Explore the impact of the mentor on the learning experience of the student nurse

The current study reports the findings of a systematic literature review of research regarding the mentorship of student nurses. Mentorship was evaluated in terms of its development, implementation, outcomes and wider effects and the identified research was presented and critically analysed with reference to each of these areas.

It was found that although mentorship was based on policy and standards, the mentor role and mentorship relationship still remain unclear and requires further clarification. A need was also identified for the supervision and monitoring of both mentors and student nurses to be expanded with mentors being more available and the whole process being more regularly audited.

Mentorship was found to indirectly enhance skill development through support, socialisation and the provision of opportunities to gain clinical experience. By creating appositive learning environment and mentorship relationship the mentor can maximise the probability that their student nurses will acquire the skills necessary to be an effective nurse.

The effect of mentorship on patient care was identified as a complex issue with it being difficult to make confident conclusions regarding the size of any effect. It does appear that mentors can indirectly improve patient care by enhancing nursing skills in their students. Finally, the mentor can play a role in creating the learning environment and mentorship relationship which can help to ensure that the student nurses have a positive learning experience.

The limitations which are associated with the methodology which was employed within this research are discussed along with the implications of the findings of this research for practice and future research projects in this field. It is concluded that mentorship has the potential to have a number of benefits for student nurses but that further research and improvements are required in each of the evaluation areas such that the effectiveness and feasibility of student nurse education can be maximised along with the quality of the care which is subsequently provided to patients.

2.0 Introduction

The world of nursing has gone through a period of significant change over the last ten years. In the acute nursing environment, nurses arousing increasingly more complex health care interventions and have to incorporate the use of advances in both medical technology and disease management. Within primary care, nurses are required to face the burden of chronic disease and to facilitate patients beginning to self-manage their own health. S

uch changes have been made as a result of Governmental policy and strategic approaches. For example, a Governmental economic review conducted by Winless (2002 and 2004)advocated changes to how services are organised and delivered.

Such changes have resulted in there being a range of extra demands being placed upon the nurse, both during and after their training. The Royal College of Nursing (2004a and 2004b) acknowledged the change which is occurring and stated that nurse education needs to be assessed and adapted to meet the changing role of the nurse. Nurses are now required to undertake tasks which were traditionally performed by doctors. These developments have ensured that the issue of the effectiveness of a nurse’s training is of up most importance.

Through these changes the need for effective mentorship within nursing has become ever more salient. As a result of the potential effects which mentor/student nurse relationship can have on the student’s learning, their experience of training, their subsequent performance on the training course, their future effectiveness as a nurse and ultimately on the quality of the care which is provided by the nurses, it is an important topic to consider within the field of adult nursing. Thus the mentor/student nurse relationship needs to be evaluated.

People have been interested in relationships throughout history. As far back as the ancient times, Aristotle and Cicero were commenting and theorising about relationships (Poulakis 1997). In more recent years, novelists, play-writes, biographers and clinicians have all been interested in the study of relationships in terms of why they matter, how they work and how one can improve their effectiveness and efficacy(Wood and Duck 1995).

However, it has only been in the last 50 years that researchers have started to empirically investigate inter-relationships between people. Such work has been undertaken from wide variety of perspectives including anthropology, child development, cognitive science, communication, social psychology, sociology, psychiatry and psychotherapy to mention just a few (Hinde1997). The focus of such researchers has started to address the issues regarding relationships between staff within the health care industry.

This systematic review will focus on addressing the relationship between a mentor and a student nurse. Whenever one is considering these of a given intervention within a health care setting, any conclusions must be based upon the scientific research which has investigated its effectiveness and efficacy via methodologically sound techniques. Any such analysis will need to consider four key aspects, each of these will be the focus of this systematic review.

The first key element of evaluation concerns the development of the intervention. Therefore this review will consider research which has assessed the theoretical and conceptual foundation of mentorship within nursing. This section will include a discussion of whether the mentoring of student nurses is based on policy or a set of standards.

The second area of focus for this review relates to the implementation of the intervention. Clearly whenever one is analysing the effectiveness and efficacy of an intervention, one must consider the way in which the intervention is operationalized and implemented as this will be likely to significantly affect the ultimate success of the intervention. This section will address the way in which mentorship is employed for student nurses and whether or not sufficient measures have been put into place to ensure that the benefits of mentorship are maximised and that any potential drawbacks are minimised. The extent to which this mentoring is adequately supervised, monitored and audited will be assessed and critically analysed.

The third key aspect of any evaluation process concerns the outcome of an intervention. Clearly an intervention can be assessed with regards to a wide range of outcomes such as economic factors, staff perceptions and customer perceptions. With regards to mentorship, it is important that it is evaluated in terms of the perceptions of the mentors, the student nurses and the patients such that a comprehensive evaluation of its outcomes can be achieved. As well as the perceptions of those involved, this section will address whether or not mentorship improves nursing skills and hence whether it helps to improve the care which is received by patients.

The fourth and final area of evaluation which will be addressed by this systematic review concerns the wider impact of the intervention. As well as focussing on the direct effects of a strategy, it is also important to consider the effect which the intervention has on other relevant issues. In terms of mentorship in nursing, this will relate tissues such as whether or not a rewarding learning experience is related to the quality of the relationship that a student nurse has with their mentor. Although the focus of mentorship may be on improving the student nurses’ skills, it is important to critically evaluate the effect which mentorship has on the student nurses’ experiences of their training programme as this could influence their subsequent career choices.

The following review will first provide some background information regarding the topic of mentorship and student nurses. The methodology which was employed within this systematic review will then be outlined. The findings of the systematic review will then be critically analysed in terms of the key evaluation aspects of development, implementation, outcomes and wider impacts The main findings of this research will then be summarised before the limitations which are associated with this research project are outlined and discussed. Finally the implications of the findings of this research will be considered along with the areas which should be the focus of future research projects within the field of mentorship and student nurses.

