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College of Nursing

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Processes Related to Students who Demonstrate Unsafe Practice

Purpose

The purpose of this policy is to outline the processes to be used by instructors and students when students demonstrate unsafe or potentially unsafe performance in the clinical or lab setting.

Policy

Definition of Unsafe Practice

From the literature: "Unsafe clinical practice is behaviour that 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 behaviour involving unacceptable risk" (Scanlan, J., Care, W.D., Gessler, S. (2001). Dealing with the unsafe student in clinical practice. Nurse Educator, 26[1], 23-27).

From faculty and student focus groups: Unsafe practice is any practice that poses an actual or potential threat to the health of a client, including physical, psychosocial, or cultural safety. Unsafe practice includes harm not only to client but also to colleagues or oneself.

The recent literature on patient safety identifies that a number of factors can come together to create an error. Therefore, an individual may be involved, but may not be solely responsible. When examining a situation(s) deemed as involving unsafe practice, it may be useful to examine it in terms of "what happened?" "Why did it happen?" and "What could be done to prevent it from happening again?"

As a profession, nursing faces significant challenges in terms of creating and maintaining a safe practice environment. The Canadian Nursing Association (CNA) identifies that additional challenges to safe nursing care include: Nursing practice environment and workforce issues, team work and communication, nursing perspective on patient safety, and the patient perspective on patient safety, technology and culture of blame. Students who are learning to be nurses are learning to adapt to working within the present health care system, and therefore may also be affected by some of the additional systemic factors that impact patient safety. In the interest of creating and maintaining safe practice environments for patients and nurses, students must meet the standards of safe practice.

The following themes and behaviors were synthesized from the focus group feedback.

Behaviors that may be indicators of unsafe practice:

It should be noted that students and faculty identified the importance of context and patterns in relation to unsafe clinical performance. These behaviours are examples and are not meant to be inclusive of all behaviours.

  1. Lack of accountability, unprofessional practice
    • Does not accept responsibility for own actions, does not admit mistakes, covers up errors
    • Is dishonest
    • Does not recognize potential for doing harm, lack of insight
    • Is reluctant to assume a professional role
    • Does not make the effort to learn, is not interested
    • Breaks confidentiality
    • Does not ask for help when unsure
    • Demonstrates inappropriate boundaries
  2. Patterns of behaviour
    • Demonstrates a pattern of problems in clinical areas
    • Disregards policy, does not know policies
    • Is frequently late or absent
    • Does not change behaviour in response to feedback; repeats mistakes even after feedback
  3. Unmet competencies
    • Has a poor knowledge base
    • Is unable to apply concepts and theory in practice
    • Poor and/or inconsistent skills in assessment and client care
    • Is unable to apply concepts and theory in practice
    • Poor and/or inconsistent skills in assessment and client care
    • Unable to set priorities; unable to care for clients at level of complexity expected for the course
  4. Inconsistent communication and lack of respect
    • Lack of respect for clients, aggressive with clients
    • Ineffective communications with client and staff
  5. Lack of judgment
    • Poor clinical judgment
    • Goes beyond own scope of practice
    • Evidence of impaired judgment due to drugs, alcohol, or lack of sleep
    • Demonstrates extreme anxiety that is disproportionate to the situation

Sources of information when identifying students who may be practicing unsafely:

  1. For faculty:
    • Direct observation and supervision.
    • Information from patients, families, staff members, other students.
    • Intuition - unable to trust student.
    • Student care plans, charting and journals.
    • Poor performance in previous rotations.
    • Student avoids instructor.
    • Critical incidents such as medication errors, client injury.
  2. Feedback from students regarding what they think they should do if another student is practicing unsafely:
    • A student who is practicing unsafely is responsible to admit his/her own mistakes.
    • It is important, as a peer, to provide feedback when one sees another student practicing unsafely. Ask the student if he/she needs help.
    • If reporting the behaviours to the instructor, do so privately and not in front of the rest of the group.
    • Do not help the student cover up by doing his/her work or always checking to see if he/she has done what needs to be done.

Suggestions for risk management in relation to students who may be practicing unsafely:

  1. Keep anecdotal notes on all students and encourage students to keep their own notes about clinical situations.
  2. Look for patterns of performance from other clinical courses.
  3. Equal distribution of weak students among clinical groups.
  4. Adjust assignment so that client safety is not compromised.
  5. Provide explicit expectations at beginning of course (verbally and in writing), explicit guidelines for process that will be used if there are problems with safe practice. For example, have discussions in orientation and in post conference about safe practice. Discuss common areas for students to make mistakes.
  6. Have another faculty facilitator help with assessment/evaluation of weaker students.

Suggestions for fairness to the student in the process of helping him/her practice safely:

  1. Discuss with student in private, try to identify cause of the problem, level of insight and self-awareness. Give the student a chance to explain.
  2. Acknowledge level of student and clinical expectations at that level. Don't compare one student with another.
  3. Provide timely feedback.
  4. Set out an action plan with student and identify specific criteria that must be met.
  5. Increase one-on-one contact between student and teacher.
  6. Validate information that comes from another student.

Section A: Processes to be used by facilitators when there is unsafe or potentially unsafe performance in the clinical/lab setting.

Underlying principle:

The student and the program have a joint responsibility for facilitating student success in providing safe and competent nursing care.

These processes are predicated by the following standards of evaluation:

Clear direction of performance expectations, course intents, policies, and evaluation processes, which have been provided to the student during orientation; provision of the opportunity for growth; timely feedback (verbal and/or written).
In a situation where a student's performance places the client, facilitator, or staff at a foreseeable risk, the student may be dismissed immediately from the clinical site. Dismissal from the clinical site is not indicative of clinical failure.

