Mentoring student nurses can be challenging. Clear strategies and a supportive environment can help to ensure student-mentor relationships are effective
Sue Nash, MBA, BSc, RGN, is facilitator of individual, team and service development, Action Learning Teams Consultancy, and an associate of the RCN Consultancy Service; Janet Scammell, MSc, PGDip, BA, RM, RGN, is senior academic for practice learning, School of Health and Social Care, Bournemouth University.
Nash S, Scammell J (2010) How to use coaching and action learning to support mentors in the workplace. Nursing Times; 106: 3, early online publication.
Using the example of mentoring pre-registration nursing students, this article explores facilitation of learning in the workplace and examines the use of coaching and action learning to support mentors and the wider clinical team. A case study is considered where the mentor has difficulties with an under performing student.
Action learning and coaching are then explored, with the aim of maximising personal and team learning. These strategies can be easily transferred to other work based learning situations.
Keywords Coaching, Mentoring, Action learning, Reflective practice
- This article has been double- blind peer reviewed
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- Work based learning is fundamental to improving individual and team effectiveness and patient care.
- Effective mentorship is crucial to enable pre-registration nursing students to develop their professional and clinical skills.
- Barriers to effective work based learning will adversely affect the development of competent practitioners.
- Coaching and action learning can help clinical teams to learn from experience and improve future practice.
Mentorship in pre-registration nursing education
A key aspect of the Nursing and Midwifery Council’s role is to set and maintain standards of education. The standards to support learning and assessment in practice were published in 2006 and updated two years later (NMC, 2008) to take into account wider policy developments. In particular, the updated standards aim to ensure adherence to the NMC (2009) equality and diversity scheme. In response to concerns over nurses’ competency at the point of registration, having raised some issues about mentors’ role with failing students, they also offer clearer guidance about the “sign-off” mentor role. They outline the requirement for local mentor registers and the necessity for ongoing records of achievement to follow students as they move from one placement to another.
The standards state that nursing students on NMC approved pre-registration programmes must be supported and assessed by mentors who have completed an NMC approved mentorship programme. Since September 2007 “sign-off” mentors who have met additional criteria have been responsible for confirming that students in final placements have met the required competencies for entry to the register.
The standards outline a framework to support learning and assessment in practice, comprising eight domains with developmental stages, reflecting mentor, practice teacher and teacher levels:
- Establishing effective working relationships;
- Facilitating learning;
- Assessment and accountability;
- Evaluating learning;
- Creating an environment for learning;
- Context of practice;
- Evidence based practice;
- Leadership (NMC, 2008).
Placement providers keep a local register of mentors and practice teachers, including those designated as “sign-off” mentors. To remain on this register, mentors and practice teachers must demonstrate updated knowledge, skills and competence (the triennial review); for mentors this includes having mentored at least two students over the three years and having attended annual mentor updates.
Nurses and midwives making judgements about students’ proficiency in practice must adhere to five principles (NMC, 2008). In brief, they must:
- Be on the same part of the register as the student they are assessing;
- Have developed their personal skills and competence beyond initial registration level;
- Hold professional qualifications at an equivalent or higher level than the students they are supporting and assessing;
- Have been prepared for their role as mentor, practice teacher or teacher;
- Hold an approved teacher qualification that may be recorded on the NMC register.
Enabling good mentorship
Much of the literature focuses on the mentor-student relationship, including mentors’ qualities and characteristics. The relationship is seen as close and by some as quite intense (Morton-Cooper and Palmer, 2000), with the best characterised as a learning partnership based on mutual respect (McCarthy and Murphy, 2008).
The literature agrees that while effective mentorship is crucial to developing student nurses’ professional abilities, it is a challenging role, not least because there is no protected time, except in students’ final placement (NMC, 2008). Nonetheless, the standards require all pre-registration nursing students to be allocated an appropriately qualified named mentor who must commit to directly or indirectly supervising 40% of students’ time in clinical practice. While 40% may seem a rather minimal standard, students must be supervised at all times while in practice, but this responsibility may be shared among the wider clinical team. However, unlike the resourcing of supervision for other healthcare professions, this is incorporated into registered nurses’ role, which suggests little value is attributed to the role or that there is minimal acknowledgement of the time required for effective supervision (Mulholland et al, 2005).
