Assessment and accountability in mentorship
Assessment and Accountability in Mentorship
A mentor is according to the Nursing and Midwifery Council a Nurse or Midwife that is responsible and accountable for facilitating learning, assessing performance and producing evidence of achievement or non- achievement of students in practice (NMC 2006). As the main aim in its Code (NMC 2008) is to protect the health of the public and the delivery of high quality care the mentors are established as “gate-keepers” to the professional register. To be able to carry out this task, the NMC further indentifies eight key skills in its' Standards that a nurse needs to develop in order to become a mentor and support learning and assessment in practice.
This assignment aims to explain the terms of assessment and accountability as applicable to a Nurse mentor on the example of two first year adult branch nursing students in a Dermatology department.
The clinical environment with its potentially unpleasant new experiences can have a big impact on a student (White and Ewan 1991cited in Stuart 2007). The relationship between mentor and student are very important to the learning experience (Davidson 2005). It is important for the mentor to introduce and orientate the students to the placement environment, explain emergency procedure according to local policy and integrate them into the team of staff within the first 24 hours (RNC 2007). In the case of the students used as an example here an initial introduction to the department and its procedures and key members were held within the first 24 and the initial Interviews within the first 48 hours. The goal of the initial interview is to determine the learning needs of the student while encouraging self-directed learning and achievable goal setting following the principles of Andragogy (Knowles 1990). Both students' agreed learning goals were documented in the learning contract.
As the mentor holds dual responsibility towards the student as well as the Patient, expectations towards the students' role in safe practice were clearly outlined during this interview, in order to prevent harm to either involved, while enabling the student to achieve the objectives. Practically this means that the students were asked not to touch any equipment without direct supervision or carry out any task without consent of their mentor.
It is widely acknowledged that the term accountability is hard to define (Tingle 1995, Eby 2000, etc.), Lewis and Batey (1982) explain it as being a “formal obligation, an institutional requirement expected of one participating in an organisation”. Dowling at Al (1996) agrees that to achieve accountability one must have formal obligations arising from governing bodies such as civil law, professional regulations body such as the NMC or the employer (i.e. NHS Trust). To the legal and professional aspect a social and ethical one, representing the values of society, is added by Eby (2000). It is noted by Lewis and Batey (1983) and Pennels (1997) that accountability cannot be isolated from responsibility and authority. Responsibility is seen as closely linked but by no means interchangeable with accountability (Stuart 2007). It indicates that one is able to judge ones' own strength and weaknesses and is an important part of and precondition in gaining accountability (Bergman 1981). In practice for the students this means that also not yet accountable, due to not yet being registered, they still are responsible to stay within the limits of their competence and to adhere to the Guidance of professional conduct for nursing and midwifery students (NMC 2009). For the mentor this means, as not only accountable for their own practice but the care delivered by the student (Stuart 2007), obtaining up to date knowledge and skill base and providing a good example of professionalism. Passing judgement of performance and deciding on, whether the student is able to deliver safe care to the public and therefore gain professional registration and own accountability (NMC 2006), is additionally expected. Stuart (2007) further states that it is up to the mentor to provide learning opportunities accommodating the learning needs.
During the interview the need for a teaching session on the principles of bandaging and four-layer compression bandaging was highlighted by the nursing student as well as the MPP-mentor. Instead of a formal planned session, following a set lesson plan, impromptu teaching was used on a suitable occasion a few days later. A SWOT analysis following Humphrey's method of assessing the Strength, Weaknesses, Opportunities and Threats of the project was carried out. The biggest threat turned out to be repeat interruptions which where avoided by gaining the support of the Department Manager and choosing a room removed from the main clinical area.
At this stage it is worth noting that there are many recognised learning styles and methods. Reece and Walker (2003) suggest that the most important learning theories are the cognitive, the behavioural and the humanistic approach. The most holistic being Humanism by Maslow(1968), which based on the theory that humans have two basic needs, the need to grow and develop and the need to be positively regarded by others, acknowledges the many different motivations that influence an individuals' learning.
According to the Dreyfus model by Benner (1984), which was originally created describing newly qualified nurses but is also applicable here, a student has to pass through four stages before in stage five becoming an Expert in a task. These stages are Novice, Advanced Beginner and Competent and Proficient. Therefore, as the student had no previous experience with bandaging this session aimed to teach her the very basics in order to achieve a foundation of skills and knowledge on which to build in future. To accomplish a holistic learning experience for the student the teaching aimed to cater to the three “domains” by Bloom's taxonomy (1956): Cognitive, Affective and Psychomotor. First the theory of bandaging and different types of bandages were explained to achieve an understanding on the Cognitive base, then the rational for bandaging and several examples for possible uses were given to cater for the Affective domain, finally the task was demonstrated several times and opportunity was given for the student to practice under supervision in order to learn the psychomotor skills. These different ways of teaching also catering for the four different learning types, being described by Honey and Mumford (1992) as Activist, Pragmatist, Theorist and Reflector or most commonly a mixture of all of the above mentioned with a preference for one.
