Performance of undergraduate nursing students across Objective Structured Clinical Examination (OSCE): a retrospective cross-sectional study

Abstract

Introduction

The Objective Structured Clinical Examination (OSCE) is widely used globally to assess a broad range of clinical competencies among medical science students. This study aimed to investigate the performance of Bachelor of Science in Nursing (BSN) students on the OSCE and identify factors influencing their success.

Material and methods

This retrospective cross-sectional study reviewed OSCE records of 324 BSN students at a nursing school in Tehran, Iran, between 2021 and 2025. The OSCE scores across multiple clinical skill stations were gathered by the census method. SPSS was used for data analysis. Statistical significance was considered at P < .05.

Results

Female students scored significantly higher than male students in the majority of stations (P < .05). Additionally, academic Grade Point Average (GPA) was associated with higher OSCE scores (P < .05). Students indicated moderate to high performance across most OSCE stations, especially in oxygen therapy and cardiopulmonary resuscitation. Regarding wound dressing and medication administration, students excelled in basic aseptic tasks and verifying prescriptions; however, they demonstrated lower accuracy in documentation, patient education, and ongoing monitoring. The weakest performance was observed in clinical interpretation and patient education stations. While the documentation was commendable in terms of legibility and adherence to standard abbreviations, it fell short in its follow-up and consultation notes.

Conclusion

This study identified female gender and higher GPA as factors improving OSCE performance among BSN students. These results underscore the necessity for focused pedagogical strategies that go beyond checklist compliance, fostering critical thinking, continuity of care, and professional accountability, especially for lower-performing groups. Additional studies are suggested to investigate the causes and assess interventions aimed at improving student success in clinical competency evaluations.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08628-7.

Introduction

Clinical skills assessment is complex and challenging. Accurate assessment of skill competencies ensures clinical capabilities and improves the learning process and quality of educational programs [1, 2]. Therefore, choosing an appropriate method has always been of concern to clinical teachers, course administrators, and medical science educators [2]. One of these assessment methods is the Objective Structured Clinical Examination (OSCE), which is a comprehensive, consistent, and standardized method for assessing students’ clinical learning experiences [1, 3]. Today, the OSCE has been globally accepted to assess a wide range of clinical competencies in medical sciences students [4]. It is a more effective technique for assessing end-of-course simulations, and its use in conjunction with or in place of other assessment tools is crucial when determining competency [5]. When instructors use OSCE as a formative assessment tool, it helps learners organize their clinical experiences. Positive feedback encourages learners to discuss their simulation experiences, increases confidence in their knowledge, and prepares them for more professional practice [5]. However, the high preparation time and separate observation of knowledge and skills, the short time spent at each station, the inflexible pre-determined checklists, the short exposure (“snapshot”) of the patient and the learner, and the unsimulatability of some skills, may make its use for assessment problematic [6, 7]. Obviously, the need for the availability of assessors proportional to the number of stations, the need to provide the same training to all assessors, and the time-consuming and costly nature of implementing the OSCE are some of the challenges of conducting the OSCE [3, 5]. Finding SPs trained in specific fields is both difficult and resource-intensive. Additionally, there are challenges in standardizing the environment or stations. All of these issues, combined with resource constraints and lack of experience, may make the OSCE challenging [7]. Despite all the challenges in administering the OSCE, it is still one of the most important methods of assessing the skills of medical students. One of the most important advantages of the OSCE is its ability to directly assess aspects of competency beyond cognitive knowledge, such as performance and patient management. The higher aspects of Miller’s pyramid include performance (“shows how”) and action (“does”), where evaluation methods should be focused on in assessing competence [8].

The use of OSCE in Iranian medical universities has a relatively short history, and since its inception, many efforts have been made by universities and stakeholders to ensure the correct implementation of OSCE. However, despite the efforts of the trustees and the recent need of the government to transform it into one of the formats of clinical competency exams in medical sciences, its development at the national level is not as expected. In this regard, Iranian medical universities have been conducting OSCEs in recent years as a formative assessment of medical and nursing students. One of the methods of improving the teaching-learning process and evaluation methods is to identify strengths and weaknesses and the factors affecting them. To the best knowledge of researchers, no evidence has assessed the students’ performance on OSCEs in Iranian nursing schools. Therefore, this study aimed to investigate students’ performance on OSCEs and identify factors affecting their success in a nursing school in Tehran, Iran.

Materials and methods

Design and setting

This retrospective cross-sectional study was conducted in a nursing school in Tehran, Iran, in 2024–2025.

