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A phenomenological study of clinical teachers’ experiences with borderline nursing students Boyer, Mary Margaret 1992

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A PHENOMENOLOGICAL STUDY OF CLINICAL TEACHERS'EXPERIENCES WITH BORDERLINE NURSING STUDENTSbyMARY MARGARET BOYERB.Sc.N., University of Alberta, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(The School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril 1992© Mary Margaret Boyer, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(SignatureDepartment of NursingThe University of British ColumbiaVancouver, Canada DE-6 (2/88)iiABSTRACTThe challenge of working with borderline students isa reality of the clinical teacher's role which hadnot been researched. Based on the review of theliterature, it was apparent that more knowledge was neededto understand the experience of evaluating borderlinenursing students from clinical teachers' perspectives. Inorder to present a description of how clinical teachersperceived their experiences with these learners, thephenomenological method of qualitative research was used toexplore the experiential meaning of evaluating borderlinestudents from the perspectives of eight diploma program-based teachers. The data were collected through the use oftwo unstructured audio-taped interviews with each informant.The concepts of role, perception, and decision-makingprovided direction for the trigger questions used in thefirst interviews. Data collection and analysis were donesimultaneously. The themes and concepts which emerged fromthe data were validated and clarified with the teachersduring their second interviews. From data analysis, threeoverlapping concepts emerged: ambiguity, student's self-awareness, and laborious decisions. It was concluded thatclinical teachers' experiences with borderline studentsinvolve evaluating individuals with an ambiguous performancewithin an ambiguous process. The ambiguity of borderlineperformance amplifies the ambiguity inherent in clinicalevaluation and in the nurse educator's dual responsibilityiiito students and to patients. Further, the experience ofevaluating borderline students entails the time-consumingprocess of fostering borderline students' awareness of theirperformance problems. Students with insight accept theirclinical standings and are less likely to appeal theirclinical failures. It was concluded that dissonance and avariety of emotions, of which uncertainty is the mostpredominant, are associated with the decision-making processabout borderline performance. Dissonance is reduced byusing various forms of rationalization and peer support isessential for dealing with the feelings of uncertainty.Finally, it was concluded that clinical teachers useintuitive strategies during the laborious process ofdeciding a borderline student's final grade. Thesestrategies include a sense of knowing, a sense of thestudent's whole performance, and a sense of whether or notthe student can be trusted as a future co-worker and/orcare-giver. The clinical teachers in this study did notvalue the use of intuition as a respectable element ofevaluative decision-making. The research findings haveimplications for nurse educators, educational preparationfor clinical teaching, and for nursing research specific toclinical evaluation.ivTABLE OF CONTENTSABSTRACT ^  iiTABLE OF CONTENTS ^  ivLIST OF FIGURES  ixACKNOWLEDGMENTS ^  xCHAPTER 1: Introduction  ^1Background to the Problem ^  1Statement of the Problem and Research Question ^ 3Purpose of the Study ^  4Conceptual Framework  4Significance of the Study  ^7Scientific Significance  ^7Practical Significance  ^7Definition of Terms  ^8Clinical Nursing Teacher  ^8Borderline Nursing Student ^  8Clinical Evaluation  ^8Experience  ^8Assumptions ^  8Limitations  ^9Research Method ^  9Organization of the Thesis ^  10Summary ^  11CHAPTER 2: Literature Review ^  12Introduction ^  12Borderline Nursing Students ^  13The Essence of Borderline Students ^  13VBorderline Students: Contributing Factors ^ 14Clinical Evaluation: The Decision to Pass or Fail^ 15Research Related to Evaluating Borderline Students ^ 16Clinical Evaluation: Stressful Responsibility ^ 17The Subjective Nature of Clinical Evaluation ^ 22Students' Rights to Academic Due Process ^ 28Relationships with Students and Colleagues  32Teacher-Student Relationships ^  32Relationships with Colleagues  36Summary and Conclusion ^  38Summary ^  38Conclusion  40CHAPTER 3: Methodology ^  42Introduction ^  42Selection of the Informants ^  42Sampling Method ^  42Criteria for Selection ^  43Selection Procedures  43Characteristics of Informants ^  44Ethical Considerations ^  46Data Collection ^  47Data Analysis  49Reliability and Validity ^  49Summary ^  51CHAPTER 4: Presentation and Discussion of Accounts ^ 53Introduction ^  53Ambiguity  54viAmbiguous Nature of Borderline Performance ^ 54Enigmatic Performance Problems ^  54Inconsistent Behavior ^  58Borderline Versus Failing Students ^ 59The Essence of Borderline Performance  61Summary ^  61Ambiguous Nature of Clinical Evaluation ^ 62Subjectivity ^  62Defining Consistent ^  63Teaching Time Versus Evaluating Time ^ 65Validation: Ambiguous Process ^  66Ambiguity: Performance and Process ^ 67Summary ^  68Ambiguity: Dual Responsibility ^  68Dual Responsibility: "The Fine Line" ^ 69Change in Responsibility Focus ^  71Summary ^  75Student's Self-Awareness ^  76The Degree of Insight  76Teacher-Student Relationship ^  77The Student's Decision ^  81Fostering Self-Awareness  83Summary ^  84Laborious Decisions ^  84A Sense of Uncertainty: Self-Doubt ^ 85Ambiguity and a Sense of Uncertainty ^ 87Coping With Uncertainty ^  88viiPost-Decision Uncertainty ^  93Summary ^  94Emotional Challenge ^  95Shared Emotions  95Dissonance and Rationalization ^  98Summary ^  104A Sense of the Whole: Gestalt View ^ 105Painting the Whole Picture ^  105Ambiguity and a Gestalt View  107Summary ^  108A Sense of Knowing: Intuition ^  108Knowing and Feeling ^  109Experience and Exposure  110Intuition and a Gestalt View ^  111The Use of Intuition ^  112Intuition and Ambiguity  115Summary ^  116A Sense of Trusting ^  116Summary ^  121Summary of the Informants' Accounts ^  121CHAPTER 5: Summary, Conclusions, and Implications forNursing ^  125Summary ^  125Conclusions  128Implications for Nursing Education ^  129Implications for Nursing Research  131REFERENCES ^  134viiiAPPENDICES ^  144Appendix A: Data Collection: Trigger Questions ^ 144Appendix B: Explanatory Letter for Agency Consent^ 145Appendix C: Agency Consent Form ^  147Appendix D: Agency Handout  148Appendix E: Letter to the Informants ^ 150Appendix F: Informant Data ^  152Appendix G: Informant Consent Form ^  153LIST OF FIGURESFigure 1 Clinical Teachers' Experiences--Conceptsand Themes ^  53ixxACKNOWLEDGMENTSFirst, I wish to acknowledge and thank the clinicalteachers who participated in this study. Their commitment,and willingness to share their experiences are appreciated.Second, I wish to acknowledge and thank the members of myThesis Committee, Ms. Anne Wyness, Mrs. Marilyn Dewis, andDr. Marilyn Willman for their guidance, support, andpatience. Third, I wish to thank my husband, Kevin, for hisunconditional love and understanding. Fourth, I wish toexpress my gratitude to Don Greggain. With Don's care andunderstanding, I was enabled to complete this thesis.Finally, a warm thanks to my family and friends for theirendless support: Dad, Mum, Aunt Verna, Uncle Al, Tara C.,Brenda, Ethel, Lenore, Linda, Mereldine, and Tara M..1CHAPTER ONEIntroductionBackground to the ProblemClinical teaching is a vital and complex part ofnursing education (de Tornyay, 1985; Infante, 1985; McCabe,1985). According to Carpenito and Duespohl (1985), clinicalteaching is "the core of all nursing education" (p. 1).Although the complexity of clinical teaching precludes adetailed description, one of the most criticalresponsibilities of the teacher's role is that ofsupervising and evaluating students' clinical performance(Carpenito & Duespohl; de Tornyay & Thompson, 1987).Clinical teaching involves accountability to students,consumers, the profession, clinical agencies, andeducational institutions (Carpenito & Duespohl, 1985).Consequently, clinical evaluation of students' performanceis a professional and legal obligation of clinical teachers.This obligation includes assigning failing grades tostudents who demonstrate unsatisfactory clinical performance(Majorowicz, 1986, p. 36).For clinical teachers, failing a student in theclinical setting is described as a debilitating experience(Carpenito, 1983; Symanski, 1991) and as an emotionallytaxing responsibility (Meisenhelder, 1982). Teachers facean even greater challenge when clinical evaluation involvesa borderline student (Brozenec, Marshall, Thomas, & Walsh,1987; Wood, 1971). This challenge results because the2clinical performance of a borderline student is inconsistentand does not clearly fall into a pass or fail pattern(Brozenec et al.). The decision to assign a passing orfailing grade is problematic and, therefore, presentsteachers with a stressful and emotional evaluative dilemma(Brozenec et al.; Welborn & Thompson, 1982). This dilemmais compounded by the subjective nature of clinicalevaluation (Brozenec et al.; Carpenito & Duespohl, 1985; deTornyay, 1985; Fowler & Heater, 1983; Infante, 1985;LeVeille Gaul, 1988; Meisenhelder; Poteet & Pollok, 1981;Reilly, 1980; Reilly & Oermann, 1985, 1990; Welborn &Thompson; Wood, 1982, 1986; Wood & Campbell, 1985; Wood &Wladyka, 1980: Woolley, 1977). Because of thissubjectivity, teachers feel uncertain about the validity oftheir evaluative decisions (Meisenhelder). Furthermore,teachers wrestle with the decision to assign a failing gradeknowing that: (a) a failure is emotionally difficult for thestudent (Brozenec et al.; Carpenito 1983; Majorowicz, 1986;Meisenhelder; Symanski, 1991; Turkett, 1987; Welborn &Thompson; (b) the student has the right to involve theeducational institution in an appeal process (Carpenito;DeYoung, 1990; Fowler & Heater; Huston, 1986; Lenhart, 1980;Majorowicz; Meisenhelder; Welborn & Thompson; Wood, 1986;Wood & Campbell; Wood & Wladyka; and (c) responses of otherfaculty members may or may not be supportive (Carpenito;Majorowicz; Symanski).The nursing literature addresses the emotional3difficulty of assigning failing clinical grades. Althoughtwo references (Brozenec et al., 1987; Wood, 1971) addressthe challenge of evaluating borderline students, a review ofthe literature did not reveal any research focusing onteachers' experiences with this phenomenon. Until themeaning of this experience is explored, it is difficult tounderstand and appreciate how clinical teachers perceivethis evaluation process.Statement of the Problem and Research Ouestion This study explored the difficult emotional dilemmathat clinical teachers face in the clinical evaluation ofborderline nursing students. Given that the clinicalperformance of a borderline student is inconsistent, andthat clinical evaluation is subjective in nature, theteacher's decision to pass or fail the student is astressful challenge. The challenge arises from theteacher's awareness of the consequences of assigning afailing grade. The teacher anticipates that there may benegative effects on the student, the educationalinstitution, and relationships with faculty members.Clinical teachers' perceptions of their experienceswith the evaluation of borderline nursing students had notbeen studied. Thus, there was little known about howteachers viewed this experience which is inherent in theirprofessional role. The research question the studyaddressed was: from the perspective of the clinicalteacher, what was the experience of evaluating borderline4nursing students?Purpose of the StudyThe purpose of this study was to present a descriptionof how clinical teachers perceived their "lived experiences"(Oiler, 1982, p. 178) of evaluating borderline nursingstudents.Conceptual Framework The concepts of role, perception, and decision-makingformed the conceptual framework for this study. Theconcepts were selected based on the review of the literatureand the researcher's own "tension-filled" experiencesassociated with the clinical evaluation of borderlinenursing students. The concepts are generally accepted aselements in all clinical evaluation situations and,therefore, provided direction for the consideration of thechallenges of evaluating borderline students.Role is a complex concept. Two components of thisconcept are the inherent obligations and relations withpeople (Joos, Nelson, & Lyness, 1985; King, 1981). Thesecomponents of role are central to the clinical evaluationprocess.With respect to the first component, the role ofclinical teacher involves a professional and legalobligation to evaluate students' clinical performance(Majorowicz, 1986). Teachers are obligated to determine ifstudents' overall clinical performance is satisfactory orunsatisfactory. Fulfilling this obligation with borderline5students is difficult because these students exhibit bothsatisfactory and unsatisfactory clinical behaviors (Brozenecet al., 1987; Wood, 1971).The second component of role, relations with people, isrelevant to the teacher's evaluative role. Relations withpeople is relevant because the clinical evaluation processinvolves an interpersonal relationship with students(Kushnir, 1986; Reilly & Oermann, 1990) and students'clinical performance is a concern communicated amongstfaculty members (Brozenec et al., 1987; Carpenito, 1983;Meisenhelder, 1982). Further, the clinical evaluationprocess, particularly with unsatisfactory students, has adirect effect on the teacher-student relationship(Carpenito; Meisenhelder). The student's potential forfailure influences the interactive nature of the ongoingclinical evaluation process. Equally as important, theevaluation process with unsatisfactory students influencesthe teacher's relationships with fellow colleagues(Carpenito; Meisenhelder; Symanski, 1991). Although somefaculty members will offer supportive input, others mayoffer only criticism which will heighten the teacher'suncertainty with respect to assigning the final clinicalgrade (Symanski)."Perception gives meaning to one's experience,represents one's image of reality, and influences one'sbehavior" (King, 1981, p. 24). Perception is subjective andunique to each person. Teachers' perceptions, based on6their own set of values and beliefs, will influence themeaning they assign to their observations andinterpretations of students' clinical performance (Fowler &Heater, 1983; Reilly & Oermann, 1985). Furthermore,teachers' perceptions of students' performance areinfluenced by their past experiences (Reilly & Oermann,1985), role obligations, relationship with the student, andrelationships with other faculty members (Meisenhelder,1982).Decision-making is the third concept that is intrinsicto the evaluation process. Clinical evaluation involves aseries of decisions which teachers make about students'clinical behavior (Wood, 1986). The evaluation of aborderline student culminates in the teacher's finaldecision to award a passing or failing grade (Brozenec etal., 1987; Wood, 1971). This decision is influenced by theteacher's perception of the situation.The concepts were used as the foci for exploringteachers' experiences and, therefore, provided a frameworkin the formulation of the interview questions used for datacollection (Appendix A). Moreover, the concepts provided apartial structure for the organization of the literaturereview.The researcher did not test the relevancy of theconceptual framework to clinical teachers' experiences ofevaluating borderline nursing students, nor did she use theconcepts as a guideline for data analysis. The data were7analyzed according to the information provided by theinformants.Significance of the StudyScientific SignificanceClinical teachers are charged with the responsibilityof determining if borderline students have mastered theexpected level of clinical competency. Although the non-research-based literature described the experience ofevaluating borderline students as problematic and stressful,the meaning of this experience from clinical teachers'perspectives had not been explored. It was clear that moreknowledge was needed to understand how clinical teachersperceived their experiences with this phenomenon. Hence,the study's scientific significance was the advancement ofnursing knowledge concerning clinical evaluation ofborderline nursing students and the study's findings maystimulate further related research.Practical Significance A research-based description of clinical teachers'experiences of evaluating borderline students had practicalsignificance for the following reasons: (a) it would enhancenurse educators' and administrators' understanding of theemotional challenge associated with this responsibility,(b) it would provide a basis for clinical teachers tovalidate their own experiences evaluating borderlinestudents, and (c) it would provide clinical teachers andgraduate nursing students preparing for this role with8insight and understanding into the complexities of thisaspect of clinical evaluation.Definition of Terms Clinical Nursing Teacher For the purpose of this study, a clinical nursingteacher is a registered nurse who has completed at least abaccalaureate degree in nursing. The teacher is presentlyemployed in a diploma nursing program.Borderline Nursing StudentFor the purpose of this study, a borderline nursingstudent is enrolled in a diploma nursing program and hasreceived an unsatisfactory appraisal or a failing gradeprior to the final evaluation in a clinical course.Clinical EvaluationClinical evaluation involves a series of decisions madeby teachers about students' clinical performance. Based onobservations and data collection, teachers are responsiblefor awarding the final clinical grade (Wood, 1986).Experience From the perspective of clinical nursing teachers,experience is the lived reality of being responsible for theclinical evaluation of borderline nursing students.Assumptions The study was based on the following assumptions:1. Evaluating a borderline nursing student is ameaningful experience for the clinical teacher.2. Perceptions of an experience lead to meaning. Human9beings can reflect on the past and verbally express theirideas (King, 1981).3. The use of in-depth, unstructured interviewsenhances the emergence of relevant and meaningfulexperiences from the informants (Schwartz & Jacobs, 1979).Limitations The limitations of the study were as follows:1. The study was limited by the clinical teachers'willingness and ability to articulate their true perceptionsof and feelings about their experiences.2. Clinical teachers' perceptions of the phenomenonunder investigation may have been limited by the time lagbetween the time of the experience and time of the study.3. The informants who participated in the study wereclinical teachers employed in a diploma nursing program.Therefore, the generalizability of the experiences may belimited to diploma program-based clinical teachers.Research MethodThe phenomenological method of qualitative researchwas selected for this study. "Phenomenology is thestudy of human experience from the actor's (actress's)particular perspective" (Knaack, 1984. p. 107). Accordingto phenomenology, people have their individual, subjectiverealities which implies that experiences are consideredunique to each person (Burns & Grove, 1987).The phenomenological method enabled the researcher toexplore, interpret, and describe the meaning (Bergum, 1989)10that clinical teachers assigned to their experiences withthe clinical evaluation of borderline nursing students.Thus, phenomenology was the most suitable method to answerthe study's research question. Furthermore, the literaturereview revealed that this experience had not beenpreviously studied. The exploration of an unknownphenomenon supported the use of a phenomenological design(Sandelowski, Davis, & Harris, 1989). Chapter Threepresents the specific details of the application of thephenomenological method in this study.Organization of the Thesis This chapter has introduced the study by addressing thebackground to the problem, problem statement, researchquestion, purpose, conceptual framework, significance,assumptions, limitations, and research method.Chapter Two presents a review of the relatedliterature. This review includes both research- and non-research-based references.The third chapter describes the application of thephenomenological design used in this study. It outlines theselection and characteristics of the informants, ethicalconsiderations, data collection, data analysis, andreliability and validity.Chapter Four presents a descriptive account of how theinformants perceived their experiences with the evaluationof borderline nursing students. The findings were analyzedusing relevant literature.11The fifth chapter includes a summary of the findings,conclusions, and implications for nursing education andresearch.SummaryClinical evaluation is a responsibility inherent inthe clinical teacher role. Fulfilling this responsibilitywith borderline nursing students who demonstrateinconsistent performance is a stressful challenge. Therewas no research found which described how clinical teachersperceived the experience of evaluating these students.This study used a phenomenological research method toinvestigate the experiences of clinical teachers who hadevaluated borderline nursing students with the concepts ofrole, perception, and decision-making providing theconceptual foci. The study should contribute to theadvancement of nursing knowledge and enhance appreciation ofthe complexities of evaluating borderline nursing students.12CHAPTER TWOLiterature ReviewIntroductionThis chapter reviews the research- and non-research-based literature which is pertinent to clinicalteachers' experiences with the evaluation of borderlinenursing students. Given that the references specific toborderline students are limited, the literature reviewapplies primarily to failing or unsatisfactory clinicalstudents. However, because borderline students receive anunsatisfactory appraisal or failing grade prior to theirfinal clinical evaluation, this literature is directlyapplicable to the phenomenon under study.This chapter is organized into three major sections.The initial section examines the essence of borderlinestudents. It describes these students and addressesfactors which may contribute to the development ofperformance problems. The second section focuses onclinical evaluation and the decision to pass or failstudents. In particular, this section reflects the conceptsof the study's framework. It relates to the concept ofdecision-making, the concept of perception which is inherentin the subjective nature of clinical evaluation, andobligations which are a component of the concept of role.The third section reviews literature regarding the relationswith people component of the concept of role. It addressesclinical teachers' relationships with borderline students13and with their colleagues during the evaluation process.Further, this section pertains to the concept of perceptionby addressing how teachers' perceptions of their relationswith students and colleagues influence their evaluativedecisions. Finally, the literature review is summarized andconclusions are drawn.Borderline Nursing Students Descriptions of students with clinical performanceproblems are found in the literature. These descriptionshelp to identify the essence of borderline students. Inaddition, the literature offers insight into why somestudents may develop performance problems.The Essence of Borderline Students The literature review reveals only two articlesfocusing specifically on borderline nursing students(Brozenec et al., 1987; Wood, 1971). Brozenec et al.describe borderline students as individuals who do notclearly fall into a pass or fail pattern. Their clinicalperformance