Assessment practices and types of knowledge in two clinical examination formats in nursing education

Background and objective: The assessment of nursing students' clinical competencies is a global concern, as different exam formats emphasize different types of knowledge and skills. There is a lack of research that uncovers the linkage between clinical exam formats, assessment practices and types of knowledge tested. This study investigates how two different formats of clinical exams—one based on written assignments (control exam), and one conducted in real patient situations (intervention exam)—influence educators’ assessment practices and the types of knowledge they enhance or limit respectively.Methods: The study applied a comparative, ethnographic design, incorporating participant observations, focus group interviews with educators, and grade analysis of 104 nursing students. The analytical framework was informed by Institutional Ethnography (IE) and Donald Schön’s concepts of reflection in practice.Results: The control exam is predictable and controlled facilitating assessment of theoretical knowledge and reflection-on-reflection-in-action but is detached from real-life patient interactions. In contrast, the intervention exam is unpredictable and complex emphasizing assessment of knowing-in-action and reflection-in-action but poses challenges in assessing theoretical reasoning and reflection-on-reflection-in-action. Despite these differences, no significant variation was found in students’ final grades between the two formats.Conclusions: The findings highlight the impact of exam formats on assessment practices and suggest that nursing education should incorporate diverse assessment methods to balance theoretical rigor with clinical competence.