‘Failing to Fail’ in healthcare - Home page | Higher …€¦ · · 2017-10-10‘Failing to Fail’ in healthcare ... • Jervis A, Tilki M. (2011) Why are nurse mentors failing

Quality Education for a Healthier Scotland

‘Failing to Fail’ in healthcare

-the global perspective

Dr Kathleen Duffy

Head of Programme Practice Education (Nursing and Midwifery)

NHS Education for Scotland

[email protected]

Presented at NET Conference

5th – 6th September 2017, Cambridge

mailto:[email protected]


• To present a critical reflection of the findings from a systematic literature review which explored ‘failing to fail’ from an international perspective across healthcare professions (nursing, medicine, dentistry & physiotherapy)

Aim of the presentation



Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA)


Review Question & Aim What are the issues around

‘failing to fail’ from an international

healthcare perspective

since 2006?

The aim of this review is to

re-evaluate the issue of

‘failing to fail’ within

healthcare from a

national (UK) and

international perspective.


Databases Key Words

• Fail*

• Underperforming

• Unsafe

• Borderline

• Unsatisfactory

• Incompetent

• Struggl*

• Remediation

• Unsuccessful

• Marginal

• Student

• Clinical practice

• Nurs*

• Medic*

• Allied health

• Therapist

• Intern*

• Undergraduate

• Assessment

ASSIA

EBSCO CINHAL

OVID EMBASE

OVID HMIC

OVID MEDLINE

EBSCO PSYCINFO

OVID MIDRIS


‘Failing to Fail’ systematic review

utilising PRISMA 2009 flow diagram


‘Failing to Fail’ systematic review

utilising PRISMA 2009 flow diagram


‘Critical Appraisal Skills Programme’

Assessment Tools (CASP)


Author & Date

Method & Participants

Purpose Results Limitations

Recommendations

Black S, Curzio J, Terry L (2013) Failing a student nurse: A new horizon of moral courage. Nursing Ethics. 21, (2) 224-238

Hermeneutic study (using Gadamer’s principles) of mentors (n=19) who had failed a pre-registration nursing student in their final placement. Recruited from 7 different healthcare organisations southeast of England.

To explore, interpret and develop an understanding of mentor’s experiences of failing pre-registration nursing students in their final placement.

Analysis framework based on Crotty’s modes of reading revealed “moral courage in mentorship” 3 key themes 1. Experiencing

moral stress 2. Demonstrating

moral integrity 3. Ensuing moral

residue

Limited geographical location.

1. Mentorship preparation to include discussions on courage 2. Coaching to mentors identified as lacking confidence 3. Early support for new mentors 4. Culture and integrity


Giving the benefit of the doubt

United Kingdom

• 13% (n=12) of 94 mentors answered yes to the statement ‘I would not fail a student that I had doubts about because I would give the benefit of the doubt’

(Mead et al 2011)

• 10% (n=182) of 1790 mentors surveyed indicated they gave the benefit of the doubt because they could not prove their concerns were valid

(Brown et al 2012)

• Failure rates for theory

outstripped practice by a ratio of 5:1

(Hunt et al 2012)

USA • 72.2 % (n=57) of 79

respondents had given

students the benefit of

the doubt when

determining clinical

competence

(Docherty & Dieckmann 2015)

11


“I’ve given this girl an okay

because honestly I know if I fail

her she will fall apart completely…”

(Cleland et al 2008)

“Shielding the student”

(Bush et al 2013)

“Organisational, professional and personal factors impact on confidence when referring poorly performing students”

(Jervis and Tilki 2011)

“And despite the fact that we set her up on a contract, and she just barely met…the points of the contract…, I really felt like I really did not want her to pass…but felt that those who were above me, would have said, well look she didn’t do anything unsafe, so why not pass her, you know”

(DeBrew & Lewallen 2014)

“Maybe its just not in the culture and you need to educate us that it’s okay to do it (fail students)” (Monrouxe et al 2011)

12

Barriers to failing


Emotional and relational aspects

“Preceptors reported a variety of

feelings…relief, fear, anxiety, self doubt, anger and frustration…”

(Luhanga et al 2007)

“Exhausting…Isolated” (Bearman et al 2013)

“I just felt ill all the time and I wasn’t

sleeping at night and I woke up feeling ill and I didn’t want to come

into work, not because of the

student but all because of the

situation…Even just thinking about it now I remember always feeling ill” (Black et al 2013)