Processes:

  1. The clinical instructor will document all aspects of performance, which may include anecdotal notes, descriptive narrative, examples of student's charting, discussions with health personnel, and student's written plan of care.
  2. Discuss and provide written documentation of performance issues with student.
    Performance issues may be resolved at this juncture or may move to process #3 or in some cases it may be necessary to move directly to process #4.
  3. Create a written performance contract with the student when this is deemed appropriate.
    A performance contract is a written agreement between the student and clinical instructor/course coordinator in which the performance issues are described and actions are identified that a student must complete within a specified time frame. The contract will specify the consequences if the performance plans are not met.

    The course coordinator, associate dean and academic advisor will be notified that a performance contract has been initiated. The contract will be sent to the academic advisor and placed in the student's file. The student will be encouraged to meet with an academic advisor.

    Please Note: If a student is on a performance contract that will be carried forward to the next clinical rotation the course coordinator will inform the subsequent course coordinator, who will then inform the next clinical instructor or preceptor. This is necessary to enhance student learning opportunities and for patient safety.

    The student will also be responsible for informing their next clinical instructor or preceptor.

    Performance issues may be resolved at this juncture or continue on to process #4.
  1. A formal meeting with the student, course coordinator, and clinical instructor will be held to discuss performance issues. An action plan to meet course intents within a specified time frame appropriate to course completion date will be identified. Counselors, academic advisors, student support persons may be present. The associate dean may be present at this meeting. Meeting notes will be kept. Issues and agreed-upon success strategies will be reviewed with the student. The student will sign and receive a copy of these meeting notes.
  2. In the event a student receives a minimal pass on the final evaluation, the clinical instructor may initiate a performance contract with the student to facilitate communication and student progress in the next clinical course. The course coordinator will be informed if a contract is initiated. The contract will be sent to the academic advisors and placed in the student file.
  3. Based on the literal descriptors, the student will be given a failure in the course if course intents are not met.

Section B: Failure in or withdrawal from a clinical course.

Underlying principle:

Refer to Section A.

1. Failure in a clinical course

Process:

  1. Documentation should include clear rationale for the failure. Include:
    • description of any untoward incidents during the clinical experience
    • documentation of any meetings that were held with the student that outline the clinical difficulties being experienced, the possible consequences of no improvement in performance, plans for improving, and evidence that the student has been informed and has identified a plan for improvement
    • literal descriptors should be used and student performance should match the descriptor for "fail"
    • clinical evaluations.
  2. At the time of the assignment of a failing grade:
    • the associate dean and academic advisor will be notified of the failure
    • the student, clinical instructor, and course coordinator will meet with the student to discuss the failure. The student can bring a support person, if desired. The associate dean may also attend the meeting if requested.
    • the following will be discussed:
      1. evidence leading to the decision to assign a failing grade
      2. exploration of possible reasons for the failure
      3. strategies the program may initiate in order to support the student if s/he repeats the course
    • document the meeting and provide copies to all parties.
    • inform the student of the right to appeal a failing grade and the appeal process.
    • provide direction on how to reapply for the course, if eligible.
    • A performance contract may be initiated at this time. The contract will be sent to the academic advisor and placed in the student file.
  3. Student will be advised to meet with an academic advisor:
    • a change in program will be created, if student is eligible
    • strategies to assist the student to be successful will be discussed and documented on the change in program
    • change in programs will be reviewed by the associate dean
    • the student will sign and receive a copy of the change in program and it will be placed in the student's file and a copy will be sent to the clinical coordinators.

2. Withdrawal from a clinical course in anticipation of a failure in the course

Process:

  1. Documentation should include:
    • description of any untoward incidents during the clinical experience.
    • documentation of any meetings that were held with the student that outline the clinical difficulties being experienced, the possible consequences of no improvement in performance, plans for improving, and evidence that the student has been informed and has identified a plan for improvement.
    • clinical evaluations.
  2. At the time of the withdrawal in lieu of failure:
    • the student, clinical instructor, and course coordinator will meet with the student to discuss the student's practice
    • strategies to support the student if s/he repeats the course will be discussed and documented
    • a performance contract will be initiated by the course coordinator or the student and placed in the student file
    • a performance contract should go forward to a new clinical placement ONLY in exceptional circumstances
    • a performance contract MUST be maintained when a student repeats a course that they have withdrawn from in anticipation of failure
    • direct the student to meet with an academic advisor.
  3. Student will meet with an academic advisor:
    • a change in program will be created, if student is eligible.
    • strategies to assist the student to be successful will be discussed and documented on the change in program.
    • change in programs will be reviewed by the associate dean
    • the student will sign and receive a copy of the change in program and it will be placed in the student's file and a copy will be sent to the clinical coordinators.

Section C: Student receives a minimal pass in a clinical course

Underlying principle:

Refer to Section A.

Process:

At the time of assigned minimal pass:

  • the student, clinical instructor and course coordinator may meet with the student to discuss the student's practice
  • strategies to support the student in the next clinical placement will be discussed and documented
  • a performance contract may be initiated by the course coordinator if necessary. This will be sent to the academic advisors and placed in the student file and sent to the clinical coordinators

Additionally, the minimal pass will be flagged by the academic advisor who will contact the course coordinator to identify if there are any particular issues.

The academic advisor will meet with the student to identify and discuss strategies to support the student in the next clinical placement. The meeting will be documented in the student file.

Download Student Performance Contract

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