important for assessing a student’s ability to engage effectively with the multi- disciplinary team, a necessity for ensuring continuity and safety in patient care. Other aspects of patient safety are also considered by mentors when taking a decision to pass or fail a student at the end of placement. In particular the student being trusted to work within their own limitations is a key criteria as the following excerpts illustrate:
‘That they know how to manage situations, they know how to communicate
with the team and that they are not just going to go off and do something without you know, that they shouldn't be doing.’ (Student AO, Mentor 41:
297-299)
‘But this student, she was safe you know, she was....' I don't know', she
wouldn't go off. And that is REALLY important because I've been burned before……. because even though I've told them nil by mouth, the patient is for theatre, another student gave a Weetabix and then denied that she had. Whereas I felt with this student, if she didn't know she would come and find me. She would check and if I gave instructions she would follow them. But she would also challenge if she didn't think it was right or if she felt
uncomfortable. I think students can question and I think they should question, there are times when we should be questioned.’ (Student AL,
Mentor 38: 272-280)
Knowledge to support the boundaries to a student’s practice is also an important dimension:
‘Whether they do know the correct readings for blood pressure, pulse etc. and what you would do if somebody had a low blood pressure. A third-year student who has just finished, she actually did a teaching for the first years on how to do a blood pressure which is quite nice.’ (Student M, Mentors 13a
& b: 438-441)
‘The way they do their work. If you allocate them, because as final year students you should be giving them some of their own work like say a bay of four patients. So if I go back and look at what they've done or what they're doing especially the documentation, you can look at the way, the decisions regarding those surgical patients in that bay and you're looking at the way they critically analyse things. And you can have a rough idea of whether they are going to pass or not.’ (Student AE, Mentor 31: 379-385)
Specific care activities such as medications and infection control also contribute to a mentor assessment of safe practice:
‘Basically you would look at your infection control... So taking cannulas out, having the sharp bin with you, using an apron and gloves. Hand washing as well.’ (Student M, Mentors 13a & b: 398-399)
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‘Basically their medications because I think that was the problem in the last placement for her. We did do a lot of practice with medication rounds and I also had other nurses do medication rounds with her because I think I made her nervous by saying that I could see that she was nervous. And I think if other people did this with her as well then that would be good feedback for her.’ (Student N, Mentor 15: 124-128)
Across these quotes it becomes evident that in forming judgements about a student and their practice, mentors consider not only skilled performance in such aspects as multi-disciplinary team working, medicines administration and infection control, but also the student’s attitude to maintaining patient safety. Mentors determine that a student has the appropriate attitude to support practice, when they feel that a student can be trusted to work within the limitations of their competence. Where mentors are unable to trust a student to work within their boundary of competence and be safe, they are left with no choice but to fail the student, as clearly
demonstrated in the following comments for failed final placement students:
‘I think if she had been safe she would have been signed off irrespective of, well maybe not being the best staff nurse in the world, but at least being safe. But we had a few near misses. Insulin was one of them. She went into a palliative patients’ house and... I think that was the thing, she wanted to seem confident and capable. But then she made the mistake of not really taking a step back and thinking or reading. So she would read stuff out loud that she was going to give and it would be incorrect because she had not taken time just to read and focus on what was going on. So she didn't read the notes in their entirety.’ (Student N, Mentor 14: 269-277)
‘My underlying need is for the student to be clinically safe to patients. That's what I look at. If the student... If we have taught a skill, go back to ECGs, if they don't get that skill that's fine, that's not clinically unsafe. They are not paid to interpret an ECG. Providing they know what to do with the ECG when they have taken it. So my underlying principle is 'are you going to be clinically safe?' Some people take longer to pick up on things than others. Not everyone can be a whiz kid. But do you know if you are taking the pulse if it is wrong? And what do I do? And we didn't feel, any of the team didn't feel that she was clinically safe.’ (Student AA, Mentor 27: 406-413)
‘I think on a really basic level it was that she wasn't meeting the NMC criteria. The accountability, the knowledge of evidence-based practice. Because of this I didn't think that she was providing a good service to the patients and I couldn't have that on my conscience knowing that...well she's not safe that's the most important thing. I don't think she dealt with the patients very professionally in the way that she spoke to them or the way that she dealt with relatives………. I think going back to your question why I failed her was that there was just no acknowledgement if she did something wrong, or the fact that she could have done something wrong. No awareness of her professional responsibilities.’ (Student Z, Mentor 41: 631-
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Across all the accounts mentors are quite clear that patient safety is paramount, in any decision that they make regarding a student and their competence. In those circumstances where students practice in a manner that may compromise patient safety, both in terms of actual skill set but more importantly in terms of attitude to patient safety, then mentors felt that the only decision that could be taken was to fail the student as they could not be trusted to practice safely.
