Student fitness to practice procedures on accredited and regulatory programmes: a narrative review of the literature

ABSTRACT

A critical task for university based professional training programmes is ensuring that students are fit to practice. Yet, in comparison with other aspects of professional training such as curriculum development or assessment, the literature on fitness to practice procedures remains sparse. This article reports the findings of a preliminary, narrative review of the literature which aimed firstly to identify what research has been undertaken in the area of fitness to practice within university settings, and secondly, to explore the experiences of university staff who are involved. Eight themes were identified from the literature: the impact on individuals, criteria for referral, fitness to practice processes, analysis of fitness to practice outcomes, factors affecting outcomes, the emotional toil in failing students, racially minoritised students and criticisms of fitness to practice procedures. It was noteworthy that the review did not locate studies which directly explored the experiences of university staff who initiate, investigate or participate in fitness to practice procedures. This omission is important to address in order to ensure universities have effective procedures and that staff receive appropriate support. Recommendations are made for future research in this area.

KEYWORDS:

• Fitness to practice
• students
• regulated and accredited professions
• university staff
• emotional impact
• evidence

Introduction

It is of the utmost importance that any student practitioner who is not competent or fit for practice should not qualify and that there are fair but robust processes to exit such students if required. It is equally important that qualified professionals who fail to meet the required standards, cause harm or breach professional ethical codes are subject to Fitness to Practice (FTP) procedures, and if proven, have conditions imposed on them, or are temporarily or permanently de-registered.

There have been a number of high-profile cases involving dangerous practitioners in the UK. Beverley Allitt, for example, a newly qualified nurse, killed four babies and injured nine others in a Grantham Hospital in 1991 (Clothier 1994, BBC 2007). Harold Shipman, a GP, was convicted in 2000 of murdering 15 elderly patients. A public inquiry was established, and it was suspected that he may have murdered around 200 patients (Smith 2003). At the time of writing, a neonatal nurse, Lucy Letby, has undergone a trial for allegedly murdering seven babies and attempting to murder ten more (BBC 2022).

While cases such as Allitt and Shipman are rare, and of course, a regulatory body cannot guarantee that dangerous practitioners will be prevented from entering or remaining in professions, there is a gatekeeping and moral duty incumbent on all professionals to ensure that the standards of their profession are upheld. In some cases, this can prove complex. FTP in terms of students’ or registrants’ health, for example, has proved controversial, not least because of concerns that regulatory body requirements might conflict with Equality Act (2010) provisions (Walker et al. 2013), particularly around issues of health and disability.

In terms of professional training within universities, gatekeeping is also an important role for university staff, who may be required to initiate and/or undertake FTP investigations as well as adjudicate. While FTP investigations involving student populations are likely to be rare occurrences, the impact will inevitably be significant for all involved including the wider university community and may affect future relationships with placement providers. Additionally, in our experience, the threat or actual pursuit of legal action can result, as well as students enacting appeals and complaints procedures. The process may also deter individuals and teams from being prepared to work with students in the future (Finch et al. 2021).

A further rationale for this exploration is our own experience of working within regulated and accredited professions and initiating and participating in FTP panels within university settings. We have observed that the experience can cause significant emotional and psychological challenges for staff. As such, the emotional burden of participating in FTP procedures would benefit from further exploration, not least because these challenges may impact effective and fair decision-making in individual cases.

A brief summary of the current landscape concerning regulation and accreditation

A number of professions are regulated, which means that university programmes must be approved or accredited by the relevant regulatory body to run qualifying programmes. Examples include the Nursing & Midwifery Council (NMC), Social Work England (SWE), the General Medical Council (GMC) and the Health & Care Professions Council (HCPC) which regulate a number of allied health professions (e.g. clinical, counselling and health psychology, radiography, paramedics and art therapy to name but a few)³. Such bodies require universities, as part of their approval procedures, to have FTP procedures in place. The HCPC, for example, has a number of standards of education and training that universities when applying for accreditation must evidence. One standard (3.16) requires that ‘… there must be thorough and effective processes in place for ensuring the ongoing suitability of learners’ conduct, character and health’ (HCPC 2017, p. 27). The guidance requires that providers:

