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Publication: Nursing Education Perspectives
Date published:
Language: English
PMID: 43404
ISSN: 15365026
Journal code: NHCP

AS TODAY'S HEALTH CARE PROFESSIONALS EMBRACE A CULTURE OF SAFETY, SO MUST NURSING EDUCATION PROGRAMS (Institute of Medicine [IOM], 2004a, 2004b; Benner, Sutphen, Leonard & Day, 2010). HOWEVER, before nursing education can embrace a culture of safety, we must clarify the concept of safety (Killam, Montgomery, Luhanga, Adamic, & Carter, 2010). What does patient safety look like in this learning phase of nursing?

First, it is important to examine specifically how we determine which student behaviors demonstrate safe (or unsafe) patient care, which behaviors impact patient safety, and which behaviors result in failure in the clinical setting. Then the question arises: Can research-based guidelines or protocols be developed to assist nurse educators in making decisions about students' clinical behaviors?

The clinical component in nursing education provides multiple opportunities for nursing students to learn to think and function as professionals in the nursing discipline (Cormier, Pickett- Hauber, & Whyte, 2010; Tanicala, 2006). It is the professional responsibility of nurse educators, as gatekeepers, to determine which nursing students are able to think and function professionally in clinical courses and which are not (Hrobsky & Kersbergen, 2002; Killam et al., 2010). In its Core Competencies of Nurse Educators (2005), the National League for Nursing addressed this professional responsibility with Competency III: Assessment and Evaluation Strategies, which directs academic nurse educators to use "extant literature to develop evidencebased assessment and evaluation practices" (p. 18).

This article focuses on Phase I of a multiphase research project to help nurse educators establish an evidence base for determining passing or failing nursing student clinical behaviors in order to ultimately promote a culture of safety. Four research questions guided the literature review and the development of questions used in focus groups for this phase of the study.

1. Which student behaviors determine that a nursing student fails a clinical nursing course?

2. How do nurse faculty determine that nursing student behavior is a threat to patient safety?

3. What processes do faculty use to determine that a nursing student is not competent and thus is failing the clinical course?

4. How do faculty learn to make decisions about competent and noncompetent behaviors?

Literature Review A search of several databases showed that few articles were published on nursing student clinical failures prior to 2000. Of 69 articles identified as potentially relevant to the study based on titles and abstracts, 41 were reviewed in detail. One initial conclusion from the review was that nurse educators have struggled for some time over the issues and inconsistencies of assessing and evaluating students' clinical behaviors (Calman, Watson, Norman, Redfern, & Merrells, 2002; Dolan, 2003; Hrobsky & Kersbergen, 2002; Pavlish, 1987; Pfeil, 2003; Killam et al., 2010). This struggle is particularly difficult when the student's clinical performance is considered borderline (Caldwell & Tenofsky, 1996; Davidhizer & McBride, 1985; Scanlan, Care, & Gessler, 2001; Teeter, 2005).

Further examination of the literature revealed common patterns in assessment and evaluation. One such pattern focused on teaching strategies faculty may employ to avoid student clinical failure (Croke, 2004; McGregor, 2007; McMullan et al., 2003; Killam et al., 2010; Papastrat & Wallace, 2003; Reilly & Oermann, 1985). Others focused on the various approaches to grading nursing students' clinical performance; for example, norm-referenced or criterion-referenced evaluation systems, pass/fail grades or letter grades, and validity and reliability of assessment/evaluation instruments (Andre, 2000; Neary, 2000; Pfeil, 2003). Orchard, as early as 1994, addressed the problems that result from a lack of evaluation standards. The lack of standards continued to be emphasized by Killam et al. in 2010. Scanlan et al. (2001) addressed issues of justice and fairness when dealing with unsafe student behavior in the clinical course. This concern continued throughout the first decade of the 21st century (McGregor, 2007).

