Role Modelling And Mentoring In Clinical Environment

This assignment is a reflective, analytical evaluation of role modelling in relation to my clinical learning environment. The relationship of this issue to my clinical learning environment will be clearly justified; focusing on current status, my role and future developments within this chosen area. Giving constructive feedback in relation to my performance as an assessor will also be critically analysed and reflected upon, thus demonstrating how its aspects have contributed to my personal growth and development. Issues of context, consent and confidentiality will be made explicit within the text of the essay and the key points of this assignment will be summed up in the conclusion.

This assignment is written in the first person as stated by Hamill (1999) that such a stance to avoid using ‘I’, ‘we’ or ‘our’ often results in the tortuous and repetitive use of the author, the writer or the present author, when students are actually referring to themselves. Webb (1992) rhetorically asks “Who, if not ‘I’ is writing these words?”

I am a staff nurse currently working in a surgical ear, nose, throat and maxillo facial ward based in a London NHS Trust, whose thirty five patient capacity consists of a fair number being major operations and long stay patients. Whilst undertaking this course I was required to keep a logbook or record of my involvement in assessment in order to facilitate reflection. Reflective practice is a mode that integrates or links thought and action with reflection. It involves thinking about and critically analysing one’s actions with the goal of improving one’s professional practice. Engaging in reflective practice requires individuals to assume the perspective of an external observer in order to identify the assumptions and feelings underlying their practice and then to speculate about how these assumptions and feelings affect practice (Hancock 1998).

Many practice-based professions, including nursing, traditionally rely on clinical staff to support, supervise and teach students in practice settings. The underlying rationale is that by working alongside practitioners students will learn from experts in a safe, supportive and educationally adjusted environment (Andrews and Wallis 1999). Mentoring must be cultivated beyond the role of supervised instruction. A therapeutic environment must be created for the student or novice nurse that fosters growth, self-esteem and critical thinking. A personal connection is essential between the new hire and the environment to provide the student with the caring and encouragement that all humans need to succeed (Whittman-Price 2003).

The rationale for choosing role modelling in relation to my clinical learning environment is that it is one of the most powerful methods in which learning occurs in the clinical setting because of its affective inspirational overtones when observers interpret the behaviours of role models based on their own past experiences and personal objectives (Davies 1993).

Guidelines were produced to meet the NMC (2002) Advisory Standards, which detail the role and function of the mentor and mentorship, summarised as follows:

Ø Effective communication with students and others in order to assist students to integrate into the practice setting.

Ø Facilitation of learning in keeping with the requirements of the students’ curriculum.

Ø The creation and development of learning opportunities that will integrate theory and practice.

Ø Effective management of the process of continuous assessment of practice

Ø Demonstration through role modelling, the ability to sustain good work relationships, manage change processes, implement quality assurance and use disseminate research.

Bidwell (1999) defined role modelling as a process through which persons take on the values and behaviours of another through identification. Unlike the deliberative long-term process of mentoring or a brief demonstration, role modelling can occur with brief or long-term contact. Role modelling may be inspired by the performances modelled by another, but where they may be no deliberate attempt to mould behaviours (Reuler and Nardone 1994).

Role modelling is an essential tool in demonstrating effective relationships with patients and clients, contributing to the development of an environment in which effective evidence based practice is fostered, implemented, evaluated and disseminated and assessing and managing clinical development to ensure safe and effective care (NMC 2002). Evidence based practice is a shift in the culture of healthcare provision away from basing decisions on opinion, past practice and precedent, toward making more use of research and evidence to guide clinical decision-making. This rigid view of evidence based practice, is one that emphasises clearly the role of research in underpinning practice (Appleby et al 1995).

Role models may demonstrate negative and or positive behaviours. Students may be easily be influenced by role models because they lack self-esteem, confidence or are dependent. Positive role models are open, constructive, accessible, responsive to the needs of others, easy to trust, comfortable with themselves and their abilities and command mutual respect. Disabling strategies include being inaccessible, throwing people into new roles ‘sink or swim’, refusing requests, over supervising and destroying by ‘dumping’ or openly criticising (Hinchcliff 2001).

