Ensuring that pre-qualifying nurses achieve specified standards for safe and competent practice is essential for nurse education and practice in the UK (Nursing and Midwifery Council (NMC) 2018a; 2018b) and internationally (Clark et al, 2011; Nursing and Midwifery Board of Australia, 2015; Zasadny and Bull, 2015). Competency-based education aims to generate a nursing workforce with the skills and flexibility to function within global markets (Foth and Holmes, 2017) and fulfil employer requirements for graduates who are fit to start employment without the need for extensive further training (Black et al, 2008). Competency-based education focuses on what nurses need to know to function safely and effectively in the clinical environment (Foth and Holmes, 2017) and can be defined as:
‘Broad clusters of general attributes which are considered essential for effective performance.’
Student nurses are required to demonstrate effective application of knowledge, judgement and skill (Paganini and Egry, 2011) and achieve set learning outcomes to advance on their programme of study and ultimately qualify to practise independently (Gravina, 2017). Assessment in clinical practice is centred on performance, with competency offering a mechanism for its measurement (Clark et al, 2011). However, assessing competence in practice is complex (Hunt et al, 2012). There is a difference between assessing a student's technical competence to perform certain skills (e.g. applying a wound dressing) and judging professional attitude and behaviour. The latter is more subjective (Elliott, 2016) and ‘impressionistic’ (Burden et al, 2018).
In the UK, mentors have an academic, legal, and professional responsibility to teach, supervise and evaluate students' clinical performance (Tanicala et al, 2011; Cant et al, 2013; Zasadny and Bull, 2015). They are required to complete an approved mentor-preparation programme demonstrating that they have integrated the NMC (2008) standards into their own practice to maintain their status on the ‘active’ register (Andrews et al, 2010). All qualified nurses are expected to work within the limits of their competence, recognising and reporting unsafe care delivered by other registered professionals (NMC, 2018a) including that of students (Tanicala et al, 2011). A mentor should only confirm a student as proficient if they feel that they have achieved the required standards of competency (NMC, 2008). If a mentor ‘fails to fail’ a poorly performing student there are significant implications for patient protection and safety as well as legal implications and consequences (Larocque and Luhanga, 2013). This is a key concern in the wake of patient safety scandals in the UK (Francis, 2013; Gosport Independent Panel, 2018). Competency standards enshrined in professional regulatory documents are underpinned by nursing ethics protecting patients from potential harm (Hunt et al, 2012). Ensuring that underperforming students do not become registered nurses is part of the mentor's role, although not explicitly referred to in the NMC guidance (NMC, 2008).
Mentors' concerns regarding underperforming students and the phenomenon of ‘failing to fail’ has been previously identified and discussed in the literature (Lankshear, 1990; Duffy, 2003; Scholes and Albarran, 2005; Skingley et al, 2007). Duffy's (2003) grounded theory study highlighted the issue of ‘failure to fail’ and identified reasons for this phenomenon, including:
This study, alongside others (Scanlan et al, 2001; Hawe, 2003), informed the NMC's (2008)Standards to Support Learning and Assessment in Practice. This framework aimed to enhance the quality of learning in practice, address mentor preparation and support, and increase mentor awareness of their role. It was clear that mentors were accountable for confirming whether the student had or had not met the required standards for safe and competent practice (NMC, 2018a). It is not clear, however, how successfully or consistently the NMC guidance, available since 2008, has been implemented as the issue of ‘failure to fail’ continues to be discussed (Gainsbury, 2010; Vinales, 2015; Elliott, 2016; Peate, 2018). The revised Standards Framework for Nursing and Midwifery Education (NMC, 2018c), due for implementation in 2019, has reignited this debate. These standards will inevitably impact upon the role of the mentor, including possible removal of the title ‘mentor’ and separation of the supervisory role from that of assessment.
Aim
The authors felt it was timely to review this issue and determine the nature of the current evidence base to inform future practice. This review posed the following question: ‘What is the evidence that mentors are failing to fail underperforming student nurses?’
