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Enhancing learning environments by maximising support to mentors

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The pan-Avon region (south west) has employed clinical education facilitators since 2000. This is in response to recommendations set out in Making a Difference (Department of Health, 1999) and Fitness for Practice (UKCC, 1999), and because the University of the West of England (UWE) was chosen as one of 15 pilot sites for a new nursing curriculum in September 2000. Clinical education facilitators are funded by the local workforce development confederation (WDC) and are employed within acute and primary care NHS trusts across the region.


VOL: 100, ISSUE: 26, PAGE NO: 36

Anne-Marie Wilkins, PGCE, RGN, is practice education facilitator

Gina Ellis, BSc, RGN, DipN, is practice education facilitator; both at North Bristol NHS Trust


The pan-Avon region (south west) has employed clinical education facilitators since 2000. This is in response to recommendations set out in Making a Difference (Department of Health, 1999) and Fitness for Practice (UKCC, 1999), and because the University of the West of England (UWE) was chosen as one of 15 pilot sites for a new nursing curriculum in September 2000. Clinical education facilitators are funded by the local workforce development confederation (WDC) and are employed within acute and primary care NHS trusts across the region.



Originally the major remit was to identify new clinical placements for preregistration nursing students. This was in response to the national agenda and the service need to increase the number of preregistration students. However, almost four years on from the original clinical education facilitator appointments, and while we still seek potential placement opportunities, the main emphasis has shifted towards developing a quality learning environment that embraces team mentoring. Our vision is one of a multiprofessional team supporting all learners to develop to their full potential.



Wards and placements
The preregistration nursing curriculum requires students to undertake clinical placements in a block of 13 consecutive weeks, twice a year. This, together with increasing numbers of students per intake, places a high demand on mentors to ensure students achieve the required learning outcomes.



To optimise opportunities for feedback to students, we promote the team mentoring and continual assessment approach. All members of the clinical team contribute to feeding back relevant information to both students and mentors. For example, a physiotherapist can observe and discuss manual handling practices, or a student may spend time with the ward receptionist to fulfil learning outcomes around communication, and storing and retrieving information.



Evaluation of the clinical education facilitator role shows that clinical staff value the role and feel it is of benefit to them in supporting students. We think one of the main reasons for this is because clinical education facilitators are practitioners. We are nurses and have been appointed from practice, where we have worked as mentors and assessed practice. We understand the pressures of having students in the ward area, and of trying to balance patient care with assessments, feedback, and support for the students, as well as the day-to-day matters that may crop up during each shift.



We are employed to support mentors and this results in mentors being more prepared to support students. How we support the mentors is difficult to quantify, but some of the common elements include:



- Troubleshooting - being available for advice and guidance when issues arise;



- Planning - maximising capacity and spreading out the numbers so students have more opportunities to learn and mentors are not overloaded with students;



- Raising awareness of students so they are taken into account when planning.



Our vision is also to raise the awareness of students across the trust. Student issues are a grey area for the clinical education facilitators. Essentially the facilitator is there to support the mentor and others in the learning environment. This is particularly important to us as the students are ‘zoned’ across the region. Zoning means the students have all their clinical placements in one area.



We believe students placed in our zone should feel valued and supported by the trust. To this end the facilitators provide an initial induction day for students before they have their first clinical placement. Students then have an annual evaluation day throughout their training. This enables us to receive feedback about the learning environment and allows students to see the changes that have occurred as a result of their comments.



In addition we have produced a handbook for students. This sets out the information all nurses employed by the trust receive, as well as specific information relevant to students. It is essential that facilitators have an overarching view of the trust, and the issues pertinent to mentors and to students.



Maintaining mentor competency
The NMC has recently increased the emphasis on teaching and assessing in the updated Code of Professional Conduct (NMC, 2002). Historically, mentoring was seen to be managed by nurses who were enthusiastic and enjoyed teaching. Now all nurses have a responsibility to facilitate learning within the workplace.



We are therefore encouraging clinical areas to use team mentoring as a framework for supporting students, as this model ensures all staff members have an input into their learning. Another model that has been developed to support the management of the increased numbers of students is the WORLD model (Channell, 2002):



- Working clinically;



- Observing practice;



- Researching a topic;



- Learning pack;



- Departmental visit.



Whichever system is used for student support, mentoring needs to be consistent and equitable for all learners.



Honey and Mumford’s (1992) learning styles have been invaluable to education, and particularly in work-based learning, as they have allowed learners to employ individual learning styles to make the best use of the learning opportunities in practice.



Since the introduction of Project 2000, mentoring in preregistration nurse education has become a widely accepted practice. However, the literature suggests that mentors are often ill-prepared for their role in supporting preregistration students in clinical areas (Duffy et al, 2000). To become a mentor, nurses are required to undertake an appropriate teaching and assessing course, and attend annual updates to demonstrate continued competence. This is not a new practice as an annual update was a requirement of the ENB and now the NMC.



Traditionally, the link lecturer would visit clinical areas and gather as many mentors as possible to talk about student-related issues. Anecdotal evidence suggests that this was piecemeal and the discussions may not have been relevant to individual mentors’ needs.



In our region it was recognised that to manage increased student numbers mentors had to develop and maintain competency. To achieve this there needed to be more mentors updating themselves on an annual basis.



As a result the local higher education institute (University of the West of England), WDC, and the regional trust stakeholders devised a four-year mentor development cycle, Maintaining Mentor Competence (Avon, Gloucestershire and Wiltshire NHS Workforce Development Confederation, 2003).



