Journal of Nursing Education

Major Article 

Characteristics of Unsafe Undergraduate Nursing Students in Clinical Practice: An Integrative Literature Review

Laura A. Killam, MScN, RN; Florence Luhanga, PhD, RN; Debra Bakker, PhD, RN

Abstract

Providing quality clinical experiences for nursing students is vital to the development of safe and competent professional nurses. However, clinical educators often have difficulty identifying and coping with students whose performance is unsatisfactory. The purposes of this integrative review were to examine the extent and quality of the literature focusing on unsafe nursing students in clinical settings and to describe the characteristics of nursing students considered unsafe in clinical settings. A structured literature search yielded 11 relevant articles: five theoretical articles and six research studies. Analysis of findings revealed three themes: ineffective interpersonal interactions, knowledge and skill incompetence, and unprofessional image. The themes reflected the attitudes, actions, and behaviors that influenced students’ ability to develop a safe milieu for client care. The findings provide clarity for early identification of students in need of increased support and facilitate clinical educators in meeting students’ learning needs to ensure patient safety.

Abstract

Providing quality clinical experiences for nursing students is vital to the development of safe and competent professional nurses. However, clinical educators often have difficulty identifying and coping with students whose performance is unsatisfactory. The purposes of this integrative review were to examine the extent and quality of the literature focusing on unsafe nursing students in clinical settings and to describe the characteristics of nursing students considered unsafe in clinical settings. A structured literature search yielded 11 relevant articles: five theoretical articles and six research studies. Analysis of findings revealed three themes: ineffective interpersonal interactions, knowledge and skill incompetence, and unprofessional image. The themes reflected the attitudes, actions, and behaviors that influenced students’ ability to develop a safe milieu for client care. The findings provide clarity for early identification of students in need of increased support and facilitate clinical educators in meeting students’ learning needs to ensure patient safety.

Ms. Killam is Professor, School of Health Sciences and Emergency Services, Cambrian College, and Dr. Luhanga is Assistant Professor, and Dr. Bakker is Professor, Laurentian University, Sudbury, Ontario, Canada.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Laura A. Killam, MScN, RN, Professor, School of Health Sciences and Emergency Services, Cambrian College, 1400 Barrydowne Road, Sudbury, Ontario, Canada P3A3V8; e-mail: laura.killam@cambriancollege.ca.

Received: September 01, 2010
Accepted: February 16, 2011
Posted Online: May 17, 2011

Patient safety is not only a mandate, but also a moral and ethical imperative when nurses provide care (Canadian Nurses Association [CNA], 2009). From a nursing education perspective, teaching and preserving patient safety is a major priority (Kopala, 1994). Clinical placement is a key component of nursing education (Scanlan, Care, & Gessler, 2001) and grounds learning in experience. Thus, providing quality clinical experiences for nursing students within diverse care settings is vital to the development of safe and competent professional nurses.

Although numerous factors affect learning, Hegge et al. (2010) asserted that the quality of clinical experiences relies on the interactions among students, patients, and educators. Educators are in a key position to shape clinical learning experiences. Students report that learning is enhanced when educators are respectful, knowledgeable, and approachable (Hanson & Stenvig, 2008; Tang, Chou, & Chiang, 2005). Educators who work closely with students promote a sense of shared responsibility for patient safety, creating a space for dialogue about potential risks (Killam, 2010). Likewise, students are expected to come to clinical settings prepared by having read about the client’s condition and developed a care plan and by possessing knowledge about interventions they will administer (Brown, Neudorf, Poitras, & Rodger, 2007). Baccalaureate nursing programs strive to create clinical learning environments where students can safely develop and practice their knowledge and skills while interacting with patients (Canadian Association of Schools of Nursing, 2006). However, despite teaching and learning strategies aimed at promoting success, some students are challenged in demonstrating safe and competent nursing care appropriate to their level of learning.

It is reported that clinical educators find it difficult to identify and cope with students whose performance is unsatisfactory (Brown et al., 2007). This difficulty may arise from several factors, including multiple interpretations of what is considered unsafe student clinical behavior, limited experience in evaluating students, different views among faculty regarding how to intervene in potentially unsafe learning situations, and unclear program policies (Brown et al., 2007; Duffy, 2003; Scanlan et al., 2001). As a result, there is a risk that students who demonstrate marginal clinical nursing practice may proceed in nursing programs, graduate, and become unsafe nurses. Thus, there is a need to further explore the issue of unsafe nursing student clinical practices. The consequences of graduating marginally competent novice nurses undoubtedly leads to poor standards of nursing care, increased patient safety risks, and a perceived lack of confidence in the nursing profession by the public (Scholes & Albarran, 2005).

