Nurse Education in Practice

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1 Nurse Education in Practice 10 (2010) Contents lists available at ScienceDirect Nurse Education in Practice journal homepage: Contemporary issues relating to assessment of pre-registration nursing students in practice Michelle Fitzgerald *, Faith Gibson 1, Kirsten Gunn 2 Faculty of Health and Social Care, London South Bank University, 103 Borough Road, London SE1, United Kingdom article info summary Article history: Accepted 7 June 2009 Keywords: Assessment Student Mentor Clinical placements are an essential part of pre-registration nurse education. Mentors have a vital role in providing constructive feedback and assessing the student throughout their placement. There have been reports of failing to fail students in practice, however, little evidence has been provided to support this. This paper provides an insight into apparent mismatches between mentor feedback given to students in their practice assessment documents and feedback given to university and Trust staff anonymously. Our findings appear to illustrate issues of inconsistency and a lack of ability to give accurate feedback on professional values and behaviours. This is in contrast to the feedback on clinical skills in which the mentors appeared to be in agreement, with the written comments being supported by congruent scores in the relevant competencies. Ó 2009 Elsevier Ltd. All rights reserved. Introduction The Nursing and Midwifery Council (NMC) is required to develop United Kingdom (UK) wide principles for the use of simulation for student nurses to support practice learning. The NMC (2007) has acted on feedback gathered from Phase 1 of the Review of Fitness for Practice at the Point of Registration (2004), which strongly supported the use of simulation and skills rehearsal (Moore, 2005). This paper will introduce the reader briefly to the aims and methods of the NMC project. However, the main focus will be on an unexpected finding related to student assessment and clinical placement feedback provided by qualified nurses: a finding revealed through reflection and discussion during the life of the project. The Simulation and Practice Learning Project (2006) was piloted across 17 universities and higher education institutions, which were NMC approved, covering all of the UK. The project involved student nurses from diploma and degree pathways, students from the 1st (Foundation), 2nd and 3rd year and encompassed all branches of the nursing programme i.e. Adult, Child, Mental Health and Learning Disability. Up to seven days (or equivalent hours) of designated practice time could be used for simulation for the period of the pilot. All the simulations across the UK took place between October 2006 and January The overall aim of the project was twofold: * Corresponding author. Tel.: addresses: [email protected] (M. Fitzgerald), GibsoF@gosh. nhs.uk (F. Gibson), [email protected] (K. Gunn). 1 Tel.: Tel.: To determine if a period of clinical placement could be spent in a simulated environment without disadvantaging the student nurse; 2. To find out if a period of practice in a simulated environment could support the development of direct care skills needed for safe and effective practice. As part of the NMC Simulation and Practice Learning Project, a joint venture was undertaken between a central London University and NHS Trust Hospital. It was proposed that second year child branch nursing students were to spend the first five days of an eight-week placement, in a simulation setting. It is this sub-element of the project that provides the focus for this paper. Background/literature Teaching and learning in the clinical setting is not a new concept and the teaching of clinical skills to nursing students ranks high on the current agenda of nurse education (Pfeil, 2003). Practice placements offer students the opportunity to apply theory to practice (Pollard and Hibbert, 2004) and influence the development of attitudes, psychomotor skills, knowledge and clinical problem solving abilities (Dunn and Hansford, 1997). As stated by Chambers (2007), the quality of clinical placements constitutes one of the most significant influences on the process of learning to be a nurse: thought to be aided significantly through a mentoring process. There are a number of different terms utilised internationally, such as mentor, buddy, supervisor and preceptor when attempting to define the role of a qualified nurse supervising a /$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi: /j.nepr

2 M. Fitzgerald et al. / Nurse Education in Practice 10 (2010) student in practice. For the purpose of this paper and consistency for the reader the term mentor will be used throughout. The mentor is seen as one who facilitates learning, supervises and assesses students in a practice setting. A mentor is responsible and accountable for a number of issues and these are depicted in Box 1. Mentoring is seen as one of the most important functions that one generation can provide to the next generation of professionals (Sherwen, 2003). It has been suggested that qualified and experienced nurses can enhance clinical learning through effective mentorship (Crooke et al., 2003). Wilkes (2006) set out to review the literature surrounding the student and mentor relationship and concluded that although the role of the mentor has changed over the years, the relationship between the nurse and student is complex and paramount to student learning. Box 1. Mentor responsibilities Organising and co-ordinating student learning activities in