3.0 Background

A significant amount of research has Been conducted regarding adult learning and mentorship within nursing (Bernard 1990). The teaching of student nurses has undergone significant changes in the past 20 years. These changes have particularly taken place as a result of Project 2000which changed the education of pre-registration nurses (United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1986). The previous diploma level system was replaced by the Common Foundation Programme which is comprised of the four branches of Adult, Child, Learning Disability and Mental Health.

Through this process, registered nurses took responsibility for the learning of student nurses. The role of the nurse is adapting to incorporate these responsibilities with the Royal College of Nursing (2004a and 2004b) calling for a particular focus upon Quality, Flexibility and Diversity. Much has been written about the practitioner as facilitator, supervisor, assessor and role model, and the overlay of role functions (Bailey 1992, Clarke et al1986, Heron 1977, Mason 1987, Myrick and Wane 1988, Windsor 1987.Despite this, there is still a lack of consensus within the literature in terms of a clear definition of what is meant by the term ‘mentor’(Hearty 1986, Morel 1990 and Phillips et al 1996).

It has been argued that the task of defining the term mentor is made more complicated byte fact that other terms are used, such as assessor, facilitator and supervisor, to describe the same role (Phillips et al 1996). As result of the wide range of aspects of the role which is played by mentor, it can be stated that a definition of mentor can only be general description as anything more specific would run the risk of excluding important elements of the position (Davies et al 1994). Forth purposes of the following review, the definition of mentor which was provided by Woolskin (1982) will be adopted:

‘Mentorship is a relationship which is aimed at guiding the novice towards an established place within the profession’ (Woolskin 1982)

In the nursing profession the aims of the mentor will be to form relationship with their student nurses which helps the student to be successful in their training programme and to go on to be effective nurses in the future. Jarvis (1995) emphasised that it is important to focus on the mentor’s role as a function and as a relationship with the student nurse rather than being about them as a teacher or practitioner.

Through this role the mentor can help to narrow the gap between theory and practice (Arbitrage and Bernard 1991). Indeed some have argued that mentor is in fact the wrong term to use within the health care industry as it is not equivalent to other industries in which the term mentor is used (Donovan 1990).

However one conceptualises mentorship, the benefit of having a good mentor has been reported by student nurses within previous research. Ina longitudinal study, Gary and Smith (2000) interviewed 10 student nurses at five different points throughout their three year training programme. The participants also kept a diary as part of the research. It was reported that the students noted the importance of having mentor which represented a good role model.

They also thought that it was important to recognise the likes and dislikes of the mentor as this had the potential to significantly impact on their assessment outcomes. The role of the mentor was found to be particularly beneficial at the beginning of the training process. As the training progresses the students felt that they grew in confidence as they became more competent. This ensured that they were more independent and that they placed a reduced demand on their mentor. Although their continued support was said to help the students finish the course and to choose longer term career in nursing.

Therefore it does appear that through effective mentorship, the chances that a student nurse completes their training programme can be increased. Research has investigated the reasons why student nurses fail their training programmes. Two key areas of reasons have been identified. The first relates to the student nurse’s inability to cope with the demands and standards required by the course (Ehrenfeld et al1997 and Fulbrook et al 2000).

It could be that a mentor can help to provide support and guidance for the student nurse to improve the chances that they can meet the requirements which are placed upon them and hence complete the training course successfully. The second key area of reasons for failure are those relating to personal factors(MORI 2003 and Royal College of Nursing 2001). This includes a range of possible factors such as financial, health or a change in circumstances. The mentor could also play a role here to help the student nurse manage their problems and to cope with them more effectively. The methodology which was employed within this research will now be outlined.

4.0 Method

A systematic review aims to integrate existing information from comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias (Clarke& Oman 2001, Hart 1998, Muldrow 1994, Oman and Goat 1993). Another words, a scientific approach will help to ensure that research evidence is either included or excluded based upon well-defined and standardised criteria. This should ensure that the possible effects of researcher bias should be kept to a minimum. Berkley and Glenn (1999)also states that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare.

4.1 Reviewing Process

Whenever one reviews or compares research reports, it is important that clear set of criteria are established upon which the evaluations can be made. Table 1 below outlines the global process which was used to conduct the literature review. This process was based upon that employed by Berkley and Glenn (1999). Each selected article was reviewed with reference to a number of different issues using a Table which was also based on Berkley and Glenn (1999). This review table is displayed in Appendix 1. Once obtained each article will be filed and stored appropriately. A computer-based list will be maintained of the articles which had been reviewed.

Table 2:

Core Principles Used in Reviewing Selected Research Articles (adapted from McInnis 2004)

Systematic reviews

Adequate search strategy

Inclusion criteria appropriate

Quality assessment of included studies undertaken

Characteristics and results of included studies appropriately summarized

Methods for pooling data

Sources of heterogeneity explored

Randomised controlled trials

Study blinded, if possible

Method used to generate randomisation schedule adequate

Allocation to treatment groups concealed

All randomised participants included in the analysis (intention to treat)

Withdrawal/dropout reasons given for each group

Cohort

All eligible subjects (free of disease/outcome of interested) selected or random sample

80% agreed to participate

Subjects free of outcomes on interest at study inception

If groups used: comparable at baseline

Potential confounders controlled for

Measurement of outcomes unbiased (blinded to group)

Follow-up sufficient duration

Follow-up complete and exclusions accounted for ( 80% included in final analysis)

Case control

Eligible subjects diagnosed as cases over a defined period of time or defined catchment area or a random sample of such cases

Case and control definitions adequate and validated

Controls selected from same population as cases

Controls representative (individually matched)

80% agreed to participate

Exposure status ascertained objectively

Potential confounders controlled for

Measurement of exposure unbiased (blinded to group)

Groups comparable with respect to potential confounders

Outcome status ascertained objectively

80% selected subjects included in analysis

Cross-sectional/survey

Selected subjects are representative (all eligible or a random sample)

80% Subjects agreed to participate

Exposure/outcome status ascertained standardized way

Qualitative

Author's position clearly stated

Criteria for selecting sample clearly described

Methods of data collection adequately described

Analysis method used rigorous (i.e., conceptualised in terms of themes/typologies rather than loose collection of descriptive material)

Respondent validation (feedback of data/researcher's interpretation to participants)

Claims made for generalizability of data Interpretations supported by data

4.2 Sources of Data

The methodology employed within the research will involve obtaining data from three key sources: Computerised searches, Manual searches, and the Internet. Each of these data sources will now be considered in more detail.