Walsh and Seldomridge (2005) acknowledged several challenges to achieving effective clinical assessment and evaluation, for example, standards for nursing practice not necessarily being appropriate measures for the learning phase in nursing education; expectations of student performance in clinical courses not being clearly defined; clinical behaviors as being more global by nature than the more discrete classroom performance behaviors and, thus, more imprecise; structures for evaluating thought processes in the clinical setting not being clearly defined; and final evaluations of student behaviors appearing to be influenced by when student behaviors occurred in the course. Those authors, along with Tanner (2007) and Aronson, Rebeschi, and Killion (2007), agreed that it is time to reexamine how we evaluate the clinical learning experiences of nursing students.

Several textbooks focusing on clinical teaching in nursing were also examined. Reilly and Oermann's seminal text (1985) includes two detailed chapters on clinical evaluation and grading, but no specific guidance for identifying students who do not achieve the clinical course objectives. Later nursing texts specifically addressing clinical teaching included content that ranged from a paragraph or two stating that failure results when students consistently perform below standards (McDonald, 2007; Penn, 2008), to a page or two describing how to manage due process issues of failing students (O'Connor, 2006). Bradshaw and Lowenstein (2006) presented case studies describing challenging situations. Reimer, Thomlison, and Bradshaw (1999) identified common difficulties indicating unsatisfactory progress but offered no specific information on how students should be assessed. The difficulties they identified are:

* Unsafe practice, such as medication errors and lack of client care and attention (e.g., failing to check patient identification)

* Unprofessional, unethical, or unsafe conduct; insufficient knowledge base (e.g., pathophysiology, medications); serious problems in applying information to direct situations

* Inability to recognize difficulties and make changes

* Unprofessional behavior and attitude

* Failure to seek help as needed

As useful as much of this review was for thinking about the issues of assessing students' behaviors in the clinical setting, it did not establish an evidence base for how nurse educators might distinguish between passing and failing student behavior in a clinical course. The research by Killam et al. (2010), which examined views on unsafe clinical behaviors of nursing students, was published after phase I of this study. Killam et al. identified nursing student clinical behaviors similar to the findings addressed later in this article.

Method Although protocol development and testing are the end goal of the five phases of this project, the groundwork began with an attempt to obtain preliminary data to support the preparation and pilot testing of a valid and reliable instrument. Phase II will focus on the development of an instrument to be sent electronically to BSN faculty throughout the United States and Canada and analysis of the responses. Phase III will develop protocols for nursing student evaluations in clinical courses. Phase IV will design a study to test the protocols, and Phase V will implement and evaluate the evidence-based protocols. Findings for all phases will be disseminated as the authors proceed.

An inductive, qualitative approach using focus groups was selected for Phase I based on a six-step, systematic approach recommended by Krueger (1998): a) sequencing questions to maximize useful data; b) electronic and note-taking data collection; c) coding data patterns; d) participant verification of data; e) debriefing the moderators after each focus group; and f) planning for dissemination of the results. Focus group questions developed by the authors were critiqued by experienced nurse educators. The resulting six questions were selected and sequenced for use with the focus groups.

1. What is your definition of failure in a clinical nursing course?

2. What specific student behaviors result in failure in a clinical nursing course?

3. How often do student behaviors need to occur to result in a failing grade?

4. Is there a specific order during a semester that the behaviors need to occur before failure is the result?

5. What is the demarcation between pass and fail in the clinical course?

6. When does pass become fail?

After approval was received from the university human subjects committee, a purposive sample of nurse educators was invited to participate in one of four focus groups. The goal of diversity was achieved; participants were nurse educators from public and private schools of nursing with full-time and part-time appointments, varied clinical specialties, and degrees from doctorates to bachelor's degrees in nursing. Eight of the 11 were from colleges and universities located in metropolitan areas; three participants represented colleges and universities located in suburban areas; there were no participants from colleges or universities located in rural areas. Demographic characteristics of the participants are outlined in the Table.

