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Supporting failing students in practice 2: Management

ABSTRACT Duffy, K., Hardicre, J. (2007) Supporting failing students in practice 2: management. Nursing Times; 103: 48, 28–29.
This two-part unit examines the issue of students who fail in clinical practice. Part 1 explored reasons for failure, assessment and emotional challenges mentors may face when supporting underperforming students. This part, part 2, discusses the management of failing students.

AUTHORSKathleen Duffy, PhD, MSc, BA, RGN, RNT, is lecturer in adult nursing, School of Nursing, Midwifery and Community Health, Glasgow Caledonian University; Jayne Hardicre, MSc, BSc, DPSN, RN(A), is lecturer in adult nursing, School of Nursing, University of Salford.

Learning objectives:

1. Know how to identify failing students and understand the importance of providing effective feedback and documentation.

2. Understand the problems and consequences of ‘failing to fail’ students in the clinical setting.


Identifying failing students
Signs of failure can be apparent early on. Mentors often have an instinctive feeling about failing students and initially may find it difficult to clearly identify their concerns.

Mentors in Duffy’s study (2003) indicated that they found it difficult to fail students who had ‘attitude’ problems. When this issue was explored with mentors, concrete examples of attitude problems emerged. Discussing an instinctive feeling with another mentor or educator very often helps identify incidents to support a point of view.

It is important to identify and document concerns to failing nursing students at the earliest opportunity and certainly no later than midway assessment.

Problems must not be ignored. For example, if a student is lacking in interest, take the time to explore the reasons with them. Awareness can sometimes bring about change. Early discussion can prompt students to consider their practice, thus facilitating satisfactory progress. Most students welcome being told about areas for improvement.

When faced with a failing student, mentors may need to look at themselves. Students need to be clear about expectations but mentors may have to consider whether their expectations are realistic. Duffy (2003) identified that mentors often have their own ‘hidden’ criteria for assessment.

Reviewing the assessment documentation will confirm the learning outcomes the student is required to achieve and, again, early discussion with mentor colleagues or educators can clarify whether or not expectations of students are realistic.

When mentors first identify that a student may fail, they should review the higher education institution’s procedures for assessment. Students failing to meet clinical outcomes should be informed without delay, given advice on how to improve, given time frames within which improvement is expected and informed of the consequences should the required improvement not occur.


Providing feedback
Ongoing feedback is essential in assessment, even for students about whom there are no practice concerns. It provides a mechanism for performance to be regularly monitored and discussed (Wallace, 2003). Halstead (1998) stressed that assessment regulations give students the right to:

- Receive timely feedback about their performance, and have the opportunity and support to correct behaviour considered unsatisfactory;

- Be made aware that their performance is not meeting the criteria set for satisfactory performance before being failed.

Feedback should be given to students regularly to ensure that they have had the best opportunity possible to improve during the clinical experience. Smith et al (2001) stressed that regular meetings give students time to reflect on their performance. At such meetings, mentors and students can jointly identify areas where practice is weak as well as areas showing improvement. It is an opportunity to discuss progress.


Practical advice for mentors
The following are some basic principles for giving feedback to students:
- Arrange for all meetings with students to be held in a private area;
- Ensure students have prior notification of the meeting;
- Ensure there will be no interruptions, such as phone calls;
- Put plenty of time aside for the meeting.


When dealing with students:
- Invite the student to conduct either a verbal or written self-assessment;
- Formulate an action plan;
- Clearly identify evidence of success;
- Formulate learning objectives for the next meeting;
- Identify appropriate learning opportunities to meet the objectives;
- Identify required knowledge inputs and the sources of these;
- Plan the date of the next meeting.

Price (2005) provided some useful investigative questions for addressing concerns with learners. Mentors may, for example, find it useful to invite students to evaluate their performance or, if discussing a specific incident, to ask: ‘What do you understand happened here?’ It is important to encourage students to self-assess against the required clinical outcomes. Listen to students’ concerns and acknowledge their opinion. Address students’ feelings of anger or failure and then provide them with honest, detailed feedback with specific examples. The need for mentors to provide weak students with specific examples and to document these was emphasised by Duffy (2003).

