Published in PLOS One on 2026-07-09, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Gabieba Donough, Katlego Mthimunye, Felicity Daniels
Source: PLOS One • DOI 10.1371/journal.pone.0353215
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Theoretical assessment design is crucial in nursing education, ensuring students develop cognitive and problem-solving skills for clinical practice. However, misalignment with learning outcomes and inconsistent cognitive level distribution remain complex issues.
This multimethod qualitative study explored theoretical assessment design in a South African nursing school through in-depth interviews with nurse educators and a document review of moderators’ reports. Stratified purposive sampling ensured diverse representation across National Qualifications Framework Levels 5–8. Data saturation was reached after nine interviews, analysed using Creswell and Creswell’s six-step thematic framework.
The document review analysed 70 moderation reports (22 internal and 48 external) from 2015 to 2019, focusing on feedback related to final theoretical assessments. Content analysis, following Krippendorff’s framework, was used to identify themes and patterns. Findings revealed an overemphasis on lower-order cognitive skills (Bloom’s taxonomy), inconsistent question distribution, and misalignment with national qualification standards. Educators acknowledged these issues but cited time constraints, inadequate training, and institutional pressures as contributing factors. Moderation reports confirmed assessment inconsistencies, emphasising the need for better alignment with constructive alignment principles. Triangulation of data highlighted a gap between perceived best practices and actual assessment quality, suggesting assessments do not fully support higher-order cognitive skill development.
To improve the validity and reliability of theoretical assessments, nursing programmes should prioritise training in assessment design, strengthen alignment with learning outcomes, and implement moderation strategies to address inconsistencies. These findings contribute to the broader discourse on improving assessment practices in nursing education globally.
Introduction
Assessment design plays a critical role in nursing education, serving as a key instrument for assessing students’ theoretical knowledge and ensuring their preparedness for clinical practice [1–3]. Unlike other fields, nursing education requires assessments that not only test knowledge retention but also assess students’ ability to apply theoretical concepts in critical, patient-care scenarios, making the quality of assessment design essential for safe and effective clinical practice [4–6]. Theoretical assessments provide a structured means of measuring students’ cognitive abilities, problem-solving skills, and understanding of fundamental nursing concepts [1,2]. Beyond assessing knowledge retention, they contribute to the development of higher-order thinking skills necessary for effective clinical decision-making [7]. Thus, quality theoretical assessments are essential for bridging the gap between theory and practice, ensuring that nursing graduates possess the competencies required to provide safe and effective patient care [8].
Quality assurance of assessment design is supported through moderation processes, which are central to maintaining the integrity and standardisation of assessments in higher education [9]. Internal moderation, conducted within the institution, ensures consistency in marking and alignment with learning outcomes, while external moderation provides an independent review to verify adherence to national standards and benchmarking across institutions [10]. Together, these processes enhance the validity and reliability of assessments. In nursing education, moderation ensures that assessments align with academic standards, maintain consistency in marking, and uphold fairness in evaluation [11,12]. The moderation process identifies discrepancies in assessment design, cognitive level distribution, and question validity, ensuring compliance with national qualification frameworks and institutional policies [2,13]. This enhances the credibility and reliability of assessment outcomes, ultimately supporting the quality of nursing education. As mandated by the South African Qualifications Authority (SAQA), moderation ensures that assessments remain valid, reliable, and aligned with the National Qualifications Framework (NQF) level descriptors, thereby maintaining academic integrity across institutions [9,14].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider research & evidence desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Gabieba Donough, Katlego Mthimunye, Felicity Daniels. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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