YNEDT-02725; No of Pages 7 Nurse Education Today xxx (2014) xxx–xxx
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Research Paper
Nursing students' expectations and experiences of mentorship Helen Foster a, Ann Ooms b, Di Marks-Maran c,⁎ a Faculty of Health, Social Care and Education, Kingston University and St George's University of London, Room 6107, Frank Lampl Building, Kingston University, Kingston Hill Campus, Kingston upon Thames, Surrey KT2 7LB, UK b Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, Grosvenor Wing, Cranmer Terrace, London, SW17 0RE, UK c Kingston University and St George's University of London, 30 Beacon Crescent, Hindhead, Surrey GU26 6UG, UK
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Article history: Accepted 7 April 2014 Available online xxxx Keywords: Pre-registration nursing Mentorship Mentors Student support
s u m m a r y Background: The literature related to nursing students' mentorship experiences is surprisingly limited and research findings related to students' experiences of mentorship is often integrated with other components of clinical placement experiences. Objectives: This study aimed to gain a greater understanding of students' expectations and experiences of mentorship and to identify the kind of support provided by the mentor that is most valued by the student, the role of the link lecturer in mentorship and how the university might further enhance the mentorship experience of their students. Design: Mixed-methods exploratory sequential design was used. Setting: This study was conducted in one university in south west London. Participants: All final year pre-registration nursing students enrolled on a Diploma/BSc in Health Studies course (n = 129) were invited to participate. Participation was voluntary resulting in a convenience sample. Fiftythree students completed the questionnaire (response rate = 45%). Methods: The research involved two stages: a semi-structured focus group in the first stage and an online questionnaire in the second. Quantitative analysis was undertaken of Likert-style questions using SPSS version 18 and qualitative analysis was undertaken using the Framework Method. Results: Students' experiences were largely positive. A picture emerged about the most valued mentor activities which included teaching and explaining, support and supervision and encouragement. Students differentiated encouragement from what they labelled as support. Contrary to the literature, the mentor role in practice assessment was not identified as highly important. Support from link lecturers was less well evaluated and students felt that the university needs to support mentors better. Conclusion: Students in this university valued the teaching, support and encouragement they received from mentors but the university needs to address ways of strengthening the link lecturer involvement in mentorship which includes the imperative for the university to explore ways of better supporting mentors in their role. © 2014 Elsevier Ltd. All rights reserved.
Introduction In the United Kingdom (UK), mentorship in nursing is integral to undergraduate nursing education and affects every nursing student. It is a requirement under the UK nursing governing body, the Nursing and Midwifery Council (NMC), that all students are supported and assessed by mentors when in clinical placement (NMC, 2008b). However, mentoring is not a simple activity and involves the development of “complex, bounded and purposeful relationships supported by knowledge, experience and opportunities for reflection” (Gilmour et al., 2007 p. 36). ⁎ Corresponding author. E-mail addresses: [email protected] (H. Foster), [email protected] (A. Ooms), [email protected] (D. Marks-Maran).
The education of nursing students takes place at multiple learning environments. In the UK, 50% of the time is spent at a higher education institution (HEI) and the remaining 50% is spent in practice, here referred to as clinical placement. While students are on clinical placement they receive support from the clinical placement and from the HEI, for example through support from practice personnel, mentors, practice educators, lecturer-practitioners, clinical tutors, and link lecturers. Although clear guidelines have been introduced related to the accountability and responsibilities of a mentor (NMC, 2008b) it has been widely agreed that mentorship includes more than supervision and also involves building professional relationships between the mentor and the mentee, consisting of nurturing, and includes educative and protective elements (Spouse 1996; Watson 1999 cited in Aston and Molassiotis, 2003). HEIs work collaboratively with clinical placements to train mentors and to support mentorship through the use of link lecturers. Effective
http://dx.doi.org/10.1016/j.nedt.2014.04.019 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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communication systems are essential to cope with issues and changes that may affect mentorship. In addition, measures for quality control are in place (RCN, 2006) to audit clinical placements to determine whether they are appropriate learning environments. Even though clinical placements and the HEIs work together to support students in the UK, the higher education institutions are accountable for both components (NMC, 2013). Due to the variety and quantity of clinical placement required within a student's nursing programme (NMC, 2008a,b) covering a range of community, hospital and other settings, there are concerns regarding equality of learning opportunities and clinical experiences of students. The literature related to nursing students' mentorship experiences is surprisingly limited and students' experiences of mentorship are often integrated with other components of clinical placement experiences. This paper aims to enhance understanding of what students expect and experience, and aims to provide insight into how this transpires in reality. The study provides a greater understanding of students' expectations and experiences of mentorship, identifying strengths and challenges of mentorship. The data could be used to guide improvements related to how the Higher Education Institution (HEI) could improve preparation and support for students and mentors alike.
Literature review Literature used within this study was accessed through several databases, including CINAHL, Education Research Complete and NHS Evidence. Key words included student support, mentorship, clinical placement and practice education. In the majority of cases a 10 year range was placed, with English being the key language. The internet allowed governing bodies and government department's web sites to be sourced correctly. Six themes emerged from the literature and will be discussed in the following sections. • • • • • •
Understanding mentors' roles/responsibilities Disinterested Feedback value Workload of mentors Support for mentors Retention issues
Understanding mentors' roles/responsibilities Education within the clinical placement is of huge importance within pre-registration nursing. It is essential that students are not only assessed in practice through the achievement of competencies but that their mentoring is both rigorous and follows the statutory guidelines (NMC, 2006). Although mentioned in Greek mythology, it has been suggested (Pellat, 2006) that Florence Nightingale may have been the first nurse mentor. “Mentoring involves primarily listening with empathy and learning (usually mutually) professional friendship, developing insight through reflection, being a sounding board, encouraging” (Gardiner, 1998, cited in Morton, 2003). In the UK formal mentoring for nursing came with the introduction of Project 2000 (UKCC, 1986). With the move of nursing education into higher education, registered nurses were given the responsibility of being mentors of student nurses (Nettleton and Bray, 2007). There is clear consensus that mentoring is pivotal to the success of students' learning (Gray and Smith, 2000; Pellat, 2006). All good practice requires the underpinning of sound theoretical knowledge and such knowledge should be integrated within practice (NMC, 2004) and par of the mentorship role was therefore perceived to include demonstrating evidenced-based practice to students.
Disinterested Although being a mentor is not compulsory for nurses, the introduction of the Knowledge and Skills Framework (KSF) in 2004 linked promotion with obtaining additional skills and competencies, of which mentorship is one (Department of Health, 2004). Although this framework may ensure adequate and constant numbers of mentors to support students, it does not necessarily result in mentors who are interested in mentorship (Papp et al., 2003). It may lead to registered nursing seeing mentorship as a necessity to promotion and not as something willingly chosen. This idea is echoed by Nash and Scammell (2010) who suggested that in some instances staff is required by their organisation to take on the role of mentor rather than it being an individual's choice. It has been suggested that a good and effective mentor is enthusiastic, understanding, approachable and someone with a good sense of humour (Gray and Smith, 2000; Carr, 2008), and who is professional and confident. The idea of good mentors being described as role models (Gray and Smith, 2000) reflects the idea of professionalism and it has been suggested that the characteristics of a positive role model are closely linked to that of a good nurse (Dotan et al., 1986; Beck 1991, Wiseman 1994; cited in Murray and Main, 2005). Feedback value Gray and Smith (2000) found that students expressed a change in their mentorship needs as they developed through the nursing course. Although students viewed a mentor as vital to their learning, they were less reliant on them as time went on, seeing teaching and constructive criticism as their roles later on in their training. Although the Royal College of Nursing (RCN) in the UK recognises that mentors should provide the appropriate level of supervision, no articulation has been given to their changing role as the student progresses through their programme (RCN 2007), despite the finding from Gray and Smith (2000) that student dependency on a mentor reduced/changed as the programme progressed and their mentorship needs changed. This was further developed by Chow and Suen (2001) who indicated that mentors were unaware of the different objectives that students at different levels might have. There may be challenges in achieving positive constructive feedback due to time constraints (Taylor, 2009) which affects nurses to differing degrees. This idea is echoed by Duffy (2003) when she highlighted the importance of constructive feedback to student nurses in order to identify areas for improvement as well as to highlight strengths. Students perceive giving positive and negative feedback on their performance as part of the mentors' role (Chow and Suen, 2001). Nash and Scammell (2010) explained that students wanted to know more and not just that they were doing well. They wanted details about how they could improve, and what they were not doing well. However, a barrier to this may be the paternalistic nature of nursing and a culture that finds confronting issues or concern constructively difficult (Nash and Scammell, 2010). Workload of mentors Chow and Suen (2001) found that students in Hong Kong were frustrated by a lack of learning opportunity caused by the demands on mentors as both carer and teacher. Facilitating learning is not always recognised as important where priorities of health services are on health care provision (Henderson and Eaton, 2013). As the nurse's role is to always act in the best interests of the patient (NMC, 2008a) in doing so this may be to the detriment of time spent on mentoring. Workload issues for mentors and how these interfere with their capacity to mentor both students and trained nurses on post-qualifying programmes have been similarly reported across a range of nursing settings (e.g., Marks-Maran, 2013; Wilson, 2010; Hurley and Snowden, 2008; Myall et al., 2008). Lack of time available for mentoring students
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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alongside the demands of the clinical workload appears to be a barrier to effective mentorship (Hurley and Snowden, 2008; Myall et al., 2008).
