“Approved education institutions, together with practice learning partners, must ensure… a range of people including service users contribute to student assessment.” Realising professionalism: Standards for education and training Part 1: Standards framework for nursing and midwifery education Published 17 May 2018, Standard 5:14.
A Framework for evaluating the impact of teaching
Morgan and Jones have modified the Kirkpatrick model to create the following suite of domains where there may be changes as a result of service user and carer involvement in nurse education:
- Learner perceptions – students’ views on their learning experience (satisfaction, perceived impact on learning)
- Service user perceptions – service user views on their involvement experience (motivation, costs and benefits)
- Staff perceptions – staff views on involving service users
- Modification of attitudes, knowledge and skills – a measured change in post-test scores or with comparison group
- Change in behaviour – are the newly acquired attitudes, knowledge and skills evident in the student’s daily practice
- Benefits to patients – tangible difference in health outcomes of patients nursed by the students
A version of this has been used at Portsmouth Hospitals to assess the impact of patients’ contributions to the preceptorship programme.
Service users and carers can contribute to both the formative and summative assessment of student nurses. Formative assessment helps people to reflect on their practice, correct any weaknesses and strengthen their work. Service users and carers have role-played the patient while the nurse is taking a clinical history and provided feedback to the student about whether they were put at ease, granted eye contact, and treated with kindness and respect. This feedback can, of course, be an anxious time for the student, depending on the skill of the service user in delivering feedback in a supportive rather than crushing or antagonistic manner. .
Feedback forms from service users and carers are often treated as an opportunity for formative learning, and it is the student’s written reflection on this feedback which contributes to the summative assessment and helps in deciding if the student may continue with their studies. However, in some establishments, where a pattern appears in which the student repeatedly fails to obtain a sufficiently positive feedback from the service users, they can be dismissed from the course.
Summative assessment makes a judgement about whether the student has met a particular level of competence, perhaps in technical skills, such as taking a blood sample, in analytical thinking and critical use of evidence, or in communication. At the University of Sunderland, for example, service users and carers have been trained and then scored student nurses against the competencies set out in an Objective Structured Clinical Examination (OSCE). Failure to meet the standard results in the same consequences for students, whether it is an academic staff member or a trained service user or carer who awards the score.
Stickley et al (2010, 2011) experimented with inviting mental health service users to participate in summative assessment of nursing students. They found that service users they worked with were reluctant to take on the responsibility for formal assessment, students were anxious about transferring power over their future away from accountable professionals, mentors were worried about the additional workload, and everyone was concerned about the impact on the therapeutic relationship. These concerns were replicated in Scotland in Gray and Donaldson’s 2010 literature review and Haycock-Stuart and colleagues’ survey of the opinions of student nurses in Scotland. Calman (2006) found that patients were concerned that a fleeting contact with the student would be insufficient grounds to judge their ability.
However, we have also encountered settings where service users and carers sit on Fitness to Practice panels, where they share in the considerable responsibility of occasionally dismissing a student from their studies, thereby showing no reluctance to exercise power. Furthermore, in a penetrating thinkpiece, Malihi-Shoja and her colleagues set out from a service user perspective why ‘failing to fail‘ incompetent students is a serious mistake. Adverse feedback from service users and carers can also provide some robust evidence of attitudes or behaviour where previously there was no more than a subjective concern about the student’s suitability for the profession.
As well as providing an illustration of coproduction of a summative assessment, the following example shows how service users and carers can be involved in the whole process, rather than just in one step of it. For one module in the nursing programme at the University of Worcester, the module leader and a service user/carer worked together to:
- Develop criteria for scoring the OSCE.
- Launch the module and co-facilitate the teaching so that they are both known to the students by the time the summative assessment is undertaken.
- Sit as joint assessors in the OSCE. The academic and the service user/carer use the criteria they have developed to award a score to the student. They do this privately and then discuss and average their scores to settle on the final score. This, alongside the qualitative remarks are fed back to the student.
- Review the module at the end and make revisions as necessary. This may lead to changes in the description of required competences, the teaching, and the scoring criteria for the OSCE so that it more closely aligns with the learning outcomes and essential skills as set out by the service user/carer.
Where the student produces assessed material, there is usually a Moderation Group to check that different fieldwork supervisors or academic staff are behaving consistently and maintaining fairness across the body of student nurses. The Moderation Group deals with anonymised materials and some learning providers have invited service users and carers to join this group.
- Some students worry that showing service users and carers their poor quality work may damage their credibility and clinical effectiveness in the field afterwards. At Sheffield Hallam University, service users and carers were consulted and expressly rejected the burden of responsibility for assessing students.
- At the University of Chester, the OSCE (Objective Structured Clinical Examination) process gathers feedback from service users who are cared for by the student nurse. The focus of the feedback is on the caring attributes and communication skills demonstrated by the student.
- At Leeds Beckett University, service users and carers comment on the design of specific practical tests set for students.
- At Teesside University, one postgraduate course includes service users and carers in the assessment of classroom presentations given by the students. At University Campus Suffolk, two staff and a service user each score a classroom presentation by the student. At Anglia Ruskin University, a similar approach is used with mock presentations and the student is given feedback. Service users and carers involved at the University of Lincoln are issued with a marking grid to score student presentations against specific criteria.
- At the University of Surrey, service users and carers read and provide written comments on one reflection a year from each student.
- At the University of Leeds, service users and carers are involved in the summative assessment of a module on communication skills and can ask a student to repeat the module.
- At the University of Essex, the clinical mentor listens to a number of service users and carers and then reports generally on the student’s relationship and communication skills.
- At the University of Essex, service users role play a clinical situation (e.g. the student instructing a patient in the correct use of an inhaler). The service user and tutor then mark the student.
- At the University of Central Lancashire, service users and carers mark written assignments snd moderate anonymised work.
- At the University of Worcester, students are subject to a summative assessment at the end of a mental health module. This assessment was co-developed with a service user/carer, who also sits as a joint assessor in the final examination.