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Assigning a failing grade to a student in the final clinical semester Greathouse, Susan Elizabeth 1993-02-23

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ASSIGNING A FAILING GRADE TO A STUDENT IN THE FINAL CLINICAL SEMESTER by SUSAN ELIZABETH GREATHOUSE B.N., The University of Calgary, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept this thesis as conforming to the required stj^ndard THE UNIVERSITY OF BRITISH COLUMBIA December, 1993 Susan E. Greathouse In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, 1 agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allov^ed without my written permission. Department of The University of British Columbia Vancouver, Canada Date DE-6 (2/88) Abstract The purpose of this study was to explore the perceptions and feelings of nurse educators on assigning a failing grade to students enroled in the final semester in a diploma nursing program. Using phenomenological methodology, and Lazarus's process-oriented theoretical framework, nine informants employed in British Columbia Lower Mainland diploma nursing programs were interviewed and audio-taped. Data analysis sought to identify the existence of the phenomena and describe the essence of the experience. The findings of the study illustrate that assigning a failing grade in the final clinical semester is a stressful event for nurse educators. The prominent overriding theme which emerged from the data was stress. Two other interrelated themes, uncertainty and isolation, were also embedded in the informants' descriptions of their experiences. These themes were stressors in themselves. Nurse educators described immediate and long-term effects of living through their experiences. Immediate effects included being more on guard, as well as modifying and refining their approach to clinical evaluation. The long-term effects resulted in these nurse educators being quite significantly affected by events. They could vividly recall the details of their experiences which left them with lasting impressions. These experiences served as points of reference for nurse educators when faced with other students having similar problems. Three major conclusions were identified. First, assigning a failing grade to a student is stressful. Informants described the experience as more stressful when the student lacked insight. Second, nurse educators expressed a need for emotional support from their peers. They reported feeling isolated and unsupported. They were acutely aware of the potential ramifications of assigning or not assigning a failing grade. This created an element of uncertainty that affected their decision-making ability. Third, the nurse educators believed that program administrators could and should have been more supportive in two major areas: 1) acknowledgement and reassurance and 2) consistent administration of educational policies. Table of Contents Page Abstract ii Table of Contents iv List of Figures vii Acknowledgements viiCHAPTER ONE INTRODUCTION 1 Background to the Problem 1 Research Question 2 Conceptual Framework 3 Definition of Terms 6 Assumptions 7 Limitations 8 Significance of the Study 8 Organization of the Thesis 9 CHAPTER TWO REVIEW OF THE LITERATURE 10 Feelings, Perceptions, and Experiences 10 Impact on Faculty 12 Summary IV CHAPTER 3 METHODOLOGY 2 0 Issues of Validity and Reliability 23 Selection of Informants 24 Criteria 2Procedures 5 Ethical Considerations 26 Data Collection 27 Data Analysis 8 CHAPTER FOUR PRESENTATION AND DISCUSSION OF FINDINGS 3 0 Characteristics of Informants 30 Content Analysis 31 Stress 32 Uncertainty  6 Isolation 42 Lack of Administrative Support 44 Variables that Influence Appraisals 50 Nurse Educator 51 Student 6Environment 7 Coping 74 Problem-focused Strategies 76 Emotion-focused Strategies 82 Immediate and Long Term Effects 89 Summing Up 92 CHAPTER FIVE SUMMARY, CONCLUSIONS, AND IMPLICATIONS 97 Summary 9Conclusions 100 Implications for Nursing 101 Nursing Education 10Nursing Research 2 References 104 Appendices 8 A. Explanatory Letter to Agencies.... 108 B. Agency Consent Form Ill C. Letter to Informants 113 D. Subject Consent Form 116 E. Demographic Data Sheet 118 F. Interview Questions 120 Adaptation of Lazarus's Framework to Depict Nurse Educators' Experiences With Assigning a Failing Grade ACKNOWLEDGEMENTS I would like to express my appreciation to the nurse educators who shared their experiences with me thus making this study possible. In addition, I would like to thank my husband Wayne, for his unending support and encouragement. Finally, I would like to acknowledge Dr. Marilyn Willman, Dr. Sonia Acorn, and Ray Thompson for their feedback and editorial comments necessary to complete this work. CHAPTER ONE Introduction Background to the Problem Empirical observations of situations involving nurse educators and failing students have shown that failing a student is a stress-producing part of the faculty member's role. It is this researcher's contention that the stress related to clinical evaluation appears to be greatest for the nurse educator who encounters a student unable to meet the program objectives in the final term of a diploma nursing program. For students, the reality of being unable to fulfil their educational aspirations often initiates a highly emotional response. In general, failure to complete the final semester of the program seems to result in student responses different from, and often more exaggerated than, failure in earlier semesters. These responses trigger a variety of thoughts and feelings in the nurse educator who is responsible for issuing the failing grade. These situations, which are often coupled with highly emotionally charged student responses, may have a major and lasting impact on the faculty member. Recent research findings lend support to this view indicating that "failing clinically unsatisfactory students" was one of the items most frequently rated as highly stressful by educators of baccalaureate nursing students (Goldenberg & Waddell, 1990, p. 537). There is general consensus among nursing authors that dealing with the clinically failing student is often a negative, debilitating, and demoralizing experience for nurse educators (Carpenito, 1983; Goldenberg & Waddell, 1990; Spink, 1983; Symanski, 1991; Turkett, 1987). Most of the literature which makes reference to the impact on the nurse educator of failing a student is based on opinion or speculation. Little has been written about the nurse educator's perceptions and what is written may or may not correspond with reality. Research Question The question addressed in this study was: What are the experiences and perceptions of nurse educators in diploma nursing programs related to assigning failing grades to students in their final clinical semester? Conceptual Framework The phenomenological transactional model of Lazarus and Folkman (1984a) is a useful framework for enhancing one's understanding of this experience. Unlike early research on stress by Selye, which focused primarily on physiological stress responses, Lazarus and his colleagues addressed mental and psychological responses to stress. They particularly focused on those cognitive, affective, and adaptive responses arising from person-environment transactions. In this individualistic, process-oriented model, the notion of stress which arises from the interplay between person-environment transactions is mediated by two primary processes: cognitive appraisal and coping. An event in the environment is considered a stressor only when an individual appraises it as exceeding his or her resources and determines that it is threatening or disturbing (Lazarus & Folkman, 1984a). The teaching-learning process, particularly in relation to dealing with the clinically unsatisfactory student, has been identified as a source of significant stress and potential cause of burnout for nurse educators (Fong, 1990; Goldenberg & Waddell, 1990; Ray, 1984; Symanski, 1991; Welborn & Thompson, 1982). Multiple person-environment transactions are involved in issuing failing grades to nursing students in the final semester of a diploma nursing program. By utilizing Lazarus's definition of stressor identification, the researcher will be able to identify how nurse educators appraise their experiences. Lazarus and Folkman (1991) believe that cognitive appraisals are influenced by a variety of person and environmental variables. Personal characteristics may include such variables as one's values and beliefs, self-esteem, prior life experiences, and the ability to recognize personal resources which may enhance or impede coping. These may be things such as financial means, social and problem-solving skills, health, and energy. Environmental variables include the nature of the stress, the timing, duration and ambiguity of the situation, other situational demands and constraints, and the existence and quality of social support resources which may facilitate coping (Lazarus & Folkman, 1984a; 1991). Multiple factors have been identified in the literature as sources of stress associated with the assigning of failing grades to clinically unsatisfactory students. Many of these factors arise from pressures and conflicts inherent in maintaining high standards of nursing practice while dealing with pressures to pass students. Other variables perceived by nurse educators as sources of stress include role conflict, role ambiguity, fear of litigation, and lack of support ( Dick, 1986; Fain,1987; Lessner, 1990; O'Connor, 1978; Pollok & Poteet, 1983). Fain (1987) postulates that role ambiguity and role conflict may lead to job dissatisfaction. Coping, according to Lazarus and Folkman (1991), is a multidimensional process and consists of cognitive and behavioral attempts to manage perceived stressors that are appraised as exceeding the resources of the individual. In this model, coping is identified as being either problem-focused or emotion-focused. Problem-focused coping processes are directed toward altering the person-environment relationship, while emotion-focused coping strategies are primarily directed toward managing emotional distress rather than changing the person-environment relationship (Lazarus & Folkman, 1991). In this way, the individual's appraisal of the stressful situation, influenced by person and environmental variables, affects the individual's coping responses. These coping responses in turn alter the person-environment relationship and affect the quality and intensity of the individual's emotional response. By examining the variables that influence nurse educators' appraisals of events, both cognitive and behavioral coping processes may be identified and patterns of coping may be revealed. This humanist-oriented model directed toward evaluating an individual's perception of, and reaction to, situations which s/he appraises as being threatening or stressful, is congruent with the phénomènelogical methodology used in this study. The theoretical framework and methodology describe the individual's perception and experience arising from the situation involving clinically failing students. Definition of Terms Words and phrases used in this study are defined as follows: Impact : the effects, or the perception of the effects, resulting from the experience of failing students on the informants. Nurse educator: an individual who is a practicing member of the Registered Nurses' Association of British Columbia, who is teaching in a diploma nursing program, in the final clinical semester. This term is used synonymously with the term "nursing faculty." Failing students: students who have been clinically evaluated by a qualified nurse educator and have been identified as not meeting the course objectives in the final clinical semester of a diploma nursing program. Diploma nursing programs: nursing programs based in post-secondary institutions that grant diplomas in nursing in the province of British Columbia. Final clinical semester: the final clinical semester prior to graduating from a diploma nursing program. Assumptions The writer assumes that any nurse educator who has failed one or more nursing students in the final clinical semester of a diploma nursing program is qualified to speak about his/her experiences related to the impact of failing a student and that the experiences are valid according to phenomenological theory. Limitations Sample selection was limited to nurse educators in the province of British Columbia who had failed at least one nursing student clinically, in a diploma nursing program. The sample, a purposive, convenience sample, was drawn from only two diploma programs and therefore, the findings cannot be generalized to all nurse educators. Significance of the Study Nurse educators' perceptions and feelings resulting from working with clinically failing students may have a significant impact on nursing education. Various authors have postulated that the multiple stresses inherent in these situations may lead to stress and burnout, and may actually result in nurse educators leaving clinical teaching (Carpenito, 1983; Goldenberg & Waddell, 1990; Lenhart, 1980; O'Connor, 1978; Ray, 1984; Turkett, 1987). Being aware of, and better able to anticipate, the feelings that may result from these difficult situations may assist nurse educators to deal with this aspect of clinical evaluation more effectively. Additional research may generate findings to incorporate into graduate programs that prepare nurse educators. Novice nurse educators may benefit from the findings of this study by gaining an increased awareness of the perceptions and feelings resulting from interactions with failing clinical students. As a result, they may find themselves better able to cope with the impact of the challenging situations which they will inevitably have to face. Organization of the Thesis This thesis is organized into five chapters. In Chapter One, the context of the problem, purpose of the study, and theoretical framework have been described. In addition, key terms were defined and the significance and limitations of the study delineated. Chapter Two presents a review of the relevant literature describing the feelings, perceptions and experiences of nurse educators, the impact on nurse educators of interacting with failing students, and the conflicts inherent in the nurse educator's role. In Chapter Three, the phenomenological method used in this study is described and an outline of the criteria used to select informants presented. Chapter Four includes the presentation and discussion of the study's findings. Chapter Five includes the summary, conclusions and implications. CHAPTER TWO Review of the Literature The review of the literature focuses on two areas. The first is related to nurse educators' feelings, perceptions, and experiences arising from interactions with nursing