Method
An integrated literature review was undertaken using a systematic approach and the following online databases: Medline, Scopus, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search was conducted between December 2015 and February 2017 and key words included: ‘mentors’, ‘mentoring’, ‘students’, ‘nurses’, ‘nursing’, ‘assessment’, ‘competence’, ‘failure’, ‘failing’, and ‘failure to fail’. Boolean operators (‘And’, ‘Or’, ‘Not’) were used to combine or exclude keywords in addition to truncation (Craig and Smyth, 2011). Inclusion and exclusion criteria were applied to focus the search and ensure inclusion of relevant papers (Aveyard, 2014) (see Table 1).
| Inclusion criteria | Exclusion criteria |
|---|---|
| Primary research | Not primary research |
| English language papers only | Non-English language papers |
| Peer reviewed | Non-peer reviewed |
| Published after 2008 | Published before the 2008 Nursing and Midwifery Council guidance |
Only primary research concerned with finding evidence rather than commentary was included in the review; however, no restrictions were applied to study type or design. Papers published prior to the revised NMC guidance (in 2008) were excluded as the evidence on this topic had already been reviewed; thus a contemporary perspective was sought. Database searching was combined to remove duplicates. Only a limited number of eligible papers were identified therefore, secondary searching was conducted via hand searching of journals and reference lists (Aveyard, 2014). Following screening of titles, 12 relevant papers were identified. Further screening of the abstracts resulted in seven of these papers being excluded because they were not relevant to the review question or because they did not meet the inclusion criteria. Full text reading of the remaining five papers was undertaken before extraction of data.
Three of the papers were qualitative exploratory studies (Jervis and Tilki, 2011; Larocque and Lahanga, 2013; Black et al, 2014). Both Jervis and Tilki (2011) and Larocque and Lahanga (2013) used semi-structured interviews with 14 and 13 participants respectively. Black et al (2014) interviewed 19 mentors using reflective interviews to explore the emotional and psychological aspect of failing a student nurse. Of the remaining two papers, Brown et al (2012) surveyed 1790 mentors using a 29-item questionnaire to elicit data and Lawson (2010) used mixed methods (interviews and pre- and post-workshop questionnaires) to explore the challenges that nurse mentors? (n = 193) and allied health professional mentors (n = 90) faced. The five papers included indicated that while there is some existing evidence that explores failure to fail, the majority is comprised of small scale, localised studies. All research articles were UK-based studies, with the exception of Larocque and Lahanga (2013) which was Canadian. Although subject to a different regulatory body (the Canadian Nurses Association), Canada has a similar educational system to the UK and provided a useful non-UK comparison. The Critical Appraisal Skills Programme tool (CASP) was used to appraise the papers and identify relevant characteristics prior to thematic analysis. The five articles are shown in Table 2.
| Aim | Study design/methodology | Key findings | Strengths (+) and limitations (–) |
|---|---|---|---|
| Jervis and Tilki, 2011 (UK) | |||
| To explore reasons why mentors were failing to fail poorly performing students, with a view to identifying the support needed to help them make difficult assessment decisions | Qualitative approach |
Three themes emerged from this study: |
(+) Semi-structured interviews facilitated further exploration of issues initially raised in the focus group, increasing validity. (Some mentors were unwilling to discuss their sensitivities in a group) |
| Larocque and Luhanga, 2013 (Canada) | |||
| To explore the issue of ‘failure to fail’ in a nursing programme |
Qualitative descriptive design |
Five themes emerged from this study: |
(+) Credibility was achieved by comparing the analyses of experienced researchers |
| Brown et al, 2012 (UK) | |||
| What influences mentors to pass or fail students? |
|
|
(+) Large-scale study: 1790 response rate out of 4341 mentors (participants) across 6 health boards in Scotland, increasing validity |
| Black et al, 2014 (UK) | |||
| To explore, interpret and develop an understanding of mentors' experiences of failing pre-registration nursing students in their final placement |
|
|
(–) Only focuses on the emotional/psychological aspect when actually failing a student nurse |
| Lawson, 2010 (unpublished) (UK) | |||
| To address common challenges that allied health professionals (AHPs) face as clinical educators and identify what support is required |
|
|
(+) Wide selection of health professionals selected to participate in the study |
Scrutiny of each paper was undertaken to identify key findings, outcomes and limitations. Potentially relevant concepts and ideas were highlighted and these were then grouped, identifying re-occurring themes and concepts within and across the studies.