is inconsistent and includes both strong andweak behaviors. Wood (1971) characterizes borderlinestudents as having a marginal, unsatisfactory, or adeteriorating level of clinical competency. Welborn andThompson (1982) describe that some students demonstrateprogress toward mastering the expected level of clinicalperformance, yet their progress is not entirelysatisfactory. This description may apply to borderlinestudents. Because learners with borderline clinical14performance have a potential for failure, they fit Reed andHudepohl's (1983) definition of high-risk nursing students.These authors define high-risk students as learners who areat risk for not completing their nursing education.The description of learners who are at risk for notcompleting their nursing education because they exhibit aninconsistent, marginal level of clinical performanceidentifies the essence of borderline students. Borderlinestudents, unlike learners who excel or whose performance isconsistently unacceptable, "walk a fine line" betweenpassing and failing. Therefore, these students may pose adistinct evaluative dilemma for clinical teachers.Borderline Students: Contributing Factors Although the literature does not outline specificfactors which may contribute to individuals becomingborderline nursing students, it does identify factors whichmay contribute to students developing performance problems.These factors include admission standards and heterogeneityamong nursing students.In recent years nursing programs have experienced adeclining enrollment (Campbell & Davis, 1990; Lenhart, 1980;Rosenfeld, 1987; Statistics Canada, 1990; Symanski, 1991).According to American authors, the decreased number ofapplicants is forcing some schools of nursing to lower theiradmission standards (Lenhart; Rosenfeld, 1987; Symanski).Symanski argues that because of the trend to lower admissionstandards, teachers "may encounter an increasing number of15marginally prepared students and fewer who excel" (p. 18).Students who are enrolling in nursing education todayare a heterogeneous group (Brown, 1991; Campbell & Davis,1990; de Tornyay, 1985; de Tornyay & Thompson, 1987;Holtzclaw, 1983; Lenhart, 1980; Reilly & Oermann, 1990).Nursing students are women, men, high school graduates,older individuals who are seeking their first career or acareer change, and they are from many cultures and ethnicminority groups (de Tornyay & Thompson; Lenhart). Holtzclawasserts that, because more females are choosing other high-ranking professions, "nursing education is experiencing a'brain drain' of the academically strong, leadership-oriented women" (p. 453). Because of the diverse studentbody, more students may experience academic difficulties,personal problems, (Rosenfeld, 1988; Welborn & Thompson,1982), family pressures, and health-related problems (Reed &Hudepohl, 1988; Rosenfeld, 1988). These difficulties,problems, and pressures may explain why some individualsbecome borderline students.Owing to lower admission standards in some nursingschools and the increased diversity amongst student nurses,the potential for borderline students in nursing educationmay increase. Thus, more clinical teachers may experiencethe dilemma of evaluating these students.Clinical Evaluation: The Decision to Pass or Fail This section reviews literature regarding the clinicalevaluation process with borderline students. It examines16research into this phenomenon, the evaluation process as astressful responsibility for clinical teachers, thesubjective nature of clinical evaluation, and students'rights to academic due process.Research Related to Evaluating Borderline Students The literature review reveals an abundance of articleson clinical teaching and the process of clinical evaluation.Although this literature is consistent in labeling clinicalevaluation as problematic (Karuhije, 1986; LeVeille Gaul,1988; Mantle, 1982; Schneider, 1984; Wong & Wong, 1987;Wood, 1972, 1982, 1986; Wood & Campbell, 1985; Wood &Wladyka, 1980), there is a dearth of reported studies ofclinical teaching in general or specific to the evaluationprocess (Daggett, Cassie, & Collins, 1979; de Tornyay, 1984;DeYoung, 1990; McCabe, 1985; Pugh, 1983; Windsor, 1987).Three published reviews of research in nursingeducation do not identify any quantitative or qualitativestudies which focus on clinical evaluation or on borderlinestudents (Allemang & Cahoon, 1983; Andreoli & Musser, 1986;Baj & Clayton, 1991). Meleca, Schimpfhauser, Witteman, andSachs's (1981) national survey of clinical teaching skillsin nursing, medicine, and dentistry does not examineclinical evaluation or borderline students. Given that thisreview of research in nursing education reveals the paucityof studies addressing clinical evaluation and no studiesfocusing on borderline students, this section examines non-research-based literature and related studies.17Clinical Evaluation: Stressful ResponsibilityThe professional and legal obligation to evaluate thequality of students' clinical performance (Majorowicz, 1986)is a stressful component of the clinical teacher's role(Fry, 1975; Little & Carnevali, 1972; Majorowicz; Wood,1986). Inherent in this obligation is the failing ofincompetent students (Fowler & Heater, 1983; Majorowicz)and, with borderline students, deciding whether the marginallevel of performance should be awarded a passing or failinggrade (Brozenec et al., 1987; Wood, 1971). Beingcharged with the responsibility of evaluating students withperformance problems intensifies the stress of theclinical teacher's role (Lenhart, 1980; Majorowicz;Symanski, 1991; Welborn & Thompson). In addition to beingstressful, Symanski suggests that evaluating students whomay fail is a devastating, debilitating, and demoralizingexperience for clinical teachers.Goldenberg and Waddell's (1990) research on stress andthe use of coping strategies amongst 70 female baccalaureatenursing teachers substantiates the theory that clinicalevaluation of unsatisfactory students is stressful innature. These faculty members cited seeking peer support astheir most often used coping strategy.The literature identifies that the stress associatedwith the clinical teacher's evaluative role may be linked tothe time involved, the element of risk in clinical teaching,burnout, and educational preparation. The literature18related to these areas is examined and discussed in relationto the clinical evaluation of borderline students.Clinical evaluation is an enormously time-consumingcomponent of the clinical teacher role (LeVeille Gaul, 1988;Little & Carnevali, 1972; Wood & Wladyka, 1980). The timedevoted to clinical evaluation may contribute to thephysical and emotional fatigue inherent in the stress ofclinical teaching (Little & Carnevali). The added dimensionof students with unsatisfactory or borderline clinicalperformance compounds the responsibility and, therefore, thestress and the time involved (Lenhart, 1980; Majorowicz,1986; Symanski, 1991; Welborn & Thompson, 1982; Wood, 1971).Given that student involvement in patient care has thepotential for error and serious consequence to the patient,there is an element of risk in clinical teaching (de Tornyay& Thompson, 1987; Knox & Mogan, 1985; Little & Carnevali,1972; Wong & Wong, 1987). This risk, particularly withunsatisfactory students, contributes to the stressful natureof clinical teaching. Unsatisfactory students, with theirincreased potential for error, require a closer degree ofclinical supervision and more time and energy is needed toplan, evaluate, and document their learning experiences.Meanwhile, clinical teachers have less time and energyavailable to devote to more capable students and to otherrole responsibilities (Symanski, 1991; Welborn & Thompson,1982). Teachers' lack of attention to other students andresponsibilities may elicit feelings of guilt and resentment19which may further increase the stress of the evaluationprocess (Welborn & Thompson).According to Welborn and Thompson (1982),unsatisfactory students with their increased potential forerror present teachers with a time-consuming, stressfuldecision-making process which tends to involve fouroverlapping phases. These phases are: problemidentification, data collection and intensive supervision,discussing the problem with the student, and resolving thesituation--the final decision to pass or fail. This finaldecision to pass or fail students is an emotional strugglefor clinical teachers (Meisenhelder, 1982; Welborn &Thompson). Further, the literature indicates that thedecision to pass or fail unsatisfactory students may add toteachers' burnout potential (Lenhart, 1980; Ray, 1984;Symanski, 1991; Zanecchia & Stephenson, 1988).Burnout, a syndrome that develops in response to stressis "a state of physical, emotional, and attitudinalexhaustion" (Ray, 1984, p. 218). The potential consequencesof faculty burnout include: the loss of experiencedteachers, ineffective teaching behaviors (Ray), and "erosionof teaching standards" (Symanski, 1991, p. 18).When clinical teachers are afflicted with burnout andcontinue to teach, they may abdicate their power andauthority to maintain standards by choosing to avoid thechallenges associated with clinical failure. Therefore,teachers with burnout may pass inept students along to other20faculty members (Lenhart, 1980, p. 425). The pressures andconflicting forces that teachers may encounter due to thedeclining enrollment in nursing programs may contribute tofaculty burnout (Lenhart). Because of the decliningenrollment, program administrators may pressure clinicalteachers to pass or retain students. Thus, teachers mayencounter conflicting forces when evaluating unsatisfactorystudents; their obligation to uphold professional andeducational standards opposes the administrative pressure toretain students (Lenhart).Although clinical evaluation is described as stressful,and teachers are obligated to decide whether to pass or failborderline students, nursing studies which focus on facultyrole and job satisfaction do not address teachers'experiences with the clinical evaluation of borderline orfailing students (Fain, 1987; Marriner & Craigie, 1977;O'Shea, 1982).The complex and stressful nature of clinical evaluationnecessitates that clinical teachers have adequateeducational preparation (Carpenito & Duespohl, 1985; Wood,1986) and continuing education in order to be effectiveevaluators (Wood, 1986; Wong & Wong, 1987). Teachers whoare ill-prepared for the demands and realities of clinicalteaching may experience more frustrations with their roleresponsibilities (Carpenito & Duespohl). These frustrationsmay add to teachers' stress and burnout potential. Giventhat evaluating students with performance problems is a21stressful reality of the clinical teacher role (Carpenito &Duespohl), the evaluation process with borderline studentswarrants inclusion in education programs focused on clinicalteaching. Hence, the stress and insecurity that newclinical teachers (Welborn & Thompson, 1982) experienceduring the evaluation process with unsatisfactory studentsmay be decreased with adequate educational preparation.Further, Ray (1984) argues that nurse educators need toengage in professional development to enhance personalgrowth and increase tolerance to stress. Because evaluatingborderline students is a stressful dilemma, clinicalteachers may benefit from professional development programsfocused on evaluating this kind of learner. The review ofnursing research on the effective behaviors of clinicalteachers reveals three studies in which evaluation is ratedhighly by students and teachers as an area in whichproficiency is required (Brown, 1981; Knox & Mogan, 1985;O'Shea & Parsons, 1979). However, Karuhije's (1986) studyof how 211 nursing faculty members perceive the adequacy oftheir graduate program in preparing them for the role ofclinical teacher indicates that many nurse educators do notfeel their education adequately prepared them for clinicalteaching and their obligation to evaluate students'performance. This research supports the importance ofeducating teachers on the process of clinical evaluation.Clinical evaluation is a stressful obligation of theclinical teacher's role. This obligation is even22more stressful when working with students with performanceproblems. These students intensify the time involved, theelement of risk in clinical teaching, teachers' burnoutpotential, and teachers' need for an adequate educationalfoundation in clinical evaluation.The subjective nature of clinical evaluation is onetopic which needs to be considered. The next sectionexplores the issues relating to this subjectivity withclinical evaluation of borderline students.The Subjective Nature of Clinical EvaluationThe literature documents extensively the subjectivenature of clinical evaluation (Brozenec et al., 1987;Carpenito & Duespohl, 1985; de Tornyay, 1985; Fowler &Heater, 1983; Infante, 1985; LeVeille Gaul, 1988;Meisenhelder 1982; Poteet & Pollok, 1981; Reilly, 1980;Reilly & Oermann, 1985, 1990; Welborn & Thompson, 1982; Wong& Wong, 1987; Wood, 1982, 1986; Wood & Campbell, 1985;Wood & Wladyka, 1980; Woolley, 1977). Given that clinicalevaluation is a decision-making process that reflects thevalues and beliefs of the participants, it is subjective(Fowler & Heater; Reilly & Oermann, 1985, 1990). Teachers'individualized subjective perceptions influence theirobservations and interpretations of students' performance(Reilly & Oermann, 1985).Although the subjectivity in clinical evaluation cannotbe removed, it can be minimized and the quality of fairnessenhanced by using clearly stated clinical objectives (Reilly23& Oermann, 1985, 1990). Objectives prevent teachers' ownpersonal desires and beliefs from becoming the focus ofstudent evaluations. Through the use of clinicalobjectives, the expected level of performance iscommunicated to students (Carpenito & Duespohl, 1985;Guinee, 1978; Reilly & Oermann, 1985, 1990). Althoughobjectives provide an explicit focus for clinicalevaluation, teachers must render a subjective judgementwhich reflects their perceptions on whether these objectiveshave been achieved (Carpenito & Duespohl; Fowler & Heater,1983; Reilly & Oermann, 1985; Wood & Campbell, 1985). Inthe end, teachers "must call it as they see it"(Meisenhelder, 1982, p. 348).Because of the subjective nature of evaluativedecisions, the clinical evaluation process "can evokefeelings of insecurity, inadequacy, and guilt on the part ofnurse educators" (Reilly & Oermann, 1990, p. xiii).Therefore, the subjectivity in clinical evaluation is theimpetus for investigating the accuracy and reliability ofevaluative decisions. Results of a half-day facultyworkshop which examined how 30 clinical teachers evaluated astudent with borderline performance indicated that teachersdid evaluate differently (Brozenec et al., 1987). Becausesome teachers evaluated the overall performance as passingand others as failing, Brozenec et al. assert that, due tothe presence of subjectivity in clinical evaluation, theprogression or dismissal of borderline students may actually24depend upon the assignment to a particular teacher. Thefindings from this workshop illustrate the subjective natureof clinical evaluation and the importance of nurse educatorssharing and discussing their evaluative strategies andexamining the clarity of their clinical course objectives(Brozenec et al.). Through the use of videotaped clinicalperformances, studies by Bondy (1984), Hayter (1973), andLoustau et al. (1980) compared how different teachersevaluated the same situations. These investigations showthat, although teachers do evaluate differently, theaccuracy and reliability of decision-making can be enhancedby using videotapes to train teachers in the clinicalevaluation process. Findings from the faculty workshop andthese studies further substantiate the need to educateteachers on the evaluation process with borderline students.The literature describes two methods of clinicalevaluation--normative-referenced evaluation and criterion-referenced evaluation (Bondy, 1983; Guinee, 1978; Krumme,1975; Reilly & Oermann, 1985). The first method judgesperformance in relation to other individuals or some kind ofideal model. It ranks students and compares their standingto others. In contrast, criterion-referenced evaluationjudges performance against specific behavioral criteria(Krumme). The trend today in nursing education is towardcriterion-referenced evaluation (Krumme; Reilly & Oermann,1990). Clinical objectives are written in terms of standardperformance and learning outcomes (Guinee, 1975). According25to Krumme, because of the explicit performance criteriainherent in criterion-referenced evaluation, this method issuperior to normative-referenced evaluation in fostering theaccuracy and reliability of the evaluation process.However, with either method, teachers must render asubjective judgement which reflects their perceptions ofstudents' performance.The grading of students' clinical performance is anarea of concern which relates to the subjectivity inherentin evaluation (Brozenec et al., 1987; Litwack, Linc, &Bower, 1985; Reilly & Oermann, 1985; Rines, 1963; Wood,1982; Wood & Wladyka, 1980; Woolley, 1977). Althoughgrading is separate from evaluation (Infante, 1985; Reilly &Oermann, 1985, 1990), it relates to summative or finalevaluation and, therefore, is relevant to clinical teachers'experiences with borderline students.Grading is the subjective process by which a symbol isused to designate some degree of academic achievement(Infante, 1985; Reilly & Oermann, 1985). Grading may bebased on a multidimensional system which uses five lettergrades (A, B, C, D, or F for failure) or on a dichotomoussystem which uses either satisfactory/unsatisfactory orpass/fail (Reilly & Oermann, 1985; Rines, 1963; Wood &Wladyka, 1980; Woolley, 1977).A controversial issue in nursing education is whichsystem of grading best suits clinical courses (Wood, 1982;Wood & Wladyka, 1980; Woolley, 1977). Rines (1963) opposes26the multidimensional system. She argues that clinicalperformance involves human behavior which is too complex topermit the fine discriminations necessary with lettergrades. Reilly and Oermann (1985) argue that although thepass/fail system reduces anxieties associated with grades,it does not distinguish between excellent and barelysatisfactory performance. Further, these authors emphasizethat, regardless of the system, grading is subjective.Brozenec et al. (1987) and Wood (1971) acknowledgethat, because borderline students exhibit both passing andfailing clinical behaviors, awarding the final grade is adifficult task. However, the literature does not addresshow the method of grading influences teachers' decisionswith respect to grading borderline performance. Forexample, with letter grades, teachers can indicate thatstudents' performance is borderline by assigning the symbol"D," whereas with the dichotomous system clinicalperformance must be graded as either passing or failing(Reilly & Oermann, 1985). However, with the pass/failformat, unlike the multidimensional system, students whoreceive an unsatisfactory clinical grade and successfullyrepeat the course will not have their final grade pointaverage influenced by the initial failure (Reilly & Oermann,1985). A second issue which relates to grading and thesubjective nature of clinical evaluation is what constitutesa failing clinical grade (Brozenec et al., 1987; Carpenito &Duespohl, 1985; Grant, 1989; Wood, 1972, 1982, 1986).27Wood's (1986) survey on the problems inherent in clinicalevaluation identifies this issue as a major concern forclinical teachers. There is no fixed rule with respect tothe number of errors or unmet objectives that willdistinguish a failing grade from a borderline passing grade(Wood, 1982, 1986). According to Carpenito and Duespohl,teachers must render a judgment on such questions as:1. How many incidents warrant failure?2. What types of incidents warrant failure?3. How much improvement warrants passing?4. How many performance deficits can be permittedfor anxiety (p. 221)?Particularly with borderline students, deciding the answersto these questions poses a challenge for teachers during theevaluation process.A review of the literature regarding the subjectivenature of clinical evaluation supports perception as aconcept relevant to a study focusing on evaluatingborderline students. The entire evaluation process anddecisions about whether to award these students borderlinepassing grades or failing grades reflects teachers'particular perceptions.Although clinical evaluation is essentially subjective,it can be fair (Reilly & Oermann, 1985). The followingsection addresses students' rights to fair evaluation, orthe concept of academic due process, and the feelings andfears that teachers share with respect to ensuring that28their evaluations are fair.Students' Rights to Academic Due Process Wood (1971) argues that nursing programs need to havepolicies and procedures which ensure positive, fairstrategies to resolve the problems associated withborderline students. Although this advice is dated, itremains applicable today. Further, educational institutionsshould have clearly delineated policies and procedures forclinical evaluation, grading, grievances, and appealprocesses (Carpenito, 1983; Darragh, Jacobson, Sloan, &Standquist, 1986; Grant, 1989; Miller, 1982; Wood, 1986;Wood & Campbell, 1985).Given that students' rights to academic due processrequire that teachers' evaluative decisions be substantiatedwith documented evidence (Grant, 1989; Huston, 1986;Majorowicz, 1986; Wood, 1986; Wood & Campbell, 1985) andthat students must be informed of their unsatisfactoryclinical progress prior to the final evaluation (Carpenito &Duespohl, 1985; Fowler & Heater, 1983; Huston; Majorowicz;Poteet & Pollok, 1981; Wood, 1986, Wood & Campbell), nursingprograms need an explicit policy regarding clinicalevaluation procedures. Written evaluations supportteachers' decisions and provide students with concretefeedback regarding their clinical standing to date.Therefore, with borderline students, teachers need adequatedocumentation to substantiate their evaluations and writtenevidence that students are aware of the possibility of29clinical failure.The fear of violating students' rights to academic dueprocess, particularly when the possibility exists thatstudents may fail, is a significant concern for clinicalteachers. With feelings of uncertainty and frustration,teachers vacillate between believing that their decisionsare valid and believing that perhaps their decisions are notquite fair (Welborn & Thompson, 1982). Borderline studentswith their marginal performance exacerbate teachers'uncertainty and frustration in making fair decisions(Brozenec et al., 1987; Welborn & Thompson).To validate teachers' evaluative decisions, severalauthors recommend that nursing programs adopt the policythat a second teacher evaluate the clinical behaviors offailing students (Brozenec et al., 1987; Carpenito, 1983; deTornyay, 1985; Meisenhelder, 1982; Welborn & Thompson, 1982;Wood & Campbell, 1985). According to de Tornyay (1985),seeking a second opinion is a sound, commendable practicewhich pools faculty expertise in understanding andevaluating students. The literature review did not revealany references specific to second opinions with borderlinestudents. However, observing students' clinical performancemust be done over a period of time (Reilly & Oermann, 1990).With respect to second opinions, the teacher observes merelya sampling of behavior which may or may not berepresentative of true performance (Reilly & Oermann, 1990,p. 223). With the inconsistent performance of a borderline30student, the second evaluator may not observe the student'sstrong and weak behaviors. In addition, the secondevaluator, who has not established a working relationshipwith the student, may enhance anxiety which results in apoorer than expected level of performance. According toKushnir's (1986) study regarding