4.2.1 Computerised Searches

The methods used in this research will include a detailed computerised literature search. Multiple databases, both online and CD–Rom will be accessed to retrieve literature because they cite the majority of relevant texts. (Loy 2000 Ford 1999) The computerised bibliographic databases are:-

• MEDLINE

• EMBASE

• CINAHL

• PSYCHINFO

• British Nursing Info BNI

• Cochrane

• Science Direct (All Sciences Electronic Journals)

• Asia

• DETOC

• HMIC

However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve a comprehensive search (Sindh & Dickson 1997).

4.2.2 Manual Searches

A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:-

• Books relevant to the topics from university libraries and web sites• Inverse searching- by locating index terms of relevant journal articles and texts

• Systematically searching reference lists and bibliographies of relevant journal articles and texts

4.2.3 The Internet

The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer. Sites accessed will include:-

• Department of Health

• National Institute of Clinical Excellence

• English National Board of Nursing, Midwifery and Health Visiting

• Google

4.3 Identification of Key Words

The selection of key words is an important task as it will have significant impact on the articles which are identified in the search. One must choose appropriate words which maximise the chance that the most appropriate research evidence can be found. Databases use controlled vocabulary of key words, in each citation. To assist direct retrieval of citations techniques Boolean logic will be applied using subject indexing, field searching and truncation to narrow the topic focus (Loy 2000, Hicks 1996, Goodman 1993). As part of this approach, key words will be based on the components of the review question.

An imaginative and resourceful technique of searching electronic databases will be used including recognising the inherent faults in the indexing of articles. Misclassification and misspelling will be included in the searches with searches utilising keywords and the subheadings, (Hicks 1996). Based on these principles, the following search terms will be used in different combinations:

• Mentorship

• Mentor

• Student

• Nurses

• Training

• Evaluation

Further search terms may be used within the methodology if they are identified within some of the initial search items. Whenever one is searching literature ‘sensitivity’ and ‘’specificity’ are important issues when conducting searches of research on a database. The searches need to be as ‘sensitive’ as is possible to ensure that as many of the relevant articles are located.

This may be a particularly salient issue with regards to the evaluation of mentorship in student nursing as the number of appropriate entries may be limited. Thus an attempt to locates many of these articles as possible becomes a more relevant and important objective. Furthermore, the search needs to be ‘specific’ Another words, it needs to be efficient where appropriate so that higher number of the articles identified through a database search can be included and hence the time allocated to reviewing articles which are ultimately of no relevance, can be kept at an acceptable level.

4.4 Inclusion and Exclusion Criteria

In order that a manageable quantity of pertinent literature is included in this study, it is essential that inclusion and exclusion criteria are applied. In order that a diverse perspective of the topic is examined broad criteria will be used. (Benignant 1997). However, it is important to note that a balance needs to be achieved through which the scope of the inclusion criteria is sufficiently wide to include relevant articles whilst also being sufficiently specific such that the retrieval of an unmanageable set of articles is avoided.

4.4.1 Inclusion Criteria

The articles which are highlighted within the proposed searches will be assessed in terms of whether or not they meet the following criteria. Each article will need to be viewed as appropriate with regards to all of these constraints if they are to be included in the final analysis.>From the pool of data which is obtained, the most appropriate articles which meet these inclusion criteria will be selected for use within the review.

• A literature review encompassing all methodologies will be applied ( Pettigrew 2003)

• International studies will be included

• Available in English

• Relate to the evaluation of mentorship within health care

• Relate to the training of student nurses

• Centre on the elderly population

4.4.2 Exclusion Criteria

The articles highlighted by the searches will also be assessed in terms of whether or not they fulfil the following exclusion criteria. If a potential relevant article meets one or more of these criteria then they will be immediately excluded from the data set and will not be included within the analysis stage of the methodology.

• Articles relating to mentorship in industries other than health care will not be included

• Literature in a foreign language will be excluded because of the cost and difficulties in obtaining translation.

• Research reported prior to 1985 will not be included within this review.

4.5 Consideration of Ethical Issues

Any research involving NHS patients/service users, carers, NHS data, organs or tissues, NHS staff, or premises requires the approval of ankhs research ethics committee (Department of Health 2001) A literature review involves commenting on the work of others, work that is primarily published or in the public domain. This research methodology does not require access to confidential case records, staff, patients or clients so permission from an ethics committee is not required to carry out the review. However, it is essential to ensure that all direct quotes are correctly referenced.

Permission must be sought from the correspondent before any personal communication may be used. All copyrights need to be acknowledged and referenced. The researcher will also act professionally when completing this report and ensure that research is identified, reviewed and reported accurately and on scientific basis. The following set of chapters will now outline the research which has addressed the different aspects of the debate regarding mentorship and student nurse education.

The following analysis will be conducted regarding the four different aspects of evaluation. As outlined by Kirkpatrick (1979) it is important to address each stage of any training intervention when conducting an analysis. Therefore, the development, implementation, outcomes and wider impacts of mentorship in student nurse education will all be considered. The most appropriate research regarding each of these four aspects will be critically analysed and compared to other relevant research findings.