All four focus groups were conducted using the same procedure. One researcher served as moderator, introduced the topic, and asked questions in the sequence identified above. One researcher took field notes, wrote comments on newsprint, and managed the tape-recorder. Each group had its own unique characteristics, responses, and flow, which resulted in normal variations in data. As Krueger noted, "the inductive properties of qualitative research assume that the researcher makes decisions and refines the quest for knowledge questions are adjusted and fine-tuned en route" (1998, p. 18).

All audiotapes, including debriefing sessions, were transcribed, and transcriptions were reviewed in comparison to the field notes. All data were independently analyzed by each of the researchers. The research assistant entered all transcriptions into NVivo, version 7, a computer-assisted qualitative data analysis program designed to manage extensive amounts of text and facilitate linkages between data and key concepts. The combination of NVivo and multiple paper-based analyses resulted in a checksand- balances process, enhancing the verifiability of the results (Krueger, 1998). Due to time constraints, data analysis results were not confirmed with participants. This potential limitation will be compensated for when patterns and themes are shared and validated by the larger sample in Phase II of this project.

Findings One major theme and five subthemes with clarifiers emerged from the data analysis. The themes were supported by participants' dialogue and were represented in all four focus groups. The selected dialogue examples presented here provide the credibility that Miles and Huberman (1994) identified as necessary for determining the quality of conclusions drawn from qualitative research data.

The major theme was context and patterns. Participants clearly described the need for nurse educators to recognize that time, place, and type of student behavior impact how student behaviors are evaluated regarding passing or failing a clinical course. For example, level of the student and timing in the course, as well as the program and the type of student behavior, influenced faculty evaluations. Participants said:

"You know we have higher expectations clearly at the end of their times and especially in that last semester of that senior year, so that an ... you know, if the same behavior were to occur first week of their junior or sophomore year, you guys have met sophomores, and the last week of their senior year, no, they wouldn't be held equally to those. I would have different expectations, but are those clearly outlined for them in a policy? No. But do I try to be clear in talking to them about those sorts of things? Yes. But there's a fair amount of subjectivity."

"Depends what the behavior is. If it's a critical competency or a critical objective for that course, then yeah, they probably would fail."

The pattern portion of this theme focused on consistency/ repetition of behaviors and/or no evidence of improvement. Participants said:

"And, you know, consistently missing a medication on the MAR that needs to be given during the shift. Missing one, you know, one week and that's all is one thing, but consistently missing a med every week ."

"So, it's not a matter of one or two - a lot of this stuff isn't a matter of they do it one or two times - but this consistency after, you know, it's the end of the semester and they stillif they still cannot do the the task correctly."

The theme of context and patterns was generally supported by Walsh and Seldomridge (2005). They identified the challenges of determining the seriousness of student behaviors based on when those behaviors occurred in a clinical course. Cormier et al. (2010) also acknowledged the importance of context when assessing nursing students' clinical performance.

Safety was a prominent subtheme. Clarifiers included actual errors, type of errors, and near misses. Participants said:

"Now the clinical failure to me is [essential, the thing is] to keep the patient safePatient safety is the number one goal."

"I would say we probably fail people fairly quickly for safe - I mean, fairly quicklycertainly after two incidents, often one, when it's issue of safety or medications."

The fact that safety emerged as a theme was not at all surprising. Several authors from the literature review acknowledged this concern about patient care (Killam et al., 2010; McDonald, 2007; Penn, 2008; Reimer et al., 1999; Walsh & Seldomridge, 2005). Safety is also the key issue in health care reform and for reforming health care education (IOM, 2004a).

The Standards (Course and Profession) subtheme was clarified in four areas: math competency, agency policies, course policies, and objectives. Participants said:

"There's a reason why those objectives are there. And I believe those objectives are there because this is the minimum standard of care to safely take care of pediatric patients. And I think all of them - you have to meet all of them [objectives]."

