Systematic review of grading practice: Is there evidence of grade inflation?

Clinical assessor's experiences of assessing undergraduate nursing and midwifery students who underperform on clinical placement: A qualitative systematic review and meta-summary

AIM

To summarise the qualitative evidence exploring the clinical assessor's experience of assessing undergraduate nursing and midwifery students who underperform on clinical placement.

DESIGN

A qualitative systematic review and meta-summary was undertaken.

DATA SOURCE

Database searches included CINAHL Plus with full text; Academic Search Complete; MEDLINE; PsycARTICLES; PsychINFO; Social Sciences Full text; SocINDEX with Full Text; ERIC; Pubmed; Scopus and Web of Science.

REVIEW METHOD

Included studies were appraised using the CASP (Critical Appraisal Skills Programme) tool. A meta-summary was conducted using Sandelowski & Barroso's method.

RESULTS

The review included 18 studies reported across 25 papers. Eight themes and 37 thematic sentences were created from 403 extracted findings.

CONCLUSION

The management of underperformance on clinical placement by undergraduate nursing and midwifery students presents a challenge for those nurses and midwives, working on the frontline of patient care, who also take on the role of clinical assessor. Addressing these challenges is essential to support the assessor and the student. Sharing of the decision making with a colleague when there is evidence of underperformance could address many of the difficulties experienced by the clinical assessor.

Perceptions and attitudes of medical students towards student evaluation of teaching: A cross-sectional study

BACKGROUND

Faculty evaluation surveys in the frame of student evaluation of teaching (SETs) are a widely utilized tool to assess faculty teaching. Although SETs are used regularly to evaluate teaching effectiveness, their sole use for making administrative decisions and as an indicator of teaching quality has been controversial.

METHODS

A survey containing 22 items assessing demographics, perception, and factors for evaluating faculty was distributed to medical students at our institute. Statistical analyses were conducted using Microsoft Excel and R Software utilizing regression analysis and ANOVA test.

RESULTS

The survey received 374 responses consisting of 191 (51.1%) male students and 183 (48.9%) female students. In all, 178 (47.5%) students considered the optimal time for providing faculty evaluation to be after the release of the exam results, compared to 127 (33.9%) students, who chose the after the exam but before the release of exam results option. When asked what happens whenever the tutor is aware about the SETs data, 273 (72.9%) and 254 (67.9%) students believed that it would influence the difficulty of the exam and grading/curving of the exam results, respectively. Better teaching skills (93%, 348), being responsive and open to student feedback and suggestions (84.7%, 317), being committed to class time and schedule (80.1%, 300), and an easier exam (68.6%, 257) were considered important factors to acquire a positive evaluation by a considerable proportion of students. Fewer lectures (P < 0.05), decreased number of slides per lecture (P < 0.01), easier exam (P < 0.05), and giving clues to students about the exam (P < 0.05) were found to be very important to obtain a positive tutor evaluation by students.

CONCLUSIONS

Institutions ought to continue exploring areas of improvement in the faculty evaluation process while raising awareness among students about the importance and administrative implications of their feedback.

Grading practice as a strategy to improve proficiencies in undergraduate nurse education: Modelling key areas of competence

BACKGROUND

In undergraduate nursing grading practice is generally avoided as it is considered educationally flawed.

OBJECTIVES

To test an innovative online grading practice tool (GPT) in undergraduate nurse education. To model the determinants of the final practice grade in four areas of clinical competence and in one cohort analysis the relationship between final practice grade and each area of clinical competence and an OSCE grade.

DESIGN

A cross-sectional study.

PARTICIPANTS

A convenience sample of 782 nursing students from one Higher Education Institution in the North-East of England were included. The sample involved two sequential cohorts of final-year students with 391 students in each cohort.

METHODS

A specifically designed online grading practice tool (GPT) composed of thirty-six objectives equally divided across four areas of clinical competence. The GPT was applied to two consecutive student cohorts on completion of their final practice learning placement.

