The Nursing and Midwifery Council (NMC) recently made changes to the way students are supported and assessed in practical placements, publishing new standards to this effect (NMC, 2018a). During a stakeholder event held in Birmingham last year, the NMC made clear that ‘the business of these new NMC Standards is to ensure that no one gets onto the register who shouldn't be there’. This reflects ongoing concerns that UK practical assessment processes have not always managed underperforming students effectively (Duffy 2003; Gainsbury 2010; Hughes et al, 2016; Burden et al, 2017) and that some incompetent students have gone on to enter the NMC register (Fordham-Barnes, 2018). One of the recent changes the NMC made regarding practice learning and assessment is the development of two distinct new roles: the practice supervisor and the practice assessor, each taking up different elements of the previous mentor role.
For some years there have been calls to separate the supervision and assessment roles undertaken by mentors (Bray and Nettleton, 2007). It has been noted that the nursing professions' concentration on mentors' tendency to ‘fail to fail’ weak students (Duffy, 2003) has diverted attention from the supportive and supervisory roles necessary to enable students to flourish (Nettleton and Bray, 2008). Various innovative models of supervision and coaching have been developed to address this (Lobo et al, 2014). However, since the NMC's announcement to separate the practice supervisor and assessor roles, concerns have been raised by, among others, the Royal College of Nursing (2018) and Mental Health Nurse Academics UK (Merrifield, 2017). The concerns are that the quality of practical assessment will be further compromised because criteria for selection and preparation of practice assessors will not be centrally, professionally regulated.
There has also been criticism that assessment may tend towards one-off events conducted by practice assessors who are less familiar with students, thus affecting the ongoing continuity of the process (Leigh and Roberts, 2018). There has, however, been some agreement that not all nurses should assess students and that forcing staff to become mentors has in the past been counterproductive (Middleton, 2012). This article focuses on the new practice assessor role and identifies the characteristics of nurses who are most likely to assess students objectively and robustly. Designating staff with such qualities to the practice assessor role will increase the likelihood that only those students who should enter the register do so.
Aim
This article reports on specific findings from a wider, previously published, research study which explored the factors that enabled some mentors to fail underperforming students in practical assessments (Hunt, 2014; Hunt et al, 2016a). It focuses on identifying the personal attributes and qualities of those mentors who would fail underperforming students and which mentors themselves have often called the ‘core of steel’.
Method
A qualitative approach, based on grounded theory methods (Corbin and Strauss, 2015), was used in this national study. Thirty-one nurses from all fields of practice, across public and private sector organisations, were interviewed about their experiences of failing student nurses in practice-based assessments. These nurses were mentor/assessors (MA), practice educators (PE) and link lecturers (LL). The study was granted ethical approval by both the relevant university and the NHS National Research Ethics Service, and seven further governance approvals were obtained from various care organisations. Safeguards were put in place to ensure informed consent was obtained from all participants, to manage both their anonymity and anyone they might mention during interview, and to ensure supportive resources were available should any participant need these. Further details of the research design are available from the following sources: Hunt (2014) and Hunt et al (2016a).
Since grounded theory takes a cyclical approach, particular elements of consequence, which that arise as the study progresses, can be pursued with subsequent participants (Holloway and Galvin, 2016). In this study it became apparent, after the first three interviews had been analysed, that there was consensus among participants that particular personal traits were evident in mentors who would fail students; one coined the term ‘the core of steel’ to describe these (MA04). The interview schedule was therefore amended to explore this with subsequent participants, with the aim of identifying what constituted this core of steel. The findings reported here demonstrate the key personal qualities and attributes the study revealed.
Findings and discussion
Participants in the study reported a number of conflicting feelings when they encountered a failing student. They often felt that, as the assessor, they were in a situation where they could not win, complicated by the pressure put on them by some universities, which they thought prioritised students' satisfaction over patient safety (Hunt et al, 2016a) and the coercive strategies that underperforming students could employ (Hunt et al, 2016b). When making assessment decisions about such students they used considerable personal reserves to manage their conflicting emotions and emphasised that they had to brace themselves to ‘grasp that nettle’ (PE02) in order to fail a student who had not reached the required standard of practice. This was regarded as an act that had potential to be painful but, if done with assurance, would be bearable. Early on in the study, one participant observed that ‘you have to have a core of steel’ (MA04) to do this.
As the study progressed, this was a view echoed by many participants and led to the exploration of what characterised this core of steel. Five key features emerged typifying assessors who were prepared to robustly assess and fail students; these were: solidarity, tenacity, audacity, integrity and dependability (Figure 1). Each of these will now be explored in more depth.