Results
Three main themes emerged:
Mentors' relationships with the university
In the UK, universities are responsible for ensuring mentors are adequately supported to support the student via specified roles such as link lecturers and placement co-ordinators (MacIntosh, 2015). This relationship should be formalised with regular contact and communication in order to addresses any issues or questions (Royal College of Nursing (RCN), 2007; 2016). The relationship and communication between the mentor and university staff was discussed in four out of the five studies (Lawson, 2010; Jervis and Tilki, 2011, Brown et al, 2012; Black et al, 2014). Respondents in both Jervis and Tilki's (2011) and Brown et al's (2012) studies reported that mentors feared that the university would overturn a decision to fail, and were worried about pressure from the university to pass a failing student. Jervis and Tilki (2011) indicated that this was based on mentors' past experiences of the university overturning decisions. Respondents in Brown et al's (2012) study reported the same concern; however, this was not informed by past experiences. In addition, although Jervis and Tilki (2011) noted that this theme emerged from their study findings, it was underexplored in their paper.
Lawson (2010), Larocque and Lahanga (2013) and Brown et al (2012) also reported mentor concerns regarding the support they received from the university; a common theme highlighted in earlier research (Duffy, 2003; Scholes and Albarran, 2005; Skingley et al, 2007). However, it is not clear whether all 13 participants in Larocque and Lahanga's (2013) study had past experiences of mentoring a student who had failed or was at risk of failing. In contrast, Brown et al (2012) found that only a small number of mentors in their study (144 out of 1790 participants) reported a problem with the relationship between mentors and the university. Some 68% (of 1790) mentors indicated that the academic practice partner (known as link lecturers in the UK) was their first choice to approach if they encountered an underachieving student. Mentors were also asked to rate the support they received from the university and although 9% (130) rated this as poor, on the whole (1243 out of 1373) mentors were satisfied with the support they received (23% satisfactory; 38% good, 29% very good). This mixed-methods study accessed mentors from six different publicly funded NHS health boards. Almost 23% (of 277) mentors who had passed a failing student reported that they had received poor support compared with 6% (of 1065) mentors who had failed a failing student.
Documentation when failing a student
Mentors must keep sufficient records to support and justify their decision of whether the student is fit to pass or fail (RCN, 2007) and the decision to fail a student must comply with professional guidance and document an appropriate action plan giving constructive feedback (Anglia Ruskin University (ARU), 2013). In an earlier study, Stuart (2007) stated that, in some cases, a decision to fail a student had been overridden by the examination board at the university because of poor documentation by the mentor. Brown et al (2012) and Lawson (2010) reported similar issues. Lawson's (2010) study of a collaborative project into the development of the knowledge and skills of mentors sought feedback from 320 nursing mentors and found that, despite regular mentor updates that included guidance in completing documentation, participants felt unable to fill out documentation on a failing student objectively. They did, however, feel capable of filling out documentation for an achieving student. Similarly, in Brown et al's study (2012) a small number of mentors (28 out of 277) who had passed a failing student felt unclear on how to complete the relevant documentation. This was also reflected in Duffy's (2003) seminal work, funded by the NMC, in which inadequate support in relation to documentation completion sometimes led to failure to fail.
Psychological and emotional impact on mentors of failing a student
Black et al (2014) and Jervis and Tilki (2011) indicated that psychological and emotional pressures on mentors can be a barrier to failing a student. The 19 mentors in Black et al's (2014) study reported feelings of guilt that led to concerns regarding their abilities as a mentor and questioning their own competence and standards of assessment. Furthermore, mentors described psychological manifestations of stress and worry resulting in sleepless nights, exhaustion and effects on their general functioning. A similar impact was reported by Jervis and Tilki (2011) who also noted the pressure placed by students on mentors. These emotional demands were also cited in an earlier study by Duffy (2003). It is likely that a poor relationship with academic partners would impact upon these anxieties (Brown et al, 2012), further undermining mentor confidence. Black et al (2014) reported that some mentors were angry with colleagues who had previously mentored the student for failing to address student performance earlier.
