All Prequalifying Nursing Students

All prequalifying nursing students required a mentor who works with them for the duration of each of their clinical placements to provide appropriate learning experiences and support in their application of theory to practice (NMC, 2004). Mentors assess, guide, supervise and teach students in accordance with requirements of the Royal College of Nursing (RCN, 2005) and Nursing and Midwifery Council (NMC, 2006; NMC, 2008).

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The required NMC standards identify outcomes necessary for successful registration (Dadge and Casey, 2009) and are comprised of eight domains/outcomes (NMC, 2008), the third one being “Assessment and accountability” which aims to safeguard the health and well being of the public via formal student nurse assessment. Evaluating and assessing students’ competencies is therefore an important aspect of mentors’ roles and according to Duffy and Hardicre (2007) one of the more challenging aspects of the role is to manage students not performing at the expected level. Indeed, Duffy (2004) suggests mentors need support in their decisions and many clearly need to strengthen their mentorship skills, enhance assessment proficiencies and alter their approach when dealing with underachieving students. Such issues will now be considered as part of a critical evaluation of how to manage a student whose practice gives cause for concern. The essay will focus on processes and strategies, which can be adopted to prevent failure of such individuals or reduce the trauma if they do fail.

Processes to follow if a student is underachieving

The NMC (2008) recognises that failing students may be difficult and states that mentors must “Manage failing students so that they may enhance their performance and capabilities for safe and effective practice or be able to understand their failure and the implications of this for their future” (NMC, 2008, p25).

Sign-off mentors are accountable for confirming that students have or have not met the NMC competencies in practice. They have a duty of care to protect the public by identify those who do not demonstrate the required competencies (Rutkowski, 2007; Duffy, 2003). According to a resource handbook for mentors supporting underachieving students published by NHS Lothian and Borders (n.d.), mentors of such students should be able to:

Identify and critically reflect on common behaviours of the underachieving student

Utilise a problem solving approach to construct an action plan to support the needs of an underachieving student

Based on the best evidence consider the implication of failing a student

Critically reflect on the consequences of failing to fail

Demonstrate recordable evidence of mentorship update, which is relevant to remain on the mentor register database

A flow diagram for processes to follow when a student is underachieving is shown below (taken from http://www.bcu.ac.uk/_media/docs/Mentor-Assessor-toolkit.pdf)

The steps in the flow diagram will now be further explored based on advice and recommendations from the literature regarding dealing with underachieving students.

Mentor training

In a study by Carr et al. (2012), community nurse mentors and practice learning team teachers made comprehensive recommendations regarding how to manage failing students. They highlighted the importance of training mentors to deal with such circumstances. Mentors and sign-off mentors must be knowledgeable and up to date, undertaking continual professional education and participating in triennial review so as to meet minimum NMC standards for supporting learning and assessment in practice (SLAiP) (NMC, 2006; NMC, 2008). The sign-off mentor is a kind of “super mentor” whose experience and education meets an even higher level and who has ultimate responsibility for entry onto the professional register (Andrew et al., 2010). Duffy (2003) recommends that mentors be formally educated regarding what to do when faced with a failing student, plus provided with clarity regarding their responsibility and accountability in these situations. Black (2011), on the other hand maintains that mentor training cannot equip people for the negative mentorship experiences of failing a student and contends some mentors are simply not equipped to manage difficult situations such as this. Therefore it is advisable that mentors have access to appropriate local mentor training programmes and updates (Carr et al., 2012).

Maintain consistency in Assessment

Andrews et al. (2010) stress the need for consistency in assessment to ensure integrity in the system. Yet whilst Staniland & Murray (2010) suggest that measurement of competence is debatable, research by Black (2011) described what mentors look for in students meeting the fitness for practice requirements as “a whole package”. This comprises of the right knowledge, attitudes, behaviours and skills. Cassidy (2009, p34) maintains that one aspect of competency is clinical proficiency, assessment of which “hinges on the credibility of assessment strategies”. He also emphasises that mentors’ subjectivity plays a crucial role in this assessment process describing two types of subjectivity, invalid and valid. He maintains that valid subjectivity provides a more comprehensive assessment but necessitates an investment in the student/mentor relationship, which instils trust and commitment from the outset. He also emphasises the importance of reflective practice to enhance subjective evaluation. Whilst Cassidy (2009) describes competency as mastering skills and possessing essential personal attributes, other researchers suggest it simply relates to ensuring patient safety (Hand, 2006; Tee & Jowett, 2009).

