To develop expertise, the World Health Organization (WHO) has recommended that the nursing profession improves support structures for post-registration programmes and, crucially, for students on pre-registration education programmes (WHO 2002a). Mentors are expected to undertake robust mentorship programmes in preparation for the mentoring role and to deliver multifaceted training, teaching, assessment and support of pre-registration nursing students while on clinical placements (Wilson, 2014). Although research is available that seeks to clarify expectation, many mentors state they are overwhelmed in practice by the responsibility of mentoring alongside their clinical work (Veeramah, 2012; Jokelainen et al, 2013; Wilson, 2014).
The Duffy report (2003) highlighted mentors' concerns about how they are facilitated to support students in practice, stating that mentors were finding it increasingly difficult to fulfil their role, leading to professional and organisational conflicts (Bray and Nettleton, 2007; Elcock and Sookhoo, 2007; Mead et al, 2011; Royal College of Nursing (RCN), 2012; Sandford, 2012; Veeramah, 2012).
Taking cognisance of the Duffy report (2003), the Nursing and Midwifery Council (NMC) (2006; 2008) published the Standards to Support Learning and Assessment in Practice (SLaiP) standards, which provided a framework for the governance standards pertaining to mentors in practice and which superseded all previous consultations (NMC, 2004; NMC, 2005) on standards (knowledge and skills that nurses and midwives needed to support learners in practice).
During the years since its publication, the findings of the Duffy report (2003) have been supported by further work by numerous authors, all highlighting a perceived lack of support for mentors from both a strategic, organisational and approved educational institution (AEI) perspective (Bray and Nettleton, 2007; Elcock and Sookhoo, 2007; Mead et al, 2011; Sandford, 2012; Veeramah, 2012). These findings were consolidated by the Willis Commission (RCN, 2012), which commented that while many mentors recognised that there was an infrastructure in place to support them, mentorship was low on the list of employer priorities. Across the literature, the reasons for mentors' inability to perform this role adequately has been fundamentally rationalised as: not having enough time; the theory–practice gap; staff shortages; lack of acknowledgement; busy clinical environments and a perceived lack of understanding of what the role entails (Duffy, 2003; Luhanga et al, 2008; Fitzgerald et al, 2010; Gainsbury, 2010; Miller, 2010; Sellman, 2010; Mead et al, 2011; Sandford, 2012; Wells and McLoughlin, 2014).
Henderson and Tyler (2011) emphasised that the clinical learning environment in practice settings is crucial to the success of the development of the pre-registration student nurse, both professionally and personally, which is why it must equate to 50% of the nursing curriculum (NMC, 2008). Mentors are being asked to facilitate the students' learning by blending different knowledge and experiences that allows capacity to improvise and enable change (McCormack, 2004). The difference between responsibility and accountability while still inextricably linked, further impacts on the facilitation of students' learning in practice as the mentor is tasked with developing interpersonal skills while assessing the student (Cornock and Nichols, 2008; Elcigil and Sari, 2008; Ousey, 2009; Stuart, 2013). A multidimensional approach is required to be comprehensive and objective, with concrete evidence of knowledge, skills and professional behaviours (Fitzgerald et al, 2010). This article considers how mentors perceive the support they are currently receiving and whether they feel it is adequate.
In 2018 the NMC introduced new student supervision standards, which replaced traditional mentors with academic assessors, practice supervisors and practice assessors (NMC, 2018). Practice assessors assess and confirm the students' achievements for practice learning, and recommend students for progression in partnership with the academic assessor. Practice supervisors supervise students on placements. All nurses and midwives should be able to act as a practice supervisors. Academic assessors will confirm the student's learning and achievement in the academic setting. However, in many trusts, including the author's own, the mentorship system is still in place. The experiences of current mentors remain pertinent for future supervisors and assessors.
Aims
The aims of the study were to:
Methods
A qualitative study was undertaken, comprising six separate semi-structured interviews, conducted and analysed using Braun and Clarke's (2006) six-stage thematic analysis. Anonymity was protected with a numerical code being assigned to each participant (ie P1). After transcribing all participant statements verbatim, initial themes were noted and then open coded while the researcher became immersed in the data (Braun and Clarke, 2006; Green and Thorogood, 2009). Participant statements were identified, and analysed through the reporting of patterns (themes) within the dataset (Braun and Clarke 2006). The organisation, description and coding of the entire data set in detail led to the identification of a number of themes. After further refinement, three distinct subthemes emerged as illustrated in Figures 1, 2 and 3. The researcher had previously worked closely with mentors, therefore to ensure credibility, enhance rigour and transparency, reflexive accounts were used as the basis of discussion, with supervisory notes and supervisory debriefing crucial to success (Coghlan and Brannick, 2005; Gray and Brown, 2016).