students who have been issued a failing clinical grade. The second relates to the impact on nurse educators of this event. Feelings, Perceptions and Experiences O'Connor (1978) speculated that the teaching-learning process, particularly in the clinical setting, can set the scene for conflicts that prove troublesome for all nurse educators. Various authors have made reference to the emotionally draining experience of dealing with students who perform unsatisfactorily in the clinical setting (Lankshear, 1990; Lenhart, 19 80; Symanski, 1991; Turkett, 1987; Wood, 1971). The literature that addresses the process of clinical evaluation as it relates to failing a student is filled with statements describing feelings arising out of this process. Turkett (1987) states that "when faced with the reality of failure both student and nurse educator become uncomfortable, tense and depressed" (p. 246). Feelings of insufficiency and powerlessness may surface. Frustration may be experienced by the nurse educator (Anderson & Saxon, 1968; Carpenito, 1983; Kelly, 1973). Carpenito (1983) points out that nurse educators may distance themselves both physically and emotionally in response to student anger and hostility. Nurse educators are often left with doubts arising from the clinical evaluation process. They wonder whether they have "done the right thing," knowing full well that opinions would vary among equally competent educators (Brozenec, Marshall, Thomas, & Walsh, 1987, p. 42). In a recent exploratory study, Goldenberg and Waddell (1990) examined sources and levels of perceived stress among 7 0 female baccalaureate nurse educators in eight Ontario universities. They found that the major stresses were primarily clinically-oriented and included "retaining failing students and failing clinically unsatisfactory students" (p.537). Although some limitations were noted in the study, the findings supported the investigators' contention that dealing with failing students is stressful. In a study designed to investigate the attitudes of 34 clinical "assessors" and nurse teachers from two different schools of nursing in northern England, the participants were asked to discuss issues related to clinical evaluation and failing students (Lankshear, 1990). Using ..."structured eavesdropping methodology" ...(p. 350), a term not defined by the author, the participants took part in seven discussion groups. Respondents described in their own words how they felt about failing nursing students. For example, they felt they experienced "flak," could be made to feel like "ogres," and felt it was a hassle hardly worth the outcome. While these comments may be of some value, the fact that they are taken out of context makes it difficult to determine their merit. Impact on Faculty Various authors have described the possible impact on faculty of having to work with failing students (Goldenberg & Waddell, 1990; Lenhart, 1980; Ray, 1984). The literature contains numerous articles that provide anecdotal commentary on the stress-filled role of the nurse educator (Carpenito, 1983; Lenhart, 1980; Ray, 1984; Turkett, 1987); however, research-based literature on stress and burnout among academic faculty is limited. Typical of this type of literature is Ray's article (1984), on the potential problem of burnout for nursing faculty. The author describes the pressures and conflicts that are inherent in maintaining high standards of nursing practice while dealing with the pressures to pass students. In a descriptive-correlational study which examined burnout in collegiate nursing programs, Dick (1986) describes a significant negative relationship between burnout of nursing faculty and intense student and collégial interpersonal relationships. The subjects in this study spent approximately half of their time in contact with students. The author concluded that while there was a slight relationship between clinical supervision and burnout, continuous contact in intense interpersonal relationships with students and colleagues was an important factor in burnout. This factor was cited as being more important than the hours worked or caseload of the faculty member. An additional stress for the nurse educator is the fear arising from the prospect of being sued (Lessner, 1990; Pollok & Poteet, 1983). Many faculty are fearful of a grievance or lawsuit for a variety of reasons. Most nursing education programs today have developed academic and clinical standards for student performance and appeal mechanisms to address student grievances. If carefully designed, these procedures, while stressful, should safeguard the rights of both educators and students (Orchard, 1992). In the past three decades, in the United States, there is evidence suggesting a general increase in litigation involving nursing education programs (Helms & Weiler, 1991). In the United States, suits against nursing education programs are more likely to be brought by students and they are often successful (Helms & Weiler, 1991). It is reasonable to assume that this pattern likely mirrors that of Canada; however, no literature could be found to support this contention. The advent of student consumerism demands that students be treated fairly and that the educational program provide the skills necessary for the new graduate to function as a competent professional. Goclowski (1985) identifies a "catch 22" scenario where it is possible for nurse educators to be sued for both failing and not failing a student. For example, graduates of nursing programs dismissed from employment for incompetence may sue for not receiving an education that prepared them to function as competent professionals; and students dismissed from nursing programs may sue a faculty member for failing to treat them in a fair and reasonable manner Goclowski (1985), O'Connor (1978) and Symanski (1991) postulate that the multiple stresses inherent in dealing with failing students may actually result in a loss of nurse educators from clinical teaching. Factors related to the multifaceted and somewhat ambiguous role of nurse educators, and the costly drain on faculty energy exacted by the failing student have also been identified as potential causes of stress and burnout. From this perspective. Fain (1987) and O'Connor (1978) found that nurse educators experience role conflict and role ambiguity from wearing two hats; those of professional nurse and educator. Role conflict and role ambiguity may lead to stress which has been linked to low job satisfaction (Schuler, 1975; Schuler, Aldag & Brief, 1977) . Numerous nursing authors have contributed to an understanding of the responsibilities and conflicts inherent in the nurse educator's role (Batey, 1969; Kramer, 1966; O'Connor, 1978; Williamson, 1972). O'Connor (1978) identifies a further conflict arising from the teaching-learning process. Faculty members often have to make difficult choices between what ought to be done and what will gain student approval and thus provide them with some intrinsic reward for the work they are doing. Diminished job satisfaction has been linked to stress arising from the role conflict and role ambiguity experienced by many nurse educators (Marriner & Craigie, 1977). In this study, junior faculty members in particular, hired into their first teaching position, expressed more job dissatisfaction than senior faculty members. Because of job dissatisfaction attributed to role conflict, ambiguity and overload, junior faculty were more likely to be planning to leave their position. Fain (1987), in a study that examined baccalaureate nurse educators' perceptions of role conflict and role ambiguity as compared to job satisfaction, found that role conflict and role ambiguity were both associated with low levels of job satisfaction. Marriner and Craigie's (1977) survey of 822 nurse educators in baccalaureate and higher degree programs in 13 American western states reported that the quality of students was one of the variables which correlated with general job satisfaction. The higher the quality of the students, the more generally satisfied educators were, and the more likely they were to remain teaching at that institution. Wood (1971) describes how, in nursing programs in Ontario and Quebec, competent faculty working with "borderline" students may leave nursing programs which have a high attrition rate for others with more rewarding teaching environments. However, no statistical data are given to support the author's contention. Summary The literature review has identified that there is a dearth of research-based information on the thesis topic. Relevant current American literature is limited, and Canadian-based literature on the topic is absent. A review of the literature reveals there is little more than opinion and anecdotal commentary to describe the experiences of nurse educators having to assign failing clinical grades to students in general. and no articles could be found that described the experience of having to assign failing grades to students in the final clinical semester. This review highlights the complexities of clinical evaluation and describes the role ambiguity and role conflict experienced by professional nurse educators as they carry out their responsibilities. Stress, burnout, and role conflict are predominant concepts that emerged from the studies examined. In addition, some issues are identified related to the impact on nurse educators of issuing failing clinical grades. The long and short term effects on faculty members of having to interact with failing students have not been specifically addressed in the nursing literature (Symanski, 1991) . In fact, a search of the related literature in general education reveals that little has been written about the impact on faculty in general of failing students. Whether these concerns are specifically related to nurse educators in diploma nursing programs is not known since no articles could be found that examined the experiences of diploma nursing faculty. The potential significance of the impact on nurse educators, and nursing education as a whole, of having to assign a failing grade to a student m the final clinical semester, combined with the lack of research in this area, has provided the impetus for this study. CHAPTER THREE Methodology In this chapter, the methodology used in the study is described. Sample selection criteria, issues of validity and reliability, ethical considerations, and data collection and analysis are also addressed. Methodology Spiegelberg's philosophical, introspective phenomenological method was used for this study. The aim of phenomenology is to describe human experience through the perception of the individual as life is experienced (Munhall & Oiler, 1986). With Spiegelberg's (1960) approach, the researcher can systematically explore meaning in the human experience. From this exploration, through the informants' perceptions, consensually validated knowledge can be derived, attempting as fully as possible to depict the totality of an experience as it is lived (Munhall & Oiler, 1986). Subjective phenomena are studied to uncover the objective essences about the reality of the phenomena under examination (Spiegelberg, 1960). The subjectivity of the phenomenon relates only to the content of the situation and description of the personal experiences as related by the informants (Spiegelberg, 1960). Spiegelberg (1960) identifies seven steps in his approach to phenomenological research. They include, in the following order: investigating particular phenomena; investigating general essences; apprehending essential relationships among essences; watching modes of appearing; watching the constitution of phenomena in consciousness; suspending beliefs in the existence of phenomena; and interpreting the meaning of phenomena. The first three steps require the researcher to intuitively grasp the particular phenomenon and analytically examine and describe it. This must be done without preconceptions. The investigator "brackets" or consciously puts aside his/her opinions and understanding of the experience under investigation. In this study, the investigator had to bracket thoughts and experiences arising out of being a nurse educator and having issued failing grades to students in the clinical setting. This enabled the researcher to view the reality from the informants' perspective and enabled the informants to fully express their views of the phenomenon. The fourth step, "watching modes of appearing" refers to the need for the investigator to explore not only what essences appear but to examine the way general essences appear. Exploration of the constitution of the phenomenon in consciousness consists of determining how the investigator perceives the phenomenon has taken shape (Spiegelberg, 1960). The purpose of the fifth step is to "determine the typical structure of a constitution in consciousness by means of analysis of the essential sequence of its steps" (Spiegelberg,1960). Suspending belief in existence, the sixth step, maintains the practice of bracketing, ensuring that the researcher will consider all the data on an equal basis preserving the content as purely as possible. The aim of this phase is the facilitation of genuine intuiting, analyzing, and describing of the given data (Spiegelberg, 1960). The final step in this process, that is, interpreting concealed meanings, aims at discovering meanings not immediately apparent from the researcher's previous intuiting, analyzing and describing. Spiegelberg (1960) suggests that there is "scope and reason to look for deeper hidden meanings whenever the conscious meanings do not adequately account for a phenomenon" (p. 698). Spiegelberg's phenomenological approach provides a systematic methodology to explore meanings of experiences and is an appropriate methodology to use in this type of research problem where little is known about the subject under study. Issues of Validity and Reliability In qualitative research, the determination of validity and reliability is directed toward understanding the phenomenon under study in natural settings with few controlling conditions. Internal validity is ultimately based on whether the data and analysis stand the test of time and whether the findings of the study "fit" the data. If validity exists, others who have experienced the phenomenon will recognize the findings as being true (Munhall & Oiler, 1986) . This means that one would expect that both informants and others familiar with the experience would view the experience in a similar or comparable, but not contradictory, manner. Obtaining validation from informants through a sequence of interviews, as was done in this study, is one way to clarify that the description is accurate. According to Leininger (1985), in qualitative research reliability should focus on "identifying and documenting recurrent, accurate and consistent (homogeneous) or inconsistent (heterogeneous) features, as patterns, themes, values, world views, experiences, and other phenomena confirmed in similar or different contexts" (p. 69). Recurrent themes which can be extracted from the data reveal to what extent the phenomenon under study consistently reflects meanings and truths about that particular phenomenon. Reliability can also be established by clearly describing the progression of events so that others can follow the thinking of the researcher. This should allow other researchers to arrive at similar or comparable, but not contradictory, conclusions. Selection of Informants Criteria The informants consisted of a purposive, convenience sample of 9 qualified nurse educators who met the following criteria: 1. Currently employed as educators in diploma nursing programs in the British Columbia Lower Mainland. 