RESULTS

There was a statistically significant difference in the mean final practice grade between the two cohorts. In the overall sample, regression modelling showed that all four areas of student assessment contributed equally to the final grade. Analysis by cohort showed that in Cohort 1 clinical thinking and professionalism had the most influence on the final grade with person-centered care and patient safety most strongly impacting on the final grades of Cohort 2. In Cohort 2 there is no statistically significant correlation between final practice grade, each area of clinical competence and an OSCE grade.

CONCLUSIONS

Practice learning is fundamental to how students develop professional awareness and learn to nurse. Findings from a novel grading practice tool applied in undergraduate nursing reveal how effectively the tool works. Nurse educators must be responsive to the realities of learning in practice and explore new ways of assessing clinical competence.

Deficiencies of Traditional Grading Systems and Recommendations for the Future

Objective. To review issues surrounding the use of grades in the educational process and provide evidence-based recommendations for how to redesign grading practices for optimal value.Findings. Traditional tiered grading systems (ie, A, B, C, etc) have historically been a major component of the formal educational process. The way grades are used and interpreted are typically based on some commonly held assumptions, including that they are accurate measures of learning, that they motivate students to learn, and that they provide feedback to learners. However, much of the research regarding grades indicates that flaws exist in these assumptions. Grades may not always accurately measure learning, they can have adverse effects on student motivation, and they are not a good form of feedback.Summary. The Academy should consider the evidence regarding the purpose, effects, and interpretation of grades in the educational process. Despite barriers and potential pushback, pharmacy educators should revise grading practices to be more accurate, interpretable, and beneficial to learner development.

Role of faculty characteristics in failing to fail in clinical clerkships

INTRODUCTION

In the context of competency-based medical education, poor student performance must be accurately documented to allow learners to improve and to protect the public. However, faculty may be reluctant to provide evaluations that could be perceived as negative, and clerkship directors report that some students pass who should have failed. Student perception of faculty may be considered in faculty promotion, teaching awards, and leadership positions. Therefore, faculty of lower academic rank may perceive themselves to be more vulnerable and, therefore, be less likely to document poor student performance. This study investigated faculty characteristics associated with low performance evaluations (LPEs).

METHOD

The authors analysed individual faculty evaluations of medical students who completed the third-year clerkships over 15 years using a generalised mixed regression model to assess the association of evaluator academic rank with likelihood of an LPE. Other available factors related to experience or academic vulnerability were incorporated including faculty age, race, ethnicity, and gender.

RESULTS

The authors identified 50 120 evaluations by 585 faculty on 3447 students between January 2007 and April 2021. Faculty were more likely to give LPEs at the midpoint (4.9%), compared with the final (1.6%), evaluation (odds ratio [OR] = 4.004, 95% confidence interval [CI] [3.59, 4.53]; p < 0.001). The likelihood of LPE decreased significantly during the 15-year study period (OR = 0.94 [0.90, 0.97]; p < 0.01). Full professors were significantly more likely to give an LPE than assistant professors (OR = 1.62 [1.08, 2.43]; p = 0.02). Women were more likely to give LPEs than men (OR = 1.88 [1.37, 2.58]; p 0.01). Other faculty characteristics including race and experience were not associated with LPE.

CONCLUSIONS

The number of LPEs decreased over time, and senior faculty were more likely to document poor medical student performance compared with assistant professors.

Failing to Fail When Disability Is a Factor

BACKGROUND

Nursing faculty may be reluctant to fail students for a variety of reasons. Faculty may fear being viewed as discriminatory when failing nursing students with disabilities.

PROBLEM

Schools of nursing may still be using technical standards that are outdated and noncompliant with the Americans with Disabilities Act (ADA) to determine eligibility for admission and may confuse essential functions with academic expectations. Lack of faculty awareness of the ADA may make faculty reluctant to fail nursing students with disabilities.

APPROACH

All nursing students should be assessed based on whether-not how-they meet academic and clinical standards safely. Disability accommodations should not affect the standards that must be met.

CONCLUSIONS

Faculty should base decisions on whether to assign failing grades to students on factors unrelated to a disability. Technical standards, when written correctly, should clarify whether inability or disability contributed to failure. Policies regarding failing should be clear, equitable, and accessible.

