You must facilitate students and others to develop their competence.

As a professional, you are personally accountable for actions and omission in your practice and must always be able to justify your decisions.

As an autonomous and accountable professional, you need to make informed and reasonable decisions about your practice to make sure that you meet the standards that are relevant to your practice. … You are responsible for your professional conduct, any care or advice you provide, and any failure to act.

• standards of personal professional practice

• standards of care delivery by learners

• what is taught, learned and assessed

• standards of teaching and assessing

• professional judgements about student performance.

Personal professional standards of practice

It is discussed in Chapter 1 that one purpose of assessment in pre-registration health care education is as a form of quality control for the outcome of the educational process. The educational and professional outcome is a nurse or midwife or physiotherapist or social worker, and so on, who is able to apply knowledge, understanding and skills to perform to the standards required in employment. This professional must have met the standards of proficiency, and prior to entry to the NMC and HCPC professional registers; students must also meet the standards of conduct, performance and ethics, and the health and character requirements of registration. The full realization of this outcome is dependent on the successful achievement of both theoretical and clinical learning and professional development measured by assessment. Assessment is an integral part of professional health care programmes. The processes of clinical teaching, learning and assessment are complex. The committed input of practice educators is required to plan and implement these processes if learning outcomes are to be achieved successfully. I would suggest that this commitment starts with the individual practitioner’s competence and standard of practice. Eraut et al (1995) state that, if aspects of clinicians’ practice are ill-defined, lack quality or make insufficient use of scientific knowledge, the next generation of practitioners will suffer.

Much of the learning that takes place in professional education does so in the practice setting (Baskett & Marsick 1992, Schön 1983). Role modelling is an important (Fowler 2008, Pollard 2008, Spouse 1998, Wood 1987), and an almost inevitable, learning strategy in this environment. Within social learning theory, Bandura (1977) suggests that, in role modelling, one person sets a pattern of behaviour that is then copied by another. Learning takes place constantly from observing role models deliver care – these practices are subsequently emulated (Charters 2000). Davies’ (1993) study of role modelling showed that major aspects of nursing were learnt by students when they observed role models providing direct patient care. Students who worked alongside knowledgeable and respected practitioners developed an enthusiasm and commitment to their professional development that was unparalleled by any other learning experience (Spouse 1998). As stated succinctly by McAllister et al (2007:305), ‘students are a product of their schooling’. It is therefore important for the practice educator to adhere to high standards of professional practice so that students learn this high standard of care and are assessed against these professional practices. A high standard of care from students cannot be expected if this is not role modelled. Without modelling high standards of practice one aspect of professional and moral accountability will not be fulfilled.

Nicklin & Kenworthy (1995:72) say that ‘assessment inevitably takes place in a role-relationship’. The usual relationship that exists between a student and a practice educator is hierarchical in nature. Neary (2000) pointed out that many practice educators take for granted their position of power in the assessment relationship. Her study in 1996 (in Neary 2000) showed the extent to which this ‘taken-for-granted’ power imbalance became explicit at early stages of the relationship when practice educators quickly confirmed their expertise and established the subordination of their students. In a review of the literature on how practice educators influence practice, Armstrong (2010) found that a student’s actual experience is one of control and coercion. Students felt powerless in challenging practice owing to their lack of status and the fear of jeopardizing their clinical assessment and securing a job.

Within this hierarchical situation, one assumption made of the practitioner as practice educator is that she/he possesses the requisite professional qualities and can recognize these in the learner (Harding & Greig 1994). This assumption is of course open to debate. Hepworth (1991:46) expressed her disagreement when she said that:

Our assessments, then, are likely to be based on our own standards of practice and perceptions of the situation. Therefore, as practitioners who are also practice educators, there is the responsibility for maintaining competent practice so that assessments are made against these standards. Furthermore, in exercising professional accountability, the NMC (2008b) and the HCPC (2008) require their practitioners on the professional registers to maintain and improve professional knowledge and competence. One point arising from debates on competence is the requirement for the practitioner to keep up to date in order to claim that practice is competent (Hager & Gonczi 1996, McGaghie 1991). Notwithstanding professional requirements, the bottom line in the argument for keeping up to date must be the legal requirement that professional health care practitioners can exercise contemporary professional practices as the law expects current practice to be the accepted practice (Dimond 2011, Young 2009, 1994). There is an expectation that practitioners will employ evidence-based practice and, generally speaking, judges will take a dim view of practitioners who fail to follow the latest clinical guidelines (Young 2009). The duty of care to patients requires practitioners to keep their knowledge and practice up to date (Griffith & Tengnah 2010).

