Nurses, midwives and health visitors are under increasing pressure due to overwork and stress, which is compounded by the need to maintain standards of care (Allen, 2001). In addition to their clinical roles, they have a duty to facilitate student nurses’ development.
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Cyril J. Murray, MSc, BA, RN, is senior lecturer
Andrew Main, MSc, RN, is lecturer, both at the School of Nursing, University of Salford, Eccles, Greater Manchester
In light of the increasing demands on their time, role modelling may be the most effective teaching method available, as students work alongside practitioners, so tasks need not take significantly more time. Mentors need to think about how to engage students in professional activities if role modelling is to be successful.
A literature review identified three key themes: what role modelling is, professional socialisation and the qualities needed in a role model.
What is role modelling?
Role modelling is a process that allows students to learn new behaviours without the trial and error of doing things for themselves (Bandura, 1977). It is a form of learning from experience that uses humanist and social learning theories (Rogers, 1983). A key feature is the experience learners bring to a situation.
Individuals want to learn and do so best when they feel free to express and choose their own direction (Rogers, 1983). When they are able to do this, mentors fulfil a dual role of teacher and learning facilitator (Rogers, 1983). They must therefore help their students to identify what direction learning should take and to facilitate the best conditions for this to occur.
Bandura (1977) describes social learning as a continually reciprocal interaction between a person and the environment. It occurs when an individual learns by observing another, and is influenced by:
- The relationship between role model and student;
- The usefulness of what is modelled;
- The student’s ability to undertake the role;
- The student’s motivation.
Social learning theory focuses on the social aspects of learning and the complexity of the interaction between the environment and the person (Callery, 1989). Knowledge of the principles of these theories will assist role models to structure their teaching to facilitate effective learning.
Role modelling is ‘teaching by example and learning by imitation’ (Dake and Taylor, 1994). The nature of nursing means it is fundamental to professional socialisation (Lynn, 1995), and skilful role models can enable students to discover knowledge embedded in clinical practice (Davies, 1993). Working with and observing a mentor enables students, through a process of reflection, to internalise their mentor’s behaviour and build on previous knowledge and experience (Schon, 1987).
Contradictory perspectives of role modelling see it as an imitative and observational form of learning in which students simply absorb their role model’s qualities and skills (Nelms et al, 1993). Students are responsible for identifying their own learning needs and must be actively involved in the modelling process to glean the knowledge the expert takes for granted (Nelms et al, 1993).
The benefits of role modelling lie in the opportunities for students to work with experienced and knowledgeable practitioners (Spouse, 1998) and observe them providing care (Davies, 1993). This helps them to develop an enthusiasm for professional development unparalleled by any other learning experience (Spouse, 1998).
Student nurses develop their professional identity through a process of socialisation, albeit an ‘ill- defined transition’, on their journey to becoming qualified nurses (Holland, 1999). Role modelling is seen as an accepted method of teaching these processes (Cope et al, 2000). In the practice environment, professional values can be repeatedly demonstrated, theory and practice integrated, and professional roles and values acquired from role models (Savage, 1998; Howe, 2002).
However, professional socialisation is not purely a reactive process. It depends on students’ past experiences and the reflective nature of the process and the values promoted in the course (Howkins and Ewens, 1999) - and these are not necessarily positive. For example, Appleton (1993) found that, to be accepted into a practice environment, students will internalise poor practice if it is the norm.
These findings reinforce the importance of positive role modelling in shaping the attitudes and behaviours of future nurses.
Qualities of a role model
The qualities of a positive role model are consistent throughout the literature but there is no information on how they can be developed. Positive role models enjoy nursing, are professionally competent and provide excellent patient care (Dotan et al, 1986; Beck, 1991; Wiseman, 1994). They interact with students and structure the environment to ensure learning occurs (Wiseman, 1994). They also lead by example, enjoy teaching and demonstrating clinical skills and have a caring attitude to patients and students (Whitman, 1990; Beck 1991; Davies 1993; Elzubier and Rizk, 2001). There is little discussion of negative qualities in the literature, but they tend to be the opposite of the above.
In summary, the literature review illustrates the underlying principles and the potential for role modelling but gives limited guidance for practitioners on how it might be implemented.
Role modelling in action
Jarvis and Gibson (1997) believe that all learning stems from experience, and that working in the professional environment is therefore the most effective learning experience that can be provided for students. Effective mentors acknowledge these concepts and provide learning opportunities for their students, rather than relying on the occurrence of unusual clinical situations to use as teaching opportunities (White and Ewan, 1991).
One skill frequently practised by student nurses is moving and handling. This gives opportunities to learn about communication skills, problem solving and how to move patients safely in a positive learning environment. Subsequent reflective discussions and repeated experiences of moving and handling patients will help to reinforce that experience and take their learning to a new level.
If teaching opportunities are to be meaningful and productive for students, planning is an important part of the mentor’s role (Watson, 1999) - simply being with a qualified nurse does not mean a student is learning (Burnard, 1988). The relationship between student and mentor will also influence the learning experience. Spouse (1996) identified five key aspects underpinning the learning process:
The following exemplar provides a framework to be used for role modelling in action. It uses moving and handling as a learning experience, breaking it down into three stages:
- Communication and assessment;
- Planning, implementation and evaluation;
- Reflection on the move.
Tables 1 and 2 display positive and negative role modelling behaviours that could be displayed during the latter two stages of moving and handling a patient. The positive behaviours relate closely to the characteristics identified by Spouse (1996). While issues of mentor competence play an important part in any nursing procedure the focus here is on illustrating what constitutes a competent practitioner who can perform the activity safely but may or may not possess appropriate role modelling behaviours to enhance student learning.