Ethical considerations
Key ethical principles of non-maleficence and beneficence were applied (Endacott, 2005; Parahoo, 2014). Ethical approval for the study was granted from the Institute of Nursing Research, the University, Research and Governance Ethics Committee and the Health and Social Care Trust where the study was taking place (IRAS202203). Confidentiality was assured and written consent was obtained.
Sample
The sample frame was an electronic register, which held a record of all registered mentors within the Health and Social Care Trust and a non-probability purposive sampling method was applied. A letter of invitation was sent out with a participant information sheet to those who met the criteria (n=60). This included:
From the total of those who met the criteria (n=60), a sample of mentors (n=6) was identified.
Results
Results from the data analysis were presented under the following headings:
Engagement (barriers versus strategies)
Engagement with the NMC SLaiP (NMC, 2008) standards was influenced by the mentors' perceived barriers and strategies to their implementation, citing lack of support from peers, ward managers and AEIs. The rigidity of the NMC SLaiP (2008) emerged as a major theme, being seen both as a barrier and a strategy. Some participants felt that there was inequality between registrants because not all had to be mentors:
‘It shouldn't be one half of the workforce's role and the other half “you don't have to do it, that's fine”…’
A number of mentors emphasised that the ward manager being supportive and knowledgeable in their role was integral to its success:
‘I mean for me the ward manager is key to that to make sure it's done properly.’
This opinion is supported by Gray and Brown (2016), who identified that, where the ward manager lacked insight into the mentorship role, negative stressors and anxieties exponentially increased.
The mentor also expressed the view that the practice education facilitators (PEFs) were also seen as helpful:
‘The role of the practice education facilitator promoting mentorship, I think, has been really key in bringing forward the new NMC guidelines …’
However, despite both the ward manager and PEF who were evident in practice being recognised as obvious enablers of this process, mentors still overwhelmingly stated that, in practice, a few nurses were given the role of mentor, leading to them becoming overburdened:
‘So it's continually the same girls who are getting the students, you know, and you are not getting the support and then you become more stressed …’
It was evident among participants that the inequality between the named mentors and other registrants within practice was a major issue. This was further compounded in areas where there was a lack of visibility and input from the AEI and the ward manager did not recognise or value the role, with mentors feeling isolated and stressed:
Support (inclusivity versus exclusivity)
Mentors were concerned with aspects of inclusivity versus exclusivity (Figure 2). Although it was acknowledged that the PEF and link lecturer were an avenue of support, it was the ethos of the ward that was particularly pertinent:
‘Well, I think it's part and parcel of your role [although] a lot of nurses might disagree with me … I think that is where positive role modelling came from and that is where I am coming from and hope that would come across to the students that I have.’
This was further echoed by the participants who commented on the importance of a positive learning environment for all staff so that mentoring was not seen as something that was optional:
‘Well, we have a very good student pack, like really good induction … so that the actual set-up for the student is really good.’
Student engagement and the learning culture within the practice area was also key in developing a shared vision and ownership of the student's progress with all members of staff. In this way it was not solely left to the named mentors to provide feedback or supervise the students.
‘Yes, whenever your colleagues help out … a colleague says, “I'll take them and do this with them, they can do this with me”, and you get on with whatever you are doing.’
These feelings of inclusivity with the process were in stark contrast to those mentors who felt isolated, citing poor staffing levels, education not being high on the agenda and that the mentor role was seen as additional work:
‘So, you know, low staff affects morale and that affects teaching and, you know, if you are feeling undervalued …’
‘Well this ward is not a good ward for students … it is very difficult to mentor students on this ward given the lack of time and the high turnover patients, so I don't think we are supported that well in terms of things that would help, you know.’
A two-tier mentoring system had also evolved, causing resentment towards non-mentors within clinical areas:
‘There are people I work with [who have been] qualified much longer than me and have never had a student, so I don't think it's fair that they are on the same band and on the same pay and they never have to take a student.’
