Background

The aim of nurse education is to prepare students with the necessary knowledge and skills to become safe and competent nurses. The nursing curriculum in many countries now includes both academic studies and clinical placements within a range of healthcare settings.1-3 Nurse academics are responsible for assessment of theoretical knowledge whereas the assessment of clinical competence is primarily the responsibility of nurses in the clinical environment.4 These nurses, often referred to as nurse mentors or preceptors, have described difficulty evaluating student performance and providing the student and their faculty with accurate and constructive feedback about clinical placement performance.5 Difficulty providing constructive feedback can result in a situation wherein the student's clinical placement report and grade does not reflect actual competence and safety in practice.6 Lack of congruence between clinical reports and actual competence can have significant implications for the mentor, student, patients, faculty and the integrity of the nursing profession.7

Evaluation of student nurse performance on clinical placement has "had a long and tortured history" of inconsistency that is readily apparent in literature.8^(p.408) A study conducted in the United Kingdom by Fitzgerald et al.9 found that seven out of 17 students had formal documentation from mentors that was inconsistent with the ratings achieved at both midway and final clinical placement performance interviews. Some of these students had received positive qualitative feedback but had received scores necessary for the student to be referred to their faculty for a formal performance and course progression review. These findings are similar to a study by Jervis and Tilki5 who found that nurses had passed underperforming students even when they were concerned about the student's safety or clinical competence. An example of this is proffered in a study conducted by Luhanga et al.7 wherein a nurse mentor gave an example of a recent nursing graduate who had completed her pre-registration program without having given an injection, despite documentation from the university describing her competence in performing this skill. A survey conducted in a National Health Service trust in the United Kingdom found that of the nearly 2000 nurse mentors surveyed, 37% had passed students despite concerns about their competence or professionalism in practice.10 A further 17% of mentors reported writing inaccurate assessments because of time constraints in the clinical environment.

The reasons why nurse mentors pass students who demonstrate unsafe practices in clinical placements appear to be multidimensional. A survey conducted by Yonge et al.11 found that student preceptorship increases preceptor workload and stress and can result in inaccurate evaluations. Time constraints may also result in the preceptor giving the student the benefit of the doubt when completing assessment reports.12 Lack of experience with competency assessment frameworks, obscure educational jargon and balancing an often complex student assessment process with direct patient care responsibilities, may also contribute to providing the student with the benefit of the doubt and awarding a pass grade.13 Anxiety related to failing a student on clinical placement is commonly experienced by mentors and can result in inaccurate clinical placement reports.14 A study conducted by Rutkowski15 found that mentor anxiety may occur because of unfamiliarity with the competency assessments or from feelings of guilt about a student's poor performance that results in a reluctance to fail students. Caring is a core professional construct in nursing and mentors have described experiencing anxiety failing a student on clinical placement as they have deemed this a vindictive and uncaring practice.16 Indeed mentors have described failing student nurses as a "horrendous, traumatic and draining" experience.6^(p.38) Even after a student has failed clinical placement, nurse mentors continue to experience anxiety, ruminating that "perhaps [they] could have done more for the student" to prevent the student from failing their clinical placement.6^(p.39)

Registration as a nurse is more than an administrative process; it is a serious matter designed to ensure protection of the public.17 Nurses within the clinical environment are at the frontline of ensuring that only those students who perform safe practices and are competent are admitted to the nursing register at the level prescribed by their nursing education.18 However, a study by Duffy6 found that some mentors did not believe it was their responsibility to fail students, rather this was the domain of the university, clinical educator or link lecturer, and the nurse academic who bridges the gap between the clinical and academic environments. These findings are echoed in a study by Brown et al.19 who indicate that some mentors do not see themselves as gatekeepers of the nursing profession and are therefore not responsible for ensuring that those gaining entry to the profession perform safe practices and are competent in the clinical environment. Mentors who do acknowledge their role as gatekeepers cite lack of academic and faculty support to fail a student as a reason for unsafe students receiving a pass mark.6,15 Furthermore, nurse mentors have lamented that even if they fail a student, a university may overturn their fail grade; thus, all the emotional anguish and personal investment in the failing procedure are not followed through.16 These mentors may continue to pass unsafe students because of previous negative or stressful experiences.20

