Support for Practice Educators using the “Cause for Concern “process. Amanda Stears QMU 25/10/2013

 Identified within QMU PT team that there was a need to strengthen our support for practice educators to help them identify students that were giving “cause for concern” and to give them a process to help support and manage the student whilst on placement.  Scoping exercise internally and externally across NMAHP professions.  Main source Kathleen Duffy (2003,2007) and Stuart (2007)  Note incidence is low 6 in last 2 years ! Why ?

 Duffy identifies patterns of behaviour that should raise “cause for Concern”  Educators can also have own hidden patterns of behaviour ie benchmarking students against previous students and not assessment criteria.  Stuart (2007) and Rowntree (1987) describe feedback as the “lifeblood of learning” as it allows the student to engage in reflecting on their strengths and weaknesses.  Contributes directly to the learning process and students self esteem.  Must be a two way process between PE and student. Identification of behaviours

 Duffy (2003) identifies that PE’s often have that “gut feeling” or concern that is difficult to objectively explain.  Duffy (2003) Gainsborough (2010) and Stuart (2007) tell us PE’s are hesitant to fail students.  One major inhibitor is that they may be over ruled on appeal.  Placement planning, support and guidance can reduce the likelihood of this occurring.  Duffy states PE’s “fail to fail because of the lack of knowledge about the assessment process.  Regardless of profession all PE’s have a duty to ensure that patients will be is safe hands with students *Duffy 2007, Hunt 2011) Intuition or fact?

 Time consuming !  Emotionally draining for the team not just PE.  Needs to be a clear and auditable process available to PE’s to support students not performing as expected.  The CFC ensures that the student is given every opportunity to improve their performance whilst at the same time recording any identifiable early pattern of behaviour.  The decision to pass or fail is made on sufficient evidence to reach a defensible conclusion. Protecting both student and PE. Management of CFC student

 Helps PE to recognise “early warning signs”  Supports PE in re-affirming their duty to themselves and their profession to recognise and deal with students who are struggling, and if despite extended support fail, these students must be failed to protect the public and the profession.  Recognise that assessment regulations give students the right to receive timely feedback about their performance, before the mid way assessment if necessary, and have the opportunity and support to correct the behaviours/practices that are considered unsatisfactory.  Be made aware that students must be told when their performance is not meeting the criteria set for satisfactory performance before being failed, giving the benefit of the doubt, or passing the buck to the next placement is not satisfactory (Stuart 2007).  Setting out good practice for meetings, allowing the student to bring another member with them for support.  Allowing students the opportunity to self assess and engage in reflection rather than being told what is wrong. Students should be asked to reflect on their performance during their initial meeting with their PE but there is formal recording before the mid way assessment. Although we recognise that PE’s may use informal feedback throughout the week or day, this risks not being seen by the student as such and in cases of an appeal, a lack of hard evidence does not support the PE.  It is as wrong to fail to fail, as it is to fail unjustly (Ilott and Murphy 1999) Purpose

Early Warning behaviours. Early warning behaviours Health or well being issues Attitude or behaviour in practice Poor attendance and time keeping Not meeting proficiencies Poor communication and inter personal skills Lack of interest Lack of personal insight Professional boundaries

Student improves and completes placement or Student does not improve and fails placement. Review goals as required may be daily or weekly Each meeting should be recorded and the completed paperwork forwarded to QMU at the end of the placement. This does not replace weekly liaison with PAT/PBL Formulate an agreed action plan with student Set SMART goals and detail how these will be achieved Agree a review date and arrange extra learning opportunities if required, document in CFC form Arrange meeting with Student Do not wait till midway to raise concernsContact students PAT or PBL Team Cause for concern identified Students struggling to meet expected competenciesOr displaying early warning behaviours CFC Process Complete Page 1 detailing concerns. contact QMU Complete page 2 and 3 at meeting and decide whether further review is required. If so detail clear action plan and timescales p3 &4. It may be that a one off meeting is all that is required. The action plan on page 4 can be carried forward and use with review meeting log on page 5. Return form to PBL at QMU

YesNo *Professional Values  Demonstrates poor professional behaviour and is unaware of professional boundaries  Is preoccupied with personal issues  Is unreliable e.g. persistent lateness/absence/sickness  Not motivated and shows a lack of interest  Demonstrates a lack of empathy and caring towards clients/carers and colleagues √√ √√ *Communication and Interprofessional Skills  Has no insight into weakness so unable to change following constructive feedback  Does not respond appropriately to feedback  Practical, Interpersonal and communication skills not appropriate to their level of training  Demonstrates inability to manage controversy *Clinical Practice and decision Making  Does not meet the required level of proficiencies for their level of training  Has inconsistent clinical performance for their level of training  Has demonstrated unsafe clinical practice  Does not have the required knowledge for their level of training or able to apply theory to practice *Leadership, management and team working  Is unable to demonstrate preparation and organisational skills to their level of training  Is unable to work within the team  Does not demonstrate respect for all members of the team  Shows lack of respect and understanding of role of external agencies and stakeholders Any other concerns not mentioned above Worked examples P1,2 and 3