5.0 Evaluation of The Development of Mentorship Programmes

Whenever one is evaluating a health related intervention, it is important to first consider the policies, standards and theoretical perspectives which underpin the approach. In terms of mentorship, one must address the questions regarding the framework and structure which they are developed in conjunction with and to determine whether or not the approach was developed in an appropriate way. The policies and structures which underpin pre-registration nurses’ education has undergone significant changes in the last twenty years.

This was particularly as a result of the introduction of Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting1986). The transformation was centred around the introduction of a Common Foundation Programme which was comprised of four different branches: Adult nursing, Child nursing, Mental Health nursing and the nursing of people with learning disabilities. This replaced the previously used diploma level education system. Through these policies, a set of standards were established for the preparation of people who are going to teach nursing, midwives and specialist public health workers.

A booklet which outlines these standards was produced by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (2004). This also sets out the guidelines for the qualifications which are recommended and required for these teachers. The English National Board has suggested that mentorship should be key part of the Project 2000 courses (An forth 1992). It is also suggested that there should be a policy to emphasise five key aspects of the role of a mentor in their relationship with their student nurse. These are Assisting, Befriending, Guiding, Advising and Counselling(An forth 1992). They also argue that the role should not include supervising, assessing or facilitating.

The following discussion within this section will now move on to consider the mentorship role which has been derived based on these relevant policies and standards. The extent to which this derivation was appropriate and how the mentorship role is subsequently perceived will be outlined and critically analysed. This evaluation will now be conducted from the perspectives of theorists/researchers in this field, the student nurses and the mentors involved.

In broad terms, these policies and standards appear to be appropriate in terms of providing a framework to govern mentorship within student nursing. However, one needs to look past the theoretical perspective and address the practical aspect of the development of mentorship. The extent to which these policies and standards are adequate when viewed during their application merits consideration. Researchers and theorists in this field have argued that despite these policies and standards, the role of mentor remains unclear as there are a number of models and frameworks which exist and which can be applied (Andrews and Wallis 1999).

Furthermore, Andrews and Wallis (1999) also go on to suggest that many mentors attend short, local training courses which are not standardised. Although they may adhere to the appropriate standards, there still remains sufficient scope for mentors to receive different types and levels of training when becoming mentors of student nurses. Also, as a result of the continued use of the terms mentor, supervisor and assessor to describe similar roles, it is argued that this continues to contribute to the confusion within this field(Wilson-Barnett et al 1995). The policies and standards require a more specific focus such that more standardised definitions, roles and training programmes can be established and agreed by all of the key stakeholders in this debate. One of the more obvious stakeholders to consider are the student nurses themselves.

The extent to which the mentorship of student nurses is appropriately grounded in policy and standards needs to also be assessed from the student nurses’ perspective. It needs to be seen to have logical foundations such that the students can have confidence in the system and that they can understand the purpose and objectives of the relevant policies and standards. One study which has addressed this topic was conducted by Watson (1999). A sample of 35 student nurses were interviewed using a semi-structured approach.

The student nurses reported to key findings. Firstly they reported that the mentorship process was not sufficiently defined by the English National Board. They stated that although there were standards in place, they did not result in there being a clear understanding of what the role and purpose of a mentor actually was designed to be.

The second key finding was that the student nurses perceived that the mentorship process was not clarified within their internal organisation. Irrespective of the over-riding standards outlined by the English National Board, the internal organisation could have put into place a clear structure and understanding of mentorship to ensure that its role was understood byte student nurses. Therefore, from the student nurses’ perspective, the presence of the appropriate policies and standards was not accompanied by an appropriate application and implementation of such guidelines. Having said this, the sample used in this study was relatively small and so the extent to which the findings can be generalised to the UK as a whole is questionable. Other similar explorative research has been conducted which has focused on the perspectives of the mentors

The introduction of Project 2000 has placed a responsibility on many registered nurses to mentor student nurses. Although the relevant standards provided by the English National Board do address this area, again they do not appear to be standardised across the country. For example, Cahill (1996) found that there were a range of mentor selection procedures as well as a range of preparation and function definitions. Further research was conducted by Near (1997 and 2000).It involved collecting data from 155 mentors.

They reported that these of the terms mentor, assessor and supervisor did result in them being confused over their role as a mentor. They were also unclear regarding their relationship with their student in terms of the nature which it should take and the extent to which they were supposed to help them. This in turn was said to lead to difficulties with regards to competency assessment as they were not sure what was expected of them and their students.

Therefore, this section has demonstrated that policies and standards regarding mentorship have been provided by the English National Boards part of Project 2000. However, questions still remain regarding the extent to which these policies and standards have been successfully applied to the practical setting. Role definition appears to be significant problem for all of the stakeholders involved and a general lack of standardisation appears to be prevalent.

It would appear that a more effective dissemination of the relevant policies and standards is required to demonstrate that the mentorship of student nurses is fundamentally based on sound objectives and principles. The extent to which mentorship programmes are effectively implemented will now be discussed with particular reference to their supervision, monitoring and auditing.

6.0 Evaluation of The Implementation of Mentorship Programmes

The second key stage of the evaluation of an intervention concerns the effectiveness and efficacy of its implementation. In terms of the mentorship of student nurses, the procedures which are established to implement the mentorship need to be considered and critically analysed. This analysis should focus on issues such as whether the mentorship experience is sufficiently supervised, monitored and audited.

It is important to conduct this evaluation from both the perspective of the student nurses as well as the mentors themselves. This is necessary as it is likely that the commitment of both of these parties will be required if the mentorship relationship is to be created and maintained with any degree of success. Research which has addressed the views of student nurses and mentors regarding this topic will now be outlined.

A relevant research study which has been conducted in this area involved student nurses and their mentors completing activity diaries for a week (Lloyd-Jones et al 2001). The data provided via the activity diaries were then analysed in order to determine the extent to which the student nurses were adequately supervised and what happened when their mentors were not present. It was reported within this research that the student nurses did spend a significant amount of time away from their mentor. It was identified that in the absence of a mentor, the student nurse was often supervised, either directly or indirectly, by another qualified member of staff.

