Mentoring and Enabling Learning in the Practice Setting

Introduction

The focus of this assignment is on the delivery of mentoring and assessment within nursing practice. The author is a mental health nurse working within a home treatment team in East London. The identified learning need is that of administration of a depot injection, a common element of the nursing role with patients with mental illness. The target audience is a student mental health nurse. The team is a multidisciplinary one with students from different professions all placed within the team for specified learning experiences and time periods.

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Mentors are usually assigned a student for the duration of their clinical placement. They meet with the student at the beginning of the placement to agree learning outcomes and plan learning needs, and then work with the student for a minimum of 40% of their clinical placement (NMC), and then complete their assessment documentation towards the end of the placement. This usually involves passing the student for competence in identified clinical skills.

Part Two – The Role of the Mentor

The role of the mentor within the nursing context is complex, because it involves teaching, facilitation, support, guidance, assessment and feedback^[1]. Assessment of a student nurse during their training is in relation to key clinical competencies, as defined by the NMC Standards of Proficiency for Pre-Registration Nursing Education^[2]. These competencies are then translated into clinical assessment areas as defined by the student’s University, and assessed against their definitions. The NMC are clear about the expectations of the nursing role in clinical practice, in relation to competence and responsibility “the nursing role involves a capacity not only to participate actively in care provision but also to accept responsibility for the effective and efficient management of that care” ^[3]. Therefore, mentoring involves not only teaching discrete clinical skills but the more complex issues of demonstrating the management of care for individual clients according to their needs. Mentoring involves the consolidation of theoretical and practical learning acquired during the student’s academic experience within the University teaching and learning setting, and applying that knowledge to practice^[4]. Therefore, it is important that mentors not only act in a way that is appropriate to their professional role and the expectations of their employer, but are also aware that theirs is the standard against which students will measure their own conduct and competence.

The role of the mentor is to teach within the clinical setting, therefore, all formal teaching which takes place is clinically oriented and clearly relates to the performance of the professional role^[5]. Research by Lloyd-Jones et al^[6] seems to indicate that not only do students get the best out of their clinical placements through the student-mentor relationship, but that the quality of their learning and development is linked to the amount of time that they spend with their mentors. Therefore, mentors need to understand that their role involves a commitment to working with their named student and supporting their learning through this close working relationship^[7][8].

The role of the mentor also involves assessing the student, against competency standards defined by the NMC and by the student’s educational institution. The NMC now requires that some mentors are sign-off mentors, which means that they sign-off the student as competent at the end of their training, and share equal responsibility with the awarding institution for that student’s competence to perform their professional role. In midwifery, all mentors must be sign off mentors. Regardless of this, it is a significant responsibility for any mentor to assess a student and confirm they are competent in key areas of clinical practice, and therefore mentors are educated and supported to understand the teaching and learning processes involved, especially in identifying how to assess competence. Some research shows that assessment can be carried out in a tripartite agreement between student, mentor and a member of the academic staff of the university (usually the student’s personal tutor)^[9]. This kind of close working relationship has many benefits, for the mentor, the student and the academic institution, and in relation to the assessment role of the mentor, provides valuable support^[10]. This also shows that another role of the mentor is that of close liaison with academic staff in relation to student progress and assessment, student conduct and behaviour. While not all institutions have this three way set up per se, many use this kind of arrangement to address student problems in achieving the required levels of assessment. Despite there being examples of good practice such as this, however, the demands of the mentorship role mean that there is still a deficit between the theory and practice of mentoring, which needs more attention^[11].

The challenges of mentorship from my perspective reflect these issues in the literature. The demands of meeting identified student needs are partly met by the training and support for mentors, but the realities of providing client-centred care whilst supporting student learning mean that the teaching and learning opportunities are not always maxmised. Developing a good relationship with students is also usually easily addressed, but there are times when it is not possible to develop a good relationship with some students and I have been aware in the past that this impacts on the quality of the learning experience. Another issue is managing students who are not achieving their designated competencies, and this process, while supported by the academic staff, is very stressful for all involved. It seems to me that the mentor role is not valued by the employer either, and in a busy workload, the required time for mentors to spend with students to provide the right kind of feedback is not factored in. However, I am also aware that this is an evolving area, and that practice is changing in line with the published standards for the preparation of mentors. Ultimately, as a mentor I have a strong commitment to ensuring the standards of the profession are maintained, and being a mentor allows me to make a valuable contribution to practice and to the profession in this way.

