Failure to fail: facing the consequences of inaction

Over the past 15 years, a series of research reports have highlighted the reluctance to fail students whose performance in clinical practice is unsatisfactory (Lankshear, 1990; Watson and Harris, 1999; Norman et al., 2002; Duffy, 2003; Scholes et al., 2004). The most recent studies have coincided with a spate of bad publicity about standards of nursing care highlighted by Magnet (2003), Sergent (2003) and the recent Dispatches programme, ‘Undercover Angels’ (Channel 4, 31·January 2005). This serves as a timely reminder that the failure to fail students, whose performance is unsatisfactory, does not go unnoticed by the public. To redress this, we need to reassure the public that we set the highest standards for ourselves in order to maintain their trust and confidence (Asbridge, 2003). And to do this, we have to grasp the nettle of the complex and sometimes painful issues that surround the failure to fail. This problem is not unique to pre-registration nursing. We assess colleagues on clinical courses undertaking D grade competency programmes, assess Health Care Assistants undertaking NVQ programmes, adaptation students and nurses returning to practice. Indeed, assessing colleagues may be more difficult than failing pre-registration students (Scholes and Endacott, 2002), but never the less the challenge needs to be confronted to assure public safety. To fail someone may seem vindictive and harsh, contrary to the educational goals of facilitation and development and the professional core construct of caring (Duke, 1996). However, nurses are not alone in finding it difficult to fail students, studies have illuminated this as problematic for physiotherapists (Cross and Hicks, 1997) and occupational therapists (Iliott, 1996) as well. Why is this so problematic? To fail a student is procedurally and emotionally difficult (Duffy, 2003). It is time consuming, with the assessor having to build a case for referral or failure, which they might feel puts them through a procedure which ultimately judges the assessor rather than the student (Duffy, 2003). Failing a student is therefore seen as an ‘act of courage’ by a mentor, one that is not taken lightly, and only in situations where the student's performance is seen to be distinctively faulty. Confidence to fail a student is therefore critical. Duffy (2003) highlighted that many mentorship programmes fail to address how to fail a student. The mentor needs to fully understand the procedure, but even where this is clearly stated in assessment documentation, this neither fully explains the process nor does it prepare the mentor for the emotional experience of failing someone (Hrobsky and Kersbergen, 2002). But sometimes, it is kinder to fail and it is certainly important for patient safety (Duffy, 2003). The essential feature is to ensure that everything was done to retrieve the fail or support the individual to redress whatever shortfall they might demonstrate, and this is where support from management and academic staff is critical (Hrobsky and Kersbergen, 2002). One of the key problems is to make known failing performance or warning signs of weak performance to the students and academic staff as soon as possible. The opportunity to work closely with a student to build a cumulative critical evaluation of their performance is frequently a luxury. Shift patterns and study days can fragment contact (Scholes et al., 2004). Students are often given time to settle before a judgement is made about their performance (Lankshear, 1990), and in critical care, the novelty of the environment means that the settling in period is frequently extended. But too much delay can mean that time for remedial action and procedure has run out. Therefore, students pass: given ‘the benefit of the doubt’ (Duffy, 2003) and often leaving the mentor with significant self doubt about their own judgements (Hrobsky and Kersbergen, 2002). So even when significant doubt has been raised why are students ‘getting through’? First, it might well be that the practice assessment document sets out clinical competencies, that are so packaged in educational jargon it makes it difficult for the assessor to link aspects of failing performance with the learning outcomes (Duffy, 2003, Scholes et al., 2004). Importantly, when assessors find the assessment tool vague, they might respond by writing obscure comments which do not help to specify the weaknesses in students' performance. Therefore, students are not provided with clear, explicit goals to redress the shortfall and can continue to migrate through their clinical placements with only a vague idea that there is a problem. This is particularly challenging when an assessor's primary concern is the students’ lack of insight into their own performance. Secondly, it might be that mentors have a concern to fail a student, because their assessment is made too early in the programme, and they hope their practice will improve with time, or conversely, they feel that it is too late to fail them so close to registration (Duffy, 2003). It may be that mentors consider the placement too specialist to match the student's specific skills, or because there has been a personality mismatch and the student has not blossomed under their supervision (Rittman and Osburn, 1995). All of these factors lend themselves to the mentor giving the student the benefit of the doubt, especially if the student's performance is ‘borderline’ (Duffy, 2003). However, the final and most striking inhibitor expressed by mentors is the concern that a fail or refer would be over ruled by the Higher Education Institute (HEI) at appeal. Thus all the emotional anguish, investment in the procedure and personal risk associated with taking this stand, is not followed through. The differing philosophical culture towards failure that might exists between the HEI and clinical setting serves to exacerbate the problem. For example, the HEI might be seen to be facilitating a student to retrieve a fail when a clinician has