Findings from the first phase of a study undertaken to explore the learning community education adviser role.
Authors Karen Elcock, MSc, FHEA, PGDip, BSc, RNT, RN, Cert Ed(FE), is project leader learning communities, practice education support unit; Dave Sookhoo, PhD, MEd, BA, DipN, RNT, RMN, RN, Cert Ed, is principal lecturer (research); both at the Faculty of Health and Human Sciences, Thames Valley University.
Abstract Elcock, K., Sookhoo, D. (2007) Evaluating a new role to support mentors in practice. This is an extended version of the article published in Nursing Times; 103: 49: 30–31.
BACKGROUND Concerns about the variable quality of mentorship in practice for pre-registration nursing students and the perceived lack of support through the link lecturer role led one university to introduce learning community education advisers (LCEAs). This new role focuses primarily on mentor preparation and support.
METHOD A qualitative approach using focus group interviews was adopted to explore the role experiences of the five LCEAs. Recorded interviews were transcribed and analysed using thematic analysis.
RESULTS Isolation, social presence, misperceptions and self-regulation were the main themes described by people in the new role. Social presence and clarifying misperceptions were prominent when supporting mentors in practice.
CONCLUSION Early indications are that this role is influencing the quality of learning in practice. There are lessons to be learnt about how service-education partnerships can support the implementation and advancement of this and similar roles nationally.
Mentors play a pivotal role in supporting students in practice. Unfortunately, the quality of mentorship in pre-registration nursing education is highly variable and a cause for concern, since it is mentors who assess students’ fitness for practice at the point of registration.
One response to these concerns has been the implementation of new roles with a remit to facilitate and enhance practice learning. This article presents the findings from the first phase of a study undertaken to explore one of these roles - the learning community education adviser (LCEA) - implemented at Thames Valley University (Sharples et al, 2007). The main remit of role is to support and develop mentors in practice. While post-holders are employed by the university, they are based primarily in practice.
The role of mentors in supporting pre-registration nursing students in the practice environment has been widely explored (for example: Pellatt, 2006; Lloyd Jones et al, 2001; Gray and Smith, 2000; Neary, 2000; Andrews and Wallis, 1999; Spouse, 1996). There is a consensus that mentors are pivotal to the success of student learning (Pellatt, 2006; Andrews et al, 2005a; 2005b; Gray and Smith, 1999). Research evidence has shown a number of factors affect the quality of the mentorship students receive, including:
Conflicting demands on mentors between supporting students and caring for patients, which mean students are often left unsupported (McArthur and Burns, 2007; Wilkes, 2006; Corlett, 2000; Neary et al, 1996; Twinn and Davies, 1996);
- Inadequate preparation for the role of mentor (Watson, 2000; Watson, 1999; May and Veitch, 1998; Neary et al, 1996);
- No protected time for the role (Watson, 1999);
- Lack of understanding of students’ programme (Corlett, 2000);
- Lack of understanding of students’ role in practice (Elcock et al, 2007);
- Variable support from lecturers because of the demands of teaching, research and publishing (Barrett, 2007; McArthur and Burns, 2007; Pollard et al, 2007; Duffy, 2004; Drennan, 2002);
- Difficulties in using practice assessment documentation (McCarthy and Murphy, 2007; May and Veitch, 1998; Twinn and Davies, 1996; White, 1996).
One consequence of these issues is that mentors do not fail students who are not meeting their practice competencies (Wilkes, 2006; Duffy, 2004; Watson, 2000). This is a major cause for concern, since only mentors can determine students’ fitness to practise (NMC, 2006).
An increasingly popular response to these issues has been the introduction of new roles. These have various names: practice education facilitators; practice educators; and clinical placement facilitators (Jowett and McMullan, 2007; Magnusson et al, 2007; Mallik and McGowan, 2007; McArthur and Burns, 2007; Lambert and Glacken, 2005). The roles were highlighted in a national evaluation of the Making a Difference curriculum as the most effective development of recent years (Scholes et al, 2004). While all focus on enhancing the practice learning environment, their implementation has varied in relation to title, employer and specific remit.