Sampling and participants

The archived records of the OSCEs that were evaluated to assess nursing students’ performance across multiple clinical skill stations from 2021 to 2025 by census method (n = 324) were assessed. The study population included undergraduate nursing students who completed the OSCE as part of their academic requirements in the same nursing school. The students who were assessed in different OSCEs in 2021–2025 were labeled as A, B, C, D, E, F, and G groups. In the nursing school being studied, typically, one cohort of students is admitted annually. However, based on the hospitals’ demand for a greater nursing staff linked to the university, there are some years when two cohorts of students are enrolled during the September and February semesters. As a result, while one OSCE is generally conducted throughout the year, it becomes necessary to hold two OSCEs when a larger number of students are admitted in two separate semesters. Hence, in 2021 and 2022, two OSCEs were held for students admitted in different semesters. A total of seven groups were studied (Table 1).

Table 1.

Individual characteristics of students in the OSCEs

Admission group	n	OSCE Administration Year	Female f(%)	Male f(%)	GPA Mean ± SD
A	59	2021	29 (49.2)	30 (50.8)	16.60 ± 1.12
B	19	2021	19 (100)	-	17.04 ± 0.99
C	32	2022	9 (28.1)	23 (71.9)	17.37 ± 1.04
D	31	2022	22 (71.0)	9 (29.0)	17.61 ± 0.93
E	25	2023	5 (20.0)	20 (80.0)	17.04 ± 0.99
F	64	2024	27 (42.2)	37 (57.8)	16.77 ± 1.22
G	94	2025	41 (43.6)	53 (56.4)	16.91 ± 1.13
Test, df, P-value					*F = 4.456, df = 6, P < .0001
Total	324	-	152(46.9)	172(53.1)	16.89 ± 1.14

n number (frequency), GPA Grade Point Average

*one-way ANOVA

OSCE in the study setting

According to the curriculum approved by the Ministry of Health, Treatment, and Medical Education (MoHTME) of Iran, nursing students are required to pass an OSCE after completing the full-time, practice-based clinical internship (transition-to-practice clinical internship) in forth year. Students who fail the examination must, based on the decision of the program director, complete an additional period of practice-based clinical internship as deemed necessary and subsequently re-sit the OSCE [9]. At the study setting, the OSCE is administered between the clinical practicum period and the transition-to-practice clinical internship. The core curriculum, learning outcomes, hours of simulation-based training before OSCE, and clinical skills requirements were almost consistent across academic years and aligned with national nursing education standards that were established by the MoHTME (Supplementary 1) [9, 10]. Mock OSCEs were not held at the study setting, but students were able to practice key skills they had covered in previous years in the school’s skill lab. The OSCEs were conducted to assess students’ clinical competencies in a standardized and objective manner in nursing school. The examination comprised five to seven stations: one quarantine station, one rest station, and other assessment stations.

The quarantine station served as a holding area to ensure that there was no prior exposure to the assessment scenarios and to preserve the integrity of the exam. While waiting in the rest station, students received a light snack.

Every assessment station showcased a clinical scenario aimed at assessing particular competencies, such as procedural performance, knowledge, attitude, and interpersonal communication.

Certain stations implemented standardized patients (SP), while others made use of simulators or mannequins. Students allocated seven minutes to each station, dedicating five minutes to executing the specified procedure and using the remaining time for transitions and quick instructions.

Every station was evaluated by two trained faculty examiners utilizing checklists. The examiners underwent training beforehand to promote consistent evaluations and reduce inter-rater variability. A manager coordinated the OSCE to supervise the examination process, while a designated staff member rang a bell to indicate the beginning and end of each station, ensuring accurate time management. Scores from all active stations were aggregated to evaluate the overall performance in the OSCE.

Teaching and assessment were delivered by faculty members from the same nursing school, with overlapping instructors and examiners throughout the study period. Although minor administrative updates occurred over time, no major curricular revisions affecting OSCE content or structure were introduced. This methodical and well-organized approach, which included realistic scenarios, standardized evaluations, and precise timing, offered a dependable, impartial, and thorough assessment of the students’ clinical competencies.

Data gathering

To collect data, in addition to the students’ gender and Grade Point Average (GPA) of previous semesters, existing examination checklists that had been collected approximately five years earlier were used to preserve confidentiality and ensure consistency of evaluation.

These checklists included: wound dressing, medication administration, basic life support (BLS), O₂ therapy, clinical findings, patient education, and documentation. Stations included wound dressing, medication administration, and documentation at OSCEs were planned and implemented every year, and the other stations varied depending on the decision of the OSCE organizing scientific committee.

These checklists included essential steps in procedures that had to be performed by students. Every checklist was developed by faculties to align with the learning goals of the specific course and included between 5 and 20 items. The items evaluated various competencies such as infection control techniques, communication abilities, clinical reasoning, technical skills, and compliance with professional standards. During the examinations, student performance was assessed in real time by examiners.