Role modelling also lends itself initially to developing more complex behaviours than does demonstration. Role modelling incorporates knowledge gained through observation of clinical role models and emphasises the artistic rather than the scientific aspects of practice. Thus, what is done and how it is done are stressed rather than the theoretical underpinnings of the action (Davies 1993).

However, as skills of the student increase, cognition assumes greater importance and explanation and discussion become as important as the demonstration of behaviour. These characteristics of role modelling are especially compelling for new students learning complex practice in a new setting or new practice in the same setting.

While role modelling as described above can be a generalised phenomenon that is always in direct control of the one who models behaviour, its potential use in a planned effort for change as recommended by Wiseman (1994) is particularly useful. He emphasised the four-stage process of Bandura’s Social Learning Theory in modelling behaviours where the observer sees and is attentive to the behaviours that increase the likelihood of retaining that information. These behaviours in observers are developed through practice and through the development of a symbolic coding system of the behaviours that often uses a verbal response to the action. Therefore, according to both Wiseman (1994) and Lynn (1995), discriminate observation and repeated presentations or rewards in the work setting are necessary before full learning of complex behaviours will occur. Chesla (1997) emphasised that direct supervision was more effective than a retrospective analysis in increasing learning.

Another application of role modelling is demonstrated in the modelling practice theory developed by Erickson et al (1983). According to these authors, by using their skills in communication, nurses develop an image of the client’s situation from the client’s perspective. Understanding the client’s world within the context of scientific knowledge permits the nurse to plan interventions in conjunction with the clients, which are then role modelled by the nurse. According to Kinney and Erickson (1990), the role-modelling concept as used here is the essence of nurturance in that one accepts patients as they are while encouraging and facilitating their growth. Using this framework in developing patient sensitive care, the expert clinician would assess the patient’s needs, determine the necessary interactions between the student and the patient, recognise the student’s abilities and knowledge, and then work with the student and the patient to institute patient centred care.

Despite its obvious strengths, role modelling has been criticised as a passive activity that in itself is inadequate for the learning of multi faceted or situationally complex nursing activities (Ricer 1995). In contrast, however Davies (1993) claims that it goes beyond imitation as it involves many behavioural and affective linkages. Nevertheless there is a growing support for the need to add other elements to role modelling to make it most effective.

Goldstein (1973) suggested there were several deficits in role modelling alone if one were interested in changing attitudes and recommended a method of applied learning which was essentially role modelling and social reinforcement. In an experimental study of skill development, Hollandsworth (1997) also advocated directed feedback and found role-modelling, role-playing and discussion was superior to any one method used independently. Others have found that debriefing sessions in which students were encouraged to reflect on their practice increased retention of information (Davies 1996). Moreover, according to Clarke (1996) understanding the reasons for an action was important as knowledge of the philosophy behind the action. In accordance with this view, it follows that some knowledge of the phenomenon of nurse/ patient interaction may be an essential underlying theory for learning family care.

In order to be a positive, effective role model in my clinical area I became more self aware and tried to only model behaviour that I would want others to adopt. In order to maintain high professional standards attending various study days and workshops not only improved my clinical skills, but also offered me the clinical and educational support necessary to increase confidence, accountability, competence, reflection and safe practice. Positive role models influence students more if they are seen to have status, power and prestige (Quinn 2000). It is essential that all nurses are aware of recommended practice because undertaking practices which are not evidence based is not in accordance with the Scope of Professional Practice (NMC 2002). Through observation and discussion, students are able to develop clinical skills, interactions with clients, professional attitudes, problem solving and prioritising strategies. I am more empowered and hope to be able to educate fellow staff, students, patients and relatives. Once a skill has been learnt it does not mean that it cannot be improved or changed and I have learned not to become complacent. My future goals are to review my knowledge, while continuing to increase it along with new procedures and continuing professional development.