Part Three – The Assessment Plan

The author set out to assess the student’s ability to carry out a depot injection, and so set up a teaching plan and assessment plan accordingly (see Appendix). Carrying out this assessment plan involved reviewing the theories of education and learning which are most relevant to the type of assessment, some of which will be discussed here. This author is aware of the theories which underpin nurse education and learning, and will address some of these here, believing that these theories still help explain how student nurses come to develop the abilities, knowledge, skills and capabilities which allow them to fulfil the requirements of the nurse’s role. Therefore, the teaching plan and the assessment plan build on this theoretical knowledge in order to maximise the student’s opportunities to learn and become competent in the chosen skills^[12]. Behaviourist theories suggest that learning takes place through stimulus response learning, and through operant conditioning, through which students’ behaviours are changed through observing, and through reactions to their own behaviours^[13]. In order to build on this, the nurse demonstrates the procedure and the kinds of behaviours that are associated with the procedure, including communications behaviours. This would need to be reinforced by discussion of these behaviours, and it is argued that basing learning only on behavioural principles is not adequate to meet the challenges of nursing learning. Cognitive theories are those which also underpin the author’s approach to teaching and assessment. Within cognitivism, which is orientated towards scientific and positivist principles, the mind of the learner is equated with theories about computing and how computers work, and knowledge is viewed in terms of symbolic mental constructs, or schema; learning can be said to have taken place when there is a change in the learner’s internal cognitive schema. Therefore, learning is said to have taken place when the individual’s behaviour has changed following acquisition of cognitive learning^[14]. Within cognitive theories, learning is based around the acquisition of factual information, and while there is no requirement for learning to have been processed on a deeper level, it does mean that the relevant knowledge has been assimilated by the learner ^[15]. Both of these theories, however, underpin much of the assessment process, because the mentor is looking for behaviour change, based on the student’s demonstration of behaviours, both physical and more interactive, and also looking for the student to be able to demonstrate the acquired knowledge and facts associated with the skill^[16][17].

However, having carried out the assessment plan, the author also learned that it is hard to assess students on their attitude and behaviour with clients. The mechanics of a procedure can be easily observed and evaluated, but the effect of being observed and assessed may affect the way the student nurse interacts with the client. The client is another factor which may affect this process as well, because the client/student relationship, particularly within a mental health setting, may not be well developed, and may be more difficult to establish. However, it is this author’s experience that the mentor’s approach, manner and preparation of the client and student can ameliorate this kind of difficulty considerably.

Part Four – The Teaching Plan

The teaching plan (see Appendix B) is based on two different theories. The first are the constructivist theories of learning, which suggest that people learn in an active way, and through this process, construct for themselves subjective forms of ‘reality’, within which the pre-existing knowledge and ‘reality’ assimilates any new learning^[18]. The second theoretical basis for the learning plan is that of humanism, a theory which supports a more nursing-oriented approach to learning, focusing on self-development and on the individual becoming what they are capable of becoming through the learning process^[19][20]. There is, however, some argument that all of the theories discussed so far are eminently applicable to nursing education, because the process is cognitive and behavioural, and combines the acquisition of facts with the competent performance of key nursing skills. Knowledge underpins practice, and helps to develop clinical reasoning, but experience helps students to reconfigure their internal schema and their deeper understanding of the world, albeit subjectively. The most important learning theory here which relates to nursing education and, in particular, to the learning which takes place in clinical practice, under the guidance of the clinica mentor, is Bandurafs Social Learning Theory^[21], because it seems to be the theory which best describes how adults learn within this context^[22].

Bandura’s social learning theory, suggests that people essentially learn from observing and imitating each other in social situations, and that through this learning process, people model themselves on others, and learn from them not only how to behave, but also acquire attitudes, and an awareness of the probable consequences of the observed behaviours^[23]. What this theory offers in particular to understanding how learning takes place in the clinical nursing context is a model which incorporates other influences on learning, including cognitive processes, the ways in which behaviours are modelled on role models, the effect of the learner’s personality, and the effect of the learning environment ^[24]. This theory is helps mentors to understand the complexities of nursing competence and its development, which requires the combination of cognitive elements, some of which may be learned in a formal classroom setting, with the modelling of behaviours of student nurses on the mentors who act as their role models^[25]. While it is clear that the clinical learning experiences of student nurses are key to development of a good knowledge base^[26] and proper professional competence^[27][28],^[29], the quality of mentorship must be considered, because through social learning theory, students come to model themselves on what they are seeing practice^[30],^[31]. This can present its own challenges, particularly when the students are not being supervised or taught by their primary mentor but by a buddy mentor^{[32] [33]}. There are those who argue that this is necessary, to expose students to different role models and behaviours, so that students can then develop their own critical thinking and judgement^[34][35], through observing different forms of clinical reasoning^[36].

