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.
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).