Although this may be a good short-term solution, it is unlikely to be standardised across organisations and to only occur when there is an appropriate member of staff available. It was found that those who saw their mentors more regularly did, overall, spend significantly more time in the presence of qualified member of staff relative to those students who saw less of their supervisor. Based on this data, it was concluded that mentor availability is an important issue. Guidelines need to be established and adhered to which outline how long the student nurse should spend with their mentor each week.

The supervision provided by other members of staff is likely to be useful but is unlikely to be preferable to more planned and strategic mentorship which could be supplied by their allocated supervisor. The student nurses need to have more structured supervision which is monitored and more systematically audited.

It maybe that the supervision which can be provided by other appropriate members of staff can be incorporated into the mentorship system to aid the mentor but this needs to be designed more strategically rather than allowed to happen when a qualified member of staff is available. Thus based on the student nurses’ activity diaries, the extent to which they are currently supervised and the degree to which their mentorship is monitored and audited could be improved.

Having said this, the methodology employed within this study can be criticised. There was the potential for students to complete their diaries in a way which put them in a positive light. They may have been concerned that the data which they provided could affect their assessments and ultimate success on the course and this may have affected the quality of the data. Attempting to ensure confidentiality can help prevent this but there may still have been the possibility that the data obtained was not entirely accurate. Further research using anonymous questionnaires may provide more accurate information upon which conclusions regarding this topic could be made. The views of the mentors themselves have also been the focus of other relevant research.

Aston et al (2001) conducted research which was commissioned by the English National Board. They collected information via documentation, one-to-one interviews and focus groups using samples of 76 lecturers and 46 practitioners. The research focused on the participants ‘perceptions of the extent to which the mentors of student nurses are adequately supervised, monitored and audited.

It was found that mentors believed that they were not sufficiently prepared, supported or monitored. They had a wide range of different experiences and they believed that there was a need for a more organised approach which would enable more consistent support and supervision to be available. It is important that the mentors themselves are supervised so that they have someone to guide and advise them in their role and to provide them with the support that they need to effectively mentor their student nurses. The methodology used in this study benefits from having a relatively large sample and because it obtained data form a number of different sources. This facilitated an overall view of the topic to be gained by enabling a more comprehensive approach.

Therefore the research evidence which has been considered in this chapter would lead one to conclude that the implementation of mentorship for student nurses does have some areas which require further attention. The student nurses themselves do not appear to be fully satisfied with the extent to which they are supervised and monitored. Although they may receive some assistance from other qualified members of staff in the absence of their mentor, this system is not consistent and is not part of an overall systematic and strategic approach.

This process also needs to be more accurately audited such that areas which need further development can be identified and appropriate alterations can be implemented. In terms of the mentors, they also appear to require more support and to be better prepared for their role as mentor. Again this aspect of mentorship also needs to be better audited to help clarify these issues and to identify other relevant areas which require adjustments. This section has therefore demonstrated that student nurses and mentors involve within the mentorship process both need to be more effectively supervised and monitored. The processes involved also need to be audited to ensure continual improvement and that the mentorship programmes are made as effective and feasible as is possible.

7.0 Evaluation of The Outcomes of Mentorship Programmes

Perhaps the most obvious way in which any intervention can be evaluated is the effects and outcomes which are associated with its implementation. In terms of the mentorship of student nurses, this will include the effect which mentorship has on the nurses’ skills and hence whether or not there is any subsequent improvement in the level of care which is provided for patients. The key issue is defining the way in which one is going to measure the competency of the nurses involved and the quality of the service which is provided to patients.

This is rather complex issue and the difficulties involved have been highlighted within previous research. For instance, Cahill (1996)questioned 16 student nurses via one-to-one interviews and focus groups. It was reported that student nurses are experiencing increasing levels of stress. This was thought to be as a result of a number of directives from the English National Board of Nursing, Midwifery and Health Visiting and because of the presence of continual assessments. It would not be wise to contribute to such stress levels by introducing further assessments in order to evaluate the mentorship process.

The student nurses were found to describe mentorship in terms of assessment and stated that there is a pre-occupation with obtaining the reward was identified. The mentorship was found to be viewed as being more about control rather than support. This situation was reported to facilitate division between those with the knowledge (mentors and those with the intention of learning (student nurses).

This research demonstrates that it may be the case that mentorship actually focuses on the development of the student nurses’ ability to pass their course rather than their ability to be a nurse. Although this difference may be subtle, it is significant one. Research which has considered student nurses ‘perceptions of the outcomes of mentorship will now be considered along with the subsequent effects on skill development and competency.

Earns haw (1995) collected data from 19 final year student nurses using questionnaire. The participants appeared to focus on elements other than skill development as being the key benefits of mentorship. Firstly support was a key aspect, particularly in the early years of the student nurses’ education. As they progressed through the course the nurses felt that there confidence and ability increased and hence they needed less support from their mentors. Another key outcome of mentorship is that the student nurses become socialised into the ward culture.

They learn the norms regarding what is expected of them as nurses and the rules which govern how they should behave when they are working. Mentorship was seen as being important in developing the skills associated with this socialisation. Regarding more specific nursing skills, the nurses reported that it was difficult to define the role of the mentor. A range of factors contributed to their skill development with the major one being their clinical experience. Such work is often supervised by the mentor and hence they have an indirect role in this form of skill development.

Although this research did use relatively small sample, the questionnaires were anonymous and confidential. This should have ensured that the data provided was more likely to be honest and to give a true picture of what the respondents ‘actually believed. Therefore, based on this research one would conclude that mentors help to facilitate skill development via indirect factors such as support, socialisation and facilitating clinical experience. One also needs to consider research which has focused on the topic of assessing pre-registration nurses and their competencies.

