The purpose of this assignment is to review and explore reflective accounts of the mentor’s developing role, using a recognised framework. Ely and Lear (2003) suggest that following a mentorship preparation course, a mentor should have sufficient information to increase their knowledge base in relation to a student’s learning needs; the effectiveness of role-modelling and effective learning environments. The ability to examine and reflect upon issues relating to; course development and facilitation and assessment of learning should also be developed. In order to achieve such; a portfolio of learning in collaboration with a reflective critical analysis and evaluation of five learning outcomes will be completed: supported by available literature, this will demonstrate the integration of theory and practice. Burns and Grove (1999) believe that a literature review should contain only current research from the last five years. However, as both mentorship and the reflective process are evolving phenomenon, it was felt significant to include reference to material, both recent and classic.
Although research into the effectiveness of reflection is extremely limited, anecdotally it does appear evident that there are multiple advantages to reflective thinking (Burton 2000). These will be discussed in more detail in outcome 2, but briefly reflection can be regarded as innovative (Pierson 1998), dynamic (Burns and Bulman 2000) and as Burnard (1989) proposes, promotes feelings, thoughts and beliefs to be challenged. Although reflection is believed by some to be an essential part of professional education and development (Atkins and Murphy 1993), it does however have its critics. The lack of research into the value of reflection has been noted by Newell (1994) and Macintosh (1998). Burnard (2005) criticises the point that reflection requires an accurate recollection of an incident. However, this would not appear to apply during reflection-in-action.
To direct the reflective process throughout this assignment, an adapted version of Gibbs reflective cycle (1988) has been implemented. As the reflective process entails a recognition of an experience and a subsequent description of such (Powell 1989), it is justifiable to incorporate the use of the first person when discussing related feelings. Hamill (1999) considers the use of first person to be suitable when writing an assignment that requires an element of personal reflection. He also believes it to be appropriate when developing personal and professional qualities of self-awareness, reflection, analysis and critique.
In accordance with the Nursing and Midwifery Council’s (2004) guidelines relating to confidentiality, the mentored student will be named Amy. Throughout the assignment, the author will be referred to as a mentor (although in reality the role was more of an associate mentor since the official requirements for mentorship had not yet been met). All paperwork and formalities were agreed and countersigned with a recognised ‘mentor’ who had previously undertaken the former 998 course. This nurse also acted as the authors mentor throughout the preparation course.
Definition of mentorship
Phillips et al (1996) note a lack of clarity in the term mentorship. A variety of definitions have been offered for the term ‘mentor’, and so for the purpose of this assignment, a considered clear-cut definition provided by a well-regarded source will be applied. ‘Mentorship is a role undertaken by a nurse midwife or health visitor who facilitates learning and supervises and assesses students in the practice setting’ (Department of Health/ English National Board 2001a).
In a longitudinal qualitative study undertaken by Gray and Smith (2000), it was again revealed that students identified a good mentor as a good role model, encompassing skills such as being organised, caring, confident, enthusiastic and professional. A bad mentor, however, was thought to have a lack of knowledge, expertise and structure in their teaching, who was unfriendly, unapproachable and intimidating. Although this study provides an insight into the effects of mentorship on student nurses, it can only really be applied to the small sample size employed, as to generalise to a wider population, the sample must be well-defined (Cormack 2000)
I was not on duty on Amy’s first shift; however, the ward manager introduced her to the nursing team, orientated her around the ward and explained the emergency procedures. During the first week of Amy’s placement, I ensured that time was allocated to discuss all her learning objectives. These had been set by the school of nursing, by Amy herself, and included objectives that I felt she would be able to achieve during her 9 weeks on the unit. Although Amy’s allocated placement was specifically the surgical assessment unit, it was agreed that as the qualified nurses rotated between this unit and the main ward, it would be beneficial for her to do the same, thus ensuring consistency of mentorship and also a broader range of experience.
The course documents were attained from the link educator, and these were discussed with Amy to ensure all outcomes were appropriate to the course module. It was agreed that although allocated time would be available to discuss her progress, both Amy and I would state any concerns or difficulties that were identified, as and when they arose.
During this initial interview Amy appeared extremely enthusiastic to learn, and despite having just entering the second year of her training, she seemed knowledgeable in many significant areas of nursing. Amy’s enthusiasm had a direct impact on my desires to become a good mentor. Despite feeling extremely nervous that I may let her down by not encompassing the necessary knowledge and experience to assist her through her placement, I felt eager to prove my capability and to learn more about the mentorship process.
