Nurses’ experiences of ‘failing to fail’: barriers and enablers in clinical nursing education

Abstract

Background:

The phenomenon of ‘failing to fail’ underperforming pre-registration nursing students in clinical placements is widely recognised. In the United Kingdom, updated Nursing and Midwifery Council guidelines aim to support registered nurses (RNs) in supervising and assessing students. The aim of the study is to explore RNs’ experiences of the phenomenon of ‘failing to fail’ underperforming pre-registration nursing students in clinical placements.

Methods:

This research is a qualitative descriptive study. Semi-structured one-to-one online interviews with 14 RNs enrolled in postgraduate nursing courses at a university in the United Kingdom. Data were analysed using Elo and Kyngäs’ content analysis framework.

Results:

Four key categories were identified: (1) The Stigma of Failure – failure perceived as stigmatised; (2) Organisational Constraints and Time Pressures – limiting effective mentoring and assessment; (3) Emotional and Relational Barriers to Failing – including personal relationships, lack of confidence and fear of repercussions and (4) Enablers – including supportive workplace culture, collaboration with universities, training and clear guidance.

Conclusions:

Failing to fail is a complex issue influenced by cultural, organisational and individual factors. It has significant implications for patient safety, professional standards and the future nursing workforce. Addressing these challenges requires changes in mentorship practices and institutional support.

Keywords

clinical supervision competency assessment mentorship nursing students patient safety qualitative research

Introduction

Globally, clinical mentorship is recognised as playing a vital role in providing learning and support to students with regard their education and preparation (Lee and Chiang, 2021; Nugent et al., 2020). Mentorship is a multifaceted concept linked to ‘assessing, supervising, preceptoring and coaching’ (Foolchand and Maritz, 2020: 2) and based on a relationship between the registered nurse (RN, mentor) and student nurse (mentee) (McMahon et al., 2016). Although the term ‘mentor’ is commonly used in nursing literature, other titles exist such as ‘tutor’, preceptor’, ‘assessor’ and ‘supervisor’ (Cosme et al., 2012; Jokelainen et al., 2013; Soto et al., 2017). However, regardless of the terminology, historically, both international and nationally extensive evidence has been published suggesting that there is a phenomenon of ‘failing to fail’ in nursing education (Bachmann et al., 2019; Hauge et al., 2019a; Docherty, 2018; Timmins et al., 2017). Failure to fail has significant consequences for patient/public safety and potential legal implications (Adkins and Aucoin, 2022; Bachmann et al., 2019; Hughes et al., 2021a).

In the United Kingdom, mentors are known as Practice Assessors (PAs) and Practice Supervisors (PSs). Research has uncovered a trend in passing underperforming students who are on the borderline of achieving competence without merit (Adkins and Aucoin, 2022; Bachmann et al., 2019; Cassidy et al., 2017; Hughes et al., 2021b). The purpose of this study is to update and add to this evidence base to explore the experiences of PSs and PAs who identify an underperforming pre-registration nursing student and the key barriers that exacerbate the reluctance of ‘failing to fail’.

Background

Clinical mentoring of nursing students is advocated worldwide due to its importance in providing high-quality healthcare (Makhaya et al., 2023). In the United Kingdom, the terminology ‘undergraduate nursing student’ and ‘pre-registration nursing student’ are interchangeable in the clinical setting. Across Europe, pre-registration nursing (undergraduate) curriculum requires students to spend 50% of their studies in clinical practice, during which time they seek to transfer theoretical knowledge into experience (Hart, 2019). Mentorship plays a crucial role in supporting the learning of both pre-registration and post-registration nursing students during clinical placements, a responsibility typically undertaken by RNs or midwives.

The Nursing and Midwifery Council (NMC) is the independent regulator for nurses and midwives in the United Kingdom. They have replaced the mentor title with ‘PS’ who are responsible for teaching and supervising students and ‘PAs’ who assess the students’ clinical outcomes (NMC, 2018a, 2023). The PA liaises with the ‘academic assessor’ (AA) to confirm that the student has met progression targets (Brown et al., 2020). The AA is the university-based assessor who is an academic member of university staff from the awarding university. This is in contrast with other European countries who continue to support the idea that mentors who attain and develop mentorship competencies are better able to support pre-registration nursing students and improve healthcare system resilience (Oikarainen et al., 2021). New guidance in the United Kingdom introduced guidelines that a PS or PA does not need to be clinically experienced within their own nursing field or be educated to postgraduate level in supporting learning and assessment prior to taking on the responsibilities expected of the role (Duncan and Johnstones, 2018). Postgraduate in this context refers to students who have already graduated from their nursing degree. Postgraduate courses are courses taken after degree graduate such as diplomas or Masters degrees.