concluded a student should not be in practice. This mismatch in expectation, unless carefully managed, can lead to mentors feeling betrayed by their academic colleagues and withdraw from student supervision altogether: a disastrous outcome for all concerned. Academic staffs are concerned about the disproportionate number of students failing academic assignments relative to their practice assessment. Furthermore, students give priority to their academic work because they recognize there is a far greater risk of failing than their practice assessments (Scholes et al., 2004). In a practice-based discipline, this anomaly is unsustainable. For patient safety and public confidence it is unacceptable. So how can we identify students whose practice is weak or failing and take action sooner? First, it is about noticing poor performance, recognizing and finding the words to articulate sometimes subtle triggers that alert us to be extra vigilant or cautiously watchful over a student (Rittman and Osburn, 1995). Often these signs seem too vague to make a clear case for feedback to the student, especially in the early stages of a placement. Some examples have been provided to help assessors think about how they might frame such feedback. For example, early signs might be in the student's punctuality, high levels of anxiety, or having poor comportment with the patients (Rittman and Osburn, 1995). They may fail to ask questions, seem unenthusiastic and avoid working closely with their mentor (Hrobsky and Kersbergen, 2002). Their care may seem incomplete, their bed space untidy, patients are not left comfortable, or even avoid direct patient contact. They fail to write clearly in the notes or convey important information (Rittman and Osburn, 1995). Their practice assessment documentation may be incomplete, they may dismiss certain learning opportunities as ‘done that before don’t want to repeat it', the evidence to support their learning is scant or poorly assembled (Hrobsky and Kersbergen, 2002). In critical care, students work under the direct supervision of their mentor and this can illuminate weaker performance sooner. Furthermore, the visual displays of patient data serves to prompt assessors to directly challenge students with questions linking their theoretical knowledge and clinical decision making. But this might be a new phenomenon to the students who seek to defend themselves from such direct questioning (Scholes et al., 2004). However, many students who participated in the evaluation of the Fitness for Practice curriculum, valued their placement in critical care, because it helped them to identify shortfalls in their applied physiology and pharmacology knowledge (Scholes et al., 2004). In this example, we can see how a deficit in knowledge stimulated learning, but a student who did not do something about this would give rise for serious concern. How do we notice weaker performance in our colleagues? In ITU, we may notice nurses who turn their back to the patient, fail to respond to the alarms in a timely fashion, medications are late, care is omitted for no good reason, or they may seem unable to respond to questioning at handover or on the ward round. They may invest excessive time in distractions away from the patient's bedside, or pursue learning opportunities that are highly technical or specialist which defends them from being questioned about their own practice. They may lack caution and are not careful (Rittman and Osburn, 1995), not alert to the possibility of error and when challenged, defend themselves with a range of excuses rather than embrace a culture of high challenge and high support (Scholes and Endacott, 2002). Once these factors have been noticed, it is the responsibility of the mentor to make their concerns clear to the student or colleague and to try to create opportunities for success and retrieval of the failing performance. That may be as simple as going back to tasks that you feel a more junior nurse should achieve and see if they can start to grow from there (Rittman and Osburn, 1995). However, if despite all these remedial interventions performance remains poor, then clear and decisive action needs to be taken that is fully supported by colleagues, managers and academic staff. This may be a painful step to take, but what are the consequences of inaction? Perhaps we should be reminded of the old test: would we want this nurse on our team, could we rely on them to support us when the work load is excessive, or are they a liability in times of crisis? Secondly, would we want to be cared for by this nurse? If not, why not and if it isn't good enough for you, why should that be good enough for the patients? Let us have some pride in our profession and consider, it may be difficult to fail a student, but failure to fail damages the standards of care and ultimately the reputation of the profession and the public's confidence in us. Furthermore, consider how your decision to give the ‘benefit of the doubt’ feels when you consider every mentor that student has encountered has taken that option. What happens when this student ultimately registers? Was your decision made because you were trying to be kind or generous? Is that an act of kindness when you consider the public disgrace that an individual might face if dismissed from the Trust on grounds of incompetence or worse, the loss of their registration and livelihood in this is referred onto the NMC and the complaint is upheld? Practice educators have done a great deal to address issues in supporting mentors undertaking assessment as well as assess ‘difficult’ students' themselves (Scholes et al., 2004). However, we can not absolve ourselves of the responsibility for assessment as this is a key component of professional self-regulation (Asbridge, 2003). We should be more courageous and decisive and participate in failing student's whose performance in practice is unsatisfactory. We owe this to the student, our colleagues, but most importantly, the patients. Julie Scholes and John Albarran Editors