Each member of a multidisciplinary team has a role to play in ensuring student nurses’ ability to contribute to clinical practice is understood and maximised
The value of student nurses in developing nursing practice has been recognised, and appreciating them not only supports the development of a learning organisation but also enables mentors to reflect on their own skills. This article identifies how students contribute to practice when they are included as members of the multidisciplinary team, and discusses a leadership framework that can be used to promote student integration within the team.
Citation: Uren C, Shepherd P (2016) Valuing the student contribution to practice. Nursing Times; online issue 9, 1-4.
Authors: Claire Uren and Paula Shepherd are university practice learning advisers at Bournemouth University.
- This article has been double-blind peer reviewed
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Students have expressed concern that not having a recognised role within the team can inhibit their development (Walsh, 2015). The proposed introduction of the nursing associate role, along with, changes to nurse education funding, has the potential to further affect placement provision (Department of Health, 2015), while the review of the current mentorship model for students will have implications for the quality of placement learning (Willis, 2015)
Francis (2015) identifies the importance of students’ contribution to high-quality care; with 50% of the student programme being completed in practice, this significant presence cannot be underestimated. As part of our role as university practice learning advisers, we provide continuing mentor education. We ran a series of workshops to explore the student role in practice. These highlighted the value of students with regard to their ability to:
- Empathise with patients;
- See the environment with ‘fresh eyes’;
- Promote their profession;
- Help mentors to appreciate their own skills and knowledge.
However, we recognised there was a need to promote a culture that invited students to participate fully as a recognised team member.
The learning process and mentors
In exploring the facilitation of the learning process, Jokelainen et al (2013) recognised the importance of inclusion for a fulfilling experience. While the key purpose of placements could be seen as an opportunity to assess student practice, it is equally recognised that the experience is greater than the sum of its parts. Students are developing cultural knowledge of healthcare: how the team works, how students are viewed, the political and social arena, and the application to person-centred care.
To develop this experience, it is important for mentors to critique their own views of student placements and their ability to lead practice education. Hunt et al (2016) recognise the mentor role as being additional to the clinical role – this may be reflected in the student experience in that they could be perceived as being on the periphery of opportunity, waiting to be invited in.
Students may view mentors as having the power to decide their future. French and Raven (1959) identified the ability mentors may have to influence the team and students: by virtue of their position as mentor, they can exert the power of reward and coercion. This is reinforced by students’ perception of their mentor’s legitimacy through knowledge, seniority, expertise and the wish to mirror their behaviour to seek acceptance. In this way the role-model approach can be a negative perception in that the learner is not included in the team as an individual, but as an addendum to the mentor. While Francis (2015) recognises the importance of the student voice, the role model element of mentoring has the potential to nullify this aspect of professional development.
The Nursing and Midwifery Council (2008) stated that mentors should provide an environment that is conducive to learning, which offers appropriate learning opportunities in an interprofessional context. This implies that the entire clinical team has a responsibility to support learners in practice. Having a supportive mentor is a key part of students’ socialisation into a new learning environment, but this needs to be reinforced by the team (Walsh, 2015).
Recognising the variance on approach and motivation towards mentorship, Willis (2015) proposes the coaching model as an opportunity to promote greater consistency in the learning experience. The need to promote inclusion to achieve this requires consideration. The use of leadership models in planning the placement experience can help identify both team strengths and individuals’ needs in supporting this approach.
Kinnell and Hughes (2010) stated that: “The importance of team cohesion and a feeling of belongingness are central to gaining the most from health care placements.”
Many studies have identified that students who are accepted by the team are likely to have a successful learning experience (Walsh, 2015; Jokelainen et al, 2013; Malouf and West, 2011). However, Walsh (2015) recognised that acceptance was often influenced by the level of contribution students could make in practice. This can either lead to them participating in a variety of learning opportunities or, conversely, can lead to them performing tasks to reduce the workload of others in the team (Henderson et al, 2012).