give students. However, these previous studies have only gone some way towards identifying the views of students.
Support for mentors
The research study
It is the responsibility of all placement providers to ensure that there are sufficient mentors to support all nursing students undertaking practice within that provider (NMC, 2008b). Service providers may suggest that a greater emphasis is given to the support universities give to students in clinical placement, given high patient workloads and staff shortages (Castledine 2002; Duffy, 2003; Scott-Donkin, 2005). Sharples and Kelly (2007) suggested that it is not only important to support mentors in clinical placement but that there are clear benefits from doing so. In a study of 71 mentors (Duffy et al., 2000) nearly half of respondents felt that mentorship support was inadequate and that the present arrangements for mentor support not only failed to meet their individual needs but they felt they lacked feedback. Additionally, this study found that more input from the university was required other than when help was directly sought by mentors (Duffy et al., 2000). Taylor (2009) takes this further by suggesting that effective learning can only be successful if the collaboration between educators and mentors is strong.
Method
Retention issues Pearcey and Elliott (2004) found the reason for students leaving the pre-registration programme was the result of bad experiences with mentors on clinical placements. This finding is echoed by Azuine (2003) whose work looked at poor mentoring and Crombie et al. (2013) who explored why students nurses stay on their nursing programmes. Dissatisfaction with the quality of clinical placements is not surprisingly cited as a factor (Chambers, 2007; Crombie et al., 2013). The importance of high quality clinical placements has been acknowledged by the Quality Assurance Agency (2001). Difficulties for placement providers have been reported, including their ability to provide both the quantity and quality of clinical placements and questions over mentors being able to support students adequately (Murray and Williamson, 2009). It may also be about timing. The Department of Health (2006) found that first year students may leave in particular, if they did not feel part of a team when in clinical placement, a finding confirmed by Crombie et al., 2013. A study by Papp et al. (2003) examined students' perceptions of this through a qualitative study. Descriptions of good clinical placements were where good team work and atmosphere existed and students were included in this. Although a small study sample (n = 16), it indicates the importance of team work in making a clinical placement positive for students. Although poor mentoring is clearly one of the influencing factors it is unclear to what degree. One has to ask what constitutes poor mentoring. “Each instance of mentorship is perceived differently based on both the mentor and the person being mentored” (Hoffman et al., 2008, p.103). Descriptions evoked of a poor mentor were reported by Gray and Smith (2000) where students perceived poor mentors as lacking knowledge clinically, and in the nursing course generally. They were either over or under protective of students, and had poor teaching skills. Their findings suggested that mentors were unclear about what the students' capabilities were and students described being “thrown in the deep end” (Gray and Smith, 2000 p.1546). Summary Previous research has identified the key roles and responsibilities of mentors. Concerns have been highlighted, suggesting some mentors were disinterested and increasing workloads affect the support mentors
Mixed-methods exploratory sequential design was used and the aim of the study was to explore the following research questions: • What are the students' expectations of mentorship? • What are the students' experiences with mentorship? • What kind of support provided by the mentor is most valued by the student? • What are the students' expectations of and experiences with the link lecturer? • What could the university do to further enhance mentorship for students? Data collection The research involved two stages: a semi-structured focus group in the first stage and an online questionnaire in the second. The purpose of the focus groups was to collect data about students' views and experiences of the support that students received from their mentors and/or the link lecturers. A convenience sample of students (n = 12) was invited to participate in the focus group, which lasted 47 minutes. The focus group was digitally recorded and transcribed verbatim. The focus group data was used to develop the questionnaire. The following table presents examples of how the focus group data merged into the themes that were used to develop the questionnaire. The questionnaire was developed using the Tailored Design Method (Dillman, 2000) and contained a combination of Likert-style, closedended and open-ended questions. The questionnaire was pilot-tested prior to administration using the think-aloud method. Survey Monkey ™ was used to administer the questionnaire online. Sample All final year pre-registration nursing students enrolled on one cohort of a Diploma/BSc in Health Studies course (n = 129) received an email inviting them to participate in the questionnaire stage of the study. Although all students would have spent a very similar number of hours in the practice setting, variations would have occurred in the practice experiences of individual students and their mentors. Participation was voluntary resulting in a convenience sample. Fifty-three students completed the questionnaire (response rate = 45%). Data analysis Quantitative analysis was carried out using SPSS v. 19. Qualitative analysis was undertaken using the Framework Method of analysis (Ritchie and Spencer, 1994). Ethical approval Ethical approval was granted by the Ethics Committee of the School of Education at the Faculty of Arts and Social Sciences at Kingston University, and the research was conducted in accordance with the required ethical framework. Confidentiality and anonymity were assured and completion of the online questionnaire constituted consent. This was explained in the covering letter inviting students to participate. Data was stored on a password protected computer and only the researcher had access to this data.
