Beyond a reasonable doubt: An enquiry into the identification of marginal clinical practice performance and interventions that assure transition to registration nursing students’ competence and confidence for professional practice

Author: Moira Kelton

Kelton, Moira, 2020 Beyond a reasonable doubt: An enquiry into the identification of marginal clinical practice performance and interventions that assure transition to registration nursing students’ competence and confidence for professional practice, Flinders University, College of Education, Psychology and Social Work

Terms of Use: This electronic version is (or will be) made publicly available by Flinders University in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. You may use this material for uses permitted under the Copyright Act 1968. If you are the owner of any included third party copyright material and/or you believe that any material has been made available without permission of the copyright owner please contact with the details.


The purpose of this study is to investigate a gap in what is known about how clinical educators form and act on judgements about transition to registration (TtR) students who do not meet the required standard of practice. Clinical placement for the practice discipline of nursing is a requirement that provides a context in which nursing students learn to apply their knowledge, develop competence and confidence in their psychomotor skills with real patients in real time, and become socialised into the future role of registered nurse. Successful transition to registration for professional practice requires assessment of students’ readiness for professional clinical practice.

The study seeks to discover if a shared understanding exists among those responsible for assessing readiness for professional practice, and in what ways this shared understanding impacts on clinical education outcomes for TtR students. It seeks to determine what intervention measures and processes are used by clinical educators to contribute to successful mitigation of poor clinical performance in order to enable TtR students to demonstrate the required competence and confidence for professional practice. The research intends to advance a more detailed understanding of clinical educators’ experiences that leads them to identify and distinguish safe, but marginal practice, from unsafe and dependent practice. It also seeks to uncover the strategies commonly used for managing and mitigating safe but marginal practice of these TtR students, who might otherwise fail so near to completion of their degree.

Gadamer’s (1989) philosophical hermeneutics is the methodology chosen because it enabled the researcher to bring a pre-understanding to explore the perceptions of clinical educators in relation to the factors that contribute to TtR students being perceived as not meeting the required clinical practice standard. Two studies were undertaken. Study 1 involved a content analysis of historical clinical reports and academic documents for nine TtR students who had not met the required standard for registration. Analysis in Study 1 provides insight into what clinical educators assess, and subsequently manage, in regard to their perceptions of the clinical performance of TtR nursing students who were failing to meet the required standard of practice. It identified the common, causal factors the clinical educators align with practice performance when these TtR students did not provide safe, competent care that was consistent with mandated beginning level RN practice; established new and measurable criteria to be used by clinical educators to determine that some students’ practice performance was unsafe and dependent; and exposed tensions between the practice environment and university arising from inconsistencies in relation to assessment and mitigation of TtR students’ practice performance.

Study 2 was based on interviews with clinical educators involved in the assessment of TtR students’ practice. This second study involved a thematic analysis of the clinical educators’ responses to semi-structured interview questions and a standardised vignette. The design of the questions and the vignette was based on findings from Study 1. The findings in Study 2 are presented using thematic analysis of the transcripts in relation to three questions that were generated from undertaking Study 1. The analysis found that clinical educators’ perceptions of TtR students’ readiness for professional practice was informed by objective measures of what constitutes safe, quality, competent nursing practice. Clinical educators use practice hallmarks to distinguish ‘safe, but marginal practice’ from ‘unsafe and dependent practice’. It was also identified that clinical educators possessed a tacit, but shared understanding, and common approaches to the management and mitigation process for marginal performance. Finally, it was found that there were context-based factors that impeded TtR students’ progress and development.

The judgement of multiple factors that contribute to perceiving TtR nursing students’ clinical performance as not meeting the required standard is complex and involves much more than merely judging whether a TtR student is ready or not ready for practice. Due to a tendency to give students the benefit of the doubt, it was found there were significant risks that clinical educators might ‘fail to fail’ TtR students in their final semester, when practice could be considered unsafe. Conversely, there was a risk of ‘failing to pass’ students whose practice was safe, but marginal, and who merely needed more time in the clinical environment to reach the expected standard of practice. This is a significant discovery, because clarifying the distinction between safe and unsafe practice is important to ensure that TtR students who are unsafe are not passed, and those who are safe, but marginal, are not failed unfairly. Implications of this study suggest that nursing education and assessment require curriculum design changes that are supported by a set of guidelines for clinical assessment presented in the final chapter.

Keywords: clinical placement, nursing students, marginal practice perfomance

Subject: Nursing thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Education, Psychology and Social Work
Supervisor: Emeritus Professor Janice Orrell