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Examining Contract Cheating, Essay Mill Use and
Academic Misconduct by Students on Health Courses
Thomas Lancaster and Robert Clarke
thomas@thomaslancaster.co.uk, robert.clarke@bcu.ac.uk
Abstract
When students obtain academic awards in the health industry that they do not
deserve, they may emerge unfit for professional practice. This paper explores the
challenges posed by academic misconduct in public-facing health fields, such as
nursing and medicine. Specifically, the paper explores contract cheating, where
students employ a third party or ghostwriter to complete assessed work. The
problem appears more crucial in health than some other academic disciplines, since
here fitness for practice is important and human lives may be at stake.
The paper argues about the importance of academic integrity in health through
multiple examples. This includes showcasing media cases where medical
professionals have been put in positions which their skills did not warrant and giving
three specific examples of attempts by students to cheat that have been detected
online. The examples demonstrate that such contract cheating starts before students
arrive at university. This misconduct continues throughout their academic career up
to postgraduate level. The overall findings in this field support the view that contract
cheating is habitual and repeated regularly by some students.
Several sources are used to show that contract cheating in health is amongst the
most popular subjects that students cheat on. Other examples show that original
essays and assessments can be purchased by students for affordable prices. These
essays will not be detected as unoriginal by Turnitin. The paper concludes by
arguing that increased academic pressure is needed to change the wider health
culture that is affording contract cheating.
Keywords
Contract cheating, academic misconduct, plagiarism, health education, nursing
education
Introduction
Ensuring academic integrity is important for all disciplines of study, but the
implications of asserting that students are fit for practice carries more potential
problems for the health discipline than many others. The definition of health is wide,
containing areas as diverse as medicine, dentistry, healthcare, paediatrics, nursing
and pharmacy.
Within health, there are real dangers if a student is able to graduate and practice
their profession when they have not mastered the skills needed for it. Such
graduation can happen when a student cheats their way through some or all of their
health related course.
The implications for cheating in health education have been widely reported in the
media. Such cheating can lead to students graduating from a course when they do
not have the necessary ability. Media stories and discussions have included both
hypothetical and actual examples.
One such example is outlined in the case of Bhavesh Shah, a registered nurse who
successfully completed a course at University of New South Wales, Australia (NSW
Government, 2013). Shah was found to have lacked English language skills and to
have mistakenly administered dishwashing liquid to a patient instead of the correct
medication. Shah was subsequently found guilty of professional misconduct.
The case of Dr. Daniel Ubani has also been widely reported in the media, for
instance in Meikle and Campbell (2010). Here a healthcare professional mistakenly
administered a dose of a painkiller to a patient that was sufficient enough to be
lethal. Due to a legal loophole, Ubani, who was a qualified GP in Germany, was able
to work as a locum doctor in the UK without demonstrating sufficient proficiency in
the English language. That legal loophole is reported to have been closed since
Ubani’s case concluded (BBC News, 2014).
A 2015 student cheating scandal in Australia found medical studies university
teaching implicated. O’Brien and Smith (2015) reported on an incident in the School
of Public Health at the University of Sydney. Students were found to have submitted
falsified information for assessment, including so-called interviews with patients who
had passed away and made-up records.
Allowing students to graduate when they have cheated also raises ethical dilemmas.
In response to an article discussing cheating in nursing education (Nursing Times,
2008), concerns were expressed about cheating continuing into hospital wards.
Potiphar (2008) asked if newly qualified nurses would:
“cheat in, say the care they provide; what about drug charts and drug errors;
the notes they take, and really anything that they do that could be cheated?”
Besser and Cronau (2015) discussed the issues of fake and undeserved
qualifications being awarded. They reported the concerns of Beale, a retired
university nursing academic exposing issues with maintaining nursing education
standards. Beale stated that a nurse who had passed a course that they ought not to
have done “might find themselves as the only registered nurse on duty. And that is
something that frightens me”.
This paper uses examples to explore the cheating that has been observed
happening during health courses. The main focus is on the issue of contract
cheating, originally defined in Clarke and Lancaster (2006). Contract cheating takes
place when a student pays or uses a third party to complete an assessment on their
behalf.