Young (1994) states that the legal implication of omitting certain information, or of giving wrong information, is potential negligence on the part of the instructor. This potential exists whenever a failure in instruction jeopardizes the safety of the learner being instructed, or of the patient in her care. I would also suggest that, unless a practice educator is also a competent practitioner, training requirements may not be fulfilled owing to the inability to teach what constitutes competent practice. The practice educator thus has a legal duty, as well as moral and professional accountability to fulfil, in terms of keeping up to date and maintaining competent practice. If it could be established that a patient/client suffered harm as a consequence of negligent instruction (e.g. incorrect information to a student), the patient/client could instigate legal action against the instructor.

Standards of care delivery by learners

The practice educator has a dual responsibility: to the patient/client and to the student. A major aspect of the concept of professional negligence in clinical practice is that practice educators have a ‘specific duty or responsibility to foresee or anticipate the possible adverse outcomes of their actions’ (Gunby 2008:414). This applies to both client care and supervision of students. Practice educators must meet a standard of care with respect to the patient/client and a standard of conduct with respect to the student. Practice educators must ensure that students have the necessary clinical experiences and supervision to develop professional competencies in such a way that the patient/client is not harmed in any way while the student is giving the care. The NMC (2008b) and the HCPC (2008) state that patient safety must always take precedence above all else. The NMC and HCPC Standards of conduct, performance and ethics (HCPC 2008, NMC 2008b) make sure that practitioners put the interests of patients, clients and the public before their own interests and those of professional colleagues: i.e. accountability to the patient is always more important than to the student.

The Bolam Test (see later discussion) applies to delegation (Dimond 2011). In the eyes of the law, the student’s performance must be equal to that of a registered practitioner. The law is quite clear that a lack of experience or knowledge is never an excuse for incompetent care (Griffith & Tengnah 2010, Young 1994). Students of health care are thus required to provide care equivalent to that of the registered practitioner. One judge (in Young 1994:56) adopted the following view:

Another judge linked the expected standard of care to that of the post rather than to the status of the person performing the care, saying:

Therefore, in a highly specialized clinical setting, the standard must be ‘not just that of the averagely competent and well-informed [nurse] but of such a person who fills a post in a unit offering a highly specialized service’ (Wilsher v Essex AHA 1988, in Young 1994).

For students to deliver care to a standard equivalent to that of a registered practitioner, that care to be given must be within the student’s capabilities. So far as the NMC and HCPC (HCPC 2008, NMC 2008a) are concerned, it is the registered practitioner working with the student who is professionally responsible for the consequences of the actions and omissions of that student. A pre-registration student, or any other unqualified staff, who is not on the professional register cannot be called to account for her/his actions or omissions as registered practitioners are accountable for care given whether directly or through delegation. It is the personal and professional responsibility of the practitioner who delegates an activity to make sure that the person carrying out the activity is trained, competent and has the necessary experience to undertake the activity safely (Dimond 2011). The delegating professional must also make sure that the appropriate level of supervision is provided. The provision of appropriate levels of supervision is developed in Chapter 7.

A number of cases of qualified staff were reported to the then United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC 1996) for inappropriate delegation of responsibilities. One case, which was closed by the Preliminary Proceedings Committee (PPC) of the UKCC, concerned the delegation, by a nurse to a care assistant, of the task of administering an insulin injection. The case was reported on the basis that such administration by a care assistant was prima facie wrong. The issue considered by the PPC was not that the care assistant could not give the injection, but whether the person to whom the responsibility was being delegated was competent to carry out the task. The UKCC concluded that the issue was about supervision, the appropriateness of the delegation and the instruction of unqualified staff, and not about the rigid demarcation of work into tasks to be done by one group or another.

It is therefore important to know when and to whom it is safe to delegate. In order to delegate safely and to avoid negligent delegation, the practitioner must be satisfied that the person performing the delegated task is competent to carry it out (Dimond 2011, Young 1994). Making the following two checks may help you to decide when it is safe to delegate. Assess:

The learning and assessment programme for the student must therefore be planned so that the patient/client is protected from harm while the student is enabled to develop and achieve the professional standards of proficiency required.

The NMC (2008c) has issued detailed guidance on delegation that is available on its website. The guidance considers the principles of delegation by nurses and midwives, the responsibility and accountability of the practitioner who delegates and the documentation required.