Portfolios are used in nursing education in the United Kingdom. A nursing portfolio is a collection of evidence, including documents, reflections and skills assessments, which showcase a student’s growth, skills and competencies. Although this is a specific requirement of United Kingdom nursing education, the concerns raised by participants could apply to any required piece of work that requires reflection and assessment in the context of nursing education.

The key role of the PS or PA remains the same, to support students and safeguard the public from incompetent nurses (Bachmann et al., 2019). Each PS/PA therefore remains accountable for raising concerns and providing support to enable students to achieve their objective competencies (NMC, 2023). Should they continue to fall below the required standard despite remediation, it remains the responsibility of the PS/PA to make recommendations to the education provider that the student should not progress through that clinical placement. However, the NMC has been criticised for not directly addressing how to manage those who fail (NMC, 2023; Pearce, 2019). The phenomena of ‘failing to fail’ and grade inflation (Scarff et al., 2019) is linked to the Mute about Undesirable Messages (MUM) effect (Dibble and Levine, 2010; Fulk and Mani, 1986; Rosen and Tesser, 1970; Sutton, 2010). The MUM effect refers to a psychological tendency to avoid delivering bad news which is thought to come from the fear of causing psychological discomfort to the recipient and damaging the public image of the person delivering the message. It can lead to messages being diluted, delayed or suppressed, which can, in turn, lead to negative consequences in terms of performance.

Although the prevalence of ‘failing to fail’ across professional groups remains unclear, the phenomenon is well established within the literature as both widespread and complex (Hughes et al., 2016; Nugent et al., 2020). Previous research consistently identifies personal, social and organisational influences as key contributors to compromised assessment decisions (Adkins and Aucoin, 2022; Brown et al., 2012; Duffy, 2003; Hauge, 2015, 2019a; Hughes et al., 2019).

Reviews of the evidence suggest that a range of personal, social, organisational and educational factors influence mentors’ decisions not to fail underperforming students (Docherty, 2018; Hauge, 2015, 2019b). These include lack of confidence and knowledge, challenges with documentation, personal beliefs and limited resources such as time, support and concerns about academic appeals. Despite this, the mechanisms underpinning ‘failing to fail’ remain poorly understood and continue to raise concerns regarding patient safety, professional standards and workforce integrity (Hunt et al., 2016; Nugent et al., 2020; Vinales, 2015; Yepes-Rios et al., 2016). Since the introduction of the term (Duffy, 2003), there has been a relative lack of empirical research, prompting calls for further investigation (Hughes et al., 2021a; Polit and Beck, 2014; Whaley et al., 2023). In particular, there is limited UK-based research exploring the perspectives and experiences of PA and PSs in relation to ‘failing to fail’ student nurses. This study aims to explore RNs’ experiences of the phenomenon of ‘failing to fail’ underperforming pre-registration nursing students in clinical placements to address this gap.

Methods

Research design

A qualitative descriptive design was adopted due to the limited research in this area and its suitability for exploring sensitive topics (Parahoo, 2014). Semi-structured, one-to-one online interviews were conducted. The interview schedule was informed by a review of the literature (Hughes et al., 2021b; Brown et al., 2020; Larocque and Luhanga, 2013). The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ; Tong et al., 2007; see Supplemental File 1).

Sample

A purposive sampling approach was taken to recruit RNs enrolled in a postgraduate nursing course at one university in the United Kingdom (n = 14). Eligibility criteria aligned to the study focus are outlined in Figure 1 (Palinkas et al., 2015). The criteria did not exclude participants based on number of years’ experience, to remove any bias that may arise due to lack in knowledge, less experience in clinical practice, in line with the new proposed NMC standards for assessment and supervision (NMC, 2023, 2018b).

Figure 1.

Eligibility criteria.

Data collection

Potential participants were approached via a designated gatekeeper at the university, who was a member of academic staff. The gatekeeper distributed the study invitation email and participant information sheet (PIS) to eligible students but was not involved in data collection, and was not informed of who chose to participate, to ensure voluntary participation and confidentiality.

Recruitment invitations, along with the PIS, a consent form and a brief demographic questionnaire were distributed via email to 49 postgraduate students inviting them to consider participation in the study. Students who expressed an interest in taking part were asked to return a completed consent form to the researcher. A total of 14 participants provided informed consent and were subsequently included in the study. No students explicitly declined participation; non-participation was attributed to the absence of returned consent forms.