practice. Supervising students in learning situations and providing them with constructive feedback on their achievements. Setting and monitoring achievement of realistic learning objectives. Assessing total performance including skills, attitudes and behaviours. Providing evidence as required by programme providers of student achievement or lack of achievement. Liasing with others (e.g. mentors, sign-off mentors, practice facilitators, practice teachers, personal tutors, programme leaders) to provide feedback, identify any concerns about the student s performance and agree action as appropriate. Providing evidence for, or acting as, sign-off mentors with regard to making decisions about achievement of proficiency at the end of a programme. NMC (2006, p. 17). Table 1 Achievement of competencies scoring. Level of performance Outcome Score The student has failed to perform or demonstrate verbally an understanding of the learning outcome/skill Has observed staff undertaking the learning outcome/skill. With direct supervision and guidance the student has performed and demonstrated verbally an understanding of the learning outcome/skill The student is a knowledgeable observer and shows an understanding of the theoretical rationale underpinning the practice of the learning outcome/ skill The student demonstrated unsafe practice through the inability to discuss or perform the learning outcome or skill safely despite repeated guidance The student can perform fundamental elements of the learning outcome/skill safely under direct supervision and guidance The student can perform the complete learning outcome/skill safely under supervision with a lesser degree of guidance and instruction Reproduced by kind permission of London South Bank University, Table 2 Practice/professional values student is assessed on at midway and final interview. Professional values 1. Maintenance of respect for the values, customs and beliefs of the child and family 2. Maintenance of consistent, safe practice 3. Demonstrates good time keeping and time management skills 4. Maintains a professional attitude and behaviour which reflects all aspects of the Code of Professional Conduct Reproduced by kind permission of London South Bank University, The nurse as a mentor has a multitude of skills to perform in order to effectively undertake the supervision of a student (Wilkes, 2006). These skills include being an information source (Allen, 2006), an evaluator and challenger (Ely and Lear, 2003), a teacher and counsellor (Quinn, 2000) and a role model that actively advises students by using open communication and inspirational motivation (Huff, 2004). It has been suggested that the skills, qualities and attitudes of a mentor are more important to a positive practice placement than the learning environment (Gray and Smith, 2000; Wilkes, 2006). The authors unanimously believe that although this paper is UK based its findings are relevant to a wider audience as students will continually need support and encouragement from their mentors throughout their training whichever, country they reside in. According to the University Practice Placement Guidelines each student should work with/be supervised by their mentor for a minimum of 40% of their time in practice and this is supported by the NMC (2006). Mentors play a vital role in supporting, teaching and assessing students in practice (Pellatt, 2006) and they are there to facilitate the overall learning experience. Although it is not necessary that the mentor work with the student all the time, a named supervisor is provided for each clinical shift. During each clinical placement, the student and their mentor meet together formally on at least three occasions: 1. At the beginning of each practice experience to identify and document personal learning outcomes the student would like to achieve that are specific to that practice experience. 2. During the middle of the practice experience to formally review progress, give mid-point scores (Table 1) and identify if additional action or support is required. 3. At the end of the practice experience to formally review the learning outcomes for the area, reflect on the experience and encourage the student to identify personal and professional development achieved during the experience and the identification of future learning needs. At this point the mentor will score each competency again (Table 1) on the basis of the student s performance, following discussion with all colleagues who have worked with the student. Each student must pass each learning outcome by the end of the allocation to enable them to pass the overall competency and skill. In addition, students must pass each of the four professional values for each placement (Table 2). Scoring allows mentors to make a fair and objective assessment of the student s performance based on their professional judgement. For Second Year Students, the minimum score to pass each learning outcome, skill and practice value is 2. A score of 1 constitutes a referral for the specific learning outcome, skill or practice value. Description of project In this Simulation and Practice Learning Project all students were from child branch (2nd Year) and all from the same cohort (n = 49). From this cohort, a decision was made to use a smaller subgroup due the space provided for the simulation. A total of 18 students were approached, who willingly gave consent and were included in the project; nine in the simulation group and nine in the comparison group. For all students, it was their second branch placement. The simulation group had their first week of placement,