the effects of clinicalteachers' presence on students' behavior, teachers need toestablish an effective interpersonal relationship withstudents to minimize their performance anxiety. Therefore,this study substantiates that second evaluators may notalways observe students' true level of competency. Secondevaluations must be viewed individually for their accuracyand reliability.Students' rights to appeal teachers' evaluativedecisions gives them an avenue to dispute treatmentperceived as unfair (Carpenito, 1983; DeYoung, 1990; Fowler& Heater, 1983; Huston, 1986; Lenhart, 1980; Meisenhelder,1982; Miller; Wood, 1986; Wood & Campbell, 1985; Wood &Wladyka, 1980). Clinical teachers share the fear of theappeal process and the legal ramifications if failedstudents were to sue (Fowler & Heater; Majorowicz, 1986;Meisenhelder; Ray, 1984; Wood, 1986) and teachers mayquestion whether or not their documentation will adequatelysupport the failing grade in the event that students appealthe decision (Welborn & Thompson, 1982).In the case of a fourth year medical student dismissedfor lack of clinical competency, the United States Supreme31Court ruled that the student had been accorded due processand upheld the rights of educators to exercise subjectivejudgement in the process of clinical evaluation (Fowler &Heater, 1983; Poteet & Pollok, 1981; Wood & Campbell, 1985).This case supports students' rights to due process andteachers' right to evaluate clinical performance as they seeit. Furthermore, it substantiates the need for clinicalteachers to support evaluative decisions with explicitdocumentation.Wood and Campbell (1985) cite a Canadian case in whichthe court ruled on behalf of the student's right to dueprocess. In this case, a nursing student failed theclinical experience without being given notice and theteacher's documentation lacked the clarity to support thefailing grade. This case emphasizes the importance ofhaving a clear grading policy and explicit documentation inthe evaluation of borderline or failing clinical nursingstudents.Findings from Orchard's (1991) study of administrativestructures and procedures dealing with clinical failures in94 Canadian nursing programs, indicate that teachers'decisions to fail students are (a) upheld in most grievancereviews within the nursing programs, (b) often modified inappeal hearings outside the nursing programs, and (c) upheldwhen they reach the courts in an external appeal.Furthermore, this study reveals that many nursing programsdo not have written policies and procedures which address3 2clinical evaluation or the grievance and appeal processes.Orchard recommends that nursing programs can avoid havingteachers' evaluative decisions modified in grievance orappeal processes by following prescribed institutionalpolicies and procedures related to clinical evaluation.This recommendation supports the literature previouslyreviewed.Each student's right to academic due process is areality of the clinical teacher's evaluative role. Ensuringthat clinical evaluation is fair and, therefore, does notviolate this right is a significant concern for teacherswhen faced with the challenge of evaluating borderlineperformance.According to Reilly and Oermann (1985, 1990), arequisite for a fair evaluation is a supportive climate.The following section includes a discussion of thepsychosocial climate for clinical evaluation.Relationships with Students and ColleaguesClinical teachers' relationships with the student andwith their colleagues during the evaluation process withunsatisfactory students are inherent in, and central to, theteacher's evaluative role. These relationships influenceteachers' perceptions of the evaluation process. Thissection examines literature related to these two areas.Teacher-Student Relationships Clinical evaluation is a dynamic, interactive processwhich involves relationships between teachers and students33(Reilly & Oermann, 1990). The dynamics of the clinicalevaluation process are influenced by perceptions. Clinicalteachers' perceptions of their relationships with studentsmay influence their evaluative decisions (Meisenhelder,1982) and students' perceptions of their relationships withteachers may influence whether or not they value clinicalevaluation as a process for personal growth and learning(Reilly & Oermann, 1985).Teachers need to establish a positive, supportive,communicative relationship with each student which ischaracterized by mutual trust and respect (Meisenhelder,1982; Reilly & Oermann, 1985). Majorowicz (1986) assertsthat through effective communication teachers and studentscan attempt to understand each others' perceptions of theirsituations and work together to deal with any concerns.Teacher-student relationships are intrinsic to thepsychosocial climate for evaluation (Reilly & Oermann,1985). Positive relationships between teachers and studentsfacilitate a supportive learning climate. This climate isessential to students accepting clinical evaluations as fair(Reilly & Oermann, 1985), valuing teachers' evaluativefeedback (Meisenhelder, 1982), and growing through boththeir successes and their failures (Carpenito & Duespohl,1985).In a supportive learning milieu teachers view studentsas individuals with their own learning needs (Reilly &Oermann, 1985). By completing comprehensive student34assessments, teachers are able to determine students'learning needs, identify potential performance problems, andplan individualized, facilitative teaching strategies(Reilly & Oermann, 1985; Wood, 1971).Further, in a supportive learning milieu, students feelsecure to evaluate their own clinical progress (Carpenito &Duespohl, 1985). Self-evaluation encourages students toexamine their own strengths and weaknesses as well asproviding a means for teachers and students to communicatetheir perceptions of the clinical experience (Brozenec etal., 1987; Carpenito & Duespohl; Majorowicz, 1986; Reilly &Oermann, 1985).According to a study of nursing students' perceptionsof unethical teaching behaviors in the classroom andclinical setting, students report lack of respect andsensitivity toward the learner as significant unethicalteaching behaviors (Theis, 1988). In comparison, studieswhich focus on students' perceptions of effective teachingbehaviors illustrate that respect, support, and concern forstudents are effective teaching behaviors that enhancelearning (Brown, 1981; O'Shea & Parsons, 1979). A study ofhow diploma nursing students explain their successes andfailures in the clinical setting shows that students viewteachers as the most important factor underlying both theirsuccesses and their failures (Davidhizar & McBride, 1988).These studies verify the importance of the teacher-studentrelationship and the need for a "supportive learning milieu"35(Reilly & Oermann, 1985, p. 96) in the clinical setting.Teacher-student relationships and a supportive learningmilieu are especially important when working with studentswith performance problems (Majorowicz, 1986; Meisenhelder,1982). Although it is important that teachers remainpositive and supportive, the clinical evaluation processwith unsatisfactory students has a direct effect on teacher-student relationships (Carpenito, 1983; Meisenhelder).There is a qualitative difference in how the individualsrespond to each other. Students may respond with denial,grief, anger, and hostility (Brozenec et al., 1987;Carpenito; Meisenhelder) while teachers may respond withanger, frustration, and guilt, or by emotionally andphysically distancing themselves from students (Carpenito;Meisenhelder). According to Meisenhelder, teachers needpatience and self-control to retain a caring approach withhostile students.Clinical teachers wrestle with the decision to assignfailing grades knowing that failing is emotionally difficultfor students (Carpenito, 1983; Majorowicz, 1986;Meisenhelder, 1982; Symanski, 1990; Turkett, 1987; Welborn &Thompson, 1982). A failing grade may threaten students'self-esteem and shatter their dreams (Brozenec et al., 1987;Carpenito; Meisenhelder). Teachers' awareness of their ownfallibility may influence the assigning of a failing gradeand the severe judgement implied by clinical failure mayconflict with teachers' beliefs about caring for, and36nurturing, learners (Meisenhelder, p. 348). Thus, teachers'perceptions of the meaning of failing may influence theevaluation process (Meisenhelder).Inherent in the clinical teacher's evaluative role isan interpersonal relationship with each of their students(Kushnir, 1986). Given that learners with performanceproblems can influence the dynamics of and teachers'perceptions of the evaluation process, relationships are anessential element of the teacher's evaluative role withborderline students.Relationships With Colleagues The dynamics of evaluating borderline students andteachers' perceptions of the evaluation process may beinfluenced by relationships with colleagues (Meisenhelder,1982). The decision to fail a borderline clinical studentmay or may not be supported by a teacher's colleagues(Carpenito, 1983; Majorowicz, 1986; Symanski, 1991).According to Carpenito (1983), faculty members may viewclinical teachers who fail students as cruel and uncaring.Furthermore, some faculty members may be labeled as "failingteachers" by their peers who have never assigned a failinggrade. Brown (1991) argues that the increased number ofgrade appeals in recent years has led to more scrutiny ofevaluative data by colleagues. Teachers may perceive thisscrutiny as lack of respect and support.Symanski (1991) asserts that teachers "should seeksupport from like-minded colleagues and temporarily ignore37the rest" (p. 21). However, ignoring one's peers appears tobe an impermanent solution which does not reconcile thedifferences in teachers' philosophies with respect toclinical evaluation. In contrast to Symanski, Brozenec etal. (1987) encourage teachers to openly exchange ideas andshare philosophies about the clinical evaluation process.If colleagues are supportive, their understanding andinput may assist clinical teachers in coping with thechallenge of evaluating unsatisfactory students (Brozenec etal., 1987; Goldenberg & Waddell, 1990; Meisenhelder, 1982;Symanski, 1990; Welborn & Thompson, 1982). Furthermore, byseeking the support of their peers, clinical teachers pooltheir expertise in understanding and evaluating students (deTornyay, 1985). Although the validity of having a colleagueevaluate an unsatisfactory student's performance waspreviously addressed, this procedure may promote facultysupport (Brozenec et al.; Carpenito, 1983; Welborn &Thompson). According to Carpenito, colleagues should viewthe actions of teachers who award failing grades as a higherform of caring which demonstrates responsibility andaccountability to the student, the clients, and theprofession (p. 33).The fact that the literature outlines that peer supportis valuable, yet not always given, when evaluating studentswith performance problems, justified the inclusion ofrelations with faculty as a focus of clinical teachers'experiences with borderline students.38Summary and Conclusions The review of the literature is summarized andconcludes with an outline of how the concepts of role,decision-making, and perception formed an applicableframework for this study. Conclusions are drawn regardinghow the current state of knowledge supported the rationalefor this study.SummaryThe limited literature specific to borderline nursingstudents described the difficult challenge that clinicalteachers face when evaluating these individuals'inconsistent clinical performance. Because these students"walk a fine line" between passing and failing, they presentteachers with an evaluative dilemma different from thoselearners who excel or consistently perform poorly. TheAmerican literature indicated that, due to lower admissionstandards and a diverse student body, there is a possibilitythat clinical teachers may encounter an increased number ofstudents with borderline performance.According to the literature, evaluating the quality ofstudents' clinical performance is an obligation inherent inthe role of clinical teacher. With a borderline student,teachers are obligated to decide whether the marginal levelof performance warrants a passing or failing grade. Becausestudents with unsatisfactory performance exacerbate thecomplex problems and stress involved in the evaluationprocess, fulfilling this obligation with these students was3 9described as debilitating, demoralizing, devastating, andfrustrating. Furthermore, the literature indicated thatclinical evaluation of unsatisfactory students maycontribute to the development of faculty burnout.The complexity of clinical evaluation was discussed bya number of authors as being linked to its subjectivenature. Teachers' subjective perceptions influence theirinterpretations of students' clinical performance. Thissubjectivity is an issue of concern for clinical teachersduring the process of deciding if a clinical failure wouldbe fair and justified. The literature identified the manyfactors that teachers take into consideration when decidingthe final grade of students with performance problems.These factors included: the amount and type of documentedevidence gathered on students' performance, students' rightsto due process, the standards of the profession, the legalramifications, and the overall consequences associated withclinical failures. The importance of educationalpreparation for clinical teachers with respect to thiscomplex evaluation process was outlined in the literatureand supported with research.The literature documented that evaluating students withperformance problems influences the teacher-studentrelationship and further emphasized that, although therelationship changes, it is imperative that teachers remainpositive and supportive. Studies which examined teacher-student relationships confirmed the importance of teachers40having a supportive approach with learners in allsituations.According to the literature, during the process ofevaluating unsatisfactory students, teachers' colleaguesvary in their attitude and support. The process ofevaluating these students may put a strain on teachers'relationships with some of their peers while others mayprove to be a valuable resource.Inherent in this overview of the related literaturewere the concepts of role, decision-making, and perception.Hence, the literature supported the relevancy of theseconcepts as the framework for this study. In brief, therole of clinical teachers includes the obligation toevaluate the quality of students' clinical performance.With borderline students, who exhibit a marginal level ofperformance, teachers wrestle with their decisions to awardeither passing or failing grades. This decision-makingprocess reflects teachers' perceptions and influencestheir relationships with students and peers.ConclusionBased on review of the related literature, it wasevident that a study exploring the meaning clinical teachersgive to their experiences of evaluating borderline studentswas justified. The literature that was available on thistopic was anecdotal in nature, focused primarily on failingstudents, and had not been presented from clinical teachers'viewpoints.41Although the literature described the challengingsubjective decisions that clinical teachers encounter whileevaluating borderline nursing students, how clinicalteachers perceived this experience has not been studied. Inaddition, there was an absence of research that explored howthe evaluation process with these learners influencesteachers' relationships with students and peers. Thus,there was a lack of understanding of how teachers viewedtheir experiences with borderline students; experienceswhich encompass a challenging decision-making process andrelationships with borderline students and colleagues. Thislack of insight, combined with the fact that evaluatingstudents' performance is a fundamental responsibility forclinical teachers, underscored the necessity of researchingthis phenomenon.The application of the phenomenological researchmethod used in this study is described in the followingchapter.42CHAPTER THREEMethodologyIntroduction This study used a phenomenological research methodto investigate and describe clinical teachers' perceptionsof evaluating borderline nursing students. In this chapterthe selection and characteristics of the informants, ethicalconsiderations, data collection, data analysis, andreliability and validity are considered.Selection of the Informants The selection of the informants was consistent with thephenomenological method. The sampling method, selectioncriteria, and selection procedures will be described.Sampling Method The informants were selected based on the criterionthat they were willing and able to speak to the phenomenon.This method of sample selection is known as theoreticalsampling (Omery, 1983; Sandelowski et al., 1989). Theprinciples of random or representative sampling were notapplicable to this study's qualitative research design(Field & Morse, 1985). Given that qualitative research isdirected toward obtaining data that are "comprehensive,relevant, and detailed" (Morse, 1986, p. 183), the samplesize was limited. The researcher selected informants untiltheoretical saturation was achieved. Morse explainstheoretical saturation as the point in data collection whenthe information is complete, makes sense, and is confirmed43with the informants. Thus, an adequate sample size couldnot be predetermined. However, the researcher estimatedthat between six to eight informants would probably beneeded to achieve theoretical saturation.Criteria for SelectionIn accordance with theoretical sampling, the clinicalteachers who participated in this study were selected basedon their willingness to share their experiences ofevaluating borderline students. In addition, the clinicalteachers were required to be registered nurses with at leasta baccalaureate degree in nursing and employed in a diplomanursing program. The selection of informants who wereinterested and able to illuminate the phenomenon (Omery,1983) minimized the possibility of having informants whowere unwilling or unable to articulate their experiences.The rationale for stipulating diploma program-based clinicalteachers related to the high number of accessible diplomanursing programs in the Vancouver area. To recruit enoughwilling informants and avoid agency-specific data, threenursing programs were used.Selection Procedures The director of each nursing program was sent anexplanatory letter (Appendix B) for agency consent (AppendixC) and a brief overview of the proposed study (Appendix D).Once agency consent from the three directors was obtained,and approval from the University of British ColumbiaScreening Committee for Research Involving Human Subjects44was granted, an introductory letter was distributed to theclinical teachers (Appendix E). Enclosed with thisintroductory letter was a brief overview of the proposedstudy. Within two weeks of distributing these letters, theresearcher presented the study to the entire nursing facultyin two agencies and to interested clinical teachers in thethird agency. These presentations provided an opportunityfor clinical teachers to meet the researcher, learn moreabout the study, and ask questions. Nine clinical teacherscontacted the researcher and volunteered to participate.All nine teachers met the selection criteria, expressed akeen interest in the research topic, and disclosed that theywould value the opportunity to share their perceptions ofthe phenomenon. In addition, the teachers asserted thattheir recent evaluations of borderline students wouldfacilitate recalling these experiences. Later, one teacherwithdrew from participating due to time commitments andillness. After the researcher had interviewed the firsteight informants, another clinical teacher volunteered toparticipate. Given that sufficient data had been collectedand theoretical saturation obtained, this person was notincluded in the sample.Characteristics of the Informants Eight female clinical teachers from three differentdiploma nursing programs participated in this study. Thedistribution per program was four, three, and one.A baccalaureate degree in nursing was the highest level45of education for three informants. Five informants hadmasters degrees distributed as follows: two in nursing, twoin education, and one in counselling psychology.The informants' years of experience in nursing rangedfrom 11 to 31 with the average being 19 years. Primarily,the informants' nursing experiences prior to clinicalteaching took place in medical-surgical and/or intensivecare units. In addition, one informant had worked as acommunity health nurse, one informant had been a pediatricnurse, two informants had practiced as psychiatric nurses,and three informants had been nursing administrators.Presently, all informants taught in medical-surgicalclinical areas and their number of years as nurse educatorswere respectively: 1, 1, 2.5, 10, 10, 12, 17, and 18. Twoof the veteran teachers had previously taught in apsychiatric setting.Seven clinical teachers spoke to their experiences ofevaluating borderline students at various levels of theprogram. The most recent clinical teaching responsibilityfor two of the informants involved evaluating students in afinal preceptorship semester. One inexperienced informanthad only taught in the middle stage of the program.The following indicates how many borderline studentseach informant had evaluated: 3, 4, 7, 10, 20, 25, 42, and100. As the informants' number of years of teachingincreased, so did the number of borderline studentsevaluated. At the time of the interviews, four of the46informants were in the process of evaluating a borderlinestudent.Ethical Considerations This researcher ensured protection of the rights ofinformants by:1. Obtaining consent from the three agencies (AppendixC), and obtaining approval from and adhering to thestandards set by the University of British ColumbiaScreening Committee for Research Involving Human Subjects.2. Explaining to the informants in writing the study'spurpose, the benefits of participating, and the expectationsfor informants (Appendix E).3. Obtaining written consent from each informant priorto conducting the initial interview (Appendix G), and byobtaining verbal consent from each informant at theinitiation of the second interview. The written and verbalconsents addressed voluntary participation, the audio-tapingof each interview, the informant's rights to withdraw fromthe study upon request, to refuse to answer any questions,and to ask that disclosed data not be included in the study.4. Assuring the informants that their participation,their place of employment, the audio-tapes and thetranscriptions of the interviews would be kept confidentialand anonymous. Therefore, each informant was assigned aletter and the audio-tapes and transcripts were codedaccordingly. The informants' consents and personalinformation were kept in a locked drawer. Further,47identifying data were deleted from the transcripts.5. Assuring the informants that the only people whomight listen to the audio-tapes were the researcher andpossibly the thesis advisors. In addition, they were toldthat the audio-tapes would be erased and the transcriptswould be destroyed upon completion of the study.6. Requesting that the informants not disclose thenames or any identifying information regarding theidentities of the borderline nursing students who wereinvolved in their experiences.Data CollectionIn order to collect data which were "comprehensive,relevant, and detailed" (Morse, 1986, p. 183), theresearcher completed in-depth interviews with eachinformant. The interviews were audio-taped, unstructured,and lasted approximately one hour. The interviews wereconducted in a quiet setting of the informant's choice.Four of the teachers chose to be interviewed in theiroffices and four requested their homes. Each informant wasinterviewed twice and the time