Development and validation of the nursing clinical assessment tool (NCAT): a psychometric research study

OBJECTIVES

The aim of this pilot psychometric study was to develop and assess the reliability, validity, and applicability of a nursing clinical assessment tool (NCAT) to assess students' clinical performance in the clinical training.

METHODS

Total of 325 forms were completed by 36 clinical raters for undergraduate nursing students who were selected using convenience sampling. International quality and safety education for nurses (QSEN) and Benson and Clark's (Benson, J., & Clark, F. (1982). A guide for instrument development and validation. The American Journal of Occupational Therapy, 36(12), 789-800) model guided the construction of the NCAT. Following literature review, a cross-cultural adaptation and psychometric testing were used.

RESULTS

This newly developed tool showed substantial overall internal consistency reliability (Cronbach's alpha = 0.74). Three factors (i.e. Care Provider, Leadership & Team Work and Professionalism and Ethical Considerations) were identified for construct validity using exploratory factor analysis (EFA).

CONCLUSIONS

This study suggests that the NCAT is a reliable, valid and applicable tool. It can be used in clinical and educational settings. Further testing of the tool in similar and different cultures is recommended.

Developing a consensus-based scoring rubric to enhance practice-based assessment of student nurses' clinical competence: A Delphi study

BACKGROUND

Concerns about reliability and validity of practice-based assessment of professional competencies are frequently reported in the literature. Difficulty in understanding competency statements or distinguishing different achievement levels has been found to be a major factor.

OBJECTIVES

To develop a consensus-based scoring rubric based on stakeholders' interpretations of level descriptors for student nurses' professional values competencies.

DESIGN

Two rounds of Classic e-Delphi.

SETTINGS

This study was conducted in a London based university using Bristol Online Survey website as a host.

PARTICIPANTS

100 stakeholders with vested interests in undergraduate pre-registration nurse education were purposefully invited to participate.

METHOD

Round one collected free-text interpretations of the United Kingdom Nursing and Midwifery Council professional values competency statements. Round two used a Likert scale questionnaire to measure the level of agreement to the level descriptor statements generated through round one. Responses were analysed through content analysis in round one and consensus measure in round two. A threshold of 70% agreement to determine consensus was set in advance.

RESULTS

In round one, 47 participants provided their interpretations of the competency statements. In round two, 51 participants completed the questionnaire. All 24 items achieved a strong consensus with 86%-100% of participants agreeing or strongly agreeing with the statements.

CONCLUSIONS

A Delphi study was successfully used to develop a consensus-based scoring rubric with clearly stated descriptors for professional values competency statements. This scoring rubric holds the potential to enhance practice-based assessment across all healthcare professional disciplines.

Moving forward: Barriers and enablers to failure to fail - A mixed methods meta-integration

BACKGROUND

Many academics and clinicians who assess nursing students as part of their work-integrated learning experiences encounter difficulties with awarding a failing grade to students who do not meet fitness for practice standards.

OBJECTIVES

The aim of this study was to explore and further our understanding of assessors' experiences of failure-to-fail of nursing students within work-integrated learning.

DESIGN

This aim was achieved through an exploratory, sequential, mixed methods research project.

METHODS

Guided by Invitational Theory, this programme of work included an integrated systematic review, one-on-one and focus group interviews, and finished with a survey.

RESULTS

The results of each of the phases of this mixed methods study were integrated to provide a greater understanding of the enablers and barriers for assessors managing poor performing students to ameliorate failure to fail. Enablers identified included: assessor supports, programme flexibility, and organisational culture. The barriers included grade inflation, in appropriate student responses, organisational processes and workload.

CONCLUSIONS

This comprehensive integration of a mixed methods study provides new and deeper understanding of the phenomenon of failure to fail. It provides clear recommendations for practical application by tertiary and clinical facilities to enhance the enablers and minimise the barriers to failure where it is warranted.

