Developing the Occupational Therapy–Specific Mini-Clinical Evaluation Exercise (Mini-CEX) for Evaluating Interns’ Clinical Skills and Attitudes in Pediatric Occupational Therapy

Abstract

Importance: The Mini-Clinical Evaluation Exercise (Mini-CEX) is highly recommended for assessing interns’ performance.

Objective: To develop a pediatric occupational therapy–specific Mini-CEX and examine its psychometrics.

Design: Stage 1 had a retrospective design; Stage 2 had a prospective design.

Setting: Pediatric occupational therapy unit in a hospital in Taiwan.

Participants: Thirty-four occupational therapy interns were evaluated with the Mini-CEX (physician version), and 57 were evaluated with the occupational therapy–specific Mini-CEX.

Outcomes and Measures: The occupational therapy–specific Mini-CEX was developed with seven items on a 9-point scale categorized into three levels (unsatisfactory, satisfactory, highly satisfactory).

Results: In Stage 1, the frequency of Mini-CEX (physician version) items receiving a rating of not applicable ranged from 1.9% to 88.1%. In Stage 2, the frequency of occupational therapy–specific Mini-CEX items receiving a rating of not applicable ranged from 3.5% to 31.6%. With the theme of evaluation taken into consideration, the frequency of not-applicable ratings was 0% to 8.8%. For the occupational therapy–specific Mini-CEX, content validity (item-level content validity index = 1, scale-level content validity index = 1) and internal consistency (Cronbach’s α = .93) were excellent. The interns’ scores on the second evaluation were significantly higher than those on their first evaluation, indicating good discriminant validity.

Conclusions and Relevance: The occupational therapy–specific Mini-CEX appears to be reliable and valid, and it is appropriate for evaluating interns’ skills and attitudes in pediatric occupational therapy practice.

What This Article Adds: The results support the development of the occupational therapy–specific Mini-CEX and its application in pediatric internship training.

The results of this study support the development of the occupational therapy–specific Mini-CEX and its application in evaluating interns’ skills and attitudes in pediatric occupational therapy practice.

According to Miller’s (1990) pyramid, the evaluation of clinical competencies in medical education involves four stages: (1) knows, (2) knows how, (3) shows how, and (4) does. It is important to evaluate interns’ “shows how”—that is, their performance—in pediatric occupational therapy clinical practice. The Mini-Clinical Evaluation Exercise (Mini-CEX) is one of the tools most frequently used to assess interns’ performance in a workplace setting (Chen, 2007; Lee, 2013; Mortaz Hejri et al., 2020). Characterized by evaluation of interns’ performance in clinical practice with real patients and provision of immediate feedback, the Mini-CEX enables clinical mentors to improve interns’ skills and attitudes and provide better supervision of clinical practices (Chen, 2007; Kogan et al., 2009).

However, previous studies regarding the effectiveness of the Mini-CEX in occupational therapy internship training have been very limited. Only one study has investigated the appropriateness of the Mini-CEX in occupational therapy internships in the field of mental health (Liu et al., 2018). That study showed that five items—medical interviewing, organization and efficiency, humanistic qualities and professionalism, clinical judgment, and counseling—were appropriate for occupational therapy education, but two items (physical examination and overall clinical competence) were possibly unsuitable (Liu et al., 2018). Some studies have focused on applying the Mini-CEX in training in other health professions in addition to occupational therapy, including nursing (Liu et al., 2019), pharmacology (Wei et al., 2019), midwifery (Sweet et al., 2013), and dentistry (Véliz et al., 2021). These studies have consistently indicated that a discipline-specific Mini-CEX is needed, probably because the Mini-CEX was originally designed and developed according to the core competencies of physicians. Thus, applying the physician Mini-CEX directly to occupational therapists could be inappropriate (Liu et al., 2019; Wei et al., 2019).

Therefore, we posed two research questions: (1) Is it appropriate to use the Mini-CEX (physician version) in evaluating pediatric occupational therapy internship training and, if not, (2) can a useful occupational therapy–specific Mini-CEX be developed? To answer these questions, we conducted this study in two stages. In the first stage, we examined the appropriateness of using the Mini-CEX to evaluate interns’ clinical skills and attitudes in pediatric occupational therapy training. In the second stage, we developed an occupational therapy–specific Mini-CEX for evaluating interns’ clinical skills and attitudes in pediatric occupational therapy training and examined its psychometrics.

