Reflection On A Mentorship Role In Medicine

During this reflective piece of work I will discuss my role, responsibility and accountability as the students assessor and reflect on approaches that I have used within the mentorship role to support and facilitate the student to achieve specified learning outcomes. The ultimate goal of mentorship is for one individual to contribute to the professional development of another. (Lanser 2000)

The NMC (2008) defines a mentor as a registrant who facilitates learning, supervises and assesses students in a practice setting. The student spends 50% theory and 50% in practice; practical training is an important and significant part of the nursing students education.

I was informed that a third year nursing student would be attending my practice area a number of weeks before the placement start date, I used this to my advantage by contemplating about learning opportunities within the practice area.

The NMC states that at least 40% of a students time at the placement should be spent with a mentor. Therefore the off duty had to be worked to reflect this, as now it is an NMC requirement for mentors to prioritise their workload to accommodate support of students. (NMC 2008) From my time as a student nurse the better placement experiences I had were when my mentor was well prepared and had thought about experiences that would enhance my learning.

I feel that it is essential that from the first contact with the nursing student you are building an effective relationship. The ultimate goal of mentorship is for one individual to contribute to the professional development of another. Prior to the students start date it is important that the student has been contacted and informed of location, uniform, start time and name of allocated mentor. Fortunately my student contacted my workplace a couple of weeks before her placement began. I took this opportunity to introduce myself and went through a little of what to expect. Baumeister and Leary (1995) suggest that if students feel accepted secure, valued and respected that it motivates the students capacity to learn and instils confidence. I feel that this initial contact takes some of that first day anxiety away. The influence of the mentor on the student begins at first contacvt and forms the foundation upon which the mentor/student relationship will be based upon.

The Nursing and midwifery council outlines eight domains of competency that a mentor must achieve in order to perform the role to an appropriate standard. These are: establishing effective relationships, Facillitation of learning, creating a learning environment, context of practice/ evidence based practice, assessment and accountability, leadership and evaluation of learning.

On my student Sarahs first day I had allocated time to orientate and introduce her to the practice area. It is the mentors responsibility to establish an effective working relationship with the student and this starts with orientating and the setting of ground rules.(RCN 2007) Whilst going through the formal, professional, legal, national and local requirements I was conscious about making the orientation a positive experience. I introduced Sarah to the rest of the community nursing team. Levett-Jones, Lathlean, Higgins and Mcmillan() in their study discussed the students need to feel like they belonged as when students feel comfortable they engage with learning opportunities. I believe that the attitude and motivation of the mentor are crucial in creating a encouraging start to the placement experience. (cited in Beskine 2009) Reflecting on my experience as a student the negative aspects of work placements were not being supported by my mentor and feeling under valued and by remembering such experiences I feel that it influences how I am as a mentor.

The benefit of working as a community staff nurse is that when a student is placed you work together on a one to one basis and have time to establish the student mentor relationship. Using this oppotunity to get an insight into her personality aswell as any concerns she has about the placement.

Although it is good to achieve a good rapport with your student Wilkes (2006) advised caution during the social development of the relationship as the professional boundries need to be clear, as getting involved with the student socially or emotionally outside of work would influence your integrity when perfoming assessments. Also as a mentor you act as a role model and The Code(2008) requires a nurse to be of good character honest and trustworthy basing this on ones conduct behaviour and attitude.

The NMC (2008) defines a mentor as someone who facilitates learning, supervises and assesses students in a practice setting. It also outlines that in order to do this effectively the mentor needs to have knowledge of the student’s stage of learning therefore selecting appropriate opportunities for that particular students learning needs.

