This two-part unit examines the issue of nursing students who fail in clinical practice. Part 1 explores reasons for failure, assessment and the emotional challenges mentors may face when supporting failing students
ABSTRACT Duffy, K., Hardicre, J. (2007) Supporting failing students in practice 1: assessment. Nursing Times; 103: 47, 28–29.
AUTHORS Kathleen 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.
1. Understand the practice placement assessment process and the reasons why nursing students may fail.
2. Be aware of the potential reactions of failing students and the impact on mentors and the team.
Most nursing students will achieve the proficiency standards they need to register but mentors may be faced with a student whose performance is weak. While these may be in the minority, evidence suggests that mentors find this one of the most challenging aspects of their role (Duffy, 2003).
The NMC Standards to Support Learning and Assessment in Practice (2006) identified mentors’ responsibility in supporting and assessing nursing and midwifery students. The standards emphasise mentors’ role in managing failing students.
ASSESSING FITNESS FOR PRACTICE
Within pre-registration nursing and midwifery education programmes, clinical competence is verified via continuous assessment in practice. Mentors assess competence in practice and have a responsibility to confirm that nursing students are capable of safe and effective practice (NMC, 2006). This requires them to identify underperforming students and manage the situation appropriately. The following are common indicators that may alert mentors to the possibility of failure (Skingley et al, 2007; Duffy, 2003; Hrobsky and Kersbergen, 2002; Maloney et al, 1997):
- Inconsistency in meeting the required level of competence for the stage of training;
- Inconsistent clinical performance;
- Lack of insight into weaknesses so unable to change following constructive feedback;
- Unsafe practice;
- Not responding appropriately to feedback;
- Lack of interest or motivation;
- Limited practical, interpersonal and communication skills;
- Absence of professional boundaries and/or poor professional behaviour;
- Experiencing continual poor health, feeling depressed, uncommitted, withdrawn, sad, tired or listless;
- Unreliability, persistent lateness/absence;
- Preoccupation with personal issues;
- Lack of theoretical knowledge.
Duffy (2003) identified that one reason mentors may ‘fail to fail’ students in practice is lack of knowledge of the assessment process. Stuart (2007) gives a comprehensive account of the process. Price (2005) said that practice-based assessments need to be conducted transparently, rigorously and fairly, and discussed the two purposes of assessment:
- Formative assessment – designed to advise a student of progress toward a goal. Here, the mentor is an adviser;
- Summative assessment – designed to judge a student’s competency as measured against stated benchmarks. It is the hurdle students must overcome if they are to qualify.
Here the mentor is an examiner. It is important that mentors are aware of the differences between formative and summative assessments as, if performed in a timely manner, one should inform the other. In general, students should have at least three formal meetings with their mentor:
- Initial assessment interview;
- Mid-placement interview;
- Final placement assessment.
Initial assessment interview
The aim of the initial assessment is to meet and discuss the needs and expectations of the placement. This is sometimes referred to as the ‘orientation meeting’ and is a formative assessment.
In addition to familiarising the student with the environment, it is an important meeting to discuss learning needs and sometimes specific learning difficulties. Action plans/personal development plans/learning contracts should be developed in line with the higher education institution’s clinical assessment documentation. The date of the mid-placement interview and final assessment should also be set.
All initial documentation should be completed within the timeline and manner stipulated by the higher education institution. This is important for all students, but particularly those who may fail.
The mid-point assessment needs to be conducted halfway through the placement and is formative in nature.
This is an important assessment as it is when the student’s progress is highlighted, as well as any areas needing development. Extensive, constructive feedback is necessary here to help students understand any concerns mentors may have. It is crucial that problem areas are clearly documented, along with plans for development. It may also be necessary to contact the student’s personal tutor to discuss concerns.
Scholes and Albarran (2005) concluded that one major inhibitor to failing a student is the risk of being overruled on appeal. This was also highlighted by Duffy (2003), when mentors discussed ‘leaving it too late’. A student can only appeal if there are grounds to do so – and not highlighting deficiencies and concerns at the mid-point assessment is one of them. In fairness, if students are unaware of any problems, they are unable to take action to overcome them.
