Thank you to all who were able to attend the journal club this week for an interesting discussion about the evaluation of students in clinical practice in nursing schools. If you were unable to come but are interested in reading the paper we discussed, it can be found here.
Exploring the Issue of Failure to Fail in a Nursing Program
Sylvie Larocque & Florence Loyce Luhanga
International Journal of Nursing Education Scholarship. Volume 10, Issue 1, Pages 1–8, ISSN (Online) 1548-923X, ISSN (Print) 2194-5772, DOI: 10.1515/ijnes-2012-0037, June 2013
Larocque and Luhanga provide a description of faculty members’, advisors’ and preceptors’ experience with what they describe as “failure to fail” in nursing education. The results from their study suggest that failing a student is a challenging process and that academic and emotional support are needed for all involved parties. There is a strong belief that consequences for programs, faculty and students follow when students fail a rotation. They outline a number of personal, professional and structural barriers to failing students, including the perceived tarnishing of the school’s reputation due to student failure. Larocque and Luhunga suggest that documentation, communication and support can improve assessment, evaluation and intervention of this process.
We started our discussion by looking at their assumption that failure to fail is an established phenomenon in nursing schools. Attendees shared whether or not they considered this was true to their own experiences and there was agreement it was a concern, although its nature remained unclear.
Regulatory and Legal Issues
The participants were asked: Are educators legally accountable for their students if they pass unsafe practitioners?
In the article, the authors argued that there is a legal responsibility of clinical instructors to ensure graduates are practicing safely. Technically, the authors argue if an issue of malpractice ensues, the instructor who gave the student a passing grade could potentially be held accountable if there was a clear audit trail of evidence that the instructor was at fault. The group suggested that because nursing is a regulated profession, it in fact would be the future nurse who would be responsible for his or her practice after graduating in the first instance not the instructor who taught them. However, they (or the patient/relatives) could still make a case it was because they had been improperly educated or assessed in some way, and pass the vicarious liability on to the School. However, the likelihood of this occuring would seem slim, and the burden of proof would rest with the student. There are grey areas, for example, students are able to work after they have graduated but before they have taken (or passed) the CRNE (although not as a full RN). The article gave an example of an instructor who decided to fail a student because they were deemed not safe to practice but the instructor’s decision was overridden by the school. It was suggested that in this case if the clinical instructor documented this thoroughly that they would not be legally liable for this students further practice, but that the School may well be.
We discussed if these issues had ever come to court in BC or Canada. However, no cases of students bringing clinical instructors or Nursing schools to court in Canada after failing clinical practice were known of, or could be found. In order to make a successful case against a clinical instructors decision, there would have to be substantial burden of proof. The paper cites cases, but none of these transpired to be for clinical practice or even in nursing. There were however, cases of students taking legal action against Universities following academic failure. In these cases the courts predominantly side with the University, unless there was clear evidence of malpractice, or unfair treatment of the student.
Teachers Responsibilities
The group was asked: how can teachers assess a student’s competence effectively in a short period of time?
In a program structured around 6 week clinical rotations, effectively assessing the safety and competency of a student’s practice is a challenge. The group noted that the criteria for safe and unsafe practice need to be clearly communicated to both clinical instructors and students. With this information clearly laid out, a conversation with a student about not meeting competencies may be less stressful. Instructors must engage in the due process required when they are worried about the success of a student (which in the School is established in a process involving learning plans, and midpoint formal assessments).
There was also a brief discussion on the possibility of peer-evaluation, although it was acknowledged the practicalities of using this for clinical practice assessment made this problematic.
Learning Plan Use
It was suggested that learning plans that are currently used could be more effective in mitigating some of the problems discussed in the article on failure to fail. Stiudents suggested that currently, some instructors use them effectively in evaluations whilst others ask students to fill them out and approve them without any further discussion or follow-up. For some students, the learning plans are therefore seen as just busy work. It was suggested that perhaps, if these learning plans were completed more consistently and instructors referred back to them throughout the rotation they would be able to assess and document students’ competence more effectively before the end of the rotation.
