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This chapter presents the study findings in two phases. Phase one will present statistical findings quantitative that were used to inform Phase two qualitative of the study. Participants' responses will be presented and discussed in relation to the research questions. The research aimed to explore the views and experiences of MHPs in relation to barriers that facilitated or hindered effective teaching and mentoring of BME students whilst on placement in mental health practice. The responses to the research questions are presented thematically and evidenced by the participants' interview translations. Additionally, data also revealed supportive factors that helped MHPs to cope with the identified barriers. These findings are linked to current research in this field.
The quantitative data used was collected using questionnaires on MHPs and BME students' views. A survey was carried out in order to gain information on the general view and perception of the research topic. According to Polit and Beck (2010), statistical procedures enable the researcher to organize, interpret and communicate information. The sample of twenty participants for both groups included both 5 male and 15 female MHPs and BME students from a range of teams, ages, experiences and ethnicities across the NHS Trust (Tables 1, 2 and 3). This was in an attempt to reflect the ethnic diversity present in the Trust.
Table 1 - Respondents' Departments
Data was analysed in relation to departments of respondents for both groups (Split into two categories of community and hospital teams to produce numbers for statistical comparison).
Table 2 - Respondent Ethnicity
Data was also analysed in relation to respondents' ethnicities for both population groups and was put in four categories of Black African, Black British, White and British Asian which included Indian, Pakistani and Chinese subgroups.
Table 4 - MHPs' Professions
Four nurses, two doctors, three social workers and one occupational therapist participated in Phase one.
The quantitative analysis sought to answer the first research question;
What are the challenges faced by BME students on placement in mental health practice?
The quantitative phase involved the examination of words more than numbers. Coding was utilised to organise data that was collected from the two sets of questionnaires provided. The researcher read through all the information from the questionnaires in order to obtain a picture of the whole topic (Argyrous, 2005). Themes were identified and similar topics were grouped together. The researcher categorised the information by verifying the selected themes through reflection on the data by discussing with other professionals in the same field. The data were then constantly compared.
Several categories of student problems and needs emerged from the data and were categorised as follows;
Cultural needs, such as diversity and understanding of the students and local cultures.
Academic needs, such as the need for tutorials and study support from placement.
Language needs, such as issues related to foreign accents and having to communicate in a second language.
Personal needs, such family and child care as well as financial support and others.
From the quantitative analysis, the level of student need in each of these categories and the severity of the barriers influenced both the MHPs and the students' expectation of each other. The quantitative information revealed that the majority of MHPs indicated problems related to support and personal needs of students whilst BME all students indicated a high level of problems with academic and personal needs. Both groups identified same problems with cultural and language needs. MHPs' responses were mostly related to the Trust's structural barriers like lack of support on diversity issues for both students and practitioners and BME students' responses were mostly related to academic and personal needs like lack of study support and family issues and finances. It was also observed that seven MHPs, 4 nurses and three social workers shared all of the students' perception of their problems. However, the doctors and one occupational therapist agreed to some of these perceptions but not all of these. They indicated that time constraints and lack of departmental support were major barriers. On the other hand the nurses and social workers mostly highlighted personal and cultural needs as barriers for the students' successful outcomes. Greater similarities were apparent among most responses for example, the need for cultural competence for both practitioners and students. Another finding observed was that not all BME MHPs shared the same perceptions as BME students. One BME social worker indicated that the level of racism was not high in contrast to what was indicated by most students. However, from the findings it can be argued that when students are faced with barriers, they require support in managing those obstacles (Loftin et al., 2012; Amaro et al., 2006 and Papadopoulous et al., 2004). BME students' perceptions of the barriers they faced ranged from moderate to several barriers. Eight students perceived that they had encountered discrimination, racism and prejudice during placement in mental health practice. However, three MHPs differed from this perception as they indicated no racism and prejudice in their responses.