Ely and Lear (2003) state that an initial discussion between the mentor and student should take place at the earliest opportunity, ideally during the first shift of the placement (Gray and Smith 2000). Phillips et al (2000) believe that the discussions regarding a students assessment, should pre pre-arranged and prioritised, to avoid the student feeling like an added burden. Time should be spent to ensure a thorough assessment is made, as hurried meetings have been suggested to be of less value (Bedford et al 1993).
Price (2005a) states that during this initial interview, the mentor should make it clear that any developing problems or concerns should be addressed as they arise. He also suggests that this initial interview act as a reference point for future discussions regarding progression. Neary (2000a) recommends clearly identifying outcomes at this point to aid the relationship between theory and practice. These objectives should express the needs required by the individual student (Gray and Smith 2000), the learning opportunities that the placement can provide (Stuart 2003) and as Price (2005b) advocates, meet the module outlines set by the school of nursing. Rogers (1961) maintains that students are more likely to succeed once they have identified, individual needs and feel confident in their ability to achieve them. He also states the importance of the student feeling comfortable to ask for advice and express their limitations. Oliver and Endersby (1994) agree, suggesting that the identification of the student’s individual needs during the initial orientation facilitates their perception of security.
A number of authors have suggested the use of a learning contract as part of the continual assessment process and as a guide to learning (Stuart 2003, Quinn 1998, Priest and Roberts 1998). Ely and Lear (2003) believe the implementation of a learning contract specifying individual evaluative criteria and outcomes, can promote the individual to take control of their own learning. This contract is thought to provide a structured plan for ongoing formative assessment, therefore assisting the learning process and providing continuity (Wallace 2003). Although this form of self-directed learning does appear to be advantageous (Hewitt-Taylor 2002), Darbyshire (1993) suggests that mentors may find it difficult to gain control over a learning situation.
Hutchings & Sanders (2001) highlight a study commenced in the Northern Devon Healthcare Trust in 1999, in which a regional project bid was placed to develop formalized, multi-professional learning pathways. The overall aim was to prepare and provide a learning environment that was dynamic and enjoyable and promoted high quality care. A learning pathway was developed in order to ensure equity and consistency in the quality of student practice place. It comprised of three steps: preparation for each placement, induction before each placement and the learning experience. The study was piloted in 6 clinical areas over 3 months, attempting to evaluate the effectiveness of the model. A baseline qualitative analysis of the perceptions of service staff and students was completed prior to the study. The results of this were to be compared to a similar evaluation on completion of clinical placements in the pilot areas. Although suggested that the model will have a positive effect on the quality of the students’ experience, it was noted that the pilot had not yet been completed, and subsequent results have not yet been published.
Conclusion/ Action plan
Following the above reflection and analysis, it would appear that most of the issues highlighted in the literature were actually met in the initial meeting with the student. It is however noted that my area of practice does not typically implement learning contracts unless a student is repeating a placement. With this in mind, I devised a form of agreement in conjunction with Amy, which would aim to meet her individual learning needs. This has been included in appendix1. The main presenting challenge was that of a time constraint. Working on an unpredictable assessment unit, it is very difficult to prearrange a discussion. To overcome this problem, Amy and I agreed to stay behind at the end of assigned shifts and to utilise any ‘quiet’ time that arose during the placement.
In order to be an effective role model, I first needed to ascertain how I was perceived by others. In order to gain an honest insight, I asked my family, friends, and chosen colleagues that I felt would not be afraid to be truthful. The outcome was that although I was considered caring and enthusiastic to teach others, I sometimes appeared impatient when under stress. I identified similar attributes when compiling my own list. With the assistance of my mentor, I compiled a list of self improvements and asked her to observe my behaviour to notice if they were being achieved.
I felt very aware and anxious, that my actions and attitudes would be observed by Amy and possibly imitated in her work. I was therefore conscious of how I acted in front of her, and realised I needed to remain professional, not only when dealing with patients but also away from the clinical area.
It has been suggested that nurses should use self assessment and reflection as part of their professional work and learning (Thorpe 2004). The Department of Health/ English National Board (2001b) profess that qualified staff should provide good role-models for best practice, valuing learning and encouraging reflection. Boud et al (1998) emphasise the importance of reflection as both a learning and teaching tool, believing it to facilitate the integration of theory and practice and develop a nurses’ capacity to contextualize knowledge to meet patients’ needs. Burrows (1995) highlights the effectiveness of reflective thinking for both enhancing clinical practice and affirming the value of practice and knowledge-in-action to the profession. Burrows (1995) does however point out that research suggests students under the age of 25 may not encompass the cognitive readiness or experience required for critical reflection. Although the student discussed in this assignment is 34 years old, the majority of pre-registration student nurses are in fact included in this category.