The total score of each checklist is reported to be 20 points. Most checklist items were scored dichotomously (1 = correctly performed; 0 = not performed or incorrectly performed), except clinical interpretation and patient education stations. Checklist items were not differentially weighted; all items contributed equally to the total score for a given station except for clinical interpretation and patient education stations. At the clinical interpretation and patient education stations, a score was assigned based on predefined criteria indicating the completeness of each item response. Raw scores were standardized by converting them into 20-point scores (Supplementary 1–7). While the checklists were developed by experts, their reliability, such as internal consistency or inter-rater reliability, was not assessed at the time of their design.

Data analysis

Version 24 of the Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL, USA) was used for data analysis. The Kolmogorov-Smirnov test was used to check the normality of the data. Descriptive statistics (frequency, percentage, mean, and standard deviation (SD)) were used to summarize data. Inferential statistics, including t-tests and analysis of variance (ANOVA), were utilized to investigate differences among groups of items or domains. The Pearson correlation coefficient (PCC) was used to measure linear correlation between two sets of quantitative data. The significance level was considered to be P < .05.

Results

Participants’ characteristics

The GPA of the students was 16.89 ± 1.14 (13.39 to 18.94). Over 53.1% of the students were male. There was a significant difference in the students’ GPA in different years (P < .0001) (Table 1).

Primary outcomes

Relationship of participants’ characteristics with OSCE scores

Female students scored higher than male students in most stations, including wound dressing (P = .023), medication administration (P < .0001), BLS (23-item) (P < .0001), O₂ therapy (P < .0001), clinical findings (5-item) (P < .0001), and patient education (P < .01) (Table 2).

Table 2.

Analysis of the mean student scores at OSCE stations by sex

Station	Sex (n)	Mean ± SD	aTest, df, P-value
Wound dressing	Female (152)	10.28 ± 5.50	t=2.294, df = 248.168, P = .023
	Male (172)	9.09 ± 3.46
Medication administration	Female (104)	14.82 ± 2.83	t = 3.714, df = 242, P < .0001
	Male (140)	13.32 ± 3.30
CPR (23-item)	Female (111)	17.26 ± 2.80	t = 4.865, df = 201, P < .0001
	Male (92)	15.33 ± 2.84
CPR (20-item)	Female (14)	16.50 ± 2.85	t = 1.731, df = 91, P = .087
	Male (79)	14.76 ± 3.56
bCPR (17-item)	Female (27)	11.00 ± 1.40	-
Oxygen therapy	Female (67)	17.41 ± 1.94	t = 7.697, df = 135.261, P < .0001
	Male (90)	13.65 ± 4.05
Clinical findings (5-item)	Female (27)	18.44 ± 2.37	t = 5.748, df = 62, P < .0001
	Male (37)	14.03 ± 3.43
Clinical findings (8-item)	Female (41)	13.07 ± 2.35	t = 0.534, df = 92, P = .594
	Male (53)	12.79 ± 2.65
1st Patient education (12-item)	Female (33)	21.04 ± 3.67	t = 4.264, df = 36.151, P < .0001
	Male (43)	18.23 ± 1.06
Patient education (10-item)	Female (63)	17.03 ± 2.91	t = 2.473, df = 123, P = .015
	Male (62)	15.74 ± 2.91
2nd Patient education (12-item)	Female (27)	9.30 ± 2.03	t=-1.919, df = 62, P = .060
	Male (37)	10.50 ± 2.75
Documentation	Female (152)	12.97 ± 2.90	t = 1.128, df = 322, P = .260
	Male (172)	12.59 ± 3.13

n number, SD Standard deviation, df Degree of freedom, CPR Cardiopulmonary resuscitation

^aindependent sample t-test

^bOnly female students were assessed with this checklist

The scores of most stations had a significant positive direct correlation with the students’ GPA, including the wound dressing (P = .026), medication administration (P < .0001), BLS (23-item) (P < .0001), O₂ therapy (P < .0001), clinical findings (P < .001), patient education (10-item) (P = .014), and documentation (P = .002) stations (Table 3).

Table 3.