Educational preparedness and allocation of mentors varies considerably around the world, with some mentors receiving no formal mentorship training whereas others receive a comprehensive preparation program. In the United Kingdom, mentors are not permitted to complete a student nurse's final clinical performance report if they have not been credentialed as a "sign-off mentor".21 Sign-off mentors have participated in a 10-day course on successful mentorship and have been assessed on their evaluation of the clinical performance of three students. Nurses completing their first year of independent practice are not eligible for endorsement as a sign-off mentor. This process aims to guarantee fair and robust student assessments ensuring students are fit and competent for registration and independent practice.22 Suitability for mentorship is also assessed, by peers and managers, to ensure that potential mentors demonstrate appropriate professionalism to shield students from witnessing breaches of professionalism and therefore avoiding normalizing such behavior.23 Credentialed mentors are placed on an approved list by the Nursing and Midwifery Council and must attend annual training. Such a robust mentor program does not currently exist in many countries including Australia, Croatia, Serbia and Spain.24,25 Only England, Ireland and the USA require mentors to possess specific qualifications and be approved for the role of mentoring students. Years of experience also vary considerably between the countries. In Australia, student nurses are frequently buddied with recent graduates who are often "finding their own feet" and are unable to effectively balance a clinical workload and student supervision and assessment.26 This is in contrast to nursing education in the Czech Republic and Italy where nurses must have at least two years of clinical experience and in Poland and Iceland where nurses must possess at least a year of clinical experience.25

Assigning a pass mark to an unsafe student can have serious consequences for the university, student, patients and mentor. The reputation of the nursing program can be diminished and clinical venues may refuse future clinical placements.27 There is increasing demand for clinical placements and some countries are facing a critical placement shortage where any further reduction in placement availability would challenge training capacity.28,29 There may be consequences for the student following registration including public disgrace, loss of registration and employment, and stress and embarrassment associated with an inquiry if their incompetence results in a sentinel patient event.16 Duffy6 describes a situation wherein a new graduate nurse was removed from their graduate year because of unsatisfactory performance after an extensive 11-month supernumerary period that identified serious gaps in clinical skill and knowledge. The nurse was subjected to a lengthy review process and their employment was terminated before they obtained their graduate nurse certificate. Failure to fail unsafe or underperforming students does not go unnoticed by the public, the very people nurses are charged to care for and protect. Illustrations of bad nursing practices and substandard patient care, including nurses leaving patients lying in their own feces for several hours while they "had a cup of tea and a biscuit", are present in the literature and public media.23,30,31 In an extreme case, a serial killer nurse's unsafe behavior had origins during her student clinical placements that were not addressed by mentors or hospital managers.21,32 Mentors who pass unsafe or underperforming students have continued to experience anxiety related to their decision, especially when they find out students have then failed final theoretical examinations because of lack of knowledge and skills.7

For patient safety and public confidence in the nursing profession, nurse mentors cannot award students a pass mark when they demonstrate unsafe practices or underperform in clinical placements. A study by Hunt et al.33 demonstrated that there was a 5:1 ratio of fails in theoretical assessments to fails on clinical placement, which highlights an inconsistency between theoretical and practical assessments. It is therefore imperative that the experience of nurses who supervise unsafe students is understood, so that support measures can be implemented to prevent such nursing students from receiving an inappropriate pass grade from their mentors. The purpose of this systematic review of qualitative evidence is to explore the experience of nurses who have supervised unsafe students on clinical placements. Prior to commencing this systematic review, the JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Database of Systematic Reviews were searched, and no previous systematic reviews on this specific topic were identified.

Inclusion criteria

Types of participants

This review will consider registered nurses who mentor and assess Bachelor of Nursing students on clinical placement. The range of participants includes direct care nurses, clinical educators, clinical support and development nurses, clinical nurse specialists and nurse academics. Participants may or may not have any formal nursing student supervision training but must have been involved with assigning pass or fail grades to unsafe or underperforming students during clinical placement.