Identify failing students

Carr et al. (2012) recommend mentors trust their judgement and intuition. Similarly, Duffy and Hardicre (2007) contend mentors often feel instinctively that certain students are giving cause for concern. Unfortunately many mentors have difficulty providing objective measurements of students who display problematic behaviour or an attitude problem (Maloney et al., 1997; Skingley et al., 2007; Duffy, 2003). NHS Lothian (n.d.) identified a number of key behaviours of the underachieving student including:

Unenthusiastic attitude -lack of motivation or interest

Unreliable – poor punctuality/attendance

Displays a high level of anxiety – lacks confidence/initiative

In consistent or erratic clinical performance

Lack of theory/knowledge skills

Care incomplete – patient not left comfortable

Avoidance of working with mentor – changing shifts

Dismissive of learning opportunities – done that before, don’t want to repeat

Poor interpersonal skills – insensitive in interactions with patients/family

Lack of insight into their behaviour

Preoccupation with personal issues/continuous health issues

Unsafe practice/judgements

Poor professional behaviour

Failure to progress and develop skills through placement

Act upon concerns quickly

Carr et al. (2012) urge mentors not to be apprehensive about discussing concerns and not leave discussions until the end of placement, early intervention serving to maximise opportunities to succeed and providing the student with a chance to improve. Duffy (2003) likewise maintains that mentors should identifying the weak students as soon as possible so as to develop a suitable plan of action including additional link tutor support. Meanwhile, Carr et al. (2012) suggest that an action plan can only be positive if it is instigated early in the placement and has clear and specific directives for improving proficiency.

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It is vital that in addition to taking appropriate and swift action mentors document their concerns appropriately. The progress of a problem student should be discussed with the individual’s personal tutor or another appropriate educational link (Carr et al., 2012), but mentors should also take time to explore the problem with the student, since just highlighting the problem might serve to resolve the issue and improve progress (NHS Lothian, n.d.). Further, agreeing a learning strategy and action plan means the struggling student has been made aware of the concerns, provided the chance to improve personal growth and development and that concerns have been documented (NES, 2007; Anderson 2011).

Ensure optimised student supervision

Carr et al. (2012) urge mentors to believe in themselves, recognise their wealth of personal experience and not be afraid to be open and honest with the student about concerns. However, to address such concerns the mentor must ensure the student has access to particular learning experiences, engages in effective ongoing formative assessment and is provided constructive feedback during summative assessments. According to Kinnell (2010, p161), a good mentors must be “non-judgemental sensitive and respect the student with non-conditional positive regard”. Mentors must try to develop a strong and trustful relationship with the student, offering additional reassurance and encouragement to underachieving students. NHS Lothian (n.d.) emphasise how it is also important to set time aside for mentor-student reflection thus enriching learning and providing even more exceptional standards of mentorship. Further, mentors must provide students with unabiguous and realistic directives regarding expectation which must be in line with the stage of their placement (Carr et al., 2012). Standards can be benchmarked by reference to assessment documentation and statutory standards (NHS Lothian, n.d.).

Obtain support from and share concerns with peers/colleagues.

Carr et al. (2012) stress the advantages of peer support for mentors in managing failing students, since reflecting with a neutral colleague helps put things in perspective. Sharing experiences and concerns, along with discussing solutions either on a one-to-one or group basis results in mentors feeling less apprehension when a poor standard of practice is identified. Often this is because such discussions result in greater clarity/transparency through evidence-based rationales, thus providing the mentor with greater confidence in their decision-making. Andrews et al. (2010) suggest sign-off mentors should collaborate and discuss decisions regarding students’ fitness to practice. Orland-Barak (2002) suggests a similar approach following their study on mentorship. He advocates group mentor supervision since results indicated group discussions and peer support allowed mentors to reflect deeply on critical incidents. Such an approach would assist consistency whilst also ensuring the mentors are assured that they are making the right decision. Accordingly, the NMC (2008) states that mentors must have the opportunity to meet and explore assessment and supervision issues with other mentors on a face-to-face basis. It is therefore important that all local health trusts instigate mentorship workshops.

Follow correct procedures and action planning

Mentors should use recognised/correct procedures, guidelines and necessary paperwork to record assessments and discussions with the student; such an approach provides added conviction and confidence when the decision to fail is made (Carr et al., 2012). Moreover, the process of identifying and supporting the failing student should include (NHS Lothian, n.d.):

The giving of constructive feed-back

The development of an appropriate Action Plan

Enhanced supervision and documentation of evidence and meetings

Providing feedback:

Ongoing feedback is vital as a method of monitoring performance (Wallace, 2003) and is especially important for failing students so they can be advised of their shortcomings and given the chance to address problems. Smith et al. (2001) suggeted mentor and student should collaboraively reflect on areas of weakness. Mentors must establish appropriate formative and summative assessment procedures, thus students must be given ample notice of formal meetings and be given sufficient time and privacy. An effective approach is to initially get the student to provide feedback on their performance; Price (2005) suggested using reflective questions like “What do you understand happened here?” Self-assessment is a powerful tool. When giving feedback the mentor should concentrate on the positive points before the negative and consider him/herself a sounding board for students to voice their concerns. Mentors must be supportive yet honest. Providing and documenting specific examples of underachievement is especially important (Duffy, 2003). This should be followed by an action plan involving learning opportunities and sources of knowledge with a target date. Additionally, feedback to the mentor from other staff, patients and relatives can be invaluable to provide further direction in the mentor’s decision making.