After orientation and Sarah shadowing me on a few visits I felt it was important to conduct the initial interview so we could discuss learning needs and opportunities in my particular area. Sarah had not had a previous community placement and didn’t know what is available to learn therefore we had an informal discussion to identify the opportunities. During the initial interview I also established the students level of knowledge and expectations. I had noticed that Sarah was quite shy and was quite nervous. We looked through her portfolio from previous placements and she had passed each one. Also by reviewing the university requirements outlined in her portfolio I was able to see if Sarah was aware of her needs from this placement. My initial impression was that she may need more support than I had anticipated at her stage of learning. It appeared that she wasn’t confident in her abilities. Sarah did express that she felt she would require support and guidance as the community setting was a completely new experience for her. Its also important to consider that studies have shown that placements can be very stressful for students especially in their first and third years of training.(Stuart 2007 cited in Beskine2009) Taking my concerns into consideration and Sarahs request we then created a learning contract, the goals set were based on mutually identified need. I decided that initially I would become as Berne(1961) described nurturing parent to Sarah to demonstrate boundries to ensure she felt safe. Until her confidence grew, then the relationship would be on an adult-adult basis on the same level for discussions and mutual expectations. Although fluctuations between different ego state as different circumstances arise throughout the mentor student relationship. In order to help Sarah I felt that by acting as an advocate would promote her confidence and self-esteem. (Neary 2000) To formulate an effective learning contract it has to have essential components as described by Stuart (2007) learning objectives, the activities to facilitate these , strategies and resources for learning.

As a registered health professional you have a responsibility to ensure the safety of the public. Therefore by mentoring pre-registration nurses you are accountable for ensuring students fulfil their learning outcomes for your practice area and develop practice competence. (NMC 2006)

Assessing a student’s competence can become complicated by the mentor’s subjective view of what is competent? (Higgins and McCarthy 2005) Duffy (2003) concurs it is often easier to identify clear incompetence than those students borderline on achieving competence. Mentors need to address the issue of non-competence as soon as it is recognised. The study Duffy (2003) carried out found that mentors tended to give students the benefit of doubt. A view which has been highlighted in a recent survey in the Nursing Times (2010) which said 40% of mentors participating in the survey passed students as they could not provide sufficient evidence to back up their concerns.

Before meeting with the student to discuss the issue it is important to collect evidence which has lead to your concerns about the student’s competence. Going through assessment documentation can help highlight if learning outcomes are achievable for that particular students ability. This evidence would be helpful for you to explore/understand reasons why the student is not achieving and early discussion can prompt students to consider their practice thus facilitating progress. (Duffy and Hardicre 2007) As the student doesn’t seem to be aware of their limitations, for patient safety it is essential that you gently alert the student of their unconscious incompetence but if the motivation is there I would as a mentor be confident that they could develop competence.

Feedback is a large part of assessment and progression and in this particular issue it is important to provide feedback so the student is aware that they are not meeting the required standard. An effective mentor should offer honest and constructive feedback to students (RCN 2007) Constructive feedback is objective and non-judgemental and should be based on specific observation to encourage discussion and allow future learning to take place. (Pearce 2004) It can be tempting to avoid giving negative feedback but performance cannot be improved without knowledge of what was wrong (Stuart 2006)

Feedback to the student would be given in the form of the praise sandwich. NMC (2006) uses this form of feedback in its documents where it state that mentors should contribute to the evaluation of student learning and assessment experiences by proposing aspects for change as a result of evaluation.

Mentors should remain positive and supportive also try to empathise with the student and how they will be feeling. A learning contract/action plan that is formulated collaboratively with the mentor and student can specify what the student will learn how it will be achieved and the time scale in which its success can be measured. (Nicklin and Kenworthy 2003) The RCN also advises regular meetings between the mentor and student to discuss progression and make adjustments to action plans based on the students learning. (RCN 2007)

Ultimately the NMC in safeguarding the wellbeing of the public sets standards for pre-registration theory and practice competency and requires students to be fit for practice and purpose at the point of registration. (NMC 2008)

Some of the learning outcomes were easy to facilitate with experiences that were available from a community placement but others not so easily accommodated. In order to address this we discussed other specialisms within the community neighbourhood team where she could spend time to achieve outcomes.

In the initial interview with my student it was important to identify what stage of learning she was at and also determine her motivation to learning. Rogers (2002) suggests adults come to learning with intentions and that they have their own personal expectations of the learning process and hold personal reasons why they want to learn. After discussing mutual expectations from the placement it is essential to understand the student’s style of learning in order to best facilitate learning activities and opportunities and select appropriate learning strategies to integrate her learning practice and academic experience. Also to be effective learner’s students should also be aware of and understand their own learning style and manage their own learning. (Siviter 2004)

There are various theories on learning styles, I chose to give my student a questionnaire based on the theory by Honey & Mumford (2000). This model is broken down into four categories Activist, Reflector, Theorist and Pragmatist. The activist is open minded, enthusiastic and enjoys immersing themselves into new experiences. The characteristics of a reflector are cautious observers. Using all the information available to them to make conclusions. Theorists think things through in a logical manner and value rationally and objectivity. Finally pragmatist act quickly on ideas and are keen to put new techniques into practice.