Stage 1: Examining the Appropriateness of the Mini-CEX (Physician Version)

This stage consisted of a retrospective study and was approved by the institutional review board of Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan City, Taiwan.

Method

Participants

Thirty-four occupational therapy interns receiving training in pediatric occupational therapy clinical practice from August 2013 to May 2019 were evaluated with the Mini-CEX by their clinical mentors.

Procedure

Occupational therapy interns received 12 wk of pediatric occupational therapy internship training at Taoyuan General Hospital, Ministry of Health and Welfare. They had at least one Mini-CEX evaluation during the first 6 wk and at least one during the last 6 wk. If they received a failing score, they were reevaluated within 1 or 2 wk to monitor the progress of their performance. The Mini-CEX examiners were five clinical mentors who had received Mini-CEX examiner training.

Measure

The Mini-CEX was developed by the American Board of Internal Medicine (Norcini et al., 1995), translated into Mandarin, and revised by (Chen, 2007; Lee, 2013). It is designed to assess the examinee’s clinical skills, attitudes, and behaviors with real patients in real clinical settings (Chen, 2007; Norcini et al., 1995). The Mini-CEX contains seven items on medical interviewing skills, physical examination skills, humanistic qualities and professionalism, clinical judgment, counseling skills, organization and efficiency, and overall clinical competence (Chen, 2007; Lee, 2013). Each item is rated on a 9-point scale categorized into three levels: unsatisfactory (1–3 points), satisfactory (4–6 points), and highly satisfactory (7–9 points; Chen, 2007; Lee, 2013). If an item is not observed during the evaluation process, it is rated as not applicable. A higher frequency of not applicable ratings indicates poorer fitness of those items for evaluation (Liu et al., 2018). However, an item that is relevant to internship training will be observed and evaluated more frequently during a Mini-CEX evaluation. Moreover, the examinee’s self-evaluation and the examiner’s feedback are included in the Mini-CEX (Chen, 2007; Lee, 2013). Studies have shown that the Mini-CEX is reliable and valid for use with medical students (Lee, 2013).

Data Analysis

Descriptive analysis was used to examine the occupational therapy interns’ Mini-CEX scores.

Results

As shown in Table 1, 34 interns received a total of 268 Mini-CEX evaluations during their pediatric occupational therapy clinical practice. Each intern received an average of 7.88 Mini-CEX evaluations (range = 2–15). Among all evaluations, the frequency of items receiving ratings of not applicable was 73.9% for medical interviewing skills, 88.1% for physical examination skills, 4.5% for humanistic qualities and professionalism, 11.6% for clinical judgment, 4.5% for counseling skills, 1.9% for organization and efficiency, and 2.2% for overall clinical competence. We asked the clinical mentors why physical examination skills (88.1%) and medical interviewing skills (73.9%) were frequently rated as not applicable, and they responded that occupational therapists usually administer standardized or nonstandardized assessments rather than physical examinations. Moreover, occupational therapists spend much of their time consulting with children’s caregivers instead of only interviewing them. Consistent with previous literature (Liu et al., 2018; Liu et al., 2019; Sweet et al., 2013; Véliz et al., 2021; Wei et al., 2019), the physician version of the Mini-CEX did not fit well with the evaluation of internship training in pediatric occupational therapy. Thus, we conducted the second stage of the study.

Table 1.

Occupational Therapy Interns’ Scores on the Mini-CEX (Physician Version)

Items	Frequency (%) of Not Applicable Ratings	Scores
Items	Frequency (%) of Not Applicable Ratings	Range	M (SD)	Mdn
Medical interviewing skills	198 (73.9)	2–6	4.1 (0.66)	4
Physical examination skills	236 (88.1)	3–6	4.13 (0.71)	4
Humanistic qualities and professionalism	12 (4.5)	1–7	4.34 (0.84)	4
Clinical judgment	31 (11.6)	2–8	4.35 (0.81)	4
Counseling skills	12 (4.5)	1–7	4.08 (0.86)	4
Organization and efficiency	5 (1.9)	1–7	4.34 (0.93)	4
Overall clinical competence	6 (2.2)	2–8	4.68 (0.83)	5

Note. The number of evaluations was 268. Mini-CEX = Mini-Clinical Evaluation Exercise.