between interviews variedfrom three to five weeks. Two interviews with eachinformant were sufficient to collect data which adequatelydescribed, clarified, and validated the phenomenon underconsideration.The initial interviews were guided by basic triggerquestions (Appendix A). These questions were open-ended andrelated to the framework's concepts of role, perception, and48decision-making. The first question addressed theinformant's overall experience. The second question focusedon decision-making. Given that evaluative decisions areinherent in the obligations associated with the clinicalteacher role and are influenced by the teacher's perceptionof the student's clinical performance, this questionpertained to all three concepts. The final two questionsexplored relationships, a component of the concept of role.The trigger questions served as a guideline and weremodified according to the data elicited from the informants.During each interview, additional questions were posed asthey naturally emerged from the informant's responses. Thisunstructured format facilitated the formulation ofsignificant questions which in turn promoted a range ofmeaningful answers from the informants (Schwartz & Jacobs,1979). In addition, the first interview included basicquestions concerning the informants' academic and nursingbackgrounds. This information provided the data needed todescribe the informants who participated in this study(Appendix F).During the second interview, the questions posed weremore structured and were directed toward expanding,clarifying, and validating informants' accounts. Expandingon and clarifying previously collected data minimized thediscrepancy between what informants had said and what theyhad meant to disclose (Schwartz & Jacobs, 1979). Thevalidation questions ensured that the researcher's49interpretation of the data faithfully portrayed theinformants' perceptions.Data Analysis In phenomenological research data collection and dataanalysis occur concurrently (Morse, 1986). The audio-tapeswere transcribed verbatim by the researcher and then, withdirection from Giorgi's (1975 a,b) approach to dataanalysis, the transcripts were analyzed. The steps used fordata analysis were as follows:1. The transcripts were read to grasp a sense of thewhole.2. The transcripts were thoroughly reexamined toidentify the natural transitions in meaning, called meaningunits.3. The similar meaning units from all the interviewswere compared, contrasted, combined, and categorized intothemes which were clarified and elaborated on by relatingthem to each other and to the whole.4. The themes were reflected on and grouped intoabstract concepts.5. These insights were synthesized and integrated intoa written description of the phenomenon.Reliability and ValidityIn this qualitative study, the rules for achievingreliability and validity in quantitative research did notapply. (Sandelowski, 1986; Yonge & Stewin, 1988). Thisstudy followed the criteria of rigor in qualitative research50which include credibility, fittingness, auditability, andconfirmability (Guba & Lincoln, 1981).According to Sandelowski (1986), a qualitative studyis credible when the findings faithfully portray theinformants' experiences. To ensure credible findings, theresearcher searched for the meaning of this experience fromthe informants' cognitive, subjective perspectives withoutany preconceptions about what this meaning might be (Ornery,1983). Therefore, in order to describe the phenomenon fromthe informants' perspectives, the researcher's beliefs andassumptions about what the experience may mean werebracketed (Knaack, 1984; Swanson-Kauffman & Schonwald,1988). The researcher's exposure to the related literatureassisted in consolidating and bracketing her experiences andbeliefs (Munhall, 1982; Swanson-Kauffman & Schonwald). Theprocess of validating the emerging themes and conceptsduring the second interviews and the use of transcriptexcerpts in data presentation enhanced the credibility ofthe study's findings.Guba and Lincoln (1981) propose that fittingness be thecriterion used to evaluate the applicability of qualitativeresearch findings. Fittingness was established by selectingthe informants from several nursing programs. The use ofmore than one agency minimized obtaining data particular toone nursing program which would have limited applicability.In addition, fittingness was ensured by including bothtypical and atypical data in the findings.51Auditability is the criterion of consistency orreliability in qualitative research (Guba & Lincoln, 1981).The findings are auditable when the reader can clearlyfollow the researcher's decision trail (Sandelowski, 1986).An explicit decision trail supports the method of dataanalysis and, therefore, the validity of the findings (Field& Morse, 1985). Throughout the research process, theresearcher's decision trail was confirmed with her thesiscommittee.The criterion of confirmability is the freedom frombias in the research process (Guba & Lincoln, 1981).Confirmability was ensured by the establishment ofcredibility, fittingness, and auditability (Yonge & Stewin,1988).SummaryThis chapter outlined the research design used in thisstudy. The selection of informants, procedures of datacollection and analysis, ethical considerations, andreliability and validity were described.The use of a phenomenological design enabled theresearcher to search for the meaning that eight clinicalteachers assigned to their experiences of evaluatingborderline nursing students. The data were collectedthrough the use of unstructured interviews which were guidedby three trigger questions, reflecting the concepts of role,perception, and decision-making.With direction from Giorgi's (1975 a,b) method of dataanalysis, the informants' accounts were analyzed. Thefollowing chapter presents a detailed discussion of theconcepts and themes which emerged from the data. Thispresentation includes a comparison to the literature andconcludes with a summary of the phenomenon's centralcharacteristics.5253CHAPTER FOURPresentation and Discussion of AccountsIntroduction From the analysis of the data emerged an intricatenetwork of interrelated themes. These themes were reflectedon and then grouped into three overlapping concepts. Theconcepts are ambiguity, student's self-awareness, andlaborious decisions. These concepts and their inherentthemes are depicted in Figure 1.CONCEPTS THEMESAmbiguity1. Ambiguous Nature ofBorderline performance2. Ambiguous Nature of ClinicalEvaluation3. Ambiguity: DualResponsibility1. Degree of Insight2. Teacher-Student Relationship3. The Student's Decision4. Fostering Self-AwarenessStudent'sSelf-AwarenessLaboriousDecisions1. A Sense of Uncertainty:Self-Doubt2. Emotional Challenge3. A Sense of the Whole:Gestalt View4. A Sense of Knowing:Intuition5. A Sense of TrustingFigure 1. Clinical Teachers' Experiences--Concepts andThemes.54This chapter is an in-depth presentation and discussionof the concepts, themes, and their interrelationships.Given that ambiguity was a recurring concept, its linkage toother relevant themes is considered. Included in thispresentation are references to the relevant literature andtranscript excerpts in which the letter "I" refers to theinformant and the letter "R" to the researcher. Thischapter concludes with a summary of the informants'accounts.AmbiguityThe predominant concept that emerged from the data wasambiguity. According to Webster's Dictionary, "ambiguous"means not clear, uncertain, vague, or open to interpretation(Guralnik, 1980). The informants used, or implied, theseterms in reference to borderline performance, the clinicalevaluation process, and their dual responsibility tostudents and to patients. According to the informants, thisambiguity contributed to their dilemma of evaluatingborderline students.Ambiguous Nature of Borderline Performance The ambiguous nature of borderline performance surfacedfrom the data as a common theme. This ambiguity related tothe informants' difficulty in isolating borderline students'performance problems and to their inconsistent pattern ofclinical behavior. It became particularly evident when theinformants compared borderline students to failing students.Enigmatic performance problems. One similarity55apparent among the informants' perceptions was theirdifficulty pinpointing the problems underlying students'borderline performance. Because students' performanceproblems were unclear, identifying them was difficult. Oneinformant described these problems as "vague" whereas,another informant stated, "The borderline student is theperson who can go either way; you can see some really goodstrengths and some other things that are a bit of anenigma." The following three transcript excerpts furthersupport that borderline students had enigmatic performanceproblems.I: I think the borderline student, to me, is the one... I spend a lot of time identifying what is goingwrong ... the "whys," why did it happen this way ...trying to figure out what it is that has gone wrong ...why can't this student pull it together? ... they arejust not clear cut ... they are hard, because it is sohard to figure out what the problem is.I: ... it's hard to pinpoint exactly what it is they'redoing wrong and what they need to do to fix it. It'snot always clear.I: ... usually when somebody is a borderlinestudent there's a whole lot of things ... a wholeconstellation of incompetencies ... it's usually never56really really clear, it's a collection of things's all this kind of subtle stuff and it's isolatedincidents and you have to connect them and it's a lotof work.Inherent in these quotations were the perceptions thatproblem identification was hard work, time-consuming, andinvolved connecting many "things" which were unclear orsubtle. Further, the rationale for the performance problemoften remained shrouded in uncertainty--"Why can't thisstudent pull it together"? In addition, various informantsdescribed how borderline students exhibit "patterns ofbehavior" and the reasons underlying their performanceproblems were so diverse and individualized that isolatingthe contributing factors was "never easy."The idea that students' clinical behaviors may resultfrom a "collection of things" was expressed by theinformants when they listed the possible determinants ofborderline performance. This list included concernsregarding their level of motivation, attitude, knowledgebase, application of theory to practice, organizationskills, communication skills, and psychomotor skills. Anadditional reason, mentioned by many informants, was theproblem of "personal baggage," "more appendages," or "morecommitments." For instance, one informant said ...I: I also find that students come with a whole lot of57baggage, tons and tons of baggage that has nothing todo with school ... but it sure does impact it.This informant went on to say that the number of studentscarrying personal "baggage" had increased and cited thefollowing reason for this ...I: ... part of it could be that we get older studentsnow. We don't have so many young students ... whichmeans they have experienced life to a greater degree.R: They have more time to gather baggage?I: Right, more time to gather baggage. They have moreappendages to their lives like children, husbands andboyfriends ...Likewise, another informant asserted ...I: ... another problem ... we are running into withborderline students is that, since we have so manymature students, they may have a lot of othercommitments in their life ... so they are not able toput so much as they really should into their studies /then we see the consequence of it ... you don't see asgood of a performance as you should.The interrelationships between students with "personalbaggage," performance problems, and a more mature and58diverse student population were identified by manyinformants. One teacher asserted that "the caliber ofstudents" had decreased because of this diversity.Similarly, the increased number of students with personalproblems caused by a diversified student population wasaddressed in the nursing literature (Reed & Hudepohl, 1988;Rosenfeld, 1988; Welborn & Thompson, 1982). Further, theinformants stated that they were often unaware that studentshad personal problems, yet they saw the consequences ofthem.According to informants, the factors whichcontributed to the development of borderline performancewere unclear or "a bit of an enigma." Although therationale for borderline performance was unclear, theinformants agreed that these students exhibited aninconsistent pattern of clinical behavior.Inconsistent behavior. The informants describedthe inconsistency of borderline performance using antipodalterms like: "up and down" and "strong and weak." In thefollowing three narratives, the informants referred to thevagueness, uncertainty, and unpredictability of thisinconsistent behavior.I: ... their performance is vague ... sometimespassing, sometimes failing ...I: ... one week fine, one week not fine, and up and59down. I guess never knowing, not being able to predictthat the student will do something right the next week... even though the student did it this week alright.I: ... they are up and down; they are okay at times andnot okay at other times. You are never really surewhere they are at. It makes it really hard.According to the informants, borderline students'inconsistent patterns of performance distinguished theselearners from those that were failing.Borderline versus failing students. When asked aboutthe difference between borderline and failing students, mostinformants explained that failing students consistentlyexhibit unsatisfactory behaviors resulting in a clear-cutperformance and a simplified clinical evaluation process.The narratives below illustrate this viewpoint.R: How would you distinguish between borderline andfailing students?I: Failing students don't meet any of the objectives,they are clearly not at the satisfactory level. Theyare much easier to evaluate ... straightforward ...I: if someone is unsafe, I don't think it is thatdifficult of a decision.R: How come it's not as difficult of a decision if the60student is unsafe?I: Well, it is definitely more clear ... it is moreclear that they are not meeting the objectives ...I: I guess the distinguishing thing is that a studentwho's failing ... it's much more clear-cut and perhapsless energy goes into that student ...In contrast to failing students, borderline students'inconsistent performance resulted in a complex evaluationprocess. Given that the term borderline contains the wordsborder and line, it was not surprising that some informantsdescribed these students as "on the border" or "walking athin line." Moreover, descriptions like "on the brink," "onthe edge," and "on the fence" were used. One teacher usedan analogy to distinguish between failing and borderlinestudents. This analogy and the other descriptions inferredthat borderline students could potentially "fall" to thefailing side.I: ... the borderline student as opposed to the failingstudent is the student who has his/her foot on thebanana peel, the failing one is falling down.Owing to the fact that borderline students were viewed asstepping "on a banana peel" or "walking a thin line," theoutcome of their performance was perceived as not clear or61certain. Most informants outlined how these students may"pass or fail;" "scrape through or not scrape through."The essence of borderline performance. Based onenigmatic performance problems and the inconsistentbehaviors of borderline students, the essence of theirperformance was conceptualized as ambiguous. Thisconceptualization was validated during the secondinterviews. Although for a few informants ambiguous was anew way of depicting borderline performance, they all agreedthat the term was appropriate and most stated that"ambiguous" was a good word.In the literature, the ambiguous nature of borderlineperformance was not captured in the two articles specific toborderline students (Brozenec et al., 1987; Wood, 1971).However, Brozenec et al. referred to the unclear nature ofborderline performance by stating, "More problematic is theborderline student who does not clearly fall into a pass orfail pattern" (p. 42). Further, like the informants, theseauthors described borderline performance as inconsistent andthey addressed the difficulty of isolating the reason forthe unsatisfactory clinical behavior.Summary. According to the informants, inconsistent,uncertain, unpredictable, enigmatic, and "on the border"behavior characterized the ambiguous nature of borderlineperformance. This ambiguous performance contributed to thedifficulty of evaluating these students.62Ambiguous Nature of Clinical EvaluationWong and Wong (1987) described clinical evaluation as"highly ambiguous" (p. 508). The ambiguous nature ofclinical evaluation was a common theme expressed or inferredby the informants during their first interviews. Oneinformant used the adjective "ambiguous" while othersfrequently commented on how aspects of clinical evaluationwere unclear, vague, uncertain, and open to interpretation.The ambiguous aspects of clinical evaluation identified bythe teachers were its subjective nature, the definition ofconsistent, and learning versus evaluation time. Theambiguity of clinical evaluation assumed greater importancein the face of borderline performance rather than withpassing or failing performance.Subjectivity. The informants shared the view that thesubjective element of clinical evaluation contributed to itsambiguous nature. The transcript excerpts below typifiedhow informants referred to this subjectivity.I: Individualistic evaluations based on individualperceptions.I: ... as objective as we try to make it, it is stillsubjective.I: ... there is no set policy on how many errors / up63to your own individual decision-making.In these quotes, the informants asserted that theinterpretation of evaluative data was based on subjectiveperceptions. The third transcript excerpt outlined how anevaluation policy was left open to one's interpretation.Most informants described evaluation policies, criteria, andparameters as either vague, unclear, or implicit. Accordingto the informants, this vagueness intensified thesubjectivity and, thereby, the ambiguous nature of clinicalevaluation. The following sections expand on the ambiguityinherent in clinical evaluation.Defining consistent. The informants reported that theywere expected to evaluate whether or not borderline studentshad consistently met the objectives. The consensus amongstthe informants was that the term "consistently" was open tointerpretation.I: ... it is based on whether or not they haveconsistently met the objectives. Consistent is thereally core word that we certainly need to look at /because meeting the objectives can be very ambiguousand so subjective.I... consistency is not defined ... the criteria forthis term is not explicit in any way.64I: In our program in order for someone to meet theobjectives they are supposed to consistently meet theobjective / so even though someone is meeting theobjectives some of the time they are on today and offtomorrow and on the next day and off the next day andthey are not being consistent ... and consistent isopen to interpretation ... everyone has a bad day evenyour best student may have a bad day ... So isconsistent 90% of the time, 80% of the time, is it 70%of the time?One informant discussed the definition of "consistent"in relation to a policy regarding clinical failure. Again,the term consistent was open to interpretation.I: We have a policy ... it talks about students whoconsistently display unsafe behaviors in the clinicalsetting may be asked to leave ... the word consistentlyis not defined anywhere / and if you have a room fullof instructors and asked them what does consistentlytell you ... once, twice, seven times you get differentanswers ... so what is the definition of consistency noone has defined it for me ...Thus, the informants shared the view that "consistent," aterm used extensively in clinical evaluation, was left opento their subjective interpretations. This lack of clarity65added to the ambiguity of clinical evaluation.Teaching time versus evaluating time. Anotherambiguous aspect of clinical evaluation articulated by a fewinformants and documented extensively in the literatureconcerned the unclear distinction between teaching time andevaluating time (Brozenec et al., 1987; Carpenito &Duespohl, 1985; Infante, 1985; MacKay, 1974; Morgan, Luke, &Herbert, 1979; Rines, 1963; Van Hoozer et al., 1987; Wood,1982; Wood & Wladyka, 1980).I: There is also that terrible dilemma ... deciding howlong is teaching and how long is evaluation andunfortunately we tend to think to be ready to defendour decision ... how do you do that if you're notdocumenting and in fact evaluating right from day one.According to Van Hoozer et al., "Failure to recognize thedichotomy between formative (ongoing evaluative feedback)and summative (final) evaluation often causes the greatestdifficulty for clinical instructors ... (they) must developstrategies that clearly differentiate the promotion oflearning from the assessment of terminal behavior" (p.1982). In the previous transcript, the informant impliedthat the division between teaching and evaluating wasambiguous. Moreover, she referred to supporting evaluativedecisions with evidence. The need of clinical teachers togather evaluative data to both support their decisions and66show evidence of academic due process may further blur thedichotomy between formative and summative evaluations. Thislack of a clear dichotomy was a component of clinicalevaluation perceived as ambiguous.Validation: Ambiguous process. During the secondinterviews the informants were asked if they viewed clinicalevaluation as ambiguous. They concurred with thisdescription and elaborated on things such as its"subjectivity," its "fuzzy nature," "vague objectives,""the lack of firm objective criteria," and how things arenot "cut and dried." One informant responded that theprocess was "very ambiguous" and asserted that becauseterms, like consistent, were so "loose" ...I: ... anyone can make a case for passing or failingdepending on the data they want ... the process is sounclear ... the process of evaluating is not clearand the criteria is not clear ...In the above narrative, the repeated use of the word unclearfurther supported the ambiguous nature of clinicalevaluation. During this validation process one of theinexperienced informants commented on how viewing theevaluation process as ambiguous was insightful ...I: it is kind of reassuring to feel that maybesomething with the process is ambiguous ... I had never67really looked at the process.This section was introduced with a reference whichdescribed clinical evaluation as "highly ambiguous" (Wong &Wong, 1987, p. 508). In addition, other authors impliedthis ambiguity in reference to clinical evaluation's unclearand subjective nature (Brozenec et al., 1987; Meisenhelder,1982; Welborn & Thompson, 1982)Ambiguity: Performance and process. During the secondinterview, the informants were asked about the ambiguitiesof borderline performance and the evaluation process. Theinformants agreed that borderline performance amplified theambiguity inherent in clinical evaluation. One informantreported, "It is very difficult and very unclear and it putsthe instructor in a real dilemma of not knowing what to do."The following transcript excerpt typified the process ofascertaining the relationship between these two themes.R: ... so the fact that you have a process that isambiguous ...I: Yeah.R: ... and then you have the student whose performanceis ambiguous ... do think these two things togethermake evaluating borderline students difficult?I: Definitely, very definitely ... yes that is right... I hadn't thought of it like this / veryinteresting.68R: Whereas, if you have the ambiguous process with afailing student or a student who excels it is easier?I: Absolutely ... yes ... because in either