…take responsibility for protecting service users and carers who interact with learners, and for making sure that learners who complete the programme meet our standards for registration and expectations of professional behaviour. We expect you to have effective processes in place to continuously reassess the suitability of learners’ conduct, character and health, and also deal with any concerns about learners. (HCPC 2017, p. 27)

The NMC, since 2009, has required that universities have FTP panels for students where there are concerns about their health and ‘character’ (David and Lee-Woolf 2010). FTP procedures in universities have two aims: (1) ensuring that students are prepared and fit to practice before starting placement and (2) that their conduct remains in line with the codes of ethics and standards in place across different professional and/or regulatory bodies.

The details of FTP tribunals are often available online. For example, SWE, HCPC, NMC and the GMC all publish details of cases brought before them. The NMC identifies issues of misconduct as lack of competence, health, criminal convictions or cautions, lack of appropriate English and determinations made by other regulatory bodies. The HCPC has the same categories with the exception of language proficiency, and SWE, (n.d.) identifies one overall category, competence, which encompasses bringing the profession into disrepute, issues of professional boundaries, health and convictions or cautions. In the early stages of writing this article, cases coming to the NMC included a nurse being struck off for lack of proficiency in English and failure to remedy the situation (NMC 2022c) and a nurse being struck off for stealing drugs from a hospital (NMC 2022b). Cases coming to the attention of the HCPC include a radiographer inappropriately accessing health records (HCPCTS 2022b) and a physiotherapist who was convicted of a drink-driving offence (HCPCTS 2022a).

Despite the standards and procedures in place, the issue of professional training and qualifications within UK universities remains complicated. Not all professions have statutory regulatory bodies. For example, the practice of counselling, psychotherapy and cognitive behaviour therapy (CBT) is informed by a number of membership bodies which may offer individual practitioner and course accreditation. Thus, the British Association for Counselling and Psychotherapy (BACP) offers accreditation for counsellors and counselling courses, and the British Association for Behavioural & Cognitive Psychotherapies (BABCP) offers accreditation for CBT practitioners and CBT courses but neither has regulatory powers.

A further confounding factor is that the fields of counselling and psychotherapy have a number of membership bodies which adds complexity in the sector. For example, the Counselling Directory identified 21 professional membership bodies for counselling, psychotherapy and therapy (Counselling Directory, date unknown). Some membership bodies, such as the BACP and BABCP, have their registers accredited by the Professional Standards Authority for Health and Social Care (PSA) but not all. The main aim of the PSA is to protect the public by enhancing the regulation and registration of people who work in health and social care. Their remit includes reviewing the work of the regulators of health and care professions and accrediting organisations which register practitioners in occupations that are unregulated (Professional Standards Authority for Health and Social CAre n.d.). We also note a variety of terms in use, including programme approval, programme accreditation and then the term accreditation and membership – sometimes at different levels, or registration by various bodies, both statutory professional bodies and membership bodies. Indeed, the terms professional body and membership body often appear conflated.

FTP requirements are concerned with initial professional training and qualified practitioners. Further, FTP is not restricted to the workplace. Any conduct within or outside the workplace (or the university or training provider) that could bring the profession into disrepute or evidence an individual’s lack of FTP can be considered. Therefore, the regulatory bodies will likely de-register professionals who have been convicted of serious criminal offences. Within social work for example, any ‘acts which may damage public confidence in the profession’ (SWE, date unknown) within or outside of the workplace, are included. Indeed, the first FTP tribunal of a social worker in England took place in 2007, and concerned a social worker who was accused of bringing the profession into disrepute because of her additional work as an escort (Currer and Atherton 2008).

This exploratory review of the literature is premised on the overriding duty of all involved in the delivery of professional education, including professional and regulatory bodies, to ensure that recipients of professional services are protected from harm by practitioners. The overall aim of this study was to explore the existing literature on FTP procedures within universities and, in particular, develop a clearer understanding of what is currently known about the experiences of university tutors who initiate or investigate FTP and/or participate in FTP panels. Specifically, this literature review sought to explore the following questions:

1. What are some of the main areas or themes upon which the existing literature on FTP has focused?

2. What has been reported in the literature about how the staff who initiate or investigate or who are members of FTP panels experience these procedures?