Clinical assessment has long been criticised for being subjective (Chambers, 1998). When faced with an underperforming student, mentors may tend to compare them with other students. Any feedback must be based on explicit expectations for clinical performance as outlined in the clinical assessment and not ‘hidden’ criteria.

It is often helpful to suggest a grade for performance as this provides concrete information and stresses the seriousness of the situation. Remember to highlight students’ achievements and strengths to build their self-esteem – it is easy to focus on the negative aspects of performance.

Students will develop over the course of the placement even if not to the final standard required to pass. Mentors should remain positive and supportive and remember that failing students require patience and self-control.


Providing evidence of failure
Several authors emphasise the importance of collecting and documenting evidence when faced with a fail scenario (Smith et al, 2001; Zuzelo, 2000; Sharp and Danbury, 1999). Sharp and Danbury (1999) emphasised that a clear, well-evidenced report not only supports assessors’ decisions but also allows students a degree of protection against an irresponsible decision to fail.

Documented evidence is critical to establish a pattern of ‘failing’ performance. The principles of good record-keeping (NMC, 2005) should be applied. Documentation must be factual, non-judgemental, identify strengths and weaknesses and include specific examples when appropriate. Each feedback session should be recorded, with details of the supportive measures taken and the learning opportunities provided to enable students to reach the level of practice required.

The evidence that mentors document will mainly come from observing students in practice. NMC (2006) standards indicate mentors should supervise students (directly or indirectly) at least 40% of the time. Mentors often support underperforming students by working extra shifts with them (Duffy, 2003).

Mentors may find it useful to have another team member assist in clinical observation. This can bring objectivity and demonstrate to students that there is a genuine interest in giving a fair evaluation. Feedback from other staff, patients and relatives can also inform mentors’ opinion. Discussing students’ own reflections on practice and examining their portfolio or student passport (NMC, 2006) can also help in the decision-making process.

When coming to a decision, some student mistakes can be accepted as part of learning and development. However, others are so serious that failure is inevitable.


Seeking support
Several mentors in Duffy’s (2003) study indicated that during the process of failing a student they had had doubts about whether they ‘were doing the right thing’. When managing a failed assessment, they need to acknowledge their feelings and get support.
Students’ reactions to being told they are underperforming can leave mentors feeling frustrated and angry. Poorer students often overestimate their performance or lack insight into their weaknesses, meaning that supportive measures are not recognised. The link lecturer, personal tutor or placement facilitator should be informed as early as possible as they can support both mentors and students. Having them present at the feedback interviews on students’ performance can be beneficial for all.

Mentors in Duffy’s (2003) study indicated that they needed support to complete the documentation associated with a fail scenario. Several mentors were aware their report would be scrutinised by an assessment board, and therefore sought support to provide an accurate, clear and well-evidenced report.

Managing underperforming students can be time consuming. Mentors may need to negotiate with line managers for extra time to support students. Students may feel isolated and inadequate and will need all the time and support possible.


Conclusion
Areas of concern about performance should be highlighted as early as possible. Feedback should give students an opportunity to show some improvement. Verbal and written feedback is vital as students should never be surprised by the details of a failed final clinical assessment.

For students to pass a placement, mentors must be confident that patients will be in safe hands if they proceed along the route to qualify as a nurse. It is important that mentors do not avoid the issue of having to fail students and that failing students are identified as it may prepare the way for greater achievement in future clinical placements.


Key References

Duffy, K. (2003) Failing Students: a Qualitative Study of Factors that Influence the Decisions Regarding Assessment of Students’ Competence in Practice. Glasgow Caledonian University.
www.nmc-uk.org/

NMC (2006) Standards to Support Learning and Assessment in Practice: NMC Standards for Mentors, Practice Teachers and Teachers. London: NMC.

NMC (2005) Guidelines for Records and Record-keeping. London: NMC.

Price, B. (2005) Assessing a learner’s progress. Nursing Standard; 19: 48, 73–74.

Smith, M. et al (2001) Legal issues related to dismissing students for clinical deficiencies. Nurse Educator; 26: 1, 33-38.

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