The Grading of Students Practice Performance
Pre-Registration Nursing and Midwifery students following the 2004 or 'Inter-professional' Curriculum have been assessed in practice against criteria taken from the experiential taxonomy of Steinaker and Bell.
The same general structure of documentation has been retained for the Practice Assessment Documents (PADs) for students following the 2009 curriculum but with some changes to the assessment structure. Under changes initiated by the NMC it is required that 2009 students are graded in their final practice. Additions have been made to their PADs to allow this. Examples of 2009 curriculum PAD's can be seen by clicking on the links at the bottom of this page. These are sample documents for illustrative purposes only and must not be downloaded or copied for student use.
A brief description of the Steinaker and Bell taxonomy is given in the Mentor Handbook and can also be found in the introductory section of the Practice Assessment Document which each student takes into practice and which their mentors will complete to record the students progress in the acquisition of practice skills.
This more detailed description is provided to help resolve any difficulties that may arise when the students progress or performance seems to be complicated or to have taken place under unusual circumstances.
The taxonomy used has five levels. Four of these will measure a students normal progress through their course. The fifth is provided to allow for the recognition of an exceptionally good performance by a senior student and is also used as a target for some skills performance by students on the Advanced Diploma in Midwifery.
Scroll down to read about the stages in the taxonomy or click the link in the list below to go direct to information on the different levels.
Level 1| - Exposure
Level 2| - Participation
Level 3| - Identification
Level 4| - Internalisation
Level 5| - Dissemination
Though the taxonomy is consistent in its description of a students steady accumulation of knowledge and skills there are, because of differences in the structure of their respective programmes, slight variations in its application between Nursing students and Midwifery students. The Nursing course is divided into two phases - The Common Foundation Programme (CFP) and the Branch (Adult Nursing, Childrens Nursing, Mental Health Nursing or Learning Disabilities Nursing). The NMC define 'Learning Outcomes' for the CFP and 'Competencies' for the end of the branch. The Midwifery course is a single structure and targets NMC defined 'Competencies' at all points of assessment.
A student of nursing will aim to reach the level of 'Participation' in all their set skills by the end of the CFP (Year One), 'Identification' by the end of Year Two and 'Internalisation' by the end of Year Three. A student of midwifery will be expected to demonstrate a level of 'Internalisation' in all their set skills by the end of each of their three years of study - though they will progress through exposure, participation and identification along the way and may be assessed accordingly.
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The student is exposed to a new and previously unlearned skill or activity as an observer.
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The student will need to observe closely the skill or activity that is being demonstrated to them by a skilled practitioner.
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The person demonstrating the skill or activity will need to give the student a clear and comprehensive explanation of what they are doing and why.
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When questioned subsequently, the student will need to show clearly that they understood what was happening.
This is a starting point for all skills development. It will dominate the first months of the first year of study but will never entirely go away.
When the Mentor is satisfied that a student has actively and effectively observed a skill or activity and has demonstrated a clear understanding of the situation then they may advance to level 2.
Level 2 - Participation
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The student participates in a previously observed skill or activity under the direct observation of a Registered Practitioner. That Registered Practitioner retains the responsibility for the safety and effectiveness of the action being undertaken.
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The student may need prompting and or guidance in the performance of the activity. The key consideration is of 'participation' rather than the independent performance of the skill in question.
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The students Practice Assessment Document describes activities the student might undertake using words like 'recognise' and 'contribute' to reflect various forms of participation.
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The student is permitted to 'lack confidence' in that they may refer back to their supervisor for help or support or they may ask for further clarification or another demonstration.
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The student must retain their clear understanding of the task they being asked to participate in and must be able to relate this to their developing knowledge base.
The goal of the first year of the Nursing course is that each student will have participated in the performance of all the essential skills described in their Practice Assessment Document. A registered practitioner should have made an entry into the PAD to confirm successful participation. The students mentor should complete and sign the periodic interviews required with students and confirm at the end of each placement that the student has performed satisfactorily in practice and is ready to progress to their next placement.
The goal of the first year of the Midwifery course will be to demonstrate internalisation of the competency targets set for that year.
Any registered practitioner evaluating a students performance and making a record in the a students Practice Assessment Document should bear in mind that, though it is an option to identify and grade a students performance at a higher level in the taxonomy than is set as the target, to have achieved the set level in the essential skills by the end of the year is to have passed the practice assessment for the year. Non achievement of these essential skills will lead to referral for further assessment or, eventually, failure to achieve the outcomes of the course.
Level 3 - Identification
After successful achievement of the year one outcomes the student progresses to year two of their programme. For nursing students this means they move up to another level of the taxonomy but with all students it should not be forgotten that they will still be encountering new and previously unlearned skills and will still have to address these at the level of exposure and participation first. It is not an insult to a second year student to identify these as levels of achievement but it is an indication to subsequent supervisors of practice that the learning processes are under way.