As highlighted by Amaro et al., (2006) and Papadopoulous et al., (2004), perceived needs of students are related to the teacher or mentor's response to influence the outcome for the students. Furthermore, if the response the student receives is positive and adequate, the outcome for the student becomes favourable (Amaro et al., 2006). Conversely, if the teacher or mentor is unable to meet the student's needs the outcome becomes unfavourable for both. This then becomes a barrier to effective learning for the student during placement (Loftin et al., 2012; Amaro et al., 2006 and Yoder, 1996). Arguably, another striking finding from the data was that there was no apparent pattern related to age differences on participants' responses for both groups.
The data analysis from Phase one of the research initiated Phase two of the study where MHPs were interviewed as to supplement the quantitative data.
The quantitative data described some of the challenges faced by BME students during placement. These challenges were then explored with the MHPs, gaining their perspectives on perceived barriers that facilitated or hindered effective teaching or mentoring of this group of students. This was mainly based on their views and experiences in relation to issues they had come across in practice. The issues that were identified from the interviews were then discussed under each research question of the study. The MHPs interviewed provided their views and opinions and these were some of the many realities which were found in the study.
It is also important to note that the MHPs were asked to identify the factors that facilitated or hindered best placement outcomes for BME students. As such, the focus for improvement was placed on both factors.
What do MHPs perceive as barriers to the successful completion of BME students placements?
Several barriers to effective teaching and mentoring of BME students in practice have been identified in literature (Loftin et al., 2012; Thomas, 2007; Amaro et al., 2006 and Papadopoulous et al., 2004). The study explored the perceived barriers to effective teaching and mentoring of BME students whilst on placement from a MHP's perspective. MHPs were asked questions about challenges that they thought students faced on placement and how availability of support structures enabled them to cope with these. The MHPs identified several barriers as discussed in the following themes and subthemes. Some of the major barriers identified by most MHPs were the lack of cultural competence, time constraints as well as conflicts between practice and academia demands. According to Loftin et al., (2012) Beecroft et al., (2006) and Chambers and Alexis, (2004), lack of time to perform the job itself represents a serious concern in health practice today.
Placement and Academic Support
Five community and hospital nurses perceived that today's student nurse training is much more difficult than when they did their training. Similarly, the other three community social workers reported having difficulty understanding the students' curriculum in relation to their placements and what was required of them to support the students in order to succeed. They stated that social work placements were too short and as such students would tend to focus on their placement documents instead of learning key job skills. Two community nurses and one occupational therapist highlighted that the stereotypical image of BME groups had led them to believe that BME students would require extra support meaning more work for practitioners above their already full case-loads. As one MHP pointed out:
"It's all changing these days unlike during our days when we trained in hospital schools. These days it's all about paperwork, paperwork and no people skills at all. The practice managers' don't bother coming around at all unless there is a serious problem. BME students are complex and it's really difficult to work with some of these students. I am sorry but hey, it's really frustrating."
All the MHPs agreed that they had not received adequate support from both their Trust and the University about the required placement and academic student support. Additionally, they reported that they were unaware of other support services available to them as teachers and mentors. The participants in the study reported that their workload and pace interfered with the students' outcomes. They also argued that the lack of flexibility in the placement schedule and clinical skills required were considered as additional barriers for some students in particular BME students.
Among MHPs the perceived lack of knowledge about, and preparation for the requirements for successful placements for the level of the student's training was identified as an added barrier. The lack of appropriate placement support from practice managers and placement tutors was also acknowledged as problematic by all participants. Four MHPs cited lack of preparation as due to the overstretched health services and financial cuts that leave no time for learning other than meeting targets.
As stated by one MHP echoing others:
"At times I don't have a clue of what I am supposed to do with the student. All we have to do is just carry on as if there are no problems, yet we are striving in them. I really wish they could support us with the students."