Early identification of unsatisfactory clinical performance is essential for promoting students’ success in learning (Teeter, 2005). Ambiguity in the literature regarding the definition of unsafe practice contributes to the challenges clinical educators face in identifying and meeting the learning needs of students. For example, Orchard (1994) and Scanlan et al. (2001) reported that many Canadian schools of nursing do not have formalized criteria for defining unsafe or safe student clinical practice. A clear description of unsafe student clinical practice would facilitate early identification of students in need of increased support (Duffy, 2003; Luhanga, 2006). This clarity would support clinical educators in both meeting the learning needs of these students and ensuring safe client care. Thus, the purposes of this integrative review were to examine the extent and quality of the literature focusing on unsafe characteristics of nursing students in the clinical setting and describe the characteristics of unsafe nursing students in clinical settings.

Method

An integrative review was undertaken to synthesize data from existing literature on unsafe nursing students in the clinical practice setting. Using the strategy proposed by Whittemore and Knalf (2005), a five-stage process was followed that included identifying the problem and purpose of the review, conducting a structured literature search, appraising the quality of the data, extracting and analyzing data, and synthesizing and presenting findings.

A literature search was designed to capture both published and grey literature related to unsafe nursing students in clinical practice. To retrieve relevant research studies, theses, theoretical articles, and reports, computerized searches were conducted of the CINAHL, EBSCOhost, PubMed, and ProQuest Nursing and Allied Health Source databases using the key words of unsafe, student, and education, clinical (subject). These key words were combined with each other, as well as with the following terms clinical, preceptor (truncated), fail (truncated), incompetent (truncated), health care, misconduct, marginal, at risk, challenge (truncated), difficult, and borderline. The searches yielded 73 potential citations based on a review of titles and abstracts.

In addition, the reference lists of the 73 articles were manually searched for additional citations that addressed unsafe nursing student practices or related issues, such as educator reluctance to fail students in clinical settings. Communication with researchers in the field and use of an Internet search engine were used to identify and locate grey literature that was unavailable through the library databases mentioned above. Most citations identified were duplicates of those found during the computerized database search. However, this effort resulted in the identification of 15 additional citations, yielding a total of 88 potential documents (Figure).

Search outcomes. Note. PhD = Doctor of Philosophy.

Figure. Search outcomes. Note. PhD = Doctor of Philosophy.

Abstracts of all 88 citations were reviewed. Quantitative and qualitative research reports, theses, and theoretical articles were included if they met the following inclusion criteria: they were published in English and they examined characteristics of unsafe nursing students in clinical practice. For the purposes of this integrated review, characteristics included unsafe or inappropriate attitudes, actions, and behaviors demonstrated by undergraduate nursing students during clinical placements. No restrictions were placed on the dates of publication. Articles or reports published up to February 2010 were included. Literature examining student safety in relation to classroom learning, advanced practice nursing students or registered nurses enrolled in baccalaureate nursing programs, and students in other professional health care disciplines were excluded. Of the 88 citations, 51 abstracts initially met the inclusion criteria. The 51 articles and reports were read in their entirety and an additional 39 were eliminated because they did not address undergraduate clinical learning situations or describe unsafe characteristics of nursing students.

Twelve articles or reports met the inclusion criteria. They included five theoretical articles, five research studies, and two theses. One of the two theses was excluded because an article had been published by the author and a review of both documents revealed that the same study findings were reported in both the thesis and article. Thus, only the article was retained. Therefore, a total of 11 articles or reports were included in this integrative review.

Each of the six research reports (five research studies and one thesis) was independently assessed for quality by two authors (L.K. reviewed all articles and F.L. and D.B. each reviewed half of the articles) using either the qualitative (Qualitative Findings Critical Appraisal Scale) (Pearson, 2004) or quantitative (Checklist for Assessing the Validity of Descriptive/Correlational Studies) (Pearson, 2006) research critical appraisal tool from the Joanna Briggs Institute. Each tool included 10 quality items for rating. For the five qualitative research reports, appraisers indicated the presence or absence of methodological congruency with the stated philosophical perspective, research question, data collection methods, and data analysis and interpretation of results; statements of reflexivity regarding the researcher’s cultural, theoretical, and methodological influence; evidence of participants’ voices; an ethical research approach; and conclusions that flowed from data analysis. The thesis was assessed using the quantitative research evaluation tool and appraisers indicated the presence or absence of sampling technique; adequate sample size and representation; inclusion criteria; a connection between the hypotheses and a theoretical framework; reliability and validity; ability to compare groups; appropriate statistical analysis; statistical or clinical significance; a link between findings and a theoretical framework; and generalizability.