What is taught, learned and assessed

The practice educator has the responsibility for ensuring that the learning environment is conducive to learning. A wide range of high-quality learning opportunities should be arranged and provided to enable the student to achieve learning outcomes and competencies. The Nursing and Midwifery Order 2001 (NMC 2001) and the Health Professions Order 2001 require the NMC and HCPC to determine the standard, kind and content of training to be undertaken with a view to registration. The standards of proficiency and standards of education required for all pre-registration health care education regulated by the NMC and the HCPC are set out in the Registration Rules (NMC 2004) and Standards of Education and Training under Article 15(1)-(9) of the Health Professions Order, 2001, respectively.

Pre-registration nursing and midwifery programmes in the UK now require students to achieve national NMC standards of proficiency (NMC 2010c, 2009). In the case of professions regulated by the HCPC, each profession has defined its own standards of proficiency with varied dates of implementation (HCPC 2011a).

It is a requirement that pre-registration programmes must be designed to enable students to apply knowledge, understanding and skills when performing to the standards required in employment and to provide the care that patients/clients require, safely and competently, in order to assume, on registration, the responsibilities and accountability necessary for public protection. Both the NMC and HCPC make it clear that these standards of proficiency are achieved under the direction of the practice educator. In accepting the roles of practice educator as defined by the NMC and the HCPC (HCPC 2009a, NMC 2008a), the practitioner is responsible for ensuring that teaching and learning activities, including clinical experiences, assist the student in achieving these standards of proficiency. This requires practitioners to have a sound knowledge and understanding of the learning outcomes to be achieved, expectations of professional conduct and assessment procedures including the implications of, and any action to be taken in the case of, failure to progress. This will enable the practice educator to identify and plan appropriate teaching and learning activities and clinical experiences.

As in any practice discipline, it is not enough just to have ‘knowledge of’ – one also needs to know what to do with that knowledge. This leads into the next ‘what for’ aspect of accountability of the practice educator: namely that of facilitating and measuring that learning.

Standards of teaching and assessing

The student is entitled to the best instruction available (Young 1994, Wood 1987). Failure to instruct properly could be construed as a negligent act (Dimond 2011, Goclowski 1985). The standard of teaching and learning that an academic institution is expected to provide is generally stated in the educational institution’s ‘student charter’. Service providers for patient/client care enter into contracts with higher education institutions to provide clinical experience for students. Within such contracts is an agreement to provide a standard of teaching and learning in the clinical setting commensurate with that set by the educational institution. To achieve the required standards of the teaching and assessment of clinical practice, practice educators need to attain and maintain competent practice in these roles (HCPC 2009a, NMC 2008a). It is recognized that clinical staff exercise a major influence on the quality of pre-registration programmes (Allan et al 2011, Eraut et al 1995). They do much of the teaching, supervision and assessment of students, and as it is likely that this will continue, it is imperative that they are capable of fulfilling these roles. Activities that practice educators are expected to provide will include planning learning opportunities for and with students to enable them to achieve their individual learning needs; facilitating and supporting the learning process; assessing learning; and providing feedback to students on their performance (NMC 2008a, Neary 2000, Eraut et al 1995). To support these educational processes in the clinical setting, higher education institutions include a policy for the management of the assessment of clinical practice in its curriculum document. Generally, the practice educator is required to carry out an initial interview with the student to negotiate and formulate a learning contract/plan to facilitate the achievement of learning outcomes and standards of proficiency. Subsequently, an intermediate interview should take place half way through the placement to review the student’s progress and achievement, and formal feedback given and documented. A final interview allows the practice educator to make a summative assessment of whether the student has achieved the learning outcomes of the placement.

Practice educators must be aware of, and be careful that, any policy regulating the assessment of practice is followed, as any deviation from such regulations could give rise to students appealing against any unfavourable assessment decision on the grounds of not having received the supervision, guidance and support to which they are entitled. Cases of students suing nursing institutions in the courts using the above grounds as educational malpractice are well documented in the North American literature (see, for example, Johnson & Halstead 2005, Goudreau & Chasens 2002, Graveley & Stanley 1993, Goclowski 1985, Spink 1983). Courts have recognized that, by virtue of their training, practice educators are uniquely qualified to observe and judge all aspects of their students’ performance. Court decision ruling in favour of the student has been on the basis of practice educators not following established guidelines for the supervision of the student.