2. Have assigned failing clinical grades to one or more nursing students clinically in the final clinical semester. 3. Willing to be interviewed and audio-taped on one or more separate occasions. The adequacy of the sample size was assessed by analysis of the data obtained from the informants. The interview data were assessed according to the relevance, completeness, and amount of information obtained as the study progressed. Analyses indicated that the saturation point had been reached, and an adequate amount of information for the study had been obtained when "nothing new" was coming out of the interviews. Procedures Informants from two college diploma nursing programs known to the researcher to have final clinical semesters in which the faculty members were responsible for clinical supervision and evaluation of students were approached. A letter of explanation (Appendix A) was sent to the program heads of the two colleges seeking consent to discuss the study with interested faculty and to request an opportunity to meet with faculty to explain the study. One program head signed the agency consent form (Appendix B) and the researcher went to this agency to present the proposal. The other agency did not respond to the request. Therefore the researcher presented the proposal to members of the Nurse Educators Interest Group of the Registered Nurses Association of British Columbia. A letter briefly describing the study and the informant's role was circulated to interested individuals. Individuals who met the criteria and were willing to participate were requested to contact the researcher by telephone. Within four weeks, nine informants, five from one agency and four from the other, were obtained. Ethical Considerations The procedures for protection of subjects' rights were approved by the University of British Columbia Behavioural Sciences Committee for Research and Other Studies Involving Human Subjects. After approval was obtained, informants were selected. Each was provided with a letter briefly describing the study and what would be expected of them (Appendix C). This information was again reviewed at the start of the first interview. A written consent form was then completed by each informant who agreed to participate (Appendix D). Data Collection Procedures A questionnaire was used to obtain demographic data on each informant for the purpose of describing the sample (Appendix E). This questionnaire was completed by each informant prior to the start of the first interview. The following information was obtained: the age of the individual, number of years of teaching experience, length of time in current teaching position, number of students informant has failed, and the educational qualifications of the informant. Data relevant to the research question were collected through unstructured interviews approximately sixty minutes in length which were audio-taped. Two interviews were needed to collect sufficient data and to validate themes and meanings derived from analysis of the first interview. The second interview was more structured since the researcher needed to seek clarification and obtain further information from the informant in order to validate data obtained in the previous interview. The researcher encountered some difficulties with scheduling of three second interviews due to workload, scheduling, and vacation commitments on the part of the informants. The time required to complete the data collection was four months. As indicated in Appendix F, the primary trigger question was: Describe what it is like (from a nurse educator's perspective) to inform a nursing student that he/she has not met the clinical course objectives in the final clinical semester. Secondary trigger questions used when these components were addressed in the interview by the informants included: 1. Describe how you felt when you had to assign a failing grade to a student in the final semester of a diploma nursing program. 2. What helps you deal with the feelings that may arise in this situations? 3. What makes the situation more difficult? Transcription occurred as quickly as possible after completion of the interviews. Data Analysis Data analysis occurred simultaneously with data collection. Data from the interviews were analyzed using Spiegelberg's phenomenological approach as previously described (Spiegelberg, 1960). The purpose of the analysis was to identify the forms and types of phenomena and to document their existence (Field & Morse, 1985). Written field notes kept by the researcher were useful in data analysis. Field notes are descriptive accounts of what the researcher hears, sees, experiences and thinks about in the course of collecting and reflecting on the data (Field & Morse, 1985). The data were transcribed, coded, categorized, and analyzed along with the field notes which helped to describe the interview context. CHAPTER FOUR Presentation and Discussion of Findings In this chapter the demographic data provided by the informants are presented, after which the study's findings are described and discussed. Using a phenomenological approach and Lazarus's process-oriented framework, the researcher examined the nurse educators' appraisal of each unique experience. The intent of the examination was to identify recurrent themes and significant variables described by the informants as having an impact on the situation. In addition, coping responses and immediate as well as long-term effects of the experience are discussed. Characteristics of the Informants The nine informants, all female, were nurse educators employed in diploma nursing programs in the British Columbia Lower Mainland. The majority (six) were 30 to 39 years old. Two were 40-49 years of age and one indicated she was over 50 years of age. The informants' educational preparation was diverse. Two held master's degrees, one in nursing and the other in education, four were currently pursuing studies toward the MSN and one was completing work for the MEd. One of the informants held a BScN and one a BA degree. All had one or more years of teaching experience with three informants indicating teaching experience in the three to six year category, and five reporting over ten years of teaching experience. Five informants had been employed in their current teaching position for one to five years and four for over ten years. No informant had taught for less than one year. The number of students in the final clinical semester to whom they had assigned failing grades . ranged from one to more than six. Three informants had assigned failing grades to only one student and two had assigned failing grades to more than six students. At the time of assigning the failing grades, four of the informants considered themselves novice clinical instructors while the other five considered themselves experienced. At the time of the interviews, five of the informants were in the process of evaluating clinically failing students. Content Analysis The content analysis of the data revealed the recurrent themes of stress, uncertainty, isolation, and lack of administrative support. Stress The predominant feeling evoked by the experience of having to assign a failing grade to a student in the final term of a diploma nursing program is stress. The degree of stress perceived by the nurse educator is dependent upon the educator's cognitive appraisal of events and what they mean to her well-being. Appraisal can be viewed as a circular process which may not be entirely conscious, rational, or deliberate (Lazarus & Folkman, 1984) . Stressful appraisals can be classified into three categories: harm/loss, threat, and challenge (Lazarus & Folkman, 1984). Harm/loss appraisals refer to damage the person has already sustained, threat refers to anticipated harms or losses, and challenge refers to events that hold the possibility of mastery or gain. It became evident during analysis that informants used a variety of words and phrases to describe stress. Some of them described their experience as being "difficult," "stressful," "scary," or "worrisome." They expressed their feelings in terms of experiencing "frustration," "distress," "shock," "annoyance," "anger," or "dread." During the validation process, informants confirmed that these terms could be accurately interpreted as stress. The following portions of a transcript illustrate how this concept was identified and depicts the process of data analysis used in this study. Throughout the thesis, accounts have undergone minor editing to delete distractors such as "um" and "eh" in order to enhance readability. In the following example, an informant describes being shocked and anxious. R: ... What was the impact on you of having to assign this failing grade in these circumstances? I: ...The impact on me was that I was shocked that she would actually even think about pulling in somebody from the outside such as a lawyer to contest my decision. So I think I was really in a state of shock and a fair amount of anxiety... One informant asserted that: I: Out of everything I do in my job I would say that's probably the most stressful thing I have to do. *R: Researcher * I: Informant She went on to say: I: Well, if I think back in terms of the amount of time and energy and all the conscious effort to make sure this student has a fair chance I'd say that it's very stressful...I think when you're going through it you just do it. You just do it automatically because you know you have to do it. It's your job to do it. And you're trying to do the best possible thing for the student. So at that time it is stressful but you're not consciously aware of it until afterwards when it's all over and you sit down and say thank God...and then you move on. Some excerpts contained a number of descriptive terms as the informants attempted to convey the feelings generated by the experience(s). In their accounts, a number of feelings were identified that were generated in the person-situation interactions. The informant spoke of feeling "angry," "annoyed," and "frustrated." Informants used similar words to describe their feelings although the sources of frustration they identified may have been somewhat different. While the majority of informants experienced frustration, not all experienced anger or annoyance. The excerpt below taken from a second interview attempts to validate the informant's feelings. This informant describes multiple sources of frustration. R: Some informants said that they experienced feelings of frustration, annoyance, and anger during this process. Did you experience those feelings? I: I was frustrated in her lack of response to what seemed to me really major deficits and frustrated in terms of what seemed to me, after a couple of attempts at remediation, no evidence of progress...maybe that was beyond her ability, I don't know. But that was frustrating for me. I wouldn't say I was ever angry, my heart went out to her in terms of wanting her to be successful, and so I certainly wasn't angry with that, I was frustrated to some degree as well as with the staff who seemed to be very supportive of her skill ability in that it was at a much lower level that what it should have been for a graduate nurse. R: And annoyance? I: No, I can't say I felt annoyed, I think it was just an element of frustration from time to time. R: Throughout the transcript, the theme that kept recurring was that this was a particularly stressful experience. Can you identify what the primary source of stress was? I: I think perhaps the concern that the student had not had sufficient preparation to reach this particular level, because the behaviour was certainly incongruent with what I would consider would be expected for earlier levels as well, and I think that was the greatest frustration.... Uncertainty Uncertainty can be conceptualized as the self-doubt experienced by the nurse educator as to whether "she was doing the right thing." Uncertainty includes an element of self-evaluation and reflection about the processes and strategies used to evaluate the student. The literature supports the informants' perceptions that the clinical evaluation process creates doubts in the minds of nurse educators as well as an awareness that opinions as to whether they have "done the right thing" may vary among colleagues and agency staff (Brozenec, Marshall, Thomas, & Walsh, 1987; Carpenito, 1983). The following quote expresses a novice nurse educator's perception: I: To be certain, to be certain. I don't know how certain anyone can ever really be. And when you're responsible for someone's future or the patient's whoever they may be... perhaps their lives then, if you have this kind of responsibility then it's a lot of weighing. Am I being fair? Am I doing the right thing? So for me I had to go through other people to try and validate. This is what I see, this is what I've documented, this is what I feel. R: And this was your first experience with failing a student at that level? I: Yes. I:...I don't know if it's experience that gets you to a point where you trust the thing that says to you, you've got data, you've got experience, you've seen this before. Or do you go through the period where you say everybody is an individual and I have to look at this independently? Which of course I'm doing anyway, which people are doing anyway and is there more to this, and do I really have all the information? So I wish that it could be just as cut and dried as it was, but it wasn't and sometimes when I'm comparing myself against people who are seasoned teachers then I am it appears through conversation that there is no doubts in their minds and they absolutely it's very cut and dried. This person can't do it. And I think, well, will I get to that point? An experienced nurse educator disclosed similar thoughts: I: ...I think there is always doubts. Am I making the right decision? Is there something that I have missed? Am I focusing on more of the student's negatives? Do I have a bias towards the student? Am I giving them the best