One such project was conducted by Colman et al (2002) based in Scotland which reviewed the different tools and instruments which are used in assessing student nurses’ competencies and considered the philosophical grounding which underpinned them. It covered 13 different institutions and data was collected via 12 focus groups and 72 one-to-one interviews. The participants included both student nurses and midwives. A change was identified in the approach which has been taken to assess the competency of student nurses since 1992.

The participants felt that there was no confidence in these assessment procedures as they had not been shown to be reliable or valid. They did not think that they were affair indication of their ability as a nurse. Significant differences were found between institutions both in terms of the assessments used and the theoretical perspectives which underpinned the techniques. As result of this lack of confidence and diversity, it is difficult to accurately determine the effect that mentorship has on a student nurse’s skills and on the quality of the care which they supply to their patients.

The ambiguity which is prevalent within this area of the research renders the task of assessing the effect of mentorship on student nurses’ skills a very difficult one. This in turn makes it difficult to determine what the effect of mentorship is on the quality of care provided. The Colman et al (2002) study was limited because it only focused on Scottish institutions. Further research would need tube conducted in the rest of the UK in order to establish whether the findings of this study are representative of the UK as a whole.

This chapter has demonstrated that mentorship has an important role to play in indirectly improving student nurses’ skills and the quality of the care which they provide. Through support, particularly in the earlier years of a nurse’s education, socialisation onto the ward and the facilitation of clinical experience, the mentor can help to enable the student nurse to be well equipped to acquire the necessary skills when the appropriate situation arises.

More consistent measures of skills and the subsequent effect on the quality of care is needed before confident conclusions can be drawn regarding the influence of mentorship on this area. The following discussion will now address the association between mentorship and the learning experience of student nurses.

8.0 The Wider Impacts of Mentorship Programmes

The fourth and final area of evaluation concerns the wider aspects of an intervention. In the case of mentorship for student nurses, the effect which mentorship has on their learning experience is an important consideration. In the research which was conducted by Wilson-Barnett et al (1995) into mentorship and clinical support it was reported that mentors were required to promote satisfaction amongst student nurses, team spirit, the link between theory and practice and the organisation of their work teams.

If this demand is successfully met then it should in theory help ensure that the student nurses are significantly more likely to have a positive learning experience. Arrange of research has been identified in this field and it will now be outlined and critically analysed in terms of the mentor, the student, international studies and longer term aspects.

Andrew and Chilton (2000) conducted a three month pilot study in order to determine the effect which a teaching and assessing qualification had on the student nurses’ learning experience. Mentors with qualification reported that they were more supportive and effective relative to those who had not obtained a similar qualification. Interestingly, however, the student nurses did not rate the level of support and quality of the mentorship as being significantly dependent based on whether the mentor had an appropriate teaching or assessing qualification.

The qualification was not found to have a significant impact on the student’s learning experience. This study was, however, only a pilot and hence the extent to which these findings can be accepted is limited. A more comprehension version of this research would provide more data upon which to assess the value of the relevant teaching qualification. Thus more research is required in order to first establish the benefits of these training courses and to identify how they could be changed in order to enhance the student nurses ‘perceptions of their mentorship and learning experience.

Research has focused on the student nurses’ perceptions of the link between mentorship and their enjoyment of the learning experience. For example, Gary and Smith (2000) conducted a study over a three year period. A sample of ten student nurses were interviewed at five different points during their education. They were also required to complete diaries of their experiences. They were questioned regarding the association between their mentor and their learning experience. Two important findings were reported.

Firstly it was noted that the extent to which the student nurses understood the likes and dislikes of the mentor was important as this effected the quality of their relationship with their mentor. The better the relationship, the more positive the learning experience was seen to be. Secondly, the learning experience was also dependent on the extent to which the student was successful on their course. Clearly the mentor has a role to play here in maximising the chance that a student nurse will be successful and hence they can therefore indirectly influence their learning experience through aiding their progress.

This study benefits from the fact that it took place over a relatively long period of time. However, the students’ responses may have been influenced by the fact that they could have been worried about the consequences of any negative comments As they were still on the course, they may have been concerned that their mentor would learn of what their students had said about them and hence the students may have been less likely to be truthful when being interviewed. This potential bias needs to be kept in mind when assessing such research. This issue has been addressed by a number of international studies.

Saarikoski (2002) collected data from 558 student nurses who were based in both Finland and the UK. They completed the Clinical Learning Experience and Supervision Instrument. The Finish students were found to be significantly more positive regarding their clinical experience and their supervision relative to the UK students. This difference was found to be significantly associated with the fact that Finish students spent a significantly longer amount of time with their mentor. This methodology benefits from using a relatively large sample.

Chow andesine (2001) conducted research in Hong Kong where clinical staff were required to mentor pre-registration nurses whilst on their clinical placement. The students’ perceptions were analysed regarding the five aspects of the mentor role which have been outlined by the ENB (Anforth1992). Assisting and Guiding were viewed as being the most important aspects of the mentorship role.

Befriending was important in helping the nurses to settle into the ward. Counselling and Advising were not viewed as being significant elements of the mentorship role. It was identified that the important features were those which were associated with the students’ learning and hence their learning experience. Thus the mentor’s role needs to include aspects which will facilitate their student’s learning experience.

The final area of research which has considered the link between mentorship and the learning experience regards longer term implications. One such study was recently conducted by Pearce and Elliott (2004) and involved interviews with 14 student nurses. Four key aspects were associated with whether or not the student nurses would be likely to go on and seek a career as a nurse in the future.

These factors included ward culture, the reaction to negative incidents, the student nurses perceptions of the qualified nurses/mentors and how these people were seen to treat the trainee nurses. Thus the mentors can help to improve the learning experience in each of these areas. They can work to create a positive ward culture and help students to learn from their mistakes whilst training.

They can also present appositive role model for the student nurses and to treat them professionally with the respect and dignity which they deserve. Through this the mentors can help to maximise the chance that the student nurse views their learning experience positively and that they then go on to become a nurse in the longer term.