The student population includes nursing students enrolled in a Bachelor of Nursing, or equivalent, who are attending a clinical placement as part of their pre-registration education. Students attending a clinical placement are assessed according to several domains including professionalism, ability to attend to psychomotor skills and rationalize nursing care. It is difficult to identify and make decisions related to what constitutes unsafe behavior or inadequate student performance.34 However, Scanlan et al.35 provide a useful definition of unsafe clinical practice that includes any behavior that places the patient or staff at risk of physical or emotional jeopardy. Some examples include failure to accept responsibility for own actions, failure to perform critical assessments, poor or inconsistent clinical decision making, failure to change behavior based on feedback from preceptors and lack of respect for patients.34 Literature that includes narratives of same or similar unsafe performance will be included in this review.

Phenomena of interest

This systematic review will consider studies that explore the experience, thoughts, feelings and opinions of nurses who have supervised unsafe nursing students on clinical placement. The review will not include studies of nurse's academics experience with students who underperform in the theoretical component of their degree.

Context

This qualitative review will consider the experience of nurses who supervise nursing students in public and private hospitals as well as community health settings. The review will consider studies conducted in any country where the study has been reported only in English as it is outside the scope of this review to include studies reported in a language other than English.

Types of studies

This systematic review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Descriptive qualitative studies that describe the experience or the impact of the experience will also be considered.

Search strategy

The search strategy aims to find both published and unpublished studies on the experience of nurses who have supervised unsafe nursing students on clinical placement. A three-step strategy will be utilized for this review. An initial search of the MEDLINE and CINAHL databases will be undertaken followed by analysis of the text words contained in the title and abstract, and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies.

Studies published after 1990 will be considered for inclusion in this review. It has been identified in a preliminary literature search that there is a paucity of evidence on this topic with the earliest discourse occurring after 1990.

The databases to be searched include CINAHL Plus (includes Pre-CINAHL), Ovid MEDLINE, ProQuest Central, PsycINFO and ERIC. These databases have been selected as being the most appropriate based on the topic under review. The search for unpublished studies and gray literature will include Dissertation and Thesis Collections, Networked Digital Library of Thesis and Dissertations, OpenGrey and ProQuest Dissertations and Thesis Global. Inclusion of gray literature helps reduce publication bias by including studies with limited, negative or neutral outcomes that may otherwise not have been published.36

Studies published in English will be considered for inclusion in this systematic review as the reviewers are only capable of comprehending English. Excluding articles based on language may introduce a language bias into the review and eliminate important cultural contexts; however, this is unavoidable as translation of articles is not possible with this review.37

Keywords and search terms

Each database will be searched by the research student, in consultation with an expert librarian, based on the following keywords and search terms. Table 1 contains the keywords and search terms that will be entered into each database and truncated wherever appropriate. The words in each column will be individually entered as a single search first and then be combined using the "OR" Boolean operator into a single group. Each overall group will then be combined using the "AND" function to produce a final list of citations that will be exported into EndNote. The results will be screened for duplicates that will be removed.

Table 1 Keywords and search terms

Assessment of methodological quality

Qualitative articles selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from articles using a data extraction tool to ensure that data extraction is consistent among all reviewers and across all studies. Data will be extracted from articles included in this review using the standardized data extraction tool JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena and population of interest, study methods and authors' conclusions. Data extraction will be completed independently by the student researcher and one of the reviewers. A third reviewer will independently perform data extraction in the event that there are discrepancies in the data extracted by the initial two reviewers. Any disagreements that arise between the reviewers will be resolved through discussion about the data being extracted.

Data synthesis

Qualitative research findings, wherever practicable, will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, by assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-aggregation to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgement

The authors would like to thank Paula Todd (Subject Librarian Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia) for her help with developing the key search terms and search strategy.

Appendix I: Appraisal instruments

JBI-QARI critical appraisal checklist for interpretive and critical research

Appendix II: Data extraction tools

JBI-QARI data extraction form for interpretative and critical research

References