In Ireland, 120 clinical placement coordinators were employed by hospitals to support pre-registration nursing students on clinical placement before the introduction of mentorship (Drennan, 2002). Three practice placement facilitators (PPFs) were brought in in the North East of England (Clarke et al, 2003). Each of the PPFs was seconded from practice by the university and attached to one NHS trust each. In Scotland, 100 whole-time equivalent posts were funded jointly by the Scottish Executive Health Department, NHS boards, higher education institutions (HEIs) and NHS Education for Scotland (McArthur and Burns, 2007). More recently, Jowett and McMullan (2007) described a joint initiative between an HEI and its NHS partners to introduce 23 practice educators linked to 11 NHS trusts.
Common to each of these roles is one or more of the following responsibilities:
- Support and teaching for pre-registration nursing students in practice;
- Support to mentors/clinical staff;
- Placement management.
The learning community education adviser role
The LCEA role was created in response to increasing concerns over the quality and level of support provided by mentors and lecturers to students on practice placements. Six full-time posts were recruited in 2004-2005, with four currently remaining in post. The role covers six key areas:
- Mentorship support;
- Support of learning in practice;
- Assuring the quality of the practice learning environment;
- Co-ordination of academic support to practice;
- Learning community development;
- Communication link between practice and the university;
- Scholarship in practice learning.
The six posts were paired so that two each were based within a defined geographical boundary known as a learning community within which students rotate during their three-year programme (Thomas et al. 2002). In two of the learning communities, one LCEA covered the acute trust and one the local primary care trusts (PCTs). In the third, a very large mental health trust, the LCEAs divided the trust between them. Each learning community has provided office space for their LCEAs, who also have a ‘home’ at the university within the practice education support unit (PESU) and are attached to a subject group within the faculty. Each LCEA was employed full time with only a small teaching commitment, delivering the mentor preparation module and some skills teaching to pre-registration nursing students in the simulation centre, the expectation being that they would spend the majority of their time in practice. University lecturers have maintained their link to practice reviewing specific roles and responsibilities. Also attached to each NHS trust and PCT were clinical placement facilitators funded by the strategic health authority but employed by the trusts. Their remit was around the quality of the placements, developing placement capacity and mentor development. Given the potential for overlap the LCEAs and clinical placement facilitators work closely together and the LCEA role has evolved to encompass the following:
- Updating mentors;
- Supporting mentors and students when there are concerns about a student’s performance in practice and assisting them to develop an action plan, with follow-up review visits as needed;
- Auditing placements;
- Teaching mentors and managers to use the university practice education website to maintain the on-line profile of the placement area, access the allocation list and review student evaluations;
- Orienting students to the learning community;
- Organising and leading students’ first practice experiences which are a series of visits and learning in practice days;
- Advising students and mentors where the student has disclosed a disability;
- Assisting mentors to develop learning activities for students;
- Developing a mentor newsletter, handbook and CD-ROM.
The aim of the study was to evaluate the LCEA role and LCEAs’ contribution to mentor preparation and learning in practice. The research question was: ‘What were the experiences of LCEAs in their role in practice?’
Ethical approval was obtained from the faculty research ethics committee. All participants were given an information sheet describing the study. Written consent was obtained before starting the focus group.
It is always a challenge to maintain anonymity and confidentiality with such a small number of participants, and this was discussed with them. As the lead investigator was the LCEAs’ manager and had been closely involved in the development of their posts, a person outside the team undertook the focus group interview.
The main study was a mixed methods approach, using focus groups in conjunction with sample surveys. The first phase consisted of three focus groups, one with the five LCEAs and two with university academic staff. This article discusses the findings from the LCEA focus group. The next phase of the study will involve a survey of the mentors that the LCEAs support. A focus group interview was selected as the method most appropriate to elicit qualitative data.
Focus groups are designed to obtain information from a small group of participants, on a topic of interest to learn more about the phenomenon. The primary purpose was to collect qualitative data from the LCEAs in order to gain insights into their reflection of the social and professional realities, experiences, perceptions, attitudes, opinions and aspirations.
The five LCEAs in post at the time agreed to take part in the focus group. There were four women and one man, with a range of nursing backgrounds and years of clinical experience. Each had been recruited from practice rather than from the university.
Data collection and analysis
A semi-structured schedule of questions was designed to act as prompts and guide conversation, with the moderator adopting a flexible but focused approach. The focus group lasted approximately one hour and 15 minutes and was tape-recorded.
The tape-recorded interview was transcribed verbatim and the data analysed using thematic analysis. Two researchers analysed the data to ensure rigour and consensus. In this instance, the analysis was not fed back to participants.
The overall aim of data analysis was to present common meanings (themes) that emerged and to clarify distinctions and similarities.