Creating a culture of success: A framework for addressing at-risk student

The lack of diversity in nursing and the projected nursing shortage is a clarion call for higher education to create inclusive programs where all students can thrive. Despite an increase in enrollment, attrition remains an issue. To address the looming nursing shortage, colleges and universities are expected to increase the enrollments in baccalaureate and accelerated baccalaureate programs. As traditional and nontraditional students are admitted into nursing programs, institutions and nursing programs will be faced with tackling issues students who are historically labeled as "at-risk" may have. To help these students succeed, colleges and universities must come up with new ways to work with at-risk students. In this paper, we are proposing a new framework for how faculty in nursing programs can perceive "at-risk" students by systematically examining the factors that lead to this at-risk status. The framework proposes that students encounter a plethora of individual and institutional critical elements, categorized into domains. By understanding the critical elements that impact student outcomes, nursing programs will be better able to strategize ways to effectively support and sustain student success.

Academic Grade Inflation in Nursing Education: A Scoping Review of the Qualitative and Quantitative Literature

AIM

The aim of the study was to answer the research question: What is known from the literature about academic grading practices and grade inflation in nursing education?

BACKGROUND

Nursing students require authentic assessment that supports their professional formation. For teachers and students, integrity is fundamental to professional nursing excellence.

METHOD

Arskey and O'Malley's framework was used to integrate and reinterpret findings from qualitative, quantitative, and mixed-method studies.

RESULTS

Twelve studies were reviewed. Contributing factors are described as institutional constraints, external standards, team teaching, lack of faculty confidence, and student incivility. Strategies that may mitigate grade inflation include establishing grading expectations and increasing pedagogical rigor with precise rubrics, valid and reliable examinations, interrater reliability, and faculty development.

CONCLUSION

Academic grading is a complex faculty responsibility grounded in ethical and relational competencies that can support or hinder students' professional formation. Evaluation of strategies to mitigate grade inflation in nursing education is urgently needed.

Clinical assessors' working conceptualisations of undergraduate consultation skills: a framework analysis of how assessors make expert judgements in practice

Undergraduate clinical assessors make expert, multifaceted judgements of consultation skills in concert with medical school OSCE grading rubrics. Assessors are not cognitive machines: their judgements are made in the light of prior experience and social interactions with students. It is important to understand assessors' working conceptualisations of consultation skills and whether they could be used to develop assessment tools for undergraduate assessment. To identify any working conceptualisations that assessors use while assessing undergraduate medical students' consultation skills and develop assessment tools based on assessors' working conceptualisations and natural language for undergraduate consultation skills. In semi-structured interviews, 12 experienced assessors from a UK medical school populated a blank assessment scale with personally meaningful descriptors while describing how they made judgements of students' consultation skills (at exit standard). A two-step iterative thematic framework analysis was performed drawing on constructionism and interactionism. Five domains were found within working conceptualisations of consultation skills: Application of knowledge; Manner with patients; Getting it done; Safety; and Overall impression. Three mechanisms of judgement about student behaviour were identified: observations, inferences and feelings. Assessment tools drawing on participants' conceptualisations and natural language were generated, including 'grade descriptors' for common conceptualisations in each domain by mechanism of judgement and matched to grading rubrics of Fail, Borderline, Pass, Very good. Utilising working conceptualisations to develop assessment tools is feasible and potentially useful. Work is needed to test impact on assessment quality.

Evaluation of Medical School Grading Variability in the United States: Are All Honors the Same?

PURPOSE

The medical student performance evaluation (MSPE) summarizes a residency applicant's academic performance. Despite attempts to improve standardized clerkship grading, concerns regarding grade inflation and variability at United States medical schools persist. This study's aim was to describe current patterns of clerkship grading and applicant performance data provided in the MSPE.

METHOD

The authors evaluated Electronic Residency Application Service data submitted to a single institution for the 2016-2017 Match cycle. Clerkship grading characteristics regarding grading tiers, school rank, location, and size were obtained. Data regarding methods for summative comparisons such as key word utilization were also extracted. Descriptive statistics were generated, and generalized linear modeling was performed.