The average student scores at OSCE stations and their correlation with GPA

GPA	n	aMean ± SD	Min	Max	PCC	P-value
Wound dressing	324	9.65 ± 4.56	0.0	19.0	0.124	0.026
Medication administration	244	13.96 ± 3.9	3	20	0.277	0.000
CPR (23-item)	203	16.38 ± 2.97	8	23	0.384	0.000
CPR (20-item)	93	15.02 ± 3.50	6	20	0.061	0.558
CPR (17-item)	27	14.48 ± 1.39	11	17	0.348	0.075
Oxygen therapy	157	15.26 ± 3.80	5	20	0.430	0.000
Clinical findings (5-item)	64	12.91 ± 2.51	6.5	17	0.664	0.000
Clinical findings (8-item)	94	15.89 ± 3.72	4	20	0.325	0.001
1st Patient education (12-item)	76	19.45 ± 2.89	16	27	− 0.008	0.944
Patient education (10-item)	125	16.39 ± 2.97	8	20	0.220	0.014
2nd Patient education (12-item)	64	9.99 ± 2.53	3	16	0.004	0.978
Documentation	324	12.77 ± 3.03	0	20	0.172	0.002

GPA Grade Point Average, n number, PCC Pearson correlation coefficient, CPR Cardiopulmonary resuscitation

^aThe average score of the checklists is reported to be 20 points

Students performed differently at OSCE stations in different years (Table 4).

Table 4.

Analysis of the mean student scores at OSCE stations by academic courses

Station	Admission group (n)	Mean ± SD	Test, df, P-value
Wound dressing	A (59)	9.32 ± 4.24	aF=17.332, df = 6, P < .0001
	B (19)	6.84 ± 6.37
	C (32)	10.81 ± 3.38
	D (31)	3.71 ± 6.29
	E (25)	10.12 ± 2.83
	F (64)	10.05 ± 3.56
	G (94)	11.59 ± 2.87
	Total	9.65 ± 4.57	Range (0–19)
Medication administration	A (59)	10.58 ± 3.17	bt=0.944, df = 76, P = .348
	B (19)	9.79 ± 3.12
	C (32)	12.97 ± 2.89	F = 14.194, df = 4, P < .0001
	D (31)	14.39 ± 3.89
	E (25)	17.44 ± 1.36
	F (64)	14.53 ± 2.60
	G (94)	12.83 ± 3.00
	Total	12.89 ± 3.82	Range (4–20)
CPR (23-item)	A (59)	17.07 ± 2.28	F = 21.950, df = 3, P < .0001
	B (19)	17.21 ± 2.48
	D (31)	18.97 ± 2.70
	G (94)	14.94 ± 2.77
	Total	16.38 ± 2.97	Range (8–23)
CPR (20-item)	C (32)	16.03 ± 2.12	F = 45.071, df = 2, P < .0001
	E (25)	11.00 ± 3.07
	F (37)	16.89 ± 2.38
	Total	15.02 ± 3.50	Range (6–20)
cCPR (17-item)	F (27)	11.00 ± 1.40	-
Oxygen therapy	F (64)	12.72 ± 4.09	t=-7.588, df = 91.386, P < .0001
	G (94)	17.01 ± 2.34
	Total	15.26 ± 3.80	Range (5–20)
dClinical findings (5-item)	F (64)	12.91 ± 2.52	-
eClinical findings (8-item)	G (94)	15.90 ± 3.73	-
1st Patient education (12-item)	B (19)	23.39 ± 3.02	F = 61.462, df = 2, P < .0001
	C (32)	18.16 ± 1.02
	E (25)	18.12 ± 1.23
	Total	19.45 ± 2.89	Range (16–27)
Patient education (10-item)	D (31)	18.29 ± 0.26	t = 6.149, df = 108.961, P < .0001
	G (94)	15.77 ± 3.09
	Total	16.39 ± 2.97	Range (8–20)
f2nd Patient education (12-item)	F (64)	9.99 ± 2.53	-
Documentation	A (59)	11.71 ± 2.85	F = 11.640, df = 6, P < .0001
	B (19)	11.42 ± 2.61
	C (32)	14.87 ± 2.62
	D (31)	11.03 ± 3.32
	E (25)	13.64 ± 1.50
	F (64)	11.87 ± 2.30
	G (94)	13.94 ± 3.13
	Total	12.77 ± 3.03	Range (0–20)

n number, SD Standard deviation, df Degree of freedom, CPR Cardiopulmonary resuscitation

^aone-way ANOVA   

^bindependent sample t-test

^cOnly female students were assessed with this checklist

^d, ^e, and ^f These checklists were only used in 2024 and 2025

Wound-dressing

The accuracy rates for essential wound-dressing stages among students are presented in Supplementary 2. More than 70% students had accurate action in removing previous dressings, wearing disposable gloves, identifying the patient, explaining procedures for him/her, and opening the dressing set sterilely.

On the other hand, less than 10% of students performed hand hygiene after the wound dressing. Additionally, only a minority of students performed the documentation of wound appearance and nursing measures, post-procedure patient positioning and education, and labeling dressings with the date.

Medication administration

The students’ accuracy in executing essential steps of medication administration was outlined in Supplementary 3. More than 70% of participants properly monitored physicians’ orders and compared medication labels with prescriptions. Additionally, more than 75% of students had high performance in patient communication. More than 60% of them adhered to key aseptic techniques, such as hand disinfection, sterile handling of syringes, and safe disposal of needles.

