Over the last decade the National Health Service (NHS) has continued its drive to optimise health outcomes, reduce health inequalities and conform to nationally agreed best practice in order to provide a more patient centred service. Accordingly, the present culture needed to adapt in a way as to encourage and strengthen clinical leadership and develop a workforce seeking to innovate and continuously improve through learning and research (Department of Health, 2005).
Such a projected change within the health service has had a direct impact on nursing careers and nurse education both pre-registration and post-registration and has implications not only for those receiving education but also for those providing education. Through review of nursing education literature, this assignment intends to critically analyse the accountability of mentors in practice, looking at how their role as facilitators of learning and assessment is utilised within my own clinical setting, and how we, as nurses, assess a student’s competence.
Furthermore discussions will focus around its impact on pre-registration students, identifying limitations mentors have in applying and reinforcing its importance in current practice. The Nursing and Midwifery Council (NMC, 2008a:p19) define the term ‘Mentor’ as a registrant who has successfully completed an NMC approved mentor preparation programme and becomes responsible and accountable for organising and co-ordinating student learning activities in practice.
This includes, supervising students in learning situations and providing constructive feedback, setting realistic learning outcomes and monitoring achievement, assessing total performance including skills, attitudes and behaviours as well as providing evidence and liaising with other colleagues if concerns are identified about the student’s achievement. Literature suggests that using of mentors in clinical placements can assist in the learning process and is it beneficial when a good mentor/student relationship has developed with mutual respect, consistency and partnership (Andrews and Robert 2003, Pulsford 2002).
The success of any nursing student within a clinical placement is multi-faceted. This is further enhanced by the complicated nature of education and the perception of competencies to be achieved whether mentee or mentor. The process of moving forward with the knowledge and skill-sets must be supported and nurtured in order to facilitate a standard of care that is deemed safe, competent and most importantly accountable.
If as nurses, we are to standardise the learning environment and assessment in practice, then the responsibility and accountability as facilitators of learning is of great importance. The Nursing and Midwifery Council monitor current nursing practice. Its main aim is to protect the public by ensuring that high standards of care are maintained through approving and monitoring the educational programme used to train pre and post-registration nurses (Quinn and Hughes, 2007 p67).
Such standards within the nursing profession are set and maintained by documents such as the Code of Professional Conduct (NMC, 2004) and Standards of Proficiency for pre-registration nurses, which need to be met in order to ensure nursing students enter the profession providing safe and effective practice for patients (NMC, 2004). In terms of pre-registration nursing, it has become a crucial role for clinical settings such as my own to ensure that standards of proficiency are met and that student nurses gain a wide variety of experience on clinical placement during their training.
The principles behind effective mentoring and effective student learning involve a number of factors, which the NMC incorporates into eight domains that provide standards for supporting learning and assessment in practice (NMC 2008b, Ali and Panther, 2008). These include; establishing effective working relationships, facilitation of learning, assessment and accountability, evaluation of learning, creating and environment for learning, context of practice, evidence-based practice and leadership.
This has great implications for mentors as they will assess student’s competence in practice and decide whether they are capable of safe and effective practice (NMC, 2006). Within my own area of clinical practice, consideration of time management, leadership and effective working relationships are deemed particularly important for students to become competent practitioners and enjoy a positive learning experience.
Caldwell et al, (2008 p39), suggests that the pressures of clinical commitments and lack of available time effects both the organisation and supervision of students during their clinical placements. Other challenges faced may include inconsistency of nurse educators and performance (Duffy and Hardicre, 2007a p28) and students who do not comply despite support (Duffy and Hardicre, 2007a p 29). Further challenges faced within my own practice a rea and indeed many areas of practice are reluctance to fail a failing student due finding the failing process too challenging or to limited and poor assessment.
Studies have shown that students appreciate mentors who are positive and supportive and the relationship that develops between mentor and mentee can be central to the success of the clinical placement (Neary, 2000 and Pulsford et al, 2002). However, it is important to identify that other factors such as, the clinical environment, the complexity of the ward and psychological factors such as anxiety can have an impact on the quality of the student support received together with relationships developed (Andrews and Roberts, 2003, Hand 2006).
Whilst mentors face many key professional challenges surrounding the facilitation of learning and assessment within the clinical placement the NMC framework to support students and mentors, by the nature of the document, is not deemed comprehensive enough to consider all aspects of competence assessment (Cassidy, 2009 p46). Research highlights that there are some levels of assessment that remains subjective despite the framework, simply due to the inherent nature of those involved and the variation of the skills to be assessed (Freshwater and Stickley 2004, Clibbens et al 2007).
