How patient and carer feedback can be used to help assess student nurses
In this article…
- How to develop a tool that allows patients to contribute to student nurse assessment
- How to use the patient testimony tool
- Ethical conerns to be aware of
Linda Chapman is education lead (mentor), Royal United Hospital Bath Trust; Jayne James is senior lecturer, adult nursing; Kate McMahon-Parkes is senior lecturer, adult nursing; both at University of the West of England.
Chapman L et al (2011) Involving patients in assessment of students. Nursing Times; 107: 34, early online publication.
The Nursing and midwifery Council promotes the idea that patients should contribute to the assessment of pre-registration student nurses. In response, staff, mentors and pre-registration student nurses from the University of West of England Bristol and the Royal United Hospital Bath worked together to develop, pilot and introduce a way of achieving this with a patient testimony tool.
The tool, which is a feedback sheet, was developed through consultation with patients and carers, then piloted and is now used in an acute hospital.
This article discusses how the tool was developed. It outlines how it was implemented and the challenges this involved, and looks at plans for development.
Keywords: Patient testimony tool, Patient feedback, Student training
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- Patients’ perspectives on care are vital to improving the quality of NHS services
- Patients occasionally give feedback on the way student nurses have cared for them, but usually in an ad hoc way
- Developing a structured tool allows patients, carers and relatives to become part of the student nurse assessment process
- Patients can evaluate communication, comfort, and treating individuals with respect
- It is not appropriate to request feedback from some patients, for example those who are sedated or too ill
Assessing student nurses’ clinical practice involves compiling a range of evidence. This includes reflection and observations of practice, simulation and question-and-answer sessions.
The Nursing and Midwifery Council’s Standards for Pre-Registration Nursing Education states: “Programme providers must make it clear how service users and carers contribute to the assessment process” (NMC, 2010a). Using patients’ perspectives on care to improve both their experience and service quality is also integral to the NHS (Department of Health, 2010).
For many years, patients have occasionally chosen to give feedback on the way student nurses have cared for them, such as through thank-you cards, letters and communication with team members. However, this has usually happened in an ad hoc way, without clear guidance and structure.
Some areas of health and social care, such as social work and learning disabilities, have identified ways of obtaining formal patient and carer feedback, which contribute to students’ assessments. But this is not widely established in the adult pre-registration nurse training.
Recognising this, staff from Royal United Hospital (RUH) Bath and the University of West of England (UWE) Bristol formed a partnership to develop a structured tool to explore how patients perceive the care they receive from student nurses. Completing this tool allows patients, carers and relatives to become part of the student nurse assessment process.
Developing the tool
There is very little evidence relating to best practice on how to seek patient or carer feedback on the performance of adult student nurses.
A small group of trust mentors and mentor leads from one acute hospital, and nursing lecturers and student nurses from a local university, were asked to pool their ideas on important areas where feedback would be most beneficial to students’ learning and development in clinical practice. We also looked at how this could be implemented safely and ethically.
Areas we identified that could be evaluated by patients were communication, comfort and treating individuals with respect. Ideas on how we might improve care were also seen as vital.
These issues fitted well with three of the four competency domains required by the NMC of pre-registration nurses, namely those relating to: professional values; communication and interpersonal skills; and nursing practice and decision making (NMC, 2010a).
As a result of feedback from the initial working groups, we produced a first draft of the tool and guidance on how to use it. Further consultation was then undertaken with a range of parties. Within the university, we consulted student nurses, lecturers and patient and carer feedback groups. Contributions from within the trust included patients and carers from the trust patient experience group, mentors, educationalists, senior clinical management, communications and Patient Advice and Liaison Service (PALS) staff.
As a result of the comments received, we produced and refined several drafts of the tool in the form of a patient feedback sheet. In the absence of clear nursing guidelines to accompany the tool, we consulted social work guidance and guidance relating to the adult field of nursing (Rees and Fruin, 2005).
Tool form and contents
The tool is in leaflet form, on double-sided A4 paper. It is designed to be integrated into the students’ records of achievement, which record their performance while in the practice area.
The centre pages include questions that ask the patient or carer to rate students’ performance when caring for them. User- friendliness and simplicity are paramount, so the questions included in the patient feedback sheet are written in a relaxed conversational style.
The questions relate to patients’ perceptions of the nursing care delivered, level of comfort experienced during interactions with an individual student, and whether they felt they were treated with respect. Three questions relate to the students’ communication skills, including listening and information giving. The questions address the patients as “you”, to give a personal feel.
A simple scale of tick boxes allow responses from “excellent” to “very poor”. Under every question, there is space for patients to elaborate on their answers if they wish. There is also a section that invites patients or carers to make additional remarks on what they felt the student did well, and comment on any areas where they perceive the student’s performance could be improved.
A further blank box is available for mentors to add their comments.
Guidance on how to complete the document is on the reverse of the tool.
As the RUH already seeks patient feedback in many ways, such as through national surveys, we felt it was important that the patient testimony document was clearly identifiable by staff and patients as being purely about feedback on student nurses’ performance, rather than on other trust objectives (DH, 2011).
To ensure all parties involved in completing the tool are clear about its purpose, the feedback testimony tool is explicitly labelled “patient feedback sheet; to enhance learning for student nurses”.
For mentors and students, more in-depth guidance accompanies this tool, including its purpose and storage advice.
Using the tool in practice
To give students time to build a rapport with their mentor, ward team and patients, they are not usually expected to obtain patient feedback within the first three weeks of their placement, unless both student and mentor feel this is appropriate.
It was important to establish a process that ensured patients and families did not feel uncomfortable or coerced into giving feedback. The guidance for mentors and students therefore stipulates they must negotiate between themselves to select a patient, relative or carer. This should be someone who knows the student well enough to give feedback on their performance, but is also both physically and psychologically well enough to be involved in the process.