opportunity to demonstrate that they can meet the objectives? *Bold type = Emphasis by the informant Another informant validated her thoughts with the researcher on a second interview when asked this question: R: When you issued the failing grade you mentioned that it was hard but you were pretty certain that it was the right thing to do. I: That's true [pause] because as I said earlier ...it's a balance thing for me and at one point are the scales tipped to the other side? And I had said earlier, too, that I like the notion of small measure of doubt. In any decision, I think there always is a small measure of doubt because they're difficult decisions and you're second guessing yourself ... there's always some doubt. You question yourself constantly... R: So it creates an element of uncertainty? I: Yes. Some informants indicated they re-evaluated their findings again and again. Others dialogued with themselves about how they felt toward the student. I: A lot of dialogue with myself about how do I really feel about this person. And always with the idea that am I being fair to her? Am I picking on her more? Feelings of uncertainty also arose from differing perceptions among agency staff and colleagues as to the criteria on which they were basing their judgements. During the validation process, one informant confirmed that differing perceptions related to clinical evaluation, both from her colleagues and staff in the clinical agency made her examine the criteria on which she based her judgements. The informant indicated that this experience caused her at times to doubt her own abilities and added to her feelings of uncertainty. Some informants termed this apparent difference in standards "inconsistency," and attributed these perceived differences to faculty having varying philosophies of teaching and evaluation. These differences also created self-doubt and uncertainty. I:...You can just pinpoint people who you know if a student is unsafe, or is not meeting objectives you know the faculty will not let the student go on... and on the other hand you know that there's faculty who will do nothing about it. R: And how does that make you feel? I: Well that divides your colleagues. Divides you into two camps. Another informant expressed concern about how she might be viewed by colleagues. The following excerpt describes her uncertainty: I: I'm always concerned about what my colleagues think about my abilities. And my approach and my philosophy and those kinds of things. I'm Interested and concerned that I be viewed well by my colleagues. And sometimes when students don't pass in [the final semester] is it my lack? Appraisal contributes to nurse educators' evaluations of what is at stake, its significance for their well-being, and aids in determining what, if anything, can or should be done (Lazarus & Folkman, 1984b). The nurse educators in this study were acutely aware of the potential ramifications of assigning or not assigning a failing grade. This created an element of uncertainty that affected their ability to make a decision even in light of overwhelming evidence that justified assigning a failing grade. The narrative below illustrates this viewpoint. I:...upon reflection, this was a clear-cut decision. The decision was self-evident. The uncertainty of how the decision will be received, the impact of the decision for that individual, including myself, is one that might make one hesitate about going through with the decision... Most stressful situations are ambiguous since information is often missing, or that which is present may be unclear. Ambiguity can itself be a source of stress and uncertainty (Lazarus & Folkman, 1984b). In an ambiguous environment, appraisal of situations becomes more difficult. The greater the ambiguity, the more influence variables such as the individual's personal values, beliefs and experiences have in determining the meaning of the situational variables (Lazarus & Folkman, 1984b). Isolation Isolation describes the perceptions nurse educators expressed about ultimately being solely responsible for the decisions they found necessary to make. This theme included an element of physical isolation. Informants described at times feeling isolated in the clinical setting, distanced from colleagues who could understand the performance expectations of the level, and thus act as a source of support. • - 43 Often they indicated they felt unsupported in carrying out their role by colleagues and administrators. Informants identified that their colleagues often had differing philosophies of teaching and evaluation. Because of this they could not always be sure that colleagues would agree and support their decision. And, finally, even when supported, some nurse educators felt a degree of isolation because in the final analysis they really were on their own. The narratives that follow describe these feelings: I: It was my decision and mine alone. That added to my stress because again I was not comfortable being solely responsible for this decision. This informant indicated she "felt like the odd man out in the scenario." I: ...I would say that, even though I could be surrounded by people who had been previously supportive in my role as an educator in general, I found myself with people around me, who had decided to take the position to side with the Student, so that did add to the feeling of isolation. One informant who was a novice reported feeling supported but recognized there were times when, in fact. she did feel alone. I: And did I feel alone? Surprisingly, I guess I felt fairly well-supported by the people here but when it got right down to it, it was just her and I ...so it is you're very much on your own then. An experienced nurse educator expressed similar views in this way: I: ...You don't have a lot of contact with your colleagues.. .but it really does come down to you cause you're the one that's there in the clinical area. You're the one that's seeing the student's performance. Even if you have a partner in the semester she's only hearing your side of the story. Lack of Administrative Support The informants indicated that administrative support was lacking in two major areas: a) consistent administration of educational policies, and b) acknowledgement of the situation and reassurance. Some informants cited "the system" for lack of support. One informant reported: I: ...I guess it's you feel that the system had let you down or let you and the student down. And then the system doesn't offer you the support. Or it's so difficult to fail a student... they've let you down up until that point and now they're letting you down yet again because they are making you jump through hurdles in order to fail this student. R: When you say the system exactly what do you mean by that? , . > I: I guess our evaluation system. Our way of promoting students from one semester to the next. Another informant expressed similar ideas. I: Nobody has ever said that the appeals committee is supportive to the instructors [laugh]....My exposure to them gave me the feeling that they thought they had expertise where they really did not have it. In addition, informants described conflicts resulting from their multifaceted and somewhat ambiguous roles as nurse educators. On one hand, they were charged with the responsibility of making a professional judgement about the abilities of the student, and yet, at the same time, many of the informants perceived a lack of support from administrators regarding their judgements. In these situations, the nurse educators' values and beliefs seemed to conflict with administrative directives, creating feelings of vulnerability and threat. The following excerpts summarize these findings: I: And so you were dealing with a lot of different issues with her. But again in that situation as an instructor you didn't feel supported, because what I was told was that this student had to pass. R: How did that make you feel? I: [laughs] Well, again from a professional perspective you just couldn't do it in all conscience. I couldn't, this woman couldn't practice as a safe nurse so you had to again accumulate this data and it seemed like no matter what how much data you collected they would give her another chance. This informant went on to say: I: It was clearly said. It was. I would lose my job if I did not pass her [laughs]. R: And was this at the team level, or was this at a higher level? I: It was a higher level. I think it was because of the type of program. It was different from a regular college program in that it was funded, the first pilot project.... In contrast, other informants had never been directly confronted to change their assessment or threatened with losing their jobs. They may, however, have thought about it as illustrated in this next quote. R: Some of the informants that I have spoken to have said that there have been subtle indicators to the faculty member to pass the student and other informants have said there have been directives to them to pass the student or their job was on the line. Have you experienced either of those situations? I: (Sigh) No, I have not. I mean, certainly directors have at times asked me why I have to fail them and (pause) but I never got the feeling that they would say that my job was in jeopardy. I think I mentally thought that. These excerpts illustrate that these nurse educators felt that their professional judgement came under scrutiny. They described feeling pressured, threatened and cross-examined. They described having ' 48 to jump through hurdles. One informant disclosed: I ...And yet she came back, a half a year or a year later with another teacher and was very successful. And that was another very interesting experience because I had no contact with her during that time but I certainly made a mental note of her progress. And I wasn't sure at that time who was being evaluated more. Whether it was I in fact who was being evaluated in terms of whether I in fact had made the best judgement at that time. So again I relive the experience and relive it many times. Going back to what were those competencies that were so important at that time and I would make the same decision today. One informant felt so sure that her assessment was accurate that she stated: I: I'd be willing to put my license on the line for that. But at the time, when the process is occurring, you're made to feel like you're not functioning as a competent number one nurse, number two educator. Finally, responses from two informants described a need to be acknowledged for having done a good job in difficult circumstances. Both informants felt this recognition was lacking. At one point in the interview one informant attempted to use rationalization to indicate that professionals shouldn't need support. I: ...So there's no support, there's no commendation to say that you did a good job. So there's no internal support... I don't believe that there would be any support for me as an individual faculty member to say that I did what I was supposed to do [sounds angry]. I: ...So again it's that admin, support and I guess that's where one of the factors for stress comes in...you need to feel that they're behind you. And that they're on your side. Not so much as them against the student sort of thing. But that they understand and empathize with what you are going through. In the second interview, this informant elaborated more on this perceived need for support. She said: I:..the student has the support. I quickly realized, hey, where is my support system! But then I thought, no, you've got to keep a handle on things. R: Why did you need support or feel you needed support? I: Well, because it's always nice to have someone to lean on when you're being attacked...when your professional abilities are questioned. And they I mean they were being questioned ...I couldn't believe it. Variables That Influence Appraisals Lazarus's {1984b) definition of stress emphasizes the relationship between the person and the environment and how an individual cognitively appraises events. Thus, informants such as those in this study, may experience stress to some degree but differ somewhat in their reaction to and interpretation of certain events. According to all informants, having to issue a failing grade to a student in the final clinical semester of a diploma nursing program was a stressful, individualized experience. Cognitive appraisals are not static processes and can be altered by changes in person/situational variables which are in a continual state of flux. The variables introduce an element of uncertainty into the nurse educator's appraisal of the situation and can in and of themselves be a source of stress. Variables which influence the appraisal of the situation can be grouped under the categories of nurse educator, student, and environment. Nurse Educator Influencing variables include the life experience, commitment, values, beliefs, health, and energy that an individual nurse educator brings into the situation. These variables influence the way a nurse educator interprets events and have an impact on the resources and coping strategies nurse educators may have available to them. Life experience. Four of the informants in this study considered themselves to be novice clinical instructors while the other five viewed themselves as experienced. Some informants, while not novice educators, were new to teaching in the final clinical term. These informants identified aspects of their performance which they felt required further refinement. It became apparent during the analyses that the informants perceived the experience of assigning a failing grade differently when they had previous experience in doing so. Although they still appraised the event as stressful, it seemed to be less so because of the coping strategies developed from the previous experience. Novice informants tended to seek support. One informant recalled what it was like for her being a novice educator teaching in the final clinical term of a new program. I: I was a rookie teacher and my expertise was not measured yet....I wasn't sure with the students. Being a rookie instructor made it very, very difficult. Novice informants disclosed that they sought out others : I: ....I did a lot of talking. I think the first time around I didn't want to appear like I wasn't sure what I was going to do. And so I only talked to one person. This time around I talked to the whole team. One informant, although not a novice educator, was teaching in the final clinical semester for the first time and reported receiving feedback about her documentation. * I: ...I really didn't have a lot of clinical documentation. And I think again that goes back to the fact that I was new to teaching this level.... The informants emphasized the importance of experience. They spoke of honing their skills and building repertoires of skills