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Findings Only one student was male; thus male nursing students are underrepresented in the sample. Twelve students (22.6%) were less than 25 years old, 33 (62.0%) were between 25 and 44 years old and 8 (15.1%) were older than 44 years, which makes the sample representative in terms of age. Students were given a series of statements with which they could agree, somewhat agree, somewhat disagree or disagree. The students' responses were mainly positive for all statements. Students' expectations of mentors and mentorship All but one student felt that a mentor should be a good role model and all but two students felt that a mentor should always act in a professional manner. The majority of the students somewhat agreed or agreed with the statement that the better the clinical placement the more positive the mentorship experience will be. The majority of the students disagreed or disagreed somewhat that they don't want any tension with their mentor in fear of failing practice. Table 1 presents the data in detail. Students' mentorship experiences Overall, the students' experiences of mentorship were positive. Most students disagreed or somewhat disagreed that not every mentor likes being a mentor and that mentors can be disinterested in mentoring students; however 16 of 53 students (29.6%) did not agree that good nurses are always good mentors. Most students received sufficient support from their mentor at the start of their clinical placement and felt that their mentoring needs are very different than when they first started the course. Most felt they received more feedback from their mentor on how to improve their practice in year 3 than at the beginning of the course. Only nine students (16.7%) believed that staff shortage had affected the mentoring they received. Only five students (9.3%) did not feel that their mentor had enough mentorship experiences to support students in practice. Twenty-eight students (51.9%) found it easy to get their practice book signed by their mentor; however nine students (16.7%) felt anxious about their mentor taking the practice book home. All students reported to also having received support from other staff in their clinical placement. Table 2 presents the data in detail. Most valued mentors' activities Students were asked to identify up to three aspect of mentorship they valued most. Some students identified three, while others listed one or two. Six general themes emerged through thematic analysis (Ritchie and Spencer, 1994). These themes were: explaining/teaching, support/supervision/help, encouragement, feedback, identifying new learning, and assessment. Table 3 shows the six themes and the corresponding number of students. Three themes emerged from the open-ended questions of the questionnaire. Students identified that teaching and explaining was clearly a mentor's role they valued (n = 40); support and supervision offered by mentors when in clinical placement was also commonly identified by students (n = 44); and a theme, and a word used by 25 respondents
was “encouragement.” Students clearly differentiated encouragement from what they labelled as support. Although “assessing” and “feedback” were highlighted by students, the number for these themes was not as significant, totalling a combined number of 27. The roles and responsibilities of mentors are discussed earlier in the literature, and this data provides additional insight into what the students' value most about mentorship. Students' expectations of and experiences with the link lecturer Students were asked three questions related to the link lecturer. Results are presented in Table 4. Most students found it important to meet with their link lecturer while they are in practice and reported an understanding the role of the link lecturer. However, not all students feel supported by their link lecturer during their clinical placement. What can the university do to further mentorship for students? An open ended question on the questionnaire allowed students to provide their views on what the university could improve. There were 49 responses to this qualitative question posed, some students making several comments or suggestions. These can be categorised in three themes: selection of mentors, support for mentors and increasing the link lecturer engagement. Selection of mentors One theme emerged around selecting mentors who are keen on being a mentor and felt the university had to ensure that mentors wanted to be mentors. Ten students identified mentors as not having the desire or willingness for the role. One student commented by saying, “there are too many mentors who simply do not enjoy mentoring.” Several students made links between career promotion and qualifying as a mentor. One student wrote: “you would then get a nurse who wanted to be a mentor instead of people wanting to do it to move up.” Support for mentors Students recognised the difficult role mentors have and felt that the university could support mentors better. Ten students provided the following recommendations for the improvement of standards and that would enable mentors to fulfil their roles: • regular mentor updates • study days for mentors • assessment of mentors Students felt it was the university's responsibility to provide this support. Link lecturer engagement Students reported that the university could provide more support to improve link lecturer engagement. Fourteen students specifically requested that they wanted to see their link lecturer during their clinical placement. One student stated: “Improve the visibility of the link lecturer.” Several students wrote that increased contact with the link lecturer would make them feel more supported and would provide an
Table 1 Students' expectations of mentors and mentorship. n
Disagree
Somewhat disagree
Somewhat agree
Agree
A mentor should be a good role model.
54
A mentor should always act in a professional manner.
54
The better the clinical placement the more positive the mentorship experience will be.
53
I do not want any tension with my mentor in fear of failing practice.
54
0 0% 0 0% 2 3.7% 36 66.7%
0 0% 0 0% 5 9.3% 17 31.5%
1 1.9% 2 3.7% 10 18.5% 1 1.9%
53 98.1% 52 96.3% 36 66.7% 0 0%
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Table 2 Students' mentorship experiences. n
Disagree
Somewhat disagree
Somewhat agree
Agree
Not every mentor likes being a mentor.
54
Mentors can be disinterested in mentoring students.
53
Good nurses are always good mentors.
54
I received sufficient support from my mentor at the start of my clinical placement.
53
My needs from mentoring are very different now than when I first started the course.
53
I receive more feedback from my mentor on how to improve my practice now than at the beginning of the course. Staff shortages have affected the mentoring I have received.
53
I feel my mentor has enough mentorship experience to support students in clinical placement. It is easy to get my practice book signed by my mentor.
53
I am anxious about my mentor taking my practice book home.
53
34 63.0% 31 57.4% 6 11.1% 5 9.3% 3 5.6% 6 11.1% 24 44.4% 0 0% 8 14.8% 28 51.9%
18 33.3% 20 37.0% 10 18.5% 1 1.9% 2 3.7% 8 14.8% 19 35.2% 5 9.3% 17 31.5% 16 29.6%
2 3.7% 2 3.7% 21 38.9% 23 42.6% 12 22.2% 18 33.3% 7 13.0% 17 31.5% 23 42.6% 5 9.3%
0 0% 0 0% 17 31.5% 24 44.4% 36 66.7% 21 38.9% 2 3.7% 31 57.4% 5 9.3% 4 7.4%
opportunity for the university to monitor the quality of the mentors, the clinical environment and practice. The focus group yielded a number of themes which supported the quantitative findings. These were: • • • • •
student expectations of mentors and mentorship students' personal mentorship experiences students' expectations of, and experience with the link lecturer support from mentors link lecturer engagement with students and mentors Table 5 provides quotes from students related to these themes.
Discussion This discussion explores the findings from this study and how they mapped against the six themes from the literature that were identified earlier.
52
53
mentors recognise the changing needs of students (RCN, 2005). However, if the focus of the feedback is on the practice assessment documentation, Fitzgerald, Gibson and Gunn (2010) found that students are not receiving enough feedback required to grow and develop professionally. Thus, for feedback to be effective, it needs to focus on all aspects of learning. Clynes and Raftery (2008) suggest that preparation for the role of mentor may affect the nurses' ability to provide feedback. They suggest that in many mentorship training programmes feedback is poorly addressed. Consideration with a specific focus on feedback for all HEI's in their mentorship training would enable students to develop and progress. Student's views on a mentor's responsibility for assessment were surprising. Although the literature is heavily focused around this responsibility (NMC, 2008b), findings from this research indicate otherwise; placing encouragement at a greater value, something which has previously not been mentioned in the literature. One possible explanation is that the word “encouragement” has been used with the students by university staff in preparing students for clinical placements. This however requires more research.
Understanding mentors roles/responsibilities Workload of mentors Overall, students were very positive about their experiences of mentorship, many feeling well supported by both mentors and the HEI. Students had a good understanding of the roles and responsibilities of mentorship and this correlated to what they valued in a mentor. It is important that students have realistic expectations of the support that is available to them, reducing misunderstandings and disappointments (Wilkes, 2006). Reducing the sense of unachieved expectations for both parties may be beneficial, especially for students where attrition is the concern and HEIs have a responsibility to communicate expectations to all nursing students. Disinterested Although some of the literature suggested that mentors are disinterested in being mentors (e.g. Papp et al., 2003; Nash and Scammell, 2010), this study did not find evidence of mentor disinterest although some students did agree that good nurses do not necessarily make good mentors. Feedback value Students indicated that they were receiving more feedback as they progressed through their course. Constructive feedback is necessary for development (Duffy, 2003) and the data would indicate that
Work load of mentors and its effect as a barrier to making time for mentoring students was an issue raised in the literature (Hurley and Snowden, 2008; Myall et al., 2008). However, in this study, students did not indicate that mentor workload prevented them from finding the time for mentorship of students and only a small percentage of students indicated that shortage of mentors was an issue. Support for mentors Students suggested that more could be done by the university to support mentors, which is also supported by the literature (Jokelainen et al., 2012). Roles such as practice facilitator/educator may help in achieving this outcome (Murray and Williamson, 2009). The literature Table 3 Themes. Themes
Frequency of statements
Explaining/teaching Support/supervision/help Encouragement Feedback Identifying new learning Assessment
44 40 25 18 9 9
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Table 4 Students' expectations of and experiences with the link lecturer. n
Disagree
Somewhat disagree
Somewhat agree
Agree
Meeting with my link lecturer in clinical placement is important.
51
I understand the role of the link lecturer in clinical placement.
53
I feel supported in my clinical placement by my link lecturer.