In our experience of working with mentors who support students who are underperforming, it has become evident that in the initial stages of the programme students may be given the benefit of the doubt. They may complete tasks to a good standard but their critical knowledge has not been evaluated. As they arrive at the later stages of their programme, this shortfall becomes increasingly apparent, resulting in pressure on both mentors and students (Dougan, 2013).
While Scammell and Nash (2010) recognised the importance of evaluating knowledge as well as skills, questioning students at the start of their programme could undermine their confidence if not done appropriately. During the workshops we held, mentors identified the challenge of understanding reasonable expectations for a first-year student. Ensuring students have a defined role, in accordance with their stage of programme, could help mentors identify learning needs in a more consistent and timely manner.
We delivered six workshops at our annual mentor conferences between July and November 2014. Each workshop lasted for an hour and a total of 188 mentors attended; 180 of these were NMC registrants from all fields. All primary and secondary care settings for the NHS and independent sector were covered and eight attendees were registrants of the Health and Care Professions Council.
In groups, participants explored the contribution students make to:
- The team;
- Their mentor;
- The profession;
- Patient care.
Their views were then fed back to the larger group using poster presentations, and the opportunities for student inclusion were reflected on. Data was collated from the posters.
The workshop findings identified that students made a valuable contribution to practice when they were supported in an environment conducive to learning. Patients valued the time students spent with them, listening and empathising. Patients recognised the youthfulness and enthusiasm students brought to the environment, fostering a positive workplace culture, which boosted morale.
Students’ up-to-date knowledge was seen to directly influence patient care when nurtured by the team.
For mentors, supporting a student was viewed as a confidence booster, with positive effects gained from supporting the next generation of nurses. Reciprocal learning was also seen as a benefit, giving mentors the opportunity to gain feedback and reflect on their role. Mentorship activities also contribute to continuing professional development requirements and can be seen as valuable evidence for revalidation (NMC, 2015).
The contribution students made to the team was seen to be beneficial as they brought a new perspective to the environment. They recognised and respected the varied roles in the team and helped to forge effective interprofessional communication. By virtue of their student status, they were able to safely question and challenge in a constructive manner.
The workshop has been developed into an activity that is used in the mentorship programme and mentor updates. This has helped clarify the mentor’s role to fully engage the team in supporting the learning experience.
Many factors can negatively affect the learning environment and students’ experiences. We know that for students to contribute to practice, they need to feel safe and supported, but the workplace culture can be detrimental to learning. Ceravolo et al (2012) identified that up to 90% of nurses experience lateral violence, such as bullying and disrespect from colleagues, which contributes significantly to a negative workplace culture. Equally, if the importance of learning is not acknowledged by the team, further barriers are created as mentors are reluctant to engage in the process if their contribution is not recognised (Henderson and Eaton, 2013).
The nature of practice learning means there is a constant flow of students passing through placement areas. This has an impact on the environment and changes occur with each new student (Walsh, 2015), so it is not surprising that teams can take some time to accept new learners. Unfortunately, students may feel their individuality is not acknowledged – terms such as ‘the student’ instead of their name may be used, leading to a feeling of non-acceptance. Walsh (2015) reported that students cannot be passive in the socialisation process – they need to develop skills that enable them to integrate effectively with teams and recognise their own contribution, thus making it a two-way process.
Mentors face numerous constraints, particularly in relation to increased workload and lack of time to spend supporting learners (Willis, 2015). This results in dissatisfaction for mentors, affecting their motivation and morale. In addition, proposed changes to student funding may lead to mentors questioning both theirs and their students’ purpose in placement, affecting the dynamics of the relationship. Students might consider themselves to be ‘purchasers’ of education, and so might feel more able to challenge the learning opportunities offered. But the proposed development of the nurse associate role and the government’s aspiration of increased pre-registration nurse programme applications could increase student vulnerability. The capacity to support students in practice needs to be examined.
Students might experience increased anxiety when not adequately supported, which can have a negative impact on their performance. They may also become task-oriented to fit in with the team. As per Henderson et al (2012), this can prevent students from developing a holistic approach to nursing, potentially putting patients in a vulnerable position.