RESULTS

Data were available for 137/140 (98%) MD-granting U.S. medical schools. Pass/fail grading was most commonly used during the preclinical years (47.4%). A 4-tier system was most common for clerkship grading (31%); however, 19 different grading schemes were identified. A median of 34% of students received the highest clerkship grade (range, 5%-97%). Students attending a top 20 medical school were more likely to receive the highest grade compared with those attending lower-rated schools (40% vs 32%, P < .001). Seventy-three percent of schools ranked students, most commonly using descriptive adjectives. Thirty-two different adjectives were used.

CONCLUSIONS

There is significant institutional variation in clinical grading practices and MSPE data. For core clerkships where most students received the highest grade, the ability to distinguish between applicants diminishes. A standardized approach to reporting clinical performance may allow for better comparison of residency applicants.

Just how bad does it have to be? Industry and academic assessors' experiences of failing to fail - A descriptive study

BACKGROUND

Failing to fail nursing students in clinical assessments is an internationally acknowledged issue that necessitates thorough examination. Despite the gravity of 'mis-grading' nursing students, current research exploring this subject is limited. Understanding the experiences of assessors when faced with an underperforming student may help illuminate some of the broad issues associated with failure to fail.

OBJECTIVES

To describe both tertiary and industry based assessors' experiences of grading nursing student performances in clinical courses when that performance was not a clear pass or fail.

DESIGN

A pilot study using a descriptive survey design was employed.

SETTING

Participants were drawn from all states and territories in Australia.

PARTICIPANTS

Academic and industry assessors of undergraduate nursing students across Australian universities participated in this study.

METHODS

A newly developed and validated survey was conducted via an online platform. Descriptive data were collected on assessors' experiences across the domains of the Invitational Theory: people; processes; programmes; policies and places.

RESULTS

Participants clearly had a strong duty of care to patients and the nursing profession. However, 23.5% of participants had given the benefit of the doubt to student performances. They reported failing student performances nevertheless reported passing students. Some participants experienced a number of coercive student behaviours. They perceived that the culture of the ward impacted on student performances in assessments. Inadequate time to assess students in clinical practice was reported by 44% of participants. Participants reported no differentiation between theoretical and clinical assessments in their organisations' assessment policies.

CONCLUSIONS

Assessors reported many challenges when assessing students who were not performing at requisite standards. This study furthered the extant literature around the impact of people and processes on assessors and failure to fail. For the first time, assessors' experiences of the assessment environment, programme design and organisational policies associated with grading marginal student performances are reported.

The effect of indapamide vs. bendroflumethiazide for primary hypertension: a systematic review

The aims of the current review were to compare the efficacy of monotherapy with bendroflumethiazide vs. indapamide on mortality, cardiovascular outcomes, blood pressure, need for intensification of treatment and treatment withdrawal. Two authors independently screened the results of a literature search, assessed the risk of bias and extracted relevant data. Randomized clinical trials of hypertensive patients of at least a 1-year duration were included. When there was disagreement, a third reviewer was consulted. Risk ratio (RR) and mean differences were used as measures of effect. Two trials comparing bendroflumethiazide against placebo, one comparing indapamide with placebo and three of short duration directly comparing indapamide and Bendroflumethiazide, were included. No statistically significant difference was found between indapamide and bendroflumethiazide for all deaths [RR 0.82; 95% confidence interval (CI) 0.57, 1.18], cardiovascular deaths (RR 0.82; 95% CI 0.55, 1.20), noncardiovascular deaths (0.81; 95% CI 0.54, 1.22), coronary events (RR 0.73; 95% CI 0.30, 1.79) or all cardiovascular events (RR 0.89; 95% CI 0.67, 1.18). Indapamide performed worse for stroke (RR 2.21; 95% CI 1.19, 4.11), even though a reduction in RR compared with placebo was observed in both groups. There was no statistically or clinically significant difference between indapamide and bendroflumethiazide in blood pressure reduction (mean absolute difference <1 mmHg). The present review highlights a lack of studies to answer the review question but also a lack of evidence of superiority of one drug over the other. Therefore, there is a clear need for new studies directly comparing the effect of these drugs on the outcomes of interest.