Background to cause for concern (please provide clear supporting evidence) Jack has been late on 3 occasions in his first week with no satisfactory explanation, and is demonstrating a lack of empathy toward his patients. Yesterday he was heard making inappropriate comments about an elderly patient who was in clinic yesterday with knee pain,where his weight was an obvious contributory factor. Assessment of the situation/ action plan required/SMART goals used/additional support and learning offered. After discussion with Jack it appears that there is no regular bus service, there is a regular bus that would get him here earlier. we have agreed that he will catch the earlier bus and we will adjust his patient list accordingly. With regards to professional behaviour we have discussed the issues of professionalism and Jack will reflect on the issues of obesity in the elderly with knee pain in his case study for this placement. Action plan agreed with student : Yes/No Yes Review date set : 1st Nov 13 Outcome : We have reviewed Jack’s progress this week and he has demonstrated a more compassionate approach to his patients and time keeping has improved. No further action is required. Background to cause for concern (please provide clear supporting evidence) Jack has been late on 3 occasions in his first week with no satisfactory explanation, and is demonstrating a lack of empathy toward his patients. Yesterday he was heard making inappropriate comments about an elderly patient who was in clinic yesterday with knee pain,where his weight was an obvious contributory factor. Assessment of the situation/ action plan required/SMART goals used/additional support and learning offered. After discussion with Jack it appears that there is no regular bus service, there is a regular bus that would get him here earlier. we have agreed that he will catch the earlier bus and we will adjust his patient list accordingly. With regards to professional behaviour we have discussed the issues of professionalism and Jack will reflect on the issues of obesity in the elderly with knee pain in his case study for this placement. Action plan agreed with student : Yes/No Yes Review date set : 1st Nov 13 Outcome : We have reviewed Jack’s progress this week and although his timekeeping has improved he is still demonstrating a lack of compassion with his patients and is showing little insight into feedback given on the matter. A meeting has been arranged with his PAT to discuss how this can be addressed. In the meantime I have asked Jack to read the CSP and HCPC standards on professional conduct.

Action Plan Lead Jo BloggsStudent Jack Smith Practice Placement MSK OPDate agreed Review Dates____8/11/13_______ ___________________ ________________ Problem/s identified SMART goal set Action required (how will goal be achieved) Date achieved or carried forward On-going unprofessional behaviour demonstrated towards patients. Demonstrating little insight into feedback given about making inappropriate comments about patients To read and reflect on CSP and HCPC standards of professionalism, To undertake pro learning module on caring and compassion and to shadow PE to gain further experiience. Give a lunchtime in service to staff on what is professional conduct PE to discuss with department manager running an extra tutorial on the use of feedback with students on site. Action Plan p.4

 Meetings should be held in a quiet area where you will be free from interruptions.  If issues are identified early do not wait until the midway assessment, early intervention can be the key.  Open by allowing the student the opportunity to self reflect on their progress. e.g. “what do you understand happened here?” Use open ended questions.  Listen to the student’s feelings, they may be afraid of failure or angry, give honest detailed feedback with clear examples that support your concerns and document these on the cause for concern form, do not use expressions such as “I have heard…. I think”. Use the feedback sandwich (this helps build self esteem).  Develop an action plan with the student and set a review date. A five day review is suggested as appropriate. Students appreciate honest feedback on areas where they can improve their performance (Duffy 2007).  Use SMART goals to achieve specific objectives, discuss how they might achieve them and inform them of the consequences should improvement not occur.  Negotiate further learning opportunities if necessary. Good Practice for Meetings and Action Plans

 Do not avoid the issues of failing students, failing a student can pave the way for greater achievement in future clinical placements. (Duffy 2007)  Do however be prepared for the students reaction which may include:  Shock and disbelief- There may be a genuine lack of insight into their own abilities, or previous mentors passing the buck or giving them the benefit of the doubt. This is neither in the interest of the student or the profession (Duffy 2003)  Shock their “friend” has failed them; students can mistake the warm, nurturing environment on placement as friendship. Practice educators need to become skilled at maintaining a professional and supportive role.  Students may become emotional, crying, angry, aggressive, be in denial, become verbally abusive, they may cite a personality clash or victimisation. If there is a hint of this a 3 rd person may be useful from either the team or QMU.  They may blame previous practice educators or QMU.  Some may be relieved and willing to fail the placement. It can be a positive outcome. It is a common assumption that students will always take it badly. Zuzelo (2000) observed that students often recognise their clinical weakness and shortcomings and are relieved when Mentors give advice on how that can be improved. (Duffy 2007 Failing the student

 Mentors should have the opportunity to discuss issues with a supervising practice educator (PEF’S, HEI)  Note not all situations with students can be resolved; you must sometimes seek advice from colleagues or your PEF.  Follow local policy.  Liaise with the QMU’s PBL team, the students PAT or the programme leader.  Acknowledge your own feelings.  Don’t give benefit of the doubt.  Don’t ignore alarm bells.  Seek support early from QMU.  Avoid bias and making assumptions.  Consider using supervision for anonymous discussion or utilise a second observer, this can help bring objectivity and prove to the student there is fairness in assessment. Support for Practice Educators

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