The term role modelling has been defined by Bandura (1977) as a process that teaches students to learn new skills from others, that does not involve their personal trial and error. Donaldson and Carter (2005), consider it to be of such importance, that they advise the value of role modelling to be discussed in the preparation for mentorship module. Effective role modelling involves competence, enjoying the profession and providing excellent nursing care, and using these qualities when interacting with students and structuring their learning environment (Wiseman 1994). Murray (2005) lists the behaviours of a positive role model as; listening and responding appropriately, displaying warmth and sincerity, maintaining eye contact and asking questions. The problems with role modelling, however, can be if the student observes bad practice and consequently mimics such (Charters 2000), or as according to Lockwood and Kunda (1999), if the student feels dampened and de-motivated when unable to achieve high standards set by a high-achieving, outstanding mentor.
Watson (1999) undertook a qualitative ethnographic study to investigate the mentoring experience and perceptions of pre-registration student nurses. Interviews were conducted within the clinical setting, with 35 students on a common foundation programme, and 15 allocated mentors. The semi structured interviews, lasting between 20 and 30 minutes, were conducted privately and recorded by the researcher. The results from the students and mentors were very similar; all saw the mentor’s role as assessor, facilitator, role model and clinical support, although the students identified an additional key role as planning. This study highlighted some important issues; however, it is not without its drawbacks. Although a small sample size is often acceptable within qualitative research (Thompson 1999), in order for the results to be generalized Dempsey and Dempsey (2000) explain that the selection of subjects must be thought to be a representation of the target population. The researcher stated using purposeful sampling, but it was not felt that 35 students at the beginning of their training from 7 ward areas met such requirements. As the researcher only used one form of data collection (Appleton 1995) and did not ask the subjects to verify the results (Nolan and Behi 1995), the results can not be deemed to hold credibility. The fact that the researcher undertook the interviews herself, the results could also have encompassed interviewer bias (Carr 1994).
Brereton (1995) believes that a mentor’s insight and understanding of the mentoring role is the most effective bridge over the theory-practice gap. A number of mentorship roles have been discussed by Thompson (2004) including; sharing personal thoughts, feelings and intuitive practice, being aware of own strengths and weaknesses and their effects on others, and being sensitive to a students needs.
Conclusion/ Action plan
Having read and internalised the literature, I would hope that I am a ‘good’ role model. To confirm the opinions held by the students, I have encompassed an anonymous questionnaire within the student booklet discussing the strengths and weaknesses of the placement area and feedback regarding their mentor. I have also learnt to reflect more in and on-action to improve on my own self-awareness and gain further insight into my actions and feelings.
My ward area currently has access to the trust intranet and internet, hospital policies and protocols, a small selection of books and journal articles and a welcome pack, notice board and information file designed and intended for student nurses. Students also have access to lockers, kitchen facilities and the staffroom. Whenever possible, a student’s off duty is planned around that of their allocated mentor and associate mentor.
Although I feel that A6 generally meets the needs of student nurses, some of the resources are very out of date, and many of the books have ‘disappeared’ from the unit. The absence of an allocated teaching room makes it difficult to discuss a student’s outcomes and/ or progress.
Price (2005a) emphasizes that the learning environment must be fit for practice and conducive to learning. The ENB & DOH (2001a) state that a clinical setting must be planned, structured, managed and coordinated, in order to provide unique learning experiences and opportunities, to enable the development of competencies for professional practice.
In a quantitative study undertaken by Hart and Rotem (1995), it was significantly verified that the clinical learning environment has a considerable impact on nurses’ perceptions of their professional development. The 516 questionnaires returned from across five metropolitan teaching hospitals suggested that; autonomy and recognition, job satisfaction, role clarity, quality of supervision, peer support and opportunities for learning all had an effect on professional development. The statistical significance of p<0.001 would suggest that the results are significant (Couchman and Dawson 1990). However over a quarter of the questionnaires were not completed in full and for a quantitative study, the sample was still relatively small, and therefore questionable for generalisability to a wider population (Fetter et al 1989).
Price (2004) believes a learning environment should address four issues; practical experience, practice resources, an approach to education and learning support. These have been individually discussed by a number of authors. The practical experience should provide sufficient supervision, ensure a range of patient/ clients and procedures, implement the nursing process and practices consistent with local protocols, policies and philosophies (Price 2004).Myrick and Yonge (2002) advise students to work alongside various members of the multidisciplinary team (MDT) and to seek relevant opportunities from other practice areas to ensure exposure to a variety of clinical experience and expertise.