those casethe student is clear-cut. One way or the other theirperformance says yes they are passing or no they arenot.This quotation illustrated how evaluating an ambiguousperformance within an ambiguous process was perceived tobe at the root of the difficulty in evaluating borderlinestudents. The narrative addressed how the ambiguity ofclinical evaluation came to the fore when working withborderline students. In addition to this informant, otherteachers shared the sentiment that conceptualizing theirdilemmas in this way was interesting or insightful.Summary. Because of the subjectivity, implicitcriteria, and the unclear distinction between teaching andevaluating, the informants viewed clinical evaluation asambiguous. The ambiguity of clinical evaluation wasaugmented for the informants when working with students whowere not clearly passing or failing.Ambiguity: Dual ResponsibilityA thematic category which surfaced from the datapertained to the ambiguity of the informants'responsibilities as nurse educators to students and topatients. Two aspects were viewed as ambiguous. First,borderline students challenged the informants' simultaneous69responsibilities to enhance students' learning and to ensurepatients' rights to competent care. Second, the informantsindicated that their responsibility changed focus from beingstudent-oriented in the earlier semesters to patient-centredin the later semesters. According to the informants, whenthis change in focus occurred was not clearly defined and,therefore, ambiguous.Dual responsibility: The fine line. Consistent withthe literature, the informants referred to a dualresponsibility (Brown, 1991; Joos et al., 1985; Langemo,1988; LeVeille Gaul, 1988; O'Shea, 1982; Redman, 1965;Sleightholm, 1985). Generally, the first area ofresponsibility encompassed students and the second areaconcerned patients. The two narratives below illustratethis viewpoint.I: On one hand you have the student's future and on theother hand you have to uphold professional standards ofnursing practice ... and the responsibility to protectthe public from people who are unsafe.I: ... I have a professional responsibilityas a nurse to ensure patient safety and I have aninstructor's responsibility to enhance learning.When faced with unclear, inconsistent performance,clinical teachers were responsible for enhancing students'70learning while simultaneously protecting patients from theincreased risk of incompetent care. Many of the informantsdescribed their responsibility to "remove or withdraw unsafestudents" from the clinical setting. However, the decisionwhether or not to remove a student who was borderline andnot assuredly unsafe, was not as clear or straightforward.In the next narrative, the informant described how the "fineline" between supporting the student and protecting thepatient was "anxiety producing."I: I walk that fine line between supporting the studentand wanting to keep them in clinical and looking at therisk factors of keeping them there. Have I put apatient at risk by keeping them there? Is thepotential for risk too great to keep the student there?That creates a lot of anxiety, because that is reallymaking a high level judgement on somebody else'sbehavior.Other informants described this "fine line" as evokingfeelings of ambivalence or uncertainty. Thus, borderlinestudents' with their ambiguous performance precipitatednegative feelings related to the informants' concurrentresponsibilities to students and to patients.I: I often tell a student your performance at thispoint in time is unsafe. I have a professional71obligation to remove you so that you don't jeopardizepatient safety ... when the student's behavior isclearly unsafe ... the problem is that the borderlinestudent ... you can see that there's a potential forsafety errors ... a calculated risk factor ... do Ileave the student in or do I bring the student outbased on my responsibilities?This quote illustrated how a clinical teacher's decisionwhether or not to withdraw a borderline student wasuncertain. To "leave in" versus "bring out" was a quandary.Change in responsibility focus. It became apparentduring data analysis that the informants' view of theirresponsibilities varied depending on the student's level inthe program. Seemingly, the focus of responsibility changedfrom students in the earlier semesters to patients and theprofession in the later semesters. Each informant validatedthis change in responsibility focus and some informantsasserted that clinical evaluation of a borderline studentwould be influenced by "the semester they are at." Althoughthe teachers agreed that the focus changed, they emphasizedthat they always have a responsibility to "it all."Concerning the earlier stage of the program, theinformants explained that clinical teachers could "affordthe luxury" of hoping students improve," "giving the studentanother kick at the can," and of "knowing that the studentwill be supervised by subsequent teachers." Another aspect72of evaluating learners in the early semesters pertained tothe socialization process. The following two quotesexemplified this viewpoint. The first transcript excerptimplied the notion of student-centred responsibility and thesecond insinuated the need to give the student the benefitof the doubt.I: ... in the earlier semesters they (teachers) arereally trying hard to socialize the student to nursingand they need to be loving, caring, and nurturing ofthe students.I: ... at the beginning you think well maybe it's thesocialization process ... it's a socialization issue... give the student another term and see what happens,maybe it's culture shock or you know the student justhasn't quite caught on ... you don't know ...In contrast, the informants' sense of responsibility inthe later semesters was oriented more toward patients andthe profession. One teacher stated, "In the later terms youfeel more of a professional, moral, or an ethical obligationto do something." Similarly, another informant asserted ...I: If someone who is going to pass and graduate ... tome the responsibility to the public and to theprofession is much heavier because there isn't another73instructor to watch after I pass them on.The degree of perceived clarity or ambiguity relatedto the responsibility shift between the early and latesemesters was a question the researcher posed. Basically,they perceived this change in responsibility focus to beeither ambiguous in itself but clear to them, or ambiguousin both ways. The informants who viewed it as clearelucidated how they had taught at "both ends of theprogram."In addition, two of the responses included anexplanation about the need for teachers, at different levelsof the program, to communicate their concerns and to discusstheir different emphasis of responsibility. The informantsdiscussed how this communication would enhance understandingamongst clinical teachers--"issues might be less contentiousif you knew the underlying dynamics."Further, one person spoke of an additional factor whichmay affect the direction of clinical teachers' focus ofresponsibility; a "knee-jerk reaction" or a "chainreaction."I: ... if a lot of students exit in one semester, thesemester before does a careful examination of what theyare doing ... this starts a chain reaction down theline ... the previous semesters exits more ... maybeyou become tighter with borderline students because74they are failing in the next semester ... knee-jerkreaction ... bumping down the semesters ... where youfeel responsible not only to the institution but toyour colleagues as well.Unlike the other informants, this teacher affirmed aresponsibility to her colleagues. This responsibilityentailed the hesitancy to pass borderline students on topeers who had recently experienced clinical failures.Finally, responses from two inexperienced informantsincluded a discussion of "passing students on." Oneteacher felt angry toward earlier colleagues for allowingborderline students to pass. This person articulated howthis change in responsibility focus may explain why someborderline students progressed--"because of thisresponsibility to the student there is always that hope." Incomparison, the other informant outlined how, before she hadtaught at the lower levels, she used to feel "angry" forthis same reason. But with first hand experience, she had anew appreciation of "where they are coming from." Although,the other informants did not address "passing borderlinestudents on" in this context, they did discuss theselearners "getting so far," and how some colleagues "neverfail." The notion of "passing students on" will beaddressed further in the section focused on the emotionalchallenge inherent in the experience of evaluatingborderline students.75A review of the literature did not reveal anyreferences which explicitly detailed how a change inresponsibility focus occurred between the early and latestages of a nursing program. However, with respect tofailing a nursing student, Mantle (1982) stated that firstyear faculty often say they have too little data while thefinal year faculty assert that steps should have been takenearlier. Mantle did not offer a solution, but posed thequestion--"How do you resolve this dilemma" (p. 61)? O'Shea(1982) researched role conflict and role ambiguity bylooking at whether nurse educators' role orientation was tostudents or patients. Although the findings left no clearimpression, they indicated that teachers tended to beslightly more student-oriented than patient-oriented.Because this study failed to differentiate between beginningterm teachers and advanced term teachers, this variant wasnot considered as an influence in the discussion of roleorientation.Summary. Evaluating students whose performance wasborderline challenged the informants' dual responsibilityto students and to patients. The responsibility forteaching the student while ensuring competent care createdan ambiguous situation and precipitated negative feelings.The informants' focus of responsibility changed from beingstudent-centred in the earlier semesters to patient andprofession-oriented in the later semesters. The timing ofthis shift in responsibility focus was viewed by the76informants to be open to interpretation.Student's Self-Awareness It became evident during data analysis that arecurrent theme was borderline students' limited awarenessof their clinical competency. This theme emerged inrelation to the student's degree of insight or self-awareness, the teacher-student relationship, the informants'discomfort about clinical failure, and the informants' fearof an appeal. Because enhanced insight would be conduciveto a positive teacher-student relationship and it wouldfacilitate the student's acceptance of his/her clinicalstatus, the informants were concerned with fostering thedevelopment of this self-awareness. A possible and optimaloutcome would be the avoidance of an appeal.The Degree of InsightThe informants contended that borderline studentstended to lack insight or awareness of their own strengthsand weaknesses. They described how these learners--"have noself-awareness," "no insight," "see themselves better thanthey are," "are poor self-evaluators," and "don't hear whatyou are saying." Limited insight was perceived as acontributing factor to the difficulty of working with thesestudents. The informants asserted that borderline studentswho lacked self-awareness "were the hardest ones to workwith," "complicated the issue," or were the "the biggestchallenge." Similarly, the literature described thechallenge of working with unsatisfactory students who tend77to overestimate their clinical abilities (Meisenhelder,1982; Woolf, 1984).The informants viewed insight as fundamental toborderline students' clinical progress. The following twonarratives illustrate this viewpoint.I: ... a very major part of the whole problem is thatthey are not able to self-evaluate, they have limitedor no insight and that is why they aren't able toimprove to meet the objectives ...I: ... insight is a key factor to students ... andusually the crux to whether they pass or fail.In addition to being perceived as a detriment to thelearner's success, a lack of self-awareness negativelyinfluenced the teacher-student relationship.Teacher-Student RelationshipAccording to the informants, the student's degree ofself-awareness affected the interactive nature of theclinical evaluation process. Generally, the greater thedegree of self-awareness, the more positive the teacher-student relationship. One informant expressed this idea asfollows.I: ... how much the student is going to allow us to getinto that teaching-learning type of relationship ...78allow themselves to be open enough to hear thefeedback, do something with it, set some objectives,and change their behavior.If the student lacked self-awareness, the informantsdescribed an inability to develop a relationship based onmutual trust. They spoke of not trusting the student toseek appropriate assistance when giving patient care--"Iwouldn't trust these people to do things on their own."Thus, decreased self-awareness seemed to correlate withdecreased trust.Further, the informants found that students who lackedinsight into their capabilities responded to negativefeedback in a defensive manner. This defensive behaviorencompassed "denial," "anger," and " hostility" which weretypically characterized by blaming their clinical teachersor some external force for their performance problems.I: I think that all borderline students go through somesort of denial where they push me away, deny thatthere's a problem ... they are going to blame to somedegree ... blame somebody ... self-preservation ....because to accept it all themselves is pretty hard.This quote linked students' defensive response to "self-preservation" while other informants related it to students'79self-esteem, self-image, or self-integrity.I: I really think that their self-esteem is low and sothey have these defenses to protect their low self-esteem. They try to convince themselves that they aredoing well ... the instructor just doesn't like themand really their performance is okay ... they areprotecting their self-esteem.I: I think it really depends on their own self-esteemand their image of themselves and their self-integrity.The literature supported the informants' perceptions thatclinical failure would threaten a student's self-esteem andresult in defensive behavior (Brozenec et al., 1987;Carpenito, 1983; Hill, 1965; Meisenhelder, 1982).The suggestion that an external locus of controlcontributed to students' defensive behavior was made by oneinformant.I: ... because they have an external locus of controlthey don't see themselves as being fully responsiblefor their performance and they blame the situation forbeing too difficult and they blame ...This informant's referral to an external locus of controland assertion that students blame others for their80unsatisfactory performance may fit with Rotter's (1954)social learning theory. This theory described individualsin terms of their tendencies to ascribe success or failureto external or internal causes.Students' defensive behavior in turn engendered anemotive response from the informants. They spoke of feeling"frustrated," "disappointed," "powerless," "helpless," and"angry." Moreover, one informant disclosed how she"wouldn't feel as positive about them either." Thefollowing transcript excerpt illustrated some of theinformants' emotions generated by borderline students'limited insight.I: ... there would be frustration with students notrecognizing their weaknesses ... the three of them thatI had did not recognize that there was anything wrong... they had problems ... very frustrating.I: You feel frustrated and it comes from a sense ofpowerlessness ... because I thought sometimes if Icould videotape them in action ... maybe that wouldhelp them to see how they were coming across ... youtry different things so they gain insight and if theydon't you feel helpless and disappointed.Like the informants, Meisenhelder (1982) described howthe dynamics of the clinical evaluation process can be81disrupted by students' defensive behavior. This authoroutlined the emotional chain reaction implied by theinformants--students reacting defensively and clinicalteachers responding to this behavior with emotionaldistancing, frustration, and anger.According to the informants, students who had ordeveloped insight responded in a manner which was motivatingand accepting. In these cases, the teacher-studentrelationships were viewed as more positive and theinformants felt "better" about their experiences.I: ... makes a difference when the student has insightmakes me feel like I have done a better job of helpingthem work through it.The Student's DecisionThe informants emphasized the importance of havingstudents develop an "honest, realistic" view of theirperformance to the point that they would withdraw ifclinical failures were inevitable. The student's self-withdrawal would reduce the clinical teacher's discomfort ofissuing a failing grade and it would eliminate thepossibility of an appeal. Students who voluntarily quit aclinical course waive their rights to claim unfairtreatment. The following quote illustrates this idea ofinsightful students making the decision. Further, it82outlines how fostering insight was perceived as hard work.I: ... it is much better if you can give studentsenough feedback so that they can make the decision thatyes I am meeting the objectives or no I am not reallyready to go on. That is the best scenario ... mosttimes with borderline students, I have been able toprovide them with enough information so that they don'tleave feeling angry like someone did this to them ...they come around to the view that I've done this ...that takes a lot of work an awful lot of work.This quote explained how students leaving on their ownaccord was viewed as a better scenario than "studentsleaving angry." The informants found that students who leftin a state of denial or anger were more likely to appealtheir final grades.I: ... if the students are in denial they're the onesthat are most likely to appeal ... they think you'rewrong.Concerning the appeal process the informants spoke ofits "emotional," "stressful," "difficult," and "time-consuming" nature. The literature's description of theappeal process was consistent with the informants' outlooks.(Carpenito, 1983; Huston, 1986; Majorowicz, 1986; Robinson &83Bridgewater, 1979). The informants viewed the enhancementof a student's self-awareness as a means to eliminate thethreat of a "stressful" appeal.Fostering Self-Awareness Often the informants described the frustration and timeinvolved in enhancing the development of students' awarenessof their clinical abilities. To foster this awareness, manyinformants elaborated on how they examined the student'sfeelings, gave verbal feedback, wrote anecdotal notes, andset learning contracts. These mechanisms were employed topromote insight and to ensure that the student was aware ofhis/her clinical status and afforded the opportunity toimprove. The informants' perceptions of how they attemptedto enhance self-awareness were outlined in the quotationsbelow.I: ... examine how they feel in the setting ... do youfeel scared, fearful ... getting students to recognizethat those feelings are precipitated by their lack ofability, confidence, and lack of knowledge ...I: ... feedback ... you say I'm really concerned aboutthis and use the word fail .... we used to use theexpression you're not meeting the objectives and Idon't think students hear that, that means you willfail or might fail ... be clear with the student.84I: ... sometimes you get frustrated because you'vedocumented to the ying yang and this person doesn'tdevelop awareness ... anecdotal note writing, contractwriting, student self-evaluations, the evaluation ofthe contract. Like all the documenting and documentingrequires a lot of time.SummaryThe concept of student's self-awareness was viewed as asignificant factor in the quality of the informants'relationship with the borderline student. Lack of insightstrained the teacher-student relationship, evoking emotionalresponses from the informants and defensiveness from thestudent. Regardless of the time and effort involved,fostering the development of insight was perceived asessential to the student's acceptance of their clinicalstanding. Additionally, it was viewed as reducing the riskof an appeal if the student was to fail.Laborious DecisionsThe informants' experiences with borderline studentsencompassed making evaluative decisions which werepredominantly described as difficult. These difficultdecisions required "personal investment" of time, "effort,""energy," and "hard work." To capture the notion of bothdifficult and hard work while remaining true to theinformants' perceptions, this component of their experiencewas conceptualized as laborious decisions. The sentiment85that working with unsatisfactory students was hard workrequiring a commitment of time and personal energy was alsodocumented in the literature (Lenhart, 1980; Majorowicz,1986; Symanski, 1991; Wood & Wladyka, 1980).The concept of laborious decisions had five inherentthemes. Two themes pertained to the emotive dimension ofmaking evaluative decisions. The informants found thatevaluating borderline students generated numerous feelings,including a sense of uncertainty, and was emotionallychallenging. The remaining three themes related to theinfromants' decision-making strategies. These strategiesincluded a sense of the student's whole performance,intuition, and a sense of whether or not the student couldbe trusted as a future co-worker and/or care-giver.A Sense of Uncertainty: Self-Doubt The informants disclosed that making evaluativedecisions about borderline students was riddled withuncertainty and self-doubt. Recurrently, they spoke of"waffling," "worry," "anxiety," "stress," questioningthemselves, and of questioning their "perceptions."Uncertainty and self-doubt were so common to thisexperience that they were often the first feelingsverbalized in response to the initial interview question.R: What was it like for you to evaluate borderlinestudents?I: very stressful, questioning, I question my judgement86quite a lot as to whether I was seeing the student theright way.R: Based on your experiences, what was it like for youto evaluate borderline nursing students?I: There's a lot of doubt / a lot of self-doubt aboutwhat I was doing because students of coursecatastrophizes the whole thing ... the end of theirlives ... students actually say that and althoughintellectually I know that is ridiculous I feel somedoubt about it ... am I really sure, am I reallyconfident about what I am doing? So there's doubt inthat sense.The last quote illustrated feelings of self-doubt andanxious uncertainty. The repercussions that a failing gradewould have on the student formed the basis of thisinformant's emotions. Similarly, the literature addressedclinical teachers' uncertainty associated with evaluatingborderline students (Brozenec et al., 1987; Welborn &Thompson, 1982) and the consequences of assigning a failingclinical grade (Brozenec et al.; LeVeille Gaul, 1988;Meisenhelder, 1982; Symanski, 1991; Welborn & Thompson).Feelings associated with giving a failing grade will beaddressed in the following section.Welborn and Thompson (1982) asserted thatunsatisfactory students exacerbated the existing uncertainty87and self-doubt that new clinical teachers experience withtheir evaluator role. Likewise, two of the noviceinformants expressed that some of their uncertainty stemmedfrom their lack of experience--"I don't think I have enoughexperience to really feel comfortable with my judgements."However, because evaluating borderline students was viewedas an ambiguous situation, a sense of uncertainty wasexperienced by both the new and veteran teachers.Ambiguity and a sense of uncertainty. Throughout thepresentation on ambiguity, the informants' feelings ofuncertainty and