Methodology

The methodology chosen was a narrative literature review. Unlike systematic reviews which use explicit criteria to identify relevant studies and synthesise results (Grant and Booth 2009), narrative literature reviews provide a means of identifying and exploring connections between varied sources of evidence including those that might appear only indirectly related to the theme of enquiry (Baumeister and Leary 1997). Thus, a narrative review affords considerable flexibility in allowing scholars to ‘… focus on different parts of a single picture’ (Hammersley 2001, p. 548). This methodological intention was consistent with the aims of this review which sought to draw upon a wide range of information that included existing research studies, reports from regulatory and professional bodies, critical reviews, potentially related literatures and our own experience (we write as academics from the regulated professions of social work and clinical psychology and have both been involved in FTP panels).

Sourcing relevant information and literature

This review began with identifying and discussing our prior knowledge and experience of FTP procedures, along with our anecdotal observations of the impact of these procedures on the university staff who undertake them. Our pre-existing knowledge of FTP procedures in our respective fields was also collated and reviewed as a basis for exploration.

The literature review was conducted using core health, psychology and social care databases – PsycINFO, EBSCO, NAHD, Medline and ProQuest Central – that were available at the university where the study was conducted. These databases were selected for their likely relevance based on our prior knowledge and experience of training practitioners for regulated and accredited health and social care professions as well as being high quality and comprehensive. Electronic searches were conducted between February 2022 and June 2023. The search terms used were ‘fitness to practice/practise’, the abbreviated term ‘FTP’, ‘failing students’, ‘failing trainees’, ‘gatekeeping’, ‘fitness to practice in universities’ and ‘fitness to practice/practise panels’.

Findings

The findings of the literature review are presented in relation to eight principal themes which emerged (1) the impact on individuals; (2) criteria for referral; (3) FTP processes; (4) analysis of FTP outcomes; (5) factors affecting outcomes; (6) the emotional toil in failing students; (7) racially minoritised students and (8) criticisms of FTP procedures.

An initial observation concerning terminology was that the terms ‘fitness to practice’ and ‘fitness to practise’ were often used interchangeably, with the term ‘FTP’ used in several distinct ways within the literature. For example, one usage focused on how to assist students to understand the nature of FTP generally (e.g. in nursing, Tee and Jowett 2009, Ashcroft and Farr 2022; and in medical education, Tyler 2006). Another area focused on the quality of training and workers’ competence to practice on graduation so that they were ‘fit to practice’ in the broadest sense once qualified (e.g. in nursing, Gosby 2007, Lauder et al. 2008, Holland et al. 2010, Wells and McLoughlin 2013; in midwifery, Fraser 2000; in physiotherapy, Lo et al. 2018 and in social work, Moriarty and Manthorpe 2013). A further area of focus was the use of FTP procedures when students or qualified professionals had breached ethical codes of conduct which would bring into question their FTP in their respective professions. It is the latter area of focus that formed the basis of this narrative review and which led to the identification of the eight themes cited above.

The impact on individuals

Research has explored the impact on individuals of going through FTP procedures once qualified. Not surprisingly, the impact is significant. Pugh (2009), for example, explored the experience of Australian nurses and found that the process caused a deep sense of loss for both the personal and professional self. Watters (2018) found that the impact on nurses going through often long NMC FTP processes included physical and mental ill health and for some suicidal ideation. Worsley et al. (2017) explored the experiences of social workers who were currently or had been subject to FTP procedures for reasons of not managing workload or health difficulties, rather than dishonesty or crime. The emotional toil was significant, with participants reporting high levels of stress. Similarly, Maben et al. (2021) explored the experience of healthcare professions involved in HCPC FTP panels and found that registrants experienced significant psychological distress.