The paper is supported with examples of the types of cheating that is happening and
the services that health students are using to have work completed for them. The
examples are intended to open the arguments on how health assessments should
be structured and assessed to minimise the potential for cheating in this discipline.
Plagiarism and Contract Cheating Research
Both plagiarism and contract cheating now seem to be ideas that are well-
understand within higher education. The debate into both related areas of cheating
largely stems from the development as an easily accessible research source for
students. Many papers have discussed the ease with which students can copy and
paste text directly from the Internet into their assignments, for instance Austin and
Brown (1999), Culwin and Lancaster (2001). Student plagiarism occurs when work is
submitted that uses the words or ideas from another source without sufficient
acknowledgement and usually involves a student not following expected academic
standards, such as referencing.
Standard recommendations also exist to reduce the potential for plagiarism. Three of
them are shown in Table 1, with the intention that they are sensible and indicative
examples. Many more proposed, tested and evaluated techniques are available in
the wider plagiarism detection literature.
Plagiarism Prevention Method
1
Set original assignments each time a subject is assessed
2
Check the Internet and other sources for assessment solutions before
deciding on a subject
3
Require students to personalise assignments based on their own
experiences
Table 1 – Three common identified methods for plagiarism prevention
First, Table 1 suggests that academics should set fresh assignments each time a
subject is assessed, so that previous work is not available as a temptation for
students to copy from. Second, academics should search online for the intended
topic of their assignment to make sure that ready-made solutions are not available.
Finally, academics can look to personalise assessments, for instance by requiring
students to reflect on their own experiences in the classroom, or within health, in the
community, workplace or professional practice. Such personalisation should make
finding a ready-made solution more difficult for students.
Computer software does exist that aims to detect when a student has plagiarised
from an online source, another student or an offline source, such as a textbook. The
most-widely used plagiarism detection software appears to be Turnitin (n.d.).
Turnitin works using text matching technology to match student work to a database
of known source material. Similar techniques are used by other plagiarism detection
tools and there is a wide range of academic research looking at the most effective
methods for automatically detecting student plagiarism. A more detailed discussion
of Turnitin, other text matching tools and the computational techniques used is given
in Lancaster (2013).
Some academics have argued against the effectiveness of Turnitin, both from
technical and pedagogical standpoints. For instance, Straumsheim (2015) reports on
a study by Shorm (2015) where six essays were constructed with small attempts at
disguise from 37 Internet sources and submitted to Turnitin. Turnitin was reported to
identify 15 of the sources (40.5%), find part of 6 sources (16.3%) and not identify the
remaining 16 sources (43.2%). Sources that were missed including academic journal
papers, newspapers, public social media content and articles on online wikis.
Translated and rearranged text was also not detected as similar to original sources,
reflecting similar conclusions found in studies in essay spinning by Lancaster and
Clarke (2009).
Despite limitations, Turnitin and other similar plagiarism detection tools appear to be
widely used as part of the assessment process. This may also be because these
tools have a deterrent effect; students would seem less likely to copy work when
they know that their submissions are being automatically checked for similarity with
other sources.
A more pressing issue of academic misconduct has appeared that will not usually be
detected by Turnitin. This takes place where a student uses a ghostwriter to produce
assessed work for them. This behaviour is commonly referred to as contract
cheating, with an original definition by Clarke and Lancaster (2006)
The definition of contract cheating has evolved and expanded since the field
developed. Lancaster and Clarke (2007) and Lancaster and Clarke (2015c) provide
a more thorough treatment of contract cheating prevention, detection and its wider
implications. Other associated areas include the term paper industry (Hersey and
Lancaster, 2015), non-originality agencies (Lancaster and Culwin, 2007) and the
availability of ghostwriters for student assignments (Sivasubramaniam and
Ramachandran, 2015).
