Placements can be inspiring or demoralising. Much depends on the mentoring experience, as Jennifer Taylor finds out
For many students, clinical placements are their first taste of nursing in practice, and where they learn the hands-on skills of their profession. Mentors are key to the success of these placements but, unfortunately for many students, the quality of mentorship in pre-registration education is highly variable.
Students having inadequate access to mentors – because staff are on sick leave, holiday or other reasons – is the main reason why placements go wrong, says Gill Robertson, student adviser at the RCN. The result, she says, is that there is no consistency when it comes to setting goals and objectives, and assessing performance.
Even when staff are present, they sometimes feel too busy to support students, says Karen Elcock, director of practice and work-based learning at Thames Valley University.
‘Left to learn by themselves, students focus on tasks that they know well. These tend to be doing observations, bedmaking and washing, so they don’t ever get the opportunity to stretch and extend their learning,’ she says.
This situation might be fine for a first-year nursing student’s placement but, if this continues into the second and third year, students keep repeating the same skills without learning new ones, explains Ms Robertson. And, she adds, students are often afraid to speak up.
‘Even if students think a placement is poor because they’re not learning or because there isn’t enough time for them, they’re often unwilling to rock the boat. It’s very hard to complain because the mentor will be signing off practice placement documents at the end that determine fitness to practise.’
Some nurses are just not suited to mentoring. In spite of this, many have to take on the role because under NMC guidelines published in 2006 – Standards to support learning and assessment in practice – all nurses must mentor two students every three years.
‘People also take on mentor roles because they want to get promotion,’ says Ms Elcock. ‘But I think if we actually asked who really wants to be a mentor, there wouldn’t be enough nurses to mentor the number of students who are going through practice at the moment.’
She adds that students look to their mentors for guidance but often staff are not explicit enough about what they want them to do. ‘If the mentor says “go and talk to a patient”, the student thinks “what should I talk about and what do I do with the information they give me?”,’ she says.
However, Lisa Johnson, nurse education lead at Ipswich Hospital NHS Trust, says first-year students on their first placements sometimes have unrealistic expectations.
‘I think for some of them, the fact that it’s not 100% close supervision can be a little bit of a shock,’ she says.
Personality clashes are another problem for both students and mentors and it is one where practice education facilitators can help. Also called clinical placement facilitators, these staff liaise between students and mentors.
Ms Robertson says they have made a difference in improving the mentoring experience for both parties. ‘Students like them,’ she says. ‘If they’ve had a row with their mentor, they like to have someone who can come into the ward with them and mediate between them.’
She adds that mentors like them because they can help put measures in place to support weak students. Otherwise, students may pass their placements because mentors are reluctant to fail them and jeopardise their career opportunities.
Poor mentorship means that students lack role models, says Ms Elcock. One problem is that students are often left with HCAs.
‘If they spend the majority of their time over three years with HCAs, the students are not stretched to think critically because these staff are very focused on doing tasks but not necessarily looking at the underpinning knowledge around them,’ she says. Poor mentorship demotivates students, which can affect attrition. ‘Most people come into nursing because they want to nurse, so the practice element is the most important to them,’ explains Ms Elcock. ‘If they’re not enjoying that, then they can’t see the point in continuing.’
Once students are allocated to a ward, induction is key to a good placement, says Keith Bradley-Adams, practice facilitator at Neath Port Talbot Hospital, which is part of Abertawe Bro Morgannwg (ABM) University NHS Trust. ‘As long as the student gets a really good understanding of what happens in the ward and the opportunities available to them, then they should have a successful placement,’ he says.
His trust has induction packs for each clinical area but he adds that the better students contact the ward to find out as much as possible before they arrive. Students should ask about the type of ward it is, shift times, the experience available and about housekeeping issues such as where to put their belongings, transport or parking, and whether there is a canteen.
It is common practice for every student at ABM University NHS Trust to be allocated two mentors on the first day they arrive on the ward, after which they will spend 40% of their time with either of their mentors.
