Art & science
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The synthesis of art and science is lived by the nurse in the nursing act
Involving patients in the
assessment of nursing students
Casey D, Clark L (2014) Involving patients in the assessment of nursing students.
Nursing Standard. 28, 47, 37-41. Date of submission: July 30 2013; date of acceptance: May 12 2014.
Abstract
Enabling patients, service users and carers to participate in the
education of students in the healthcare sector is widely espoused, both
in the literature and by professional regulatory bodies. This article
focuses on one aspect of this: the issue of patient involvement in the
assessment of nursing students in the practice setting. The challenges
and complexities that may arise are explored, and recommendations
are made for further work in this area.
Authors
Deborah Casey
Senior lecturer, Faculty of Health and Social Sciences, Leeds
Metropolitan University, Leeds.
Liz Clark
Principal lecturer, Faculty of Health and Social Sciences, Leeds
Metropolitan University, Leeds.
Correspondence to: d.e.casey@leedsmet.ac.uk
Keywords
Literature review, patient and service user involvement, practice
setting, pre-registration nursing students, student assessment
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Josephine G Paterson
THE CONCEPT OF USING patient feedback
as part of quality assurance processes is at the
forefront of several health policy imperatives. In
response to the Francis Inquiry and catastrophic
failure of care at Mid Staffordshire NHS
Foundation Trust, the Department of Health (DH)
(2013) made a commitment to ‘…a renewed focus
on putting patients at the centre of everything it
does’. This is exemplified in the introduction of the
NHS Friends and Family Test, which allows health
service users to provide feedback on the quality
of care and treatment received (DH 2012). The
Nursing and Midwifery Council (NMC) (2014)
consultation on revalidation suggests that: ‘Nurses
and midwives will also need to reflect on feedback
from patients, service users, carers and colleagues
to improve the services that they provide.’ The
philosophy underpinning such initiatives is that
they can potentially help practitioners to refocus
on issues crucial to a patient’s experience of
health care but which could be overlooked by
standard assessment approaches that focus on
professional expertise. Ultimately, the aim is that
patients should be central within decision-making
processes for influencing and shaping current and
future healthcare provision.
Implicit within the patient involvement agenda
is the need for patients to be meaningfully engaged
in health education. As lecturers involved in the
development and delivery of mentor preparation
programmes for nurses, midwives and allied health
professionals, to support learning and assessment
in the practice setting, we were particularly
interested in how far patients could be usefully
involved in the assessment of nursing students
on placements. This is ethically desirable and
professionally and politically necessary. However,
the NMC (2012) acknowledged that, while patients
july 23 :: vol 28 no 47 :: 2014 37
Art & science literature review
should be involved in nurse education, the desirable
outcome may require complex implementation
strategies. In addition, consideration is needed as
to how the different aspects of patient feedback on
their experiences of health care can be integrated
and used more coherently to assess performance at
individual practitioner as well as organisational and
service levels.
This article offers a review of and reflection
on some of the potential issues alluded to by
the NMC, such as what the scope of patient
involvement should be, how patients should
be selected and briefed for the role, and how
the process should be managed to ensure the
authenticity of the assessment. The article also
provides a view from the mentor’s perspective to
develop and inform the debate.
The term ‘patient’ is used here to represent any
individual who may access nursing services and
encompasses terms such as ‘service user’ or ‘client’.
It is acknowledged that relatives and carers may also
have a role in contributing to meaningful feedback
on the performance of nursing students in practice,
and literature reflecting this has been included.
Background
The document Standards for Pre-Registration
Nursing Education (NMC 2010) requires
that: ‘Programme providers must make it clear
how service users and carers contribute to the
assessment process.’ Mentors are required to
consider evidence from a variety of sources,
including input from patients and carers, when
making judgements on the performance of nursing
students. This is usually done on an informal
basis, whereby mentors use ad hoc feedback from
patients and carers to inform their assessment
decisions. However, it is difficult to quantify
the value and weighting of patient input to the
assessment process in relation to the judgements
of the mentor.