Solidarity
Participants who demonstrated a core of steel emphasised their role in maintaining public trust and ensuring that patients received high-quality care. They were committed to their fiduciary relationship with the public, recognising their professional duty to keep safe patients who were relying on them (Milton, 2018). This extended to keeping patients safe from the poor practice of students and they recognised that they had a moral obligation to fail such students in order to protect the public. A strong sense of loyalty to the standards of their profession was also evident, and most described their determination to uphold these professional values. This included a sense of interconnectedness with colleagues; emphasis was placed on the role of gatekeeper to the profession and ensuring the entry criteria remained well monitored to protect the integrity of everyone already within the profession. Participants were committed to preserving the interests of both patient and professional groups, and felt a strong and cohesive responsibility towards them. This was typified by the following nurse who remembered telling a failing student:
‘I'm failing you because I don't think you're up to joining my profession. It's not because I don't like you and it's not because I don't have time to spend with you … There's only that reason and we've tried and we can't put it right.’
Several studies support the view that mentors who assess effectively have a strong sense of professional unity (Rooke, 2014) and moral duty (Black et al, 2014). Basnett and Sheffield (2010) have suggested that, in social work, this reduces stress by offering an ‘emotionally focused response’, which gives a wider perspective and reduces emphasis on the individual student. It is possible that this is the same for nurses when they are assessing students.
Tenacity
Participants with a core of steel persevered even when they knew that failing the student would be a difficult process. Most nurses reported encountering a number of challenges and obstacles when they identified an underperforming student and noted how determined and persistent they had needed to be when they encountered barriers; one nurse termed this ‘fighting to fail’ (MA01). This was particularly apparent when others put pressure on them to change their mind, as noted by one participant:
‘They said, “Will you change your mind, Sister?”
And I said, “No, I will not! I will not change my mind”.’
Nurses in DeBrew et al's (2014) study also reported having to resist attempts to persuade them to pass failing students. Participants in both studies likened the challenges they faced to those experienced by other whistleblowers (West et al, 2018) who needed to reassert their concerns repeatedly before they were taken seriously. Francis (2013) noted that similarly tenacious qualities were essential in the healthcare workers who had drawn attention to concerns at the Mid Staffordshire NHS Trust. Participants who had failed students were not prepared to tolerate more senior colleagues and university partners trying to ‘sweep concerns under the carpet’ (MA03), but had often had to be adamant in their assertions to achieve this.
Audacity
Participants also reported having a set of qualities that together signify audaciousness. Black et al (2014) previously noted that mentors who fail students need to have moral courage, and participants in this study agreed, further pointing out that this often meant going where no one in their work area had ventured before, because students were so rarely failed. Those who had failed students and were prepared to challenge convention were unlikely to give in to intimidation and so were ready to rechallenge later when further evidence came to light. Above all, they were willing to speak up against those in positions of power, as this nurse highlighted when recollecting the challenges of speaking up to what she perceived as the might of the university:
‘The official line [from the university] is that we all should be working collaboratively to fail students. But then, when you're actually faced with the reality, the response that you get, unless you are particularly confident, is don't fail people.’
Participants often expressed a willingness to be bold and courageous, faced opposition assertively and were undaunted when threatened, even though, as West et al (2018) noted, speaking up in the workplace can often seem futile or dangerous. Highlighting this, nurses often reported that students had counter-challenged them, accusing them of bullying, discrimination and other inappropriate practices that they had then been investigated for. Universities also overturned their decisions based on technicalities, rather than because the student was competent, using what mentors felt were undermining strategies. Nevertheless, they stood by their decision, even though the only way some of them had been able to vindicate their judgement was when the student was subsequently struck off after registering, which Fordham-Barnes (2018) points out is not an uncommon occurrence. This further supports Black et al's (2014) view that ‘it takes courage to stand up to the norms of a particular organisation or culture’.
Integrity
Participants involved in failing students presented themselves as being consistent in their decision-making and having strong moral principles. Their expectations of students did not fluctuate, they remained focused on what was right, worked according to a clear set of principles, and were undaunted by the personal cost.
‘You've got to have strong values to fail someone and [to] say these are your issues.’
Participants had their own internal, ethical compass that they aligned with the NMC Code (2018b). They could differentiate between the student as a person and the level of competence they were demonstrating. Levine's (1973) seminal work emphasised that making this differentiation is critical when acting with professional integrity in nursing. Here, assessors could, therefore, appreciate that failing the student in a practical assessment did not equate to disparaging them as a person. This also helped to manage feelings of guilt, which are an obstacle to failing students (Hunt et al, 2016b). Schaffer (2013) reported similar qualities among practice assessors in the USA who highlighted the need for scrupulousness when assessing their protégées, whether they passed or not.
Dependability
It was recognised that, at times of tension, participants needed composure and commitment to see the process through to an appropriate outcome. Those who had done this were loyal to their obligations, could be relied upon to follow procedures and did what they said they would. One nurse stressed how important it was to speak with clarity, so that everyone appreciated the consistent severity of the concerns that had underpinned her decision to fail:
‘There's no point in mincing your words. I'm not prepared to put you in a situation where you are going to lose your PIN, because that's not fair.’
