Nurses too nice or too wary to fail nursing students?

1 August 2014

Some nursing students shouldn’t ever become nurses. But failing them is easier said then done – a process not helped by the looming possibility of facing not only unhappy students but also their parents and lawyers. FIONA CASSIE talks to Sally Dobbs about her doctoral research into nurses failing nurses-to-be.

 

Sally Dobbs spent most of her nursing career in the British military.

In combat, you don’t get second chances, says Dobbs. She was very much accustomed to the culture that if you fail to make the grade, you’re out – be you a soldier who can’t fire a gun correctly or a nurse whose practice is unsafe.

So she was somewhat surprised just days after entering ‘civvy street’ down under to hear a clinical nurse educator ask the question: “What do we do if we have a failing student?”.

“I thought that was absolutely clear – fail them,” recalls Dobbs, who at the time was coming to grips with a new country and a new job as programme leader for third year nursing students at the Southern Institute of Technology (she is now head of the nursing school).

But as the discussion ensued, she realised failing a failing student was not as simple as it sounds, and her other dilemma – finding a doctoral research proposal in a hurry – was resolved.

Soon after, she had her own first-hand experience of failing a Kiwi student: a third year student who had provided “really, really unsafe care” during her clinical practice placement. “Boy, did we have problems actually failing her.”

With lawyers called in to challenge the decision, Dobbs went through the student’s second year assessment notes and found the student had attempted to take a blood pressure with the cuff on one arm and the stethoscope on the other.

“She couldn’t understand why she couldn’t hear a blood pressure.”

After a second go at the clinical placement, and excuses being made for her, she was allowed to enter the third year, where things got steadily worse.

A literature review early in Dobbs’ research revealed to her that nursing was not unique in struggling to fail students on their practical skills, with teacher, medical, occupational therapy, and social worker educators also finding the process challenging.

Her next step was to interview 14 clinical nurse educators, employed by polytechnic nursing schools across the country to assess students during clinical placements*, about their experiences of assessing ‘failing’ students (*ethical approval precluded Sally conducting interviews within her own institution).

The educators had a range of experience and qualifications, with five having a Master’s degree and a teaching qualification, but the majority were still studying towards a teacher qualification. Eight of the educators had failed students – with the least experienced less likely to fail someone – and five of the 14 had regretted not failing a student.

Dobbs found the clinical nurse educators straddled, somewhat uncomfortably at times, two worlds: the nursing world, with its caring ethos and professional responsibility for patient safety, and the education world, with its different responsibilities, including to the student.

 

Would I want them nursing my loved ones?

The common ‘litmus test’ used by educators when making the call to pass or fail was “would I want this person looking after me or my family member”, says Dobbs.

But some educators still opted out of failing students, with some confessing “I just hope someone else catches them later”.

Dobbs’ thesis – due to be submitted for her Doctor of Education degree later this year – is exploring why nurses failing would-be nurses appears to be so hard.

Assessing clinical practice at first-year level is often a simple tick box list to check off when students wash their hands, introduce themselves etc., but it becomes more complex and nuanced as students enter second and third year and begin being assessed against the Nursing Council’s competency domains. Assessing clinical practice is also not as black and white as marking a written exam.

Dobbs says a number of the educators reported being “thrown into the world of education” with minimal training on assessment, particularly with the novices finding failing hard. One “very nurturing” educator, who was also very new to the role, reported she would do anything she could to help a student pass.

Themes raised during the educator interviews included confusion over the point where an educator stops teaching and starts assessing a student’s clinical skills; assessing a student on a practicum in an area, like Plunket or district nursing, where a student is more often observing than delivering care; or if the placement was only for a week or too short get a clear picture of the students ability in that practice area.

“The duration and location of placements was really important.”

Educators always seek additional feedback from the students’ nurse preceptors, but even that has its limitations, as some preceptors aren’t well-prepared, preceptors may have different expectations and criteria from educators over what is a work-ready nursing student, and a student may have many different preceptors throughout their clinical placement.

Dobbs says educators also reported dilemmas of having students who showed great aptitude for surgical nursing but showed no empathy in mental health settings, or vice versa.

“But they have to pass absolutely everything,” says Dobbs, as the New Zealand degree is a comprehensive degree and registration allows them to work in all fields.

This meant talk of passing students, as while “they’d be no good in surgical, they’d be all right in aged care”, which was of concern.

Some educators, when wobbling on the fence over a student’s clinical performance, let the student’s academic record sway their decision.

“They are really good in the classroom – they are getting A’s in sociology and sciences so they will be fine – they will be a good nurse,” was the rationale they gave for passing a marginal student. Dobbs says educators also showed they were influenced by the ‘halo effect’, where people find it much harder to fail a student they like.

Other themes that emerged included educators wanting to be popular and liked by students rather than having a reputation for failing, plus the need for educators to be ‘strong’ and have enough courage in their convictions to follow through and fail an unsafe student. A number reported opting out of taking responsibility for failing a student and handed on their assessment to the next in line, saying, “it’s not my job to fail” and it was “management’s problem”. Those who did fail students often felt “gutted” and all felt unsupported.

 

Appeals, lawyers, and professional integrity

The ‘failing’ stakes go up if a struggling student is allowed to move from year two to year three; added to the educator’s ‘pass/fail’ dilemma is the time and money a student has invested in getting a nursing degree. The stakes get even higher if a student has already failed that clinical practicum once before, as Nursing Council policy is for no student to have more than two opportunities to pass a clinical experience placement.

Straddling the two worlds of nursing and education also raised questions over who the educators were foremost responsible to when considering failing a student: the nursing profession, with its responsibility to protect patient safety? Or their polytechnic employer? In the current education environment, polytechnics are under pressure to balance maintaining academic standards and their obligations to their funders – the fee-paying students and the Tertiary Education Commission. Dobbs says at least two polytechnic chief executives had made it clear to staff that nursing schools were not to consider themselves ‘gatekeepers’ to the nursing profession.

That tension between the two worlds is heightened when a student appeals. Students bringing in lawyers to fight an appeal case is far from unknown, and Dobbs says nurse educators are all very aware that their decision may be scrutinised in an appeal process. “They find it very stressful.”

She says educators feel their professional integrity is being challenged, and some also shared “harrowing stories” of being physically threatened by students and facing angry parents.

“A lot of people are taking massive proactive measures to make sure they have their own files on students,” says Dobbs.

A key reason was to have evidence if a decision was appealed, and if the need arose, to take to the Nursing Council.

A number of educators spoke of having their decisions overturned by somebody further up the chain or during the appeal process.

“It’s farcical to fail because so many decisions are overturned,” is how one educator put it to Dobbs.

Some also reported that Nursing Council standards were “being overridden” by their polytechnic’s appeals process.

 

Failing someone can be less fraught

Failing someone is never easy for either the assessor or the student, but Dobbs believes that doesn’t mean the clinical assessment process cannot be improved.

She points to the UK model, which has adopted ‘essential skills clusters’ that set out clear national criteria for clinical skills – from compassion to fluid monitoring and communication to taking blood pressures – that must be achieved by certain ‘progression points’ along a nursing training programme.

Along with considering national clinical assessment criteria, Dobbs would like to see more support and accountability for clinical nurse educators, including a nationally recognised training programme in clinical assessment. She would also like to see more student accountability, with the possible adoption of student ‘indexing’ or ‘registration’ like that carried out by the Australian Nursing and Midwifery Board.

Failing a nursing student may never be clear-cut in the military sense, but maybe it can be less fraught and more transparent for all involved.