3 160 M. Fitzgerald et al. / Nurse Education in Practice 10 (2010) a total of five days, with the Student Practice Facilitators (SPF). The SPF s were put in place in 2003 to bridge the theory practice gap which had always been a challenge due to the specialised arena of paediatric nursing. Although initially the role was fully funded by the Trust, in 2005 the University began part funding. The SPF team consists of four full time senior staff nurses who work Trust wide with all student nurses, to teach and support them in acquiring numerous clinical and professional skills. The team provides daily teaching sessions covering a range of clinical and professional skills i.e. normal observations, fluid balance, infection control and professionalism. The SPF s provide 1:1 teaching and support as well as student group teaching of up to 20 at any one time. The team supports both the student and mentor in practice, and if required, support both in setting student objectives through action plans. The five days spent with the SPF s were interactive and took place in a simulated ward environment with the use of manikins. Content included practical workshops and lecture style teaching covering admissions, assessment, documentation, specific conditions (e.g. respiratory and orthopaedic) and infection control. According to Zimmerman (2003) learning occurs when auditory, visual and kinetic approaches are used and if they are utilised together, which encompasses both sides of the brain, accelerated learning will be achieved and this was the reason for utilising such an approach. The week was followed by seven weeks on their allocated ward. The comparison group completed the full eight weeks on their allocated ward and were able to attend (if appropriate and/or applicable) the SPF teaching sessions. All students had access to the support of the SPF s throughout their practice allocation. As part of the project, data were collected in the form of Continuous Assessment of Practice documents (CAP) from all students (n = 17) and anonymous questionnaires competed by the mentors on each student involved in the project at the end of the placement (n = 17). These questionnaires were devised by the NMC project steering group and the student had not seen the content prior to use. The questions asked were: j Did the student achieve their expected learning outcomes in practice? j How would you rate the student s ability to perform clinical skills on placement? j How would you rate the student s confidence to perform clinical skills on placement? j Are there any particular skills in which you felt the student excelled? j Are there any particular skills you felt the student lacked? Inclusion criteria and ethical consideration Inclusion criteria for the simulation group consisted of the students being on their first hospital placement after a minimum period of six months. This group was made up of seven students who had been in the community for their first practice placement of branch and two students who had been on personal interruptions for six months so were rejoining the programme. None of these students were known to the SPF team, which reduced any bias. The comparison group consisted of nine students who were on their second hospital placement of Branch. Exclusion criteria were applied so that for both groups, no student had a previous referral in practice, no student who was on a Theatres placement was included (as this would have introduced another variable as this particular placement consists of a rotation through anaesthetics, theatres and recovery) and no student who had altered placement dates (e.g. started placement early through negotiation for personal reasons) were included in the project. All students, mentors and ward sisters/managers that were involved in the project were prepared with both verbal and written information. Written information sheets and an outline of the consent process were distributed, with the reassurance that they (students and mentors) were free to withdraw from the project at any time, without giving a reason for withdrawing. Students were also reassured that withdrawal would not jeopardise their course of study. One student withdrew from the DipHE programme for personal reasons during the clinical placement and is not included in the final analysis. All of the students who completed the practice placement passed (n = 17). An initial informal review of the CAP books by the researchers revealed discrepancies between the documented feedback given and the scores the students had received. This was reviewed further with the lead Nurse for Pre-Registration Education in the Trust and a decision was made, based on the above findings, to examine and analyse the data further. The researchers independently reviewed the data. Agreement was initially 90%; however, following further additional review, total agreement was reached for all students. By carrying out an in depth analysis confirmation was gained on the initial observations, revealing a variance between the following: (a) Written feedback the student received from their mentors in their CAP document and scores given for relevant competencies at midway and final interviews, (b) Written feedback the student received from their mentors in their CAP document and the anonymous questionnaire completed by the mentors and given to the NMC project team. The review of the data collected to assess and evaluate the NMC project revealed an unexpected insight into contemporary issues relating to assessment of student nurses in practice. The following is a report relating to