Participants were contacted and screened to ensure they met the eligibility criteria and then invited to take part in an online interview on MS Teams at a suitable time. The interviews were conducted by one female researcher who is an RN with qualitative training in conducting interviews, who did not have any prior relationship with any participant. Interviews lasted between 17 and 34 minutes. All interviews were audio-recorded with consent.

Participants were asked four open-ended questions designed to explore their experiences of assessing underperforming student nurses, with follow-up questions used to clarify understanding (see Figure 2). Participants were interviewed during October and November 2023. Participants were aware that the researcher was an RN. The researcher was not known to any of the participants prior to the study. No one else was present at the interviews. Field notes were recorded by the interviewer to aid analysis.

Figure 2.

Interview schedule.

Data analysis

The research team was comprised of a primary female nurse researcher and two female academics/researchers with expertise in qualitative methodology and nurse workforce research. Interviews were anonymised, transcribed verbatim and checked for accuracy by two researchers. Data were analysed using Elo and Kyngäs’ (2008) inductive content analysis framework, through the development of categories and subcategories derived from the data. For clarity of presentation, the main categories are reported as overarching findings. Elo and Kyngäs’ (2008) three-staged framework for inductive content analysis includes preparation, organisation and reporting. In the preparation phase, transcripts were read and re-read by two researchers to achieve immersion and identify units of analysis. During the organisation phase, open coding was undertaken, with codes grouped into categories and sub-categories. In the reporting phase, categories were abstracted and presented to reflect the participants’ experiences. A coding tree is included at Supplemental File 2 outlining this.

Given the complexity of the phenomenon ‘failing to fail’, data saturation was determined through ongoing analysis alongside data collection. No new categories or meaningful insights emerged in the later interviews. The decision to stop data collection was based on the research team’s judgement that the data provided adequate depth and richness to address the study aim, in line with qualitative research guidance (Thorne, 2020).

Two researchers independently coded the data and subsequently met to compare and discuss their coding. Consensus was reached through iterative discussion and refinement of codes, rather than through the calculation of formal inter-coder reliability statistics, in line with guidance for qualitative content analysis, which emphasises interpretative consensus over quantitative measures of agreement. Consistency in coding was ensured through regular comparison of coding decisions, ongoing dialogue between the researchers and the development and refinement of a shared coding framework.

Trustworthiness

To ensure the trustworthiness of the data, measures of credibility, transferability, dependability and confirmability were applied (Lincoln and Guba, 1985). To ensure transferability, all interviews were recorded, and verbatim quotations were used as part of the analysis. The dependability of data was ensured by involving two researchers in the data analysis process. Confirmability was ensured by keeping an audit trail of the collected and analysed data. As the primary author was an RN with experience of being a PA and PS, she kept a reflective notes to detail any potential bias.

Member checking was not undertaken in this study. This decision was informed by the recognition that transcripts represent a record of participants’ spoken accounts rather than definitive representations of meaning, and qualitative analysis involves an interpretative process co-constructed by the researchers. Instead, credibility was enhanced through alternative strategies, including researcher triangulation, the maintenance of a detailed audit trail documenting analytic decisions and the use of verbatim quotations to illustrate and substantiate the analytic interpretation.

Ethical consideration

The study was granted ethical approval from the Ulster University School of Nursing Ethics Filter Committee [NURFC 22-004]. Participants were informed in writing and verbally that their participation in data collection was voluntary, would not affect their grades and no identifiable information would be published. Written informed consent was obtained from all participants. The study followed the ethics governed by the World Medical Association Declaration of Helsinki (WMA, 2013).

Results

Demographics

Table 1 sets out the demographic characteristics of the sample. All participants (n = 14) were female and aged between 27 and 54 years. Experience as an RN ranged between 9 and 30 years, and all had experience in the role of PA or PS of nursing students on clinical placement. Ten out of fourteen participants believed that failing to fail was an issue within the nursing profession.

Table 1.

Demographic profile of participants (n = 14).

Category	N
Age group
21–26	0
27–34	4
35–44	6
45–54	4
55–65	0
65+	0
Years registered
1–5 years	0
5–10 years	2
10–15 years	5
15–20 years	4
>20 years	3
Work banding
5	0
6	4
7	5
8a	4
8b	1
Clinical setting
Acute	8
Community	6
Is ‘failing to fail’ an issue in the nursing profession?
Yes	10
No	1
Do not know	3

Thematic analysis

Four categories were identified from the analysis of the data. Table 2 presents these categories and their associated sub-categories.