National survey: Developing a common approach to grading of practice in pre-registration midwifery

This paper presents the final phase of a national project exploring grading of practice in programmes leading to registration as a midwife in the United Kingdom. The aim was to develop a generic framework for grading practice, enhancing standardisation while enabling flexibility in application of current and new educational standards. A mixed method on-line survey considered existing practice assessment tools, factors contributing to robust and reliable assessment and perceptions of two assessment tools developed by the research team: a 'Lexicon Framework' and 'Rubric', which were tested through scenarios. Participants included 170 midwifery and nursing academics, clinicians and students, representing 20 universities in the UK. Seven key themes emerged, from which an 'Evidence Based Model for Professional Practice Assessment' was developed. The proposed tools were overall positively evaluated and demonstrated a good level of reliability. A national tool to standardise midwifery practice assessment is recommended, and scope for transferability of our tools to all midwifery programmes and to nursing was identified. Other recommendations include engagement of key stakeholders in development of practice assessment documentation, and maintaining the professional purpose of grading practice as central to the process. A set of key principles for assessing practice is presented.

Exploring mentors' interpretation of terminology and levels of competence when assessing nursing students: An integrative review

OBJECTIVES

The purpose of this integrative review is to evaluate the empirical and theoretical literature on the challenges mentors face in interpreting and assessing levels of competence of student nurses in clinical practice.

DESIGN

An integrative review of the literature.

DATA SOURCES

An extensive and systematic literature search was conducted covering the period 1986-September 2016 across twelve databases covering health and education related publications. Grey literature was searched from wide relevant sources.

REVIEW METHODS

Sources were eligible for review when they referred to mentor's interpretation or assessment of student nurses' level of competence in practice settings. Methodological rigor of the included studies was evaluated with the Mixed Methods Appraisal Tool.

RESULTS

After screening 1951 records by titles, abstracts and full text, 8 were selected for review. The methodological quality of the studies was moderate. The studies reported: Accurate and fair assessment of students is impeded by a lack of transparent and explicit criteria.

CONCLUSIONS

There is a need to establish a transparent and common language to distinguish between and facilitate interpretation of different levels of competence. Well-designed rubrics might offer the solution to the challenges faced in practice-based assessment and necessitates further research into their use.

Interrater Reliability and Usability of a Nurse Anesthesia Clinical Evaluation Instrument

BACKGROUND

No Student Registered Nurse Anesthetist (SRNA) clinical evaluation instrument (CEI) has undergone interrater reliability or usability testing, to the authors' knowledge. This project determined the interrater reliability and usability of a new SRNA CEI.

METHOD

This was a prospective, mixed qualitative and quantitative, fully crossed observational design with a usability survey. SRNAs' recorded performance during simulation was evaluated by participants, who also completed a usability survey.

RESULTS

Interrater reliability is high, intraclass correlation coefficient = .982, 95% CI [.884, .960], indicating strong agreement of SRNA clinical performance among participants (n = 10). Internal consistency is excellent (Cronbach's α = .943), indicating the CEI is constructed appropriately and participants found it easy to use.

CONCLUSION

This CEI may advance the aim of impartiality in the evaluation of SRNA clinical performance through an instrument that is reliable, with good construct, and ease of use. [J Nurs Educ. 2018;57(7):446-449.].

Failing to Fail in Undergraduate Nursing: Understanding the Phenomenon

AIM

The aim of the study was to explore and understand the phenomenon of "failing to fail."

BACKGROUND

Phase 1 of a mixed-methods study suggested faculty in clinical settings instructed students that should not have passed preceding placements; students in didactic settings also passed exams that merited a fail. Phase 2 explored this phenomenon.

METHOD

A multisite qualitative case study targeted baccalaureate and community college faculty to support analysis using replication logic. Data collection was conducted via semistructured interview.

RESULTS

Eighteen demographically diverse cases were recruited (including age, experience, and full-/part-time status). Factors supporting failing to fail included being good enough, clinical/didactic dichotomy, team grading, and being the bad guy.

CONCLUSION

The consistency of enabling factors suggests a collective approach is required to address failing to fail, including pedagogical preparation and cross-school mechanisms for ensuring grading parity. Effort must address integrity and teaching excellence in all aspects of nursing education.