Recommendation 194 of the Francis Inquiry
(2013) stated that nurses should, as part of annual
performance review, be required to demonstrate
‘… commitment, compassion and caring for
patients, evidenced by feedback from patients…
on the care provided by the nurse’. Developing a
robust model for obtaining feedback from patients
about the performance of nursing students has the
potential to contribute to the future performance
management processes of healthcare professionals.
This could include, for example, the requirement
for every student to obtain a minimum number
of testimonials on his or her practice performance
in relation to specific NMC practice standards, to
support the judgements of work-based mentors.
38 july 23 :: vol 28 no 47 :: 2014
Literature search
A literature review was conducted to examine
patient assessment of nursing students using the
British Nursing Index, CINAHL (Cumulative
Index to Nursing and Allied Health Literature)
and Medline databases. Keywords used to search
the databases included education, assessment,
practice experience, patient, service user, student
assessment and student nurses. Other sources
of literature were sought from reference lists
contained in articles obtained from the database
search. Inclusion criteria were:
Peer-reviewed journals.
English language.
Published in the UK.
Published from 2005 onwards.
Primary focus: the participation of patients in
the assessment of nursing students.
A total of 105 articles were retrieved. The abstracts
of the articles were reviewed for relevance. The
majority of articles were focused on patient
involvement in recruitment and selection for
nursing courses, curricula design and planning,
classroom teaching and simulation, and these
articles were rejected. Following this rapid
appraisal, a final 11 papers were reviewed.
Literature review findings
The overall findings are in agreement with Gray
and Donaldson’s (2010) international literature
review, which concluded that service user and
carer involvement in the education and training of
healthcare professionals was variable and in need
of further work particularly in the assessment of
practice. Literature that is focused on practice
assessment of students tends to be drawn from
other disciplines, including social work and
medicine (Humphreys 2005, Rees et al 2007).
Chapman et al (2011) addressed this in their
descriptive article on a patient testimony tool,
a questionnaire related to patient perceptions of
care delivered, level of comfort experienced and
whether they were treated with respect. They
describe a process whereby the mentor and
student negotiate to select a patient or relative.
Other than the patient being identified as
emotionally and physically fit to provide an
evaluation on the student, the issue of which
patients might be included in the assessment of
students in practice does not appear to be widely
addressed in the literature. Speers (2008) stated
that it is important to have protocols and guidance
to provide structure for all those involved, and
Gray and Donaldson (2010) stressed the need for
mentor involvement in the selection. Speers (2008)
also reported that some staff were concerned about
© NURSING STANDARD / RCN PUBLISHING
patients’ ability to make an informed judgement
on students’ performance commensurate with
their stage of training. This suggests the need
for all involved to be clear about the purpose of
the feedback. Patients are likely to be in a better
position to judge aspects of care such as privacy,
dignity and communication skills, compared
with assessment of clinical competence against
evidence-based practice guidelines.
Potential benefits
The literature revealed potential benefits
of involving patients in the assessment of
pre-registration nursing students undertaking
clinical practice placements. Patients can provide
a unique insight into their experience of care
provided by nursing students and the extent to
which their needs are addressed (Atkinson and
Williams 2011). This could provide the nursing
student with a different way of reflecting on his
or her practice by ensuring that self-evaluation
involves benchmarking against the needs and
experiences of the patient. In this way, patient
feedback can help in the development of insight
and self-awareness.
Townend et al (2008) identified that, from a
health professional student perspective, education
was enriched as a result of patient involvement
in the assessment process. Patient feedback is
valuable in ensuring assessment captures the
responses of nursing students to unpredictable and
complex patient needs and events that cannot be
replicated in the classroom, for example events
such as meeting the needs of distressed or bereaved
relatives. Patient feedback therefore enriches the
assessment process in terms of capturing the
challenges of the unpredictable nature of practice
learning (Schön 1983). Capturing feedback on
the lived experience of the patient provides an
extra dimension to existing mentor feedback
by providing a fuller understanding of student
performance (Debyser et al 2011).