Table 2.

Categories and sub-categories.

Category	Sub-categories
Category 1: The stigma of failure	Failure as stigma and blame Ambiguity in understanding ‘failing to fail’ Failure to fail as a complex issue
Category 2: Organisational constraints and time pressures	Competing demands and clinical workload pressures Administrative burden and lack of training/support Limited one to one time and associated feelings of guilt
Category 3: Emotional and relational barriers to failing	Personal relationships and reluctance to cause distress Lack of confidence in assessment and decision-making Fear of professional repercussions and accountability External pressures and expectations to pass students
Category 4: Enablers to support decision-making	Training, experience and professional development University-practice, collaboration and support Shared responsibility and student engagement Supportive workplace culture and open communication

Although the first three categories relate to barriers influencing the phenomenon of ‘failing to fail’, they operate on different levels. ‘The Stigma of Failure’ category reflects the broader cultural context in which failure is stigmatised. The ‘Organisational Constraints and Time Pressures’ category captures organisational constraints that impact the ability of PAs and PSs to effectively support and assess students. In contrast, the ‘Emotional and Relational Barriers to Failing’ category relates to individual level factors, including personal relationships, confidence and fear of repercussions, which influence decision-making in practice. The fourth category, ‘Enablers’ captures factors that support effective decision-making and mitigate these barriers.

Category 1: The stigma of failure

Participants identified a cultural barrier whereby failure was stigmatised within nursing practice.

Sub-category: Failure as stigma and blame

Regardless of situation, clinically failing a student was viewed by all participants to be challenging and highly subjective. Many were critical that the issue of failing a student was perceived to be a black or white, blame-free decision by management and educators. They believed that the concept of failure has been stigmatised in nursing, connected with disapproval and shame and interpreted as a deficiency in both the student and the educator to effectively teach and motivate. Many perceived that failure was not tolerated in nursing and viewed as an obstacle, rather than a learning opportunity. Some participants believed that these ingrained experiences of failure created an environment in which the phenomenon of failing to fail could flourish, becoming an unspoken dilemma in practice.

Staff . . … are potentially afraid of any confrontation that could come from trying to fail students. Having enough evidence to say that a student shouldn’t pass and getting support from other members of staff. It’s a big responsibility to pass and fail a student, so it’s having the confidence to be able to do that. (Participant 5)

Sub-category: Ambiguity in understanding ‘failing to fail’

When participants were asked about their understanding of the term ‘failing to fail’, similar views were noted. However, some participants believed that the term was misleading and open to differing interpretations, with a biased focus on the individual nurse assessor. Some explained that it provided little consideration to other people involved in the process such as the student, nursing colleagues, the academic system, wider mentoring structures or the complexity of the clinical environment.

. . .we inappropriately pass student nurses that may not actually be competent, because we don’t want to see someone fail. We can pass them because they’re trying their best, they’re a good nurse, but we want to do the best we can for them and so we might overlook certain, maybe competencies that they should have. (Participant 10)

Sub-category: Failure to fail as a complex issue

For many participants, ‘failing to fail’ was not just about the act of failing, but was viewed as a complex and cyclical process involving personal, professional and organisational factors with widespread ramifications. Participants highlighted that the complexities of the clinical environment, working relationships and role pressures were often not recognised by management. In addition, participants reported that decisions to fail or not fail a student had social, economic, psychological and emotional consequences for the student, assessor and wider profession. Participants reported that failing or not failing a student had a bearing socially and economically with an impact on the psychological and emotional status of all concerned.

. . ..but from personal experience I have had to fail students. It’s not a nice experience and it’s a very difficult topic to discuss and it’s very emotional as well. You have to juggle a lot of information as well as the student and any fall out. (Participant 4)

Category 2: Organisational constraints and time pressures

Analysis revealed several factors that acted as key barriers to prevent ‘failing to fail’ occurring. Time constraints were described as a significant organisational barrier. This category also captured broader organisational constraints, including workload pressures, lack of training and support, and competing demands within the clinical environment.

Sub-category: Competing demands and clinical workload pressures

One of the most common barriers, expressed by 12 participants, related to time management and constraints which limited the time a PA/PS had to spend on and deliver one-to-one teaching. Many reflected that they had to adopt multiple roles as a PA/PS to educate, motivate, administer and navigate student learning in conjunction with carrying a significant clinical workload. Concerns were also expressed regarding the time and administrative skills it took to complete portfolios to the required standard.