However, further support can be given to the NMC standards to support learning and assessment in practice by documents such as ‘Guidance for mentors or nursing students and midwives; (Royal College of Nursing (RCN), 2007). This toolkit is frequently used in my own practice area as it assists nurses to provide support and strategies. Levett-Jones, Tracy, Lathlean et al (2009, p316) suggest that mentor-mentee relationships are an important influence on students experiences of belongingness and their clinical learning.
Notwithstanding, the clinical placement experience accounts for 50% of the pre-registration course, the role of the mentor in facilitating learning and educating is therefore optimised, assessing and supporting learners’ throughout their clinical experience. Neary (2000, p467) in his 1997 study, suggested that students described a mentor as someone to ‘emulate, a person of contact, have a chat with, teacher and guide, assessor and supervisor’. Morton-Cooper and Palmer (2009 p42-43) define the role of a mentor as Advisor, Coach, Counsellor, Guide, Role
Model, Sponsor, Teacher and Resource Facilitator. Such essential attributes of the mentors role will enhance the learners’ experience of clinical placement, exert a powerful influence on their thought processes, emotions, behaviour, health and happiness in order to achieve the optimum level of success of experience of learning. Dolan (2003 p141) states that the role of an assessor and facilitator of learning is complicated by the balance and demands of every day duties within the clinical placement, this, in turn leads to the learners’ experience of assessment being fragmented and not prioritised.
The supportive role of mentoring is to be objective and unbiased. Quinn and Hughes (2007: p300) note that in assessing the learner, caution should be taken in not feeling that our care is solely to the learner by being generous in assessment and evaluation and conversely not underrating the learner with the perception of the general characteristics of the learner. There is considerable opportunity for the mentor to gain knowledge about the learners’ learning needs, previous experience in order to form strategies to aid further learning, Wallace (2003 p36).
Kolb (1985 p38) suggests, knowledge of an individuals’ learning style will enable learning to be effective. If a learning style was identified such as Honey and Mumford’s (1992) which defines learner’s into categories such as Activist, Reflector, theorist and Pragmatist, this might determine how the mentor might choose to teach a skill by either teaching theory first (theorist) or letting the learner experiment (activitist) with a skill first, (Hand, 2006).
However, Hand (2006) suggests that only learning which incorporates knowledge and skills will inform practice, and that if there is a lack of knowledge then practice will become unsafe as will lack of skill lead to incompetency. Healthy mentoring relationships often involve some form of accountability and for many, whilst this is great in theory, it remains confusing in practice but makes a healthy contribution to mentoring relationships. Phillip and spratt (2007 p55) suggests that accountability should be based on clear terms, specific goals, objectives and good communication.
An open and safe atmosphere will contribute to trust and moves us away from defensive, self-justification or unnecessary self-condemnation attitudes. Accountability should focus on growth, not merely preservation and protection; whilst these are crucial, they can make us more susceptible to failure. Healthy accountability should focus on motivation, helping to visualise growth and take responsibility for modelling and mentoring. Assessment decisions must be evidence based, as mentors, we are accountable for decisions made to either pass, defer or fail a learner, (NMC 2008a:p32).
Assessment is defined as the action of evaluating, estimating the nature, ability or quality (Oxford Dictionary 2011). Rust (2002) suggests that assessment includes judgement, which will hold an element of subjectivity; therefore it must be objective, fair and transparent. The mentor is assessing the learners competency which the NMC (2008a) defines as ‘having skills abilities to practice safely and effectively without the need for direct supervision’, this being achieved through periods of clinical experience during the learners’ programme.
Practice based assessment is a core method of assessing knowledge, skills and attitudes of students (Wallace, 2003 p 36). Dolan’s study of 2003, (p37) identified that learners’ need to gain the holistic experience of clinical practice in order to achieve some level of competency. The method of assessment must be considered in terms of reliability, validity, acceptability, educational impact, cost effectiveness in order to evaluate the suitability of the assessment itself (Chandratilake et al, 2010).
Exposure to a holistic experience gives opportunity for the learner to achieve all aspects of the domains of professional and ethical practice, care delivery, care management and personal and professional development, (NMC, 2004). Assessments may be made by anyone with the clinical placement which could involve the multi-disciplinary team, patients, peers as well as the learners’ self- assessment through reflection, (Gopee 2008:p135). The NMC (2008b) recognise that working with the inter-professional team can offer opportunity for the learner in the formative episodes of assessment.
Neary (2000 p474) points out that, skilled practitioners in the clinical setting are dealing with intended and unexpected situations, which will enhance learning and provide opportunity for formative assessment. This illustrates what Quinn and Hughes (2007;p346) describe as an ‘effective’ learning environment in order to develop learning and foster behaviour where the learner may make the most of opportunities for learning and critical judgement. Direct observation is the assessment in which the NMC (2008a) identifies as greater evidence of competency.