Stage 2: Developing an Occupational Therapy–Specific Mini-CEX and Examining Its Psychometrics

This part was a prospective study and was approved by the institutional review board of Fu Jen Catholic University and Taipei Hospital, Ministry of Health and Welfare.

Method

Participants

Fifty-seven occupational therapy interns receiving pediatric occupational therapy internship training from August 2017 to May 2018 were evaluated with the occupational therapy–specific Mini-CEX by their clinical mentors at 12 hospitals.

Procedure

First, an expert committee was established. It included three teachers in a university department of occupational therapy and six experienced pediatric occupational therapists. This expert committee developed a draft of the occupational therapy–specific Mini-CEX, based on the Mini-CEX and the core competencies of occupational therapy in Taiwan (Chang et al., 2020; Taiwan Occupational Therapy Association, 2019).

Second, six videos were made to pretest the scoring of this draft. The videos included both good and poor occupational therapy intern performances in the areas of interviewing and consulting with a parent, evaluating a child, and providing intervention with a child. The first author (Chung-Pei Fu) discussed the scoring discrepancies with occupational therapy clinical mentors from 17 different hospitals after they used the occupational therapy–specific Mini-CEX draft to rate the videotaped performances. The occupational therapy–specific Mini-CEX draft was revised by the expert committee according to suggestions from these occupational therapy clinical mentors, and the final version of the occupational therapy–specific Mini-CEX was then determined.

Third, five pediatric occupational therapy clinical mentors with an average of 12.6 yr of clinical experience and 8.8 yr of teaching experience rated the fitness (including clarity, concreteness, centrality, and importance) of each item of the occupational therapy– specific Mini-CEX to examine its content validity.

Fourth, 57 interns from 12 different hospitals received their first occupational therapy–specific Mini-CEX evaluations during the first 6 wk of their pediatric occupational therapy clinical practice. Of these interns, 39 received a second evaluation during the last 6 wk of their clinical practice. Some interns were not evaluated a second time because of conflicts with other evaluations arranged by intern stations.

Measure

The occupational therapy–specific Mini-CEX (see the Supplemental Appendix, available online with this article at https://research.aota.org/ajot) was developed with reference to the Mini-CEX (Chen, 2007) and the core competencies of occupational therapy in Taiwan (Chang et al., 2020; Taiwan Occupational Therapy Association, 2019). It contains seven items: interview with client or caregivers, evaluation, intervention (treatment, consultation, education), clinical reasoning and judgment, organization and efficacy, professional attitude and ethics, and overall clinical competence. The examiners chose one or more items from the first three as the main themes for observing interns’ performance during the assessment because interns sometimes lacked sufficient time to perform the interview with the client or caregivers, the evaluation, and the intervention in one treatment session. The other four items were always graded by the examiners. Each item was rated on a 9-point scale categorized into three levels: unsatisfactory (1–3 points), satisfactory (4–6 points), and highly satisfactory (7–9 points). The time of the observation and the feedback were recorded. The examiner’s and the examinee’s satisfaction with the evaluation process and the examinee’s self-evaluation of their overall performance were rated on a 9-point Likert-type scale. The examiner’s comments (including strengths, weaknesses, strategies to improve performance, etc.) and the examinee’s self-evaluation (including strengths, weaknesses, strategies to improve their performance, suggestions, etc.) were also recorded.

Data Analysis

The data were analyzed in IBM SPSS Statistics (Version 21). The descriptive analysis was performed first, and then the content validity, internal consistency, and discriminant validity of the occupational therapy– specific Mini-CEX were examined.

The content validity was examined with the item-level content validity index (i-CVI) and the scale-level content validity index (s-CVI). The i-CVI was computed as the number of experts giving a rating of 3 or 4 for the relevancy and clarity of each item divided by the total number of experts (Lee, 2013; Zamanzadeh et al., 2015). An i-CVI higher than .79 indicates that the item is relevant (Zamanzadeh et al., 2015). The s-CVI was calculated by dividing the sum of the i-CVIs by the total number of items (Zamanzadeh et al., 2015). An s-CVI higher than .90 indicates excellent content validity (Shi et al., 2012).

