Frequently when a student appears unlikely to be able to successfully complete a baccalaureate nursing program, a faculty member must work with the student to decide whether she* should continue in the program. The student may be unable to handle the academic work or to demonstrate safe practice in the clinical area, may be upset by personal problems which interfere with performance, or may discover that nursing is not appealing after all. Some students are able to make the decision to withdraw independently. However, in other cases, the faculty member has to decide that the student's performance is not acceptable for continuation in the nursing program, even though the student feels she should continue. Such decisions, when they are based on clinical performance, involve the most complex personal involvement by the faculty because clinical evaluation is generally less objective and clear cut than theory course grades, which are based on written examinations.
Working with a student who is doing unacceptable clinical work involves activities and elicits feelings which are very stressful for both student and faculty member. The experience may be especially stressful for a new faculty member who is not yet secure in her role. Fortunately, the situation generally arises with only a few students in a class, and usually with students who are in the first year of an upper division nursing program. However, we have had a few senior students whose performance was considered by faculty to be unacceptable for continuation.
In our experience, the decision-making process tends to fall into four sometimes overlapping phases: identifying the problem, collecting data and supervising the student, discussing the problem with the student, and resolving the situation. The discussion below describes these phases and proposes strategies for dealing with reach of them.
Identifying the Problem
Recognition that a student is having difficulty in the clinical area usually comes first. The faculty member begins to notice unsatisfactory performance. For instance, the student appears very anxious when trying to perform familiar skills such as bed ma king, administering injections, or taking blood pressures. Or she may not recognize her own limitations - administering an unfamiliar medication without checking with a faculty member, for example. The student may not be able to apply theory in the clinical situation; following a class on the care of a surgical patient she cannot discuss or carry out postoperative care. Or inabili t y toestablish helping relationships with patients may be the problem; the student may focus exclusively on her feelings. The student may be unable to develop a clear, safe nursing care plan, or fail to observe for complications or provide comfort measures indicated by the patient's condition.
One or two examples of unacceptable performance are not necessarily serious, but when a pattern of unsatisfactory performance seems to be developing it becomes clear that this is a problem situation. The faculty member may notice that the student repeatedly demonstrates unsafe behaviors or that her performance continues to be unacceptable e ven after she has been given specific feedback about it.
Apprehension and uncertainty are common faculty reactions during the stage of identifying the problem. You feel apprehensive because you know the problem will have to be handled and it will be difficult and stressful (and the apprehension is especially likely if you have had a similar experience before). You may feel uncertain about the identification of the problem: you wonder if anyone else has noticed the pattern of unacceptable behavior.
Once a problem has been clearly identified, a strategy must be planned for handling the situation. This might involve such things as scheduling extra conference time and finding ways to spend more of your time in the clinical area with the student involved. If you have never been in this situation before, you might seek help from another faculty member to clarify your responsibilities and develop your strategy. Also at this point you should begin to seek validation from colleagues that your perception of the situation is accurate.
Data Collection and Supervision
Once it is clear that a pattern of unacceptable behavior is emerging, it is time to begin implementing the strategy and to move into the second phase -collecting data and intensively supervising the student. In order to be fair to the student, the data collected on her performance must be as complete as possible. Types of data to collect include observed behaviors in the clinical area and written materials that demonstrate the student's use of theory and describe her nursing care. At our institution two types of written materials are frequently used. One of these, the process recording, provides data about the student's communication skills and ability to recognize the patient's thoughts and feelings instead of focusing on her own feelings. Another type of written material is the nursing process worksheet, which provides data on the student's ability to develop a clear, safe nursing care plan and to apply theory.
To collect observational data it takes time watching and talking with t he student, and more time recording the observations accurately and completely. Daily notes should be kept and recorded as soon as possible on a permanent form. There must be clear, specific examples of when and how the student's behavior was unacceptable, and it must be obvious that the behavior represents a pattern. At this point extra help and supervision may alleviate the problem. If the behavior persists, however, you must confront the student with the fact that her overall performance is unacceptable.
During such confrontations, we have found that students generally react in one of two ways. The student may be able to recognize the problem, hear the feedback, and propose a plan of action. Or the student may be convinced that there is no problem, fail to hear your feedback, and blame every t hing on someone else. Initially, one might think that the outlook for the student who reacts in the first way is more favorable. But that student may have a positive attitude, try harder, and still be unable to perform satisfactorily. If the student's initial reaction is negative and this does not change in time, the outlook is, of course, not very favorable. However, if in time the student is able to recognize the problem and actively work on it, the outlook may become more hopeful. We do not believe that you can accurately predict the outcome based on the student's initial reaction.
The student needs intensive supervision during this phase - because a problem student cannot function as independently as other students, and patient safety must be ensured. This student may need a great deal of help even with familiar procedures like administering medications, performing comfort measures, or collecting data from patients. The intensive supervision may have beneficial or detrimental effects. The benefits include assurance of patient safety and improvement of student performance. But, at the same time, the intense supervision may increase student anxiety, restrict independent behavior by the student, and decrease the faculty member's interactions with other students in the clinical group.
Activities during this phase of intensive supervising and data collecting on the student are both time consuming and anxiety provoking. The faculty member may experience uncertainty about her skill in handling data collection, and wonder if the exampies are accurate or if the right things are being looked at. She may feel anxious a bou t the ot her student's reactions: they are aware of the problem student's behavior and are watching to see how it is handled. Sometimes we have found ourselves concerned about appearing either to let the problem student "get by'Or to"pick on" that student. Either of these situations can affect the other students' performance as well as their interactions with the faculty member.