Lack of recognition (strategic versus organisational)
A lack of recognition, inequality with peers and being undervalued as a mentor could be classified as problems both at a strategic level and an organisation level (Figure 3). Participants voiced their difficulty in translating the NMC SLaiP (2008) standards into practice, citing that they felt isolated when trying to assess the student in practice, with the student's portfolio offering little guidance:
‘And, you know, they will argue that you have that in the portfolio but, to be honest, I find the way the portfolio is written very waffly… it's written down in NMC terminology and sometimes I find it hard to read when you are trying to get something very simple across.’
‘You feel recognised by the student, obviously… But from your manager's point of view you don't really get any recognition.’
Although some mentors accepted this as part of the role, there was a substantial number of participants who felt that this was unfair and also contributed to the negative perception of the role within the profession:
‘I just get on with it. You don't get paid any more for doing it but you are expected to do it and there are people on the ward who have said, “No, I don't want to do it”. If I had a choice, I wouldn't have done it either because you just think of all the paperwork.’
The link lecturer's role of offering guidance and expertise on the student's assessment and curriculum was missed by the mentors within all practice areas, which echoes the findings of several years ago (Mallik and McGowan, 2007; Myall et al, 2008; O'Driscoll et al, 2010). Considering the huge investment in infrastructure to support mentors and teachers in practice settings, which includes a variety of approaches, the discovery that mentors stated they felt unsupported and therefore struggled to assess students was disconcerting. This could possibly be attributed to the variation of approaches across the UK to the NMC SLaiP standards (2008) and the range of responsibilities and support given to mentors, which was subject to local education policy and variable funding commitments (Davidson and Devlin, 2012).
‘I think that would be really helpful if you could have greater examples in practice of what they should be doing. I don't think the portfolio currently links us with the university. You know the students think, “this is your placement and this is your theory”, and the two aren't really matching up or gelling together.’
The complexities of the mentoring role were evident because there was no consensus among the participants on how issues might be resolved. Remuneration for the mentoring role and less structure needed in relation to the preparation of mentors was suggested by some as the way to entice registrants to be involved, while for others this would only further exacerbate the inequality within the profession:
‘I think that the university should be more involved, and the ward manager even should be more involved … because you don't get any extra for doing the role … you don't get paid.’
Some mentors stated that, if newly qualified registrants were to take on a mentoring role without adequate support and quality assurance frameworks, this would be perilous, leaving not just mentors and students but the profession at large in a vulnerable position:
‘You do need the structure. You can't expect somebody who has just come out of university to teach somebody else what they have just learnt last week.’
Limitations
The limited number of participants, the inability to recruit from all fields of practice and the researcher's involvement with mentors had the potential to introduce bias because the mentors who responded to the researcher might have had a similar mindset to the researcher. Future studies could be enhanced by extending to other sites, with a greater number of participants across all fields of practice, to explore the identified issues in more depth.
Recommendations for practice
Balancing conflicting demands on the mentor's time with little or no recognition from peers or management made many mentors in this study feel undervalued and ignored, and questioning the credibility of the role. A comprehensive and consistent review of the frameworks in practice as stipulated by the NMC (2018) requires further exploration. These frameworks could be further enhanced by greater collaboration with practice colleagues with expertise in mentorship across all key stakeholders in order to maximise engagement with non-mentors to support students on the pre-registration curriculum. The development of workshops that highlight the importance of collective leadership and ownership of the students' progress and assessment need to be developed and embedded within practice.
Conclusion
The launch of the new NMC standards for education and training (2018) herald a new beginning. It is imperative that the lessons learnt from the previous NMC SLaiP standards (2008) are not forgotten. Some registrants were not active in the supervision and assessment of pre-registration students and a fairer distribution of these roles is needed. This is particularly pertinent given the introduction of the roles of practice supervisor and practice assessor. According to the latest NMC standards (2018) the practice supervisor role can be fulfilled by either a registered nurse or by another registered health and social care professional; however, the practice assessor role must be fulfilled by a registrant in the same field of practice.
The structure governing the regulation and assessment of students must be more clearly specified by the regulatory body, and then translated in partnership at an operational level by both health and social care organisations and universities. A coherent and cohesive approach creating a shared vision must be agreed upon by all key stakeholders to ensure the regulation of the profession is secured.