self-doubt were discussed or implied. Thepairing of an ambiguous performance with an ambiguousevaluation process created the sense of uncertainty andself-doubt experienced by the informants.I: With this student who's doing well you neverquestion yourself / you don't question yourself as muchas you do when you have a student who's on the edge.I: When things are vague / it is very unsettling and Ifeel really indecisive about it / what my ultimatedecision might be about that student.Because ambiguity was inherent in the informants'experiences, making evaluative decisions was haunted withuncertainty and doubt. A "stressful" and "difficult"process of evaluating borderline students resulted from the88informants' feelings of uncertainty. The following sectiondescribes how these feelings were overcome in order todecide the final clinical grade.Cooing with uncertainty. To cope with theiruncertainty and self-doubt, arrest their vacillation, andreduce their stress, the informants articulated how theywould informally seek their colleagues' "input," "advice,""reassurance," and "support." They spoke of: "checking withinstructors," "drawing on their peers' experiences,""talking things out," and "hashing out their decisions."Similar to the informants, the literature outlined howclinical teachers' doubts concerning their evaluativedecisions may be dissipated by seeking peer support(Brozenec et al., 1987; Meisenhelder, 1982; Symanski, 1991;Welborn & Thompson, 1982). Goldenberg and Waddell's (1990)study of faculty stress substantiated peer support as themost significant coping strategy used to deal with thestress of evaluating problem students. However,other research on the same or related topics did not explorethe stressful uncertainty of evaluating unsatisfactorystudents (Fain, 1987; Fong, 1990; Langemo, 1988; O'Shea,1982; Sleightholm, 1985).In contrast to the literature, the general consensusamongst the informants was that their peers were a valuablesource of support (Carpenito, 1983; Majorowicz, 1986;Symanski, 1991). According to the informants, they receivedassistance because they "knew who to speak to," "were89selective in who they asked," and relied on those they"respected." The informants avoided faculty members whoseviews of clinical failure, heavy workloads, or interests,would not be helpful. "Knowing who to ask" paralleledSymanski's assertion that "teachers should seek support fromlike-minded colleagues" (p. 21).In addition to "checking with instructors" on aninformal basis, each informant mentioned seeking support inteam meetings. For some informants the decision to pass orfail the student was their independent responsibility whilefor others the decision was formally approved by a team or acommittee. Team meetings were outlined as a formal means tovalidate their concerns, discuss their perceptions, andsolicit input on teaching strategies. However, oneinformant implied that the team's subjective input wasinconsistent. This inconsistency could compound theambiguity inherent in clinical evaluation.I: I've decided that this is not uncommon to have a lotof difficulty making the decision and although I hadfound the semester team supportive, they were notconsistent in their opinions ...During the discussions concerning "checking withinstructors," many informants identified teaching in theclinical setting as a contextual barrier to peer support.Working in a health care agency, a reality of the clinical90teaching role, was viewed by the informants as aninfluential factor in their experiences. They spoke of"isolation," "loneliness," and the "hunger to shareexperiences." Further, the informants referred to thefrequently cited idea that nurse educators are "guests" or"visitors" in the clinical agency (Brown, 1991; Christy,1980; Johnson, 1980; Sleightholm, 1985; Smith, 1988).I: I believe very much in the importance ofconversation with colleagues and teaching clinical is avery lonely job ... you are representing another agencywhile you're working in another one ... you can be inthe clinical setting all day and not see anyone you canreally bounce heads with / teaching issues / so thereis this hunger; I believe that teachers have to shareexperiences.I: I do feel isolated and I have always felt veryisolated in the clinical setting who you work for isnot who the RNs on the floor work for ... isolated andif I have a borderline student ... it is my judgementthat they are borderline so I feel on my own ... I havecalled people when I got home because I have been soupset it can be so stressful ... it is a very lonelylife ...I: One thing I have found about teaching is that it can91be a very lonely job. You are a guest in theseagencies you are isolated from your peers ... youdevelop short term relationships with your students butthat is not the same as bouncing ideas off with anotherinstructor. It takes awhile for the staff to know youand accept you as a teacher and as a nurse ... you haveto show them you know what you are doing before theywill start to trust you and I have been in threedifferent hospitals since I've been teaching ... soit's hard. I think sometimes you feel lonely whenevaluating students with problems.The last quote described the need to develop a trusting,respectful relationship with the clinical staff whichlongevity would facilitate. However, this informant hadworked in three agencies in her first year of teaching. Theimportance of establishing trusting relationships withclinical staff and familiarity with the setting wereidentified by many informants. For example ...I: If you go back to the same agency you get asense of trust between the staff and you get used tothe clinical setting and it is a lot easier to assessstudents in a setting where you're comfortable.In contrast, one informant denied feelings of loneliness inthe clinical area because of her familiarity with the area92and the staff.R: Do you feel alone?I: No, I don't feel alone. I have worked in a lot ofthe agencies. I know a lot of the staff ...The view that working in an outside agency may generatefeelings of isolation and loneliness for clinical teacherswas addressed in the literature (Ray, 1984; Wong & Wong,1987). For instance, Wong and Wong outlined how theseteachers, unlike their colleagues on campus, cannot seekadvice and assistance from their peers as needed.Furthermore, these authors asserted that clinical teachers'feelings of isolation may be so pervasive that they may facea period of anxious uncertainty.The feelings of isolation and uncertainty could bereduced by having a second teacher present in the clinicalsetting to provide support and/or evaluative input.Although having this second person was a strategy welldocumented in the literature, (Brozenec et al. 1987;Carpenito, 1983; de Tornyay, 1985; Meisenhelder, 1982;Welborn & Thompson, 1982; Wood & Campbell, 1982), only threeinformants mentioned this idea. Further, they disclosed howthey had minimal or no experience with it.Most informants identified that they solicitedevaluative input from the staff nurses working alongsideborderline students. This input would help validate93teachers' perceptions and interpretations of students'clinical behaviors. Further, nurses' viewpoints were anadditional source of feedback used to foster students' self-awareness.I: ... but I think another resource for clinicalinstructors are practicing nurses ... very helpful toan instructor ... I could say what do you think of soand so and they would say s/he does this, this andthat. I could confirm with them and I felt veryconfident in their assessment.Similar to the above narrative, Symanski (1991) stated, "Itis a validating experience to have a staff nurse confirmyour assessment that a student is not up to par" (p. 20).The need to "check with instructors" to dissipateuncertainty, may not end with making the final evaluativedecision. Peer support may be required to deal withteachers' post-decision uncertainty.Post-decision uncertainty. Even when the finalevaluative decision was made, the uncertainty and self-doubtdid not dissipate. Post-decision uncertainty centred on thequestion--"Did I make the right decision"?I: Making the decision is really difficult and there isalways a little bit of ambiguity after you have madethe decision wondering if you have made the right94decision.I: ... difficult and unsatisfying because even afterthe decision is made, I'm not sure that you don't havea sense that it was necessarily always the rightdecision. I think it is going to be uncertain in theend anyway because I think the ambiguity will be thereperiod ... even when you say yes the student will passor no the student will fail ...With respect to passing a borderline student, theuncertainty related to the student's future success in thenext semester--"will the student improve," "were myperceptions correct?" With an individual who fails, theuncertainty rests with the student's right to appeal thedecision. If the appeal process was initiated, theexperience with the student would not end. According to theinformants, it would continue in a new "stressful,""difficult," "unpleasant" and "time-consuming" direction.Summary. The evaluation experience with borderlinestudents was shrouded with uncertainty and self-doubt thatdid not end with the awarding of the final grade. Theinformants coped with this uncertainty by seeking peer andstaff nurses' support and validation that their evaluativeperceptions were correct. Although uncertainty and self-doubt were two feelings engendered from making evaluativedecisions, the informants reported on numerous other95emotions.Emotional Challenge Emerging from the data analysis was the theme thatmaking the laborious decision to pass or fail borderlinestudents was an emotional challenge--a challengeencompassing a range of emotions, some of which wereconflicting. The informants' conflicting emotions createddissonance which was reduced through the use ofrationalization.Shared emotions. Repeated references to the emotiveaspects of making evaluative decisions were found in thedata. The informants described their experiences as:"challenging," "unsatisfying," "unhappy," "uncomfortable,""frustrating," "heart-wrenching," "gut wrenching,""painful," "emotionally draining," "always emotional," "verydifficult," "never easy," "no easier with experience,""anxiety producing," "time-consuming," and "very stressful."Disclosures of a more positive nature were infrequent andlimited to the occasional comment concerning the decision topass the borderline student. However, due to the post-decision uncertainty associated with passing borderlinestudents, this scenario was not perceived as positive by allinformants.Comparable to the informants, the literature addressedthe emotional side of evaluating unsatisfactory or failingstudents. Wood and Wladyka (1980) labeled the clinicalteacher's experience as difficult, time consuming, and96frustrating. Meisenhelder (1983) described it as anemotionally taxing responsibility which was difficult,uncomfortable, painful, and never pure or easy. Similarly,Symanski (1991) characterized the experience as stressful,emotionally draining, devastating, debilitating, anddemoralizing.In addition, the informants shared similar emotions inrelation to evaluating borderline students within thecontext of the clinical group. Like the literature, theinformants disclosed how the additional time spent withborderline students evoked feelings of "guilt,""resentment," inadequacy," and "anger" (Symanksi, 1991;Welborn & Thompson, 1982). They asserted how "the goodstudents suffered," and "if the borderline student failed,it was a waste of good teaching time."To grasp the essence of the informants' experiences,the researcher asked them to summarize their perceptions ofevaluating borderline students in either a word or a phrase.Their responses were similar and many inferred the conceptof laborious decisions. Some of the informants reiteratedtheir emotions while others adopted a personal standpoint toelaborate on their experiences. Their accounts cited: "anambiguous process," "really difficult," "challenging,""ominous and necessary task," "frustrating and time-consuming," "stressful," and "anxious uncertainty." Oneclinical teacher explained the essence of her experience97as follows:I: I think borderline students just got to be thehardest decision of the teacher ... they create moreanxiety ... endless amount of work in all sorts of waysand they impact not only our work life but the rest ofour life as well. They are just really difficult tomake a decision on ... difficult because they areinconsistent and ambiguous ... not clear cut ... theyare hard because it so hard to figure out what theproblem is.This transcript excerpt made reference to ambiguity and thesentiments that making evaluative decisions generatedanxious uncertainty, was difficult, hard work, and wouldinfluence the teacher's personal life. Thus, this quotationexemplified the concept of laborious decisions. In the nextnarrative the informant alluded to the post-decisionuncertainty and discussed how, regardless of the outcome,the experience was unrewarding and dissatisfying.I: ... it is challenging either way ... pass or failthere isn't a lot of reward in it ... it is not asatisfying thing ... you can feel good in that Isuppose that you have protected the public and theprofession ... it is not like having a student who hasdone really well ... whereas with the borderline98student ... either way ... if you let them go on youworry about how they are going to do in the future andif they don't you feel badly ...This quote identified another emotive dimension of makingevaluative decisions. Like many informants, this teacherused rationalization to deal with her feelings--"you canfeel good in that you protected the public and theprofession." Seemingly, this rationalization was employedto reduce the dissonance experienced in evaluatingborderline students.Dissonance and rationalization. Festinger (1957)proposed a theory of cognitive dissonance which stated thatif a person held two incompatible cognitions dissonance wasexperienced. Because this dissonance is psychologicallyuncomfortable, the person would be motivated to reduce thediscomfort. Deci (1975) described dissonance as achallenging motivator. According to Festinger, makingdifficult decisions may result in dissonance which peopletend to reduce by justifying or rationalizing their choice.This notion of dissonance was relevant to the informants'accounts. They spoke of guilt and of a difficult,emotional, personal challenge which involved two opposingperceptions. Their desires for a successful student werechallenged by their visions of possible clinical failure.Further, most of the informants used rationalization whenthey discussed their perceptions about making evaluative99decisions with borderline students.Concerning their desires for a successful student, someinformants disclosed "wanting the borderline student to makeit," others worried that they were "too hard on thestudent," and a few teachers spoke of their "personalinvestment"--their personal investment in terms of time,energy, and effort to help the student to pass ...I: I think part of what makes it really difficult witha borderline student is you invest a lot of yourselfinto helping them to reach a satisfactory level ...Similarly, another informant stated ...I: ... difficult from the personal sense you arefeeling for your students you want them to do well.You want each one to have the best chance to do well.The implications of a clinical failure resulted in theinformants' longing to pass the student. For instance oneteacher disclosed that ....I: ... I feel like this person's future is resting inmy hands ... my decision effects student's life sodramatically ...100Likewise, another informant expressed that ...I: ... your judgement of the student / you're greatlyaffecting their education if you should fail them.Wanting the student "to do well" and appreciating theconsequences of a failure, the teacher would favor a passinggrade. However, these feelings were opposed by their viewsthat the student's performance was borderline and the riskof failure existed. Meanwhile, the situation was perceivedas ambiguous. Deciding to give a failing grade would be asevere judgement based on ambiguous data because thestudent's performance was not clear-cut.Generally, the informants' opposing views wereexpressed concurrently and immediately followed by arationalization or justification which took a variety offorms. These various forms will be discussed.Two of the inexperienced informants described blamingthemselves for the student's failure while some of theveteran teachers declared that they used to feel moreresponsible for the student's downfall. Nurse educatorsblaming themselves for the student's clinical incompetencewas cited in the literature (Hill, 1965; Turkett, 1987).The following two transcript excerpts illustrate the use ofself-blame to rationalize the student's failure.I: ... you almost feel like you have failed if they101don't reach the level especially when inexperienced.I: ... when I was a brand new instructor, I felt thatit was my problem when students failed ...A notion previously addressed and mentioned primarilyby the novice informants involved blaming the student'sformer teachers for their dilemma.I: ... why didn't someone deal with this sooner? ...frustrating if you feel that you have been left withsomething no one else has wanted to deal with ...The experienced informants spoke of how they havedeveloped an attitude that they "will do their best work,"or "do all that they could," yet ultimately they viewed thestudent, not themselves, as responsible for the finaldecision ...I: I'll do the best ... I'll work with you as long as Ican or to whatever extent I can ... I've come to therealization, over time, that students have a big stakein this ... they can either choose to use the help thatthey're being offered and work with it and pass or theycannot ...I: ... the student has a large part in this ... I have102resolved that the student has a big responsibility inthis ... I can do what I can do to direct the studentand help ... if the student doesn't do it well ...This view that clinical teachers were not personallyresponsible for nursing students' failure (Turkett, 1987) orfor learners' personal lives (Symanski, 1991) was emphasizedin the literature.Some informants seemed to deal with the dissonance byprotecting their identities as "nice people" despitepossibly rendering a failing grade. The informants wantedto ensure that borderline students saw them as "sincere,""helpful, " "their ally," and "on their side." Most teachersoutlined how they would ask the student if there was"anything more they could do," or if they were "impacting ontheir success in any way."According to the Jourard (1974), the informants need tobe regarded as "sincere" or as "an ally" related toprotecting their public self. Jourard described public selfas "the identity a person wishes to have in others" (p. 162)or the "subjective side of one's social role" (p. 152).Seeking the approval of others or constructing theimpression others may have of you would relate toconstructing one's public self. Similarly, Allen (1990)described the "tendency to present oneself in a positivelight" (p. 83).Two forms of coping with the dissonance were linked to103the informants' dual responsibility to students and topatients. First, to help justify clinical failure, theinformants spoke of how "it was necessary," how they had"protected the public," or how they could "rationalize thatthe student was unsafe."I: I think I have come to the realization that if aborderline student fails our ultimate responsibility isto provide safe care to patients and if that student'sperformance to this point does not demonstrate that,then I think that I am also doing the right thing.Second, a form of dissonance reduction corresponded tothe change in responsibility focus that was previouslyaddressed. This form related to the informants' suggestionsthat early semester teachers can afford to give the "studentthe benefit of the doubt" or "a second chance." By givingthe student a "second chance," teachers avoid the discomfortof clinical failure.The final way of dealing with the dissonance was linkedto the concept of student's self-awareness. If a borderlinestudent developed self-awareness and withdrew from thecourse, the informant's clinical evaluation process was "alot easier." Hence, the student's withdrawal reduced theteacher's discomfort of having to award the final grade.When the informants discussed this withdrawal, they madereference to how it was "easier on the student," "best104scenario if the student decides," "much easier if thestudent admits," and "easier if student voluntarily makesthe decision." The student's willingness to self-withdrawbenefitted the teacher insofar as it eliminated anuncomfortable evaluative responsibility.Blaming oneself, blaming one's peers, protecting one'sidentity, giving the responsibility to the student,protecting the public, giving the student a second chance,and having the student make the decision were the differentways that the informants dealt with their dissonance whenconfronted with borderline students. Newer teachers tendedto blame themselves and their colleagues. Veteran teachersseemed better able to separate themselves from the situationand give the onus back to the student.Like the informants, Meisenhelder (1982) described howevaluating unsatisfactory students creates conflictingemotions. This author described "external and internalforces that pull the instructor toward both passing andfailing grades" (p. 348). According to Meisenhelder,assigning a failing grade may conflict with the teacher'snurturing self-concept. Further, the teacher "mayanticipate the student's hurt and humiliation and feelguilty about inflicting pain by confronting the student'sweaknesses" (p. 349).Summary. Clinical evaluation of borderline studentswas an emotional challenge. Because some emotions wereconflicting, dissonance developed which the informants105seemed to deal with through various forms ofrationalization. This emotional challenge contributed tothe difficulty inherent in their laborious decisions.A Sense of The Whole: Gestalt ViewThe school of gestalt psychology views things as awhole, with the whole being greater than the sum of theconstituent parts (Hinchliff, 1979). The informants sharedthe notion that evaluating borderline students requiredhaving a sense of the whole or the gestalt view of thesituation. This gestalt view was one facet of makinglaborious decisions with borderline students. One informantmade explicit the use of this view when evaluating thequality of borderline performance.I: ... sometimes the whole concept that we have ofstudent and the performance is sometimes a greaterindicator than the individual data ... the sum of theparts does not equal the whole; the whole is sometimesquite a bit greater ... as I work through moreborderline students, I have to keep in mind what is thewhole, not just the individual data ...Painting the whole picture. The literature described asense of the whole as a requisite of clinical evaluation.For instance, authors emphasized the necessity of looking atthe overall picture of students' clinical performance(Majorowicz, 1986; Robinson & Bridgewater, 1979; Wood &Campbell, 1985). With respect to looking at the completeperformance, the informants spoke of taking isolatedincidents and connecting them together to paint the wholepicture. The three narratives below implied this need tograsp a sense of the whole picture.I: ... it's collection of things or an accumulation ofevents, not just one event or two events ... isolatedlittle incidents which you have to connect them andit's a lot of work ... try to not see little incidentsas little incidents but come up with ... what's thelearning problems.I: You have a vague sense and little bits of data aboutthings that on their own they don't mean very much butyou