Students say they like it because they know from the outset which mentors they will be working with. While all nurses work to the same policies, procedures and guidelines, the advantage of students having two mentors is that they learn more through the two different approaches.
It’s also better for assessment, says Mr Bradley-Adams. ‘Sometimes, there are personality clashes but, if you’ve got two mentors, it’s far more likely that there will be an objective assessment taking place.’
He adds that if a student fails, often their first instinct is to blame the mentor. ‘If two experienced practitioners are making the same judgment call then it’s likely they’re telling the truth,’ he says.
Achieving standardised, high-quality practice in student mentoring has long been a priority for the NMC. For this reason, it decided to tighten up practice through its 2006 standards for supporting learning and assessment in practice.
Under these guidelines, to be a mentor nurses need to have been registered for at least one year. They have to attend annual updates at which they can discuss any problems in assessing students’ fitness for practice and must undergo a triennial review to show they continue to meet NMC mentor requirements.
First-time mentors must take an NMC-approved course at a university. This is normally part time for three months and includes 10 days of protected time.
A new role of sign-off mentor has been introduced in the new standards. Staff in this role are responsible not only for determining that the student is proficient to enter the register but also, significantly, are held accountable by the NMC for their decision.
There is no set period for the sign-off mentor’s liability, says Jan Goldsmith, professional adviser for education at the NMC.
‘It is no different from any other area of practice in that any registered nurse or midwife is accountable to the NMC for their actions and must always be able to justify their decisions,’ she says.
As long as a sign-off mentor can demonstrate that they made a safe and appropriate decision, having taken account of the evidence available at the time, they could not be held accountable for a mistake a student made after qualifying,’ she adds.
Nevertheless, nurses are nervous about an increased level of responsibility. ‘A lot of people are saying “I don’t want to be a sign-off mentor”,’ says Ms Elcock. ‘They’re finding it quite daunting. Nurses are frightened that a student they sign off after three years could do something wrong after they have qualified, and they would then be held responsible for this.’
ABM University NHS Trust is one of the first to have implemented the sign-off mentor role, with students who finished
a return to practice programme in July.
To put the role into perspective, Mr Bradley-Adams compares it with being a driving test examiner. ‘What they’re giving really is a snapshot. They’re saying that, at that time, the student was safe,’ he explains.
Student educators hope that once the NMC’s new standards bed in, they will improve the quality of mentoring and, in particular, ensure that weak students will be identified and supported.
‘If they are failed earlier on, we can work with them to help them improve,’ says Ms Elcock. ‘Whereas if it gets to the end of their training it’s far harder to make those corrections because they’ve got three years of ingrained poor practice,’ she adds.
‘I’m hoping the standards overall will make a difference across the three years.’
How problems arise
Rebecca O’Reilly – Third-year student
Rebecca is a third-year nursing student at Swansea University. When NT spoke to her, she was in the last few days of her final placement, the management placement. She was on Ward F at Neath Port Talbot Hospital, which has 23 acute beds and two detox beds allocated for the community drug and alcohol team.
During her placement she has been helping her mentor, Anna, who is a staff nurse, to review care plans and risk assessments.
Rebecca says: ‘Anna has been a really, really good mentor and has shown me the running of the ward step by step.’ Having a good placement experience has left her feeling prepared that she will be able to fulfil her role as a nurse.
She says it is important that mentors give students their time and adds: ‘A good mentor is a nurse who can empathise with you and remember that they’ve been a student themselves.’
Anna James – nurse mentor
Anna recalls that before she qualified in 2006, she had a range of placements with good mentors. They were positive about helping her get involved to learn new things and she has used that approach with Rebecca.
‘Rebecca has been involved in managing groups of patients and taking ward rounds. All of this has been under supervision but she has taken a lead role in it,’ she says.
The final placement is where all of the training fits together, she explains: ‘All students get to their management placement and worry that they have nearly qualified but don’t have enough knowledge. But once they complete it, they become confident in the majority of their skills.
‘When you’re a student you can’t imagine being qualified and mentoring others,’ she says. ‘But this has been a really positive experience.’