The availability of a variety of resources, including journals, books and relevant articles has been suggested by Stengelhofen (1993). Oliver and Endersby (1994) recommend access to policies, procedures and protocols, product and department information, health education literature and a list of contact names. Ely and Lear (2003) advise the implementation of a dedicated teaching area, believing the use of patient day room, staff rooms and nursing stations to be unsuitable for structured teaching. Mentors should be knowledgeable of learning centres and resources and take the time to inform students of their availability (Myrick and Yonge 2002).
Characteristics of a good clinical learning environment are said to include a humanistic approach to students in which they are treated with kindness and understanding and encouraged to feel part of the team (Quinn 2000). Quinn (2000) also emphasises the importance of an efficient management style, encompassing nursing practice that is consistent with that taught in university. The National Audit Office (2001) strongly encourages partnerships between the school of nursing and the clinicians applying learning in practice to improve the quality of practice placements.
To ensure students are adequately supported, Eaton (1999) insists staff must be dedicated and adequately prepared to undertake the role of the mentor. The off duty must be carefully planned to coincide a student’s shifts with those of their mentor, and arrangements should be made to ensure other members of staff will ‘look after’ them in their mentor’s absence (Gray and Smith 2000). Although Landers (2000) suggests that the supernumerary status of students can accentuate their insecurities if they are lacking direction and guidance, Ferguson and Jinks (1994) insist that student allocation should be for the purpose of learning rather than service needs. Spouse (2001) believes that the ideal situation for learning is an environment encompassing good staffing levels of active learners engaged in problem solving, where there is a knowledge transmission, together with trust and companionship.
Conclusion/ Action plan
On examining my ward area as a conducive learning environment, the literature appears to support the conclusion that it holds many positive aspects, with staff members attempting to make the student experience enjoyable and informative. During recent weeks, the area was audited by the university as a positive learning environment, with no recommendations given for improvements.Although this is extremely encouraging, it is felt that there are areas that could be improved. Following discussion with the ward manager, I have devised a teaching system within the ward, which entails a monthly update of a teaching board and a short presentation for the junior staff members, including students. This is maintained by the link nurse for each speciality and has received excellent feedback for the two months it has been implemented. I have also updated the student booklet and have suggested providing the students with these prior to the placement with an invitation for them to visit the unit in advance, should they wish to do so. The ward manager and I have also ordered a selection of books suitable to the ward area and are now continuously updating the policies and protocols on the ward.
As discussed in the previous outcome, my ward area does currently discuss relevant issues and ideas to ensure practice is evidence based. On gaining a password from the IT department, all staff has access to the trust intranet, and at the discretion of the ward manger, internet access is also granted. All staff members, including students, have access to the library. This ensures access to a variety of sources of research.
Although relevant and up to date literature is accessible, it is felt it would be beneficial for my ward to hold more recent books and articles on surgical nursing. Although I do feel that students are relatively well supported in my area of practice, I think they could be more involved in decision making and the planning of patient care.
Sams et al (2004) identify three largely unresolved problems within the healthcare setting: an existing gap between evidence and practice; unnecessary variations in practice and an increasing cost of healthcare. They explain that these factors are changing nursing practice from routines and opinions to critical appraisal and practices substantiated by evidence. In doing so; quality and safety of patient care is ensured through the nurse performing the right thing, the right way, the first time (Caramanica et al 2003). Sackett et al (1996) describe evidence-based health care as the conscientious utilisation of clinical experience and current best evidence in decision making and patient care. Evidence-based guidelines have been said to include three sources: clinical expertise, patient preferences and most importantly scientific findings (Hinds et al 2003)
Webster (1990) advises clinical staff to keep up to date with current practice to ensure that what is carried out relates to what is taught in university. Krichbaum (1994) believes student learning in the clinical setting is related to their mentors’ behaviours, including using objectives, providing practice opportunities and asking effective questions. It has also been argued that teaching methods reflect what the student perceives as most effective (Burnard and Morrison 1991). Thomson (2004) advises a mentor to transmit their view of nursing into the student’s mind in order for them to understand and evaluate practice from their perspective. To maximise the benefits of a clinical placement, mentors should teach from the experience the student is having through a combination of a teacher driven approach and the reflective process (Thomson 2004). The use of reflection has been discussed further in the facilitation of learning, to demonstrate an understanding of concepts, knowledge, skills and attitudes (Dix and Hughes 2004). Neary (2000a) explains that to reflect in a way that enables them to understand and learn through their experiences, students will need advice and guidance from their mentors.
Craddock (1993) suggests teaching students to process information in a way that becomes more meaningful to them, enabling the integration of theory and practice. Self directed learning has been proposed as an effective method of achieving such, providing a foundation for practice based on evidence (Burnard and Chapman 1990).