Since work produced through these mechanisms is original, text matching tools,
such as Turnitin, are not sufficient for detection. Consider the three plagiarism
prevention methods outlined in Table 1. All of these continue to represent good
practice. However, an employed and paid outsourced worker can produce original
assignment solutions to get around all three plagiarism prevention methods. Their
solution will be original and need not rely on copying from a previous student
(method 1). Their solution will not be found during a search of pre-existing material
on the Internet (method 2). The solution can include personalisation, particularly if
this is undertaken in discussion with the student in order to ensure that the
personalisation is appropriate (method 3).
A general finding relating to contract cheating is of interest when trying to profile the
type of students involved. The first study of contract cheating explored an agency
site primarily used by computing professionals, but also including students looking
for their work to be completed for them (Clarke and Lancaster, 2006). The site has
gone through name changes and mergers with competitors, but is currently known
as Freelancer (n.d.) and operates using an auction process, where students solicit
financial bids of varying monetary value and the student pays to have the work
completed for them. The study showed that contract cheating was not an occasional
endeavour, with many students returning repeatedly to pay for their assignments and
outsourcing large chunks of their course. Within health, this may reflect students
missing key areas needed for a future practitioner role.
Contract Cheating and Essay Mill Use Within Health
Whilst pre-existing studies specific to contract cheating in health and nursing are
limited, some general information to refer to here is useful. Specific providers related
to completing health assignments for students has been identified. Marketing
directed solely at students in areas related to health has also been observed.
Figure 1 provides an example of the marketing on one such service, which
advertises itself solely as providing essays for nursing students. The link to the site is
deliberately not provided, but links to this and similar sites can be easily found using
a search by the curious.
Figure 1 – Sample marketing materials on an essay provider targeted at nursing
students
Some selling points worth noting here including the clear assertion that the essays
purchased will be “plagiarisms free”. Note the unusual spelling here and elsewhere
on the advertising copy, which may suggest non-native English speaking writers.
The stated number of more than 1,000 previous “successful” customers also
provides assurance to assignment buyers that they will receive work to an
appropriate standard, as do the apparent testimonials from previous customers. A
more detailed forensic analysis of this company, from published Internet logs and
records, actually reveals that the testimonials are unlikely to be genuine, that the
writers may not specialise in nursing essays at all and hence asserts may not
receive work of the standard that they would expect.
Buying health assignments of this type is not limited to nursing essay sites.
Lancaster (2015a, 2015b) provides more specific examples of sites used by nurses
and the ways in which these are positioned to market towards students requesting
additional support. These examples include freelance writers, advertising through
social media sites commonly used by students, a ready-made supply of previously
written essays easily available for students and the use of auction sites, on which
candidates, including those stating that they are medical professionals, bid for the
opportunity to contract cheat for students.
Prices to have health assignments vary, with some indications that they reflect the
ability of students to negotiate and find solutions that are cost-effective for them. A
media investigation by Nursing Times (2008) collated prices for a second-year
degree level essay on palliative care and received three quotes ranging from £83
and £179 (British pounds). A 1500 word essay on dignity and privacy in nursing,
requested by the BBC and reported by Lancaster and Clarke (2015a) was purchased
for £296. It is interesting to note here that the essay topic requested did require
reflection on personal experiences, as suggested as good practice in Table 1, and
the essay company used were able to construct and provide realistic looking nursing
examples.
The full extent of contract cheating and essay mill use within health is not known.
Many commentators, including Matthews (2013) have noted that providing accurate
figures of this potentially fraudulent activity is difficult, since only a small proportion of
cheating students appear to be detected.
One study of the scale of cheating in health, relative to other academic subjects, is of
interest. Lancaster and Clarke (2012) examined 627publically accessible requests by
students to have assignments completed for them using Essaybay (n.d.) over a 5
month period. That site is not currently operational, but many other services operate
in the same space. The EssayBay study classified the 627 requests according to
UCAS subject classifiers. “Subjects aligned to medicine” were ranked by the volume
of requests in position 4 out of the 15 subjects, with 41 out of 627 (6.5%) cases.
Some health topics may have also overlapped with other classified areas, such as
position 2 ranked “social studies” and position 6 ranked “biological sciences”.
Table 2 further supports the conclusion that health contributes substantially to the
contract cheating industry. It shows and ranks the publically shown number of
assignment solutions sold in different subject areas, as sold and classified on a
“homework help” site.