to enhance their ability to teach and evaluate. The following two excerpts illustrate this coping strategy. R: ...what helps you deal with the feelings or cope with the feelings that arise in these situations that you've talked about? Being shocked? I: ...basically just talking with other people and what would you have done in a similar situation and that sort of thing. And I guess just learning that better documentation [helped]. And I think that certainly repeated experiences within the semester I did [numerous] years in [the final clinical semester] and I think that my ability to focus in on the problem student certainly was honed to a fine point. I: Well, I constantly think of those situations when I'm confronted with another student that has a similar problem...if they have similar little patterns then...I'11 try them with this one and I'll try some others...building up your repertoire of skills that you pull out to try and help this student.... Commitment. Lazarus and Folkman (1984b) describe commitment as that which is important and has meaning to an individual. Commitments influence an individual's appraisal of a situation. Individuals' commitments reflect their goals and influence the choices they make. Lazarus and Folkman postulate that commitments influence appraisals in two major ways. First, the greater the commitment the greater the potential for an encounter to be appraised as threatening or challenging. Second, commitment creates vulnerability, and vulnerability can act as a motivating force that directs a person toward a course of action that can reduce threat and help to sustain coping efforts in the face of stressors. The informants in this study were unanimous in their commitment to passing only those students who could meet the semester objectives. The informants expressed their feelings of concern and caring for the student who was unable to demonstrate an acceptable level of performance. They spoke of feeling guilty and sad for the student while at the same time recognizing there was no doubt that the student was not functioning at the expected level. However, regardless of their feelings, novice and experienced nurse educators felt responsible for, and committed to, graduating students who had the necessary skills to function competently and safely. Faced with a variety of stressors, the informants utilized a number of coping strategies to achieve their goal. One novice informant expressed her thoughts in this way : I: ...initially to be able to tell a student that they're not meeting the objectives. Initially it makes me feel somewhat guilty. Somewhat sad. Guilty because I feel responsible that I should have done more for them. I should have picked up on this sooner. I should have found some creative alternative way to help them get to the place where they needed to be. And, then at some point I feel very relieved [laughs]. The informant went on to say: I: . . . So I felt a little sad because as many-breaks as I felt I had given this person, I just couldn't give them a break for this...it was really absolutely clear that she could not concentrate on the simplest of procedures... absolutely... if I was to let her go through thinking that she'll get it together I couldn't I couldn't sleep with the idea. I couldn't live with the idea.... Similarly, an experienced informant described how she felt: I :...she certainly had the theory background. You couldn't fault this student theory-wise at all. It's just that she couldn't she was all thiombs in the clinical area..and I really felt sorry for this wonderful person was going to have to fail. But the bottom line was that there's no way that I could pass this student and put her forth as a representative of our program out onto the unsuspecting public as a nurse or even to the unsuspecting nursing people that she was going to have to work with. Values and beliefs. Appraisals are always made within the context of the encounter and depend upon the informant making a series of realistic judgements about the situation and its impact on their well-being. Vulnerability and one's commitments and values go hand in hand. The more a person cares, the more strongly one holds to his/her values, and the more vulnerable he or she is to a particular threat (Lazarus & Folkman, 1984b). Thus, an individual's values and commitments can create ambiguity and feelings of vulnerability that result in situations being perceived as threatening. Descriptions in the literature depict the responsibilities and role conflicts inherent in the nurse educator's role (Batey, 1969; Kramer, 1970; O'Connor, 1978; Williamson, 1972). Numerous authors have postulated that, as a result of their multifaceted and somewhat ambiguous roles, nurse educators may experience stress, burnout and diminished job satisfaction (Fain,1987; O'Connor,1978 ; Marriner & Craigie, 1977; Schuler, 1975; Schuler, Aldag & Brief, 1977; Wood, 1971) . The excerpts below illustrate the complexity of the nurse educator role, and the conflicts some of the informants experienced. These conflicts primarily related to the educators' perceptions of a lack of administrative support for their professional judgement and the nurse educators' values and commitments to graduate only competent nurses. R: And how does that make you feel? ["to have to be particularly cautious and very, stringent in what you do?" To make sure you give them every opportunity to demonstrate they can make the objectives"]? I: Personally it calls into question my professional judgement. I have been hired as the educator and if I have to go into such long drawn out discussions and rationalize to justify my professional decision then that has an impact on me in terms of my ability to make this decision. Another informant described being labelled "as a teacher who fails students:" R: And how does that make you feel? You said earlier about being labelled as a teacher who fails students or who works with students and then makes the decision that the student can't pass. I: Well, my professional conscience is clear. I think I would be more upset if I had let a student .59 continue on or graduate who I knew was not safe or was not ready to assume that role. Health and energy. The way a person copes is also determined partly by his/her resources, including the level of health and energy individuals have to bring to the situation. Informants acknowledged that during these events they assessed this resource. This, in turn, assisted them in the determination of which strategies to use. One informant indicated that just being aware of her resources helped her to deal with the stress. This section describes the informants' perceptions of their health and energy. It is generally recognized that health and energy facilitate coping efforts. If one is energized and healthy, one is better able to cope with the demands of stressful events. All informants talked about experiencing a significant increase in workload while working with the student who was having difficulties progressing to the expected level of performance. One informant was inconsistent in her view as to whether she thought her workload was excessively more but indicated "it feels like more." Those who perceived an increase in workload attributed it to longer hours, more documentation, more meetings and planning sessions and additional•preparation should the student grieve the nurse educator's decision. One informant described the effect on her of working longer than usual hours : I: ...at the very end there I felt relief actually because I was exhausted from the hours that I had put in there. This informant commented on the energy she put into working with this student: I:... I really didn't think that it was fair to have this student come back a third time into the program registered into [the final clinical semester] and abuse the resources of an instructor. The time and energy that it took for me to put into this one student was phenomenal! Another informant indicated that: I: I was really tired and I don't think I physically was unhealthy but I certainly felt a lot more tired. More tired physically. I had considerably less energy too, I think, to give to the other students and to my own personal life. And probably I was somewhat edgier too. In addition, one informant described losing weight and experiencing sleep difficulties. I: ...I lost weight, [and had] sleepless nights. R: Sleepless night? I: ...You turn over the same things again and is there any other way of doing it? I thinlc it has an impact when you spend that many hours. These findings suggest, that the demands placed upon nurse educators in these circumstances may adversely affect their health. Student The second group of variables which influence the appraisal of the situation are termed student variables. Student variables include the students' insights related to clinical performance, their general expectation that they are entitled to receive a passing grade once they reach the final clinical semester, and other extenuating circumstances. Insight. The experience of assigning a failing grade to a student in the final clinical semester carried with it some degree of stress, but assigning a failing grade to a student who lacl^ied the insight to recognize the deficits in his/her performance was even more stressful. Informants were unanimous in their views that situations where students lacked insight into their performance would be appraised as stressful. On occasion, informants cited experiences where they had more than one student in jeopardy of not meeting the course objectives at the same time. These situations compounded the faculty members' stress. I: ...it depends so much on the student and their awareness of their progress or lack of and how well they receive it. If they have insight or not. And from my experience I would say I had one student that had no insight or very very little. And it was quite frustrating when you're dealing with that type of student and you're trying to hopefully have them recognize it.... I: ...that's where the stress for me comes. Is when when they don't have the insight.... The same informant disclosed that: I : I had enough data that I knew the student was not safe. So I didn't have stress with that. I had stress with the way she reacted to it. General expectations. In addition, informants generally believed that assigning a failing grade in the final clinical semester rather than earlier in the program usually met with more resistance on the student's part and was more difficult for faculty. This was particularly true if significant others also had difficulty coming to terms with the decision. One informant summed it up this way: I...at least if they fail earlier in .. a previous semester you think, okay, (Sigh). They can come back at another time. They have a little extra time to repeat. But when they fail in the final clinical term] [pause] if they go back to five[pause] it's just not the same...I think because it's the final semester. They're not graduating with their friends... their family are anticipating them to graduate. So I think that's more difficult for the student. That makes it more difficult for the instructor. Because even though you can't think about that, you have to focus on the objectives. It still has an impact. R: I know that you have experience in some of the lower semesters. Do you think there is a difference between failing a student at this level and failing a student at a lower level? I: Yes, because at a lower level there's not so much investment on the student's part or on the faculty's part. As an instructor you don't feel like there's so much energy and time and effort gone into the whole scenario. And so it is easier I think to say to a student then. For some reason the students tend to have, I won't say, more insight but they are more accepting. It may be that they see you in a more authoritarian role in those lower semesters but they seem to take what you say as something constructive and not something that is a personal attack. I: Well, in my experience I think it is more difficult [to assign a failing grade to students in the final clinical semester] than it is with students in lower semesters... it is much more difficult. I think also we have to face certain questions from other instructors because I think some of them have a vested interest. They have known the students. Maybe they did fine in their semester but they are not fine in [the final clinical semester] now because it is very different. They are now having to pull all their knowledge together. This informant went on to identify other "pressures" she experienced. I: ...if they have done well or at least met the objectives from past semesters,...