Criteria for referral

We identified research which explored reasons for referral to university FTP panels. David and Bray (2009) explored FTP data from one university from a range of health care students. They found that the following reasons prompted referral: plagiarism, dishonesty, criminal convictions, mental ill health, physical health issues and other issues. Of the 50 cases they examined, only 17 progressed to the FTP panel, 10 were still under investigation at the time of the study, and the remainder were being managed by initial advice, academic failure, other disciplinary processes and the students voluntarily withdrawing from the programme. Research also identified reasons for referral to regulatory bodies. For example, a Finnish nursing study explored FTP data from 2007 to 2016 in an attempt to define more clearly what is unprofessional conduct and to identify the key triggers for referral (Papinaho et al. 2022).

FTP processes

We identified some commentary and research which directly focused on FTP processes within universities. For example, MacLaren et al. (2016) focused on FTP processes for nurses in Scotland, and David et al. (2009) and David and Ellson (2010) have examined the FTP processes for undergraduate health care students. Currer (2009) explored two universities FTP processes for social work students and found differences in approaches. A focus of all these studies was trying to identify the most effective processes and how to ensure fairness and consistency across the university sector. These studies raise important questions about the purpose of such procedures; if the aim is to protect the public from the potentially incompetent or dangerous practitioners of the future, this will likely override more immediate educational aims, such as enabling students to learn from mistakes. We return to this theme later in the article when criticisms of FTP procedures are explored.

Analysis of FTP outcomes

Work has been undertaken across professions and internationally to look at the outcomes of FTP panels, mostly at regulatory body level. In terms of registrants’ demographics, age, gender and ethnicity have been explored (see West et al. 2017, Wise 2019, Worsley et al. 2020). David’s et al. (2009) examination of the outcomes of 50 healthcare students referred to FTP in one university (see above) found that of the 17 eventually referred to the panel only one was excluded from the programme and one was suspended. The remainder continued on the programme. The outcomes of FTP procedures at regulatory body level have similarly been explored (see Johnstone and Kanitsaki 2005, Leigh et al. 2017, Worsley et al. 2020). We also noted reports by regulatory bodies themselves detailing outcomes, for example, the NMC Annual Fitness Report 2021 details reasons for referrals and outcomes, although it does not go into detail about registrants’ demographics (NMC 2022a). We also identified one New Zealand study that looked at the correlation between medical students going to FTP and later sanctions applied as qualified doctors (Braatvedt et al. 2014).

Factors affecting outcomes

Within the literature that analysed referral patterns and outcomes of FTP panels, some research has focused on what might contribute to a more favourable adjudication or sanction. Leigh et al. (2017) explored FTP outcomes for social workers and found an apparent mismatch between the gravity of the alleged misconduct and the severity of sanction applied. What appeared to impact the sanction was the individual’s degree of engagement in the process, insight into the issue at hand and credibility as a witness. Similarly, an Australian study of nursing FTP panels found that significant factors in more positive outcomes included nurses reflecting upon, and demonstrating a full understanding of their conduct, taking responsibility for their actions, and being candid and contrite (Johnstone and Kanitsaki 2005).

Emotional toil in failing students

We identified literature from a range of professions that, while not focused on FTP directly, examined the challenges associated with failing a student in a university or placement setting. This connected literature could, we believe, prove helpful in identifying what might be the emotional impact when making difficult decisions about students and how this might impact on the decision-making process. The evidence from a range of professions suggests that there may be a reluctance to fail students on placement (Finch et al. 2021). Various reasons have been offered for this alleged reluctance, although the evidence is not robust about the extent of what has termed a ‘failure to fail’ (Finch and Tedam, 2023). The reasons include:

• Placement procedures not being followed correctly (Finch et al et al. 2021), thus making it hard for fails to be upheld as students had not experienced a fair or transparent assessment process, with little opportunity to address alleged concerns.

• Practice educators/mentors not being adequately supported by managers, agencies and the university, resulting in feelings of isolation (Schaub and Dalrymple 2011).

• Role strain or confusion, that is, the struggle to reconcile the assessor and enabler of learning function inherent in the practice educator/mentor role (Finch et alet al. 2021).

