prepare OSCE stations and checklists every time.OSCE also can be used when there is scarcity of patients due to limited psychiatric centers in the country. OSCE can be conducted in laboratories in the college, using simulated patients. The greatest advantage of using OSCE is that it can be set up to integrate theory and practice in the form of small scenarios, simulations, case studies, standardized patient by which nursing students can improve their own learning and reflection in a safe environment. In the OSCE, evaluation of clinical skills is essential feedback and it plays an important motivating role between students and teachers to ensure the quality and appropriateness of a learning process.

CONCLUSION:

OSCE is an effective method of evaluation when compared to TPE. This is reflected through a better performance of the students in selected clinical competencies in psychiatric nursing in OSCE than TPE. OSCE has been well accepted by a majority of the nursing students as a good evaluation tool for assessing their clinical competency when compared to TPE. The study findings are supported by the studies conducted across the world in nursing and other health disciplines. Literature supports that OSCE has many advantages over the traditional practical examination and satisfies the important criteria of evaluation such as reliability, validity, objectivity. Therefore, OSCE can be used as a supplementary method of evaluation to improve reliability and validity in addition to TPE.

ACKNOWLEDGEMENT:

Authors are grateful to all the patients, teachers and 3^rdyrB.Sc Nursing students, hospital authorities and administrative staff for their cooperation and active participation in this study.

CONFLICT OF INTEREST:

None

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Received on 03.08.2017 Modified on 15.09.2017

Asian J. Nur. Edu. and Research.2017; 7(4): 561-568.

DOI: 10.5958/2349-2996.2017.00109.4