The student that I assessed was told of the purpose and nature of the assessment and their verbal consent was obtained. I assured the student that the logbook would be a record of my own experience of assessing and not the details or capabilities of the student being assessed. Confidentiality was maintained throughout the assessment and the writing of this assignment in accordance with the NMC Code of Conduct (2002).

Giving feedback is a verbal or non-verbal process through which an individual lets others know their perceptions and feelings about their behaviour (Black 2000). It is a very important interpersonal skill that effects change through influences and motivation. Students are encouraged to be independent learners in my clinical area and to define their learning opportunities in collaboration with their allocated mentor. Before offering feedback I considered barriers that could affect the intent of my message and worked out strategies to get round them. I ensured that the student I was assessing had set realistic goals and clear learning objectives and I also encouraged her to question me on things she did not understand. If no clear parameters have been set, negative feedback will come as a shock (Bartlett 2001).

The mentor should provide formative evaluation and feedback to assist the students to achieve their learning goals and demonstrate competence. If feedback is an integral part of the organisational culture, and if feedback is routinely given as small corrections and acknowledgement of good work, then there is much less chance of a negative reaction. Feedback is a return flow of ideas and opinions as the students are doing a job. Students need feedback on their clinical practice so that they can improve on their level of performance. Feedback can be seen as criticism and hence good communication skills are very important. Appropriate feedback can provide important information to students about the level of their performance. It can help them to rate their clinical practice in a realistic way. It can also help them to be more self-regulated.

Feedback should be completed soon after the event, before the student or the teacher forgot the details of the event. This can provide the stimulus for further learning. Some may react to feedback with excuses instead of listening and thinking about it. Greenwood (1993) argues that the feedback will enhance student learning when it provides further information to correct or modify action through the construction and activation of a more appropriate subroutines. With this information, the student should be able to move to a deeper level of understanding. Certain characteristics of feedback will promote constructive interaction between the student and the teacher and lead the student to address weaknesses in their performance and make changes to improve. Feedback should be focused on behaviour rather than the person, and on observations or descriptions rather than inferences or judgements.

The amount of information given to the student must be what the student can use, rather than the amount the teacher may wish to give. A feedback sandwich starting and ending with a positive statement with a negative statement in between approach should be used. Positive feedback reinforces knowledge and motivates people (Twinn and Davies 1996). Feedback should always be focused on behaviour that the student can do something about. Confidentiality and privacy must be respected when giving feedback; when giving negative feedback, it must be in an honest and sensitive manner and alternative behaviours should be suggested. It is always best to check that the student has understood the feedback. Milde demonstrated that visual and verbal feedback together is most effective.

Demonstration of specific techniques and good communication skills through role modelling and reflective practice by practitioners is suggested as one effective approach to integrate learning within various clinical learning environment. Feedback had the ability to enhance my performance and make me feel confident and competent in my role, especially when the feedback was immediate. It allowed for reflection in practice and offered me the opportunity to meet the NMC’s guidelines of reflective practice. I have developed skills in giving and receiving feedback and am able to determine whether the feedback is evaluative, judgemental or helpful. I am now constantly soliciting feedback as it enables me to gain other people’s perceptions and feelings about my behaviour. I accept it positively for consideration rather than dismissively for self-protection, which in turn helps me to be more responsible for my behaviour and consequences.

In conclusion, mentorship is about a partnership approach to learning by the student and mentor. The mentor and the student need to be aware of the competency level and learning outcomes, and each other’s responsibility in achieving these. The mentor is there to facilitate and assist the student in achieving learning outcomes in a variety of ways appropriate to the learning environment. The partnership between the mentor and the student is also based on effective communication and effective feedback on progress, development and performance – both positive and constructive on achievements and progress made. It is also through this partnership approach that students and mentors acknowledge each other’s role: the mentor is not only that student’s mentor, he or she is also an accountable and responsible nurse, patient advocate, member of the multidisciplinary team and he or she might be mentoring other students as well. In my role as qualified staff nurse I am able to appreciate the hard work and dedication of mentors in preparing students to become registered practitioners.