The themes that emerged from the focus interview were:
- Social presence;
- Misperceptions of role.
The latter two themes are explored here as they focus particularly on how the LCEAs support mentors across very diverse practice settings.
The LCEAs were distinctly aware of the impact their role was having in the learning environments.
In the absence of a direct role to support mentors previously, mentors relied on link lecturers for support to manage students’ supervision and assessment. With the LCEAs based in practice, mentors and students ‘felt’ their presence even when they were not physically present. Thus, the LCEAs’ involvement and engagement with students and mentors was reflected in their ‘social presence’. It began with their visibility and physical presence in the learning environments, to be seen and to be identified as such:
- ‘A lot of the role was about being present and being seen as being out there.’
- ‘Saying…I am here for you … I am here for you; I am here for you … to [the] mentors.’
Interactions with mentors were through varied approaches, namely face to face, by telephone and by emails. The social presence was reflected in the ‘being there’ phenomenon often referred to by the LCEAs when describing mentors’ responses to their role.
- ‘If I ever went to a ward and said that I couldn’t help because I had to be at TVU teaching they would just automatically put me in the same box as every other lecturer they have ever had - that’s it, that’s the end of our support.’
In the early stages, the LCEAs quickly identified that mentors required much practical help on how to support students and manage the challenges they sometimes pose.
- ‘And when I went into post they needed so much day-to-day practical support … proactive and reactive.’
The reactive and proactive role was described as:
- ‘Having a preventive but also a reactive role … so the training update is still about preventing … any future problems, but should there be any problem with the mentors and students, then we have a reactive role as well.’
- The biggest challenge for mentors was around failing students. This is where the LCEA presence became important, as they explained the processes to be followed and ensured that due process was adhered to.
- ‘If you need to fail this student, you need to follow the process, you know It’s about doing it the [right] way, in doing it that way it safeguards your interest and the student’s.’
- As mentors started to call on the LCEAs for help with students they began to gain in confidence, with LCEAs stating that mentors were now reporting that they felt empowered to carry out their professional responsibilities. Through their interpersonal, professional relationships and working with mentors in the learning environment in sometimes difficult situations, the LCEAs were enabling mentors to become competent in dealing with the learning, supervision and assessing processes.
- ‘Empowering mentors to do the job.’
Another illustration of the empowerment of mentors came from the observation that mentors were enthused and became more confident.
- ‘They are doing it themselves, because they feel confident. Before they were so scared to talk to students, really scared … these are registered nurses with years of clinical experiences.’
Misperception of roles
There was ample scope for the role to be misrepresented or misinterpreted by colleagues. Historically, role definitions in practice settings have been diffuse and varied. Many role titles such as clinical teachers, link lecturers, lecturer practitioners and clinical education facilitators have specific responsibilities and focus on working with students and not always directly with mentors. It is not surprising, then, that there was some degree of role misrepresentation. In the early days when an LCEA arrived in a practice setting, it was not unusual for a mentor to say: ‘You have to make an appointment - I have not got a student out here. Why not come next week?’
The expectation was that the LCEA had come to see the student rather than the mentor, which reflected how link lecturers had managed their visits in the past.
Interestingly, although the clinical teacher role was abandoned in the late 1980s, the view of educators as clinical teachers still persists:
‘We would be asked by the trust to teach students how to do … we had been asked to do medication round and we are like, mmm … that’s not my job, mentors are there doing that. How insulting is it to the mentors?’
These tensions were gradually resolved through the clarification of roles, and agreement over responsibilities for different aspects of the learning environment. In addition, the LCEAs produced a twice-yearly newsletter for mentors that helped to clarify their role.
Students were also initially confused by the role, which one LCEA explained as follows: ‘If I give you a fish you will have dinner, that’s great, but if I teach your mentors how to fish … they are going to see far more students than I ever will…’
Working with and developing one mentor would affect all the students that mentor would support, whereas working with one student affected only that student.
‘And then some students who get it who totally get it … there they totally understand I can’t be everywhere at every point … some students understand that.’
Unfortunately some students saw the LCEAs as a threat:
‘And sometimes the students get very, very, very concerned about who I am and what I do and they get really confused … and they get very distressed, and I have been the butt of a lot of anger because of it, despite what I say.’
This negative response arose when mentors called in the LCEA to help and advise when they had concerns over a student’s performance. With the support of an LCEA, mentors were enabled to voice and document their concerns and if necessary to fail students. It is likely that through the student grapevine, students became aware that the LCEA’s presence meant the outcome of their assessment would be put under joint scrutiny and they would be unlikely to succeed if they were underperforming.