This encourages all qualified mentors to spend time updating by completing a relevant component every year. The format has encouraged mentors to recognise different styles of learning and to adapt them to the student or workplace. It is a practical model, which sits very clearly in practice. For example, the reflective component ensures the mentor reflects on how they are performing as a mentor (Box 1). The evidence collected and included in the professional portfolio enables the mentor to demonstrate that she or he is maintaining mentor competence through an annual update.



A key mentor in each placement area acts as a link with the clinical education facilitators. They are experienced mentors who can take the lead on student-related issues and support less experienced mentors. The facilitators give information to the key mentors who then cascade this through their department.



This role has been pivotal in our success. Each key mentor also ensures that the live register of mentors required by the NMC is sent to local higher education institutes every year.



As part of our role we have developed a resource that can be used by students and mentors. This is a file that is available in each placement area and on a website (Box 2). The aim is for mentors to use it as a reference to help them support students.



Tripartite relationships
As stated before, we are funded by the WDC, employed by the trusts, and work very closely with colleagues at the university. This has been defined as a tripartite relationship and it is necessary to drive forward the national agenda for the NHS and nurse education.



However, one of the criticisms of the clinical education facilitator role is that facilitators spend much of their time attending task and steering groups. In our defence, this means facilitators are able to put forward the service perspective, and to raise issues both back in practice and in development sessions such as task groups.



This means ideas and developments are able to fit in the practice situation as well as in the higher education institutes wherever this is necessary.



Practice development
When considering mentors and education it is easy to forget that, for nurses, mentoring is yet another part of a multifaceted role where patient care is, and must always remain, the priority. However, developing quality learning environments leads to more knowledgeable learners, who are appropriately supervised and work within their boundaries of responsibility, and this will improve delivery of patient care.



The mentor should be a person who is not afraid to challenge the learners who are not achieving and not simply sign students off because the mentor is a nice person and does not wish to upset the students.



Student will only develop if mentors support them and teach them how to learn in practice, as this is very different to learning through lectures. This is particularly true for nursing students on their first placements.



As clinical education facilitators we consider much of our job to be centred on empowering mentors to make sound judgements based on the evidence available. Research from Canada indicates that clinical instructors who work with students in practice are one of the major factors influencing students’ ability to learn in the clinical setting (Rowan and Barber, 2000).



Preregistration students are encouraged to challenge practice and discuss patient care in the spirit of clinical governance. Particular discussions and sharing of knowledge take place in regard to evidence-based practice. Feedback from senior nursing staff, for example, provides evidence throughout the trust that newly qualified nurses are more adept at planning and practising discharge procedures for patients, especially those with complex needs. As a result communication, teamwork, and patient care have been enhanced.



In the summer of 2002, UWE and Avon, Gloucestershire and Wiltshire WDC commissioned a report into student learning in practice. This was completed in October 2002 by an external consultant.



The evaluation of learning in practice was carried out through three methods:



- Analysis of documents addressing current support of learning in practice;



- Analysis of previous reports about supporting learning in practice;



- Consideration of the perspectives of the students, link lecturers, and clinical education facilitators.



In addition, other universities in the UK were questioned to identify other approaches used to support learning in practice.



Several elements were considered noteworthy, including:



- The success of work-based learning days;



- Efforts made by lecturers and practitioners as well as students;



- The success of the evolving role of the clinical education facilitators.



The report identified that UWE was not alone in ‘getting it right’ when it came to supporting learning in practice.



The results concluded with a number of recommendations, which, if implemented, would go a long way towards supporting learning. These include (Goom, 2004):



- Adopting a true partner organisation approach with equal division of responsibilities and accountability;



- Establishing ‘learning communities’ - changing the culture so that learning in practice is valued;



- Clear and unambiguous role specifications;



- Equitable clinical education resources across the WDC area;



- Appropriate preparation for students to study in practice and to undertake their own responsibilities for learning in practice.



Following the report, a project board was formed to consider implementation of the recommendations. An action plan has been formulated that, after wide consultation and structured implementation, is now ongoing. The five main areas are:



- The partnership organisation;



- Learning communities;



- Roles supporting education in practice;



- The practice learning unit;



- Student preparation for practice.



Most notable as far as practice is concerned is a change of title from clinical education facilitator to practice education facilitator. In addition to this change, the role will have a more standardised approach across the region and the number of facilitators will increase.



This will be achieved by all practice education facilitators being employed by the WDC and professionally managed by the trust.



The evaluation also found evidence of a role overlap between clinical education facilitators and link lecturers. Therefore the traditional link lecturer role will cease and clinical education facilitators will be pivotal in supporting learning in practice. Lecturers will continue to have input through the academic in practice role, whereby they support trust-based academic activity. Their projects will be determined through the academies project plan, or in the short term until all academies are operational through individual trusts negotiated through the university head of school.



There will be senior practice education facilitator posts, which will provide opportunities for career progression and development of the role, as well as developmental posts identified to develop potential practice education facilitators. It is anticipated that in the near future the role will be expanded to include midwifery and allied health professionals.



In the past three-and-a-half years, the clinical education facilitator role has grown and developed, and continues to change its focus to meet the demands of supporting learners in practice.



Mentors are now more confident in their assessments of students in practice, and facilitators are committed to supporting and developing learning environments that provide optimum opportunities for students to maximise their potential as future nurses.



This article has been double-blind peer-reviewed.

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