• Fear of litigation (Cole & Lewis, 1993), although actual litigation is a rare occurrence in the UK context (Finch and Taylor, 2013).

• The rule of optimism (Dingwall et al. 1983, Vacha-Haase et al. 2004, Author et al. 2021) which pertains to a phenomenon, albeit a controversial one, within child protection social work. The phenomenon is the tendency of social workers to reduce or minimise concerns about a child by being overly optimistic about the parents or carers. In this context, practice educators may be overly optimistic about the student’s performance and minimise or ignore areas of concern.

• A misplaced hope that ‘things sort themselves out’ without intervention (Hoffman et al. 2005) resulting in the failure to address concerns in a timely fashion or following placement processes.

• The challenging emotional experience that failing a student may engender (Bogo et al. 2007) which may subsequently impact accurate decision-making.

The last point in particular is pertinent to this literature review, namely, that the process of working with, or in this case initiating, investigating or adjudicating FTP, is likely to have an emotional impact. Using the examples of mentors or practice educators assessing students on placements, a range of emotional states were routinely highlighted in the literature. Such feelings included, stress, guilt, anger, fear and isolation (Finch and Taylor, 2013). Finch and Schaub (2015) hypothesised that some of these emotional states could impact adversely on the assessment process and decision-making when one’s reflective capabilities are reduced due to defending against anxiety. This may result in failing to follow the assessment processes properly, making unevidenced or rash decisions, or giving a student the benefit of the doubt when inappropriate to do so.

Racially minoritised students

The evidence across professions seemed clear that racially minoritised students are more likely to appear in FTP procedures. In social work education, such students are overrepresented in taking longer to complete their placements. They are also more likely to be subject to FTP procedures and to fail their programmes (Bernard et al. 2011, Sangha 2022). This phenomenon has been observed in other jurisdictions including Australia (Zuchowski et al. 2013), the United States (Johnson-Ahorlu 2012) and Canada (Razack 2001). It has also been seen in nursing (Pryjmachuk et al. 2009, Hill and Albert 2021), physiotherapy (Williams et al. 2015) and teacher training (Siraj‐Blatchford 1991, Wilkins and Lall 2011).

In terms of FTP procedures at regulatory body level, Wise (2019) found that between 2012 and 2017, 1.1% of racially minoritised doctors were referred to the GMC compared with 0.5% of white doctors. For those who qualified overseas, the figure was 1.2%. There is a similar pattern in terms of referral to the NMC, which reported in 2019 that while 7% of registered nurses identified as ‘Black African’, there were disproportionate numbers appearing at tribunals (12%) (NMC 2019). West et al. (2017) also found that older nurses, racially minoritised men and registrants trained in Asia or Africa were disproportionately represented at FTP tribunals. The same study analysed referrals and outcomes and found similar patterns. The former social work regulatory body, the General Social Care Council (GSCC) found that of the 4,118 referrals for misconduct between 2004 and 2012, 16.2% were black social workers despite representing only 10.8% of social work registrants. Black social workers therefore were 1.7 times more likely than white social workers to be referred to FTP (GSCC 2012).

Criticisms of FTP procedures

Scholars across professions have raised concerns about FTP procedures being too lengthy (Worsley et al. 2017, Watters 2018) and legalistic (Kirkham et al. 2019) thus tending towards blame and findings of guilt, as opposed to learning. Other criticisms identified have included a lack of support for those subject to FTP, both legal and personal, and a lack of information provided about the process itself (Maben et al. 2021). Chamberlain (2011) and Maben et al. (2021) have argued in favour of a mediation or rehabilitative orientation rather than the current legalistic approach. Worsley et al. (2020) in their study of FTP outcomes across nursing, social work, midwifery and medical professionals found that there was a lack of fairness, consistency and equity across the professions, for example, social workers’ FTP panels appeared more punitive compared with those for nurses which focused more on remedial solutions. The study also noted differences in support, including legal support, with social workers having the least support. Criticisms have also centred on the failure of FTP panels to deal appropriately with some scenarios, for example, Kurz (2017) examined cases referred for issues relating to poor expert witness reports in criminal or family courts and argued that FTP procedures were not sufficiently robust in such cases.