Underpinning the implementation of any new role that spans practice and education is the collaborative partnership between the NHS and the HEI (Department of Health, 1999). At each site the role was discussed in advance, a practice representative was on the interview panel and information was sent to all staff at the university.
Despite this, concerns were still raised about the role of the LCEA and how it overlapped with similar roles such as the clinical placement facilitator and link lecturers, who also saw their role as encompassing mentor support. Certainly, another aspect that warrants critical consideration is active student inclusion in the wider dissemination of innovative roles within learning in practice and nurse education in general.
Misunderstanding about the remit of these type of roles is a constant theme within the literature (McArthur and Burns, 2007; Lambert and Glacken, 2005; Clarke et al, 2003; Drennan, 2002). This often arises because post-holders are perceived as undertaking multiple roles or to be there as clinical teachers, working alongside students to demonstrate and enable learning in practice. This finding in both this study and Drennan’s (2002) perhaps signifies that mentors may not only lack confidence in assessing students but also in facilitating their learning.
The university was clear that the LCEAs were not there to teach students. While recognising that there is a shared responsibility for learning in practice (McNamara, 2007), the university believes that mentors are best placed to undertake this role and should, therefore, be the focus for the LCEAs.
The importance of a ‘physical presence’ was highlighted by McArthur and Burns (2007). Jowett and McMullan (2007) referred to accessibility and responsiveness as crucial elements to the success of the role, as well as the importance of supporting mentors when a student’s level of performance was causing concern.
There is also little doubt that because the LCEAs were recruited from practice they were seen as credible and had recent first-hand experience of mentors’ constraints (Jowett and McMullan, 2007).
Over the first year of the LCEA role implementation, much of the time with mentors was spent assessing student performance and failing them if they were not meeting the required level of competence (Sharples et al, 2007). The need for mentors to be supported when faced with a failing student was a key recommendation made by Duffy (2004), while Jowett and McMullan (2007) also found it an important element of the practice educator role.
The presence of an LCEA when meeting with a student helped mentors to gain confidence. When next faced with a failing student, they were often happy with a quick phone conversation to check they were following procedures correctly, rather than requiring the physical presence of the LCEA when meeting with the student.
The empowerment of mentors was also a finding by Clarke et al (2003), where the practice placement facilitator role enabled mentors to be more proactive in managing student problems. There is little doubt that the positive perception of the social and professional relationships that the LCEAs built through their daily interactions with mentors made their ‘social presence’ a matter for mutual recognition of the distinct contributions to learning in practice.
The negative response by some students when the LCEAs came to a placement following a mentor’s request for help has not been identified in the literature before, although students in Drennan’s (2002) study did express concerns that the clinical placement coordinators had a policing role that was in opposition to their support role. It is possible that, as other similar roles also had a remit to teach and support students, this mediated the students’ response.
In contrast, in this study some students only saw the LCEA when a mentor was concerned about their performance and the perceived threat was an unsuccessful assessment outcome. The presence of the LCEA role was therefore being linked to what was seen as a negative event for students rather than a learning one.
However, there were clear indications that despite the negative perceptions and experiences, LCEAs gradually became proactive in their interactions and relationships with mentors and students, informed in part by their collective experiences and reflection. Fundamentally they also possessed a genuine motivation to enable mentors and students to achieve the professional standards expected by the NMC.
Effective mentor support is crucial to produce nurses who are fit for practice. However, the demands of practice coupled with the persistent changes in nurse education mean that mentors need support themselves if they are to meet NMC standards. Roles such as the one described here can offer that support and ensure that due process is followed.
- In considering innovative ways of delivering quality learning in practice and, importantly, enabling mentors to continuously assess students against NMC standards, the following recommendations are made for implementation of new posts to support mentors:
- Implement whole-time equivalent posts with a distinctly identified focus and deliverable remit in a collaborative partnership between HEI and healthcare trust;
- Involve key stakeholders in the early stages to ensure both support for the posts and clarity over the role;
- Ensure the predominance of learning in practice commitments over university-based commitments, which should be kept to a minimum;
- Equip the LCEA with easy-to-access communication systems (for example, a mobile phone, IT and an internet connection) to counter effects of physical distance and enhance social presence;
- Allow latitude in developing the role to meet local needs and changing learning environments within the professional regulatory framework.
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