[pause] why now? I think there is also...the pressure, the grad pins, the bake sales, the [laugh] and students give you that...like I have bought my pin. I, have participated in raising money for graduation and what are you saying? I think sometimes, because they have more invested their insight is not very good. Many of them have already made plans where they are going to go work.... Extenuating circumstances. Further compounding the nurse educators' appraisals of events were a number of extraneous variables which added to the uniqueness of the situation. These included student illness, financial problems, and family stresses. One or more of these variables may be present in a given situation. The excerpts below identify some of these variables and describe the informants' views on the impact of the variables on the evaluation process. I: ... you see how they really... students are under a lot of duress. Financial, family stresses. They really put themselves out on the end of the rope. And so they lose sight. And all they want to do is reach that goal at no matter what cost. Often in talking with nurse educators in previous semesters instructors could identify extenuating circumstances which prevented the student from failing in an earlier.semester. The following excerpt identifies some of those extenuating factors. I: [In talking with another faculty member} ...and then they'll say she was doing this and actually that sometimes is quite helpful because you can say why the hell didn't you do something about it in semester four...then they will tell you that for this, this, or this, reason either the student had a lot of illness or the student used absentee time or a change of instructor or something to pacify or to make it not seem to shift the blame from the student's behaviour to whatever..... R: So, for whatever reason there was some extenuating circumstances the student didn't fail at that particular point? I: Yes. R: And continued on? I: ...that you think previous semester instructors] should have failed them but then you can understand why they were unable to. Environment During the interviews, informants identified a variety of environmental variables which influenced their appraisal of the situation and tended to introduce an element of uncertainty into the decision making process. These external stressors which contributed to the uniqueness of each situation could be grouped into two categories: the clinical agency and the educational institution. Clinical agency. Informants spoke about the suitability of the clinical agency in terms of being able to provide appropriate types of clinical experiences, the ability and willingness of agency staff to work with the student and instructor, as well as internal agency problems which may adversely affect the students' learning environment. R: ...Can you think about what else makes this situation particularly difficult? .68 I: Well, you can think in terms of the agency itself. If you look at the particular unit. What type of unit is it? And if you have a weak student or a failing student who's on an unstable floor that's very busy and has changing patients.... That poses particular problems because you have to be on your toes. And make sure that you're there to ensure that the student is safe.... The staff. What qualifications do the staff have in terms of the length of experience? Are they new to that hospital? Are they new to being a student guide? Are they new to [educational agency's name] program? Have they been a preceptor for another program? You don't really get an opportunity to look at the particular student guides. In this last situation they were just assigned. I don't know the hospital, I don't know the staff, so I'm coming in cold. I don't know my students other than what I've read in their files. So I'm coming in cold. I : So I have to find out as we go along in the rotation what the experience is of the guides. So that is a problem. If there's any internal problems on the unit. Like one of the floors there is some problems related to using the students as workload. Another informant commented: I: ...If I've got faith in the student guide I sleep better. Educational institution. Within the educational institution, particular policies, priorities, and initiatives were pinpointed as variables which might influence the informant's appraisal. Also identified were the adequacy of the resources available to the nurse educator which might restrict the informant's options and/or strategies. Furthermore, concerns regarding job security were also expressed. In this next narrative, the researcher asked the informant about how she felt when she had laid out her plan and really tried hard to work with the student and nothing was happening. Her response reflected concerns about the program's admission criteria. I: Well they're not ready or they're out of their league. Like the student shouldn't be here, she shouldn't have been allowed to come into the program. Two other informants recalled being sensitized to circumstances that arose because their programs were new. The informants implied they felt pressure under the scrutiny that came with the new programs. I: This was [the program] very very new to the college and certainly at that time, my colleagues, I mean this was their favorite program...we had all worked on the curriculum and why were they not passing? I: ...and I think it was because of the type of program. It was different from a regular college program in that it was funded, the first pilot . project that was funded by.... Other informants responded in this way: R: So what if anything is the impact of you assigning a failing grade to a student in the final clinical semester? I: I think we have an internal problem in terms of how far we let a student go before they're actually failed. And I think this goes back to the issue of retention and remediation. Particularly for a student who it's their last chance. They don't have another opportunity to corne back into the program so you're particularly cautious and very stringent in what you do to make sure you give them every opportunity to demonstrate they can make the objectives. This informant went on to say: I: ...no practicum students were designated as • being eligible for remediation... so that certainly impacts on your decision. Then, when you're making up your learning plan and you have to realize that you have to make sure that the time you spend with that failing student is adequate and also the time you spend with your good students is adequate...because you're not going to be receiving any help, any clinical help, therefore that puts into context what you can achieve. What kind of learning strategies can I use then if I'm on my own? I: ...however I have to say that one of the factors that probably impinged a great deal on that decision was a budgetary one. And that is another interesting aspect in terms of once you identify problems how much remediation can you offer within the resources that you personally R: And how does that make you feel if the resources limit your ability to provide appropriate remediation? I: Well, one of the things it's done for me is that I know that many times I have extended myself by far above and beyond the expectations of my role and as well above and beyond what my colleagues are prepared to do. Rightly or wrongly, I have done that. But I have done that for the benefit of the student and in many instances I have to say it has been beneficial for the student. Don't know that it's been beneficial for me. In addition, problems related to limited resources were compounded by time limits in which the decision had to be made. I: ...at the time I felt very limited in the kind of resources I had. And it seemed also [speaking quickly] that things were moving quickly. More than one informant commented about the re entry opportunities available to students. I: I felt particularly bad because I knew that this would be the last. She wouldn't have another chance to re-enter. And so it made it all the more difficult. It wasn't like I could offer her and say well now come back and repeat it... In contrast, another informant saw the reentry policy as being too lax thus creating another source of frustration for the nurse educator. I: Well, it's a very lax re-entry policy. The way it's supposed to work is they are supposed to have 32 months to complete the program. That's giving them one semester off, allowing for sickness or whatnot and they will extend it. They say one semester, so an extra four months in very _ extenuating circumstances. Yet they I've seen them extend it and extend it beyond I think any point that they're doing the student any good. R: So you don't have one or two clinical failures or academic failures and then they can't re-enter? I: Well, I think we do have that but it's not adhered to. And that's the frustrating part. Because I think if you put a student through a semester three times then they will eventually get it. That doesn't mean they're a competent nurse but it's just that you wouldn't have enough data to fail them the third time through. In this next excerpt another informant described how the policy influenced her approach. I: Because of the unique situation of this student [the informant indicated she spent a lot of time talking with other people, planning her approach]. I think the fact that she had spent so much time in our program and she was repeating the semester and she was at the limits of her 32 months because she had been extended to finish [the final clinical semester]. These excerpts indicate that administrators need to be consistent in the implementation of educational policies. Policies need to be designed to utilize instructor resources optimally. In this way, nurse educators can be assured that they are working to achieve a common goal; that of graduating competent and safe nurses. Coping Two fields of scientific inquiry have extensively examined the concept of coping: animal physiology and psychoanalytic psychology (Lazarus & Folkman, 1984b). The animal model focused on the concept of drive with the emphasis primarily on avoidance and escape behaviours. This model of coping was simplistic and lacked a cognitive component. The psychoanalytic approach recognized the significance of cognition but tended to downplay the importance of behaviour. Hierarchical patterns of coping were identified. These systems tended to describe styles and traits used by individuals to adapt to situations and thus reduce stress. Coping was not conceived as a dynamic, changing process. This study used Lazarus and Folkman's (1984b) definition of coping. These researchers view coping as a context-specific, dynamic, cognitive and behavioral process. They define coping as an individual's "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984b, p.141). They believe that effective coping depends on the relationship between the demands of the situation and the person's resources. In order for one to cope effectively, coping efforts must not be in conflict with an individual's values, commitments, and beliefs (Lazarus & Folkman, 1984b). Unlike other models, this one takes into account that many sources of stress cannot be effectively managed. Regardless of outcome, effective coping in these instances then is defined as "anything a person does or thinks, regardless of how well or badly it works" (Lazarus & Folkman, 1984b, p.142), which "allows the person to tolerate, minimize, accept, or ignore what cannot be mastered" (Lazarus & Folkman, 1984b, p. 140) . Coping is determined by cognitive appraisal. Individuals use problem-focused and emotion-focused strategies. Often these strategies are utilized concurrently. The problem-focused processes used by informants in this study can be classed into two broad categories: 1) information seeking; and 2) direct action to alter one's approach. Problem-focused Strategies Information seeking. All informants emphasized the importance of talking with others. This was viewed as an easy and effective coping strategy. By talking, they sought out information, validated their actions. vented their frustrations and, at the same time, often received some emotional support. The narratives below summarize the informants experiences: I: [I] discussed it with the other semester instructor. We spent lots of hours on the phone because she was teaching at[name of agency] at the time. I spent a lot of time talking it over with the department chairman and with the student affairs coordinator.... And finally we decided that we needed to go a contract route with this student and I set up a very specific contract. In the previous transcript, the informant sought direction, took direct action and altered her approach because "of the unique situation of the student." Another informant disclosed: I:...But it was very, very, frustrating. I remember going home every night not knowing what to do. R: And how did you deal with that when you didn't know what to do? I: ...I had lots of friends but one in particular that who had actually been my instructor as well in the diploma program and her big thing was • , . 78 documenting. And just documenting really - -accurately what went on and what the scenarios were. And making sure that I had a running tab... so instead of just documenting and not saying anything to her, saying it to her and asking her to sign that she had read what I had written so that she couldn't come back later and say that she didn't have a clue what was going on. Another informant indicated that: I: It was very helpful just to talk to the other people..I did not only just go to the people that I respected because that's who I went to first. So that I myself could get some feedback from them first so that I wouldn't feel so ineffective as an instructor in the last clinical semester. So they could give me some feedback and I could say. Okay maybe I'm on the right track here. Maybe...I am doing my job.... And then I went to people that I respect but I don't know so well who have a . different philosophy or different approach to students and have a different reputation...with the students...but the message kept coming through despite who I talked to that there's really just no way that this person can go through. Inherent in this quotation is an element of seeking emotional support. By receiving validation for her decision from multiple faculty members, this novice educator obtained confirmation that she was indeed "doing her job" and was "on the right track." In contrast, an experienced educator sought out specific colleagues who were familiar with the educational level of the student and had had similar types of experiences: R: What helps you cope with the feelings that arise in these situations? I: [Long pause] Well, I guess the support from colleagues. But you have to seek out specific colleagues who will give you support. If I wanted support I would go to individuals and say this is the situation. This is the student's behaviours. This is what I'm doing. Can you give me some suggestions? So very specific people would be identified to offer support. I wouldn't expect or want the whole faculty to give me support. It would be specific people whom I respect and know that they've been in a similar situation and therefore can help me out. They can comment on it. Clearly, this quotation indicates that the experienced nurse educator sought out specific resources. In this case, they were individuals who had • experience at the final clinical semester and thus might be able to provide her with specific information. This informant used the term support in referring to acquiring suggestions and feedback. This experienced informant did not appear to require validation or reassurance that she was doing a good job. Direct action to alter one's approach. Informants often altered their approach to clinical evaluation on receiving suggestions and feedback from others. Prior experience with having to issue a failing grade may in itself be a motivator to alter one's approach. One informant reported that: I: The instructor that I was working with there had taught [the final clinical semester] a number of times and helped me a lot actually in how I • could better focus my time when I went to the clinical area. In a second interview, the researcher validated that an informant had, in fact, indicated that her practice had changed because she perceived increased risk. R:... [you also said that] concerns about increased risk resulted in [you] putting into practice ways to be very through and conscientious about student/instructor and ward responsibilities. I: Right. R: So you actually increased your surveillance, I think that was one of the things you said? I: Yes. R: Your monitoring of the student because you were worried about the legalities with the care that surrounded this? I : Yes. Another informant disclosed that: I: So those two left me like wow, [sitting back in chair]. You really have to get a system down and that's actually what happened. I