Some participants referred to RNs being forced into the role of PS/PA and not wanting to do it:

Sometimes mentors are put into the role, and they don’t really want to be a mentor, I think that’s a big issue. They’re doing it because that is the role and responsibility, but it’s not necessarily that they want to do it. So, if they don’t really want to, they don’t have a passion to teach and educate. Then the’ll just get them through and that’s their bit done whilst thinking I hope I don’t get another student for a while. (Participant 13)

Many participants reported they worked in areas with acute staff shortages, combined with increased complexity of patient cases, and this meant that the time they had to be a PA/PS was limited. They believed that their primary focus needed to remain on the patient, but the complexity of balancing both roles was believed to hinder either their nursing role or the mentoring role. Being allocated to a pre-registration nursing student was not built into existing work patterns of clinical demands and added to additional pressure.

. . .chronic staff shortages with increased workloads and all that feeds into why this system can sometimes fail these students. (Participant 14).

Sub-category: Administrative burden and lack of training/support

Participants articulated that as an RN they also lacked time and training to develop their own professional practice as a nurse and/or PA/PS. The lack of preparation and training opportunities for PA/PS to be educators, as well as dealing with situations when students do not meet expected standards, was viewed as problematic. Several participants also referred to problems interpreting the portfolio requirements and the expectations surrounding it. Some participants also pointed to a lack of support within the workplace and the supervising university over portfolio requirement and student placements. Consequently, this created feelings of incompetence, anxiety and fears, which may impact on the decisions being made when assessing competence in pre-registration student nurses.

I don’t know if we’re giving our staff enough time to develop their own confidence and competence within their roles, before we’re pushing on the role of mentoring a student nurse. (Participant 6)

Sub-category: Limited one-to-one time and associated feelings of guilt

Some participants revealed that they were more likely to fail an underperforming student if they had not spent enough one-to-one time with them teaching or documenting supporting evidence. Several participants alluded to ‘guilt’ if they believed that they had not spent enough time with a student. In such scenarios, many reflected that it was their incompetence as a mentor (PS/PA) that was resulting in underperforming students, not students.

Time, it takes time to sit down with somebody and address issues if they’re issues and if you’re in a very busy ward [clinical] environment, that’s very challenging. It’s very stressful. (Participant 13)

Category 3: Emotional and relational barriers to failing

Participants described a range of emotional and relational factors that influenced their decision-making when assessing underperforming students. These included the development of personal relationships with students, fear of causing distress, lack of confidence in their own judgement and concerns about professional repercussions. These factors often contributed to reluctance in failing students, even when performance concerns were recognised.

Sub-category: Personal relationships and reluctance to cause distress

Over two-thirds of participants referred to recognising that a student was failing but not acting on it. This professional inertia was believed to be due to several factors. Participants reported that over time they developed a personal relationship/connection with the student which made it difficult to fail them. In addition, a student’s personal situation and high expectations being placed on students in their first/second year also influenced experiences and decision-making. The preference to maintain good relationships meant that they actively avoided wanting to cause hurt. This was achieved by not using negative language, providing more verbal feedback to help resolve the situation and giving students the benefit of the doubt which resulted in students not failing.

. . .how do you fail somebody that you’ve built a personal relationship with rather than a professional relationship. (Participant 1)

Sub-category: Lack of confidence in assessment and decision-making

Over half of the participants suggested that some RNs do not possess the confidence in their own practices to fail students when concerns are identified. Some attributed this to being novice nurses who were still settling into the role of the nurse within the clinical setting.

Whenever you’re young, freshly qualified nurse you don’t have confidence. Even though you’ve been for training days, you’re just new to yourself and you’re trying to grow yourself. (Participant 3)

Seven participants cited a lack of confidence in delivering negative feedback and a further seven reported issues with confidently completing the necessary paperwork, procedures and protocols involved in failing a student on placement.

. . .some people hide away a bit because they know that their own competencies may be brought into (consideration). . ., (Participant 6).

Sub-category: Fear of professional repercussions and accountability

A significant number of participants were concerned that failing a student would reflect poorly on their own practice as a training mentor and most significantly their abilities within their nursing role. This was further complicated as just under a third of participants reported that students would challenge decisions made by their assessor and then, due to a lack of confidence from the RN, decisions would be changed.