However, some safety-critical fundamental measures showed suboptimal performance. Only less than half of the students matched Medication Administration Record (MAR) or Kardex records to patient identities, and about one-third of them properly labeled micro-infusion sets. Additionally, avoiding recapping of needles (47.2%), correct waste disposal (51.5%), and checking the date and condition of IV catheters (54.9%) were not ideal.

BLS

Supplementary 4 summarizes the rate of accuracy in performing essential BLS steps by students. Overall, students showed high competency in fundamental cardiopulmonary resuscitation (CPR) steps. In students who used the 23-item checklist, between 70 and 92% demonstrated proper scene safety evaluation, pulse assessment, and the start of CPR. Satisfactory cardiac compressions, appropriate compression depth, and delivery of rescue breaths were also recorded.

In this study, only about 45% were successful in correctly removing foreign bodies, and about 56% were aware of when rescuers should change positions. In groups using 20-item and 17-item checklists, findings were generally consistent, with female students (F group) obtaining perfect scores on several important items, including scene safety, pulse evaluation, and the initiation of CPR. In contrast, there was less precision in ensuring complete chest recoil and proper hand placement.

O₂ therapy

Supplementary 5 outlines that students’ performance in O₂ therapy procedures was acceptable. More than 95% of students chose the correct oxygen device, applied it properly, and adjusted the flow rate according to the doctor’s order. A high level of adherence was also noted in assessing the doctor’s order, assembling the necessary equipment, and confirming the patient’s identity.

Less than half of the students respected patient privacy and consistently monitored oxygen levels and distilled water every thirty minutes.

In fact, students revealed strong technical proficiency but lower performance in continuous monitoring, documentation, and patient communication aspects of O₂ therapy.

Interpreting of clinical findings

The learners’ performance in interpreting essential clinical findings was presented in Supplementary 6. Each scenario required students to analyze laboratory (lab) data and respond to clinical questions measuring diagnostic reasoning, lab interpretation, and pathophysiology knowledge.

In the F group, students showed the highest performance on identifying a probable diagnosis from lab results and recalling normal laboratory values. The lowest accuracy was observed for defining anisocytosis.

For the G group, students displayed relatively high accuracy in explaining causes of elevated urea and identifying normal urea and creatinine levels. Lower performance was recorded in stating the normal hemoglobin value and assessing the Arterial Blood Gas results.

Patient education

Supplementary 7 summarizes nursing students’ accuracy in patient education. Students in the B, C, and E admission groups showed generally high proficiency in communication and educational interaction. The greatest mean scores were observed for receiving feedback from SPs and communicating appropriately. In contrast, lower scores were recorded for teaching lifestyle modification and documenting the education delivered.

In the F group, scores were significantly lower. Although students performed relatively well in measuring blood pressure, they demonstrated limited abilities in self-introduction, learning needs assessment, alleviating patient stress, and documenting patient education.

The D and G groups acquired overall strong outcomes, particularly in communication, wound care, diet education, feedback, and documentation. These students also demonstrated high proficiency in introducing themselves and avoiding personal judgment.

Documentation

Supplementary 8 demonstrates students’ adherence to essential documentation steps. The highest compliance rates were recorded for the use of standard abbreviations, legible writing, and error-free records. About 80% accurately documented patient mood and consciousness, and dietary status.

The weakest adherence was found in follow-up documentation, consultation, and patient instruction records, and time/date and nurse identification.

Discussion

This study examined BSN performance on the OSCE and the factors affecting their success. The findings showed that female students performed better than male students at most stations. Other studies showed that some OSCE stations are gender-sensitive [4, 11, 12]. Similarly, Shelton et al. reported that female students achieved higher scores than male students in both the warfarin OSCE therapeutic knowledge and general communication skills assessments [12]. Additionally, Zhang et al. indicated that female Chinese undergraduate medical students achieved higher results than male students in all modules and overall scores in the OSCE, except auxiliary examination analysis [4].

This study demonstrated that students with higher GPAs were more successful on the OSCE. Aligning with this study, Manuaba et al.‘s study indicated that overall OSCE scores and GPA were notably linked to undergraduate medical students’ preparedness for clinical rotation assessments in the areas of teamwork, comprehensive care, and communication skills [13]. Additionally, Purnamasari and Setyawan demonstrated that the knowledge component affects students’ preparedness for clinical education [14]. This suggests that GPA influences the preparedness of medical sciences students for clinical rotations, serving as a measure of their knowledge about patient health issues.