Internal consistency was examined by computing Cronbach’s α. Cronbach’s α coefficients greater than .9 are regarded as having excellent internal consistency; greater than .8 as having good internal consistency; and greater than .7 as having acceptable internal consistency (George & Mallery, 2010; Vangeneugden et al., 2005). Discriminant validity was examined by comparing item scores on the occupational therapy–specific Mini-CEX between the first and second evaluations using the paired-samples Wilcoxon signed-rank test.

Results

Descriptive Analysis

As shown in Table 2, the frequency of items receiving ratings of not applicable was 19.3% for interview with client or caregivers, 26.3% for evaluation, 31.6% for intervention (treatment, consultation, education), 8.8% for clinical reasoning and judgment, 5.3% for organization and efficiency, 3.5% for professional attitude and ethics, and 5.3% for overall clinical competence. Moreover, when the examiner chose any of the first three items (interview with client or caregivers, evaluation, intervention) as the main theme, the frequency of the chosen corresponding items receiving ratings of not applicable was 0%.

Table 2.

Occupational Therapy Interns’ Occupational Therapy–Specific Mini-CEX Scores

Items	Frequency (%) of Not Applicable Ratings	Scores
Items	Frequency (%) of Not Applicable Ratings	Range	M (SD)	Mdn
Interview with client or caregivers	11 (19.3)	3–6	4.67 (1.01)	5
Evaluation	15 (26.3)	3–8	4.93 (1.31)	5
Intervention (treatment, consultation, education)	18 (31.6)	3–7	4.82 (1.12)	5
Clinical reasoning/judgment	5 (8.8)	2–7	4.37 (1.05)	4
Organization and efficacy	3 (5.3)	2–7	4.59 (1.16)	5
Professional attitude and ethics	2 (3.5)	2–8	5.04 (1.33)	5
Overall clinical competence	3 (5.3)	3–7	4.78 (1.08)	5

Note. The number of evaluations was 57. Mini-CEX = Mini-Clinical Evaluation Exercise.

The mean scores on the items ranged from 4.37 to 5.04. The median score on each item was 5, except for clinical reasoning and judgment, which was 4 (see Table 2). The average observation time was 37.0 min (SD = 17.4), and the observations ranged from 10 to 90 min in length. The average feedback time was 12.6 min (SD = 6.0), and the range was 3 to 30 min. The mean score for satisfaction with the evaluation process was 6.3 (SD = 1.4) for examiners and 6.0 (SD = 1.4) for examinees. The mean score for examinees’ self-evaluation of their overall performance was 5.5 (SD = 1.2).

Content Validity

The mean of fitness for all items was 4.0, except those for organization and efficacy (3.6) and clinical reasoning and judgment (3.8). The i-CVI of all items was 1.0, and the s-CVI was 1.0.

Internal Consistency

Cronbach’s α for the occupational therapy–specific Mini-CEX was .93. Deleting any item of the occupational therapy–specific Mini-CEX did not increase the value of Cronbach’s α.

Discriminant Validity

Mean scores on the first occupational therapy–specific Mini-CEX evaluation ranged from 4.37 to 5.04, and mean scores on the second evaluation ranged from 5.52 to 6.08. The results of the Wilcoxon signed-rank test indicated that the interns’ second occupational therapy–specific Mini-CEX scores were significantly higher than those on the first evaluation (Table 3).

Table 3.

Comparison of Occupational Therapy–Specific Mini-CEX Scores Between the First and Second Evaluations

Items	M (SD)		z	p
Items	First Evaluation	Second Evaluation	z	p
Interview with client or caregivers (n = 31)	4.67 (1.01)	5.97 (1.62)	−4.46	<.001
Evaluation (n = 31)	4.93 (1.31)	5.52 (1.81)	−3.48	.001
Intervention (treatment, consultation, education) (n = 28)	4.82 (1.12)	6.07 (1.46)	−3.81	<.001
Clinical reasoning/judgment (n = 32)	4.37 (1.05)	5.56 (1.61)	−3.74	<.001
Organization and efficacy (n = 35)	4.59 (1.16)	5.74 (1.44)	−4.20	<.001
Professional attitude and ethics (n = 38)	5.04 (1.33)	6.08 (1.40)	−4.44	<.001
Overall clinical competence (n = 36)	4.78 (1.08)	6.06 (1.41)	−4.46	<.001

Note. Mini-CEX = Mini-Clinical Evaluation Exercise.