“…miserable…I felt

anxious…unsure about

anything…making mental errors…My goal was to simply

tolerate the rest of the

practicum and survive until I

was done” (Scanlon & Chernomas 2016)

“I felt paralysed. Numb. Alone”

(Willigens & Sharf 2015)

13


Failing behaviours

“Key themes to emerge where

consistency (repeatedly making the same mistake),

safety (near misses, inability to

predict outcomes of their

care), communication (quality of written communication,

inappropriate interactions with

patients), thinking (inability to

look at the bigger picture, blending theory and practice)

unethical behaviour (lying, not

seeking assistance)”

(Tanicala et al 2012)

“…residents requiring

remediation often have

deficiencies in multiple

competencies…remediation is

most successful for medical

knowledge (85.8%) and least

successful for professionalism

(41.2%)

(Dupras et al 2012)

“Our population of failing

students demonstrated critical

deficiencies in all eight PCRS

competency domains…”

(Nixon et al 2016)

14


Enablers of failing

• “…dependability, integrity, audacity, tenacity and

professional solidarity which comprised a ‘core of steel”

(Hunt et al 2016a)

• “bravery” (Luhanga et al 2008a)

• “…recognition of the locus of the fail” (Hunt et al 2016b)

• “You need to look at yourself…see whether or not you are not

imposing some sort of philosophy…” (Luhanga et al 2008b)

15


Supportive strategies

“Sharing information” (Frellsen et al 2008)

“Recognize unsuccessful behaviour early in placement”

(Lewallen & DeBrew 2012)

“Strategies to promote confidence” (Poorman & Mastrovich 2014)

“Clear policies and processes” (Killam et al 2010)

“Honest and constructive feedback” (Luhanga et al 2010)

“Academic and emotional support” (Larocque & Luhanga 2013)

7

16


Limitations

• No consistency in data collection in

quantitative studies

• No possibility of meta-analysis

• Varying response rates

• Qualitative studies number ranged

from 6-70 in sample number

17


Still a relevant issue?

“Difficult to determine if progress is being

made in addressing assessors’

reluctance to fail underperforming

students in practice” (Hunt et al 2012, p.354)

“The evidence from this project clearly

supports the work of Duffy (2004) in that

we are failing to fail” (Fitzgerald et al 2014, p.162)

18


References

• Bearman M, Molloy E, Ajjawi R, Keating J. (2013) ‘Is there a plan B?’: clinical

educators supporting underperforming students in practice settings.

Teaching in Higher Education, 18, 5 ,531-544.

• Black S, Curzio J, Terry L (2013) Failing a student nurse: A new horizon of moral

courage. Nursing Ethics. 21, 2, 224-238.

• Brown L, Douglas V, Garrity J, Shepherd C K. (2012) What influences mentors to pass

or fail students? Nursing Management 19, 5, 16-21.

• Bush HM, Schreiber RS, Oliver SJ. (2013) Failing to Fail: clinicians’ experience of

assessing underperforming dental students. European Journal of Dental Education, 17,

198-207.

• Cleland J, Knight LV, Rees C, Tracey S, Bond CM. (2008) Is it me or is it them? Factors

that influence the passing of underperforming students. Medical Education, 42, 800-

809.

• DeBrew J, Lewallen K, Porter L. (2014) To pass or to fail? Understanding the factors

considered by faculty in the clinical evaluation of nursing students, Nurse Education

Today, 34, 4, 631-6.

• Docherty A & Dieckmann N (2015) Is there evidence of failing to fail in our schools of

nursing? Nursing Education Perspectives. 36, 4, 226-231.

19


References

• Duffy, K. (2003) Failing students: a qualitative study of factors that influence the

decisions regarding assessment of students’ competence in practice. Glasgow:

Glasgow Caledonian University.

• Duffy, K. (2006) Weighing the Balance: A grounded theory study of the factors that influence the

decisions regarding the assessment of students’ competence in practice. PhD thesis, Glasgow:

Glasgow Caledonian University. Access via

http://rcn.sirsidynix.net.uk/uhtbin/cgisirsi/?ps=VerQF9sVDq/LONDON/185360011/2/1000

• Duffy K. (2013) Deciding to Fail: nurse mentors’ experiences of managing a

failed practice assessment. Journal of Practice Teaching and Learning. 11 (3), 36-58

• Dupras DM, Edson RS, Halvorsen MS, Hopkins RH, McDonald FS. (2012) “Problem

Residents”: Prevalence, Problems and Remediation in the Era of Core Competencies. The

Association of Professors of Medicine, 125, 4, 421-425.