Waging the War on Clinical Grade Inflation: The Ongoing Quest

This study examined the presence of grade inflation in clinical courses 9 years after implementing strategies to improve grading precision. A comparison of clinical grades for cohort I (1997-2002) with cohort II (2009-2016) showed statistically lower grades in 2 courses (Adult 1 and Maternity) for cohort II. Suggestions for changing the way clinical experiences are planned, executed, and evaluated are provided.

Grade Inflation in Nursing Education: Proposed Solutions for an Ongoing Problem

PROBLEM

The purpose of assigning grades at the conclusion of a course is to convey the level of achievement of learners. However, with the presence of grade inflation in nursing education, it poses a great threat to the evaluation process.

PURPOSE

The purpose of this article is to highlight the factors that influence grade inflation and to explore possible solutions to minimize the incidence of grade inflation in nursing education.

FINDINGS

A review of the literature revealed that a variety of factors influenced grade inflation and educators were indeed lenient with their grading practices, which hence attenuates the purpose of grading and evaluation.

CONCLUSION

While it may be an arduous task for nursing faculty to evaluate nursing students, nursing faculty have the obligation to preserve academic integrity and must devise appropriate solutions to address the incidence of grade inflation in nursing education.

Effects of limited midwifery clinical education and practice standardisation of student preparedness

AIM

To explore the perceptions of midwifery educators regarding effects of limited standardisation of midwifery clinical education and practice on clinical preparedness of midwifery students.

BACKGROUND

Investigation of levels of clinical competency of students is a critical need in the current era. Such competency levels are especially important in midwifery practice in South Africa as there is a significant increase of maternal deaths and litigations in the country. Most of the deaths are in the primary healthcare level maternity units where the newly qualified midwives practise. These areas are mainly run by midwives only. The current article seeks to report the findings of the study that was conducted to investigate how midwifery educators prepare students adequately for clinical readiness.

SETTINGS

The study was conducted amongst midwifery nurse educators on three campuses of the Nursing College in the Eastern Cape.

DESIGN

A qualitative, explorative, descriptive and contextual research design was used for the study.

DATA SOURCES AND METHODS

Seventeen purposively selected midwifery educators, with the researcher using set criteria, from a Nursing college in the Eastern Cape, were the participants in the study. Data was collected using focus-group interviews that were captured by means of an audio-voice recorder. Tesch's data-analysis method was used to develop themes and sub-themes. Trustworthiness of the study was ensured using the criteria of credibility, transferability, dependability and confirmability.

RESULTS

Inconsistent clinical practice amongst midwifery educators in their clinical teaching and assessment were found to be the major factors resulting from limited standardisation. The inconsistent clinical practice and assessments of midwifery educators was found to lead to loss of the necessary skills required by the students which led them to perform poorly in their final clinical assessments.

CONCLUSION

There are some barriers in the current clinical teaching and education strategy used in this college that prohibit the production of confident, independent, and safe practitioners as planned. Midwifery educators need to be assisted in reviewing the current teaching strategy. Furthermore management should be involved if not the initiators of that reviewing and should put in-place new measures to support the teaching of the clinical module.

'Seeking authorization': a grounded theory exploration of mentors' experiences of assessing nursing students on the borderline of achievement of competence in clinical practice

AIM

To develop a substantive theoretical explanation of how mentors make sense of their experiences where nursing students are on the borderline of achievement of competence in clinical practice.

BACKGROUND

The reluctance of Registered Nurse mentors to fail nursing students in clinical practice despite concerns about competence remains a contemporary issue in international healthcare education. Mentors' assessment decisions have considerable impact for a variety of key stakeholders, not least for students in these circumstances.

DESIGN

Grounded theory qualitative study.

METHODS

Phase one involved 20 individual semi-structured interviews with nurse mentors in one United Kingdom National Health Service Health Board (July-October 2009). Phase two included eight individual semi-structured interviews and seven focus groups with mentors and practice educators (n = 38) in four further Health Boards (June 2011-February 2012). Data were analysed using open, axial and selective coding consistent with grounded theory method.