Ranking
Subject
Reported Number of
Homework Help Solutions
1
Business
1743
2
Law
1119
3
Computer Science
936
4
Mathematics
537
5
Professions and Applied Science
232
6
Humanities
110
7
Social Sciences
96
8
Natural Sciences
86
9
Languages
67
10
Economics
22
11
Engineering
1
Total
4949
Table 2 – Reported figures for number of solutions available on “homework help” site
(Student Lance, 2015)
From a manual inspection of the site referred to in Figure 2, the health discipline
most clearly overlaps with the “Professions and Applied Science” category. This is
ranked in position 5 out of 11, and provides 4.7% (232 out of 4949) of the available
solutions.
Some properties specific to this assignment help service are of note. Unlike many
contract cheating sites, once an original assignment solution is sold, the result
remains available for other customers to purchase for a fee. The indications from a
cursory inspection of the site are that most assignment solutions are only sold once,
so this does not add any further risk for the student. The figures update as more
solutions are provided, so these values are indicative only. The engineering figure
also seems low, but seems to reflect that most assignment requests are posted in
multiple categories. A more detailed analysis of the specifics of the solutions
provided would be needed to draw more general conclusions.
Both the EssayBay study (Lancaster and Clarke, 2012) and the initial analysis of
Student Lance (2015) suggest that there is an issue with contract cheating in health.
The differing proportions and rankings seem to reflect the user-base of the sites, with
Student Lance positioned more towards numerical, scientific and technical solutions,
whilst, as its name suggests, Essay Bay provided more traditional written solutions.
In both cases, the health discipline ranks in the upper half of the academic subjects
upon which most unacknowledged support is requested. This unacknowledged
support will not be available to the same extent if graduates enter practice, so the
consequences for this discipline are more severe than they are for many others.
Three Indicative Examples of Contract Cheating Within Health
This section contains three examples of contract cheating for health related subjects
that have been observed on agency websites used for contract cheating. The
examples have been found during a detection and attribution process, similar to that
outlined in Lancaster and Clarke (2012), where a detective inspects the requests for
assignment solutions posted online and attempts to notify academics that they have
a student who is trying to cheat. The three examples have been selected to be
indicative of a wider range of contract cheating issues as they affect the health
academic discipline.
Contract Cheating Health Example #1 – Palliative Care
Figure 2 shows a request made on an agency website for an essay on palliative
care, a common topic in nursing education. The academic setting the work required
this to be linked to a particular topic.
“Models of death and dying and grief and loss enhance our understanding of and
guide the delivery of palliative care practice.
Critically analyse this statement with reference to the provision of palliative care to
individuals with a life limiting illness and their families.
Guideline:
In addressing this assignment, you are expected to incorporate the key themes from
the theoretical input of the Principles and Philosophy of Palliative care module.
This will involve a critical analysis of the relevant literature, your clinical practice and
the wider palliative care practice arena.”
Figure 2 – Principles and philosophy of palliative care assignment request
The detective process traced this request to an MSc level course in Dublin, Ireland.
The level of the request was of concern, since this suggests that this was likely being
made by a nurse who had already obtained previous qualifications.
Since the records for this agency site were left visible to the public, it was possible to
verify that the work here was completed in five days, for a cost price of €128 (Euros).
This is approximately £90 (British Pounds), assuming an exchange rate of €1 to
£0.70. This is a lower price than the examples given earlier in the paper which used
essay mills, rather than the agency sites that put students in direct contact with
workers.
A further analysis revealed that this was not an isolated incident. The student had
requested several other assignments from the same MSc course. This links in with
previous research showing that contract cheating can be habitual.
Contract Cheating Health Example #2 – Final Year Dissertation
The second example shows a request for work on a final year dissertation. Figure 3
gives examples from the posted request.
“The 15,000 dissertation has been submitted and the lecturer has made comments.
YOU need to take it all on board and rewrite/edit/amend the paper accordingly! and
with quality !!!