For both quality tools, items were scored as no (0), yes (1), or unclear (0). A total score was then tabulated for each study, ranging from low quality (0) to high quality (10). The research studies and the thesis were then ranked based on their total appraisal score as low quality (1–3), medium quality (4–6), or high quality (7–10). All three authors participated in quality appraisal, and inter-rater comparison of the two appraisers for each study showed that 1-point discrepancies for total score occurred with three studies. These discrepancies were analyzed by all authors to reach a consensus in the final ranking.

The six identified research reports were summarized in tabular form and relevant data were extracted, including study purpose, design, sample and setting, methods, and findings (Table 1). For each report, descriptions of student attitudes, actions, or behaviors that were reported by the study authors as indicators of unsafe student clinical practice were extracted verbatim. Relevant data extracted from the five theoretical articles included article type, purpose, and descriptions or conclusions about unsafe students in the clinical setting (Table 2). Extracted descriptions of unsafe student characteristics (attitudes, actions, and behaviors) from all 11 documents were reviewed and grouped into categories based on similarities. Synthesis occurred though categorizing, summarizing, comparing, and interpreting findings within and across articles and reports to identify themes that reflected characteristics of unsafe nursing students.

Summary of Research ReportsSummary of Research Reports

Table 1: Summary of Research Reports

Summary of Theoretical Articles

Table 2: Summary of Theoretical Articles

Results

Extent and Quality of Literature

The structured search of the health care literature yielded only 11 relevant citations. The five theoretical articles identified (Table 2) were descriptions of policy development (Brown et al., 2007; Darragh, Jacobson, Sloan, & Standquist, 1986; Scanlan et al., 2001), an editorial on the consequences of not failing unsafe students (Scholes & Albarran, 2005), and a commentary on the legal aspects of failing students (Parrott, 1993). The research reports (Table 1) included mainly explorations of unsafe students from educators’ perspectives. Only one study explored the students’ viewpoint (Killam, 2010). Researchers examined characteristics of unsafe students using grounded theory (Duffy, 2003; Luhanga et al., 2008a), phenomenology (Girot, 1993), and qualitative description (Hrobsky & Kersbergen, 2002). Data collection methods consisted of unstructured and semi-structured interviews, focus groups, reflection, and document review. Case study methodology was used to examine one preceptor’s experience with an unsafe student (Rittman & Osburn, 1995). In addition, Q-methodology (Killam, 2010) was used to capture both the students’ and educators’ views of unsafe clinical learning situations.

All six research studies were rated as medium to high quality. Some qualitative studies did not meet all 10 criteria of the critical appraisal tool (Pearson, 2004) because they lacked a clear philosophical perspective; statements of reflexivity regarding cultural, theoretical, or researcher influence; or evidence of ethical approval. The research study using Q-methodology was assessed as a quantitative study; however, not all questions in the critical appraisal tool (Pearson, 2006), such as those related to random sampling and hypothesis formation, were relevant or appropriate for this type of inquiry (Brown, 1980).

Characteristics of Unsafe Nursing Students

Analysis of findings related to descriptions of unsafe nursing students in clinical learning situations resulted in three themes: ineffective interpersonal interactions, knowledge and skill incompetence, and unprofessional image (Table 3). These themes reflected the attitudes, actions, and behaviors that influenced the students’ ability to develop a safe milieu for client care.

Synthesis of Unsafe Nursing Student Characteristics

Table 3: Synthesis of Unsafe Nursing Student Characteristics

Ineffective Interpersonal Interactions. The theme of ineffective interpersonal interactions comprised two categories that describe communication and relational challenges (Table 3). The category of poor communication included unsatisfactory verbal and nonverbal cues that occurred between the student, clinical staff, the clinical educator, or patients. Descriptions of a student’s inappropriate verbal or nonverbal communication included making harmful remarks to patients (Duffy, 2003); ineffectively conveying information (Brown et al., 2007; Luhanga et al., 2008a); eye rolling, yawning, or sighing (Luhanga et al., 2008a); or facial expressions displaying panic (Rittman & Osburn, 1995). Examples of unsafe written communication included unclear documentation of a patient’s situation or nursing care activities (Rittman & Osburn, 1995; Scholes & Albarran, 2005). Failure to articulate their learning needs was deemed unsafe if the student avoided asking questions or seeking assistance in learning scenarios (Girot, 1993; Hrobsky & Kersbergen, 2002; Luhanga et al., 2008a; Rittman & Osburn, 1995; Scholes & Albarran, 2005).

Difficulty developing relationships with the educator or patient compromised safety. Ineffective interactions included the student being argumentative, failing to listen and accept feedback, and being disrespectful (Brown et al., 2007; Luhanga et al., 2008a). Not listening to instructions or feedback was reported to lead to repetitive errors, difficulty with self-evaluation, and performance ability (Luhanga et al., 2008a). Several authors indicated that ineffective interactions with the educator resulted in the educator not being able to trust the student to report important information (Brown et al., 2007; Girot, 1993; Rittman & Osburn, 1995; Scholes & Albarran, 2005), seek appropriate backup or assistance in patient care situations (Rittman & Osburn, 1995), or follow directions (Luhanga et al., 2008a).