53
1 1.9% 3 5.6% 11 20.4%
5 9.3% 3 5.6% 14 25.9%
15 27.8% 18 33.3% 18 33.3%
30 55.6% 29 53.7% 10 18.5%
shows that mentors request regular visits from link lecturers to clinical placements, and wanted feedback on their own performance (Jokelainen et al., 2012), which is what students in this study recommended. Jokelainen et al. (2012) concluded that mentors felt they benefited from mentorship preparation sessions and annual updates which helped to develop their knowledge and skills. Beneficial changes such as increasing the status of being a mentor, providing additional support through the use of practice facilitators/educators as well as continuous education and feedback to mentors could improve the students' experiences. HEIs could provide additional support to mentors in many different forms and could increase the value of mentorship accordingly. Retention issues Although some previous studies (e.g. Crombie et al., 2013) suggest that poor mentorship can lead to students thinking about leaving their nursing programme, students in this study did not indicate that this was an issue for them. Link lecturers, collaboration and mentorship One additional finding from the study presented here that appears as an issue only in a small amount of the literature is the role of the link lecturer and the part that link lecturers play in making mentorship work. Students in this study are well aware of the role of the link lecturer. However, not all students feel supported by their link lecturer during clinical placement. This supports findings from Murray and Williamson (2009) who found that students identified that academic staff do not understand students' needs in the clinical placement and suggested that HEIs need to provide more visible support to students. A lack of appreciation or understanding of practice by academic staff could result in their inability to meet the needs of students. Although supporting students is the responsibility of link lecturers (RCN, 2006) this support is not being felt by students in this study. In order for the support to be effective and efficient, HEIs need to support students and clinical mentors; support provided to mentors will eventually also benefit all the students that will be mentored by that mentor in the future (Papp et al., 2003; Taylor, 2009). This is a more effective use of resources and is a more holistic approach to support. This idea is supported by Kerridge (2008) who found a direct positive correlation between support provided by link lecturers to the mentor and the mentor support received by the student. Further research into the impact of support provided by link lecturers is needed.
It is disappointing to see that some students felt unsupported by link lecturers. There may be several explanations for that, including students' not needing support or link lecturers only devoting their attention to places where problems arise. However, although this requires more research, the university where this study took place implemented a continuous evaluation of students' experiences in practice, allowing for an additional method for measuring and monitoring quality and equality of clinical placements including access to link lecturers (Ooms et al., 2014). Facilitating learning is not always recognised as important where priorities of health services are on health care provision (Henderson and Eaton, 2013). Nurses have a duty to care for patients first and foremost (NMC, 2008a,b). However, increasing the status of the role of learning facilitator by placement providers may further enhance mentorship for students. Students in this study also made several recommendations with regard to meeting the required standards of mentorship (NMC, 2008b), supporting previous studies that recommended better collaboration between HEIs and placement providers (Murray and Williamson, 2009; Taylor, 2009, Duffy et al., 2000). Limitations This study has several limitations so generalizations need to be made with caution. Convenience sampling was used to recruit students from one pre-registration nursing student group from one university based in London, UK. Mentors were not included in the study; however their inclusion could have provided a more complete and balanced picture. The focus group was arranged and led by the researcher. Focus group participants were known to the researcher which could potentially compromise students' honesty, professional boundaries and participant's vulnerability (Robson, 2002). However, appropriate measures were taken to prevent any possible chance of coercion and that professional boundaries were maintained. Conclusion The study presented here focused on understanding students' expectations as well as their own experiences of mentorship and how these align with current policies and procedures regulated by professional bodies. Furthermore, it offers an insight into the relationship between student's expectations and their experiences of mentorship.
Table 5 Themes and quotes from focus groups. Example of student quotes
Theme arising from focus group
“I think the mentor should be a teacher and motivate us, to help us progress, to guide us in practice.” “I notice people don't want to do it (mentoring), they think it is too much work.” “What I've heard from other students is that if you have any problems, they [the link lecturer] are there and willing to help.” “When I saw my link lecturer, she asked if I had any problems and she were very, very supportive, but you don't see them enough.” “Your needs do change.” “My needs from year one to three were completely different.” “We always know how to access them [link lecturers].”
Students' expectations of mentors and mentorship Students' mentorship experiences Students' expectations of and experiences with the link lecturer
Support from mentors Link lecturer engagement
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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This data will contribute to a greater understanding, thus providing focus on how best HEIs can prepare and support both the students and mentors for learning in clinical placement. Some of the findings from this study supported existing studies of mentorship; however, new insights were gained into students' expectations and experiences of mentorship, and the university's role in mentorship. References Aston, L., Molassiotis, A., 2003. Supervising and supporting student nurses in clinical placements the peer support initiative. Nurse Educ. Today 23 (3), 202–210. Azuine, R., 2003. Listen up. The NMC should take a stand against bad mentors'. Nurs. Times 99 (28), 18. Beck, C., 1991. How students perceive faculty caring: a phenomenological study. Nurse Educ. 16 (5), 18–22. Carr, J., 2008. Mentoring student nurses in the practice. Pract. Nurs. 19 (9), 465–467. Castledine, G., 2002. Castledine column: students must be treated better in clinical areas. Br. J. Nurs. 11 (18), 1222. Chambers, D., 2007. Comment: is the modern NHS fit for nursing students? Br. J. Nurs. 16 (2), 74–75. Chow, F., Suen, L., 2001. Clinical staff as mentors in pre-registration undergraduate nursing education: students' perceptions of the mentors' roles and responsibilities. Nurse Educ. Today 21 (5), 350–358. Clynes, M.P., Raftery, S.E.C., 2008. Feedback: an essential element of student learning in clinical practice. Nurse Educ. Pract. 8 (6), 405–411. Crombie, A., Brindley, J., Harris, D., Marks-Maran, D., Morris-Thompson, T., 2013. Factors that enhance rates of completion: what makes students stay? Nurse Educ. Today 33 (11), 1282–1287. Department of Health, 2004. NHS knowledge and skills framework. Available at: http:// webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_4009176 (Accessed: 17 March, 2013). Department of Health, 2006. Managing attrition rates for student nurses and midwives. Available at: http://webarchive.nationalarchives.gov.uk/20080905235643/dh.gov. uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_ 073230 (Accessed: 16 March 2013). Dotan, M., Krulik, T., Bergman, R., Eckerling, S., Shatzman, H., 1986. Role models in nursing. Nurs. Times 82 (3), 55–57 (Occasional Paper). Dillman, D.A., 2000. Mail and Internet Surveys: The Tailored Design Method, 2nd ed. John Wiley & Sons, New York. Duffy, K., 2003. Failing Students: A Qualitative Study of Factors that Influence the Decision Regarding Assessment if Students' Competence in Practice. Glasgow Caledonian University, Glasgow. Duffy, K., Dockerty, C., Cardnuff, L., White, M., Winters, G., Greig, J., 2000. The nurse lecturer's role in mentoring the mentors. Nurs. Stand. 15 (6), 35–38. Fitzgerald, M., Gibson, F., Gunn, K., 2010. Contemporary issues relating to assessment of pre-registration nursing students in practice. Nurse Education in Practice 10 (3), 158–163. Gardiner, C., 1998. Mentoring: towards a professional friendship. Mentoring and tutoring: partnership in learning 6 (1–2), 77–84. Gilmour, J.A., Kopeiki, A., Douche, J., 2007. Student nurses as peer-mentors: collegiality in practice. Nurse Educ. Pract. 7 (1), 36–43. Gray, M.A., Smith, L.N., 2000. The qualities of an effective mentor from the student nurse's perspective: findings from a longitudinal qualitative study. J. Adv. Nurs. 32 (6), 1542–1549. Henderson, A., Eaton, E., 2013. Assisting nurses to facilitate student and new graduate learning in practice setting: ‘what support’ do nurses at the bedside need? Nurse Educ. Pract. 13 (3), 197–2002. Hoffman, S.J., Harris, A., Rosenfield, D., 2008. Why mentorship matters: students, staff and sustainability in interprofessional education. J. Interprof. Care 22 (1), 103–105. Hurley, C., Snowden, S., 2008. Mentoring in times of change. Nurs. Crit. Care 13, 269–275. Jokelainen, M., Tossavainen, K., Jamookeeah, D., Turunen, H., 2012. Seamless and committed collaboration as an essential factor in effective mentorship for nursing students: conceptions of Finnish and British mentors. Nurse Educ. Today 33 (5), 437–444. Kerridge, J.L., 2008. Supporting student nurses on placement in nursing homes: the challenges for the link-tutor role. Nurse Educ. Pract. 8 (6), 389–396. Marks-Maran, D., 2013. Primary Care Nursing/GP Training Pilot Project: Report of the Evaluative Research Study. GP Deanery, London. Morton, A., 2003. Continual Professional Development. Series No 2: Mentoring. London and Teaching Support Network, York. Murray, C.J., Main, A., 2005. Role modelling as a teaching method for student mentors. Nurs. Times 101 (26), 30–39.