This dissertation represents a critical appraisal of theory and methodology in the field
of endodontology (root canal therapy). The focus of this dissertation is on the
practical results of the mechanical aspects of the instrumentation for the cleaning
and shaping of root canals, using synthetic blocks. Modern Nickel-Titanium (Ni-Ti)
rotary instruments allow easy negotiation the curved root canals during endodontic
treatment. Hence, the purpose of this study was to examine if there are any
detectable differences in final preparation shape when using less than the
recommended number of instruments in order to achieve the glide path in root canal
instrumentation”
Figure 3 – Request for rewrite of dentistry project
Although many requests have been observed and reported by contract cheating
detectives for entire projects and dissertations, the request for just a rewrite is more
unusual. It is not clear if this request is at undergraduate or postgraduate level.
The use of requests for a rewrite is particularly of the provision of feedback by an
academic, which is being passed on to an external worker. There is guidance on
avoiding plagiarism and cheating in dissertation writing that suggests that regular
communication between student and supervisor is essential. What this doesn’t often
note is that students may then be communicating with a third party to request the
necessary changes, rather than making them for themselves.
A dissertation of this type often represents the summit of a course and so should be
being treated as important. It appears likely from this request that the student will be
moving into the dentistry profession. Based on this request, there must be concerns
raised about the standard of care and diligence that should be expected and whether
this student would be fit for professional practice.
Contract Cheating Health Example #3 – University Nursing Application
The final example, shown in Figure 4, is for a request by a student for support for a
personal statement to support an application to study nursing.
“Appliaction For enrollemnt into UNI
I Need help with just 1 page:
What main reason for wanting to undertake this course? Enrolled Nurse
Include your career plan or goals and any other factors that are relevant to your
appliance:”
Figure 4 – Application for nursing course request
The country for which this request was made could not be identified, but the level of
English in the request looks like it is a cause for concern. Career planning is often a
part of nursing education and selection of nurses who are able to reach the required
standard should be important.
This example also indicates the wide variety of levels at which requests by health
students to have their work completed for them can be made.
The student here posted identical requests several times. It was not possible to
assert whether or not the student was successful at gaining a place on course to
become a qualified nurse.
Conclusions and Recommendations
This paper has introduced the challenges that contract cheating and other forms of
academic misconduct pose to the health discipline. Cheating has been shown to
take place as multiple academic levels. Examples of students who cheat regularly, or
habitually have also been presented.
There is much scope for further study and publicity in this area. Specialised training
is needed for academics working in this area, showing them how to set assignments
to minimise the potential for contract cheating and how to recognise work that has
been ghostwritten by a third party.
When marking assessments, ideas from Sivasubramaniam and Ramachandran
(2015) appear to hold potential. They spoke to several ghostwriters, who saw
themselves as providing a valued service, rather than helping students to cheat.
Indicators of outsourced work that they noted included work presented perfectly
formatted and with very good technical English. However, work which is written by a
third party, often writing multiple essays in a single day, may lack depth or personal
insights.
When setting assessments, thinking about areas that cannot be easily outsourced is
key. Many areas of health education require examined elements, particularly where
clinical skills are involved. Despite this, academics can still be under pressure to
pass students before they are ready to start professional employment. Gallant (2015)
discussed the pressure that academics are under to not fail students and the wider
cultural implications of changes to the educational landscape that are supporting
cheating.
It is perhaps towards the professional and safety implications that academics should
be looking, leading to fitness for practice. Gallant (2015) asserts that maintaining
educational standards should be applauded and cites examples of award
ceremonies with prizes for academics leading the forefront towards academic
integrity. Only through innovations like this, within health education and the wider
academic community, can it be ensured that the students who have worked hard and
deserve professional opportunities are best placed to take advantage of them.
Acknowledgements
An initial presentation of some ideas referred to in this paper was provided at the
Birmingham City University Pedagogies, Practitioners and Identities in Education
Conference 2015. Slides from the presentation are available (Lancaster and Clarke,
2015a). These slides include a greater range and volume of examples than are
included in this paper. A recorded screencast video presentation of the talk is also
available (Lancaster and Clarke, 2015b).
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