Finally an important criteria influencing mentors across the programme, but particularly in evaluating a borderline student, is consideration of student development across the placement and whether sufficient development has occurred to merit a pass decision. As outlined earlier when examining mentor management of learning and development, target setting and achievement of targets for student ‘AK’ resulted in the sign-off mentor deciding to pass the student because:
‘Like I said everything that I asked her to do she did and the other members
of the staff on the ward said she had improved.’ (Student AK, Mentor 37:
297-298)
Student development and improvement was pivotal to the final evaluation of the student; a point not lost on the sign-off mentor when identifying this and
considering whether the correct decision had been taken:
‘Yes she had improved but I don’t know whether she had improved enough. And I don’t know whether we passed her on the right conditions or not.’
(Student AK, Mentor 37: 309-311)
What this does show is that though consideration of student development and improvement across a placement is desirable and valued when it comes to
evaluating a student’s overall competence, as a specific measure of achievement of a certain standard of practice it may be limited.
At the end of the programme evaluating a student against additional mentor
expectations of being ‘fit to register’ and ‘employable’ at the end of the programme, enables the sign-off mentor to feel confident in the decision taken:
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‘Some of them really function like staff nurses. Theatre preps...they'll be there and they'll do it. And they come to you and say can you just double check and it's all perfect. She knows what she is doing there. Shall I just start the care Plans? And I'll say that I will come and have a look. And you look at the care plans and it's as though they have been written by qualified staff. Some of them are so good. And then when you do medications though come and stand there with you and then you'll say do you want to do them? And then you'll be checking with her as she goes and you'll be seeing that confidence in doing things. And then she'll even be suggesting things like.... Do you think we should be giving out these things because of that? Because they realise that some medications are in certain groups... They're making the links. They already making decisions as they go along. You can see that they are already looking at their theory and trying to apply it on their placement.’ (Student AE, Mentor 31: 493-505)
‘I'd expect to feel that they would be competent to qualify and be a staff nurse I suppose. Like with ‘AI’ she was ready to be qualified.... It's about being able to take your own team of patients, which is generally what we aim towards. And whether you think they are ready; if you saw them as a qualified nurse on a ward would that scare you? Or would that be all right. Because I think a lot of stuff you don't learn until you qualify anyway, you can't do.’ (Student AI, Mentor 35: 275-381)
Confident in the decision taken they are then prepared to offer a job:
‘Yes, straightaway. Because.... It's really difficult to point to... I think
because she had the whole package. To be a good nurse you need to be aware of your limitations and your abilities. Like she could acknowledge that and alongside be a nice person, genuine, kind. She had the personality of a nurse, you know caring and gentle, she was professional, she knew how to deal with situations. But at the same time if she was unsure about
something she'd ask and she wasn't scared to ask either. You know like reflecting on practice which is what we want.’ (Student AO, Mentor 41: 341-
348)
However when asked if she would give the student a job, Mentor 37 replied:
‘No……Difficult to work with as a student (laughs). That's really bad isn't? The thing is she was a difficult one because she was very, very confident and came across as very knowledgeable, and her tutor questioned her knowledge a bit sometimes, when she came to see her, but when she was with her, she wasn't that confident and she stuttered and she stammered a lot. And I just think, you know, if I was given a choice of her and somebody that I hadn't met I wouldn't touch her.’ (Student AK, Mentor 37: 416-422)
This is an interesting comment from the mentor, who had passed the student on the basis of improvement, but was not sure whether there had been sufficient improvement, and certainly was not prepared to give the student a job. It suggests that the mentor herself is aware that improvement as a deciding criteria for passing the student is not enough, but lacking any other clear evidence to support her