My student felt that she was a reflector and was motivated by understanding nursing processes in order to be able to work well and be a valuable team member. I felt that the strategy I would commence in order to meet the needs of a reflective learner would be facilitating experiential learning followed by reflective practice. Students benefit from action planning to assist them through the transitional period onto new placement areas by setting goals (Quinn & Hughes 2007) A learning contract that is designed collaboratively by the mentor and student can specify what the student will learn, how it will be achieved and time span. (Nicklin & Kenworthy 2003). Considering this we decided to match the nursing procedure to be trained with specific learning outcomes from the student’s portfolio and discussed in the initial interview process.

Urinalysis was the skill that we focused on in this exercise. Therefore it was appropriate to teach this skill in the sluice area which was a quiet and spacious area where we wouldn’t be disturbed. We discussed possible reasons why as a nurse you would take this test for example infection and as a reflective learner I felt that I should explain how her ability and knowledge of urinalysis would benefit her when working as a fully qualified nurse. We then went through the procedure showing all the clinical equipment needed and different ways in obtaining a sample. I tried to relate to practice to enable the student to take what she has learnt to future placement areas.

In order for us to reflect on the task we went to a quiet office to avoid distraction. Studies have shown having quality time for reflection and one to one discussion with their mentor were very important to the student. Watson(2000)

I felt that the student centred teaching strategy worked well with this particular student as she learnt best by doing and reflecting on the procedure afterwards rather than just being informed by others. Kolb’s(1984) learning cycle describes four stages in the learning process from the experience to applying the new learnt information to similar situations, and therefore a component of reflective learning.

NMC (2006) suggest that prioritised workload while you are mentoring giving you time to carry out the mentor role. I ensured that the allocated workload would enable me to have more time for effective listening and discussion. Also it gave us the opportunity to discuss events of the day and reflect and give feedback on a daily basis.

The process of assessment I feel has to be continuous and developing with my student Sarah due to her lack of confidence I didn’t want to increase any anxiety by making formal assessments of her practice. As the ENB/DOH( 2001)document that a mentor should observe a students achievement of a period of time to ensure validity in assessment. Having identified the learning that needed to take place from the university portfolio and personal development on the students part as discussed in the learning contract. The NMC (2007) clearly outlines the requirements for assessments of student nurses. The students performance should be assessed in practice with accountability resting with the mentor who is carrying out the assessment. It is important that a student is able to self assess, and after our discussion in the initial interview Sarah did identify that she needs more support to enhance her self-confidence, and due to this we incorporated this in our learning contact along with the learning outcomes in her portfolio. It is also important for a student with confidence issues to self assess as they will see that progression is being made in their learning, therefore gaining confidence.(chap. assessment of student practice from uni lib) A continuous assessment of the students practice is a more reliable tool as supervising/assessing the student on a day to day basis in a relaxed environment it is more likely to reflect the true ability of that student. (Stuart 2007)

The NMC (2006) under the leadership domain specifies that mentors need to display leadership qualities within the practice environment. I feel that by planning series of learning opportunites for the student and prioritising workload to ensure time to support the student i have achieved this. Without planning or prioritising a busy workload it would inevitabley be to the detriment of the students experience.