Students showed varied performances across different OSCE stations in various years. Also, the average score of students at some stations was higher than at other stations. The reason for the difference in student performance, in addition to their knowledge and skills, is probably due to the strictness or lenience of the assessors, minor variations in teaching staff, clinical exposure, or educational context across academic years. In line with this study, the varying competencies of assessors, the rotation of assessors across various stations, the need to standardize the environment or stations, the experience of high levels of stress [15], and the rigidity of some evaluators are among the challenges faced by the OSCE that have been highlighted in previous studies [1]. For instance, evidence indicates that the credibility of an assessor’s evaluation can diminish if the activities in a station are overly complicated and lengthy, leading to examiner demoralization and fatigue that affects the validity of the exam [16].

This study indicated that learners exhibited an adequate level of technical skill in fundamental clinical skills like oxygen therapy, medication administration, and basic CPR. Nevertheless, their performance waned in more intricate, comprehensive, or reflective domains, which encompass patient education, clinical reasoning, and documentation, which is discussed below.

Wound-dressing

This study showed notable differences in students’ adherence to important wound-dressing steps, revealing strengths in basic procedural tasks but significant deficiencies in infection control and follow-up care. Students exhibited strong qualifications in initial patient relationship and basic aseptic techniques, such as identifying patients, communication, proper glove usage, and preparing a sterile field. However, critical infection-prevention measures, including final hand washing and mask utilization, were often neglected, highlighting a lack of consistency in following aseptic protocols. In this regard, Poacher et al. demonstrated that medical students widely believe that education on wound management is a crucial aspect of both the undergraduate curriculum and postgraduate training, yet they feel their educational requirements in this area have not been adequately fulfilled [17]. Evidence indicates that simulation-based education greatly enhances both wound care knowledge and the practical application of clinical skills in nursing education [18]. In this study, low accuracy in wound assessment, documentation, and patient education suggests insufficient emphasis on holistic wound-care measures. The very low rate of documenting the date on dressings may be attributed to a lack of knowledge regarding continuity-of-care practices. These actions are emphasized in the curriculum, so these weaknesses may be attributed to limited hands-on practice and insufficient clinical supervision.

Medication administration

This study showed that while learners performed well in patient identification, interactions, and initial medication verification steps, there were some gaps in medication safety skills and aseptic protocol. High performance in relationship management and prescription confirmation stands on adequate theoretical knowledge and interpersonal skills. Nonetheless, the limited adherence to verifying patient identity through MAR (Kardex) records and suboptimal labeling practices indicates deficiencies in patient-safety behaviors and continuity-of-care documentation. As well as inattention to disinfecting vial entry points and a lack of proper needle recapping, further emphasize inconsistencies in infection-prevention protocols. In this regard, Salami explored common medication errors reported by nursing students in Jordan and assessed their adherence to best practices. Findings indicated that nursing students were most compliant with several best practices, including verifying the patient’s armband before giving medication and taking the MAR sheet with them during the preparation of medications [19]. Errors in medication administration rank among the most significant adverse events within healthcare systems. To reduce the likelihood of these incidents, nursing training programs should stress the paramount importance of patient safety. Active teaching methods such as simulation have been demonstrated to be an effective way to gain proficiency in the safe delivery of medication [20, 21]. Improving clinical training regarding verification systems, infection-control techniques, and safe-injection measures may enhance students’ preparedness for clinical medication administration and decrease medication-error risks.

BLS

This study indicated that although students understand the essential sequence of BLS, there were still shortcomings in airway management, foreign-body extraction, and specific technical details. In contrast, significant deficiencies in airway clearance, coordination of roles, and ensuring ideal compression quality indicate that procedural integration may not be fully complete, and there could be gaps in practical training. Evidence showed that proper CPR decreases mortality associated with in-hospital cardiac arrest when patients are treated by well-trained and specialized healthcare providers [22]. Miri et al. identified ongoing shortcomings in nursing students’ capacity to apply BLS knowledge effectively in CPR performance during OSCEs. They determined that shortcomings in compression quality, automated external defibrillator usage, and decision-making underscore the limitations of existing training methods [23]. Additionally, López-Herce suggested that the OSCE serves as a reliable tool for assessing paediatric basic life support (PBLS) competencies in medical students and for comparing various educational approaches and enhancements to training programs. Medical students trained through a Paediatric Immediate Life Support course demonstrate superior PBLS skills compared to those who complete a PBLS course [24]. The weakness of students in this study reflects the complexity of integrating cognitive abilities and psychomotor execution. Reinforcing repeated scenario-based simulations, using high-fidelity simulators, immediate debriefing, and structured real-time feedback could address these gaps and enhance long-term retention of BLS competencies. By employing active learning strategies like simulation, learners are required to participate in a clinical scenario while focusing on problem-solving and decision-making, which can yield effective results [22].