Discussion

The Mini-CEX has been widely used to evaluate the core competencies of medical students and residents. Nurses (Liu et al., 2019), pharmacists (Wei et al., 2019), midwives (Sweet et al., 2013), and dentists (Véliz et al., 2021) have adapted or developed profession-specific Mini-CEX evaluations to fit students’ needs in their professional education. To our knowledge, this study is the first to develop an occupational therapy–specific Mini-CEX for occupational therapy interns.

The results of Stage 1 of the study showed that two items of the Mini-CEX—physical examination skills (88.1% not applicable) and medical interviewing skills (73.9% not applicable)—might be inappropriate for evaluating the clinical competencies of occupational therapy interns because the capacities described in these two items were often not observable during occupational therapy internship training. Our results are consistent with those of a previous Mini-CEX study conducted in the field of mental health–related occupational therapy (Liu et al., 2018). In addition, most of the clinical mentors thought that the Mini-CEX (physician version) did not evaluate some core competencies of pediatric occupational therapy. Therefore, we adapted the Mini-CEX by integrating these core competencies and expert opinions. The results obtained in Stage 2 indicate that the frequency of items rated as not applicable on the occupational therapy–specific Mini-CEX (3.5%–31.6%) was lower than that for the Mini-CEX (1.9%–88.1%). If the chosen theme of evaluation was taken into consideration, the frequency of three items (interview with client or caregivers, evaluation, intervention) receiving ratings of not applicable was 0%. The frequencies of other items receiving ratings of not applicable ranged from 3.5% to 8.8%. These results indicated that the items contained in the occupational therapy–specific Mini-CEX were frequently observed during occupational therapy interns’ training. Therefore, the occupational therapy–specific Mini-CEX was more suitable for occupational therapy education than the Mini-CEX.

As shown in Table 2, the clinical reasoning and judgment item (M score = 4.37) was the most difficult item on the occupational therapy–specific Mini-CEX, and the professional attitude and ethics item (M score = 5.04) was the easiest. This result implies that occupational therapy clinical mentors should pay more attention to teaching clinical reasoning to interns.

The whole process of evaluation, including observation (M time = 37.0 min) and feedback (M time = 12.6 min), took less than 1 hr. Using the occupational therapy–specific Mini-CEX in pediatric occupational therapy takes less time than using the Mini-CEX in mental health occupational therapy (observation time = 40.6 min; feedback time = 19.8 min; Liu et al., 2018).

Moreover, both the occupational therapy interns (M satisfaction score = 6.0) and the clinical mentors (M satisfaction score = 6.3) were moderately satisfied with the evaluation process using the occupational therapy–specific Mini-CEX. Perceived satisfaction was less than for the Mini-CEX (physician version), for which medical interns’ mean satisfaction score was 8.08 and mentors’ was 8.06 (Alves de Lima et al., 2007). A possible reason might be that occupational therapy interns and mentors were not as familiar with the Mini-CEX as were medical interns and mentors in Alves de Lima et al.’s (2007) study. The Mini-CEX has been widely used in medical education since 1995 (Norcini et al., 1995).

The occupational therapy–specific Mini-CEX has excellent content validity, excellent internal consistency, and good discriminant validity. The high mean for fitness (3.6–4.9) and high i-CVI (1) of all the items indicate that all the items were relevant. The high s-CVI (1.0) supported the excellent content validity of the occupational therapy–specific Mini-CEX, and its excellent internal consistency (0.93) indicated that all the items measured the same construct. The interns’ scores on the second evaluation were significantly higher than those on the first evaluation, indicating that the occupational therapy–specific Mini-CEX had good discriminant validity.