. . .a lot of nurses out there that may feel that it is a reflection on their teaching, that they don’t feel that they are able to fail students. (Participant 4)

Fearing the student would be held back or misjudged meant that some participants said that they gave them the ‘benefit of the doubt’, especially if it was their first-year placement, as they were very young, a novice of caring and/or if they obtained a good report from another placement.

Sub-category: External pressures and expectations to pass students

Both explicit and implicit academic pressures to sign off students from management and universities were also reported.

. . .a colleague who had concerns was made feel that she was the problem, and it was very difficult process for her to go through to try and identify the specific reasons why this student doesn’t meet what the portfolio, uni [university] and NMC want. It was stressful for her, and she really was not supported. (Participant 8)

There was also reference made to not enough nursing students making it through with the perception being that training deficiencies could be fixed once qualified and in the job.

. . .pressure to pass that student because you know the pressure probably from management as well. You need to get these students through, and you need to get them signed off because we need to get these nurses on the ground. (Participant 1)

Category 4: Enablers to support decision-making

Participants highlighted several enablers that would support them in decisions around underperforming students. These enablers also reflected the need to challenge and de-stigmatise failure within nursing education and promote a more supportive and learning-focused culture.

Sub-category: Training, experience and professional development

All participants believed that the provision of more person-centred support should be given to all staff who are PS/PAs which should be provided by both the workplace and overseeing university. Half the participants believed being an experienced nurse with the knowledge and skills to deliver training at the expected standard needed to be recognised by each PA/PS. Two-thirds of participants suggested that there should be opportunities for PS and PAs to attend regular training updates together and share their experiences which would help build confidence and competence.

If you had like a learning reflection on or about students who are failing every now and then. And with the university, if you had an update so that you were aware of the processes, then people wouldn’t have fears of having to go through that process of failing someone they didn’t think were passing. (Participant 5)

Effective communication and processes you need those in place, meetings with your academic institutions online, but to me the old face to face definitely was a better way of getting to see the student’s overall performance and assurance. (Participant 14)

Sub-category: University–practice collaboration and support

All participants referred to the need for professional support to enhance collaborative working between clinical placements and universities. For example, guidance from academics and workplace educators on portfolio expectations was one element that participants believed would assist PS/PA both in delivery of more robust placement training and confidence. Calls for clear guidance and support from universities to support an RN to pass/support an underperforming student were also made.

. . .documenting behaviours throughout, three years is really important. If you don’t document it at all, then it rolls over into the next placement, and they are then unaware of issues and the cycle continues for someone who has had poor behaviour throughout the whole three years, and it just has never been properly addressed. (Participant 10)

Good support, good relationships with the practice educators and the universities too. Building that relationship up where you have confidence, and you feel supported by them would definitely enable you to make the right decision. (Participant 13)

Sub-category: Shared responsibility and student engagement

Participants also noted the need for shared responsibility between PS/PA to pass and/or fail pre-registration students and it should be a joint decision. There was also a perception that the university should empower/educate the student to understand what is required to achieve the portfolio competencies enabling them to take ownership/responsibility, and guiding the PS/PA in the clinical setting.

. . .student setting out at the onset of their placement, what their goals are and what they want to gain out of that placement. (Participant 6)

Sub-category: Supportive workplace culture and open communication

The need for organisational support enabling a supportive culture was also identified as important. Just over two-thirds of participants also believed there was a need for a supportive culture within the workplace that would facilitate raising issues, removing blame and being transparent. Individual and institutional change should also enable the ability to act early when failure is recognised and be aligned with support for all involved. An ethos of open communication between PS/PA and nursing student to celebrate the good and focus on areas for improvement were also suggested. This approach was perceived as key to reducing the stigma associated with failure and supporting more open and constructive decision-making.

Having an open and honest culture in the workplaces is very important too, workplace culture is a big thing in the NHS [National Health Service] at the minute. I think if you work in a department where the culture is toxic, for example where there are cliques. It can be very challenging to go against the grain and stand up and say something’s not right here. (Participant 13)

Discussion

Findings from this study add to the existing knowledge base of PS/PA views and experiences of failing to fail underperforming nursing students in the clinical setting. It is over 20 years since Duffy published her seminal work on failing to fail in nursing, and the topic has remained controversial and relevant ever since (Quick, 2023). All participants in this study recognised that failing a student is a complex process involving cultural, organisational and individual/personal factors, which can have a psychological and emotional impact on the RN. This aligns with the findings of Hughes et al. (2016) which emphasises the need for comprehensive support systems, including professional development, mentorship and transparent organisational processes to mitigate the emotional and psychological impact on assessors.