Difficulty developing relationships with patients was reflected in a student not knowing how to approach the patient (Rittman & Osburn, 1995), displaying poor conduct with patients (Scholes & Albarran, 2005), or crossing professional boundaries through self-disclosure (Luhanga et al., 2008a). One study reported a patient’s reaction to a student’s failure to develop a therapeutic relationship; the patient reacted negatively to care, became angry, and told the student to “go practice on another patient” (Rittman & Osburn, 1995, p. 219). In the study that examined students’ viewpoints (Killam, 2010), the student sample indicated that feelings of being pressured to go beyond the scope of student clinical practice to please educators or hospital staff could also lead to a student performing unsafely.

Knowledge and Skill Incompetence. The theme of knowledge and skill incompetence reflected a student’s failure or inability to demonstrate knowledge and skill development at a level compatible with his or her year of study. It included both a deficiency or inappropriate use of knowledge and skills. This theme had two categories: limited cognitive ability and weak skill demonstration (Table 3).

Limited cognitive ability reflected a student’s unsatisfactory level of knowledge, critical thinking, and insight into his or her own practice. Limited knowledge development was reported in all research reports as the inability to plan and implement required patient care. Examples that demonstrated knowledge deficits included not knowing what to do and not knowing the side effects of medications the student was administering (Parrott, 1993; Rittman & Osburn, 1995).

An inability to think critically about nursing interventions jeopardized patient safety (Brown et al., 2007; Killam, 2010; Rittman & Osburn, 1995). Unsafe student characteristics related to critical thinking included failure to recognize what or why interventions were needed (Rittman & Osburn, 1995), difficulty providing rationale to support actions (Scholes & Albarran, 2005), and an inability to solve problems (Rittman & Osburn, 1995). In addition, unsafe students demonstrated a lack of insight into their strengths and weaknesses (Brown et al., 2007; Duffy, 2003; Girot, 1993; Luhanga et al., 2008a; Rittman & Osburn, 1995; Scanlan et al., 2001). If an error was made, unsafe students were unable to articulate their decision making (Girot, 1993) and often insisted they were not at fault or did not make an error (Rittman & Osburn, 1995).

Documentation of weak nursing care skills involved descriptions of how students conducted patient assessments and basic care and whether they demonstrated increasing ability to organize and prioritize care and not make mistakes. It also included observations of students’ incompetence in motor skills (Darragh et al., 1986), technical skills (Duffy, 2003), medication administration (Duffy, 2003), and dosage calculation (Luhanga et al., 2008a). Students were deemed unsafe if patient assessments were missed, inconsistent, or not documented (Brown et al., 2007; Scholes & Albarran, 2005) and if basic care was sloppy or incomplete, particularly when students indicated care was finished but the patient’s needs were not met or addressed (Brown et al., 2007; Luhanga et al., 2008a; Rittman & Osburn, 1995; Scholes & Albarran, 2005). One study reported that unsatisfactory demonstration of “skill performance” was an objective indicator to identify and validate concerns about student safety in the clinical setting (Hrobsky & Kersbergen, 2002).

The occurrence of repeated student error was behavior that was viewed with great concern (Brown et al., 2007; Darragh et al., 1986; Killam, 2010; Luhanga et al., 2008a). Errors resulted when the student did not ask questions or follow instructions. These errors included medication errors, going to the wrong patient, performing procedures incorrectly, misinterpreting orders, or missing important reactions to medication (Darragh et al., 1986; Luhanga et al., 2008a; Parrott, 1993; Rittman & Osburn, 1995).

Unprofessional Image. The third theme involves the projection of an unprofessional image. This theme has three major categories: inappropriate attitudes, inappropriate behavior, and lack of accountability (Table 3). Inappropriate student attitudes included displays of repetitive errors, disrespect, anger, defensiveness, overconfidence, low confidence, and apathy (Brown et al., 2007; Darragh et al., 1986; Killam, 2010; Luhanga et al., 2008a). These attitudes were perceived to impede the student’s ability to create a safe care environment because they often resulted in the student ignoring client needs (Killam, 2010), crying, or engaging in an intense argument with the instructor when confronted (Luhanga et al., 2008a). An attitude of overconfidence was deemed unsafe when a student became defensive and unreceptive to feedback or blamed the educator for performance issues (Girot, 1993; Luhanga et al., 2008a). Alternatively, low confidence and apathy were perceived to compromise safety when students were unsure of themselves (Killam, 2010; Luhanga et al., 2008a; Rittman & Osburn, 1995), lacked concern for patients (Girot, 1993; Scholes & Albarran, 2005), were unenthusiastic about nursing (Hrobsky & Kersbergen, 2002; Luhanga et al., 2008a), or had difficulty engaging in learning (Killam, 2010).