This chapter has considered the wider impacts of mentorship on the student nurses. It has particularly focused on its effect on the students’ learning experience whilst they are on the training course. The discussion has considered this topic from both the mentor and the student nurses’ perspective and has included research regarding their views. International studies and longer term implications have also been addressed. It appears that mentorship is associated with the student nurses’ learning experience as a result of both direct and indirect factors.

9.0 Summary of Findings

This systematic literature review has critically evaluated the research evidence which has addressed mentorship and student nurses. There search was considered within four different areas of the evaluation process. The mentorship of student nurses was assessed in terms of whether or not it was based on policy and a set of standards(Development), whether or not it was sufficiently supervised, monitored and audited (Implementation), the effects which it has on the student nurses’ skill acquisition and the care provided by them for their patients (Outcomes) and the extent to which mentorship was associated with the learning experience of the student nurses (Wider Effects). The findings within each of these four areas will now be summarised.

Significant changes were identified in nurse education over the past twenty years. These were predominantly based on the guidelines set out within Project 2000. The Common Foundation Programme system was introduced and a set of standards were established regarding mentorship and the qualifications which are required by teachers of student nurses. The role of mentor was found to be focused on the five key aspects of Assisting, Guiding, Befriending, Advising and Counselling, as set out by the English National Board.

The extent to which the development of mentorship was sufficiently based on these relevant policies and standards was considered from the perspectives of researchers, student nurses and mentors. Researchers and theorists in this field were seen to argue that there are a number of different models which have been provided for conceptualising the role of mentor and that these were based on a variety of philosophical principles. There is a need for the standards and the role of mentor tube more accurately defined such that there is a common understanding of what is expected by all of the key stakeholders involved in the mentorship relationship.

Researchers were also found to suggest that the courses undertaken by nurses who were to become mentors were not sufficiently standardised and that they varied significantly between different institutions. Student nurses appear to agree with the assertion that the role of mentor is not clear. They were reported to demand that the policies and standards provided by the English National Board and internal organisations be translated into practical terms such that an improved understanding of the mentoring process could be facilitated.

As for the mentors, there were two important findings. Firstly a range of different selection approaches and criteria have been identified which ensure that the mentor selection process is not standardised system. Secondly, as there are no clear definitions of the role of mentor, it means that it is difficult to assess the mentors ‘competency within their role and to identify areas which may require further development and training. Therefore, although the policies and standards are present, mentorship does not appear to be sufficiently grounded in these to the extent that a clear concept of what the mentorship role entails is held by both the mentors and the student nurses involved.

The second area of the evaluation of mentorship which was considered by this systematic literature review focused on the implementation phase. It was particularly concerned with the question of whether the mentorship of student nurses is sufficiently supervised, monitored or audited. Research which has addressed the views of mentors and student nurses on this topic was included in the review. In terms of the student nurses it was found that they did spend a significant amount of time away from their mentors.

However, it was often the case that another qualified member of staff would provide a source of supervision, either direct or indirect, when the mentor was not available. Although such an intervention should be encouraged, it is important that the student nurse receives systematic and standardised education. The involvement of another member of staff who does not have the knowledge of the student nurse which the mentor has acquired, may cause additional difficulties.

Therefore, efforts need to be made to ensure that the mentor is available whenever possible and that other potential supervisors are made more aware of the student nurse’s educational position such that more effective and appropriate supervision can be provided in the mentor’s absence. As for the mentors, the research indicated that they felt that they were not adequately prepared, supported or monitored.

Within any mentorship programme it is likely to be important that the mentor themselves are in turn mentored such that their skills can be developed and their subsequent training needs can be identified. It appears that both the student nurses and the mentors are experiencing the same problem in that the mentorship is useful when it is available but that it is perhaps not available as often as they would like it to be.

The third evaluation area centred on the research which had attempted to quantify the effects of mentorship in terms of the student nurses ‘skill acquisition and the subsequent quality of the care which was received by patients. In terms of the student nurses’ skills, an interesting finding was that there was a perception that the training and mentorship was focused on the student getting the award and that there was a culture of assessment and control rather than one of support and development.

The concern here is that there may be an over-emphasis on the student nurses simply passing their training rather than actually learning the skills which they require to become an effective nurse. Mentors were perceived by the student nurses to be effective in providing support, particularly in the first year of training. They were also important in the nurses’ socialisation into the norms of the ward and the institution in general. It is difficult to determine the size of any direct effect which mentorship has on the skill acquisition of the student nurses but these indirect contributions do have a significant part to play.

Clinical experiences likely to be key in allowing the nurses to develop their skills and mentors can facilitate this process by providing support for the student and aiding their socialisation into the health care environment. In terms of the direct benefits which mentorship has on the care provided to patients, this is a complex topic and one which is rendered very difficult to accurately assess due to the range of different measures of nurse competency which are available.

In the absence of large studies in this area, or the availability of a nationally recognised competency tool which would allow the data from different projects to be pooled, it is hard to find the research evidence upon which to confidently assess this issue. It can be concluded that mentorship is likely to again provide the indirect sources of assistance which ultimately help the nurses to provide improved care to their patients. However, the magnitude of such an effect is very difficult to determine.

The fourth and final section considered the wider implications of mentoring and particularly focused on the effect which mentorship has on the student nurses’ learning experience. Research has indicated that student nurses feel that understanding their mentor’s likes and dislikes as well as being successful on the course are both important in facilitating a positive learning experience. Interestingly, research was identified which demonstrated that whether or not a mentor had teaching qualification did not significantly affect the way in which their students rated their effectiveness.

Having said this, it does appear that the mentor does have a role to play in terms of the learning experience. International studies have reported that the mentor’s availability was associated with a positive learning experience as to was the mentor’s ability to assist and guide their students. Broader research has shown that learning experiences are linked with factors such as the ward culture, the way in which negative events are managed, the student nurses’ perceptions of their mentor and the way in which trainees are treated.