Despite criticising the lack of time and opportunity for questions, the student felt that my teaching session was useful and on the same day advanced to practice her skills on a Patient under supervision.
During their stay in the Department the nursing students are almost constantly assessed by myself and my colleagues, consciously or subconsciously (Stuart 2007), in order to check their progression because as Mooney (2007) states in his article, the goals of evidence- based practice and holistic care cannot be achieved if students fail to become skilled in assertion, critical thinking and self-reflection.
To assess a student fairly and justifiably, assessment methods have to be chosen individually, considering the learning needs and preferences established in the learning contract otherwise there is the danger of discrimination. Or as Rowntree (1987) put it “to treat people equally is not necessarily to treat them fairly. Indeed, people being so different, equal treatment mean injustice for most”. This shows quite clearly in the case of the students used as examples for this assignment, as one is very conscious about her writing skills and awaiting a dyslexia test, while the other posses a previous degree in English literature. Therefore comparing written reflective pieces by the two would put the one with the weaker writing skills in disadvantage without assessing the subject knowledge. To avoid this, the self-conscious students' knowledge was tested by questioning her and observing her directly, while the other was being observed and asked to write a reflection.
In order to chose the right methods first the goals have to be clearly defined using the, originally for project management invented, SMART (S=specific, M=measurable, A=attainability, R=relevancy, T=timely) criteria (Doran, 1981). In this case, using the example of bandaging again, this would mean: The Student needs to understand and be able to carry out the principles of bandaging (Specific) under supervision (Measurable) by the end of the placement (Timely). As bandaging is frequently used in the department the task isof Relevancy and there will be plenty of opportunity to practice (Attainability). Furthermore the methods have to posses four cardinal attributes of validity, meaning it must test what it was mend to test, reliability, meaning the accuracy of the test giving similarly results every time it used, feasibility, meaning it's practicality and discrimination power, meaning it must be able to clearly establish whether the outcome has been met or not (Quinn 2000). Lastly the assessment method has to show that learning has occurred on all three aspects defined in Bloom's taxonomy.
Taking all the above in account and recognising that most of the students competence should be assessed by direct observation (NMC 2008) the decision whether the student has achieved competency in carrying out bandaging was based on direct supervision, question and answer, testimony by other nursing staff and a piece of reflective writing by the student. Direct constructive feedback was given every time following the task by the supervising member of staff as verbal feedback according to Butler (1988 cited in Stuart 2007) has more effects on learning than other forms of feedback such as written comments.
Even so a Mentor fulfils many rolls to the mentee, Darling (1984) indentifying as many as fourteen different ones ranging from Role model over supporter to problem solver and counsellor, the role of the assessor seems to be the most difficult as it seems to take less priority than the roles of Psychological support, Friend, Counsellor and Advisor (Neary 2000). Yet it is the most important one in achieving the goal of “safeguarding” the public from harm as required by the NMC (2008).This might explain why there is a problem with mentors “failing to fail”. This phenomenon is described by Duffy (2004) in her study for the NMC. She notes that failing a student is a professional as well as personal dilemma for many mentors and often puts them under considerable strain. It is noted that also mentors are commonly able to identify the weak student early on in the placement they will give the “benefit of a doubt” instead of launching an action plan. The fact that the competency seems “impossible to define” (Duffy 2004) plays a strong role.
In case of the students used as an example here there was no concern of any kind. One student has already passed the placement and one will go on to pass. Any concerns arising in future should be addressed by the midpoint interview to give the student a clear time scale in which to improve in, so that the failing does not come as a surprise. At this stage it is recommended to establish an action plan in writing and gather clear evidence in order to support the mentor's decision (Sharp and Danbury 1999) and the tutor should be involved for support and guidance (Duffy 2004).When confronted with actual failure in the final interview the student might react in many different ways ranching from grief, denial to anger and aggression (Duffy 2004, Stuart 2007) depending on personality and personal circumstances and the mentor will have to address these in a sensitive manner. But it is also recognised that failing can be in some cases a positive experience, as it might enforce the decision to follow a different career pathway after previously lacking the courage (Maloney at al 1997 sited in Stuart 2007) and a powerful motivator to improve in future.
However in case of the passing student the final interview is used to reflect on the placement and to record the students' achievements, strength and weaknesses in the CAP- document. This will equip subsequent mentors with evidence of the students' development and needs and helps to foster future learning progress (Stuart 2007).
According to Ali and Panther (2009) “mentoring is an important role that every nurse has to assume, formally or informally sooner or later in their professional life.” In order to be that “gate-keeper” to the register, that will keep the public from harm, a mentoring nurse not only has to develop new knowledge of learning styles/theories, human psychology and assessment methods, but also has to closely examine and evaluate their own practice and behaviour constantly in order to help the student develop. Considerable personal as well as professional responsibility is placed on the mentors' shoulders but also the chance to help shape the future generation of nurses. This very generation of nurses that will nurse our selves one day.
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