got a lot more quick off the mark about learning plans as soon as I thought there was some uneasiness. I guess it's the way in which you use the tool. I use it as you're doing you're trying really hard. Here's a plan so that you can be successful. And I try to put it in that light. But I also do it to cover my butt [voice low, as if not wanting to be heard]. This narrative describes a similar viewpoint: I: ...So you're a little more stringent with your boolckeeping. You can sometimes sense when you are going to have a difficult student. Someone who's going to appeal or someone who's going to fight. Someone who doesn't have any insight and can't ^ recognize that they're not ready to graduate. They could not work as a graduate nurse with their current abilities. Emotion-focused Strategies Informants used a number of emotion-focused strategies directed toward lessening their perceived emotional distress. These included: a) seeking emotional support; b) venting of anger; c) engaging in physical activities; d) rationalization; and e) distancing. Seeking emotional support. In the next narrative, one informant disclosed how talking helped her to cope through the decision-making process and a subsequent appeal. I: I was coping through the decision and the appeal and those kinds of things. And what was I doing to cope? Talk, and talk, and talk. Some informants sought support from significant others: their husbands, families, friends, and nursing colleagues. The following narrative depicts one informant's experience: I : So I did talk to a lot of people. R: Any people that were not nursing-related people necessarily? I: Truthfully? My babysitter [laughs]. My babysitter is my confidant... R: So a significant other then? I: A significant other. Yes, very much so. And I speak to her about it not because I'm trying to sensationalize the situation but because she can see how stable I am. She can see a part of me that they don't ever get to see at school. So she can see just how stable I am in my own personal life and can give me feedback on whether I seem irrational about this situation or not. However, not all informants sought support or feedback from significant others. A number of informants realized that family members were often too removed from the context of clinical practice and the professional aspects of practice to be able to provide effective support. In these cases, the informants looked to other colleagues for support and advice. For example : I: ...Well, I am married and I have a family. Probably my husband does know when I'm in the throes of anxiety over a student, or having a problem with a student, or if I'm having a semester that's not going well. But he's totally removed from the medical or paramedical profession period... I think as far as he's there for me and recognizes that maybe I'm having a difficult time in the clinical area, and if I'm particularly busy he certainly has stepped in and has taken over some of the family responsibilities, and....; R: So supportive in a different way? I: Yes. Yes, supportive, not supportive of me making the decision because he certainly can't help me make the decision. That has to come from me and if I'm going to get help making that kind of decision I think it has to be from my colleagues more than people external to the nursing program. Venting of anger. Some anger is caused by frustration. Expressing one's frustrations can reduce stress (Levy, Dignan & Shirreffs, 1987). One informant disclosed that she used her family to help her cope with some of the feelings that arose out of the situation. I: ...I must say I do use [laughs] my family or my husband quite a bit for that and I think it's good because he's that one step removed and he can present I think more of the student's side of the story. Because he's not in the evaluator role and hasn't been in that role as my peers have been. And yet when I'm being emotional or being angry at this student saying why won't this student do this? I felt like wringing her neck or whatever. It's okay to ventilate that and say that, express your emotions in those terms to him whereas you couldn't or I don't feel as comfortable doing to a colleague. Similarly, another informant expressed this view: I: ...So I have to say that my family members were probably they provided the most support at that time for me and I would come home and air my [pause] perhaps frustration about not being able to ma]<;e enough progress within the time left. Physical activity. Engaging in physical activities to get one's mind off a problem can -effectively reduce stress. Exercise seems to discharge the tensions we experience when we are under stress (Corbin & Lindsay, 1985). In this study, a number of informants engaged in physical activities to reduce the stress they experienced. Thus, physical activities can be described as coping strategies. I: Exercise. Exercise. R: Exercise? I: Oh. I'm an exercise fiend. I thinly; that's so critical. When stressed regardless of what it is. Especially worJcing with students. You need to get away and so to spealc blow out the carbon. Get out there and wor]<: it out. So that you can come back refreshed and look at it from maybe a different angle. Not that exercise is going to help you do that. But I find it really helpful dealing with stress. And if you can bring your stress level down then, you can look at things maybe from a different angle. Rationalization. Emotion-focused coping processes can be used to maintain hope and optimism. In this study, rationalization was sometimes used in this manner. When some informants rationalized, they reflected back on the encounters and identified some positive outcomes. One informant disclosed: I: ...I'd never really encountered to this degree [the magnitude of problems] with other students... so it was good for me. Distancing. Distancing refers to mechanisms by which the informants attempted to shield themselves from perceived threat. Informants made statements like "Is it worth it?" and "Well, can I not work for a whole semester?" One informant disclosed that she used prayer effectively to keep her emotions in check while a student vented her anger. I: ..I use prayer and that's one thing that really helped me get hold because I literally was just praying whilst this woman, I had to give her the opportunity to blow off steam...I was literally saying little prayers as she was building to a crescendo with some of these comments... Another informant disclosed that: I : ... I was thinking I am never going to teach in this semester again. R: Because of your wish or because you wouldn't be placed? I: No! My wish.. I was a sessional instructor.. So, I mean to say here I was thinking. Well, can I not work for a whole semester and have no money? Yes I could but, I mean on the other hand I did like teaching...and I was thinking I want to get a position there [deep breath] and to get it I have to do that [work.] I: Well I guess you think is it worth it? [laughs]. There's a lot of other jobs I could be doing that don't have this amount of stress involved in it. And you think well am I in the right [laughs] it makes you second guess whether you're you should be in this line of work. These quotations provide support for Carpenito's observations (1983) that nurse educators may distance themselves both physically and emotionally in response to student anger and hostility. Likewise, these narratives give additional support for the positions of O'Connor (1978) and Symanski (1991) . They postulate that the multiple stresses inherent in dealing with . failing students may actually result in a loss of nurse educators from clinical teaching. Immediate and Long-term Effects The outcomes of having to assign a failing grade to a student in the final clinical semester of a diploma nursing program were varied. Each situation was individualized, influenced by the variables which were unique to that particular situation. Informants used a variety of coping strategies to influence the outcome. Feelings of stress and uncertainty were always present and, in certain circumstances, informants felt isolated. The experience left a lasting impression with the nurse educator. Nurse educators could vividly recall circumstances and events which occurred during this period of time. The following narratives describe the informants' perceptions of how they had been affected. Immediate Effects The majority of informants described feeling relief. I: ...I actually felt relief. With all of them I felt relief because of patient safety...it's like it all three were, especially the first and third were patient safety concerns, ... [I] just thought, thank God. R: And when it's over? When you've assigned the failing grade, gone through grievance if that's what's required and it's over? I: It's like a weight has been lifted off your shoulders. I: ...So in the whole scenario it made it easier for me to deal with the other two students who • were weak clinically and had a lot of difficulties making decisions under pressure. So it made it a lot easier. One was so close to failing as well and I had to spend a lot of time with him. So I was relieved because I felt like I had some tools. Some success. Some experience to draw from. I: ...those two experiences, those initial experiences have really put me on guard. In the second interview, when this informant was asked to describe what she meant by being on guard she replied: I: Okay. On guard. I think it's as soon as the emotions start to come out and you have to initiate a learning plan or something like that to be really aware of what's going on and to involve other people. Whereas normally in the past I wouldn't have. Now, I'll be much more ready. I:...you really had to get a system down and that's actually what happened. I got a lot more quick off the mark about getting learning plans as soon as I thought there was some uneasiness.... I: ...I definitely modified my approach with the second one.... Long Term Effects In the long term , nurse educators were quite significantly affected by the experience of failing a student. I:(the experience) ... I guess when I think about how clearly I can recall given the span of years that have transpired from that time. It must have affected me quite significantly. I do reflect on it anytime anyone else shares their experience about doing a similar thing. • I: ...Well, I constantly think of those situations when I'm confronted with another student that has a similar problem. I: ...when she did come back into the program and do so well. That really, I think, made me feel more confident in failing students. R: That there were some positives there? I: That there was positive aspects, that maybe my judgements weren't all bad. Because I think often when you are failing this student in the final semester you do feel that here's this student.. she can see the finish line, and you're saying no, that you're going to trip them up one hundred yards short of their goal. Summing Up The predominant overriding theme which emerged from the data was stress. Two other interrelated themes embedded in the informants' descriptions of their experiences were uncertainty and isolation. Nurse educators often felt unsupported in their role. These themes are interrelated and in themselves can be identified as stressors. The nurse educators' perceptions of their experiences were influenced by their subjective appraisal of the variables present in each situation and the degree of harm, threat, or challenge they perceived. Variables included such characteristics as the life experience, commitment, values, beliefs, and health and energy of the nurse educator. Additional factors often identified as external stressors can be broadly classified into student variables and environmental variables. By assessing student and environmental variables, the nurse educators determined whether the experiences and their consequences were irrelevant, positive, or stressful. Once a cognitive appraisal was made and the degree of threat determined, the educators made judgements as to what might or could be done. In doing this, the informants examined their coping resources and the strategies available to them. This included an assessment of the situational support available to them from peers and administrators. In order to deal with their stressful experiences, the nurse educators used a variety of coping strategies. These consisted of problem-focused and emotion-focused actions directed toward problem-solving, along with efforts to control the emotional reactions arising from the situation. Problem-focused coping strategies included information seeking and the taking of direct action to alter one's approach. Emotion-focused responses included seeking emotional support, venting of anger, physical activity, rationalization, and distancing. In addition, informants identified immediate and long-term effects of living through their experiences. Many of the effects they identified had positive aspects such as feeling a sense of relief as well as confidence in their ability to handle similar situations in the future. Immediate effects described-by informants included being more on guard in situations which might require early intervention, as well as modifying and refining their approaches to clinical evaluation. In the long term, faculty members were quite significantly affected by their experiences. These situations provided an experiential base for the nurse educator or for her colleagues who were working with other students having similar problems. A number of informants described the experience as confidence-building. The experience served to reinforce that "their judgements weren't all bad." Some informants described feeling more confident in their abilities to work with students who were not able to meet the semester objectives while others expressed a desire to distance themselves from the situation by never teaching in that particular semester again or leaving teaching altogether. The following framework (Figure 1) graphically represents nurse educators' experiences with assigning a failing grade. VARIABLES INFLUENCING APPRAISAL Nurse Educator 1. Life Expartenco 2. Commitment 3. Values and Beliefs 4. Health A Energy \ SUPPORT / \ /7 \ / A / \ /< ^ Cognitive A Appraisal student 1. Insight 2. Expectations 3. Extenuating Circumstances Environment 1. Clinical Agency 2. Educational Institution Throat ^ OR^ "Challenge ^ COPING STRESS Figure 1. Adaptation of Lazarus's Framework to Depict Nurse Educators' Experiences with Assigning a Failing Grade. Coping Strategies Problem-focused 1. Information Seeking 2. Direct Action to Alter One's Approach Emotion-focused 1. Seeking Emotional Support 2. Venting of Anger 3. Engaging In Physical Activities 4. Rationalization 5. Distancing / IMMEDIATE EFFECTS \ LONG-TERM EFFECTS CHAPTER FIVE Sliinmary, Conclusions, and