The mentor has a role to play through each of these factors and the research identified within this systematic literature review indicates that mentors can have an impact, both direct and indirect, on their students’ learning experiences. The various limitations which are associated with the methodology which was employed within this research will now be discussed as well as the implications of this project’s findings for mentorship in student nurse education and for future research.

9.1 Research and Ethical Issues

It is possible to identify a number of limitations which are associated with the methodology used in this systematic literature review. Firstly the research process can be said to be constrained by the fact that the Berkley and Glenn (1999) guidelines were selected for application. It could have been that the use of other approaches may have helped to locate other relevant issues and research evidence.

Whenever one selects a set of guidelines, and thus rejects the others available, there are bound to be limitations which are associated with the chosen approach. However, the limitations involved with the Berkley and Glenn(1999) approach are no greater than other approaches which could have been used and hence these limitations are unavoidable and have to be accepted.

The second area of limitations which are associated with this research concerns the sources of data which were used. Research evidence was identified using computer-based search engines, manual searches and the internet. Computer databases can be limited because research studies may have been misclassified and hence may not be identified. Also, although a large number of studies are contained on such databases, they are not all-inclusive and hence this approach is somewhat limited as computer searches may not locate all of the relevant research evidence. Although steps were taken to overcome such limitations, such as those outlined by Sindh and Dickson (1997), they can never be completely eliminated

In terms of manual searches, they face some of the limitations associated with the computer searches. It may be that manual searches can be used to help overcome some of the limitations of computer searches and hence be used as a complementary approach. The internet also has limitations as one cannot be sure of the source of any information. Some of the research discussed on the internet may not be accurate or presented in a scientific way.

Therefore, the internet should be used as a back-up source for more general information and the possible limitation regarding the quality of this information should be kept in mind. The methodology used in this research can also be criticised in that other professionals or industries were not used as a source of data. The exclusion criteria used in this study ensured that only research which focused on mentorship and student nurses was used. It may be that research regarding mentorship and other health care workers could have provided some useful information as well as research concerning the evaluation of mentorship in other industries.

As the methodology employed in this research did not require any access to case records, patients or members of staff there was no requirement for the research to be considered by an ethics committee. However, there may be a limitation regarding ethics as it is assumed that the researchers discussed in this review conducted their studies in an ethical way. It is assumed that they have presented their results accurately and hence the current study may be limited by the ethical limitations which are associated with the research studies which have been reviewed. Therefore the present study can be said to be limited in terms of the research process, the source of data used and with regards to ethical issues. However, efforts were made to ensure that these limitations were minimised where possible to enhance the quality of the methodology employed.

9.2 Implications for Practice

The findings of this research have a number of implications for mentorship and student nurses. These can be outlined regarding the four areas of evaluation which have been the focus of this review. Firstly, although the policies and standards which have been outlined to govern mentorship are in place there does appear to be a need for them to be more effectively translated to practice such that both mentors and students can understand the underlying goal of mentorship and what is required of them.

Secondly there are implications regarding implementation in terms of supervision, monitoring and auditing. Works required in each of these areas to improve the mentorship of student nurses. It is important to note here that both the mentors and student nurses need to be effectively mentored and supervised with this process being regularly monitored and audited. This should ensure that the system can continually improve. Although student nurses were found tube supervised by other qualified members of staff in the absence of their mentor, this approach is not standardised and could become inconsistent.

It may prove useful to incorporate other members of staff into the mentorship relationship such that a more rounded source of supervision can be made available and that the student nurse can be more effectively mentored. Future research is required in this area to enhance the understanding of how the mentorship process can be better supervised, monitored and audited in the future. Approaches need to be identified which have the support of both the student nurses and the mentors as this will be likely to influence the ultimate success of the approach.

The research discussed in this review also has implications regarding the outcomes of mentorship and student nurses. It appears that the mentors can indirectly contribute to the development of their student nurses’ skills by creating a relationship and an environment which facilitates learning. They need to be made aware of the importance of supporting their students, socialising them onto the ward and in providing opportunities for their students to experience the clinical and practical aspects of nursing.

Future research would help to clarify the most effective ways in which this can be achieved. Furthermore, research is required to investigate the relationships between the student nurses’ skills and the subsequent care which they provide to patients. As a result of the variety of tools which are available to measure nurse competency it is difficult to assess which is most appropriate for assessing whether mentorship ultimately effects the quality of care provided. A nationally recognised measure of patient care is required which is particularly relevant to student nurses’ and their skill acquisition.

The fourth area of evaluation concerned the wider implications and the students’ learning experiences. Again it appears that the mentor has an indirect role in creating a mentorship relationship and a learning environment which facilitates a positive learning experience. This has implications for mentors as they need to be available for the student whenever this is possible. Future research could help to clarify what contributes to a positive learning experience and how the mentor can play a role in creating the necessary situation for this to occur. It’s unlikely that a student nurses’ learning experience will be positive if their relationship with their mentor is a negative one and hence this is an important research topic for subsequent research to focus on.

This systematic literature review has demonstrated that mentorship, both directly and indirectly, has the potential to have a number of beneficial effects on student nurses. Through a greater understanding of the mentor’s role, the mentoring relationship and its effects on skill acquisition and patient care, appropriate steps can be taken to ensure that these benefits are maximised and that any potential drawbacks are kept to a minimal level.

The role of the nurse has changed significantly in recent times (Royal College of Nursing 2004a and 2004b), and this change looks likely to continue into the future. Considerable amount of research has focused on mentorship and student nurses and again this research looks as though it will continue into the short and medium term to aid a further clarification and application of the benefits of mentorship. This should facilitate arrive towards more effective and feasible student nurse education and a more positive learning experience for the student nurses. In turn this should aid a more effective development of the student nurses’ skills and ultimately achieve the goal of continually improving patient care.

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