Gut feeling: A grounded theory study to identify clinical educators' reasoning processes in putting students on a learning contract

Abstract

Aim To develop a substantive theoretical explanation that makes sense of the decision‐making process that clinical instructors use to place students on a learning contract. Background Clinical instructors are challenged with the task of objectively evaluating students using subjective tools such as anecdotal notes, diaries, unstructured observations and verbal feedback from other nurses. Clinical instructors' assessment decisions have a considerable impact on a variety of key stakeholders, not least of all students. Design Grounded theory method and its heuristic tools including the logic of constant comparison, continuous memoing and theoretical sampling to serve conceptualisation were used in the process of data collection and analysis. Methods Seventeen individual semi‐structured interviews with clinical instructors in one university in Western Canada were conducted between May 2016–May 2017. Data were analysed using open, axial and selective coding consistent with grounded theory methodology. The study was checked for the Standards for Reporting Qualitative Research (SRQR) criteria (See Appendix S1). Findings Three subcategories, “brewing trouble,” “unpacking thinking” and “benchmarking” led to the study's substantive theoretical explanation. “Gut feeling” demonstrates how clinical instructors reason in their decision‐making process to place a student on a learning contract. Conclusion Placing a student on a learning contract is impacted by personal, professional and institutional variables that together shift the process of evaluation towards subjectivity, thus influencing students' competency. A system‐level approach, focusing on positive change through implementing innovative assessment strategies, such as using a smart phone application, is needed to provide some degree of consistency and objectivity. Relevance to clinical practice Making visible the objective assessments currently being done by clinical instructors has the potential to change organisational standards, which in turn impact patient and clinical outcomes.

The shift from disbelieving underperformance to recognising failure: A tipping point model

“…This disbelief was related to surprise or bewilderment at encountering an underperforming trainee and was strikingly similar to the unsettling and uncomfortable gut feelings experienced by nursing instructors while interacting with underperforming nursing students 36 . Although supervisors tended to give the trainee the benefit of the doubt, as is common, 6,8,12,16,37,38 they were also inclined to gather additional observations to make sense of what they were seeing 35,36 . The shift from disbelieving to recognising underperformance hinged on perceiving how responsive the trainees (and the deficits) were to teaching and coincided with a realisation that continued, intensified supervisory efforts would likely be futile 35 .…”

“…In recent work, we sought to better understand how supervisors recognise trainees who are underperforming and we identified a phase of disbelief as supervisors encountered unexpected signs of underperformance 35 . This disbelief was related to surprise or bewilderment at encountering an underperforming trainee and was strikingly similar to the unsettling and uncomfortable gut feelings experienced by nursing instructors while interacting with underperforming nursing students 36 . Although supervisors tended to give the trainee the benefit of the doubt, as is common, 6,8,12,16,37,38 they were also inclined to gather additional observations to make sense of what they were seeing 35,36 .…”

Psychometric Testing of a Theory-Based Measure to Evaluate Clinical Performance of Nursing Students

“…One of the key strengths of the GFS is that its items reflect the core construct of gut feeling, which stems directly from a grounded theory of clinical instructors' experiences (El Hussein & Fast, 2020). This responds to the call by Lewallen and Van Horn (2019) to use a theoretical framework to form the foundation for an evaluation tool.…”

“…Alarming sensations trigger clinical instructors to initiate thorough evaluative maneuvers, represented by the learning contract, to articulate their gut feelings. Gut feelings initiate multiple but simultaneous heuristic processes of brewing observations and unpacking thinking while concurrently comparing the evidence to benchmarks to generate an evaluative hypothesis (El Hussein & Fast, 2020).…”

“…In this work, we address challenges in evaluating nursing students and document the development of grounded, theory-based measures of instructors’ “gut feelings” related to the evaluation of student performance. Gut feeling is the term used when clinical instructors are unable to articulate a vague, unsettling sensation about underperforming students in practicum courses (El Hussein & Fast, 2020). Based on students’ persistent patterns of “did not do” and in an attempt to label this perception and attitude, instructors unpacked the thinking of underperforming students and conceptualized their observations as “brewing trouble.” Clinical instructors continuously compare unpacked thoughts to course benchmarks.…”