Student behaviors that were unprofessional included uncontrolled nervousness or anxiety, lack of preparation, lateness, avoidance, and violation of procedures. Students who were unable to control their anxiety and nervousness had difficulty focusing on client care (Killam, 2010). Such behaviors were often noticed by patients (Luhanga et al., 2008a; Rittman & Osburn, 1995; Scholes & Albarran, 2005). Lack of preparation for patient care as demonstrated by arriving in the clinical area without having read about the client’s condition or having developed an adequate nursing care plan was an indicator of an unsafe student (Brown et al., 2007; Killam, 2010; Luhanga et al., 2008a; Parrott, 1993). Other behaviors such as inadequate sleep before clinical (Brown et al., 2007), lack of punctuality, avoiding contact with patients or the educator, dismissing learning opportunities, performing only the minimum required tasks (Hrobsky & Kersbergen, 2002; Luhanga et al., 2008a; Scholes & Albarran, 2005), or violating unit procedures (e.g., improper handling of medications or ignoring aseptic technique) (Darragh et al., 1986; Luhanga et al., 2008a) were all described as unsafe student characteristics.

Behaviors indicating a lack of accountability included failure to report important information, crossing professional boundaries, displaying dishonesty, carelessness or risk taking, and illegal behaviors (Brown et al., 2007; Killam, 2010; Rittman & Osburn, 1995; Scholes & Albarran, 2005). In addition, a student lacking professional accountability often demonstrated a poor work ethic, such as sleeping or eating on the unit (Duffy, 2003; Luhanga et al., 2008a). Other examples included dishonest behavior, such as covering up mistakes through lying or embellishment (Brown et al., 2007; Hrobsky & Kersbergen, 2002; Killam, 2010; Luhanga et al., 2008a); risk-taking behaviors, such as performing procedures beyond the scope of student practice (Duffy, 2003); and illegal behaviors, such as arriving on the unit while under the influence of drugs or alcohol (Brown et al., 2007). In addition, student behavior that indicated patient negligence or verbal or physical abuse was a clear indicator of unsafe practice (Duffy, 2003; Luhanga et al., 2008a).

Discussion

This integrative review revealed that unsafe students are characterized by ineffective interpersonal interactions, knowledge and skill incompetence, and projecting an unprofessional image. Students exhibiting such attitudes, behaviors, or actions are challenged to meet baccalaureate nursing program objectives or practice competencies outlined by nursing regulatory bodies for new graduates. Students’ ineffective interactions interfere with the provision of safe patient care because the continuum of care is disrupted. These disruptions risk harm to the patient psychologically or physically because important information may be missed or misinterpreted. Knowledge and skill incompetence at the student’s level of study places patients at risk for clinical errors. Students who do not think critically may not question their practice, resulting in poor clinical judgments and decision making. Although a single incidence of incompetence may cause concern, persistent ineffective interpersonal interactions, repeated errors, or inconsistency in skill performance are particularly dangerous.

Professionalism is a key component of nursing care. Students are accountable for conducting themselves in ways that promote respect for the profession (College of Nurses of Ontario [CNO], 2009). Inappropriate attitudes and behaviors can interfere with the students’ ability to self-evaluate and improve on weak performance. Extreme dishonesty, such as lying, violates both the legal and ethical standards of nursing practice (CNA, 2008). Because of the potentially devastating effect, prevention or detection of clinical cheating or lying should be a priority for clinical educators (Gaberson & Oermann, 1999; Luhanga, 2006).

Implications for Practice

Although instances of unsafe student performance are not daily occurrences, they do require vigilance and careful intervention (Brown et al., 2007). Evaluation of the clinical experience can present several challenges to educators (Dolan, 2003). One influential factor is the subjective nature of assessment. The complexity and subjectivity of the clinical assessment process has been identified as problematic for maintaining a consistent approach to addressing student incidents (Kevin, 2006; Mahara, 1998). Clinical educators may have a difficult time weighing some of the nuances within the varying degrees of unsafe student behavior. A medication error can range from being late, to giving a drug by the wrong route, to continuing a trend of errors based on unclear or inaccurate information.

Although all of these errors are unsafe, the clinical educator must consider several factors when determining an appropriate response. The response involves the consideration of the type of event, the pattern and frequency of the behavior, the level of risk associated with the student’s behavior, the student’s year of study, and the timing in the semester. For example, if feelings of worry and anxiety happen once in the first week of a placement, it may hold a different meaning in terms of being unsafe than if it occurs throughout the placement. A student who is able to demonstrate growth in areas of weakness is less likely to be considered unsafe than one who does not modify his or her behavior. Orientation of clinical educators is necessary to prepare them for identifying and coping with such students (Brown et al., 2007; Luhanga, Yonge, & Myrick, 2008b). Findings from this integrated review can be incorporated in these sessions to facilitate early identification of unsafe students.