Interim interview is the first more formal assessment of the students abilities/progress so far. The learning outcomes/competences were discussed and documented at initial interview in the form of a learning contract. I ensured that we had time to discuss Sarahs progress and competences. Although Sarah has made progress with her self-confidence there is still areas to improve therefore a new action plan was formulated and mutually agreed. We clarified the area of weakness and advised how she would progress further and arranged for her to work with other assessors within the team so to ensure fairness. (Gopee 2008) Feedback is essential in the process of formative assessment Pryor (1998) highlighted the importance of feedback not only identifying what the student has learned but also what they may accomplish in future practice. ( cited in Gopee 2008) Feedback should when possible be given in private (RCN 2007) as this would prevent other people from listening to any discussion. There is also the potential for the ‘audience effect’ (Quinn and Hughes 2007) where the student feels that everyone is watching or listening to the feedback in her performance. Feedback is most effective when given at the time or soon after and activity occurs. This ensures that the experience is still fresh in both mentor and students mind. Therefore the information discussed is more accurate and detailed making it more useful for the student. Not only is a mentor there for supervising and supporting the student it is advantageous to the student when giving detailed feedback it guides the to learn what is expected of them to improve that particular episode of nursing. My main concern was making Sarah feel comfortable when receiving feedback as within the interim interview there still remained things to improve on. I ensured that my body language was warm and open. Giving eye contact and smiling and nodding. It is important that when giving positive feedback she felt that I was honest and when discussing feedback on a more constructive basis she felt that I was self-assured in the information that I was imparting. We collaboratively devised an action plan for the last couple of weeks of placement. Involving Sarah enhancing her management skills and to gain confidence in her own decision making. The NMC (2004) state that prior to entry to the register pre-registration students should be able to manage the delivery if care with the scope of ones own responsibility. (cited Duffy&Middleton 20??) To facilitate this I delegated the care of patients within a residential home, as working in community it isn’t easy for the student to work independently without direct supervision due to visiting patients within their own homes. But in the residential home environment I was around but not directly supervising. At this stage in the placement I felt that Sarah had developed her confidence and that this experience would help in realising her own capabilities.

As Sarah had now spent a couple of weeks within the practice environment and within the community nursing team she began to open up about previous experiences whilst on placement. She felt that not all of her relationships with her mentor has not been a positive experience. Darling (1984) did some research about the mentor/mentee relationship and creating the learning environment and those mentors who didn’t create a positive environment he described as toxic mentors. Three different forms of the toxic mentor were dumpers, blockers and destroyers. The first of these describes those individuals who ‘dump’ there students into experiences out of there depth. Blockers were those who didn’t allow the student to partake in learning opportunities. Destroyers as the word describes, destroys a student confidence by undermining them and criticising without offering another possibility. Darling (1984) was also able to identify what the basic attributes that a mentor should possess, roles as an inspirer, investor and supporter. (cited in Pellatt 2006) Whilst discussing the subject with Sarah it became apparent that her confidence had been knocked by two negative mentor experiences in the past. As a girl who is quiet in nature was having trouble recovering from this. Refecting on my discussion with Sarah I came to realise the impact the mentor can have on the student and how detrimental this had been for Sarah.

I was fortunate enough to be able to take part in all of Sarahs placement and therefore feel that spending time with my student put me in a better position to assess and be content with my evaluation on Sarahs ability. It enabled us to focus on areas were highlighted in the initial meeting. (Stuart 2006)

Working in community one of the challenges as a mentor which you have little control over is the learning environment. Whilst for the interviews I was able to ensure we had a quiet room back at base. And reflective discussions took place in the car. The actual learning environment altered every visit to different homes. As Sarah hadn’t had a community placement before I felt that I would inform her of problems that may arise. These included poor hygiene, living conditions but also discussed that we live within a culturally and socially diverse environment.

The final interview is the only summative part of the assessment process as a mentor it is my job to reflect on the students abilities as a whole in my opinion and also draw on other team members experiences with my student. Therefore being an objective view, also by using the university portfolio as a guide to see if all learning outcomes have been completed. As a mentor I am aware of the accountability that I have when deciding if a student meets the required standard. Especially on a students last placement there can be no ‘benefit of doubt’ as the pre-registered student will not have time to develop before registration occurs. Time was allocated at the end of the final meeting to ask the student how she had found her experience with me as a mentor .

The role of the mentor is very important in the stage immediately prior to student nurses achieving registration is imperative in producing nurses who are fit for practice and purpose. (NMC 2004)

The study carried out by Duffy and Middleton(20??) concurred that a longer last placement gives students time to settle and become part of the team encouraging their confidence to grow. It enables the student to get their practical skills up to the required standard and also developing their management competences, an essential skill within the staff nurse role.