have to put them all together and sometimes ittakes awhile to put it all together to realize what youare dealing with as being poor performance.I: ... look at whole patterns of behavior ... piecingtogether the little bit of data here and this littlebit of data there ...The last transcript excerpt illustrated how a gestalt viewenabled informants to grasp a better understanding ofperformance patterns. This need to look at the wholepicture to see "patterns of behavior" was also addressed in106107the literature (Mantle, 1982; Welborn & Thompson, 1982).According to Mantle, a few pieces of data may not constitutesufficient evidence of a behavior pattern, but may whencombined with other data gathered overtime.The informants' need to paint an overall picture of thestudent's performance was linked to the concept ofambiguity. A sense of the whole facilitated decision-makingwithin an ambiguous situation.Ambiguity and a gestalt view. During the secondinterviews the informants were questioned about therelationship between a gestalt view and the themes ofambiguous performance and ambiguous process. The followingquotation typified this questioning.R: ... if the process is ambiguous and the student'sperformance is ambiguous and you have mentioned in theinterviews the need to look at the whole picture ... soI am wondering if you need to look at the whole picturebecause of the ambiguity?I: Yes, I think so and I think with borderline studentsbecause they sometimes do things alright and then thenext time they don't you don't get clear messages allthe time / so it is difficult to know what you aredealing with and I think that is why you need to lookat the whole picture. You need as much information aspossible in order that you can make the best decisionthat you can ... It makes a lot of sense why you need108to look at the whole picture / amazing.This quote outlined the relationship between a sense ofthe whole and ambiguity. Further, this narrativeillustrated how many informants were unaware of why theylooked at a gestalt view.Summary. One aspect of the evaluation experienceshared by the informants was the need to look at the wholepicture; the student's overall performance. The ambiguousnature of both borderline performance and the clinicalevaluation process heightened the necessity of having asense of the whole in making their laborious decisions withthese students.A Sense of Knowing: Intuition Given that all eight informants recognized either asense of knowing or intuition as a component of makingevaluative decisions, this topic became a thematic categoryin data analysis. Blomquist (1985) supported intuition asvaluable component of evaluating clinical nursing students.The author linked both a sense of the whole and the use ofintuition in clinical evaluation by stating, "Evaluation isthe making of subjective judgement about the meaningfulnessof the whole both from the parts that are measurable andfrom those the must be assessed intuitively" (p. 11). Inthe following section, intuition will be explored in termsof how the informants described and used it, how it linkedto the sense of the whole, and how it related to the109ambiguity of borderline performance and clinical evaluation.Knowing and feeling. The informants either identifiedtheir intuition in terms of knowing, feeling, or as bothknowing and feeling--"I feel that I just know." Althoughthe informants referred to a: "sense," "sense of knowing,""sixth sense," "gut feeling," "gut reaction," "intuitivething," or "you just know," they all agreed that either asense of knowing or intuition fit for them as a way todescribe these notions.The informants spoke of their intuition as somethingthat was "innate," "intangible," "not concrete," "difficultto articulate, "difficult to document," and "just like innursing." This comparison between the use of intuition innursing practice and clinical teaching was done by mostinformants ...I: ... you know it is like that sixth sense, it islike when you are caring for patients / I know there issomething not right about them ... while that is kindof how it is with a student too.Rew's (1988) research on the use of intuition in clinicaldecision-making also found that nurses identified theirintuition in terms of either feelings or knowing. Accordingto Rew (1988), experienced individuals comfortable with theuse of intuition may view it as knowledge rather than asemotion. However, in this study there was no apparent110connection between how the informants identified theirintuition and their clinical teaching experience. Theinformants' inability to articulate or document theirintuition or a sense of knowing was also described in theliterature. For example, Polanyi (1966) stated, "We canknow more than we can tell" (p. 4).Experience and exposure. Most informants shared theview that their ability to evaluate using intuition wasbased on both "exposure" and "experience." Experience interms of teaching was strongly advocated by those informantswho were veteran teachers. The following quote typifiedthis viewpoint.I: ... I think it takes exposure and experience ... Ithink it does have a lot to do with experience inteaching and I think you just get better at identifyingmore quickly those behaviors that could be problematicand hopefully then you are able to help the studentearlier.Two of the informants, new to clinical teaching, didnot discuss their intuition in relation to teachingexperience. Instead, these informants advocated that theirintuition was "based on their past nursing experience." Incomparison, the third inexperienced informant found that,although she brought her intuitive abilities from nursingpractice into her new role, it had taken teaching experience111to "transfer" and "adapt" it.The literature documented experience as a definiteprerequisite to intuition. Intuitive abilities wereassociated with experts (Benner, 1984), "seasoned" veterans,(Benner & Tanner, 1987), and connoisseurs, or qualifiedindividuals who can make discriminating judgements (Polanyi,1962). According to Bruner (1965), the effectiveness of a"good intuiter" rests upon familiarity and a solid knowledgeof the subject. Likewise, Benner's (1984) research foundthat the use of intuition in clinical practice was reservedfor the expert nurse with an enormous background ofexperience.Intuition and a gestalt view. Most informants assertedthat their use of intuition related to a gestalt view of thesituation--"You get a sense ... is this really what thiswhole picture tells me"? One informant suggested that one'svision of the whole picture was grounded in an intuitiveunderstanding of how smaller pieces of data interrelate.Likewise, another informant spoke of intuition in terms ofthis ability ...I: ... your intuition ... is your abilities to look andput all the pieces of the puzzle together.The relationship between the gestalt view of a situation andthe use of intuition was documented in the literature. Forinstance, Rew (1986) identified one of the defining112attributes of intuition as knowledge perceived as a whole.Polanyi (1966) linked intuition, or what he termed tacitknowledge, to a sense of the whole by stating, "Tacitknowledge dwells in our awareness of particulars whilebearing on an entity which the particulars jointlyconstitute" (p. 61). Similarly, Blomquist (1985) referredto intuition as the ability to grasp a situation asa whole and separate relevant from irrelevant information.The use of intuition. The majority of the informantsspoke of using intuition early in the clinical process withborderline students. They would get a "gut feeling" or a"sense" that "something was wrong." One informant describedhow she experienced a "sense" or how "little warning bells"would go off in her head which indicated that "something wasnot quite right." Another informant stated ...I: I use intuition when I'm trying to identify aproblem ... try to pursue those things in order to getmore facts.Regarding making the final evaluative decision, themajority of informants acknowledged that they used intuitionwhich they would substantiate with "hard data" or"documented evidence." The informants spoke of knowing thata borderline student had the "potential," "could improvewith another chance or another block of time," or theysensed that the student "just wasn't ready." The following113two quotations were examples of how informants viewedintuition in relation to the final decision.R: Do you use intuition in making the final decision?I: Oh yeah, I think we do, I think we try to justify itby a bunch of facts and bunch of examples ... I have asense but we'll go through all the rest of the hoopsuntil the end of it.I: Instructors may have an intuitive feeling that thestudent shouldn't go on and won't do well in the futuresemesters but they don't have the hard data to supportthese intuitive feelings so they can't go on intuitionalone you have to say you did this and this ... ifthere is an appeal you want to be able to support yourdecision ... I think maybe the decision you make to alarge degree is intuitive but once you have made thedecision you then look to see if you have the data toback it up.The informants described "down playing" their useof intuition. According to the informants, intuition wasnot a respectable way of making evaluative decisions. Forexample one informant stated ...I: We make such a big deal at school out of beingobjective that I'm down playing, I'm saying no this is114not intuitive, this is based on these facts becausethat's what pushed a lot ... it could beintuitive but we have a little way of wrapping it up sothat it doesn't look intuitive. ... I would never saythat it's an intuitive sense because first of all, Idon't think that intuition is a very respectedcommodity anywhere ...In contrast to the informants, the literature substantiatedthe use of intuition as an essential element of thedecision-making process. According to the Frenchphilosopher Bergson (1946/1968), intuition is an essentialcomponent in higher intellectual activities. Likewise,Ferguson (1987) described intuition as a superior form ofknowing that encompasses the intellect. Cosier and Alpin's(1982) study of managerial problem-solving found that peoplewith high levels of intuitive ability made better decisionsthan those with low levels. Marquis and Huston's (1987)description of the decision-making process includedintuition as an intrinsic element. Rew and Barrow (1987)recognized intuition as a "component of the perceived viewof science and a legitimate way of knowing in nursing" (p.50). Further, these authors addressed how clinically-basednurses refer to their reliance on intuition as an essentialcomponent of the decision-making process.Like the informants, the literature addressed the needto substantiate intuition with "confirming evidence"115(Benner, 1984, p. xix). Bruner (1965) explained howintuition must be validated through analytical thinkingwhich is more concrete and characteristically proceeds inexplicit steps. The informants' analysis of their"anecdotal notes," "hard data," or "documented evidence"would correspond to this type of thinking.Intuition and ambiguity. During the second interviewsthe informants were asked if they perceived a link betweentheir use of intuition and the ambiguous nature ofborderline performance and the evaluation process. Mostinformants agreed that they heavily relied on intuition whenworking with borderline students and acknowledged that thiswas due to the student's ambiguous performance beingevaluated with a subjective or ambiguous process.I: If those things (borderline performance and clinicalevaluation process) weren't ambiguous, thingswould be much more clear-cut and you wouldn't have torely on your intuition or gut feeling.The use of intuition in decision-making with incompleteor ambiguous data (Rew, 1988; Rew & Barrow, 1987) or insituations which involve uncertainty, uniqueness, andunpredictability (Schon, 1983) was substantiated in theliterature. Given that borderline students' performance hasbeen characterized as ambiguous with unpredictable,uncertain, individualized behavior and that making116evaluative decisions involved an ambiguous process,intuition as a valuable component of this experience fitswith the literature.Summary. The informants used intuition or a sense ofknowing to make evaluative decisions with borderlinestudents. Due to the ambiguous nature of borderlineperformance and the clinical evaluation process, theinformants found that they relied on their intuitiveabilities more with borderline students. How the informantsdescribed their intuition and validated it with confirmingevidence was similar to descriptions in the literature.However, unlike the literature, intuition as a form ofhigher intellectual ability and as a respectable element ofdecision-making was not addressed or implied by theinformants.A Sense of TrustingData collection and analysis for the theme concerning asense of trusting transpired differently. Contrary to theother themes, the greater part of the data were elicitedduring the second interviews. Thus, this theme will bepresented according to data collection during the two setsof interviews.During the initial interviews, three informantsdiscussed two comparable criteria used to assist them inmaking their difficult decisions to pass or fail aborderline student. Two informants envisioned the studentas a care-giver for self or family members. Another teacher117thought about the student as a future co-worker. Thefollowing three quotations illustrate the presence of thistheme in the initial interviews.R: During your experience with borderline students, howdid you go about making the final decision whether topass or fail the student?I: Whether I'd like them to look after me personally... I have had students that I won't want them to lookafter my dead cat ... basically the bottom line iswhether I want them at their level of expectations inthe program ... looking after me, or one of my familymembers. Would I want them to be there?R: How do you deal with this self-doubt?I: ... thinking about whether you'd want the studenttaking care of you ... when you're feeling doubtful ...that's when you kind of go, no I wouldn't feel safewith this person, I wouldn't want this person takingcare of me or my family ... it's not that s/he's arookie / there's just something missing, I wouldn'tfeel safe.I: To pass or fail, it is a real simple way I have ofdoing it. ... I always thought at this rate of theirprogression in another eight months would they be at alevel that I would want to work with them as a grad? I118always imagined working with them on a night shift andthey would be at one end of the hall and I would be atthe other end, if I felt comfortable with this personworking at the other end of the hall ... if I wouldfeel safe with them. That was my simple criteria forjudging whether or not / because the objectives you cansometimes / you can meet them with this only onebehavior. My gut feeling is whether I would want towork with them, feel safe with them if they were a newgraduate.Indirectly, this last quotation illustrated theinterrelationships between a sense of trusting, theambiguous nature of clinical evaluation, and one's gutfeeling or intuition. The informant alluded to how, becausethe objectives were ambiguous, she judged her perceptions ofthe student's performance based on her intuition--"gutfeeling" and whether or not she could trust the student asa future co-worker--"feel safe."Although only three of the eight informants spoke aboutthis notion of trusting, many of the others suggestedtrustfulness. For example, "I just can't trust thestudent." In these instances, the informants did not expandon their perceptions or discuss how they evaluated thistrust.During the second interviews the researcher asked theinformants whether or not this twofold sense of trusting fit119with their decision-making process. Given that allinformants used at least one or both of these criteria, thetheme was unanimously validated.First, with respect to considering the student as acare-giver, the informants agreed to this criterion. Sevenof the informants were definite in their responses. Theyreplied with responses such as: "Definitely," "Yes very muchso," and "I think that's a real good indicator as to whetheror not they're competent to be nurses." The one otherinformant discussed how, until recently, neither herself nora family member had ever been hospitalized. Therefore, thenotion of having the student as a care-giver was unfamiliar.However, because this person's mother was ill recently, sheasserted that this criterion seemed feasible.Second, the informants' responses to the question aboutthe borderline student as a future co-worker received mixedreviews. This criterion fit for those individuals who hadrecently nursed at the bedside. However, for those teacherswho had limited hospital-based clinical experienceconsidering the student as a co-worker was less valid. Thefollowing transcript excerpts typified the two differentresponses.I: Yeah, as a co-worker, yeah ... would they be able tohold their weight, would I be carrying all theresponsibility as opposed to them ... yeah I thinkabout that ...I: No, I haven't because my hospital experience islimited and I think that makes a difference ...According to the informants, a sense of trusting was aproduct of their intuition and their analysis of "hard data"or "documented evidence" of the student's performance.Marquis and Huston (1987) explained that people makedecisions by evaluating their perceptions with analyticalthinking, intuitive thinking, and/or with feelings.Therefore, in accordance with this explanation, theinformants evaluated their perceptions of students' clinicalperformance by analyzing their "hard data", using intuition,and determining if they would "feel safe" with thesestudents as co-workers and/or care-givers.The ambiguity of evaluating borderline students wasinherent in the discussions about a sense of trusting. Toassist them in making their evaluative decisions withambigous data, the informants questioned whether or not theycould trust the student as a future co-worker and/or care-giver.I: Definitely and I have had other instructors say tome, if you are having trouble making the decision thinkabout whether or not you would want this student120121looking after your relative or you if you were sick.Summary. During the clinical evaluation process witha borderline student, the informants would ask themselves ifthey would "feel safe" with the learner as a future co-worker and/or care-giver. Because of the ambiguity ofevaluating borderline students, using the criterion oftrust may afford the informants' some clarity and directionin making evaluative decisions. Although a review of theliterature did not refer to this theme, according to thisstudy a sense of trusting was a valuable decision-makingstrategy.Summary of the Informants' Accounts Three overlapping concepts with inherent, interrelatedthemes emerged from the analysis of the informants'accounts. These concepts were ambiguity, student's self-awareness, and laborious decisions. Of these concepts,ambiguity was the most prevalent.The informants viewed borderline performance andclinical evaluation as ambiguous in nature. Borderlinestudents' enigmatic, inconsistent performance was difficultto evaluate within an ambiguous process. The process wasdescribed as ambiguous because of its subjective element,implicit criteria, and the unclear distinction concerningwhen to teach and when to evaluate. The ambiguity ofclinical evaluation was magnified when applied to anambiguous performance.122According to the informants, borderline studentschallenged their simultaneous responsibilities to studentsand to patients. These students were perceived as "walking"an ambiguous "fine line" between safe and unsafe. Further,ambiguity pertained to the clinical teachers' focus ofresponsibility. Informants teaching in the earliersemesters tended to be more student focused, whereas latersemester teachers were more patient-and profession-oriented.Exactly when this focus of responsibility changed was deemedambiguous.The concept of student's self-awareness focused onborderline students' lack of insight into their clinicalcompetency. Students' limited awareness precipitated theirdefensive responses which in turn evoked an emotionalresponse from the informants. Thus, limited insightinfluenced the teacher-student relationship and complicatedthe process of evaluating these students. Althoughfostering a student's self-awareness was viewed as hardwork, it was germane to eliminating defensiveness andreducing the possibility of an appeal if a failing grade wasassigned.The concept of laborious decisions pertained to theinformants' emotional decision-making process. Thelaborious nature of this process was, in part, fuelled byambiguity.Uncertainty was one of many negative emotions generatedfrom evaluating borderline students. Primarily, the123informants dealt with their anxious uncertainty by seekingpeer support and validation. Being separated fromcolleagues in the clinical setting evoked feelingsof loneliness and a longing for peer support. Otherengendered emotions related to the excessive time devoted toborderline students. In addition, deciding a borderlinestudent's passing or failing clinical grade createddissonance. Wanting the student to be successful pushed theinformants toward awarding a passing grade while perceivingthe performance as unsatisfactory pulled them towardassigning a failing grade. The informants dealt with thisemotional discomfort by rationalizing their decisions.Intuition was an intrinsic component of the informants'decision-making process. The use of intuition encompassed asense of the student's whole performance and a sense oftrusting. Intuition, holism, and thinking about the studentas a future co-worker and/or care-giver helped to diminishthe ambiguity and arrest the informants' irresolution overthe final grade. The informants did not view their use ofintuition as a positive element of their decision-makingprocess.In summary, the experience of evaluating a borderlinestudent was shrouded in ambiguity and involved working witha defensive learner who had limited self-awareness. Thedecision to pass or fail the student was laborious,uncertain and emotional. The foundation of the decision-making process was intuition which encompassed a sense of124the whole and a sense of trusting.This chapter discussed the informants' accounts in thecontext of the relevant literature. Pertinent referencesreviewed in Chapter Two were reexamined and additional oneswere discussed. Many of the themes were supported by theliterature. In particular, the informants' perceptions thattheir experiences were difficult, hard work, emotive, andchallenging were congruent with the literature. Althoughthe literature was consistent with various thematiccategories, there was no explicit reference to borderlineperformance as ambiguous, no reference to a change inresponsibility focus from early to late semesters, and nomention of a sense of trusting as an evaluative criterion.Further, in contrast to the informants, the literaturedescribed intuition as a high-level thinking process and arespectable decision-making strategy.The study's summary, conclusions, and implications fornursing education and research will be the focus of thefollowing chapter.125CHAPTER FIVESummary, Conclusions, and Implications for NursingSummary Borderline nursing students present clinical teacherswith an evaluative dilemma because they exhibit aninconsistent marginal level of clinical performance. Thechallenge of working with borderline students is a realityof the clinical teacher role; however, research whichinvestigated the experience of evaluating these studentswas not found. This study was undertaken to describe howteachers perceived their experiences with this phenomenon.The researcher selected the phenomenological method.Because this qualitative method explores experientialmeaning, it