the first simulation practice project and presents a re-analysis of data following an unexpected finding, and therefore focuses primarily on identified issues concerning student assessment in clinical placement. Aims j To reveal further insight into the disparity of documented feedback between CAP documents and anonymous questionnaires. j To provide evidence of failure to fail. Data analysis Through analysis of the CAP documents, it was possible to see that seven out of the 17 students (41%) had formative feedback documented that was inconsistent with their scores at midway and final interview. As previously stated all mentors were asked to complete an anonymous questionnaire after the student had completed their placement. These were collated within one week of the student concluding their placement. Once again, discrepancies were found between the feedback received on the questionnaire to that reported in the students CAP book. It was identified that four mentors had given feedback in the CAP books which contradicted the information on the questionnaire. Inconsistencies in feedback and scores In some cases, the mentors highlighted areas for further development at mid-way interview however these identified areas for improvement were often accompanied by pass scores in the relevant competencies. For example, one student received negative comments about professionalism and communication issues at

4 M. Fitzgerald et al. / Nurse Education in Practice 10 (2010) midway, however, pass scores were awarded. At the final interview, professional issues were again identified as an area for future development and again, pass scores were given. In contrast, students received positive comments at midway, yet also received referral scores. For example, one student received very brief formative feedback at mid-point interview progressing well and developing well yet the student received two referral scores (1.2a demonstrates knowledge of legislation relevant to nursing practice and 5.1a identifies normal and abnormal development in a range of settings ). A non-specific action plan was documented consisting of complete whatever objectives left over by the end of placement and ensure participation in all aspects of patient care. At final interview once again the documentation was very brief and non-specific. In addition, there was no reference to improvements made although the student received improved scores in every competency and all practice values. Action plans appeared to be completed on an ad hoc basis and sometimes although an action plan was drawn up, it did not relate to issues identified. For example, one student had issues identified concerning communication and documentation at the mid-way interview. Whilst an action plan was drawn up, it only addressed communication and this was in a very non-specific way stating the student was to build up more confidence to approach members of staff. There was no reference to documentation and how to improve on this in the action plan. Another student received a very positive mid-way interview highlighting professional values and behaviours as being of a high level; however, an action plan was formulated identifying two areas for improvement ( progress on communication skills and drug calculations ). Despite this, both of the related competencies were scored at two at mid-point. No further feedback is documented on the student s progress relating to these two areas and there is no mention of them in the final interview. One student received six referrals at their mid-way interview. Whilst an action plan was documented this was again non-specific with non-measurable outcomes, e.g. focus on drug calculations, to learn more about seizure types. At final interview it was documented that the student had worked hard to improve but still needed to concentrate on two skills in particular ( drug calculations and neurological observations ). The student passed all competencies and practice values at the final interview. Another student, at their mid-way interview, had documented that there were areas which required further development. However, these areas were not identified apart from communication. A detailed and specific action plan was documented but this only focused on verbal communication skills. The student received a referral score in one competency only at midway; 2.1a effectively uses a range of interpersonal skills and communication techniques. At final interview it was documented that this student had made huge improvements over the last few weeks however, the majority of scores remained unchanged, except for competency 2.1a, which now was scored a 3. One of the students received positive feedback at their midpoint interview with scores of two in all competencies and practice values. An action plan was written by the student and identified four objectives for learning during the remainder of the placement mainly relating to working with members of the multi disciplinary team. At final interview the mentor documented that several issues had been discussed that had arisen during the placement. There was no evidence of these issues in the student s formative feedback this was the first documentation of any concerns. Many areas were highlighted for further development (time management, assessment, care planning, observations and anatomy and physiology knowledge) at final interview, even though this had not been identified anywhere else in the CAP book. The student received scores of two in all competencies and practice values at final interview. Discrepancies between anonymous mentor feedback