Our study supports the appropriateness and importance of using the occupational therapy–specific Mini-CEX to evaluate occupational therapy interns’ clinical skills and attitudes during their pediatric internship training. First, the occupational therapy–specific Mini-CEX enables mentors to directly observe and evaluate interns’ clinical performances with real patients under real clinical circumstances (Lee, 2013). It provides different perspectives than other methods of assessment, such as paper-and-pencil tests, which mainly evaluate examinees’ knowledge, or objective structured clinical examinations, which evaluate examinees’ clinical performance with simulated patients under simulated clinical circumstances. Second, the occupational therapy–specific Mini-CEX is practical and feasible to use. Mentors can observe interns’ clinical performance anytime and anywhere. Moreover, observation takes only about 37 min, and giving feedback takes about 13 min. Using the occupational therapy–specific Mini-CEX to examine interns’ clinical performances would not place a burden on mentors and interns.

Third, the occupational therapy–specific Mini-CEX helps interns self-examine their clinical performance instantly and helps mentors provide feedback immediately. Fourth, using the occupational therapy–specific Mini-CEX is cost-effective. The whole examination process is conducted during real clinical practice, so it does not entail additional expense. Fifth, the occupational therapy–specific Mini-CEX is reliable and valid. The results of our study demonstrate that it has excellent content validity, excellent internal consistency, and good discriminant validity. Sixth, the occupational therapy interns and clinical mentors were moderately satisfied with adoption of the occupational therapy– specific Mini-CEX. Therefore, we recommend using the occupational therapy–specific Mini-CEX to evaluate interns’ clinical performance.

Limitations and Suggestions

This study had two limitations. First, we examined only the internal consistency, content validity, and discriminant validity of the occupational therapy–specific Mini-CEX. Future studies should examine its interrater reliability, intrarater reliability, and convergent validity. Second, the occupational therapy–specific Mini-CEX has been examined only in undergraduate-year training in pediatric occupational therapy. Further examination of the usefulness and psychometrics of the occupational therapy–specific Mini-CEX in both postgraduate-year training and physical and mental health occupational therapy could provide more information on its generalizability.

Implications for Occupational Therapy Education

The occupational therapy–specific Mini-CEX measures interns’ clinical skills and attitudes in clinical practice with real patients. It helps occupational therapy interns self-evaluate their clinical performance, and it helps clinical mentors give instant feedback.

Conclusion

The occupational therapy–specific Mini-CEX appears to be reliable, valid, practical, feasible, and cost-effective. It is appropriate for evaluating occupational therapy interns’ clinical skills and attitudes in pediatric internship training.

Supplemental Material

Supplemental Information

Supplementary material for Developing the Occupational Therapy–Specific Mini-Clinical Evaluation Exercise (Mini-CEX) for Evaluating Interns’ Clinical Skills and Attitudes in Pediatric Occupational Therapy

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2022.049319.pdf for Developing the Occupational Therapy–Specific Mini-Clinical Evaluation Exercise (Mini-CEX) for Evaluating Interns’ Clinical Skills and Attitudes in Pediatric Occupational Therapy by Chung-Pei Fu, Yu-Lan Chen, Nung-Chen Kuo, Chia-Ting Su, Ching-Kai Huang, Ming-Wei Li, Hsin-Yu Chi, Chien-Lun Yang and Wan-Ying Chang in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

We are grateful to the occupational therapy mentors and interns from 18 hospitals who participated in this study. The hospitals were Camillians Saint Mary’s Hospital Luodong; Cathay General Hospital; Changhua Christian Hospital; Cheng Ching Hospital; China Medical University Hospital; Hsinchu MacKay Memorial Hospital; Linkou Chang-Gung Memorial Hospital; Lotung Poh-Ai Hospital; National Taiwan University Hospital, Hsin-Chu Branch; Shin Kong Wu Ho Su Memorial Hospital; Sijhih Cathay General Hospital; Taichung Tzu Chi Hospital; Taipei Hospital, Ministry of Health and Welfare; Taipei Medical University Hospital; Taipei Municipal Wanfang Hospital; Taipei Veterans General Hospital; Taoyuan General Hospital, Ministry of Health and Welfare; and Tri-Service General Hospital. This study was supported by research grants from the Ministry of Science and Technology (105-2511-S-030-004 and 106-2511-S-030-005) and the Ministry of Health and Welfare (10705), Taiwan, Republic of China.

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