The impact of the 40% rule, however, is that time to support students in work based learning is likely to be at a premium as their needs will inevitably take second place to clinical demands. Similarly, any educational role is difficult to accommodate given the high acuity of care in many clinical placements. Both student learning and support for facilitators may suffer. It is important that clinical leaders acknowledge and support time for essential development activities such as coaching and action learning. By taking time for reflective practice and individual development, quality of care can be enhanced.
Mentorship and interpersonal skills
Personal communication skills are important, but only part of the picture in effective mentorship. Cope and Cuthbertson (2000) identified that a significant part of mentors’ role was to orientate students to the social and professional norms of the practice community. For example, mentors can be vital in helping students adjust to employers’ expectations, such as arriving on time and being appropriately dressed.
Furthermore, literature on attrition indicates that first year students in particular may leave if they do not feel part of the clinical team (Department of Health, 2006). Mentors can be vital in introducing and including students in the wider nursing and healthcare team. Wilson-Barnett et al (1995) also identified that students wanted “good team spirit” to help orient them to new placements. Interestingly, Gray and Smith (2000) found a perception that poor mentors were people who “did not fit in” and were disliked by other members of the team.
Some research highlights personal factors in forming relationships, although it is obvious that some mentors will not like some students and vice versa. The assumption is that as professionals and aspiring professionals, they will rise above such considerations. However, Gray and Smith (2000) found that students perceived that poor mentors disliked their job and/or students and were distant, less friendly and unapproachable.
Obstacles to good mentorship
Organisational constraints can be an obstacle to effective mentoring. Work pressures can result in conflicting roles and responsibilities towards patient care versus student support. Ideally the two should be combined but time out to reflect, even briefly, on activities is essential. However, teaching care skills can take longer than completing care oneself.
Nonetheless, if students and mentors are not rostered to work together regularly, it can be difficult for mentors to judge students’ developing competence and confidence over the placement. Continuity of supervision is the reasoning behind the 40% rule but this must be facilitated and supported in daily practice. Part time workers can find this problematic but this can be overcome by linking with another mentor to offer team mentorship, which also offers students the benefit of expertise from two practitioners.
Finding time, particularly to provide reflection and feedback, can be challenging but must not be viewed as optional; a lack of feedback is a significant barrier to learning and leads to considerable frustration for students. An evaluation by Scammell et al (2007) indicated that students did not want to simply hear they were “doing fine” but wanted to know:
- In what way?
- How could they improve?
- What were they not doing well?
This is the same for any practitioner at any level – constructive feedback is essential for continuous professional learning.
Effective working relationships
Poor working relationships in the form of personality clashes can also be a barrier to effective mentoring. Ideally these should be worked through, since nurses cannot choose who they work with or care for. The learning environment should be such that students or mentors can discuss these issues with a clinical leader or practice based teacher to find a resolution.
Unfortunately, many clinical areas have difficulty in recruiting enough mentors to support the students on placement. This means some registered nurses who do not want to take on the role may be required to do so by their organisation. However, as indicated earlier, students soon pick up disinterest from mentors and may feel not only unsupported but also unable to maximise learning through questioning and shadowing activities.
Accountable practice demands that all practitioners are open about their strengths and areas of concern. In a supportive clinical team, mentorship in this situation may be shared, while reluctant mentors should be encouraged to share their difficulties with a clinical supervisor and be coached to address these. Education of junior staff – students or otherwise – is, after all, part of registered nurses’ role.
Personality clashes also affect other supervisory relationships. For example, some participants in clinical supervision want to choose their supervisor or the colleagues they work with in action learning. This may not always be possible but the situation can provide the ideal arena to practise giving constructive feedback and to develop relationships with the supervisor or facilitator who was not their choice. However, this opportunity is often missed due to intransigence or unwillingness to participate in a group where they have been unable to choose their supervisor/facilitator.
As stated earlier, this mirrors the workplace where nurses cannot choose colleagues, leaders, managers and patients to work with, but nonetheless need to be able to develop skills and the ability to form good and effective working relationships. Where better to do this than in a supervision group, where this can be explored safely with the challenge and support of facilitator and peers?