Discussion

To the best of our knowledge, this is the first study that has attempted to explore the literature on FTP across professions and to some extent across jurisdictions. As such, this article makes an original contribution to knowledge. We identified eight areas of focus within the existing literature: the impact on individuals, criteria for referral, FTP processes, analysis of FTP outcomes, factors affecting outcomes, the emotional toil in failing students, racially minoritised students and criticisms of FTP procedures. What was striking was the absence of literature relating specifically to the experience of initiating, investigating or being on an FTP panel in a university setting (or indeed the experience from a student’s perspective). We did, however, identify additional literature that, while not focused on FTP directly, could nonetheless prove helpful in better understanding the adverse emotional impact for staff involved in making difficult decisions which will likely have significant consequences for the students concerned. This suggests an urgent need for research directly focused on the experiences of university staff. It would also be useful to know how many students go through such procedures, relevant demographic information, the reasons for referral and the subsequent outcomes and any differences across professions. Based on this literature review, studies that attempt to address the following questions would be a helpful contribution to furthering knowledge at this time:

1. How do university staff describe their experiences of FTP procedures? What are the factors that contribute to these investigations being experienced as relatively positive or negative?

2. What do university staff believe that they need from their employers in terms of training, guidance and support in order to engage with FTP procedures optimally?

3. What is the emotional and psychological burden of these procedures on the individual staff members concerned? Is there any association between participation in FTP investigations and the onset of states of depleted emotional well-being including depression, anxiety or even post-traumatic stress disorder?

4. How, if at all, does the emotionally challenging nature of FTP investigations influence the course of decision-making in relation to (i) an individual’s decision to instigate an investigation and (ii) how investigating panels come to a decision about outcome?

5. How might staff be effectively prepared for FTP procedures?

6. How can universities develop more robust procedures to ensure fair and transparent decision-making for the benefit of all concerned? What structures and processes need to be in place to enable this?

Finally, an additional and very important focus of future research arising from this literature review would be a better understanding of the apparent tendency to ‘fast track to failure’ (Tedam & Mano, 2022) students from racially minoritised groups who disproportionately appear in FTP procedures. This suggests a need to better understand how decision-making processes might be impacted by a variety of student characteristics and perceptual and interpretive errors such as unconscious bias and racism.

Limitations

In considering directions for future research, the findings of this literature review come with a caveat. At the outset, a decision was made to undertake an exploratory, narrative review of the literature rather than using a more robust methodological process. Given the underdeveloped state of the research, it would have been unfeasible and premature to attempt a systematic literature review. Equally, the option of conducting a scoping review was considered and discounted. While a scoping review aims to identify the extent and nature of the existing research, this review aimed at exploring two questions arising originally from the authors’ own experience. The underlying aim fitted better therefore with a narrative review rather than a scoping review (Grant and Booth 2009) with the anticipation that it represents a starting point for undertaking subsequent, more methodologically robust literature reviews and empirical research. Nonetheless, it is hoped that this study might make the emotional climate of these investigations more explicit including raising awareness among trainers, employers, and scholarly and professional communities that when undertaking FTP investigations, staff are making complex, difficult and often uncomfortable decisions. There may also be gain in exploring membership or regulatory body panel members’ experiences, not least because of the continued importance of ensuring that those who work with service users do not pose any risk or harm.

Conclusion

From our preliminary, exploratory review of the literature, this study identified a number of important areas on which the FTP research literature has focused and which have implications for all professional training within universities. We identified a range of areas where empirical research is urgently indicated, including the experience of university staff, given the dilemmas and complexity involved in making decisions about students’ fitness to practice. Additionally, while FTP procedures have been criticised, there is a continuing need to ensure that such processes are conducted fairly and transparently, with students rights upheld, given that some demographic groups are at higher risk of being involved in an FTP procedure than others. Equally, service users’ rights to not be harmed by unethical, incompetent or dangerous students (or qualified practitioners) must remain paramount.

Disclosure statement

No potential conflict of interest was reported by the author(s).