The importance of the patient’s role in validating
the assessment process through shared decision
making with the mentor is acknowledged in the
statement by a student: ‘…it’s like being marked
by the people who actually count’ (Bailey
2005). Self-reported increases in confidence and
motivation from students (Duxbury and Ramsdale
2007) suggest that there is a real benefit for
students in developing the quality of their practice
in response to patient involvement and subsequent
comments on their performance.
Rees et al (2007) and Morris et al (2010)
identified feelings of empowerment for patients
involved in assessing nursing students. Patients’
self-esteem was increased by the feelings of being
© NURSING STANDARD / RCN PUBLISHING
able to ‘give something back’ when asked to help
evaluate student learning and/or performance.
It seems likely that involving patients could
increase the validity (the extent to which the
process measures what it is designed to measure)
and reliability (the consistency of the results when
used on more than one occasion) of the assessment
process. Although mentors make judgements in
terms of assessment against evidence-based criteria,
patients’ insights, while not trumping professional
judgement, are a crucial part of determining and
evidencing best practice. If the outcome of
pre-registration education is a practitioner who
can respond effectively to the needs of his or
her patient group, then any assessment must be
incomplete without this perspective. Reliability
may be enhanced by the process of a service user
supporting the judgement of the mentor. It could
be argued that a more appropriate model of
assessment would be to start with the service user’s
judgement and the mentor’s role would then be to
support or refute the view. However, implementing
that patient-centred approach raises some significant
potential challenges for mentors, nursing students
and patients.
Potential challenges
There appears to be only limited acknowledgement
of the potential problems in implementing patient
involvement in nursing student assessment. Three
themes were identified within the literature: power
imbalance and the risk of patient coercion, quality
of feedback and the risk of tokenism.
Stickley et al (2011) warned that assessment
processes could give rise to power imbalances,
which may be intimidating for patients. The
mentor and nursing student who approach a
patient for performance feedback remain in the
caregiver role and, however collaborative the
intentions are, there is a potential tension inherent
in the situation. This may lead the patient to be
reluctant to evaluate a student critically because of
anxiety regarding both the student’s progression
and the effect on his or her future care. Townend
et al (2008) reported anxiety among patients
regarding the responsibility of evaluating students.
The effect of this stress on the patient’s health and
wellbeing is recognised by Lathlean et al (2006).
This may be a particular issue if there is poor
preparation of patients for the role. This risk may
be minimised by making the patient aware that
the responsibility for assessment decisions is the
mentor’s, not the patient’s. Preparation is inevitably
challenging in acute settings where patient episodes
are brief.
The second theme identified is that feedback
may not be genuine or meaningful, for example
july 23 :: vol 28 no 47 :: 2014 39
Art & science literature review
it may not address a nursing student’s areas for
development or may be subjective (Speers 2008,
Stacey et al 2012). This may be as a result of a lack
of understanding of the purpose of the feedback or
a difficulty for the patient in articulating his or her
experience of care. The effect of illness may be a
factor in limiting the patient’s capacity to provide
useful information on a student’s performance.
In addition, the patient may reference the nursing
student’s performance against other nurses, rather
than against objective criteria. These issues may
be related to lack of preparation.
The potential for ‘tokenism’ was identified
by Lathlean et al (2006) and Stacey et al (2012).
Tokenism can occur when educational and service
providers have processes that do not capture the
patient’s real experiences of care, so rather than
being focused on either improving the quality of
the assessment or, more importantly, the quality
of care provided, the process is superficial and
mechanistic (possibly reflecting a ‘tick box’
culture), lacks real commitment and focuses
exclusively on meeting regulatory requirements,
perhaps at the expense of other quality outcomes.
Stacey et al (2012) suggested that to involve
patients as ‘assessors could be unethical and
potentially damaging’. The authors’ anxieties
focused on the validity of assessment and, in
particular, the potential that service users may
use the assessment process to express their
frustrations with services as a whole rather than
a true reflection of the care delivered by the
student. These challenges need to be recognised
and addressed in the development of assessment
models.