Promoting student inclusion
Kumar et al (2014) identified the value of Collins’ (2001) Five Levels of leadership for health professionals. In its application to the role of mentorship and student contribution to practice, it helps to realise the differing roles of the mentor, student nurse and the team and identify opportunities to enhance practice learning. Willis (2015) speaks of the mentor ‘badge of honour’. Promoting the student role can help highlight mentors’ significant contribution to leading the profession of the future. Locally, the development of practice education teams, which work collaboratively with the university practice education team, has raised the profile of mentorship as an integral part of clinical practice.
The NMC (2010) clearly identified the need for students to develop the skills of team working, change management and coordination from the outset of their programme. Using Collins’ Five Levels approach can provide teams with the framework for enhanced student inclusion as well as team development in mentorship. It can also help to differentiate the role of the mentor from assessor. Box 1 describes the theory, as applied to healthcare students.
Box 1. Enhancing student inclusion
The Five Levels approach can be used to enhance student inclusion.
- Level 1: students are able to demonstrate good knowledge, skills and work attributes and recognises the need to actively engage in placement learning
- Level 2: while continuing to meet level 1, students are able to contribute to team working. They do not work in isolation but are able to use their individual skills to enhance the team effectiveness
- Level 3: having developed to this level, students are able to organise others and manage resources effectively under supervision to attain team objectives
- Level 4: further progression sees students being able to place their experience in the context of their programme. By recognising their transferable skills and by virtue of their experience, they can acknowledge the wider political and social arena
- Level 5: an extremely hard level to achieve as it is about leaving a lasting legacy. It is akin to servant leadership (Greenleaf, 2002) in that the student’s influence is demonstrated through a team that is able to continue to build and grow after they have left
This hierarchy of leadership provides an opportunity for the placement area to develop an appreciation of students’ role within their team; it can also help students to appreciate their current level of ability and, more importantly, understand how to hone these skills in readiness for life as a registered nurse. Third-year students have spoken of the huge step-up required of them in the final stage of the programme. This increased expectation, along with their own anxiety about transition to registered status, can cause significant pressure, potentially marring their learning in the final placement. By developing their leadership skills as individual members of the team, students’ contribution can be recognised. In addition, mentors, who hold the position of assessor, are able to gather objective evidence to help them evaluate individual students’ practice.
Mentors have been identified as ‘failing to fail’ (Duffy, 2003) but it is not always reasonable to expect a mentor to address shortcomings with confidence. Valuing students’ contribution creates potential to identify issues sooner and, as a team, help mentors address developmental needs; it also highlights the need for students to be realistic in their own achievements. Table 1 (attached) suggests how the Five Levels model could be applied to practice.
Training and mentoring students to ensure safe and effective practice is an important part of succession planning, as students will be the future workforce who will influence and shape the profession. Effective leadership skills can help to nurture a culture in which innovation is encouraged and students can make an active contribution to developing practice (Henderson et al, 2012). When students feel valued, they are more likely to have the confidence to question practice and suggest innovative solutions (Henderson and Eaton, 2013). Practice learning should encourage students to develop leadership and conflict resolution skills and give them the confidence to become a ‘clinical questioner’. This can only be achieved if students have a sense of belonging.
Professional bodies have identified that registered nurses have a responsibility to support students and work in partnership. This includes acting as a professional role model and advocate. Appropriate supervision and delegation is crucial to a positive learning experience, along with promoting respect and acknowledging the contributions of others.
The use of a framework that supports the development of all involved in the learning process can enhance understanding of the roles of the team, of which students are integral members. The work environment needs to promote a culture of listening, questioning and active inclusion – this will show students that their contribution is valued, thereby boosting their confidence and self-esteem.
- Students’ contribution to practice needs to be recognised
- The student experience can be enhanced by having a defined role within the healthcare team
- Student integration into the team can facilitate a questioning approach to enhance practice
- Mentors can promote student inclusion
- Effective team working aids reliable assessment
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