FINDINGS

Three categories 'the conundrum of practice competence,' 'the intensity of nurturing hopefulness,' and 'managing assessment impasse,' led to the study's substantive theoretical explanation - 'Seeking authorization: Establishing collective accountability for mentorship.' This demonstrates how mentors are dependent on key sources of support and feedback to validate their assessment decision-making, notwithstanding substantial personal, professional and organizational pressures.

CONCLUSION

We conclude that management of borderline assessment situations is considerably developed by recognition of the authorizing effects of a wider community of assessors. Consequently, we identify the personal, professional and organizational implications involved in the preparation, support and regulation of mentors specifically during borderline assessment circumstances.

'Failure to fail' in nursing - A catch phrase or a real issue? A systematic integrative literature review

'Failure to fail' is the allocation of pass grades to nursing students who do not display satisfactory clinical performance. This issue can have significant implications for individual students and assessors involved, as well as for nursing professionalism and patient safety. The aim of this systematic integrative literature review was to determine what is currently known about the issue of 'failure to fail' within undergraduate nursing programs. A literature search of five databases up to May 2015 was conducted to identify primary research papers. The search yielded 169 papers of which 24 met the inclusion criteria. The majority of papers had moderate or good methodological rigour, with most of the literature originating from the Northern Hemisphere. Five main themes emerged: failing a student is difficult; an emotional experience; confidence is required; unsafe student characteristics; and university support is required to fail students. The results suggest that 'failure to fail' is a real issue in tertiary facilities, with many complex facets. Given the costs of nurse education and the potential social and professional costs of poor quality nursing graduates, further rigorous research is required in this area.

Do Occupational Therapy Graduates Benefit from Grade Inflation on Practice Placements?

Introduction:

Graduate records from Brunel University (United Kingdom) occupational therapy student cohorts from 1995–2005 were examined to discover the impact of practice placement marking on overall academic performance. Numeric grades for practice placements were introduced in 2000; prior to that, practice placement marks were recorded as either pass or fail.

Method:

1057 records were examined to compare whether overall academic averages differed between pre-practice marking and post-practice marking.

Findings:

Significant differences were discovered in the academic averages for 1995–99 (pass/fail) cohorts and 2000–04 (placement marking) cohorts. Further evaluation of the 2000–04 cohorts' marks (n = 593) revealed that practice placement marks contributed to that increase, and showed a significant rising trend when considered separately from marks from academic modules.

Conclusion:

An upward trend in practice placement marking can be seen, year on year, which indicates that grade inflation is present in practice placement marking.

The clinical viva: an assessment of clinical thinking

In order to enable Masters level pre-registration students to demonstrate sophisticated cognitive abilities, integration of knowledge, complex problem solving, critical opinion, lateral thinking and innovative action; an innovative assessment tool is required (Sadler, 2009). A clinical viva was devised to enable third year students in their final transitional placement prior to qualifying demonstrate both the art and science of nursing practice. The assessment combines some of the viva element of an Australian assessment model described by Levett-Jones et al. (2011), together with the think aloud approach suggested by Banning (2008); whereby the think aloud model acts as a catalyst for eliciting students' understandings and knowledge and the SOAP model is a mechanism for the assessment of students' understandings and knowledge. Rust (2002) calls for students to be afforded opportunities for regular formative feedback; therefore, the assessment includes a replica formative assessment, one week prior to the summative assessment. This formative test prevents assessment being seen as a snapshot of the student's development and encourages assessment for learning and is an approach which is suggested to discourage surface learning (Rust, 2002). A holistic rubric was developed in an attempt to capture the students' abilities against the six cognitive operators or heuristics suggested by Banning (2008). Open-ended questions were devised to be asked of the students as advocated by Levett-Jones et al. (2011), to uncover the student's cognitive abilities, integration of knowledge, complex problem solving, critical opinion, lateral thinking and innovative action. Roberts (2011) calls for new and innovative ways of assessing student learning which bridges the artificial divide between theory and practice and enables students to demonstrate both the art and science of nursing practice (p610). The clinical viva has the potential to be one such mechanism.