These findings highlight that ‘failing to fail’ is not simply an individual decision-making issue, but a multifaceted phenomenon shaped by cultural, organisational and individual/personal influences. Addressing the stigma associated with failure is important, with findings suggesting that fostering a culture of openness, support and shared responsibility could help to normalise failure as part of professional learning rather than as a marker of personal or professional inadequacy. Although the true prevalence of ‘failing to fail’ remains unknown, participants in this study acknowledged that this is a real and significant issue for the nursing profession. These findings can be understood across three key domains: cultural (stigma of failure), organisational (time and workload pressures) and individual (emotional and relational barriers).

The findings of this study are reflective of previous international research (Dixon and Vahid Roudsari, 2022; Hughes et al., 2021b; Bachmann et al., 2019) highlighting the range of factors that contribute to situations where failure to fail occurs. Consistent with Hughes et al. (2021b), this study found that workload pressures and organisational processes are key factors that may lead to nurses failing to fail. Similarly, reflecting Dixon and Vahid Roudsari’s (2022) work, the findings highlight the influence of the nurse–student relationship on decision-making. In addition, a lack of PS/PA experience, alongside limited support from both universities and the workplace, was found to have an emotional impact on assessors, aligning with the findings of Bachmann et al. (2019).

However, unlike previous research, participants in this study emphasised the need to de-stigmatise failure, suggesting that it should not be viewed as something to be ashamed of, but rather reframed as an opportunity to support learning and professional development. This highlights the need for a shift in culture and language within nursing education and practice to better manage the impact of failing to fail.

In this study, many participants were critical that insufficient time was allocated to both PS and PA roles during placements to fully deliver the required support and teaching of pre-registration nursing students reflecting findings from Hughes et al. (2021b) and Nugent et al. (2020). Participants described multiple complexities within organisational processes that made it more difficult for PS/Pas to fail underperforming students. These included limited support from universities and AAs, pressures from workplace management, lack of confidence in the processes required to fail students, challenges within personal and professional relationships, staff shortages and insufficient training and updates. Collectively, these factors impacted on RNs’ confidence in performing their role as PS/PA and in maintaining their professional accountability.

Implications

The findings of this study have important implications for nursing education and clinical practice. There is a clear need for structured support for PAs and PSs, including regular training, protected time for student assessment and access to appropriate resources to support their role in mentoring and evaluating student performance. Strengthening collaboration between universities and clinical placement areas is essential to ensure clear guidance, consistent expectations and shared responsibility in decision-making. This includes improved communication, joint working and enhanced support from academic staff and practice educators. In addition, fostering a supportive workplace culture that promotes open communication, transparency and shared accountability may enable more effective and timely identification of underperforming students. Reframing failure as a learning opportunity, rather than a source of stigma, could be key to supporting both students and assessors in the assessment process. Addressing these factors is important to ensure patient safety, maintain professional standards and support the development of a competent and confident nursing workforce.

In relation to health policy, these findings highlight the need for a system-wide approach to strengthen assessment practices in clinical nursing education. The persistence of ‘failing to fail’ has implications for patient safety and workforce quality, indicating a need for clearer regulatory guidance and accountability in student assessment processes across healthcare systems. Policies should support PA/PSs through protected time, manageable workloads and access to standardised education and training to enhance assessment confidence and consistency. In addition, greater alignment between higher education institutions and clinical practice settings is required to ensure shared expectations, clear communication pathways and coordinated decision-making. Addressing the stigma associated with failure through supportive organisational and regulatory frameworks may further enable timely and appropriate assessment decisions.

Findings from this study highlight the need for further research to better understand the complexities underpinning the ‘failing to fail’ phenomenon. Future studies should explore strategies to support PAs and PSs in making difficult assessment decisions, and evaluate interventions aimed at improving confidence, consistency and decision-making in clinical education. In addition, further research is needed to examine how organisational culture, training and university–practice collaboration influence assessment practices across different clinical contexts.

Strengths and limitations

This study provides valuable insight into the phenomenon of ‘failing to fail’ from the perspectives of PSs and PAs within the United Kingdom, contributing to a limited but growing evidence base in this area. A key strength of the study is the use of semi-structured interviews, which enabled in-depth exploration of participants’ experiences. The inclusion of participants with a range of clinical experience enhanced the richness of the data, and the use of a systematic approach to data analysis, guided by Elo and Kyngäs’ content analysis framework, supports the credibility and transparency of the findings. In addition, measures to ensure rigour, including independent coding by two researchers and maintaining an audit trail, strengthen the trustworthiness of the study.