Communication and assessment
During the communication and assessment stage, an effective mentor would plan the activity away from the patient with the emphasis on the holistic needs of the patient. In contrast, the negative role model would not pre-plan and would place an emphasis on getting the job done at the expense of the student’s learning needs (Andrews and Wallis, 1999). By viewing the whole nursing process for a patient, students gain greater insight into care delivery than if they participate in a collection of disconnected tasks (Saarikoswi, 1999).
Positive role modelling behaviours will see the mentor displaying warmth, genuineness and interest in the student manifested by eye-to-eye contact, keen questioning skills, a willingness to listen to students’ responses and replying in an appropriate and caring manner. For example, Jarvis and Gibson (1997) state that a relationship of trust and respect is essential if there is to be ‘an enriching teaching and learning transaction’. The mentor must create trust in an atmosphere where the student can ask questions freely without feeling foolish (Ellis and Hartley, 2000). Poor role modelling behaviours would see the mentor allowing no time for questioning and creating an atmosphere of possible fear, hesitancy and a lack of trust and respect.
During this stage, the mentor will assess the student’s abilities and plan to move from the known to the unknown. Stuart (2003) says that students must be clear about their roles and responsibilities, and when they should or should not participate.
The mentor should display positive role modelling behaviours with the patient at the bedside. This will give the student the opportunity to observe the mentor’s role modelling behaviours in action as the assessment phase is completed (Chow and Sven, 2001).
The mentor displaying negative role modelling behaviours may practise a task-orientated approach to care, interacting minimally with the patient. This places emphasis on work practices at the expense of effective communication with the patient and learner (Chant et al, 2002).
Planning, implementation and evaluation
In this stage of the moving and handling procedure, the problem-solving processes of care delivery will be enhanced. Positive role-modelling behaviours will encourage the student and other staff to participate in moving the patient according to their abilities.
Role modelling is not always a passive event - it can be an active procedure for the student, resulting ultimately in meaningful learning. Positive role-modelling behaviours will see the mentor encouraging the student to participate in moving the patient according to their level of ability. By adopting a patient-centred focus, this interactive approach will help the student to develop problem-solving capabilities (Martin and Bulla, 1990).
Negative behaviours may mean the procedure becomes a task and the student learns the fundamentals of performing an automatic job at the expense of meaningful, experiential learning (Fretwell, 1982; Rogers, 1983). Furthermore, mentors may be unclear about their students’ abilities and be overprotective by only allowing them to observe tasks or alternatively may give them too much to do (Gray and Smith, 2000).
The effective role model will use this stage to promote reflection in action if an unexpected event occurs during the routine operation of the move. Schon (1983) believes this is the best method of developing knowledge in a practice setting as it occurs during the procedure of moving the patient without having to interrupt the action. The ability to reflect in action and make changes to practice is, according to McAllister et al (1997), ‘a hallmark of students moving from an intermediate to advanced level of clinical skills’.
Reflecting on the experience
The final stage of the activity involves reflecting on the procedure. The experience is the stimulus for learning and positive role models view reflection as an opportunity to advance their students’ nursing knowledge and clinical practice. They display enthusiasm for the process, ask questions at a level appropriate to students’ abilities and stage of training and listen attentively to their responses.
The busy clinical environment does not always give mentors and students an opportunity to discuss a procedure immediately after undertaking it. While this is the most effective time for the discussion to take place, time pressure is not a valid excuse for failing to consolidate students’ learning through discussion, as the situation can be reflected upon later if necessary.
Students see feedback as an important element of their learning. Chow and Suen (2001) believe it should be confidential and should take place in a safe environment, so that students do not feel humiliated by the experience. Student nurses need the right environment to grow psychologically and ineffective mentors can demotivate their students if they provide destructive feedback or fail to provide any feedback on performance.
Mentors are finding that their workload pressures are increasing, placing greater demands on their time and abilities to support other nurses. Alternative approaches to teaching and learning are required to enable practitioners to offer this support while minimising its effect on their clinical practice. Role modelling can allow them to do this because it enables students to develop an understanding of the knowledge, skills and attitudes they need while working alongside an experienced mentor, thereby enhancing their professional socialisation (Davies, 1993). However, it depends on the mentor displaying positive role-modelling behaviours.
Moving and handling is a clinical skill that provides an opportunity to promote learning. Good mentors identify and use any opportunity to promote learning, but the modelling process must be a purposeful, structured activity in which the mentor is aware of the cognitive, psychomotor and affective abilities being modelled. Students’ learning does not have to take second place to tasks to be completed as role modelling can become a normal part of the mentor’s clinical practice, thereby enhancing the development of other staff.
The potential of this exemplar lies in its applicability to other clinical nursing skills such as washing and dressing patients, admissions or more technical activities involving wound care, venepuncture or even cannulation. The framework can also be transferred to other disciplines in which there is a strong work-based clinical focus to the role and in which practitioners may need to consider alternative ways of supporting students.
Within each health care discipline, clinical skills range from simple to complex, depending on the elements involved, the knowledge base underpinning the activity and the dexterity of the practitioner. Role modelling as an approach to teaching is not only applicable to any single discipline. It can be adapted to the simplicity or complexity of a clinical skill and to the behaviours expected of students in meeting their professional work role requirements.
This article has been double-blind peer-reviewed.
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