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Murray, S.C., Williamson, G.R., 2009. Managing capacity issues in clinical placements for pre-registration nurses. J. Clin. Nurs. 18 (22), 3146–3154. Myall, M., Levett-Jones, T., Lathlean, J., 2008. Mentorship in contemporary practice: the experiences of nursing students and practice mentors. J. Clin. Nurs. 17, 1834–1842. Nash, S., Scammell, J., 2010. Skills to ensure success in mentoring and other workplace learning approaches. Nurs. Times 106 (2), 17–20. Nettleton, B., Bray, L., 2007. Current mentorship schemes might be doing our students a disservice. Nurse Educ. Pract. 8, 205–212. Nursing and Midwifery Council, 2004. Standards of proficiency for pre-registration nursing education. Available at: http://www.nmc-uk.org/Educators/Standards-foreducation/Standards-of-proficiency-for-pre-registration-nursing-education/ (Accessed, 17 March 2013). Nursing and Midwifery Council, 2006. Standards to support learning and assessment in practice NMC standards for mentors, practice teachers and teachers. NMC, London. Nursing and Midwifery Council, 2008a. The code: standards of conduct, performance and ethics for nurses and midwives. Available at: http://www.nmc-uk.org/Publications/ Standards/ (Accessed, March 17 2013). Nursing and Midwifery Council, 2008b. Standards to support learning and assessment in practice. Available at: http://www.nmc-uk.org/Documents/Standards/ nmcStandardsToSupportLearningAndAssessmentInPractice.pdf (Accessed, 16 March 2013). Nursing and Midwifery Council, 2013. Quality assurance framework. Available at: http://www.nmc-uk.org/Documents/EdandQA/Quality%20assurance%20framework%20FINAL%2017.06.13.pdf (Accessed, September 5 h 2013). Ooms, A., Sharples, K., Marks-Maran, D., 2014. A longitudinal evaluation model for monitoring the quality and equality of nursing practice placements: The students' view. Poster presentation, American Educational Research Conference, Philadelphia, April 2014. Papp, I., Markkanen, M., von Bonsdorff, M., 2003. Clinical environment as a learning environment: student nurses' perceptions concerning clinical learning experiences. Nurse Educ. Today 23 (4), 262–268. Pearcey, P.A., Elliott, B.E., 2004. Student impressions of clinical nursing. Nurse Educ. Today 24 (5), 382–387. Pellat, G., 2006. The role of mentors in supporting pre-registration nursing students. Br. J. Nurs. 15 (6), 336–340. Quality Assurance Agency, 2001. Code of Practice for the Assurance of Academic Quality and Standards in Higher Education: Placement Learning. Quality Assurance Agency, Gloucester. Ritchie, J., Spencer, L., 1994. Qualitative data analysis for applied policy research. In: Bryman, A., Burgess, R. (Eds.), Analysing Qualitative Data. Routledge, London, pp. 173–194. Robson, C., 2002. Real World Research: A Resource for Social Scientists and Practitioner– Researchers, 2nd ed. Blackwell, Oxford. Royal College of Nursing, 2005. The Practice Placement Experience. A survey of RCN Student Members. RCN, London. Royal College of Nursing, 2006. Helping students get the best from their practice placements. Available at: http://www.rcn.org.uk/_data/assets/pdf_file/0011/78545/ 001815.pdf (Accessed: September 5th 2013). Royal College of Nursing, 2007. Guidance for mentors of nursing students and midwives. Available at: http://www.rcn.org.uk/_data/assets/pdf_file/0008/78677/002797.pdf (Accessed: September 5 2013). Scott-Donkin, A., 2005. The majority of mentors are doing an exceptional job. Nurs. Stand. 20 (8), 39. Sharples, K., Kelly, D., 2007. Supporting mentors in practice. Nurs. Stand. 21 (39), 44–47. Spouse, J., 1996. The effective mentor: a role model for student centred-learning. Nurs. Times 92 (3), 32–35. Taylor, C., 2009. Mutually supportive. Nurs. Stand. 24 (1), 61. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986. Project 2000: A New Preparation for Practice. UKCC, London. Watson, N., 1999. Mentoring today — the students’ views. An investigative case study of pre-registration nursing students’ experiences and perceptions of mentoring in one theory/ practice module of the Common Foundation Programme on a Project 2000 course. J. Adv. Nurs 29 (1), 254–262. Wilkes, Z., 2006. The student–mentor relationship: a review of the literature'. Nurs. Stand. 20 (37), 42–47. Wilson, A., 2010. Are the demands of nurse mentoring underestimated? Nursing Times. http://www.nursingtimes.net/are-the-demands-of-nurse-mentoring-underestimated/ 5015817.article (Accessed 20 November 2013). Wiseman, R., 1994. Role model behaviours in the clinical setting. J. Nurs. Educ. 33 (9), 405–410.
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Research Paper
Nursing students' expectations and experiences of mentorship Helen Foster a, Ann Ooms b, Di Marks-Maran c,⁎ a Faculty of Health, Social Care and Education, Kingston University and St George's University of London, Room 6107, Frank Lampl Building, Kingston University, Kingston Hill Campus, Kingston upon Thames, Surrey KT2 7LB, UK b Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, Grosvenor Wing, Cranmer Terrace, London, SW17 0RE, UK c Kingston University and St George's University of London, 30 Beacon Crescent, Hindhead, Surrey GU26 6UG, UK
a r t i c l e
i n f o
Article history: Accepted 7 April 2014 Available online xxxx Keywords: Pre-registration nursing Mentorship Mentors Student support
s u m m a r y Background: The literature related to nursing students' mentorship experiences is surprisingly limited and research findings related to students' experiences of mentorship is often integrated with other components of clinical placement experiences. Objectives: This study aimed to gain a greater understanding of students' expectations and experiences of mentorship and to identify the kind of support provided by the mentor that is most valued by the student, the role of the link lecturer in mentorship and how the university might further enhance the mentorship experience of their students. Design: Mixed-methods exploratory sequential design was used. Setting: This study was conducted in one university in south west London. Participants: All final year pre-registration nursing students enrolled on a Diploma/BSc in Health Studies course (n = 129) were invited to participate. Participation was voluntary resulting in a convenience sample. Fiftythree students completed the questionnaire (response rate = 45%). Methods: The research involved two stages: a semi-structured focus group in the first stage and an online questionnaire in the second. Quantitative analysis was undertaken of Likert-style questions using SPSS version 18 and qualitative analysis was undertaken using the Framework Method. Results: Students' experiences were largely positive. A picture emerged about the most valued mentor activities which included teaching and explaining, support and supervision and encouragement. Students differentiated encouragement from what they labelled as support. Contrary to the literature, the mentor role in practice assessment was not identified as highly important. Support from link lecturers was less well evaluated and students felt that the university needs to support mentors better. Conclusion: Students in this university valued the teaching, support and encouragement they received from mentors but the university needs to address ways of strengthening the link lecturer involvement in mentorship which includes the imperative for the university to explore ways of better supporting mentors in their role. © 2014 Elsevier Ltd. All rights reserved.
Introduction In the United Kingdom (UK), mentorship in nursing is integral to undergraduate nursing education and affects every nursing student. It is a requirement under the UK nursing governing body, the Nursing and Midwifery Council (NMC), that all students are supported and assessed by mentors when in clinical placement (NMC, 2008b). However, mentoring is not a simple activity and involves the development of “complex, bounded and purposeful relationships supported by knowledge, experience and opportunities for reflection” (Gilmour et al., 2007 p. 36). ⁎ Corresponding author. E-mail addresses: [email protected] (H. Foster), [email protected] (A. Ooms), [email protected] (D. Marks-Maran).