Oxygen therapy

In O₂ therapy, students showed strong adherence to technical tasks, including device selection, setup, and flow-rate adjustment, which indicates sound procedural understanding. However, no ideal performance in the patient’s privacy maintenance, ongoing monitoring, and patient education highlights a gap between students’ technical and holistic care abilities. Aligning with this study, Kord et al. revealed that 90% of the nurses did not comply with the O₂ therapy standards before using a neonatal oxygen hood. Additionally, in relation to the stated standards, more than 84% the nurses demonstrated moderate and poor performance during and after O₂ therapy [25]. In the current study, the students’ weakness in checking equipment and re-evaluating oxygen flow indicates low awareness of continuous safety monitoring, which is vital for preventing hypoxia and equipment-related risks. Additionally, inattention to documentation and inconsistent privacy protection may indicate low time during the OSCE or insufficient reinforcement of professional ethics during the training process.

Interpreting clinical findings

In this study, learners demonstrated greater proficiency in recognizing lab ranges and clarifying abnormal values than in interpreting clinical implications and acid–base imbalances, with variability between scenarios. Students performed better on questions requiring recall of normal laboratory ranges and straightforward diagnostic explanations, while no ideal competence was demonstrated in advanced interpretation tasks, such as recognizing acid–base imbalance. Evidence indicates that integrating knowledge from various disciplines is crucial for solving clinical issues. As it is not easily visible, providing proof of learners’ cognitive integration poses a difficulty [26]. In this study, the deficiencies in acid–base analysis suggest insufficient depth in applied pathophysiology and clinical reasoning training. Also, weakness in interpreting blood cell count with differential (CBC diff) findings demonstrates gaps in hematology knowledge. The low ability of students to articulate physiologic explanations behind lab abnormalities emphasizes the importance of improved simulation and case-based learning focused on critical thinking and clinical decision-making. The development of diagnostic reasoning in preclinical students affects the way curricula are designed and executed for this group of students [26].

Patient education

In the patient education station, the results showed moderate to high communication skills, but highlighted diversity in students’ ability to integrate educational content with patient-centered engagement. The majority of students demonstrated confidence in communication, feedback, and teaching skills. Evidence emphasizes that nurses have an essential role in educating patients and require a variety of communication, teaching, encouragement, and evaluation skills [27]. Eslamnik et al. also showed that the general performance of medical students in patient education concerning various diseases and procedures in the obstetrics and gynecology ward was viewed as average by the students, while the staff rated it positively. Regarding the specifics of patient education for each disease or procedure, some students did not perform satisfactorily [28]. As well, Yuan pointed out that nursing undergraduates are capable of providing patient education on disease descriptions, medications, diet, and activities, but their communication abilities and awareness of cultural competency require enhancement [29]. In the current study, low scores in stress management, needs assessment, and documentation of education highlight a common weakness between technical demonstration and reflective practice. Students did not prioritize evaluation and emotional support. Incorporating organized feedback, patient-simulation activities, and reflective debriefing may enhance these skills. Improving and promoting the patient education skills of nurses is essential for raising the standard of patient education, care, and safety, as well as for furthering the nursing profession and its standing [29].

Documentation

This study shows that although students manage basic recording skills well, they frequently neglect detailed follow-up and interdisciplinary communication elements essential for comprehensive nursing documentation. It may be due to limited awareness of the broader continuity-of-care process. As well, low accuracy in time stamps and nurse identification outlines potential lapses in accountability training. These shortcomings have implications for patient safety and legal protection, as inadequate documentation can hinder communication within healthcare provider teams. Highlighting real-case chart reviews, electronic-record simulations, and formative evaluation during training may address this issue. Based on the research conducted by Kamil et al., more than 80% of nursing students at Universitas Syiah Kuala demonstrated insufficient knowledge regarding the documentation of the nursing process [30]. The recording of patient interactions is a crucial subject that frequently receives insufficient attention in medical school curricula. The implementation of OSCEs and simulated patient encounters could offer a straightforward, effective approach. These strategies would cultivate and evaluate a student’s capability to collect information while concurrently recording it – a challenging skill that is becoming more necessary due to the time constraints of contemporary clinical practice [31]. According to Kamil et al.’s study, the primary challenges associated with nursing documentation were: (1) insufficient oversight for nurses regarding nursing documentation; (2) deficiencies in documentation skills; and (3) a lack of confidence and motivation related to documentation [30]. Education ranks as one of the leading factors that enhance the quality of nursing documentation [32].