Being prepared to assert oneself with certainty from a firm foundation, based on the preceding four qualities of the core of steel, fostered internal stability. This enhanced mentors' capacity to withstand conflicting demands and confront difficult situations. Mentors with previous experience of failing a student were aware of what to expect and this further aided their focus and resolve, helping them to stand firm and see their decision through each time they needed to, as illustrated here:
Interviewer: ‘So your previous experiences …’ MA04: ‘… have bolstered me for this, so I've got no hesitation in doing it again if I have to.’
Rooke (2014) suggested that this quality of dependability is most likely to be present in those who have chosen to undertake the assessing role. Assessors were at their most confident in failing a student if their previous experience of doing so had been tolerable and fair to them as well as the student. However, in spite of this, they noted how difficult it was to cope with such pressure alone. Even those with the strongest core of steel, characterised in Table 1, recognised the importance of human support networks to bolster them at such times (Hunt et al, 2016a), rather than the oft-proffered toolkits, websites and handbooks that provided no emotional support at all.
| Key attribute | Characteristics |
|---|---|
| Solidarity |
|
| Tenacity |
|
| Audacity |
|
| Integrity |
|
| Dependability |
|
Mentors who exhibited a core of steel appeared most able to avoid becoming involved in drama triangles with students (Karpman, 2007). These are social interactions where people unconsciously take on roles in conflict situations; in this particular scenario, the failing students cast themselves as victims and the assessors as persecutors. This is a counterintuitive role for a nurse to take on, and those assessors who do not have a core of steel often reframe themselves as rescuers through passing the underperforming the student. This links with Finch et al's (2013) argument that social work assessors who are aware of ego-defensive stances (Shehata and Ramadan, 2017) are more able to manage the uncomfortable feelings that can prevent them failing an underperforming student.
This present study demonstrates that the qualities a nurse needs to have to be a rigorous assessor are not necessarily those associated with ‘good’ mentoring traits linked to the nurturing and teaching aspects of the role (Schaub and Dalrymple, 2013). The qualities reported here fit with the ‘hawk and dove’ model of assessment proposed by McManus et al (2006). Those with ‘dove’ tendencies are influenced to boost grades in face-to-face assessment scenarios and may be better suited to the nurturing role of the practice supervisor, while those with ‘hawk’ attributes are less influenced by the interpersonal nature of practical assessment and are more exacting in their expectations. Tunstall (2001) and Morgan et al (2002) also identified discrete traits that lend themselves to either the mentoring or assessing role. Together, these studies support the presence of a group of essential qualities required in practice assessors that are identified here as ‘the core of steel’.
Recommendations for selecting practice assessors
Anecdotal evidence suggests that some organisations may be considering transferring every current mentor across to the practice assessor role in an attempt to expediently implement the new NMC (2018a) standards. This paper strongly challenges this practice. Given that the most recent evidence suggests that many mentors are still reluctant to fail underperforming students (Cassidy et al, 2017; Timmins et al, 2017), assigning all mentors to the practice assessor role will continue to perpetuate the known, ongoing problem of ‘failure to fail’ and will not help to achieve the NMC's ambitions of ‘ensuring that no one gets onto the register who shouldn't be there’, as was emphasised at the stakeholder event in Birmingham last year.
It is instead recommended that processes are put in place to identify those current mentors who exhibit the five qualities identified here as the ‘core of steel’ and that they be supported to fulfil the role of practice assessors. It is suggested that practice organisations and partner universities could use selection criteria based on the findings of this study to do this.
Figure 2 offers an assessment tool that could form the basis for selection processes. The tool comprises five continuums, each of which can be used to assess a potential practice assessor's tendency towards one or other of two opposing characteristics. Identification with the qualities towards the left of each continuum indicates close alignment with the ‘core of steel’. Identifying with the contrasting characteristics on the right-hand side of each continuum suggests the person would not be well aligned to the role and would require significant development to become an effective practice assessor. Since mentors in this study could recognise the qualities of the core of steel in themselves, it is possible that self-assessment could be one effective way of using this tool to select practice assessors.
This tool can also assist in recognising those with potential to develop into the practice assessor role by identifying areas where professional growth can be supported in those with some of the necessary qualities. Further research is recommended to explore how best this could be achieved.
Conclusion
While it is recognised that it is everybody's business to help students learn and develop in practice placements, not everyone has the characteristics necessary to robustly assess students. Forcing all mentors into this role will be counterproductive, perpetuating ‘failure to fail’. All organisations who offer placements to nursing students should, therefore, work with their partner universities and approved education institutions to consider carefully the criteria they set so that they identify the members of staff who will assess robustly. Selecting practice assessors with a ‘core of steel’ is likely to have a positive influence on the NMC's aim of ensuring that no one get onto the register who should not be there.