Equality and diversity
One further issue which may inhibit effective mentoring relationships is discomfort surrounding equality and diversity issues between mentor and student. Reflecting policy developments in this area, the updated standards (NMC, 2008) require mentors, practice teachers and teachers to promote equality of opportunity regardless of race, gender or disability and to prevent intentional or unintentional discrimination. However, this is challenging if any individuals have difficulty in responding constructively to those they perceive as different.
Thomas (2001) referred to “protective hesitation” in describing the problems in cross-race mentoring relationships of raising potentially difficult issues, where they are often not tackled to avoid accusations of prejudice. This issue is evident in the case study, adding another challenging dimension to concerns about an underperforming student.
Duffy (2003) identified that weak students tend to have poor interpersonal skills, are disinterested in practice learning and frequently late, and lack personal insight and awareness of professional boundaries. Duffy recommended that early intervention is essential; if mentors or members of the clinical team notice an issue or concern about students, time must be made to discuss it. There may be other pressures affecting performance and these mitigating circumstances may need to be taken into account. However, performance must meet the required standard.
It is important to encourage students to express their feelings about the placement and to highlight any concerns. Realistic expectations in line with their set learning outcomes have to be made clear so they know what to aim for and how to achieve them. Ideally, by working together, appropriate action plans and realistic goals can be developed to improve performance. However, situations are frequently confounded by other factors, as the case study illustrates.
Box 1. A mentoring case study
Sonya* is an adult branch student who has recently started her third year. She is about to start the fourth week of a six week hospital based placement. Her mentor Gino* met with her on her first day to discuss her past experience, set personal learning objectives and develop an action plan to help Sonya meet the practice assessment requirements for this placement. Gino felt Sonya seemed a little uninterested but put this down to first day nerves. Gino and Sonya were scheduled to work the same shifts.
Gino, who trained overseas, has been a qualified mentor for one year. Sonya’s mid-placement interview is overdue. Gino has some concerns but he is unsure how to tackle them. He has approached a colleague who tells him he is worrying too much as Sonya still has time to improve. His concerns are:
- Out of 15 shifts over three weeks, Sonya has been off sick on four separate occasions and on the first two she failed to notify the ward team;
- She has been late arriving on duty for most shifts;
- Sonya has changed her shifts without Gino’s knowledge, resulting in them not working together for the last two weeks;
- She has been asking other mentors to sign her assessment documents instead of Gino and colleagues have done so;
- Gino has noticed that Sonya seems to be off-hand with people who have difficulty communicating, notably those with hearing problems and limited English language abilities, tending to shout and look annoyed.
*Names have been changed.
Issues and actions
Clearly Sonya is under performing in a number of ways. There may well be reasons for this and some important first steps have been taken. Gino met with Sonya at the start of the placement and developed an action plan. This gives him a baseline from which to judge future performance. Unfortunately, due to heavy workload pressures, this meeting was not documented and so is subject to memory distortion, although the learning objectives were recorded.
Gino feels out of his depth and has sought support from a colleague. However, the advice is inappropriate, as Sonya has less than half the placement left, and also seems to undermine Gino’s judgement. Sonya has been aware from the start of the placement that a midway review was planned; this provides a useful opportunity for both student and mentor to discuss any concerns and flag up areas of strength and those needing development. Unfortunately, this is late and so although timely intervention is needed, Sonya is not being confronted with her mentor’s concerns nor does Gino feel able to do this.
While feeling unsupported, nonetheless Gino does not seek the advice of a clinical leader but feels he should cope and “get on with it”. He arranges the mid-placement interview and although Sonya changes her shift, Gino spots this and comes in so he can see her. He uses Sonya’s set learning objectives as a measurable framework to discern progress since the initial placement interview, and then starts to highlight his concerns. Preparation is essential but unfortunately Gino has not written a list of concerns as well as strengths so when Sonya becomes defensive and states they have a personality clash, he becomes flustered and ends the interview more quickly than planned. Sonya goes on to complete the placement and asks different staff members to sign her objectives. On the day Gino arranges her final interview Sonya is off sick. She has, however, passed the objectives for that placement and so progresses. Gino feels frustrated as well as a failure.