The education of nursing students takes place at multiple learning environments. In the UK, 50% of the time is spent at a higher education institution (HEI) and the remaining 50% is spent in practice, here referred to as clinical placement. While students are on clinical placement they receive support from the clinical placement and from the HEI, for example through support from practice personnel, mentors, practice educators, lecturer-practitioners, clinical tutors, and link lecturers. Although clear guidelines have been introduced related to the accountability and responsibilities of a mentor (NMC, 2008b) it has been widely agreed that mentorship includes more than supervision and also involves building professional relationships between the mentor and the mentee, consisting of nurturing, and includes educative and protective elements (Spouse 1996; Watson 1999 cited in Aston and Molassiotis, 2003). HEIs work collaboratively with clinical placements to train mentors and to support mentorship through the use of link lecturers. Effective
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Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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communication systems are essential to cope with issues and changes that may affect mentorship. In addition, measures for quality control are in place (RCN, 2006) to audit clinical placements to determine whether they are appropriate learning environments. Even though clinical placements and the HEIs work together to support students in the UK, the higher education institutions are accountable for both components (NMC, 2013). Due to the variety and quantity of clinical placement required within a student's nursing programme (NMC, 2008a,b) covering a range of community, hospital and other settings, there are concerns regarding equality of learning opportunities and clinical experiences of students. The literature related to nursing students' mentorship experiences is surprisingly limited and students' experiences of mentorship are often integrated with other components of clinical placement experiences. This paper aims to enhance understanding of what students expect and experience, and aims to provide insight into how this transpires in reality. The study provides a greater understanding of students' expectations and experiences of mentorship, identifying strengths and challenges of mentorship. The data could be used to guide improvements related to how the Higher Education Institution (HEI) could improve preparation and support for students and mentors alike.
Literature review Literature used within this study was accessed through several databases, including CINAHL, Education Research Complete and NHS Evidence. Key words included student support, mentorship, clinical placement and practice education. In the majority of cases a 10 year range was placed, with English being the key language. The internet allowed governing bodies and government department's web sites to be sourced correctly. Six themes emerged from the literature and will be discussed in the following sections. • • • • • •
Understanding mentors' roles/responsibilities Disinterested Feedback value Workload of mentors Support for mentors Retention issues
Understanding mentors' roles/responsibilities Education within the clinical placement is of huge importance within pre-registration nursing. It is essential that students are not only assessed in practice through the achievement of competencies but that their mentoring is both rigorous and follows the statutory guidelines (NMC, 2006). Although mentioned in Greek mythology, it has been suggested (Pellat, 2006) that Florence Nightingale may have been the first nurse mentor. “Mentoring involves primarily listening with empathy and learning (usually mutually) professional friendship, developing insight through reflection, being a sounding board, encouraging” (Gardiner, 1998, cited in Morton, 2003). In the UK formal mentoring for nursing came with the introduction of Project 2000 (UKCC, 1986). With the move of nursing education into higher education, registered nurses were given the responsibility of being mentors of student nurses (Nettleton and Bray, 2007). There is clear consensus that mentoring is pivotal to the success of students' learning (Gray and Smith, 2000; Pellat, 2006). All good practice requires the underpinning of sound theoretical knowledge and such knowledge should be integrated within practice (NMC, 2004) and par of the mentorship role was therefore perceived to include demonstrating evidenced-based practice to students.
Disinterested Although being a mentor is not compulsory for nurses, the introduction of the Knowledge and Skills Framework (KSF) in 2004 linked promotion with obtaining additional skills and competencies, of which mentorship is one (Department of Health, 2004). Although this framework may ensure adequate and constant numbers of mentors to support students, it does not necessarily result in mentors who are interested in mentorship (Papp et al., 2003). It may lead to registered nursing seeing mentorship as a necessity to promotion and not as something willingly chosen. This idea is echoed by Nash and Scammell (2010) who suggested that in some instances staff is required by their organisation to take on the role of mentor rather than it being an individual's choice. It has been suggested that a good and effective mentor is enthusiastic, understanding, approachable and someone with a good sense of humour (Gray and Smith, 2000; Carr, 2008), and who is professional and confident. The idea of good mentors being described as role models (Gray and Smith, 2000) reflects the idea of professionalism and it has been suggested that the characteristics of a positive role model are closely linked to that of a good nurse (Dotan et al., 1986; Beck 1991, Wiseman 1994; cited in Murray and Main, 2005). Feedback value Gray and Smith (2000) found that students expressed a change in their mentorship needs as they developed through the nursing course. Although students viewed a mentor as vital to their learning, they were less reliant on them as time went on, seeing teaching and constructive criticism as their roles later on in their training. Although the Royal College of Nursing (RCN) in the UK recognises that mentors should provide the appropriate level of supervision, no articulation has been given to their changing role as the student progresses through their programme (RCN 2007), despite the finding from Gray and Smith (2000) that student dependency on a mentor reduced/changed as the programme progressed and their mentorship needs changed. This was further developed by Chow and Suen (2001) who indicated that mentors were unaware of the different objectives that students at different levels might have. There may be challenges in achieving positive constructive feedback due to time constraints (Taylor, 2009) which affects nurses to differing degrees. This idea is echoed by Duffy (2003) when she highlighted the importance of constructive feedback to student nurses in order to identify areas for improvement as well as to highlight strengths. Students perceive giving positive and negative feedback on their performance as part of the mentors' role (Chow and Suen, 2001). Nash and Scammell (2010) explained that students wanted to know more and not just that they were doing well. They wanted details about how they could improve, and what they were not doing well. However, a barrier to this may be the paternalistic nature of nursing and a culture that finds confronting issues or concern constructively difficult (Nash and Scammell, 2010). Workload of mentors Chow and Suen (2001) found that students in Hong Kong were frustrated by a lack of learning opportunity caused by the demands on mentors as both carer and teacher. Facilitating learning is not always recognised as important where priorities of health services are on health care provision (Henderson and Eaton, 2013). As the nurse's role is to always act in the best interests of the patient (NMC, 2008a) in doing so this may be to the detriment of time spent on mentoring. Workload issues for mentors and how these interfere with their capacity to mentor both students and trained nurses on post-qualifying programmes have been similarly reported across a range of nursing settings (e.g., Marks-Maran, 2013; Wilson, 2010; Hurley and Snowden, 2008; Myall et al., 2008). Lack of time available for mentoring students
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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alongside the demands of the clinical workload appears to be a barrier to effective mentorship (Hurley and Snowden, 2008; Myall et al., 2008).
give students. However, these previous studies have only gone some way towards identifying the views of students.
Support for mentors
The research study
It is the responsibility of all placement providers to ensure that there are sufficient mentors to support all nursing students undertaking practice within that provider (NMC, 2008b). Service providers may suggest that a greater emphasis is given to the support universities give to students in clinical placement, given high patient workloads and staff shortages (Castledine 2002; Duffy, 2003; Scott-Donkin, 2005). Sharples and Kelly (2007) suggested that it is not only important to support mentors in clinical placement but that there are clear benefits from doing so. In a study of 71 mentors (Duffy et al., 2000) nearly half of respondents felt that mentorship support was inadequate and that the present arrangements for mentor support not only failed to meet their individual needs but they felt they lacked feedback. Additionally, this study found that more input from the university was required other than when help was directly sought by mentors (Duffy et al., 2000). Taylor (2009) takes this further by suggesting that effective learning can only be successful if the collaboration between educators and mentors is strong.