The perceived purpose of clinical placement experiences may also influence the clinical educator’s perception of a potentially unsafe learning situation. Clinical education may be viewed as a time for practice and learning or as a time for demonstration of competence. As a learning experience, clinical placements provide students with an opportunity to integrate theoretical and practical knowledge in real-world settings (Severinsson & Sand, 2010). Therefore, the clinical expectation focuses on the development of knowledge, technical skills, reflection, and problem solving (Severinsson & Sand, 2010). As students progress through a baccalaureate program and gain experiences, clinical placement expectations move to demonstrations of basic nursing skills and applications of knowledge, problem solving, and critical thinking that more closely meet the competencies of a graduate nurse (CNA, 2008; CNO, 2009).

Clarification of the philosophy underpinning clinical education throughout all levels of the course of study may aid educators when making decisions about unsafe students. For example, clear objectives that are leveled by year of study and linked to policies outlining behavioral and attitudinal expectations would promote consistency among clinical groups and support educators in the early identification of threats to safety. After an unsafe learning situation has been identified, documentation of the educator’s concern and the action taken is critical. Regardless of the type of event or remediation approach chosen, Emerson (2007) advocated that all episodes of unsafe student behavior be formally reported.

Implications for Policy

There is considerable reference in the literature to the phenomena of the “failure to fail” students even when they display unsafe clinical practice. Educators are often reluctant to assign a failing grade to students. This hesitancy may be due to fear of litigation, lack of confidence, limited knowledge of evaluation or remediation procedures, and perceived or actual lack of support for a decision that results in failure (Brown et al., 2007; Duffy, 2003; Scanlan et al., 2001). Assigning a failing grade is often a complex, time consuming, and emotionally challenging process (Duffy, 2003; Diekelmann & McGregor, 2003). Clear policy documents must be augmented with support from faculty during difficult decision making processes (Luhanga et al., 2008b; Yonge, Krahn, Trojan, Reid, & Haase, 2002).

The literature indicates that courts support decisions to fail students for unsafe clinical practice providing that the evaluation process is fair and well documented (Osinski, 2003; Parrott, 1993; Smith, McKoy, & Richardson, 2001). The existence of clear expectations within policy documents forms a legal basis for removal of a student from the clinical setting. However, many schools of nursing do not have clear policies or procedures for identifying and managing unsafe practice (Orchard, 1994; Scanlan et al., 2001).

Implications for Research

Of the six research studies that met the inclusion criteria for this review, the examination of unsafe nursing student characteristics was conducted primarily from the perspective of the educator. Only one of the studies included the students’ perspective (Killam, 2010). From a philosophical perspective, it is important to involve students in self-evaluation. Promoting critical reflection among students is a key strategy for learning in clinical environments (Allen, 2010; Ranse & Grealish, 2007). Further research involving perspectives and experiences of the students, clinical educators, preceptors, faculty members, and unit managers would aid in clarifying the concept of unsafe student practice from multiple viewpoints. A study by Killam, Montgomery, Luhanga, Adamic, and Carter (2010) demonstrated that students were able to recognize and report characteristics of unsafe students in clinical learning situations. To clarify the expectations of clinical evaluation, further research could also examine at what point student evaluation should move from the assessment of learning and practice to that of performance and competency. In addition, research focusing on the development and evaluation of strategies aimed at supporting students in need of increased assistance and the orientation of clinical educators and preceptors is recommended.

Limitations

The literature search was designed to capture as much research and grey literature as possible. Strategic searches of several electronic library databases and manual searching of reference lists provided confidence that the available research studies published in English were retrieved. However, it is not known whether all grey literature on the topic was retrieved. More extensive consultation with experts in the field or a comprehensive examination of schools of nursing policies both nationally and internationally may have retrieved more grey literature.

Conclusion

The core question guiding this review was “What are the characteristics of unsafe nursing students in the clinical setting?” In 2001, Scanlan et al. described unsafe clinical practice as:

Behavior that places the client or staff in either physical or emotional jeopardy...[and] unsafe clinical practice is an occurrence, or pattern of behavior involving unacceptable risk.

The findings from this integrative review expand this definition of unsafe clinical practice by addressing student characteristics that are deemed to be unsafe. Thus, characteristics of an unsafe student in clinical practice include any action, attitude, or behavior related to ineffective interpersonal interactions, including communication and relationship difficulties; knowledge and skill incompetence, including deficits or failures of appropriate application; and projections or reflections of an unprofessional nursing image.