The faculty member may experience guilt because time is being taken away from the other students in the clinical group. You know that they are not getting as much from the clinical experience as they would if you had more time for discussion, questioning, and role modeling with them. You may find yourself resenting the extra time spent in data collection and supervision of the problem student.
To handle t he difficult ies of t his period, it is helpful to use colleagues for validation of your data and strategy. This helps particularly in dealing with the feelings of uncertainty. You also may begin to vent your feelings to colleagues and other support people. We have found this extremely helpful in dealing with all of the feelings elicited and in making us better able to focus on the tasks of this phase.
The faculty member also may need to do such things as plan clinical time around activities with the problem student, think of ways to evaluate others students when time with them is reduced, and find alternate means of providing supervision for the other students.
Discussing the Problem with the Student
The third phase focuses on discussions of the situation with the student. Extra individual conferences are often needed during this time, and special problems can occur during these sessions. Students some times express the feeling that the y a re being "attacked." How do you point out unacceptable behavior and yet have the student realize that you are not attacking her as a person? That's one kind of problem. Another is the student who can not e ven hear t he criticism. As teachers, we are taught to always point out positive as well as negative aspects of a student's performance. But suppose the student "hears" only the positive- How do you at this time make her realize the importance of unsafe behavior? Sometimes we hear from students the recurring theme "It's all your fault, your expectations are too high." The student can't hear you and you become increasingly frustrated with this lack of communication. Then the question becomes "Is it my fault?" "Am !expecting too much?" The student can become upset to the point of tears, which can be an emotional drain on the instructor as well. The student begins to cry, to tell you she wants nursing more than anything, her mother, grandmother, and aunts are nurses, her family expects thisofher, she ha sail of these other problems right now (boyfriend, girlfriends, health, part-time job) and they are affecting her clinical work . . , she just needs more time. How do you as a teacher sort out all of this and make your decision based on behavior related to clinical performance?
Discussion of the problem often leads to decision making. If the student improves and corrects her problem behavior, then she continues in the nursing program. If on the other hand, no improvement is seen, the student should not continue. Sometimes a student cannot be counseled out of a nursing program and you must make the decision for the student not to go on. The question then is when and how do you say to the student, "You have failed?"
Two issues must be considered in answering this question. The first is this: can you make the decision that a student has failed before the end of a grading period if the student is making no progress? On the other hand, a second issue arises when the student is making progress by the end of the grading period but the progress is not entirely satisfactory. What decision should one make then? We do not think that there are clear-cut answers to these questions. Policies may vary from institution to institution. We do think it is imperative that all faculty be clear as to their institution's policy in order to comply with i t so a s not to violate student rights.
Whenever and however you do make the decision, you will probably vacillate between knowing that you did the right thing and feeling that you weren't quite fair (maybe you should have given the student another chance, maybe you should have weighed the data differently). Feelings in this phase include both frustration and uncertainty. You feel frustrated when the student can'thear what you are saying, and when you are spending so much extra time in conferences. At the same time, you wonder if your expectations are too high, if you are being unfair to the student. You become torn between considering personal data and the student's desires on the one hand, and your data about unsafe performance on the other. You think about possible violation of the student's rights, and if you made the decision for the student not to go on, was it the right one? Symptoms of stress occur during this time, expecially sleeplessness; we ha ve lai n a wake for hours planning a strategy to handle the problem or thinking how it could have been handled differently.
We have found several approaches helpful during this phase, in order to decide when to tell t he student a bou t her behavior, weigh the alternatives and base the decision on the indi vidual situation. It is helpful to think of possible reactions ahead of time and possible consequences. Plan ahead how you will deal with them. Secondly, involve others formally in this situation, for example, course coordinators, You may arrange for a three-way conference with the student, course coordinator and yourself. The course coordinator can serve as an objective person who can facilitate communication between you and the student. Another approach is to arrange for an additional observerin the clinical area. This person can validate what you see and will not have to deal with persona I da ta (such as external problems, etc.) that you may be considering. Do not hesitate to increase your use of support people - we have found more experienced faculty members who have dealt with problem students before especially helpful.
During conferences allow students to vent their problems if this seems necessary. Listen, but then put these problems in perspective. Remember that no matter how bad personal problems are, unacceptable behavior cannot be ignored. An alternative to suggest may be that the student should handle personal problems now if they are urgent and think, of nursing as an option for a later time.
Resolving the Situation
When the decision is finally made and the student has dropped out of nursing either temporarily or permanently, there are still several possible outcomes. If immediately, or in time, the student agrees that this was the best decision and shares this with you, the resolution becomes easier. Most often, the student may feel you did the wrong thing "to her." Then you must get resolution on other points: data collection was as complete as possible, data were validated with appropriate others, etc.
Feelings of relief almost always occur during this phase - no matter what the outcome. You are glad that it is all over and you can begin to focus on other students.
Several approaches may be helpful in bringing the situation to resolution. Remember that this was a learning situation for you; because of this situation you may be better at it next time. If the student continues to blame you, continue discussions with support people so that you can learn to live with the student's feelings. Remember that in most cases, the ultimate decision does not have to be yours. Most schools of nursing have an appeals process. If the student feel strongly that you were unfair, she has the right to appeal her case. This provides an opportunity for both sides to be looked al by objective others, who then make a decision based on the data.
At best, this process is a difficult one for faculty and student. At worst, it leaves the student and faculty member with very bad feelings. A planned strategy which utilizes available resources can make the situation less stressful. We have found that thinking of the process in these four phases -identifying the problem, data collection and supervision, discussing the problem with the student, and resolving the situation - makes it seem easier to plan and implement strategies and deal with anxiety and uncertainty. Then both student and faculty member may be able to view their actions as positive and feel that they made the right decision.