A formal assessment strategy for direct observation, which is utilised in this author’s clinical setting, is the use of a performance criteria, often Trust wide guidelines and policy, which is a list actions to be demonstrated based on knowledge and skills attained from theory which is evidence based from research and may come from organisations such as the National Institute for Clinical Excellence and the Institute for Innovation and Improvement, (Gopee 2008a: p 106-107).
When assessing students, it is important to establish four key areas (Hinchliffe, 2009); knowledge skills, performance and motivation. Checklists or performance criteria can service as a useful tool in establishing a level of observational assessment, Quinn ad Hughes (2007). Cassidy (2009 p46) documented that this performance is a list of behaviours which the learner can demonstrate but it does not indicate how well that behaviour was demonstrated.
However, this method of using a set criteria to reference against offers, an opportunity to ensure consistency in the mentor’s assessing role in alignment with other mentors’ consistency, otherwise defined by Goppee (2008) as ‘intra- and inter-mentor reliability. Another assessment strategy partly adopted in my own clinical setting is that of continuous assessment. The use of continuous assessment gives the mentor an opportunity to make a cumulative judgement of the learner’s progress and level of knowledge and competence, (Gopee 2008 p40).
Neary (2002 p473) suggests that continuous assessment allows the dynamism in the behaviour of the learner in any given situation which may be expected or unexpected. However, Price (2007 p41) suggests that continuous assessment does have its limitations with regards to validity and reliability for numerous reasons including; stress and anxiety for the learner; they may feel that they are constantly being scrutinised by patients, family, relatives and other professionals within the clinical placement.
Additionally, Price (2007) notes that at the summative stage of assessment and through the accumulation of information, could influence the assessor to ‘average out’ the learners’ performance leading to an allowance made for weaker performance. To some extent, this author suggests that this strategy of assessment is utilised because the assessor’s role is balanced with dealing with every day duties such as care management and care delivery or liaising with the multi-disciplinary team. However, caution should be taken as this use of assessment may leave the learners’ time fractured and not a priority, (Rutowski, 2007 p40).
Indeed, the high demands on day to day role of the assessor nurse was finding by Phillips et al (2000) study which determined that time factor was a dilemma in the assessor making valid or reliable assessments. Another dimension of continuous assessment is self-assessment by the learner. This is what Gopee (2008:p135) suggests is one of the most valuable forms of assessment at the formative stage of learning as it may include informal learning as well as formal learning through the use of reflective diaries.
However, while it is recognised as an important part of assessment, Fordham (2005) suggests that the learner may exaggerate or manipulate their evidence of learning which may go unchallenged, especially by a novice mentor, therefore rendering the learning as unreliable. In Neary’s (2000) study, it concluded with a suggestion to a new approach to assessing clinical competence through utilising what she describes as ‘Responsive Assessment’ which offers the learner and mentor opportunity to identify competency through written reports of assessment and judgement within the situational context.
This same study suggests that may incorporate views and opinions from other service users including patients and help the assessor and learner identify current learning, acknowledge necessary adjustments and stimulate reflection to aid future learning. From this study, Neary (2000), established that the participating 80 assessors preferred this approach, as it gave flexibility and enabled them to report learning alongside the pre-set academic objectives.
This might suggest that this form of assessment might provide support for effective evaluation of learning assessment and judgement. An important aspect of assessment is regular feedback which needs to be organised by the mentor on a regular basis in order to discuss with the learner the outcomes of pre-planned opportunities of learning, discuss situational learning and reflection retrospectively, discuss the learners’ commitment and self-assessment in order to ensure validity of the assessment process, (Wallace 2003).
This will also facilitate an opportunity to discuss limitations and remedies such as the difference in aborting assessment as opposed to failing an assessment or whereby it has been identified that the placement has a lack of capacity for certain assessment which can be remedied by arranging with practice educators for clinical experience elsewhere to fulfil this gap, (Price 2007 p41). Failure to discuss and evaluate learning on a regular basis could ultimately result in problems for the learner not being addressed early enough in the placement resulting in mentors’ giving the student the benefit of doubt in certain situations, (Duffy, 2004).
The benefactors of competent mentorship are everyone. Government benefits from improved patient care with improved outcomes. The nursing profession benefits as continuity and quality of care is ensured through sound practice founded through supportive and evidence-based learning, thus promoting a better image and greater emphasis on trust. Patients and their families benefit as the mentored nurse provides the best possible care and treatment ensuring best possible outcomes. Achieving standardised, high quality practitioner in student mentoring has long been a priority for the NMC and will continue to do so.