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Summary of Research Reports

AuthorPurposeDesignSample/SettingMethodFindings Describing Unsafe Student Characteristics
Duffy (2003)To uncover mentors’ and lecturers’ experiences regarding “failure to fail.”Grounded theoryTheoretical sampling: 14 lecturers and 26 mentors from three Scottish diploma programs in the United Kingdom.Unstructured and semi-structured interviews. Constant comparative analysis.Ill treatment; being abusive verbally; saying things that are detrimental to a person’s health; cannot administer medications properly; interfering with people’s tracheostomy tubes and things unsupervised; lacked insight and knowledge yet willing to go ahead and carry out care; poor technical skills or lack of knowledge; inappropriate professional behavior; decided to sleep in the middle of the afternoon.
Girot (1993)To explore how experienced ward sisters measure and help others measure performance in the real world of practice.Phenomenology10 experienced ward/departmental sisters.Interviews and structured reflection. Analysis not clearly stated.Overconfidence; tend to become blasé; lacked patience with demanding patients, intolerant; lack of concern for particular types of patients; inability to work out why things are being done; inability to prioritize; unable to ask for help or show insight into the lack of safety of decisions.
Hrobsky & Kersbergen (2002)To explore preceptors’ perceptions regarding unsatisfactory clinical performance by students.Qualitative descriptivePurposive sampling: 4 preceptors from college nursing programs in the United States.Semi-structured interviews. Analysis process not clearly described.Red flags occurred early: not asking questions, having an unenthusiastic attitude toward nursing, and demonstrating unsatisfactory skill performance; did not ask questions; said that she knew everything but couldn’t show anything; students were just putting in time; gave impression that she had finished learning; didn’t want to do anything; too much self-disclosure; didn’t know her injection sites and did not check landmarks before giving an injection.
Luhanga, Yonge, & Myrick (2008a)To explore how nursing preceptors manage or cope with students whose level of performance is borderline or unsafe.Grounded theoryTheoretical sampling: 22 preceptors associated with final year clinical practicum in a variety of placement settings.Semi-structured interviews and documents review. Constant comparative analysis.Inability to demonstrate knowledge and skills; sloppiness; lack of organizational skills; inability to ask questions; ineptness to follow instruction; frequent repetitive mistakes; failure to practice basic safety measures; ill prepared; minimal clinical skills; lacks knowledge base; medication errors; not alert to the possibility of making mistakes; careless. Attitude problems; overconfidence; “know-it-all”; defensiveness: an unreceptive attitude to feedback; not alert to the possibility of making mistakes; indifferent, “I don’t care” attitude; not interested in learning or nursing. Unprofessional behavior; poor work ethic; dishonest; lack of confidence; extreme nervousness; hesitant and unsure; intentional unsafe behavior; negligence, laziness, gossiping, crying, eating, using cell phones while on duty; disrespectful to staff; lying, hiding errors, not admitting one’s own mistakes; verbal or physical abuse; embellishment. Poor communication skills; inappropriate interaction with preceptor or instructor (being too argumentative and disrespectful); inappropriate nonverbal communication such as eye rolling, sighing in front of patients; chewing gum; yawning; personal behavior that interferes with students’ ability to self-evaluate and perform work responsibilities; intense argument with instructor; inappropriate interactions with patients; boundary crossing such as self-disclosure.
Killam (2010)To describe undergraduate student nurses’ and their clinical educators’ viewpoints about unsafe clinical student practices.Q-methodologyConvenience sampling: 56 students and 13 clinical educators from three programs in northern Ontario.Focus group and literature review conducted to identify Q-sort statements. Analyzed using PQ Method (Schmolck, 2002).Lack of professional integrity; covering up mistakes; lack of professional accountability; violating standards related to established nursing practices of recording, reporting, and performing clinical skills; repeated errors in the delivery of care; pressure to please others; inability to focus on care; not prepared to care for a client beyond his/her skill level; lack of respect for client needs and inability to critically think; not sharing responsibility for client care; lack of preparedness for and discomfort with independent patient care; not being engaged in clinical learning; lack of social, cognitive and/or behavioral engagement; does not attend to the educator’s instructions or the client’s wishes; challenges with thinking critically about nursing interventions; unprepared for client care; violates procedures; lack of adherence to minimal expectations, disinterest, and inability to focus on patient care.
Rittman & Osburn (1995)To describe a preceptor’s journey through a difficult senior practicum experience.Case studyOne case: preceptor/senior student.Journaling, hermeneutical analysis.Cannot depend on student to seek appropriate backup or assistance in patient care situations; sloppy in patient care; lacks thoroughness; very anxious; late; having to get caught up; concerned facial expressions/look of panic; unsure of herself; patients often reacted negatively to care; did not know how to approach the patient; practicing at a level commonly encountered with beginning clinical students; patient’s room cluttered with dirty linens on the floor; difficulty in grasping and managing multiple facets of basic patient care; did not recognize gaps in patient’s care; difficulty organizing the smallest assignment; inconsistency in performance; inability to function at a senior level; difficulty with flexibility and organization; inability to establish routines; not exercising caution; deficiencies in basic skills; errors; failure to critically question practice and show alertness to possibility of making an error; difficulty remembering aspects of care in organizing and completing work; inability to complete tasks in a timely way; patients recognized that student had difficulty completing tasks, resolving problems, or knowing what needed to be done.