Implications Summary The purpose of this study was to explore the impact on nurse educators of assigning a failing grade to students enroled in the final clinical semester of a diploma nursing program. Using phenomenological methodology, and Lazarus's process-oriented theoretical framework, nine informants currently employed in British Columbia Lower Mainland diploma nursing programs were interviewed and audio-taped. From the informants' accounts data analysis sought to identify the forms and types of phenomena and to describe the essence of the experience. The educational preparation of the informants was diverse. They were all female and had one to over ten years of teaching experience. Three informants had issued failing grades to only one student while two had assigned failing grades to more than six students. The findings of the study illustrate that assigning a failing grade to a nursing student in the final clinical semester of a diploma nursing program was a stressful event for nurse educators. The prominent overriding concept which emerged from the data was stress. Stress was defined as the "relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being" (Lazarus & Folkman, 1984b, p. 19). While the sources of stress varied, both novice and experienced educators described feeling some degree of stress. Two other interrelated themes, uncertainty and isolation, were also embedded in the informants' descriptions of their experience. Uncertainty was conceptualized as the self-doubt experienced by nurse educators as to whether they were doing the right thing. Isolation described the perceptions the nurse educators expressed about ultimately being solely responsible for their decisions. Often they indicated they felt a lack of support from colleagues and administrators. In addition, informants described at times feeling physically isolated in the clinical setting, and distanced from colleagues who could act as a source of support. These two themes were interrelated in the informants' accounts and were, in themselves, stressors. The uniqueness and complexity of each situation was influenced by multiple variables and the interrelationship among them. The variables influenced the way the nurse educator appraised events. Uncertainty as to the multiple ways that variables could be interpreted led to ambiguity and thus contributed to nurse educators appraising the situation as threatening or stressful. Based on their appraisal of the variables, the informants examined their resources and made judgements as to what might or could be done. The educators used a variety of coping strategies consisting of actions directed toward problem-solving along with efforts to control the emotional reactions arising from the situation. These included information seeking, direct action to alter one's approach, seeking emotional support, venting of anger, physical activity, rationalization, and distancing. In addition, educators identified immediate and long-term effects of living through their experience. Many of the effects they identified had positive aspects. Immediate effects described by informants included being more on guard, as well as modifying and refining their approach to clinical evaluation. The long-term outcomes indicated that faculty members were ' quite significantly affected by their experiences. These situations served as a point of reference for nurse educators when faced with other students having similar problems. A number of informants described the experience as confidence-building, serving to reinforce that "their judgements weren't all bad." Some informants described feeling more confident in their abilities to work with students who were having difficulties meeting the semester objectives and in ultimately having to assign a failing grade. However, not all informants felt this way. One informant recalled not ever wanting to teach in the final semester again, while another informant disclosed thoughts of looking for other job prospects with less stress and more job satisfaction. Conclusions Three major conclusions can be identified from the findings. First, assigning a failing grade to a student is a stressful event. Second, nurse educators expressed a need for emotional support from their peers. Third, program administrators could and should be supportive to nurse educators in two areas: acknowledgement of the situation and reassurance and consistent administration of educational policies. Implications for Nursing Nursing Education Graduate programs preparing nurse educators may benefit from the findings of this study which enhance the understanding of stress and its impact on the nurse educator and nursing education as a whole. This in turn may provide the basis for the development of curriculum content related to the teaching/evaluation process. Thus, actions can be directed toward minimizing the stress nurse educators experience and decreasing the potential of their leaving clinical teaching for less stressful and seemingly more rewarding positions. Furthermore, administrators of nursing education programs need to examine the effects of policies and program initiatives and their implementation on faculty, and how these may ultimately have an impact on the quality of the graduate. Resources should be made available to provide nurse educators with adequate support and assistance to deal with the increased workload experienced when working with failing students. Debriefing opportunities should be provided. Educational administrators need to acknowledge that they recognize the stresses inherent in the situation and appreciate the considerable effort that faculty members expend during the process. • Educational administrators of nursing programs may wish to explore the potential benefit faculty mentors may provide, particularly to novice faculty members. These mentors may be able to provide the much needed support, validation, and feedback many nursing faculty seem to lack when working with failing students. Nursing Research , There is a need for further research in this area. Using a phenomenological perspective, it may be useful to examine whether nurse educators in baccalaureate programs share similar or contrasting perceptions of their experience. Additional insights might be gained by examining the relationship of the variables and the effectiveness of coping responses, and the nurse educator's experience level. In addition, the concept of stress and the interrelationships of uncertainty and isolation warrant further in-depth analysis. Lastly, research is needed to confirm whether or not nurse educators do, in fact, leave clinical teaching because of these experiences and, if so, what is the impact on nursing education. This thesis has provided a phenomenological description of the perceptions and feelings experienced by nurse educators who assign failing grades to : students enroled in the final clinical semester of a diploma nursing program. The findings have attempted to encapsulate the essence of the experience as viewed through the eyes of the informants. References Anderson, D. M., & Saxon, J. (1968) . Performance evaluation of nursing students. Nursing Outlook, 16 (5), 56-58. Batey, M. V. (1969). The two normative worlds of the university nursing faculty. Nursing Forum, 8, (1), . 5-17. Brozenec, S., Marshall, J. R., Thomas, C, & Walsh, M. (1987). Evaluating borderline students. 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I am a nurse educator currently enroled in graduate studies in nursing at the University of British Coltimbia. My master's thesis entitled The Impact of Assigning a Failing Grade to a Student in the Final Clinical Semester is directed toward describing this experience from the perspective of college nurse educators. It has been my observation that failure to complete the final clinical semester of a nursing program often results in student responses different from and more exaggerated than clinical failures in earlier semesters. These situations which are often coupled with highly emotionally charged student responses, may have a major and lasting impact on nurse educators. The lack of researched-based data on this topic has lead to the development of this study. Being aware of the feelings and reactions that may result from such situations may assist nurse educators to cope with this aspect of clinical evaluation more effectively. My purpose in writing to you is two fold: (1) to request consent from you to discuss the study with interested faculty members and (2) to request an opportunity to meet with your instructors to explain the study. I welcome the opportunity to meet and present itry proposal and respond to any questions you or your faculty may have. It is my intention to interview nurse educators who have assigned a failing grade to at least one nursing student in the final clinical semester. Faculty who agree to participate in this study would require a series of two or perhaps three one-hour unstructured audio-taped interviews. In addition, each participant will be asked to answer a few demographic questions. All information obtained is confidential. The name of the agency, student(s) or faculty member will not be revealed. An abstract will be available to you and to any interested faculty member on request once the study is complete. For purposes of the University of British Columbia ethical review committee, written evidence of agency consent is required for approval of the study. Please find enclosed the agency consent form. Please contact me to arrange an appointment. My home phone number is Thank you for your cooperation. Sincerely Susan E. Greathouse, RN, BN Thesis chair: Dr. Marilyn D. Willman Ill Appendix B Agency Consent Form I, the undersigned, give permission to Susan Greathouse to meet with faculty regarding participation in her study entitled The Impact of Assigning a Failing Grade to a Student in the Final Clinical Semester. Signature of Department Head: Agency: Signature of Researcher: Date: Thesis Chair: Dr. Marilyn D. Willman Appendix C Letter to Informants THE UNIVERSITY OF BRITISH COLUMBIA School of Nursing T. 206-2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Fax: (604) 822-7466 Dear Nursing Colleague: My name is Susan Greathouse. I am a nurse educator currently enroled in graduate studies in nursing at the University of British Columbia. My master's thesis entitled The Impact of Assigning a Failing Grade to a Student in the Final Clinical Semester is directed toward describing this experience from the perspective of college nurse educators. It has been m/ observation that failure to complete the final clinical semester of a nursing program results in student responses different from and more exaggerated than clinical failures in earlier semesters. These situations, which are often coupled with highly emotionally charged student responses, may .have a major and lasting impact on nurse educators. The lack of researched-based data on this topic has lead to the development of this study. Being aware of the feelings and reactions that may result from such situations may assist nurse educators to cope with this aspect of clinical evaluation more effectively. I am seeking your participation in this study if you have had to fail one or more students in the final clinical semester. Your involvement in this study will include sharing your experiences in a series of two or perhaps three one-hour unstructured audio-taped interviews. These interviews will be • conducted at a convenient time for you and in a mutually agreed upon location. In addition, you will be asked to answer a few demographic questions. All information obtained will remain confidential. The name of the agency, student(s) or faculty member will not be revealed. Upon completion of the study all audio-tapes and written transcripts of interviews will be destroyed. You are under no obligation to participate in this study and refusal to do so will in no way affect your teaching position. You may withdraw from the study at any time or refuse to answer any questions. If you are interested in participating in this study, or need more information, please contact me at Sincerely, Susan Greathouse, RN, BN Thesis chair: Dr. Marilyn D. Willman Appendix D Subject Consent Form The Impact of Assigning a Failing Grade to a Student in the Final Clinical Semester I understand that Susan Greathouse's study concerns my experience with assigning a failing clinical grade to a nursing student in the final clinical semester of a diploma nursing program. I understand that being a subject will involve two to three interviews, each approximately one hour in length. The interviews will be audio-taped and transcribed and will take place at a mutually agreed upon place and time. I understand that confidentiality will be maintained by coding of the transcripts. My name and any identifying information obtained in the study will not be revealed. I understand I am under no obligation to participate in this study and refusal to participate will not affect my teaching position. I may withdraw at any time or refuse to answer any questions. My questions have been answered and I understand that I can contact Susan Greathouse at if I have further queries. I, the undersigned, understand the nature of Susan Greathouse's study and give my consent to participate. I acknowledge receiving a copy of this consent. NAME PHONE NUMBER SIGNATURE DATE Appendix E Demographic Data Form The following data are to be used in aggregate from only. Please check the appropriate response and/or fill in the blanks. PERSONAL BACKGROUND DATA; 1. What is your age bracket? ( ) 20-29 ( ) 30-39 ( ) 40-49 ( ) 50 and Over 2. What is the highest level of educational preparation you have obtained? ( ) BScN ( ) MSN ( ) MEd ( ) PhD ( ) Other (Please specify) 3. How many years of teaching experience do you have? ( ) 0-12 months ( ) From 1 to 3 years ( ) From 3 to 6 years . • ( ) From 6 to 10 years ( ) Over 10 years 4. How long have you been employed in your current teaching position? ( ) Less than 1 year ( ) From 1 to 3 years ( ) From 3 to 5 years ( ) From 6 to 10 years ( ) Over 10 years 5. How many students who have been in their final clinical semester have you failed during your teaching career? ( ) 1 student ( ) 2 students ( ) 3 students ( ) 4-5 students ( ) More than 6 students Appendix F Interview Questions Trigger Questions: Primary : 1. Describe what it is like (from a nursing educator's perspective) to inform a nursing student that h/she has not met the clinical course objectives in the final clinical semester. Secondary: 1. Describe how you felt when you had to fail a student clinically in the final semester of a diploma nursing program? 2. What helps you deal with the feelings that may arise in this situation? 3. What makes the situation more difficult? 


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