Method
Retention issues Pearcey and Elliott (2004) found the reason for students leaving the pre-registration programme was the result of bad experiences with mentors on clinical placements. This finding is echoed by Azuine (2003) whose work looked at poor mentoring and Crombie et al. (2013) who explored why students nurses stay on their nursing programmes. Dissatisfaction with the quality of clinical placements is not surprisingly cited as a factor (Chambers, 2007; Crombie et al., 2013). The importance of high quality clinical placements has been acknowledged by the Quality Assurance Agency (2001). Difficulties for placement providers have been reported, including their ability to provide both the quantity and quality of clinical placements and questions over mentors being able to support students adequately (Murray and Williamson, 2009). It may also be about timing. The Department of Health (2006) found that first year students may leave in particular, if they did not feel part of a team when in clinical placement, a finding confirmed by Crombie et al., 2013. A study by Papp et al. (2003) examined students' perceptions of this through a qualitative study. Descriptions of good clinical placements were where good team work and atmosphere existed and students were included in this. Although a small study sample (n = 16), it indicates the importance of team work in making a clinical placement positive for students. Although poor mentoring is clearly one of the influencing factors it is unclear to what degree. One has to ask what constitutes poor mentoring. “Each instance of mentorship is perceived differently based on both the mentor and the person being mentored” (Hoffman et al., 2008, p.103). Descriptions evoked of a poor mentor were reported by Gray and Smith (2000) where students perceived poor mentors as lacking knowledge clinically, and in the nursing course generally. They were either over or under protective of students, and had poor teaching skills. Their findings suggested that mentors were unclear about what the students' capabilities were and students described being “thrown in the deep end” (Gray and Smith, 2000 p.1546). Summary Previous research has identified the key roles and responsibilities of mentors. Concerns have been highlighted, suggesting some mentors were disinterested and increasing workloads affect the support mentors
Mixed-methods exploratory sequential design was used and the aim of the study was to explore the following research questions: • What are the students' expectations of mentorship? • What are the students' experiences with mentorship? • What kind of support provided by the mentor is most valued by the student? • What are the students' expectations of and experiences with the link lecturer? • What could the university do to further enhance mentorship for students? Data collection The research involved two stages: a semi-structured focus group in the first stage and an online questionnaire in the second. The purpose of the focus groups was to collect data about students' views and experiences of the support that students received from their mentors and/or the link lecturers. A convenience sample of students (n = 12) was invited to participate in the focus group, which lasted 47 minutes. The focus group was digitally recorded and transcribed verbatim. The focus group data was used to develop the questionnaire. The following table presents examples of how the focus group data merged into the themes that were used to develop the questionnaire. The questionnaire was developed using the Tailored Design Method (Dillman, 2000) and contained a combination of Likert-style, closedended and open-ended questions. The questionnaire was pilot-tested prior to administration using the think-aloud method. Survey Monkey ™ was used to administer the questionnaire online. Sample All final year pre-registration nursing students enrolled on one cohort of a Diploma/BSc in Health Studies course (n = 129) received an email inviting them to participate in the questionnaire stage of the study. Although all students would have spent a very similar number of hours in the practice setting, variations would have occurred in the practice experiences of individual students and their mentors. Participation was voluntary resulting in a convenience sample. Fifty-three students completed the questionnaire (response rate = 45%). Data analysis Quantitative analysis was carried out using SPSS v. 19. Qualitative analysis was undertaken using the Framework Method of analysis (Ritchie and Spencer, 1994). Ethical approval Ethical approval was granted by the Ethics Committee of the School of Education at the Faculty of Arts and Social Sciences at Kingston University, and the research was conducted in accordance with the required ethical framework. Confidentiality and anonymity were assured and completion of the online questionnaire constituted consent. This was explained in the covering letter inviting students to participate. Data was stored on a password protected computer and only the researcher had access to this data.
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Findings Only one student was male; thus male nursing students are underrepresented in the sample. Twelve students (22.6%) were less than 25 years old, 33 (62.0%) were between 25 and 44 years old and 8 (15.1%) were older than 44 years, which makes the sample representative in terms of age. Students were given a series of statements with which they could agree, somewhat agree, somewhat disagree or disagree. The students' responses were mainly positive for all statements. Students' expectations of mentors and mentorship All but one student felt that a mentor should be a good role model and all but two students felt that a mentor should always act in a professional manner. The majority of the students somewhat agreed or agreed with the statement that the better the clinical placement the more positive the mentorship experience will be. The majority of the students disagreed or disagreed somewhat that they don't want any tension with their mentor in fear of failing practice. Table 1 presents the data in detail. Students' mentorship experiences Overall, the students' experiences of mentorship were positive. Most students disagreed or somewhat disagreed that not every mentor likes being a mentor and that mentors can be disinterested in mentoring students; however 16 of 53 students (29.6%) did not agree that good nurses are always good mentors. Most students received sufficient support from their mentor at the start of their clinical placement and felt that their mentoring needs are very different than when they first started the course. Most felt they received more feedback from their mentor on how to improve their practice in year 3 than at the beginning of the course. Only nine students (16.7%) believed that staff shortage had affected the mentoring they received. Only five students (9.3%) did not feel that their mentor had enough mentorship experiences to support students in practice. Twenty-eight students (51.9%) found it easy to get their practice book signed by their mentor; however nine students (16.7%) felt anxious about their mentor taking the practice book home. All students reported to also having received support from other staff in their clinical placement. Table 2 presents the data in detail. Most valued mentors' activities Students were asked to identify up to three aspect of mentorship they valued most. Some students identified three, while others listed one or two. Six general themes emerged through thematic analysis (Ritchie and Spencer, 1994). These themes were: explaining/teaching, support/supervision/help, encouragement, feedback, identifying new learning, and assessment. Table 3 shows the six themes and the corresponding number of students. Three themes emerged from the open-ended questions of the questionnaire. Students identified that teaching and explaining was clearly a mentor's role they valued (n = 40); support and supervision offered by mentors when in clinical placement was also commonly identified by students (n = 44); and a theme, and a word used by 25 respondents
was “encouragement.” Students clearly differentiated encouragement from what they labelled as support. Although “assessing” and “feedback” were highlighted by students, the number for these themes was not as significant, totalling a combined number of 27. The roles and responsibilities of mentors are discussed earlier in the literature, and this data provides additional insight into what the students' value most about mentorship. Students' expectations of and experiences with the link lecturer Students were asked three questions related to the link lecturer. Results are presented in Table 4. Most students found it important to meet with their link lecturer while they are in practice and reported an understanding the role of the link lecturer. However, not all students feel supported by their link lecturer during their clinical placement. What can the university do to further mentorship for students? An open ended question on the questionnaire allowed students to provide their views on what the university could improve. There were 49 responses to this qualitative question posed, some students making several comments or suggestions. These can be categorised in three themes: selection of mentors, support for mentors and increasing the link lecturer engagement. Selection of mentors One theme emerged around selecting mentors who are keen on being a mentor and felt the university had to ensure that mentors wanted to be mentors. Ten students identified mentors as not having the desire or willingness for the role. One student commented by saying, “there are too many mentors who simply do not enjoy mentoring.” Several students made links between career promotion and qualifying as a mentor. One student wrote: “you would then get a nurse who wanted to be a mentor instead of people wanting to do it to move up.” Support for mentors Students recognised the difficult role mentors have and felt that the university could support mentors better. Ten students provided the following recommendations for the improvement of standards and that would enable mentors to fulfil their roles: • regular mentor updates • study days for mentors • assessment of mentors Students felt it was the university's responsibility to provide this support. Link lecturer engagement Students reported that the university could provide more support to improve link lecturer engagement. Fourteen students specifically requested that they wanted to see their link lecturer during their clinical placement. One student stated: “Improve the visibility of the link lecturer.” Several students wrote that increased contact with the link lecturer would make them feel more supported and would provide an
Table 1 Students' expectations of mentors and mentorship. n
Disagree
Somewhat disagree
Somewhat agree
Agree
A mentor should be a good role model.
54
A mentor should always act in a professional manner.
54
The better the clinical placement the more positive the mentorship experience will be.
53
I do not want any tension with my mentor in fear of failing practice.
54
0 0% 0 0% 2 3.7% 36 66.7%
0 0% 0 0% 5 9.3% 17 31.5%
1 1.9% 2 3.7% 10 18.5% 1 1.9%
53 98.1% 52 96.3% 36 66.7% 0 0%
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Table 2 Students' mentorship experiences. n
Disagree
Somewhat disagree
Somewhat agree
Agree
Not every mentor likes being a mentor.
54
Mentors can be disinterested in mentoring students.
53
Good nurses are always good mentors.
54
I received sufficient support from my mentor at the start of my clinical placement.
53
My needs from mentoring are very different now than when I first started the course.
53
I receive more feedback from my mentor on how to improve my practice now than at the beginning of the course. Staff shortages have affected the mentoring I have received.
53
I feel my mentor has enough mentorship experience to support students in clinical placement. It is easy to get my practice book signed by my mentor.
53
I am anxious about my mentor taking my practice book home.