Students should be encouraged to participate in clinical knowledge by sharing ideas on practical issues, facilitated with time to visit the library (DOH/ENB 2001).
Andrews and Roberts (2003) suggested that a mentors’ role was that of support, and to ensure students received adequate teaching within the clinical area, a clinical guide should be employed. They undertook a study consisting of self-report questionnaires administered to 239 first year students and 450 clinical guides across eight NHS trusts. They indicated that the students valued the clinical guides’ impartiality, gained further insight into the practice experience and became more proficient in problem solving. The level of confidence that can be placed in the results is however extremely limited. Only 65% of students and 21% of clinical guides responded to the questionnaires, the subject’s demographic characteristics were not described (Ryan-Wenger 1992), and no reference was made to the sampling method, (Parahoo 1997) the validity and reliability of the data collection (Mathers and Huang 1998) or the study’s credibility (Carter and Porter 2000).
Conclusion/ Action plan
Following the above literature review, I now understand the importance of involving a student in the assessment, planning and evaluation of a patients’ care as well as the implementation. I try to involve students in all aspects of the nursing process, explaining our rationale for all decisions. I have also implemented a self-directed learning approach, asking Amy to briefly research and feedback issues that have arisen. She seemed to enjoy, and benefit from this style of learning, and in the process I also gained further insight into current evidence.
I used the outcomes set in the initial discussion as a benchmark for Amy’s learning and assessed her competency on how well I thought she achieved these outcomes. Amy would observe a task, we would research it where appropriate and I encouraged Amy to ask questions. When we mutually decided Amy was ready, and on gaining the patient’s consent; I allowed Amy to perform a task, such as completing an admission, administering an injection or redressing a wound.
I was extremely nervous of misjudging Amy’s level of competence and consequently allowing her to administer care she was not capable of or restricting her learning.
Myrick and Yonge (2002) emphasize the importance of assessment and evaluation of a student’s learning in facilitating their experience. Effective assessment is vital in judging a student’s competence to practice (ENB/DOH 2001a). Watson et al (2002) noted a lack of clarity surrounding the term competence. However, the NMC’s (2004) definition describes ‘possessing the skills and abilities required for lawful, safe and effective professional practice without direct supervision’.
Rowntree (1987) identifies reasons for assessment as; motivating students, establishing progress and providing feedback, identifying strengths and weaknesses and establishing the level of achievement. To uphold the reputation of nursing, Price (2005c) considers it vital to assess a learners’ ability to practice in a professional, sensitive and safe manner. Watson et al (2003) believe that having the competency to practice involves having the competence to learn. This involves having a positive attitude to learning, taking initiative, recognising learning needs, seizing learning opportunities and understanding how to reflect on; analyse and critique practice. Benner (1984) advises skilful teaching in the practice setting to ensure students pass through five levels of proficiency from novice to expert.
Calman et al (2002) undertook a study in Scotland to determine the methods, preparation of assessors and student views relating to the assessment of students’ practice. A combination of postal questionnaires, review of programme documentation and interviews with key stakeholders were completed. They concluded that students had little confidence in competence assessment methods, there is a lack of consistency in the training of student assessors in the clinical areas and a limited number of approaches to clinical assessment are used. Credibility was ensured through presenting the results to the subjects to verify (Nolan and Behi 1995) and by the implementation of a triangulative data collection method (Appleton 1995).
Wilkinson (1999) states that to ensure an assessment is reliable; student’s abilities should be consistent and the assessment should be made over a period of time and agreed by others. Validity can only be assured when a students’ performance involves an integration of cognitive, affective and psychomotor skills (Wilkinson 1999). A vital part of clinical assessment is direct observation, which must involve sufficient time to observe, an awareness of observer bias and the observer effect, and the incorporation of a checklist (Hull 1994). Greenwood and Winifreyda (1995) devised a model to aid teaching and assign which the use of direct observation with diagnostic questioning of students. This elicits a students understanding and performance and should be followed up with constructive feedback including; instructions, revisions, encouragement and guidance. A study by Watson (2002) supports the use of reflective learning contracts as an assessment tool although this has been criticised on ethical grounds. As no single procedure is adequate for assessing clinical competence, a continuous assessment incorporating a variety of methods should be employed (Neary 2000b).
Conclusion/ Action plan
On reviewing the literature, I feel that I now have a deeper understanding of the methods of assessing a students’ competence and will attempt to implement such in the future. I will also try to provide feedback and constructive advice whenever possible to assist a student in meeting their initial outcomes.
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