Remediation in clinical practice for student nurses - A scoping review

BACKGROUND

Clinical practice provides an opportunity for undergraduate nursing students to develop the professional attitudes, knowledge and skills required for the delivery of safe competent care. Some students, however, are challenged to consolidate learning in clinical practice and are therefore at risk of failing courses or programmes. Supporting these students requires remediation strategies specific to clinical practice. This is challenging, however, as remediation approaches frequently centre on supporting students in theoretical components of courses/programmes, rather than clinical practice.

OBJECTIVES

A scoping review was conducted to explore and summarise literature in undergraduate nurse education related to remediation support for clinical practice.

METHODS

The research question was developed using the Population/Concept/Context model. Following the identification of keywords, five databases (CINHAL Plus, MEDLINE, ProQuest, Scopus and Informit) were searched. Abstracts and full-text articles were independently screened by two authors. Data from included studies was extracted and then thematically analysed.

RESULTS

Twenty papers met inclusion/exclusion criteria (five literature reviews, one concept analysis, six commentary papers and eight original research studies). Research studies used qualitative, quantitative, or mixed methods research designs. Populations included nurse academics, mentors/preceptors, health professional students (including nursing students) and nursing students exclusively. Three themes were identified: pre-placement remediation strategies; on-placement remediation strategies and post-placement remediation strategies. All authors highlighted the importance of remediation for at-risk students in clinical practice.

CONCLUSIONS

This review identified several remediation strategies that may support undergraduate nursing students in clinical practice. Few, however, were well-defined or rigorously evaluated, highlighting the need for additional research on nursing student remediation in clinical practice. A partnership-based approach to remediation that engages students, educators, and healthcare providers and is underpinned by clear processes may be of further benefit to nursing students in clinical practice.

Causes and outcomes of at-risk underperforming pharmacy students: implications for policy and practice

OBJECTIVE

This study aimed to understand the key determinants for poor academic performance of students completing a Bachelor of Pharmacy (BPharm), Bachelor of Pharmacy and Management (BPharmMgmt), or Master of Pharmacy (MPharm) degree.

METHODS

Data were collected on pharmacy students who had not met academic progression requirements between 2008 and 2018 at The University of Sydney, Australia. This included: age at the start of pharmacy degree; gender; whether they transferred from another university; whether they were a domestic or international student; Australian Tertiary Admissions Rank upon entry, previous studies in biology, chemistry, or mathematics; show cause triggers (units of study failed); number of show causes; students' written show cause responses; weighted average mark at last show cause or graduation; whether they graduated and were a registered pharmacist; and, the number of years they spent studying the degree. Descriptive studies were used to analyse student characteristics using SPSS software, and student self-reported reasons for poor performance were analysed reflexively using thematic analysis procedures using NVivo.

RESULTS

This study included 164 pharmacy students enrolled in a BPharm (79.3%, n = 130), BPharmMgmt (1.2%, n = 2), or MPharm (19.5%, n = 32). Of the students, 54% (n = 88) were men, 81% (n = 133) were domestic students, 15% (n = 24) transferred from another degree program, and 38% (n = 62) graduated from the course. Show cause students were less likely to graduate if they transferred from another degree program (P = 0.0002) or failed more than three units of study (UoS; P < 0.0001). The most commonly failed UoS were related to organic or pharmaceutical chemistry, and the top student self-reported reasons for poor performance was stress/anxiety, physical health, and depression.

CONCLUSION

Pharmacy schools should aim to address student foundational knowledge in chemistry, identify at-risk students early using pre-subject testing, and provide better services to address student mental health.

Understanding underperformance in a high-stakes clinical-based simulation assessment in physiotherapy: a descriptive analysis

BACKGROUND

High-stakes assessments are often used as a 'gate-keeper' activity for entry into the health professions by ensuring that the minimum core competency thresholds of the profession are met. The aim of the study was to explore if common areas of underperformance existed in international candidates assessed with a high-stakes clinical-based simulation assessment for entry into the physiotherapy profession in Australia.

METHODS

A retrospective mixed methods analysis of the clinical assessments completed by international candidates over a one-month period in 2021 that were deemed as not meeting competency. The clinical assessments were completed in one of the three practice areas: cardiorespiratory, musculoskeletal, or neurological rehabilitation. Each assessment was scored by two independent assessors, who discussed the performance and then completed a moderated assessment form. The assessment form used to score competency included seven domains such as initial assessment, effective treatment, communication skills, and risk management.

RESULTS

Fifty-one clinical assessments graded as not competent were analysed. Across the practice areas, a high failure rate was found in domains related to interpreting assessment findings and developing a treatment plan. This trend was also observed in the qualitative data, suggesting candidates struggled to meet competency in areas of planning and prioritisation, interpretation and implementation of the information gathered, and selection and evaluation of effective treatment.

