British Journal Of Midwifery - Supporting failing students: How collaboration is key

Abstract

Nursing and Midwifery Council (NMC) standards state that the balance between clinical practice and theory in pre-registration midwifery programmes must be no less than 50% practice and no less than 40% theory, with students being supported by ‘midwife teachers’ and ‘midwife mentors’ (NMC, 2009:18). Midwife teachers are expected to be involved in learning and assessment in both academic and practice learning environments by engaging in activities such as link tutoring; facilitating mentor development and updates; having a part-time clinical role or being involved with practice development, midwives' continuing professional development (CPD) or practice-based research activities.

Clinical practice is supervised and graded by sign-off mentors, ‘gatekeepers to the profession’ who confirm that students are clinically competent, commensurate with their level of training, and are fit for entry to the midwives' part of the register at the end of their 3-year programme of study.

This article will consider the importance of a collaborative approach between universities and clinical placement providers, particularly in relation to supporting failing students as, while ‘there has to be the recognition that some students need to fail’, sometimes students just require more focused support and planning to achieve the required skills, competencies and confidence in practice.

At the University of Northampton, the role of the midwife teacher/academic in clinical practice assessment is to advise and support mentors, with the ultimate decision on whether the student is competent in practice resting with the sign-off mentors, the ‘gatekeepers to the profession’ (Peate, 2018:355) (Box 1). Watson and Harris (1999:51) found that many mentors did not understand or realise that grading was their responsibility, with one participant stating:

‘I don't think we can actually fail assessments. We can only put down what we feel, and if we're not happy, I think it's up to the college then to decide if they've actually failed their placement or not.’

Box 1.

Criteria for a sign-off mentor

Sign-off mentors who are on the same part of the register and in the same field of practice may confirm that students have met the relevant standards of proficiency for the particular programme leading to registration or a qualification that is recordable on the NMC register.

Placement providers must ensure that a nurse or midwife designated to sign-off proficiency for a particular student at the end of a programme is:

Identified on the local register as a sign-off mentor or a practice teacher

Registered on the same part of the register

Working in the same field of practice as that in which the student intends to qualify

Additionally, to be a sign-off mentor they must have:

Clinical currency and capability in the field in which the student is being assessed

A working knowledge of current programme requirements, practice assessment strategies and relevant changes in education and practice for the student they are assessing

An understanding of the NMC registration requirements and the contribution they make to the achievement of these requirements

An in-depth understanding of their accountability to the NMC for the decision they must make to pass or fail a student when assessing proficiency requirements at the end of a programme

Been supervised on at least three occasions for signing off proficiency by an existing sign-off mentor

A working knowledge of current programme requirements, practice assessment strategies and relevant changes in education and practice for the student they are assessing

The achievement of these requirements

An understanding of the NMC registration requirements and the contribution they make to meeting these requirements

Source: Nursing and Midwifery Council (NMC) (2008:27)

It is therefore not surprising that the study also identified that mentors were sometimes ‘failing to fail’, with 125 mentors out of 272 (46%) agreeing with the suggestion that students were sometimes allowed to pass practice placement assessments when in fact their performance was unsatisfactory.

In 2003, Duffy conducted a qualitative study to explore why some student nurses were passed in practice without having demonstrated ‘sufficient competence’. Her findings (Box 2) were supported in a more recent literature review that identified the following key themes (Elliott, 2016:251):

Difficulties in assessing a student's attitude

The subjective nature of assessment

‘Benefit of the doubt’ culture

Perceived lack of support when failing a student

Confidence to make a decision to fail a student.

Box 2.

The academic's perspective

Mentors' verbal concerns were not always acted upon by academics and so they did not feel supported in their role (‘why bother?’)

Some mentors were reluctant to document their concerns and so gave students ‘the benefit of the doubt’. Consequently some students were in their final year before being identified as failing, putting additional emotional pressures on mentors perceived as ‘ending students' careers’ at the final hurdle

Some mentors felt the practice assessment documents were ambiguous and could contribute to the issue of ‘failing to fail’

If due process in terms of timely identification of issues and appropriate action planning and documentation was not followed, this could negatively impact on academics feeling able to support mentors to fail students

Failing students is time consuming and mentors did not feel supported by managers, with staff shortages, lack of time and increasingly complex caseloads contributing to the perception of ‘not having time’ to fail students

Mentor updates did not address the issue of ‘failing to fail’, therefore mentors did not feel adequately prepared for this difficult role, which was particularly anxiety-provoking for underconfident mentors

Mentors' decisions not to fail students were sometimes influenced by students' personal situations, ie they felt sorry for them

Failure to fail on attitude grounds was an area of frustration for academics as they felt that these attributes were not given equal weighting with clinical competencies