Action planning:

Carr et al. (2012) emphasise the importance of an effective collaborative action plan for improvement. The plan should be evidence-based and formulated against specific achievable terms. Those mentors who find formulating an action plan difficult, need to enlist the support of colleagues (NHS Lothian, n.d.). Action planning is a critical process to the failing student as it is a means of setting them clear objective goals and target dates. The plan must detail areas for development along with specifications regarding the criteria used to confirm the learning outcomes has been achieved (NHS Lothian, n.d.). An example of an action plan can be found in the appendix 1. In this example the student was deemed to be unable to administer medicine correctly. Actions to enable improvement included reading appropriate/relevant documentation and accompanying/observing nurse on a drugs round. Definitive success criteria were specified including mentor’s observations, feeback from others in the team plus reflection and discussions with the student. Review dates for such feedback was weekly.

If the student still does not meet the necessary competencies following completion of the action plan, the mentor should fail the student otherwise they would be “guilty of misleading the learner, potentially jeopardising patient safey and failing in their accountability to the NMC” (Sharples et al, 2007, p44). However, the process must be handled sensitively and the student should be aware of the possibility of failure.

Enhanced supervision and documentation of evidence:

Clinical assessment is notoriously subjective (Chambers, 1998). According to Duffy and Hardcourt (2007) this could lead to mentors cross comparing students rather than basing preformance on set criteria. Thus accurate well-evidenced objective documentation is important to support assessors decisions and to adhere to the NMC (2005) princliples of good record-keeping.

Mentors often provide extra support to those students causing concern (Duffy, 2003) over and above the statutory recommended 40% supervision time. This is especially true for students with disabilities on placement (Skill National Bureau for Students with disabilities, 2005). Thus mentors must make reasonable adjustments for students with dyslexia since they would have problems with spelling, reading and with organising work. The RCN (2010) provides information for mentors so that they can understand how dyslexia affects students. However, patient safety may be of significance when student nurses have certain other disabilities and are underachieving in certain areas. For example, students with dyscaliculia would probably have problems in drug and fluid calculations, which may be insurmountable and inevitably result in failure (Beskine, 2009).

Deal with failing students positively

Students who continue to not meet required standards should be made completely aware of possible consequence. As “gatekeepers” to the professional register, mentors will inevitably need to fail some students. Carr et al. (2012) recommend mentors try to facilitate the procedure of failing in positive terms by encouraging students to use the feedback to succeed in the future and restore their confidence. When students overestimate their performance or lack any real insight into their failings, the acceptance of failure can be hugely trauatic, both for student and for the mentor. Indeed, many mentors seek support to complete documentation for failed students, recognising the significance of its content and potential subsequent repercussions (Duffy 2003). The mentor must be prepared to deal with a number of possible reactions from the student, ranging from anger and denial to possibly relief (Stuart 2003). In uncomfortable and non-productive situations Carr et al (2012) recommend taking time out, reflecting and/or getting advice and support to ensure that discomfort and distress to all is minimised. They also highlight the fact that by mentors seeking support from colleagues the distress associated with failure can be reduced, by the knowledge that their judgement was fair. Students, meanwhile, can obtain additional support to help them through the fail process from their tutors/link lecturer at the university, via counselling and also through student union services.

Supporting and managing the underachieving student

The aforementioned processes are well summarised in the diagram below:

Supporting and managing the underachieving student (taken from www.cppsu.dundee.ac.uk )

Conclusion

In conclusion, mentors often experience difficulty in managing failing students for a number of reasons such as uncertainty regarding expected levels of competence, time constraints, lack of confidence dealing with the issue or lack of support for the mentor. Underperforming students require extra investment, with mentors having to spend additional time and effort supporting them. In turn, mentors should themselves receive support from peers and via mentorship workshops. Certain steps can be taken to facilitate effective management of failing students. Ongong feedback is vital to forewarn habitually underachieving students of their situation. By building a healthy relationship, and adhering to appropriate procedures, the mentor should have made the student aware of their shortfalls early on, but still provided the opportunity to meet the required standard. Students should thus have been fully prepared for the possibility of failure in their final clinical assessment, and those who do fail must be treated sensitively, encouraged to keep positive and given any additional support necessary.