and documentation in students CAP book One mentor highlighted in the anonymous questionnaire that the student had improved her practice enough to pass yet the midway and final scores for the relevant items were identical. Furthermore, the mentor went on to state there were instances of poor communication and lack of awareness of the NMC Code of Professional Conduct, confidentiality, barriers, knowing ones limitation. In the CAP document, formative feedback was given regarding a breach of confidentiality, however, the student scored 2 at both midway and final interview for Professional Value 4, and for Competency 1.2b ensures confidentiality at all times. An action plan was documented; however, this was related to clinical skills and experiences with no reference to the concerns raised regarding professional behaviours. Several of the mentors identified in the anonymous questionnaire that students lacked certain skills, for example; lacked competency in drug calculation skills ; lacked in several skills. Neither of these comments were identified in the student s CAP books in the formative feedback, nor were they reflected in the scores given for skills. One mentor identified that the student lacked communication skills in that questions where being asked at inappropriate times. Also, this mentor highlighted the student lacked knowledge in basic anatomy and how and when baseline observations were required. In addition, in response to the question Did the student achieve their expected learning outcomes in practice? the mentor stated To some extent. In response to How would you rate the student s ability to perform clinical skills on placement? the mentor wrote As expected for their stage in the course but with more supervision. Again, none of these issues were highlighted in the student s CAP books. Discussion The importance of feedback has been widely documented (Latting, 1992; Marriot and Galbraith, 2005). It is seen as information given to specify the level of competence that has been attained in the performance of a specific task (Marriot and Galbraith, 2005). Effective feedback serves two key functions it instructs by helping to elucidate divergence between preferred and actual behaviour; and it motivates by increasing student desire to perform well (Latting, 1992). There appeared to be reluctance on the part of the mentors to highlight difficulties/issues with students directly who were not performing as expected. Castledine (2007) stated that criticism is mounting that student nurses are not as well prepared clinically as they used to be. However, it is possible that part of the problem relates to the assessments of the students not being as accurate as they need to be. One of the roles of the mentor is as a gatekeeper to the profession. As stated by While (2004), the mentor is required to feel personally and professionally confident when assessing the student s performance. With the widening of the entry criteria for University studies, the profile of students has evolved and now includes a wider range of age and experiences than previously. It is not clear if there is a link between these inconsistencies and the changing profile of nursing students generally with wider entry criteria there are now more mature students with more life experiences than previously, students appear to be more assertive and there has been documentation of aggressive nursing students (Ehrmann, 2005). While (2004) identified that assessing the adequacy of student performance requires judgement and this may be difficult, especially when the students performance is borderline. However, the examples highlighted in this project do not appear to relate to borderline students particularly.

5 162 M. Fitzgerald et al. / Nurse Education in Practice 10 (2010) At the time of this study in order to be a mentor in the Trust, a registered nurse must have attended a 1 2 day course (depending on previous experience) run in a Training and Development department and delivered by the SPF s and University Link-Lecturers. Following attendance on this course, the nurse is permitted to be a mentor and complete initial, midway and final interviews and assessments. No data were obtained from the mentors involved in the project about their experience in mentoring, length of time since graduating and educational level. There is, at present, no form of assessment to determine competence in the role as mentor. Support for mentors in practice is provided in the form of SPF s, a Trust Wide Student Link Group, Link Lecturers from the University and the Lead Nurse for Pre-Registration Education. The evidence from this project clearly supports the work of Duffy (2004) in that we are failing to fail. However, our findings for these reasons do not correlate with those of Duffy (2004). For example Duffy (2004) found that staff were unwilling to fail students early in their programme and that they take into account students personal situations. The issues we have highlighted relate to inconsistencies between feedback given to students and feedback given to the university in a confidential manner that the student would never see. This confidential feedback appeared to be more honest. Our findings appear to illustrate a much deeper issue of inconsistency and a lack of ability to give accurate feedback on professional values and behaviours. This is in contrast to the feedback on clinical skills in which the mentors appeared to be in agreement with the written comments being supported by congruent scores in the relevant competencies. We, as registered nurses, are responsible in maintaining