"Cause, you know, we have a standard to keep, if we want them to be out there taking care of patients, standards should be high."

"Well, we also have maththe math competency, leads to. They - if they cannot pass the math test, they fail in all the clinical courses, they fail and have to move on."

In addressing the issue of standards, Walsh and Seldomridge (2005) warned of applying professional standards to students. They did not comment on curriculum standards established by faculty for courses. McDonald (2007) and Penn (2008) also addressed problems when students consistently perform below standards. Killam et al. (2010) addressed students' difficulty in adhering to standards with their theme of "Compromised Professional Accountability" (p. 7).

The subtheme of Communication emerged in a variety of ways. It was clarified with issues such as quality of written communication, inappropriate interactions with patients, and uncaring behaviors toward patients. Participants said:

"Communication is a tremendous issue, especially with the diversity that you see in the community. And you see it in the hospitals too. But I think a student that is unable to communicate sensitively to different populations, or inappropriately, I think that is unsafe."

"A student was supposed to give insulin, she took the blood sugar and the level was low, so she didn't give the insulin, but she never told the staff nurse that she was holding that insulin at that point."

Communication was not directly addressed in the early literature. Reimer et al. (1999), however, implied issues of communication when they identified "failure to seek help as needed" (p. 171) as a concern of unsatisfactory progress in the clinical course. Kotecki (2002) noted how communication skills had a direct correlation with nursing students' effective clinical behaviors.

The Thinking subtheme was clarified with respect to inability to look at the bigger picture, blend theory and practice, and think critically in the decision-making process. Participants said:

"Critical thinking. Connecting some dots. Once again, that ...synapses, you know, putting everything together."

"I feel that clinical [failure] is the inability of the student to blend theory with technical, hands-on experience. "they can go through motions but how do...they can't put it all together."

"Putting those pieces together, critically putting them together about what type of care are we going to now do for this patient."

The early literature was silent regarding thinking and unsatisfactory clinical behavior. Reimer et al. (1999) implied difficulties with thinking when they named the "inability to recognize difficulties and make changes" (p. 171) as an example of unsatisfactory behavior. Killam et al. (2010), however, found thinking skills to be closely related to effective clinical behaviors. Their three themes, "Compromised Professional Accountability, Incomplete Praxis, and Clinical Disengagement," captured issues of critical thinking (pp. 7-10). Their findings were closely related to two of the thinking subthemes in this study: "not able to think critically in decisionmaking process" and "inability to blend theory and practice."

The subtheme of Ethics encompassed the clarifiers of lying/falsifying documentation or attending the clinical day under the influence of alcohol or drugs, or not seeking assistance when needed.

"They will not be honest and say, 'I don't know how to do this;' they will just go ahead and do it. Or they will say yes [they did a task] when they really didn't. And if they are doing that as a student, in a hospital setting with the clinical instructor there, in a group, it makes you wonder what they're going to when they're out in the community, or on a home visit where they're on their own."

"I had a student who went in to do a physical assessment on a patient and he said that he listened to the lungs and they were clear, however, you could hear the patient rattling from out in the hall. The patient said that he [the student] never put the stethoscope on his chest, and he [the student] had already documented in the chart that the lungs were clear."

In the literature reviewed, Reimer et al. (1999) clearly addressed the issue of unethical behavior as representing unsatisfactory student progress in the clinical setting. Killam et al. (2010) addressed this area when they acknowledged that a common thread through all their characteristics was "Violated Professional Integrity" (p. 11).

Discussion/Synthesis With Research Questions The Clinical Evaluation Map (CEM) (see Figure), was developed to visually capture the themes, subthemes, and clarifiers that emerged from Phase I of this project. It illuminates the concerns expressed by the four focus group participants regarding student behaviors resulting in passing or failing in clinical courses.