Discussion
The issue of ‘failing to fail’ features regularly in the UK literature and is informed by ongoing concerns regarding assessment of student nurse competence and the implications for professional practice and patient safety (Clark et al, 2011; Black et al, 2014; Burden et al, 2018). This review has shown that, although there is some evidence regarding this topic and valid concerns regarding this issue in clinical practice, overall the quality and extent of the existing evidence does not fully explain this particular phenomenon. Nor does it account for the substantive number of mentors who are confident in their assessment of students. Hunt et al (2012) found that a larger number of students failed theory when compared with practice (a ratio of 4:1) and concluded that this offered some support for the argument that mentors were failing to fail underperforming students. However, assessing competence in practice is complex and subjective and occurs in a high-pressured environment in which individual mentor judgements may not lend themselves well to competency-based assessment processes (Burden et al, 2018).
Mentors have substantive professional knowledge and expertise in assessing students in clinical practice and this must be recognised and valued by their partner universities (National Nursing Research Unit (NNRU), 2014). When mentor decisions are overturned or challenged by the university this can impact upon trust and respect, damage relationships and undermine confidence. Addressing perceived lack of support and enhancing confidence in decision-making is key to sustaining this relationship; these were issues also identified in a previous review (of literature between 2003 and 2011) by Elliott (2016). Mentors must liaise with university representatives if a student is at risk of being failed or there are concerns regarding competence (Anglia Ruskin University, 2013). This is essential to ensure that the psychological and emotional issues attached to failing a student nurse do not discourage some mentors and that additional support and guidance with decision-making is provided. Both Black et al (2014) and Jervis et al (2011) indicated that this may be an area where practical support for mentors could be provided by peers and/or the university partner.
Although failing a student nurse in practice may be difficult, it is a necessary requirement of mentors and the majority remain confident in their ability to effectively undertake this role. Mentor concerns regarding failure to fail may be a consequence of other factors including mentor experience, relationship with the student and competing clinical demands (Elliott, 2016). It is important that new mentors are supported in the early stages of their mentoring career until confidence and competence is established. Being an experienced nurse may not necessarily equate with being an experienced mentor; it could be argued that these are distinct roles and the skills and competencies required of mentors are different. The quality of the mentor may well depend upon whether this particular role has been chosen or not (Andrews et al, 2010; NNRU, 2014).
Since guidance was issued by the NMC in 2008, assessment has become a more substantive component of the mentor role (Andrews et al, 2010) and this role is increasingly being delivered within the context of ongoing workforce retention issues and increased workloads and demands (Buchan et al, 2017).
Under the new NMC guidance, students will be supervised in clinical practice by any registered health or social care professional (NMC, 2018c), as opposed to the current situation where students are supervised and assessed by a registered nurse with mentor status. The RCN (2017) has supported the NMC proposals and the benefits of inter-professional learning while highlighting the need for safeguards to ensure practice supervisors have the necessary knowledge, skills and experience to observe and supervise the student in practice (RCN, 2017). Of concern, however, is that the current requirement of a national training level for mentors and the maintenance of a mentor register is no longer advocated. Although any registered health professional can supervise a student nurse, assessment will be solely the responsibility of a registered nurses undertaking one of two roles; ‘nominated practice assessor’ or ‘nominated academic assessor’ (NMC, 2018c). Roles and responsibilities will need to be clarified (RCN, 2017). There does appear to be some merit in the splitting of these roles as it has long been recognised that combining supervision and assessment, with the responsibility for both traditionally falling to one individual mentor, does cause tension for many (Neary, 2000).
This review has indicated that further focus is required on documentation. For universities, establishing stronger supportive relationships with their partners in practice is fundamental to safe and effective student learning and assessment and this should include proactive and pre-emptive approaches such as ‘early warning systems’ to identify potential difficulties. ‘Failing to fail’ does warrant further research and investigation that explores the range and extent of this phenomenon in a systematic way. Key to further research in this area is ensuring that the perspectives of students and academic staff are also included in this research and debate. As this review focused on primary evidence (rather than other literature reviews), few research papers were identified to inform the review. Equally, using the term ‘mentor’ may well have limited the search to UK-only studies as other terms may be more culturally appropriate for supervisory and assessment arrangements in other countries.
Conclusion
There is some, though limited, evidence of the phenomenon of ‘failing to fail’ a student nurse in the UK, but, arguably, this is not as pervasive as previously suggested. Although this may be a concern and challenge for some mentors in practice, the majority are competent and comfortable in the decisions they make regarding student competence. Many universities have established and effective approaches to shared decision making regarding student competence in practice that are embedded in policy and practice. These should be sufficient to address the assessment of competence in practice.