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The student is able to perform a skill or activity under supervision though they may require some guidance in some aspects of care.
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The student may be permitted to demonstrate a 'lack of confidence' as before by requesting further advice, explanation or demonstration without this being seen as a fault.
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By this stage the student should be safe and effective in all their forays into care delivery. Safety and effectiveness will be achieved through appropriate supervision from Registered Practitioners, who still retain overall responsibility, and through a developing ability on the part of the student to recognise and operate within their own limitations.
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The principal consideration in whether a student is demonstrating 'Identification' in their practice is that they are very clearly demonstrating their understanding of the activities they are undertaking and are applying their developing knowledge and skills to the activities in hand.
A useful analogy to the skill of identification is that of sight. In any given day we will, for instance, see lots of people. Some of them we have seen before, we will recognise them and, if we respond to them appropriately, identification is clear. Some of the people we see we will not have previous knowledge of. However we may identify them as 'types' or 'categories' - a man, a woman - younger, older and so on and if we respond appropriately to these cues we can be deemed to have identified these good people effectively, even though we could have been more fluent had our previous knowledge of them been more detailed. Some of the skills and activities the student encounters they will have 'seen' before and will 'recognise'. They will give their supervisor clear descriptions and accounts and propose appropriate action based on sound knowledge 'identification' will be evident. The student will also see relatively new things but instead of saying "show me ..." or "tell me about ..." they will draw on their knowledge of types and categories and say "this is like ..." and propose a response based on developing knowledge. The response may not be fluent and an experienced practitioner will correct and explain this to aid the students further growth, but the process is nevertheless of 'identification'.
Again there is no operational advantage to the student to have their skills performance rated at a higher level of the taxonomy than the target for the year. Achievement at target still brings a 'Pass' and non achievement a 'Refer' or 'Fail'. Students will derive great personal benefit from a clear expression of their individual strengths and weaknesses given by a qualified practitioner and this can also be given verbally, or written down as part of their final interview record.
Level 4 - Internalisation
After successful completion of the year two outcomes nursing students join their midwifery colleagues in the pursuit of the skills of 'Internalisation', another notch up in the taxonomy. The demonstration of internalisation is the goal for the end of the pre-registration programmes. Students will still be encountering new and previously unlearned skills, they will still require 'exposure' to situations, the opportunity to 'participate' under the watchful and supportive guidance of a registered practitioner, the opportunity to 'identify' the elements of new situations and relate them to their growing body of professional knowledge and skills. The challenge will be to 'Internalise' their understanding of situations and responses to situations to the point where they will, as a newly qualified practitioner, discharge their duties safely and effectively. They will, like all of us, still have a lot of growing to do but they will be fit for purpose and practice. To demonstrate that they have achieved internalisation the student will need to meet these criteria.
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Is able to perform a skill or activity under supervision. The Registered Practitioner is always the person who bears the ultimate responsibility regardless of the stage of the students programme.
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The student is safe, confident and effective in all of their practice and has the capacity to perform skills and activities with minimal or no guidance.
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The student is able to demonstrate the key aspects of the skill or activity and make a direct application to practice.
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The student can offer a rationale for their care interventions that draws on their professional knowledge base and is both coherent and consistent with current professional standards.
Achievement of all essential skills at the level of internalisation is the standard set for completion of the pre-registration programmes. Students who reach this standard have met all of the the NMC competencies for entry to the register and have demonstrated fitness for practice and purpose.
Level 5 - Dissemination
In the year three Practice Assessment Document a fifth level of the taxonomy is introduced that can be used to describe a senior students performance. This is the level of dissemination. Dissemination describes an individuals ability to analyse situations, critique underpinning knowledge and thus express their knowledge and understanding of their professional discipline in such a way that it enhances the knowledge and understanding of their colleagues. This complex and demanding skill is set as a target for students who undertake the advanced diploma in midwifery. It should not be confused with the ability to accurately and lucidly express a knowledge and understanding of those aspects of professional knowledge and actions that maintain the standards of contemporary care.
Actions that maintain an established standard of care are founded on the skill of internalisation. Dissemination describes actions that promote or enhance those standards.
If a mentor or other practice supervisor assesses a students performance at the level of dissemination they effectively declare that they have witnessed an aspect of performance by that student that has influenced for the better their own practice or the practice of other registered practitioners. This could be a result of the guidance or advice the student has given or by the example they have set in practice. Whilst this grade should be awarded if it has been earned, it is not appropriate to use it to 'reward' a student who has demonstrated an unusually graceful skill at the level of internalisation. As before each parties interests are best served in such a situation by a clear expression of specific personal strengths and weaknesses given in a co-operative manner as colleague to colleague.
Reference: Steinaker N and Bell M (Eds) (1979) Experiential Taxonomy, Academic Press, New York.
Practice Assessment Document 2009 Curriculum|
Pre-Registration Midwifery: sample PAD - BSc (2009) Route
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