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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
Presented at NET Conference
5th – 6th September 2017, Cambridge
Quality Education for a Healthier Scotland
• 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
Quality Education for a Healthier Scotland
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Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA)
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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.
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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
Quality Education for a Healthier Scotland
‘Failing to Fail’ systematic review
utilising PRISMA 2009 flow diagram
Quality Education for a Healthier Scotland
‘Failing to Fail’ systematic review
utilising PRISMA 2009 flow diagram
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‘Critical Appraisal Skills Programme’
Assessment Tools (CASP)
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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
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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)
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“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)
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Barriers to failing
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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)
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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)
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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)
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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)
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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
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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)
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Quality Education for a Healthier Scotland
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.
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Quality Education for a Healthier Scotland
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
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Quality Education for a Healthier Scotland
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.
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Quality Education for a Healthier Scotland
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
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Quality Education for a Healthier Scotland
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.
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