Unfortunately it must be acknowledged that not all students will achieve the required outcomes to become competent and safe practitioners. Duffy (2005) stated that there has to be the recognition that some students need to fail. It is important to be aware as a mentor the assessments that we are taking is to safeguard professional standards, patients and the general public. During my time with my student it was essential that both Sarah and i recognised her lack of confidence and doing so early as possible interventions can be initiated within the work placement to achieve the required competences.

As the mentor is accountable it is important that along with the professional standards and competences outlined, the NMC require that the registrants are of good health and character. Another aspect that the mentor is responsible for. Most teaching within the practice area does deal with all those aspects, the clinical skill itself and the interpersonal and management skills involved. The educational taxonomy considers that any learning topic has to be judged from three angles in relation to what the student has to learn. Those being psychomotor; the physical skills to conduct the duty. Cognitive; the understanding of the evidence base for the duty. Affective is the ability to conduct the duty with the appropriate communication and interpersonal skills.

The assessment was mainly continuous in a formative basis and using the aids of learning contracts and facilitating achievement of the outcomes by allocating patients and tasks, liasing with professionals. On all the tasks I felt that my student Sarah had arrived with a lack of confidence but through the process of practice feedback and reflection and the support she was given from myself and the community nursing team all of the outcomes were achieved well.

As a mentor it is my responsibility to identify and apply research and evidence based practice to my area of practice (NMC 2008) I think it is important that as a mentor you should assess your personal strengths and weaknesses as to me it is important that I gain confidence in my abilities as a nursing student mentor.

Feedback from the student perspective on the practice area as a learning environment is advantageous as it is part of the ongoing evaluation of the learning environment. As it reviews the learning opportunities and audits the placement so to develop skills of the professionals within the team. Enabling the workforce to contribute in developing the profession for the next generation of nurses. (ENB/DOH 2001) Also these audits will highlight the practice areas where students are struggling to achieve and thus giving the University opportunity to address the concerns.

The University have a responsibility to where possible ensure the placement has the necessary opportunites to facilitate adequate learning experiences to reflect the student experience. (RCN 2006)

Action plans are defined as ‘a must achieve device that identifies competences that need to be achieved by an identified date during the practice placement,non achievement of which would lead to a fail mark being awarded.’ (Gopee 2008)

It is essential within any assessment that a mentor perfoms you are prepared, fair ,objective, honest timely and give effective feedback. All these componets ensures that evidence collected and documented within the students portfolio is a true objective illustration of the students competences and ability.

Barriers that would affect the mentors role is documented by Gopee (2008) organisation, lack of resources, personality clashes attitude problems either student/mentor. As a mentor the main challenge in being able to perform mentor duties is that there is inadequate time to fulfil this role along with your clinical duties. Obviously on a day to day basis it is hard to forsee how your day may go as you never know what you will find when you open the door to each patient. But to minimalise this as much as possible I put my leadership and management skills into practice so that opportunites /experiences were planned to an extent and timetabled as much as we could with the nature of the profession. Therefore reassuring the student that I my motivation was that she got the best out of her experience within the community nursing team.

By setting an action plan also helps promote underlying skills such as planning, scheduling, goal setting, negotiations and management.

Skinners theory devised in1974 states that the environment is essential to any learning that takes place and if the environment is suitable then learning will occur as connections are formed from responses to stimuli and reinforcement of these occurs.(cited by Quinn 2000)

As part of Sarahs action plan we discussed other resources available to her for example having practice days with other professionals within the neighbourhood teams.

Nurses are expected to be able to validate their clinical decisions with research based evidence that results in care should be patient centred and clinically effective. (DOH 2000) Within the community some of the treatments we provide for example compression therapy for treatment of leg ulcers have a large evidence base for that treatment but also as a professional we also use the evience from patients living with these condtion and consider both those as evidence to provide a rational for certain decisions made about treatment. Fitzpatrick(2007) in her literature review found that opinions on what evidence based practice was depended on the perspective of the individual. Evidence can be sourced from experts, literature and views of patients.

All assessment descisions must be evidence based. This is seen as crucial as the future of the profession, in both its integrity and knowledge are in the hands of students currently training to become registered nurses. (Hand 2006)