53
34 63.0% 31 57.4% 6 11.1% 5 9.3% 3 5.6% 6 11.1% 24 44.4% 0 0% 8 14.8% 28 51.9%
18 33.3% 20 37.0% 10 18.5% 1 1.9% 2 3.7% 8 14.8% 19 35.2% 5 9.3% 17 31.5% 16 29.6%
2 3.7% 2 3.7% 21 38.9% 23 42.6% 12 22.2% 18 33.3% 7 13.0% 17 31.5% 23 42.6% 5 9.3%
0 0% 0 0% 17 31.5% 24 44.4% 36 66.7% 21 38.9% 2 3.7% 31 57.4% 5 9.3% 4 7.4%
opportunity for the university to monitor the quality of the mentors, the clinical environment and practice. The focus group yielded a number of themes which supported the quantitative findings. These were: • • • • •
student expectations of mentors and mentorship students' personal mentorship experiences students' expectations of, and experience with the link lecturer support from mentors link lecturer engagement with students and mentors Table 5 provides quotes from students related to these themes.
Discussion This discussion explores the findings from this study and how they mapped against the six themes from the literature that were identified earlier.
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mentors recognise the changing needs of students (RCN, 2005). However, if the focus of the feedback is on the practice assessment documentation, Fitzgerald, Gibson and Gunn (2010) found that students are not receiving enough feedback required to grow and develop professionally. Thus, for feedback to be effective, it needs to focus on all aspects of learning. Clynes and Raftery (2008) suggest that preparation for the role of mentor may affect the nurses' ability to provide feedback. They suggest that in many mentorship training programmes feedback is poorly addressed. Consideration with a specific focus on feedback for all HEI's in their mentorship training would enable students to develop and progress. Student's views on a mentor's responsibility for assessment were surprising. Although the literature is heavily focused around this responsibility (NMC, 2008b), findings from this research indicate otherwise; placing encouragement at a greater value, something which has previously not been mentioned in the literature. One possible explanation is that the word “encouragement” has been used with the students by university staff in preparing students for clinical placements. This however requires more research.
Understanding mentors roles/responsibilities Workload of mentors Overall, students were very positive about their experiences of mentorship, many feeling well supported by both mentors and the HEI. Students had a good understanding of the roles and responsibilities of mentorship and this correlated to what they valued in a mentor. It is important that students have realistic expectations of the support that is available to them, reducing misunderstandings and disappointments (Wilkes, 2006). Reducing the sense of unachieved expectations for both parties may be beneficial, especially for students where attrition is the concern and HEIs have a responsibility to communicate expectations to all nursing students. Disinterested Although some of the literature suggested that mentors are disinterested in being mentors (e.g. Papp et al., 2003; Nash and Scammell, 2010), this study did not find evidence of mentor disinterest although some students did agree that good nurses do not necessarily make good mentors. Feedback value Students indicated that they were receiving more feedback as they progressed through their course. Constructive feedback is necessary for development (Duffy, 2003) and the data would indicate that
Work load of mentors and its effect as a barrier to making time for mentoring students was an issue raised in the literature (Hurley and Snowden, 2008; Myall et al., 2008). However, in this study, students did not indicate that mentor workload prevented them from finding the time for mentorship of students and only a small percentage of students indicated that shortage of mentors was an issue. Support for mentors Students suggested that more could be done by the university to support mentors, which is also supported by the literature (Jokelainen et al., 2012). Roles such as practice facilitator/educator may help in achieving this outcome (Murray and Williamson, 2009). The literature Table 3 Themes. Themes
Frequency of statements
Explaining/teaching Support/supervision/help Encouragement Feedback Identifying new learning Assessment
44 40 25 18 9 9
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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Table 4 Students' expectations of and experiences with the link lecturer. n
Disagree
Somewhat disagree
Somewhat agree
Agree
Meeting with my link lecturer in clinical placement is important.
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I understand the role of the link lecturer in clinical placement.
53
I feel supported in my clinical placement by my link lecturer.
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1 1.9% 3 5.6% 11 20.4%
5 9.3% 3 5.6% 14 25.9%
15 27.8% 18 33.3% 18 33.3%
30 55.6% 29 53.7% 10 18.5%
shows that mentors request regular visits from link lecturers to clinical placements, and wanted feedback on their own performance (Jokelainen et al., 2012), which is what students in this study recommended. Jokelainen et al. (2012) concluded that mentors felt they benefited from mentorship preparation sessions and annual updates which helped to develop their knowledge and skills. Beneficial changes such as increasing the status of being a mentor, providing additional support through the use of practice facilitators/educators as well as continuous education and feedback to mentors could improve the students' experiences. HEIs could provide additional support to mentors in many different forms and could increase the value of mentorship accordingly. Retention issues Although some previous studies (e.g. Crombie et al., 2013) suggest that poor mentorship can lead to students thinking about leaving their nursing programme, students in this study did not indicate that this was an issue for them. Link lecturers, collaboration and mentorship One additional finding from the study presented here that appears as an issue only in a small amount of the literature is the role of the link lecturer and the part that link lecturers play in making mentorship work. Students in this study are well aware of the role of the link lecturer. However, not all students feel supported by their link lecturer during clinical placement. This supports findings from Murray and Williamson (2009) who found that students identified that academic staff do not understand students' needs in the clinical placement and suggested that HEIs need to provide more visible support to students. A lack of appreciation or understanding of practice by academic staff could result in their inability to meet the needs of students. Although supporting students is the responsibility of link lecturers (RCN, 2006) this support is not being felt by students in this study. In order for the support to be effective and efficient, HEIs need to support students and clinical mentors; support provided to mentors will eventually also benefit all the students that will be mentored by that mentor in the future (Papp et al., 2003; Taylor, 2009). This is a more effective use of resources and is a more holistic approach to support. This idea is supported by Kerridge (2008) who found a direct positive correlation between support provided by link lecturers to the mentor and the mentor support received by the student. Further research into the impact of support provided by link lecturers is needed.
It is disappointing to see that some students felt unsupported by link lecturers. There may be several explanations for that, including students' not needing support or link lecturers only devoting their attention to places where problems arise. However, although this requires more research, the university where this study took place implemented a continuous evaluation of students' experiences in practice, allowing for an additional method for measuring and monitoring quality and equality of clinical placements including access to link lecturers (Ooms et al., 2014). Facilitating learning is not always recognised as important where priorities of health services are on health care provision (Henderson and Eaton, 2013). Nurses have a duty to care for patients first and foremost (NMC, 2008a,b). However, increasing the status of the role of learning facilitator by placement providers may further enhance mentorship for students. Students in this study also made several recommendations with regard to meeting the required standards of mentorship (NMC, 2008b), supporting previous studies that recommended better collaboration between HEIs and placement providers (Murray and Williamson, 2009; Taylor, 2009, Duffy et al., 2000). Limitations This study has several limitations so generalizations need to be made with caution. Convenience sampling was used to recruit students from one pre-registration nursing student group from one university based in London, UK. Mentors were not included in the study; however their inclusion could have provided a more complete and balanced picture. The focus group was arranged and led by the researcher. Focus group participants were known to the researcher which could potentially compromise students' honesty, professional boundaries and participant's vulnerability (Robson, 2002). However, appropriate measures were taken to prevent any possible chance of coercion and that professional boundaries were maintained. Conclusion The study presented here focused on understanding students' expectations as well as their own experiences of mentorship and how these align with current policies and procedures regulated by professional bodies. Furthermore, it offers an insight into the relationship between student's expectations and their experiences of mentorship.
Table 5 Themes and quotes from focus groups. Example of student quotes
Theme arising from focus group
“I think the mentor should be a teacher and motivate us, to help us progress, to guide us in practice.” “I notice people don't want to do it (mentoring), they think it is too much work.” “What I've heard from other students is that if you have any problems, they [the link lecturer] are there and willing to help.” “When I saw my link lecturer, she asked if I had any problems and she were very, very supportive, but you don't see them enough.” “Your needs do change.” “My needs from year one to three were completely different.” “We always know how to access them [link lecturers].”
Students' expectations of mentors and mentorship Students' mentorship experiences Students' expectations of and experiences with the link lecturer
Support from mentors Link lecturer engagement
Please cite this article as: Foster, H., et al., Nursing students' expectations and experiences of mentorship, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.019
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