Limitations

This study has several limitations. First, while the OSCE checklists were developed by expert faculty members, their psychometric characteristics have not been formally validated before holding OSCEs. In particular, evaluations of internal consistency (such as Cronbach’s alpha) and inter-rater reliability were not examined, which could hinder the interpretation of the results. Nevertheless, OSCEs are widely accepted in medical sciences education as authentic assessments of clinical competency, and checklist-based scoring remains a common and practical approach for evaluating observable skills. Second, although all cohorts were drawn from the same nursing school and followed a standardized curriculum, minor variations in teaching staff, clinical exposure, or educational context may have occurred across academic years. Such cohort-related differences are inherent in retrospective educational studies and may have influenced individual OSCE performance. On the other hand, many factors have been reported that influence OSCE performance, including individual learner characteristics such as gender, health status, internship courses [33], examination context, examinee characteristics, examinee-examiner interactions, examiner characteristics [34], level of stress and anxiety before the test [15]. In the current study, factors such as the core curriculum, learning outcomes, hours of simulation-based training before OSCE, and clinical skills requirements, examination context, and examiners were almost consistent across academic years, and only gender and GPA, as overall academic performance, were available and were assessed as explanatory variables. However, factors such as stress, anxiety, and students’ self-confidence may also affect the results of the OSCE, which could not be examined due to the retrospective nature of the study; therefore, it is suggested that they be considered in future longitudinal studies.

Conclusion

This study demonstrated individual disparities in clinical skills assessment based on OSCE results among Iranian BSN students, where female gender and higher GPA were factors improving OSCE performance. Additionally, this study outlined that in many procedures, nursing students showed high proficiency in technical skills and initial procedural steps compared to their follow-through and follow-up actions (such as documentation, reassessment, interpreting findings, and teamwork). Interpreting findings, documenting, and ongoing monitoring represent complex clinical reasoning, reflective practice, and clinical thinking processes rather than isolated technical skills. They require integration and synthesis of data, anticipation of care needs, prioritization, and evaluation of intervention outcomes, which are a cognitive process. This trend indicates that while cognitive recall and psychomotor skills are well-developed, there is a need for ongoing educational emphasis on higher-level clinical reasoning, comprehensive patient care, promoting critical thinking, continuity of care, and professional ethics and responsibility.

Strengthening OSCE skill reinforcement, receiving real-time feedback, simulation-based training, and clinical case discussions may enhance students’ ability to integrate nursing competencies into their clinical practice. Emphasizing clinical reasoning and pattern recognition strategies may help shift learners to the higher levels of Bloom’s Taxonomy, where they move from mere memorization to analytical thinking that is required for safe practice.

This study highlights the need to strengthen integrated teaching that combines procedural accuracy with patient-centered care. Embedding reflective debriefings and emphasizing the reasoning behind each step in different procedures may promote critical thinking, clinical reasoning, and enhance adherence to professional standards in students. It is recommended to employ future studies with prospective designs and conduct formal validation of assessment tools, and use global rating scales alongside checklists to increase measurement validity and robustness of findings.

Abbreviations

OSCE

Objective Structured Clinical Exam

BLS

Basic life support

O₂ therapy

Oxygen therapy

CPR

Cardiopulmonary resuscitation

SP

Standard patient

GPA

Grade Point Average

SPSS

Statistical Package for the Social Sciences

SD

Standard deviation

PCC

Pearson correlation coefficient

PBLS

Paediatric Immediate Life Support

MAR

Medication Administration Record

Authors’ contributions

ZF contributed to the conceptualization, planning, data analysis, interpretation, and writing the manuscript. FT contributed to the conceptualization, planning, and data collection. HH was involved in the conceptualization, data gathering, and interpretation. RS contributed to the conceptualization. All authors collaborated in the study, and they read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors to date. Aja University of Medical Sciences approved this study (No. 97003034, Date: November 25, 2024). This study was conducted for academic purposes and did not receive any support from organizations subject to international sanctions. Aja University of Medical Sciences was not involved in the design, execution, analysis, or reporting of the findings.

Data availability

The data that support the findings of this study are available in Persian from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was carried out as a retrospective cross-sectional study utilizing data that had been gathered earlier. No new data were gathered from participants, and no individuals were reached out to for this study. All data underwent anonymization/de-identification before analysis. The research protocol received review and approval from the Research Ethics Committee of Aja University of Medical Sciences (ID: IR.AJAUMS.REC.1403.229). Informed consent was not necessary since the study presented minimal risk and utilized pre-existing data. All procedures adhered to applicable national standards and regulations. Additionally, the researchers adhered to the guidelines outlined in the Declaration of Helsinki. The confidentiality of students’ data was maintained, and their educational and career status was not threatened. The principles established by the Committee on Publication Ethics (COPE) were upheld throughout this study.

This research was carried out with the supervision of the Education Development Center and Vice Chancellor for Research and Technology at Aja University of Medical Sciences from the approval of the proposal until the study’s completion, and it was reviewed and validated by two peer reviewers. The results were communicated to the research setting and Aja University of Medical Sciences officials.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.