CONCLUSION

These findings align with published data on the underperformance of Australian physiotherapy students in clinical placement settings, suggesting these issues are not specific to high stakes assessment of overseas physiotherapists, and that education needs to focus on improving these skills within the profession at all levels. With the identified areas of underperformance aligning with the ability to use higher order thinking and skills integral to clinical reasoning, improvements in the education and implementation of clinical reasoning may be a place to start.

Working with underperformance in surgical training: Educational strategies for supervisors

Underperformance is a significant challenge for surgical educators. This paper outlines some educational strategies to manage the very complex demands presented by underperformance during training in the workplace. Preventative approaches include: setting expectations with early conversations; conscious attention to the workplace curriculum; and building trainee evaluative judgement through assessment and feedback. Once underperformance has been identified, other approaches including: developing a joint action plan; reducing or increasing feedback opportunities; and ensuring the trainee remains motivated. While these strategies cannot prevent failure, they offer the trainee opportunities to succeed.

Just-in-time faculty development: a mobile application helps clinical teachers verify and describe clinical reasoning difficulties

BACKGROUND

Although clinical teachers can often identify struggling learners readily and reliably, they can be reluctant to act upon their impressions, resulting in failure to fail. In the absence of a clear process for identifying and remediating struggling learners, clinical teachers can be put off by the prospect of navigating the politically and personally charged waters of remediation and potential failing of students.

METHODS

To address this gap, we developed a problem-solving algorithm to support clinical teachers from the identification through the remediation of learners with clinical reasoning difficulties, which have significant implications for patient care. Based on this algorithm, a mobile application (Pdx) was developed and assessed in two emergency departments at a Canadian university, from 2015 to 2016, using interpretive description as our research design. Semi-structured interviews were conducted before and after a three-month trial with the application. Interviews were analysed both deductively, using pre-determined categories, and inductively, using emerging categories.

RESULTS

Twelve clinical teachers were interviewed. Their experience with the application revealed their need to first validate their impressions of difficulties in learners and to find the right words to describe them before difficulties could be addressed. The application was unanimously considered helpful regarding both these aspects, while the mobile format appeared instrumental in allowing clinical teachers to quickly access targeted information during clinical supervision.

CONCLUSIONS

The value placed on verifying impressions and finding the right words to pinpoint difficulties should be further explored in endeavours that aim to address the failure to fail phenomenon. Moreover, just-in-time mobile solutions, which mirror habitual clinical practices, may be used profitably for knowledge transfer in medical education, as an alternative form of faculty development.

Country of qualification is linked to doctors' General Medical Council performance assessment rate, but is it linked to their clinical competence?

Mehdizah and colleagues recently described the prevalence of General Medical Council regulatory performance assessments by doctors' country of primary medical qualification. This article has caused anger within the UK-international medical community because it identifies graduates of certain countries with significantly raised prevalence.The present article comments on evidence from published Royal College of General Practitioners' data that support these conclusions. However, in an increasingly international age of medical education, the ambiguity of attributions of qualifying from a certain country needs addressing. Some medical students of British nationality, for example, who fail to obtain a place at a UK medical school, train in medical schools abroad, and thus may be identified as international medical graduates.Please see related article: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-017-0903-6 .

Does neuropsychological test performance predict outcome of cognitive behavior therapy for Chronic Fatigue Syndrome and what is the role of underperformance?

OBJECTIVE

A subgroup of patients with Chronic Fatigue Syndrome (CFS) has cognitive impairments, reflected by deviant neuropsychological test performance. However, abnormal test scores can also be caused by suboptimal effort. We hypothesized that worse neuropsychological test performance and underperformance were related to each other and to a smaller reduction in fatigue, functional impairments, physical limitations and higher dropout rates following cognitive behavior therapy (CBT) for CFS.

METHODS

Data were drawn from a previous trial, in which CFS patients were randomized to two conditions; 1) guided self-instruction and additional CBT (n=84) or 2) waiting period followed by regular CBT for CFS (n=85). Underperformance was assessed using the Amsterdam Short Term Memory Test (<84). To test neuropsychological test performance, the Symbol Digit Modalities Task, a simple reaction time task and a choice reaction time task were used. Interaction effects were determined between underperformance and neuropsychological test performance on therapy outcomes.

RESULTS

Underperformance was associated to worse neuropsychological test performance, but there were no significant interaction effects of these two factors by therapy on fatigue severity, functional impairments and physical limitations, but there was a significant main effect of underperformance on functional impairments, physical limitations and dropout rates.

CONCLUSION

Underperformance or neuropsychological test performance was not related to the change in fatigue, functional impairments, and physical limitations following CBT for CFS. However, underperforming patients did drop out more often. Therapists should pay attention to beliefs and behavioral or environmental factors that might maintain underperformance and increase the risk of dropout.