our standards to a high level. It is the role of the mentor to supervise, educate and nurture the student nurse. If trained nurses are unable to challenge poor practice and give direct, honest and accurate feedback, is it fair that we then blame the student for poor performance? Realistic and measurable learning objectives need to be set from the start whereby everybody is clear and in agreement with what will be achieved and by when. We need to be able to give clear and concise feedback to all of our students if we are to expect changes in the current system. There appears to be a culture that is working its way into the profession, whereby it is becoming acceptable not to challenge behaviour in students, whether related to professionalism and/or clinical skills. The findings from this project highlight to the nurses detriment, the mixed messages given to students and the inconsistencies in the feedback received. Limitations Findings outlined above relate to a small subgroup of one cohort of child branch students at one Trust in central London, and therefore, may not necessarily be applicable to other branches, cohorts and locations. Implications for the assessment process As a result of the NMC Simulation and Learning Project, several changes have been made to the students CAP documents. There has been an increase in pages for formative feedback and a sample action plan has been incorporated. In addition a clinical skills session has been introduced at the beginning of the branch programme. In line with the NMC guidelines for Mentor Preparation, mentor training has evolved significantly and all new mentors undertake a post-registration unit, prior to mentoring a student. In addition, mentor updates are incorporated into Band 5 and 6 nursing study days and also included in clinical updates in the Trust to highlight the issues identified in this project. Mentors are encouraged to document feedback on a daily basis and this has led to an increase in documented feedback in all students CAP books when on placement in the Trust. Whilst this has required the mentors to document the students progress on a more regular basis, thus increasing their workload, it has had the positive effect of providing Link Lecturers, Mentors and Personal Tutors with more detail of the students progress. It has also been beneficial when students are not progressing well on a ward, as there is documented evidence of concerns throughout the placement, which can serve as a mechanism for referral. Benefits of this approach are also to the student; they are made aware of concerns and can work towards further development in the highlighted areas. Conclusion The above findings indicate the need for review of practice assessment and competence, especially in relation to professional values. It also highlights the need to further develop mentor training as identified by the NMC (2006). There is a need for increasing awareness of the widening entry criteria and the possible impact of the changing student profile. There is also a need for close working relationships between Trusts and education providers to ensure consistency and the upholding of professional standards, leading to fitness for practice. Students need to take responsibility for their behaviours and as they develop personally and professionally, reflect on the feedback received and act on it when appropriate. However, this project has clearly highlighted that some student nurses are not receiving the feedback that they desperately need and ought to have in order for them to grow and develop into the kind of professional required. It is believed that the findings from this paper can be used internationally as the evidence has shown withholding constructive feedback from nursing students is a practice that needs to be addressed. This is essential to ensure professional standards are met and graduates are fit for practice and purpose wherever they undertake their training. The full report of the NMC Simulation and Practice Project can be found at adisplaydocument.aspx?documentid=3703. References Allen, S., Mentoring: the magic partnership. Canadian Operating Room Nursing Journal 24 (4), Castledine, G., Tighter controls of student mentors may be problematic. British Journal of Nursing 16 (5), 327. Chambers, D., Is the modern NHS fit for nursing students. British Journal of Nursing 16 (2), Crooke, L., Curtis, P., Thomas, G., Learning communities: innovations in nurse education. In: Supporting Learning in Nursing Practice. Palgrave, London. Duffy, K., Mentors need more support to fail incompetent students. British Journal of Nursing 13 (10), 582. Dunn, S., Hansford, B., Undergraduate nursing students perceptions of their clinical learning environment. Journal of Advanced Nursing 25, Ehrmann, G., Managing the aggressive nursing student. Nurse Educator 30 (3), Ely, L., Lear, D., The practice learning experience. In: Glen, S., Parker, P. (Eds.), Supporting Learning in Nursing Practice. Gray, M., Smith, L., The qualities of an effective mentor from the student nurse s perspective: findings from a longitudinal study. Journal of Advanced Nursing 32 (6), Huff, B., Leadership and mentoring. Canadian Operating Rooms 22 (1), Latting, J., Giving corrective feedback: a decision analysis. Social Work 37, Marriot, J., Galbraith, K., Instructor, observer and provider of feedback. In: Rose, M., Best, D. (Eds.), Transforming Practice through Clinical Education, Professional Supervision and Mentoring. Churchill Livingston, UK. Moore, D., Assuring Fitness for Practice. 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