• Fitzgerald M, Gibson F, Gunn K. (2010) Contemporary issues relating to assessment of pre-

registration nursing students in practice. Nurse Education in Practice. 10, 158-163.

• Frellsen SL, Baker EA, Papp KK, Durning SJ. (2008) Medical school policies regarding

struggling students during the internal medicine clerkships: results of a national survey.

Academic Medicine, 83, 9, 876-881.

• Hunt L A, McGee P, Gutteridge R, Hughes M. (2012) Assessment of student nurses in practice:

A comparison of theoretical and practical assessment results in England. Nurse Education

Today. 32, 351-355

20

http://rcn.sirsidynix.net.uk/uhtbin/cgisirsi/?ps=VerQF9sVDq/LONDON/185360011/2/1000


References

• Hunt L A, McGee P, Gutteridge R, Hughes M. (2016a) Failing securely: The

processes and support which underpin English nurse mentors’ assessment

decisions regarding under-performing students. Nurse Education Today, 39, 79-86

• Hunt L A, McGee P, Gutteridge R, Hughes M. (2016b) Manipulating mentors’ assessment

decisions: Do underperforming student nurses use coercive strategies to influence mentors’

practical assessment decisions? Nurse Education in Practice. 20, 154-162

• Jervis A, Tilki M. (2011) Why are nurse mentors failing to fail student nurses who do not

meet clinical performance standards? British Journal of Nursing. 20, 9, 582-7

• Killam LA, Montgomery P, Luhanga FL, Adamic P, Carter (2010) Views on Unsafe Nursing

Students in Clinical Learning. 7, 1, Article 36, DOI:10.2202/1548-923X.2026

• Larocque S, Luhanga FL. (2013) Exploring the issue of failing to fail in a

nursing program. International Journal of Nursing Education Scholarship. 10, 1, 1-8

• Lewallen LP, DeBrew JK (2012) Successful and Unsuccessful nursing

students. Journal of Nursing Education. 51, 7, 389-395

• Luhanga F, Myrick F, Yonge O. (2010) The preceptorship experience: an

examination of ethical and accountability issues. Journal of Professional Nursing.

26, 5, 264-271

• Luhanga F, Yonge O, Myrick F. (2007) Precepting the unsafe student: the role of faculty.

Nurse Education Today. 28, 227-231.

21


References

• Luhanga F, Yonge O, Myrick F. (2008a) “Failure to assign failing grades”: Issues

with grading the unsafe student. International Journal of Nursing Education Scholarship,

5, 1, 1-14

• Luhanga F, Yonge O, Myrick F. (2008b) Strategies for precepting the unsafe student. Journal

for Nurses in Staff Development. 24, 5, 214-219.

• Mead D, Hopkins A, Wilson C. (2011) Views of nurse mentors about their role, Nursing

Management. 18, 6, 18-23

• Monrouxe LV, Rees, CE, Lewis NJ, Cleland J. (2011) Medical educators’ social acts of

explaining passing underperformance in students: a qualitative study. Advances in Health

Sciences Education. 16, 239-252.

• Nixon LJ, Gladding SP, Duffy BL. (2016) Describing failure in a clinical clerkship: implications

for identification, assessment and remediation for struggling learners. Journal of General

Internal Medicine. 31, 10, 172-179.

• Poorman SG, Mastorovich ML. (2014) Teacher stories of blame when assigning a failing

grade. International Journal of Nursing Education Scholarship. 11, 1, 1-10

• Scanlan JM, Chernomas WM (2016) Failing clinical practice & the unsafe student: A new

perspective. International Journal of Nursing Education Scholarship. 13, 1, 109-116

22


References

• Tanicala ML, Scheffer BK, Roberts MS. (2011) Defining pass/fail nursing student clinical

behaviours phase 1: moving towards a culture of safety. Nursing Education Perspectives.

32, 3, 155-161.

• Willgens AM, Sharf R. (2015) Failure in clinical education : using mindfulness as a

conceptual framework to explore the lived experiences of 8 physical therapists. Journal of

Physical Therapy Education. 29, 1, 70-80.

23

Documents

‘Failing to Fail’ in healthcare - Home page | Higher …€¦ · · 2017-10-10‘Failing to Fail’ in healthcare ... • Jervis A, Tilki M. (2011) Why are nurse mentors failing