The first research question was addressed by the findings. The major theme (Context and Patterns) and five subthemes (Safety, Thinking, Ethics, Communication, and Standards) with their clarifiers demonstrated that participants identified several student behaviors that could result in failure in a clinical nursing course. Two of the clarifiers for safety (near-miss events, actual errors) have clearly been acknowledged by the IOM as key factors needing attention (2004a; 2004b).

The findings began to address the second research question regarding how to determine threats to patient safety. Again, the themes that emerged reflected the participants' professional judgment regarding behaviors that could pose a threat to patient safety. Analysis of data from the focus groups indicated that the subtheme of Standards (both Course and Professional) was one of the factors used to assist faculty in determining student competence.

More research is required to answer the last two research questions regarding the processes faculty use and how faculty learn to make decisions about competent and noncompetent behaviors that threaten patient safety. How faculty learn to make decisions about competent and noncompetent behaviors was not answered with this study. One assumption is that education of the faculty, and experience in both educational and clinical practice settings, are factors in learning to make such decisions.

Limitations of this study include the lack of collecting data from nursing students and administrators in schools of nursing. This additional data would provide broader perspectives of behaviors that result in failure in a clinical course. Also, the sample of participants had limited diversity regarding ethnicity or gender; all participants were white women. This lack of diversity in the sample, however, is consistent with the current composition of the population of nurse educators in baccalaureate nursing programs in the United States.

Conclusion This study (Phase I) was designed to better understand the factors nurse educators consider when distinguishing students' clinical performance behaviors in that borderline area of passing or failing. The findings from this preliminary work allowed the researchers to construct a survey instrument that was pilot tested with 26 expert baccalaureate clinical nurse educators in the Midwest. Findings of the pilot study guided the construction of a 12-item survey. The 12 items consist of clinical scenarios requiring faculty decision-making about student clinical behaviors. The instrument will be distributed electronically to a national random sample of baccalaureate nurse educators in Phase II of this project.

Analysis of that larger dataset will provide quantitative evidence for nurse educators to use in making distinctions about passing or failing behaviors in the clinical setting. The researchers believe this evidence will not only improve nursing education, but will benefit students, health care organizations, and the public. The emerging themes of safety, ethics, communication, thinking, and standards that were identified by participants in Phase I of the study are consistent with key elements addressed in the NLN's Excellence in Nursing Education Model and the eight core elements necessary to achieve and maintain excellence in nursing education (NLN, 2006). They also reflect strong similarities to the findings from Killam et al. (2010) on unsafe nursing student clinical practice.

It is anticipated that the revised instrument will also be tested with nursing students to gain another perspective regarding passing or failing student behaviors in the clinical setting. Phases III through V of this project will result in protocol implementation and evaluation.

With the growing focus in health care on creating a culture of safety, versus the current approach of blame and punishment in both practice and education, the researchers believe that nursing clinical education must engage in a culture shift. That shift moves from individual student error to analyzing errors from an educational perspective (Gregory, Guse, Dick, & Russell, 2007). How students learn to keep patients safe and what role the educational processes play in patient safety need to be determined by nurse educators. Experiential learning in high-risk clinical situations, as seen in clinical education today, requires supportive learning environments to assist both faculty and students in creating a culture of safety in nursing education (Benner, 2001; Benner et al., 2010).


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Author affiliation:

About the Authors Martha L. Tanicala, EdD, RN, is an associate professor, School of Nursing, Eastern Michigan University, Ypsilanti. Barbara K. Scheffer, EdD, RN, is a professor in the EMU School of Nursing and current associate dean (1), Eastern Michigan University, College of Health and Human Services. Melina S. Roberts, MSN, RN, is a member of the nursing faculty at Washtenaw Community College, Ann Arbor, Michigan The authors were recipients of an NLN Nursing Education Research Grant and a grant from the Eta Rho chapter of Sigma Theta Tau; they are grateful to Elizabeth Bucciarelli, EMU health sciences librarian, and Karen Bush, EMU director of faculty development, for their valuable assistance. Contact Dr. Tanicala at

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