A systematic review and meta-analysis of measurement properties of objective structured clinical examinations used in physical therapy licensure and a structured review of licensure practices in countries with well-developed regulation systems

Abstract

Background: The Objective Structured Clinical Examination (OSCE) is a commonly used tool internationally to assess clinical competency. Physical therapy (PT) licensure processes vary internationally. The OSCE is the tool used in Canada to assess clinical competency for PT graduates seeking licensure. Previous studies that examined the measurement properties of OSCEs present contradictory results.

Objectives: The first objective was to investigate the reliability and validity of OSCEs when administered to PTs during their education or as part of a licensure process. The second objective was to conduct a structured review to report PT educational and licensing components and policies in 17 countries with well-developed PT regulation systems.

Methods: An electronic search was performed in four databases from inception to 31st March 2021 to identify relevant articles. Two reviewers performed the critical appraisal of the included studies using a validated quality assessment tool. We deployed a random effects meta-analysis on reliability and validity estimates of OSCEs and examined sources of heterogeneity with univariate meta-regressions. We searched websites of professional regulatory bodies and associations for data on educational and licencing components and policies. Educational and licensing components across countries were synthesized descriptively.

Results: A pooled estimate of Cronbach's alpha of 0.55, (95% CI: 0.41, 0.67) was determined for OSCEs. The pooled estimate of Intraclass Correlation Coefficient (ICC) between assessors was 0.77 (95% CI: 0.70, 0.83). The pooled estimate of Pearson Correlation between multiple OSCE stations' scores was 0.27 (95% CI: 0.15, 0.39); and between each station score and the total score was 0.71 (95% CI: 0.61, 0.79). The pooled estimates for kappa Coefficients were 0.75 (95% CI: 0.58, 0.86) and 0.84, (95% CI: 0.72, 0.91) for intra-rater and inter-rater reliability of the standardised patient respectively. From the 17 included countries, Canada (excluding Quebec) was the only country that required both a clinical and written competency exam following graduation from an accredited PT program. Two countries (USA, UAE) required a written competency exam. The remaining 14 countries did not require an additional competency examination after completion of degree requirements from an accredited program.

Conclusions: We found weak evidence that OSCE examinations items are internally consistent when used to assess PTs. Canada (excluding Quebec) is the only country out of 17 implementing a national clinical competency examination for their PT graduates to achieve licensure after completing professional degree requirements.

Fig 1. PRISMA flow chart.

Fig 2. Meta-analysis of Cronbach’s alpha on OSCEs in physical therapy students.

Forest plot presenting the meta-analyzed estimate on Cronbach’s alpha. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid vertical line represents no reliability, and the solid diamond indicates the overall summary measure.

Fig 3. Funnel plot to for publication bias.

Funnel plot presenting the studies alpha values from OSCEs, were each circle represents a study.

Fig 4. Meta-analysis of Pearson correlation between OSCEs stations in physical therapy students.

Forest plot presenting the meta-analyzed estimate on Pearson’s r. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid vertical line represents no reliability, and the solid diamond indicates the overall summary measure.

Fig 5. Meta-analysis of Pearson correlation between individual OSCEs stations’ score and total score in physical therapy students.

Forest plot presenting the meta-analyzed estimate on Pearson’s r. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid diamond indicates the overall summary measure.

Fig 6. Meta-analysis of intraclass correlation coefficient (ICC) on OSCEs in physical therapy students.

Forest plot presenting the meta-analyzed estimate on ICC. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid diamond indicates the overall summary measure.

Fig 7. Meta-analysis of kappa coefficient for inter-rater reliability between standardised patients on OSCE’s in physical therapy students.

Forest plot presenting the meta-analyzed estimate on kappa coefficient. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid diamond indicates the overall summary measure.

Fig 8. Meta-analysis of kappa coefficient for intra-rater reliability between standardised patients on OSCE’s in physical therapy students.

Forest plot presenting the meta-analyzed estimate on kappa coefficient. Each square presents the results of an individual study with the size of the square being proportional to the weights used in the meta-analysis and the horizontal lines indicating the 95% confidence intervals. The solid diamond indicates the overall summary measure.