However, several limitations should be acknowledged. The study’s participants were recruited from one university in the United Kingdom, which may limit the transferability of findings to other contexts. The sample included a range of ages and years of experience but lacked gender diversity, with all participants being female. Furthermore, the reliance on self-reported data may introduce potential bias, and the use of interviews alone means that findings are based on experiences rather than observed practice. Future research incorporating a more diverse sample and additional data sources, such as observational methods, may provide a more comprehensive understanding of the phenomenon.

Conclusion

This study highlights the complex phenomenon of ‘failing to fail’ underperforming pre-registration nursing students in clinical placements and its significant implications for patient safety, professional standards and the future nursing workforce. The findings demonstrate that this issue is shaped by interconnected cultural, organisational and individual factors, including stigma associated with failure, workload pressures and emotional and relational challenges in assessment. Enablers such as supportive workplace culture, strong collaboration between universities and clinical practice, regular training and clear guidance are essential to support effective decision-making. The study underscores the need for changes in mentorship practices, enhanced training and shared responsibility between PAs, PSs, universities and healthcare organisations. Reframing failure as a learning opportunity and fostering a culture of openness and support may enable more timely and appropriate assessment of underperforming students. Further research is required to develop evidence-based strategies and guidance to address the ‘failing to fail’ phenomenon effectively.

Key points for policy, practice and/or research

Clinical mentorship plays a vital role in supporting student learning; however, the phenomenon of ‘failing to fail’ underperforming pre-registration nursing students in clinical placements remains widely recognised and has implications for patient safety and professional standards.

‘Failing to fail’ is influenced by interconnected cultural, organisational and individual factors, including stigma associated with failure, workload pressures and emotional and relational challenges in assessment.

Reframing failure as a learning opportunity may help to de-stigmatise the process and support more effective decision-making in clinical education.

Enablers include structured training, protected time for PSs and PAs, clear guidance and strong collaboration between universities and clinical placement areas.

Strengthening support systems and fostering a culture of openness and shared responsibility are essential to enable timely and appropriate assessment of underperforming students.

Supplemental Material

sj-docx-1-jrn-10.1177_17449871261446842 – Supplemental material for Nurses’ experiences of ‘failing to fail’: barriers and enablers in clinical nursing education – a qualitative study

Supplemental material, sj-docx-1-jrn-10.1177_17449871261446842 for Nurses’ experiences of ‘failing to fail’: barriers and enablers in clinical nursing education – a qualitative study by Joanna Lannon, Felicity Hasson and Sinead Keeney in Journal of Research in Nursing

Supplemental Material

sj-pdf-2-jrn-10.1177_17449871261446842 – Supplemental material for Nurses’ experiences of ‘failing to fail’: barriers and enablers in clinical nursing education – a qualitative study

Supplemental material, sj-pdf-2-jrn-10.1177_17449871261446842 for Nurses’ experiences of ‘failing to fail’: barriers and enablers in clinical nursing education – a qualitative study by Joanna Lannon, Felicity Hasson and Sinead Keeney in Journal of Research in Nursing

Footnotes

Acknowledgements

The authors would like to thank the participants who took part in this study and the gatekeeper for their assistance in recruitment.

Author contributions

Joanna Lannon: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Validation; Visualisation; Writing – original draft; Writing – review & editing.

Felicity Hasson: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Supervision; Visualisation; Writing – original draft; Writing – review & editing.

Sinead Keeney: Data curation; Formal analysis; Methodology; Project administration; Writing – original draft; Writing – review & editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study was granted ethical approval from the Ulster University School of Nursing Ethics Filter Committee (NURFC 22-004).

ORCID iDs

Felicity Hasson

Sinead Keeney

Supplemental material

Supplemental material for this article is available online.

Joanna Lannon is an Advanced Nurse Practitioner, completing her MSc in 2024. She has extensive practice supervisor and practice assessor experience across clinical settings.

Felicity Hasson is a Senior Lecturer at Ulster University with 30 years of experience in research, completing her MSc in 1996 and PhD in 2012, with extensive experience of qualitative, quantitative and mixed-method research.

Sinead Keeney is a Research Associate at Ulster University with over 25 years of experience in research using mixed methods, qualitative and quantitative approaches. She completed her Masters of Research in 1998 and PhD in 2007.

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