Perspective of mentors
The literature review findings were shared in two
workshops at a local conference for healthcare
professionals who mentor pre-registration nursing
students on placement. These findings generated
discussion, and additional concerns raised by
mentors included:
The ethical dimensions of patient assessment
of nursing students, such as the anonymity of
patients who provide written feedback within
practice assessment documents. Interestingly,
little reference to this issue was found in the
literature review. This is an important issue to
address in the development of written guidance
on patients making direct entries onto students’
practice assessment documents.
The selection of patients. It was suggested that
the mentor should be the conduit for patient
selection, for example ensuring the patient was
well enough and had enough time with the
40 july 23 :: vol 28 no 47 :: 2014
nursing student to make a sound judgement.
This was a particular concern for mentors
working within mental health settings.
The need to prepare and support patients to
assist in attaining meaningful feedback. Patients
may be unclear about the expectations and
criteria on which to make a judgement. The
issues included potential coercion of patients and
ensuring that the process of information giving
to patients was adequate for valid consent to be
obtained.
Potential tokenism was viewed differently by
mentors, who highlighted the need to ensure
nursing students do not select patients on the
basis of a positive relationship, for example
asking for feedback from ‘nice’ patients only.
Additional time required for mentors to involve
patients in student assessment was of concern
because the time pressure on mentors has been
acknowledged as a potential risk to the quality
of practice placement learning (Willis 2012).
Mentors expressed anxiety about the process of
overseeing the involvement of patients in student
assessment when they felt they already had
increasingly complex and conflicting roles.
Discussion and implications
The findings from the workshops with mentors
appear to mirror some of the challenges identified
in the literature. Initiatives to formalise patients’
involvement in the assessment of students on
placements should be carefully monitored and
evaluated, and mentors should be involved early in
their development. The following principles should
be used to underpin its introduction:
Student assessment should focus on a specific
practice or performance standard with clear
criteria or cue questions for the patient to focus on.
Mentors should be prepared for patient
involvement as part of mentor preparation
programmes and updates.
Patient selection should be made by the student
in consultation with their mentor.
Mentors rather than students should approach
the patient to provide information and gain
consent. Written and verbal information should
be available for patients on the purpose and
nature of the feedback required.
Anonymity of patients should be assured by
the mentor rather than the patient.
The literature review demonstrates a lack of
empirical work on the benefits for patients, nursing
students and the profession as a whole. There is
a limited number of examples in the literature
of how patients have been enabled to provide
feedback or assess nursing student performance
© NURSING STANDARD / RCN PUBLISHING
during placement. The following areas could
provide the focus for future professional
discussions and empirical investigation:
Preparation of patients, mentors and nursing
students to support the process. How can
patients, mentors and nursing students be
adequately prepared for their role in what is
likely to be a skilled and resource-intensive
process? In particular, a focus on appropriate
selection and briefing of patients is required.
Capturing feedback. How should feedback
within student practice assessment
documentation be captured? Is verbal
feedback to a mentor who then documents it
acceptable? Should there be written feedback
from a patient? What framework should
be used to capture feedback, for example
a questionnaire on a specific aspect of practice
such as how far the student respected the
dignity of the patient?
Scope of feedback. Should the focus be related
to specific NMC practice standards only? Is an
open-ended testimony sufficient?
Nature of feedback. Should patient feedback
contribute to the summative assessment
process for students or should feedback be used
formatively to support development learning
contacts between the mentor and students?
Should patient feedback be mandated, for
example a minimum of one patient testimony
for each practice placement?
Conclusion
There are important benefits for nursing students,
mentors, patients and potentially the future
nursing workforce in involving patients in the
practice assessment of nursing students. However,
enthusiasm needs to be tempered with caution
and an acknowledgement that further work is
required. This could include the development of
national guidance with agreed principles to enable
processes to be developed at a local level involving
all stakeholders, including patient groups, student
representatives, placement providers, university
staff and mentors NS

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