Final placement assessment interview
The final assessment is summative and should hold few surprises for students (Marsh et al, 2004). This is when they are formally graded as having passed or failed the assessment when compared with the benchmarks or competencies in the clinical assessment documentation.
Assessments that are transparent, rigorous and fair take time and should include input from students. The required time needs pre-planning.
REACTIONS TO FAILURE
Failing students may react in a number of ways and this should be a consideration for mentors. While it is not possible to predict students’ reactions, the need to plan extra time for these situations is clear. Gomez et al (1998) suggested students may need time to grieve for the loss of a personal dream. They will need time to digest the reality of it and to discuss their feelings with mentors.
- Students may respond with disbelief and shock to a failed assessment. This may be due to an inaccurate self-assessment of their own abilities and competence. It may also be due to previous mentors ‘passing the buck’ or giving them the ‘benefit of the doubt’ (Duffy, 2003). This is neither in the interest of the student nor the profession;
- Students may feel betrayed and hurt that their ‘friend’ has failed them. Some interpret the nurturing, supportive mentorship role as a close friendship. This requires skills from mentors to develop and maintain a professional, supportive role;
- Many students cry when they realise they have failed, which can be upsetting for mentors. It is important to give them time to cry before moving forward to discuss the assessment results in further detail;
- Students may react with anger/aggression and/or denial, and may verbally abuse their mentor. Some may accuse mentors of bias or victimisation and may not accept the outcome of the assessment. Duffy (2003) reported students saying the failure was due to personality clashes with their mentor or trying to undermine their mentor and even threatening ‘legal action’, putting tremendous pressure on mentors. Stuart (2007) suggested that if anger is anticipated at this stage, it may be wise to enlist the help of a third person, perhaps the student’s personal tutor;
- Students may react by blaming others. Several mentors in Duffy’s (2006) study indicated that students blamed ‘previous mentors’, ‘lack of appropriate placements’, and ‘their university course’ for their deficits;
- Some students may be relieved and willing to accept a failed assessment. Failure can sometimes have a positive outcome. A common assumption is that students always react negatively to failed assessments. However, Zuzelo (2000) observed that they often recognise their clinical weaknesses, are concerned by their shortcomings and consequently are relieved when mentors highlight areas that need improvement.
Challenges for mentors
It is clear that decisions to fail have emotional consequences for students. These occasions also present mentors with challenges.
One participant in Duffy’s (2003) study described the experience of the final interview as ‘heated and emotional’. Milner and O’Bryne (1986) said that failing a student can be an unpleasant, messy and emotionally fraught experience. This can leave mentors with feelings of sadness, anger, exhaustion and relief (Duffy, 2003; Burgess et al, 1998) and can result in the mentor experiencing a sense of personal failure (Duffy and Scott, 1998).
Failing students can have emotional consequences for the whole team. A mentor in Duffy’s (2006) study described a student who went behind her back to other team members, in an attempt to rally support for her view of her practice. Therefore, as well as having to cope with the emotional reaction of the student, mentors may have to deal with disharmony within the team.
It is important that mentors do not avoid these uncomfortable situations by passing students when they feel that they have not achieved the outcomes required of them, whatever the reason.
Part 2 of this unit, which looks at how to manage failing students, will be published in next week’s issue.
Duffy, K. (2003) Failing Students: a Qualitative Study of Factors that Influence the Decisions Regarding Assessment of Students’ Competence in Practice. nmc-uk.org
Marsh, S. et al (2004) Assessment of Students in Health and Social Care: Managing Failing Students in Practice.
NMC (2006) Standards to Support Learning and Assessment in Practice. London: NMC.
Skingley, A. et al (2007) Supporting practice teachers to identify failing students. British Journal of Community Nursing;
12: 1, 28–32.
Stuart, C.C. (2007) Assessment, Supervision and Support in Clinical Practice: A Guide for Nurses, Midwives and Other Health Professionals. London: Churchill Livingstone.