Assessment decisions and support for struggling undergraduate nursing students in clinical placements: An integrative...

To synthesise how concerns about struggling undergraduate nursing students in clinical placements are recognised, what influences fair decisions and action and what supports an appropriate response.

Clinical assessors may recognise concerns yet struggle to convert them into documented, defensible progression decisions. Evidence on recognition, decision-making and support has remained fragmented.

Integrative review with a prospectively registered protocol, reported using PRISMA 2020 and relevant SWiM items.

We searched six databases and used citation tracking for English-language sources published between January 2010 and December 2025. Two reviewers independently screened records extracted data and appraised studies using design-appropriate tools; a third reviewer resolved disagreements. The thematic synthesis used five stages: recognising, naming, authorising, acting and reflecting.

Fifty-four sources from nine countries and at least ten regulatory contexts were included. Concerns centred on competence and patient safety, identified through objective markers and intuitive judgement. Across 99 decision-action observations, barriers outnumbered enablers by approximately 2.8-1 and clustered at authorising and acting. Cognitive uncertainty dominated early stages, role and system constraints authorisation and moral and affective forces action. Failure-to-fail was explicit or background in 92 observations. Fifty-eight support observations were identified, but most were proposed or described rather than comparatively evaluated.

Reported barriers concentrate at authorisation and action. A programme-level pathway combining documentation, student discussion, shared authorisation, action and review warrants comparative evaluation of decision quality, fairness, student outcomes and assessor experience.