The assessment processes built in to the mentoring relationship are a very important feature of learning and development, because student nurses must learn from any errors and omissions, and this continues on into their professional practice once qualified^[37]. Learning to manage one’s own learning and development, identify ways to learn from errors or difficult situations, within the practice setting, reflects the principles of social learning theory^[38]. However, the author is also aware of the need for students to develop a realistic understanding of practice, and how the errors and challenges which can arise during their clinical work may be related to them not having the knowledge and skills needed to meet the needs of the clients^[39], and thus learning is about identified how to develop to meet those needs nursing l^[40]. Ulitmately, becoming a nurse means the ability to meet the standards of the profession, through knowledge,^[41] skills, clinical reasoning, critical thinking and application of experiential and theoretical evidence to practice^[42], which is quite demanding for all those involved in the training of students. Ultimately, student nurses are socialised into their profession as well as being trained how to perform their role, ^[43], and while this in itself may not always be an ideal, because the organisational culture may not always be positive^[44], it is important for students to learn all aspects of the profession^[45][46].

Although there is always the possibility that nurses may learn good as well as bad behaviours, ^[47], a good mentor would support such students to develop the critical awareness and reflective skill to be able to identify the positive models and reject the negative models as part of their learning journey^[48].

Part Five

Personal Development and Learning as a Mentor

The process of learning to become a mentor has opened new vistas of experience and knowledge for me, as a nurse, as a mentor, and as a person. While it is challenging to hold up a mirror to oneself and appraise what kind of role model you are presenting to the students you are working with, this is a positive experience because it allows you to identify your own strengths, and celebrate them, whilst also identifying your weaknesses, and take steps to address these. In particular, for me it has demonstrated that while my practice is good, my understanding of some issues is not based on the latest evidence available, and working with students who ask about the evidence base for practice really motivates me to seek out that evidence. I have also become aware of my own tendency to make value judgements, labelling students good or bad, and I have examined the qualities which lead to these as well as overcoming this unconscious stereotyping. ~I learned that I wanted to empower students to take charge of their own learning^[49], but learning how to do this was a longer process for my own development.

Learning about learning is also a process of self-discovery which is then applied to mentorship practice. Understanding assessment principles and learning theories has changed the way that I ‘teach’ students and really given me insight into how assessment can best be carried out. It has also helped me to understand the terminology used within the clinical assessment documents. The need to develop better working relationships with the academic staff has also emerged as a feature to be applied to my future practice.

Overall, this experience has shown me that mentorship, which can be onerous and demanding in the current clinical situation, is also an investment, in the future of the profession and in the future wellbeing of clients. It can enhance my own capabilities, and provide me with more opportunities to reflect and to reconsider my professional personal and competence. Ultimately, I aim to be a good mentor, but in order to do this, I must be a competent nurse. Therefore, the process has been a form of reciprocal learning.

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Appendix A

Assessment Plan

Competence to be assessed: administration of depot injection

Plan

• Check student knowledge and simulated technique prior to administration
• Prepare student and client for procedure.
• Observe student and assess stated assessment points.
• Provide feedback to student.

Assessment Points

• Student has checked prescription is correct
• Student has checked prescription against client identity and care plan.
• Student has discussed procedure correctly and appropriately with client.
• Student has ensured client confidentiality and privacy during procedure.
• Student has discussed effects/side effects with client
• Student draws up correct dose, checks drug properly with qualified staff, and prepares to administer injection in correct site.
• Student performs injection with correct technique
• Student communicates with the client appropriately
• Student records procedure in appropriate records, correctly.
• Student ensures client is comfortable post-procedure.
• Student can discuss properties of medication, side effects, route, dose and any contra-indications
• Student can discuss holistic care of the client.

Appendix B

11

Footnotes

^[1]Andrews, M. and Wallis, M. (1999)

^[2] Nursing and Midwifery Council (2004) p 8.

^[3] Nursing and Midwifery Council (ibid) p 8.

^[4] Mattila, L-R. and Eriksson, E. (2007) p 569.

^[5] Phillips, R.M., Davies, W.B., and Neary, M. (2008) p 1080

^[6] Lloyd-Jones, M., Walters, S. and Akehurst, R. (2001) p151.

^[7]Bankert, E.G. and Kozel, V.V. (2005)

^[8] Lloyd-Jones (Ibid) p 160.

^[9] Doughty, R., Harris, T., and McClean, M. (2007)

^[10]Doughty et al (ibid)

^[11] Myall, M., Levett-Jones, T., Lathlean, J. (2008)

^[12]Knight, P. (1995)

^[13] Learning Theories Knowledgebase (2008)

^[14] Learning Theories Knowledge base (ibid).

^[15] Learning Theories Knowledgebase (ibid)