was an appropriate approach to study clinicalteachers' perceptions of evaluating borderline nursingstudents. The researcher recruited eight diploma program-based clinical teachers who had evaluated these students.The teachers taught in medical-surgical settings, theiryears of teaching ranged from one to 18, and their reportedexperiences with borderline students varied from three to100.Data were collected through the use of two unstructuredaudio-taped interviews with each informant. The initialinterviews were guided by trigger questions which wereformulated with direction from the concepts of the study'sconceptual framework. These concepts were role, perception,and decision-making and were selected based on their126relevance to the clinical evaluation process and the reviewof the literature.Consistent with the phenomenological approach, datacollection and analysis were done concurrently. Theinterviews were transcribed and analyzed according toGiorgi's (1975 a,b) approach to data analysis. The themesand concepts which emerged from the data were validated andclarified with each informant. This validation processensured that the researcher's interpretations of theaccounts remained faithful to the informants' experiences.During the process of data analysis, three overlappingconcepts with inherent, interrelated themes naturallyunfolded. The concepts were ambiguity, student's self-awareness, and laborious decisions.Ambiguity was a central concept which pertained to thenature of borderline performance, the clinical evaluationprocess, and the clinical teachers' dual responsibility tostudents and to patients. The ambiguity contributed to thedifficult dilemma of evaluating borderline students. Inparticular, the ambiguous nature of clinical evaluation wasbrought to the forefront when working with students whodemonstrated ambiguous performance.The informants described borderline students asindividuals who lacked awareness of their strengths andweaknesses. The teachers perceived fostering this awarenessas hard work and time-consuming, yet requisite to studentsimproving, accepting their clinical status, or withdrawing127if failures were imminent. Students with insight weredeemed less likely to appeal their clinical failures. Inaddition, the accepting attitude of insightful studentsfacilitated positive teacher-student relationships.Five themes surfaced concerning the concept oflaborious decisions. Two of these themes pertained to theuncertainty and emotional challenge of making evaluativedecisions. The remaining three themes, a sense ofthe whole performance, a sense of knowing or intuition,and a sense of trusting, related to the process of makingthese decisions. The concept of ambiguity underscored whyevaluating borderline students was laborious in nature.The ambiguity of evaluating borderline studentscontributed to the informants' anxious uncertainty which wasintensified for the three novice teachers. Primarily,seeking support and validation from their peers was thestrategy used to dissipate this uncertainty.Further, evaluating borderline students generatednumerous other emotions and created dissonance which wasreduced through various forms of rationalization. Having todevote extra time to the special needs of borderlinestudents in the clinical group and being separated fromcolleagues in the clinical setting also contributed to theinformants' emotional challenge of working with thesestudents.In order to evaluate an ambiguous performance within anambiguous process, the informants would grasp a sense of the128student's whole performance, use intuition, and decide ifthey could trust the student as a future co-worker and/orcare-giver. A sense of the whole performance and a sense oftrusting were both intuitive in nature.Chapter Four presented and summarized these conceptsand themes in detail, discussed their interrelationships,and analyzed them with reference to the relevant literature.While some of the thematic categories paralleled those inthe literature, others offered a new perspective. Thefindings supported the researcher's initialconceptualization of the research problem. The conceptualframework's concepts of role, perception, and decision-making were inherent in the descriptions of the informants'accounts.Conclusions The conclusions drawn from this study are as follows:1. The experience of evaluating borderline nursingstudents is shrouded in ambiguity. Ambiguity characterizesborderline performance which amplifies the ambiguityinherent in clinical evaluation and in the nurse educator'sdual responsibility to students and to patients.2. Borderline students tend to have limited awareness oftheir performance problems. Fostering students' awareness,though time-consuming, is an essential element of clinicalteachers' work with these students.3. Dissonance and a variety of emotions, of whichuncertainty is the most predominant, are associated with the129decision-making about borderline performance. Dissonance isreduced by using various forms of rationalization and peersupport is essential for dissipating the uncertaintyinherent in this decision-making process. Evaluatingborderline students in clinical settings away fromcolleagues precipitates feelings of loneliness andintensifies the need for peer support.4. Clinical teachers use strategies which are basedon intuition during the laborious process of deciding aborderline student's final grade. These strategies includea sense of knowing, a sense of the student's wholeperformance, and a sense of whether or not the student couldbe trusted as a future co-worker and/or care-giver. Theinformants minimized the value of using intuition byunderscoring the importance of having documented evidence.Implications for Nursing EducationThe findings suggest a number of implications fornursing education. The first five are for nurse educatorsand the remaining implications are for educationalpreparation for clinical teaching.1. Clinical teachers may find the results informativeand the description of the informants' accounts may providea basis to validate their own emotional, laboriousexperiences of evaluating borderline nursing students.2. Faculty members need to develop and implementstrategies which ensure that colleagues receive support whenfaced with the challenge of evaluating borderline nursing130students. In particular, faculty members need to structureways to provide this support to teachers who work inclinical settings separated from colleagues.3. Clinical teachers, from different levels in theprogram, need to share their concerns, approaches, andinterpretations of evaluative criteria and data. Thechanging dynamics of evaluating students in the earlierversus late semesters needs to be discussed amongst facultymembers.4. In order to facilitate students' acceptance of theirclinical standing and reduce the likelihood of appeals,clinical teachers should have the understanding andcapabilities of fostering learners' awareness of theirclinical competency.5. Clinical teachers must acknowledge the inescapable,underlying subjectivity and, hence, ambiguity of clinicalevaluation. Teachers need to accept that, in the end, they"must call it as they see it" (Meisenhelder, 1982, p. 348).Using intuition, a sense of the whole performance, and asense of trusting should be considered as appropriatedecision-making strategies to resolve the dilemma ofevaluating borderline nursing students.6. Future nurse educators need to be introduced to thechallenges of evaluating borderline students. Educationalpreparation should realistically, yet sensitively, elucidatethe laborious and emotive dimensions of this experience.7. Courses focused on clinical teaching need to give131significant attention to the ambiguity inherent in theevaluation process with borderline students. Emphasis ondeveloping an understanding of and skills in evaluativedecision-making that includes the use of intuition would beappropriate course content.8. Course content focused on working with borderlinenursing students needs to encompass: ways to structure peersupport into the clinical evaluation process, strategies tofoster students' awareness of their clinical competency, andthe impact that these learners have on clinical teachers'dual responsibility to students and to patients.These last three implications apply equally forcontinuing education programs, workshops, or facultydevelopment focused on teaching and evaluation forexperienced clinical teachers.Implications for Nursing Research This study's findings suggest the following areas ofresearch which would enhance understanding of thecomplexities of clinical evaluation.1. According to the informants, failing students, incontrast to borderline students, were less challenging.Their clinical performance was viewed as more "clear-cut"and the evaluation process perceived as more simplified.However, clinical teachers' perceptions of their experienceswith clinical failure or with failing students have not beenstudied. Research of this nature may enhance understandingof the differences between evaluating borderline and failing132students. It may also determine if the crux of thedifficulty rests in the ambiguous performance of theborderline student or the act of rendering a failing grade.2. This study explored the experiential meaning ofevaluating borderline students from the perspective ofdiploma program-based clinical teachers. Repeating thisstudy with baccalaureate faculty members would enrich theunderstanding of this phenomenon and contrast the nature oftheir experiences.3. The findings indicate that new teachers facedheightened uncertainty and tended to reduce their dissonancewith self-blame or blaming their peers. Further, althoughthe literature associated the use of intuition with a solidknowledge base and experience (Benner, 1984; Benner& Tanner, 1987; Bruner, 1965; Polanyi, 1962), this study'sthree inexperienced teachers confirmed its use. A studyspecific to new clinical teachers' perspectives wouldenhance understanding of this phenomenon.4. Studies exploring the strategies used by clinicalteachers to cope with the uncertainty and dissonancespecific to the clinical evaluation process would add to thelimited research concerning the emotive dimensions of thisprocess.5. Although all of the informants used intuition as anintrinsic component of their decision-making, a review ofthe literature did not reveal any research on clinicalteachers' use of intuition. 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Evaluation of student nurse clinicalperformance--a continuing problem. International NursingReview, 29(1), 11-18.Wood, V. (1986). Clinical evaluation of student nurses:Syllabus needs for nursing instructors. Nurse EducationToday, 6, 208-214.Wood, V., & Campbell, D. B. (1985). The instructor, thestudent and appeals. Nurse Education Today, 5, 241-246.Wood, V., & Wladyka, J. (1980). Grading student nurses.The Canadian Nurse, 76(6), 30-32.Woolf, P. J. (1984). Increasing self-esteem through self-evaluation. Journal of Nursing Education, 23(2), 78-81.Woolley, A. S. (1977). The long and tortured history ofclinical evaluation. Nursing Outlook, 25(5), 308-315.Yonge, O., & Stewin, L. (1988). Reliability and validity:Misnomers for qualitative research. The Canadian Journalof Nursing Research, 20(2), 61-63.143Zanecchia, M. D., & Stephenson, C. A. (1988). Careermanagement. In M. D. Zanecchia (Ed.), Career guide fornurse educators (pp. 149-190). Toronto: Prentice-Hall.144APPENDICESAppendix AData Collection: Trigger Ouestions 1. Based on your own experiences, what was it like foryou to evaluate borderline clinical nursing students?2. During your experiences evaluating borderlinenursing students, how did you go about making the decisionwhether to pass or fail them?3. During your experiences evaluating borderlinenursing students, what was your relationship like with thesestudents?4. During your experiences evaluating borderlinenursing students, what was your relationship like with yourcolleagues?Appendix BExplanatory Letter for Agency ConsentSchool of NursingThe University of British ColumbiaVancouver, B.C.Dear Director:My name is Mary Boyer. I am presently doing graduatestudies in nursing at the University of British Columbia.For my master's thesis, I am interested in studyinv clinicalteachers' perceptions of their experiences evaluatingborderline nursing students. My interest in this topicstems from my own experiences as a clinical teacher inAlberta. I anticipate that the benefit of this study willbe an enhanced understanding of the challenge that clinicalteachers face in the evaluation of borderline students.I would like to request the volunteer participation ofmembers of your nursing faculty. I hope to interviewclinical teachers who have evaluated at least one borderlineclinical nursing student, are willing to share theirexperiences, and have completed at least a baccalaureatedegree in nursing. For the purpose of this study aborderline student is defined as student who received anunsatisfactory appraisal or failing grade prior to the finalclinical evaluation.Due to proximity I am accessing various college nursingprograms in the Vancouver area. The use of more than onenursing program will facilitate insight into a wider rangeof experiences and will ensure finding enough clinicalteachers who can speak to the experience.The teachers' participation in this study would involve 2 or3 unstructured audio-taped interviews that would lastapproximately 1 hour, would be scheduled 2 to 4 weeks apartat a time convenient for them, and would be in a setting oftheir choice. The initial interview would involve theteachers answering a few questions regarding their academicand nursing backgrounds. At the completion of the study anabstract of the study will be available to your facultymembers.The names of the college and teachers, the audio-tapes, andthe reporting of the written findings will be keptconfidential and anonymous. The teachers will be asked notto name or reveal any identifying information about the145146borderline clinical nursing students.For purposes of the University's ethical review committee, awritten consent from the college is required for my study tobe approved. Please find an enclosed agency consent formand a brief overview of the proposed study. In person, Iwould appreciate an opportunity to further elaborate on mystudy, answer any questions, and if approval is grantedobtain your written agency consent. In addition, I wouldappreciate an opportunity to present the study to yourfaculty members. Please contact me to arrange anappointment at your earliest convenience. My home phonenumber is 737-2908. Thank you for your attention to myrequest.Sincerely,Mary Boyer, RN, BScN147Appendix CSchool of NursingThe University of British ColumbiaVancouver, B. C.Agency Consent FormI, the undersigned give permission to Mary Boyer toapproach the clinical teachers in order that she may conducther study entitled " A Phenomenological Study of ClinicalTeachers' Experiences with Borderline Nursing Students" withthe clinical teachers employed at this college nursingprogram.Director's Signature ^College NameResearcher's SignatureDate148Appendix DSchool of NursingThe University of British ColumbiaVancouver, B. C.Agency Handout: A Phenomenological Study of Clinical Teachers' Experiences with Borderline Nursing Students Overview of the Proposed StudyThe study is designed to explore the difficult,emotional dilemma that clinical teachers face in fulfillingtheir professional and legal obligations in the clinicalevaluation of borderline nursing students (Brozenec,Marshall, Thomas, & Walsh, 1987, Carpenito, 1983;Majorowicz, 1986; Meisenhelder, 1982; Welborn & Thompson,1982; Wood, 1971). Given that the clinical performance of aborderline student is inconsistent, the teacher's decisionto pass or fail a student is a stressful challenge (Brozenecet al.; Welborn & Thompson; Wood). Although nursingarticles depict the clinical evaluation of borderlinestudents as stressful and challenging, the meaning of thisexperience from the teacher's perspective has not beenexplored. Therefore, it is clear that more knowledge isneeded to understand how teachers perceive this experiencewhich is inherent in their professional role. The purposeof this study is to present a description of how clinicalteachers perceive their experiences of evaluating borderlinenursing students. The study will be significant in theadvancement of knowledge in the clinical evaluation process149with borderline students.This study uses a phenomenological approach, a form ofqualitative research which searches for the meaning of anexperience from an individual's subjective perspective. Thedata will be collected through the use of two or threeaudio-taped, one hour, unstructured interviews (open-endedquestions) with clinical teachers who are willing and ableto speak about their experiences. Through a process ofanalysis the study will conclude with a description of howclinical teachers perceive their experiences of evaluatingborderline students.ReferencesBrozenec, S., Marshall, J. R., Thomas, C., & Walsh, M.(1987). Evaluating borderline students. Journal of Nursing Education, 26(1), 42-44.Carpenito, L. J. (1983). The failing or unsatisfactorystudent. Nurse Educator, 84(4), 32-33.Majorowicz, K. (1986). Clinical grades and the grievanceprocess. Nurse Educator, 11(2), 36-40.Meisenhelder, J. B. (1982). Clinical evaluation: Aninstructor's dilemma. Nursing Outlook, 30(6), 348-351.Welborn, P., & Thompson, D. (1982). Strategies for dealingwith students whose clinical performance isunsatisfactory. Journal of Nursing Education,21(5), 26-30.Wood, V. (1971). Borderline student nurse. McGill NursingPapers, 3(2), 15-26.150Appendix ELetter to the InformantsSchool of NursingThe University of British ColumbiaVancouver, B.C.Dear Clinical Teacher:My name is Mary Boyer. I am presently doing graduatestudies in nursing at the University of British Columbia.For my master's thesis, I am interested in studying clinicalteachers' perceptions of their experiences evaluatingborderline clinical students. My interest in this topicstems from my own experiences as a clinical teacher.The way I hope to learn more about teachers' experienceswith the clinical evaluation of borderline students is tointerview individuals who have evaluated at least oneborderline clinical nursing student, are willing to sharetheir experiences, and have completed at least abaccalaureate degree in nursing. For the purpose of thisstudy a borderline student is a student who received anunsatisfactory appraisal or failing grade prior to the finalclinical evaluation.If you feel you are interested and agree to participate, thestudy will involve two or three audio-taped unstructured(open-ended questions) interviews, about two to four weeksapart, at a time convenient for you, and in a setting ofyour choice. The interviews will each last approximatelyone hour. The initial interview would involve you answeringa few question regarding your academic and nursingbackgrounds. Your name and any identifying information willnot be included in the tape recordings and transcripts ofthe interviews, nor will they be revealed in any printing ofthe findings. The name of the college, the students, andany identifying information will not be revealed. The onlyindividuals who might listen to the audio-tapes will bemyself, and possibly my thesis advisors. I will erase theaudio-tapes and destroy the transcripts of the interviewsupon the completion of the study.You are under no obligation to participate in this study.Whether or not you participate will have no effect upon yourrole as a clinical teacher. If you agree to participate andlater change your mind you are free to withdraw yourconsent. You are free to ask and refuse to answer anyquestions. You have the right to ask that disclosed151information be erased from the tape and, therefore, beexcluded from the findings.I anticipate that the benefit of this study will be to helpme learn more about teachers' experiences in evaluatingborderline clinical students and that the study will enhanceunderstanding in this area of nursing education. I do notanticipate any direct benefits to you for participating.There are no financial benefits in participating.For your information, I have enclosed a brief overview ofthe proposed study and at the completion of the study anabstract of the thesis will be made available. If you areinterested in participating in this study, or need moreinformation, please contact me at 737-2908. In addition,for more information you may contact my Thesis Chairperson,Anne Wyness at 822-7485. Thank you for your cooperation.Sincerely,Mary Boyer, RN, BScN152Appendix FInformant Data The following questions will be posed during the firstinterview with each informant. This information will beused to describe the characteristic of the informants whoparticipated in this study.1. What is your educational background?2. Please briefly highlight your experiences in nursingprior to your role as a clinical teacher.3. How many years of experience do you have in clinicalteaching?4. What clinical area(s) do you teach in?5. How many borderline students have you evaluated?153Appendix GInformant Consent FormTitle of the Study: A Phenomenological Study of ClinicalTeachers' Experiences with Borderline Nursing StudentsResearcher:^Mary Boyer, RN, BScN (737-2908)Master of Science in Nursing StudentThe University of British ColumbiaThesis Chairperson: Anne Wyness RN, BSN, MN (822-7485)Associate ProfessorSchool of NursingThe University of British ColumbiaI understand that:1. The purpose of this study is to find out how teachersperceive their experiences evaluating borderline clinicalnursing students.2. The benefit of this study is to help the researcher learnmore about the teachers' experiences of evaluatingborderline students, and promote an understanding in thisarea of nursing education. I will not receive direct orfinancial benefit for participating.3. This study will involve the following:a) Two or three audio-taped recorded interviews whichwill be scheduled at my convenience, at a setting ofmy choice. The interviews will be conducted two tofour weeks apart and last approximately one hour.Therefore, my participation in this study will totalbetween two to three hours.b) During the first interview, I will answer a fewgeneral questions on my academic and nursingbackground and disclose the number of borderlinestudents I have evaluated.c) During the interviews, I will answer open-endedquestions with respect to my experiences with theclinical evaluation of borderline students.4. I am under no obligation to participate in the study. IfI decide not to participate in the study, it will have noeffect on my role as a clinical teacher.5. The researcher will ensure confidentiality and myanonymity by:154a) My name and other identifying factors will not beincluded on the audio-tapes, the transcripts of theinterviews, nor be revealed in the printing of thisstudy.b) I am not to name or reveal any identifying factorswith respect to the borderline clinical nursingstudents or the college.c) At the completion of the study the audio-tapes will beerased and the transcripts, and any notes taken duringthe interviews will be destroyed. The only people whomight listen to the audio-tapes will be the researcherand possibly her thesis advisors.6. I may:a) ask any questions and ensure that the questions areanswered to my satisfactionb) withdraw from the study at any timec) refuse to answer any questionsd) ask that specific disclosed data be erased from theaudio-tape, and therefore not be included in theprinting of the study.7. A copy of the abstract of this study will be madeavailable to me at the completion of the study.8. That by signing this form, I have voluntarily given myconsent to participate in this study and the signingacknowledges that I have received a copy of this consentform.DateInformant's SignatureResearcher's Signature


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