Summary of Theoretical Articles

AuthorsPurposeDescription of an “Unsafe” Student
Brown et al. (2007)Describes the development of a systematic approach for identifying and addressing unsafe clinical performanceInadequate level of preparation for providing care; fails to perform critical assessments; provides unsafe nursing care; does not report critical events; unethical or unprofessional conduct; authors quote Scanlan et al. (2001) definition of unsafe clinical practice; five themes presented: accountability and professional behavior, respect and judgment, patterns of behavior, competencies, and communication.
Darragh, Jacobson, Sloan, & Standquist (1986)Describes the process used to develop a policy for addressing unsafe student practice.Failure of a student to provide safe nursing care for attitudinal or physical reasons; lack of cognitive or motor skills needed for safe care of patients; exceeding the bounds of nursing; delegating responsibility for charting; failing to report incompetent nurses or doctors; medication errors; misinterpreting medical orders; pattern of behavior endangers a patient’s, peer’s, staff member’s, or clinical instructor’s safety.
Parrott (1993)Outlines legal aspects of failing students from an American perspective.Arrive in the clinical area unprepared for the day, without having read about the client’s condition or without an adequate nursing care plan; assigned to administer medications to one or more clients without knowing why certain drugs are being given to an individual or the common side effects of the drug; student, if allowed to continue, would only be “pushing pills” and might miss some major untoward effects of the medication on a client and would not be administering safe, informed care to their clients (unsafe medication administration).
Scanlan et al. (2001)Describes issues relating to justice, fairness and policy in relation to unsafe students. Outlines development of a policy in a Canadian context.Clinical teacher cannot leave the student alone; has no insight into his or her strengths and weaknesses; places the client or staff in either physical or emotional jeopardy; physical jeopardy is the risk of causing physical harm; emotional jeopardy means that the student creates an environment of anxiety or distress which puts the client or family at risk for emotional or psychological harm; unsafe clinical practice is an occurrence or pattern of behavior involving unacceptable risk; getting angry at the patient; violent gesture toward staff nurse; referred to the patient as “old bugger.”
Scholes & Albarran (2005)Describes contributing factors and consequences of “failure to fail” unsafe students, highlighting the need for appropriate assessments and failure of unsatisfactory students.Punctuality, high levels of anxiety, or having poor comportment with the patients; fails to ask questions; unenthusiastic; avoids working closely with the mentor; care may seem incomplete; bed space untidy; patients are not left comfortable; avoids direct patient contact; fails to write clearly in notes or convey important information; practice assessment documentation incomplete; dismisses learning opportunities as “done that before don’t want to repeat it”; evidence to support their learning is scant or poorly assembled.

Synthesis of Unsafe Nursing Student Characteristics

ThemeCategoryFindings
Ineffective interpersonal interactionsPoor communicationWeak verbal and written communication skillsFailure to articulate learning needs (ask questions and asks for help)Inappropriate nonverbal communication
Difficulty developing relationshipsInappropriate interactions with patients
Ineffective interactions with educators and other health care professionals
Knowledge and skill incompetenceLimited cognitive abilityKnowledge deficit
Lack of critical thinking
Poor insight
Weak skill demonstrationInconsistent assessment skills
Fails to perform basic care/skills
Lack of organizational skills
Unprofessional imageInappropriate attitudesRepetitive errors
Disrespect
Anger
Defensiveness
Overconfidence
Low confidence
Apathy
Inappropriate behaviorUncontrolled anxiety/nervousness
Lack of preparation
Lateness
Avoidance
Violating procedures
Lack of accountabilityNot reporting important information
Crossing boundaries
Dishonesty
Carelessness/risk-taking behavior
Illegal behavior
Authors

Ms. Killam is Professor, School of Health Sciences and Emergency Services, Cambrian College, and Dr. Luhanga is Assistant Professor, and Dr. Bakker is Professor, Laurentian University, Sudbury, Ontario, Canada.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Laura A. Killam, MScN, RN, Professor, School of Health Sciences and Emergency Services, Cambrian College, 1400 Barrydowne Road, Sudbury, Ontario, Canada P3A3V8; e-mail: .laura.killam@cambriancollege.ca

10.3928/01484834-20110517-05

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