In this case study, issues of discrimination appear to be evident, as well as the reluctance to fail students identified by Duffy (2003). Duffy’s report has been extremely important in influencing the review of competence of newly qualified nurses (Moore, 2005) and the revision of the NMC (2008) standards. However, a recent survey of experiences of practice assessment (Scammell et al, in press) indicated that some mentors still had concerns about failing students. When asked how confident they felt to fail students, 60% (n=67) of mentors in the sample expressed confidence to fail those whose competence was in question. However, 18% (n=20) were not confident, while a further 20% (n=22) responded with a neutral grade to this question. Clearly this area of mentorship continues to be challenging and indicates the need to review current practice on preparing and supporting mentors in failing students.
Coaching and action learning
The references and examples given above explore the barriers to good mentoring relationships with student nurses. However, the learning from this can be applied to the processes of coaching, clinical supervision and action learning. In the case study, the opportunity was missed when Gino tried to explore the issue with a colleague. He was given advice which was inappropriate for the context. Had an action learning or coaching process been used, even in the informal one to one exchange between peers, Gino may have felt more supported and empowered to tackle the issues with Sonya.
In the first in this two-part series (Nash and Scammell, 2010) we referred to the impact of disempowerment in nursing culture; although this problem is beginning to be challenged, it may act as a barrier to enabling nurses to confront issues of concern constructively. This may be interpreted as a culture of telling, an attitude that can be challenged through coaching and action learning. Gino, his colleague or any other team member could have used a coaching model instead of giving advice.
The GROW model can be used as a framework for coaching; an example is shown in Box 2.
Notes should be made and kept in students’ personal files. Follow up should be identified and a date set when the action plan will be discussed and progress identified: “holding to account” (Nash and Scammell, 2010).
This framework of structured yet open questions could have been used between Gino and his colleague. It does not need to take long to work through, and time invested now would be outweighed by the resources required to limit poor performance or quality of care in the future.
Reluctance to fail students and the general difficulty some nurses have in giving constructive feedback may be due to personality type. The Myers-Briggs type indicator (MBTI) of personality was developed from Carl Jung’s theory of psychological type (Briggs-Myers et al, 1998). In decision making and the general way of evaluating perceptions and communications there is the differences between thinking (T) and feeling (F) (Briggs-Myers et al, 1998). Feeling “types” emphasise involvement with people in their lives and practices. They like harmony and if they have not developed their T capacity, they often allow their own or others’ likes and dislikes to influence decisions. F types dislike, and may avoid, telling people unpleasant things. Developing the T capacity involves considering something analytically, logically, looking at the advantages and disadvantages, cause and effect and being objective.
Without development, T types may upset people if they have not considered the impact they may have when expressing their concerns. However, F types may disguise feedback so much with the aim of being gentle that they fail to get the message across.
Anecdotal evidence suggests that nursing has a higher prevalence of F types. Briggs-Myers et al (1998) described the importance of type functions in occupation choice and that those with an F preference are more likely to want to help people in practical ways, such as in healthcare and education. Constructive feedback therefore needs to be objective, logically looking at the issue but sensitively considering the impact. It therefore needs to be about being “hard on the issue and soft on the person”.
Box 2. The GROW model
- GOAL: what do you (mentor and student) want to get from today’s coaching/mentoring? Defining what needs to be achieved
- REALITY: what is happening? Understanding the situation - strengths noted and celebrated, areas for development identified
- OPTIONS: how can we get there? Discussion of the options available
- WRAP UP: do what? When? Agreeing the course of action with SMART objectives
Source: Passmore (2006), originally developed by Alexander in 1984 (Alexander and Renshaw, 2005)
Since workplace learning is key to improving individual and team effectiveness and ultimately patient care, awareness of the barriers is essential, as well as understanding the underpinning skills and attributes required.
An effective learning environment is one where all staff are learners, working to develop personal and team insights to enhance practice. Mentoring, coaching and action learning can be useful strategies in meeting this aim.
- For further information, please contact email@example.com or firstname.lastname@example.org
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