Practice educators require adequate preparation to enable them to manage the educational activities to support learning and assessment. Subsequently, regular updates are important to keep abreast of developments and/or changes in the curriculum, the assessment process and new local and national policies influencing health care education. In the case of nurses and midwives and registrants with the HCPC, the NMC and HCPC require practice educators to update regularly (HCPC 2009a, NMC 2008a). The practices of mentoring and assessing can be enhanced if these ‘update’ sessions are also used as opportunities to discuss assessment problems and how these had been dealt with by individuals.

Unfortunately, there is current unease about the expertise of practice educators. Research shows that the initial preparation and continuing development of practice educators are inadequate, particularly with respect to knowledge of programmes and assessment of practice (Luhanga et al 2008, Duffy 2004). Whereas practice educators are personally accountable for their practice of the supervision and assessment of students (HCPC 2009a, NMC 2008b), service providers and higher education institutions have the joint responsibility for ensuring that training, support and updating opportunities are provided for practitioners to develop their role as practice educator (HCPC 2009a, NMC 2008a, Department of Health 1999).

Professional judgements about student performance

By virtue of their role, practice educators have the right to make, and are indeed vested with the onerous responsibility and accountability for making, professional judgements about the performance of students (HCPC 2009a, NMC 2008a, 2005). These professional judgements require the practice educator to make and report on two important professional decisions: first, they are reporting on the degree to which a student has met the programme learning outcomes and standard; secondly, they are reporting on the ability of the student to provide professionally competent and safe care to the public. Practice educators to students on NMC-approved programmes leading to registration, or a qualification that is recordable on the register, are accountable to the NMC for their assessment decisions about fitness to practise of students to enter the register, and whether they have the necessary knowledge, skills and competence to take on the role of registered nurse, midwife or specialist community public health nurse (NMC 2008a, 2005). Whilst the HCPC does not make a direct reference to accountability for summative assessment decisions, it may be inferred from the Standards of conduct, performance and ethics (HCPC 2008) that HCPC registrants who are practice educators are also accountable, thus:

It is important for the practice educator to remember that professional judgements not only assess the student’s current competence but also provide a prediction of the student’s potential ability to practise as a professional nurse or midwife, or physiotherapist, or social worker and so on. Therefore, the conclusion about a student’s performance should attempt to elicit reliability and predictive validity. These important criteria of sound assessments are discussed in Chapter 5.

Literature on the assessment of clinical practice abounds with discussions about the subjective nature of this process. Ashworth & Morrison (1991:260) stated that:

Assessments about a student’s performance frequently reflect the practice educator’s personal perception of what performance constitutes professional practice. Such an assessment is based on both objective and subjective criteria. There is, therefore, a danger that some decisions about student performance may be biased and unfair. Practice educators should be aware that many factors, some of which they are unaware of, can interfere with fair and equitable professional judgements, resulting in the student being treated unfairly.

As noted earlier, students have the right to expect that they will be notified of any deficiencies in their performance. The practice educator is behaving unfairly and unethically if the student is not informed about unsatisfactory performance (Orchard 1994). Furthermore, practice educators who fail to evaluate a student’s unsatisfactory performance accurately, either through reluctance to expose the student to the experience of failure or through a fear of potential redress by the student, are guilty of misleading the student, potentially jeopardizing patient/client care and placing the higher education institution in a difficult situation. It is much fairer to students to inform them of unsatisfactory performance as soon as such performance is identified. Informing students of deficiencies in a caring and constructive way allows students the opportunity to improve their performance; not to inform them denies them this opportunity and right (Killam et al 2010, Johnson & Halstead 2005).

Practice educators have a moral responsibility to fail incompetent students (Gopee 2008, Beaumont 2004, Ilott & Murphy 1999). Beaumont’s call came after Duffy (2004) reported that practice educators were ‘failing to fail’ nursing students. Being ‘kind’ to students by not failing them is not in the best interest of the student, especially when there is a delay to fail until late into the programme, such as in the final year. Having to inform family and friends that one will now not be able to graduate owing to failure, after having been on the programme for two years, can do untold damage to the self-esteem of that student. Failing to fail students is also not in the best interest of the profession for obvious reasons. An awareness of those factors that contribute to ‘failure to fail’ may be a first step to understanding why difficulties are experienced when dealing with a failing student, and may assist the practice educator in not passing a student when a fail is clearly warranted. It is suggested here that the responsibility for seeking assistance and/or support to make valid summative assessment decisions rests with the individual practice educator. The issues of the unsafe student and ‘failure to fail’ will be explored further in Chapter 7.

I have put forward what I see are the main aspects that practice educators are responsible and accountable for when they supervise and assess learners. The next section examines the ‘TO WHOM?’ aspects.