Shift Duration
Another suggestion was to increase the number of rotations employing eight hour shifts three times per week instead of twelve hour shifts twice per week. The twelve hour shifts have become popular, but this means the students spend less actual days in the units. With eight hour shifts, students have more days in the hospital with their clinical instructor in which to be assessed and worked with.
Continuity of Assessment
The group were asked: should teachers be able to see a student’s previous performance in the program?
Attendees had mixed responses to this question (generally along faculty/student lines). Some felt that they might be unfavourably labelled when instructors looked at past assessments, if the student had experienced difficulties. Others felt that as professional educators they should be able to see if the current behaviour they are experiencing the students clinical practice is a trend, and knowledge of what the strengths and weaknesses and levels of experience of all students is educationally valuable. The issue of trust is important here. If students feel they cannot trust their instructors then the whole assessment process becomes problematic. Student’s do have a right to appeal and there are processes to raise concerns if they feel they are being unfairly assessed. However, the power differentials were acknowledged. In the School the instructor is asked to look at the student’s previous evaluations to better support their development in practice, and overall this was seen to be a positive action.
It was also noted that if instructors were able to see that they were not the first instructor to struggle with a particular aspect of student competence they would feel more confident in approaching the course leader. It was also suggested that in some cases instructors may be reluctant to make the decision to approach the school or fail a student, as it could be seen as a failure on their part. It was argued that there will most likely have been many issues along the way (rather than single catastrophic events) and if instructors can see this in previous evaluations, they may feel better placed to make sound assessment decisions.
Program Structure
Another consideration raised in the paper was deciding if a student should fail a clinical practicum may also be affected by where it occurs the structure of the program. The research in the paper was with final-practicum students and preceptors in a single university. There may have been different results if the research had been undertaken with first or second year clinical courses, or in different program structures. For example, if a student fails a professional course in our BSN program, they will normally require an additional year to complete the program. With the previous BSN structure, it was acknowledged that students more often left the program for either four or eight months, and could then rejoin. It was suggested that these factors may be taken into account in assessment decisions but was agreed that these considerations would never trump decisions on competence and the safety of patients.
Critique of Paper
Overall the paper was felt to be rather problematic from a number of perspectives. The group concluded that the findings from this work are interesting but overall appear rather self-evident, bringing little new to knowledge of the phenomenon. Details of the methodology were a bit scant, and the research question posed was poorly constructed as a highly leading question. We were left wanting more discussion of the phenomenon, and discussion of practical details, trends and potential solutions to these issues. The group felt that the phenomenon of failure to fail and it’s characteristics would be very difficult to establish by the means undertaken by the researchers. The sample was very small (n=13) and targeted at specific instructors who had negative experiences (one of whom had experienced having their own assessment decision overturned). Other indicators such as historical failure rates, higher incidence of malpractice or clinical incompetence in new graduates might help substantiate it as a significant educational issue Furthermore, a more open investigation of instructors experiences in dealing with students in jeopardy might have helped achieve more useful information to substantiate and characterize the phenomenon of failure to fail.
Overall the phenomenon was found to be ill-defined, and this paper specifically examined clinical failure at the end of the program. We considered if this would this be any different than if the questions were targeted earlier in the program. Earlier in the discussion it was suggested that these students should be flagged and supported much earlier in the program. However, it was suggested that perhaps a reason while students might fail their preceptorship (rather than other practicums) was because they simply cannot put all the pieces together with a more challenging full patient load. The preceptor experience requires integration of skills and knowledge beyond what is expected in other rotations, and this is therefore a higher level of practical assessment
Much of the research and references from this paper were from other disciplines and from academic failure (and this was not explicitly indicated in the paper). This would tend to indicate that more research is needed on this topic. Failure to fail may indeed exist, but further work is needed to establish its prevalence and nature. As yet there would seem little evidence it is a seriously widespread phenomena affecting patient safety.
We welcome further commentary and discussion below, and hope to see you all in December for cookies and another great Journal Club session! Check back here for details on the next workshop.