It is explicit in this guidance that patients and carers can choose not to take part, and that it should be made clear to them that declining will not compromise the care they receive in any way.
Those who do wish to take part but are not able to write on the feedback sheet can express their thoughts to another person who can write on their behalf. This may be a relative, member of staff or student nurse mentor.
Once the patient feedback sheet has been completed, it is returned to the mentor (or, in their absence, a named nurse). The sheet can be handed in at any time, including on the day of discharge if patients prefer this. Students are advised they must not discuss points raised directly with patients once they have provided this information.
As well as providing evidence of how a patient perceives a student’s performance, the feedback contributes to the student’s and mentor’s reflective and critical thinking in terms of clinical practice and future professional development.
Students are expected to store the feedback sheet in their portfolio of evidence as part of their clinical assessment.
Anonymity of patients, carers and relatives involved is maintained.
Piloting the tool
In 2010, the patient feedback tool had been piloted by seven students in six acute hospital wards during one 12-week placement. Feedback from the pilot sites was obtained from students and their mentors. As a result, minor changes to the tool’s design were recommended, but no changes to the questions posed were needed.
Initially, students were slightly apprehensive about seeking patient feedback, as this was a new concept for them. Including patients’ and carers’ perspectives as part of assessment is an added dimension for mentors to consider.
However, the constructive comments students received from patients and carers via the feedback process were considered useful and enhanced students’ learning and development.
In 2009, Davies and Lunn found patients had a unique perspective that allowed them to contribute to the assessment of students’ interpersonal skills. Mentors supported this as they found the direct patient feedback useful in assessing students’ communication and interpersonal skills.
We considered several ethical concerns when deciding where, when and with whom the tool could be used.
The tool cannot be used for all patients, such as those who are sedated, or simply too ill. In some such cases, it may be appropriate for carers or relatives to complete the forms instead, as their interactions with the students may put them in a position of being able to give feedback on issues such as communication skills and empathy.
We envisage that, once the full benefits of the tool and the process of obtaining feedback are clear, it can be developed further for use in other areas. It can be adapted through the trust’s usual translation service for patients who do not speak English.
Other concerns we needed to consider were which procedures should be followed if patients or carers revealed dangerous or unprofessional practice. This is an issue of general importance in practice so, should any such behaviour be revealed, it would be dealt with through the same channels as other complaints.
Although adult-branch student nurses from UWE Bristol are now using the patient testimony tool, learning is still in progress.
Plans include implementing the tool at other trusts in the South West region where students from UWE undertake their practice experience, and expanding it to get the opinions of patients in more diverse clinical settings.
Plans are in place to formally explore the views of those participating in patient feedback initiatives and to evaluate the level to which they enhance student nurses’ clinical practice through primary research.
Such evidence will contribute to further changes and dissemination of the patient carer feedback tool to more trusts and to different clinical areas in the South West region.
The implementation of the patient testimony tool is still in the early phases.
Through consultation with user groups and staff, and collaborative working with education and practice providers, a tool is now in place that can be formally evaluated from the perspective of patients, students and mentors.
In the future, the tool could be adapted or amended to make it appropriate for use in more diverse areas. These could potentially include any areas where patient feedback is required on not only the performance of pre and post registration nurses, but also the appraisal of any professionals who come into contact with patients or their carers.
Research is planned to decide the scope of the tool, so it may change over time. Such research will give educationalists and practitioners a shared understanding of where the limits and strengths are in its implementation.
Box 1 Why develop a patient testimony tool?
- It is a response to the NMC (2010a) Standards for Pre Registration Nurse Education, which promotes the idea that patients should contribute to student assessment
- There was no formal means for patients and carers to feed back on the performance of student nurses in adult-field pre-registration training
- The patient testimony tool provides a way for patients, carers and relatives to contribute to students’ learning and development in clinical practice, in particular around communication skills, giving comfort and treating individuals with respect
- The tool is an innovative and effective way for patients, carers and relatives to give feedback on their perceptions and experiences of students delivering, coordinating and managing care
- Patient and carer involvement and collaboration between NHS and university staff was paramount in overcoming challenges and developing an effective testimony tool
Box 2. The patient testimony tool: aims and considerations
- During the process of obtaining any feedback, students and mentors must comply with NMC (2010b; 2008) requirements and make the patients their first concern
- Feedback from patients, carers and relatives must be treated in confidence by the student and mentor
- The tool must allow students and mentors to gain information from patients, carers or relatives to support students’ evidence of learning
- The tool and process must be simple to use and not time consuming for mentors, patients, carers and students
- Because some patients are not able to comment on their care, the tool must be able to capture the views and perception of patients’ carers and family members as their insight is recognised as valuable (Karlsson et al, 2010)
- There will be instances where it would not be appropriate to use this tool due to patient or carer circumstances. It is therefore vital to be careful when selecting who should give feedback. The mentor should be ultimately responsible for approaching and selecting patients
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Department of Health (2010) The Nursing Roadmap for Quality: a Signposting Map for Nursing. London: DH.
Karlsson V et al (2010) Relative experiences of visiting a conscious, mechanically patient – a hermeneutic study. Intensive and Critical Care Nursing; 26: 91-100.
Nursing and Midwifery Council (2010a) Standards for Pre Registration Nursing Education. London: NMC.
Nursing and Midwifery Council (2010b) Guidance on Professional Conduct for Nursing and Midwifery Students. London:
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Rees K, Fruin H (2005) Involving People Who Use Services and Carers in Assessment of Social Work Students: A Case Study and Good Practice Guide. Leeds: Skills for Care North West.