With the move into higher education, clinical grades could sometimes excessively inflate final classifications and there was a tension between maintaining professional standards and student retention

Source: Duffy (2003)

Duffy's recommendations, which are transferable to midwifery education, included the need for more regular mentor updates on how to deal with failing students and the formal processes to follow, as well as the importance of early identification of failing students and information on the support mechanisms in place for mentors, both from academics and managers. The introduction of tripartite meetings in practice as part of the clinical assessment process was identified as being key to maintaining good channels of communication between approved educational institutions and clinical placement providers, thereby ensuring that mentors and students are well supported. Elliott (2016) again concurs, identifying that early identification and effective management of failing students based on an open, honest and professional student/mentor relationship was key to a successful outcome.

The academic's perspective

Students have three discrete placement areas per year: community, labour ward and the antenatal/postnatal wards, with sign-off mentors in each area grading students' practice. There is a formal mid-placement review/tripartite meeting for each placement with either the personal academic tutor (PAT) or senior lecturer in practice (SLiP). Informal support is offered throughout, with mentors and students being encouraged to contact either the PAT or SLiP if they have concerns. The mid-placement review provides an opportunity for the student, mentor and academic to discuss the student's progress, and identify whether the student is on track to achieve all required clinical skills and competencies by the end of the placement. If the mentor and/or student voice concerns, a learning development plan is put in place, with a focus on areas requiring targeted support. If a student does not meet the requirements of their learning development plan and practiced assessment document, they will be referred, and a formal action plan will be designed for their second opportunity placement.

The University of Northampton's clinical practice support model follows Duffy's (2003) recommendations of comprehensive support for mentors during mentor updates and throughout clinical placements. Mid-placement reviews and an ‘open door’ policy for dialogue between academics, mentors and students promote an environment of mutual respect, open communication and collaboration.

The clinician's perspective

Working with students who are underperforming in practice can be extremely stressful, particularly as working closely together over an extended period means a relationship will have developed. There is an investment in them succeeding and the mentor can sometimes feel that the success or failure of a student is a reflection on their ability to teach. However, failing to fail underperforming students leads to risk: both to the lives of women and their babies, and to colleagues, who expect them to practise safely and competently. Not failing a student also means that the student does not have the opportunity to be the best that they can be.

The benefits of a collaborative approach

A collaborative approach between the PAT/SLiP and sign-off mentor to supporting students in practice means that the perceived ‘theory-practice’ gap is closed; mentors feel more supported (particularly when working with an underperforming student); there is open dialogue between student, university and placement provider; and women and their families will receive care from well trained, competent and confident midwives.

The Code (NMC, 2015) requires midwives to have a professional ‘duty of candour’, meaning that they are duty bound to raise any concerns they have in practice that may put the women and babies in their care at risk. They also have an obligation to be a ‘model of integrity and leadership’ (NMC, 2015:15) and in the context of mentoring, this includes carrying out the challenging task of failing underperforming students. For students who subsequently pass a second opportunity placement, repeating can be a positive experience as it allows them to develop their skills and confidence; consolidate what they have learned and develop a richer, more in-depth knowledge base. It also requires them to develop their resilience, which is a key attribute of confident and competent midwives in today's maternity services (Hunter and Warren, 2013). For students who subsequently fail a second opportunity placement, the mentor should look to The Code for reassurance that they have acted appropriately to preserve the safety of the public and the reputation of their profession. They should also remember that, despite their best efforts, ‘there has to be the recognition that some students need to fail’ (Duffy, 2003:83).

Top tips for supporting students in practice

Top tips for supporting all students in practice

At the start of any placement always refer to the student's Ongoing Record of Achievement (ORA) as this is effectively a ‘handover’ sheet from previous mentors, identifying strengths and areas for development

Give regular constructive feedback (ideally every shift) so there are no ‘surprises’ at the end of the placement

Mid-placement reviews/tripartites are a forum for an honest and open discussion between mentor, student and personal academic tutor (PAT)/senior lecturer in practice (SLiP)

Additional tips for supporting underperforming students in practice

Inform the student's PAT and SLiP as soon as you have any concerns about a student's practice so that a meeting can be arranged to create a learning plan for the rest of the placement

State clearly, in writing, what you expect from the student and how the student can achieve this

There should be regular contact between the PAT/SLiP, the sign-off mentor and the student for the rest of the placement to monitor progress

If you refer a student, clearly document the learning objectives/competencies/clinical skills that have not been achieved, and give examples so that the student and subsequent mentors are clear on targets for the second opportunity placement

If a student is referred, then the same approach to support should be adopted for the second opportunity placement