Teaching and Mentoring
One community nurse identified that the lack of minority placement mentors and role models is challenging for BME students. They highlighted that BME students required mentors to support them to be more successful on placement. The participant identified other BME MHPs would be easier to approach for BME students. They stated that:
"A BME mentor is something that these students require, I wish there are enough BME MHPs in practice for them to look up to. It is shame that no one is addressing that despite all the equality and diversity initiatives in the Trust"
There was further consensus from other two MHPs that BME students had described having felt uncomfortable approaching a non BME practitioner. Additionally, some BME students had expressed having a perceived hesitancy to engage with a non BME practitioner due to fear of the unknown. Furthermore, six MHPs identified that these students felt more comfortable engaging with BME MHPs as compared to the other non BME practitioners. The same sentiments have been highlighted in other studies (Thomas et al., 2007; Amaro et al., 2006; Yoder, 1996).
Professionalism and Technical Support
Three MHPs expressed that BME student forums had been reported to be very supportive to BME members as they provided placement support and information on ways to improve placement and academic performance. In addition, being a group member provided with other benefits such as professional and social support. However, such groups are not always available for BME students during placement. For the few that are involved, their busy placement and academic demands prevent them from effectively attending these support groups.
On the other hand, three MHPs noted that despite the availability of information technology support for students some mature students were reluctant to utilize this readily available support. Computer technology competence was reported as a significant barrier to successful placement and academic outcomes. Students had reported struggling with completing assignments and informational searches. As further highlighted by one MHP, BME students had also identified not having essential key board skills and using basic Microsoft applications as additional challenges.
Emotional and Moral Support
Almost all the participants identified that the lack of emotional and moral support was a key barrier for BME students on placement. Some of the MHPs argued that this lack of support could bring on feelings of loneliness and social isolation, racism and discrimination as well as family support issues (Thomas et al., 2007; Amaro et al., 2006 and Papadopoulous et al., 2004).
Loneliness and Isolation
Research studies have indicated that having low numbers of Black African students in health training reduces the chance for BME students to connect and develop fruitful relationships with other Black British students. This may lead to loneliness and isolation (Allan, 2010 and Papadopoulous et al., 2004). The same can be said for African Americans and other international students. This lack of other BME students on placement as suggested by all participants, can contribute to more isolation of BME students during placement. However when there was another BME student in their placement students eventually overcame these feelings of loneliness. Four MHPs argued that it was much more difficult for those whom English was a second language. Some students had described to MHPs, feelings of isolation and loneliness both inside and outside the learning environment. These students described being the last person to be selected for activities as well as having difficulty finding someone willing to study with them (Amaro et al., 2006 and Papadopoulous et al., 2004).
Discrimination and Prejudice
Multiple research studies have provided information on the discrimination and issues related to racism of BME students in practice. This has been argued to be from institutions, other fellow students, practitioners and service users. As one MHP stated:
"A mature Black African student was once told by a non BME service user to speak proper English and not use a jungle accent here in Britain"
Another MHP recounted a service user assuming that a BME medical student was the assistant and not the medical student while presuming that the non BME assistant was the medical student. Another MHP recalled an incident whereby a non-BME service user refused to have an injection administered by a BME student nurse stating that he did not trust 'these people'. The perception that mental health institutions have a negative bias towards both BME groups has been expressed in several studies (Allan, 2010 and Papadopoulous et al., 2004). One MHP reported,
"A colleague of mine was once told by a non-BME senior manager that he did not like 'these people' and that 'they all look the same."
Similarly, another MHP commented that:
"The perceived discrimination encountered by BME groups can be very hurtful, horrific and painful."
Furthermore, some African and Indian students had described their learning environment as not friendly and unsupportive (Amaro et al, 2006). They highlighted that they were required to perform twice as better than their counterparts. Another MHP also stated that the African students' names were difficult to pronounce. She giggled:
"I end up calling them what I think is easier for me......"
From the findings four MHPs agreed that BME students were treated as the 'others' and this impacted negatively on their learning outcomes. All British Asians and one Black African and one Black British MHPs shared similar views on students' challenges related to culture and diversity. However, one Black British MHP cited that culture was not always an issue for BME students only for those born abroad specifically Africans.
In the research, MHPs expressed their concerns about the lack of the students' cultural knowledge and competence by practitioners as a barrier that hindered effective teaching and mentoring of BME students. This is in line with literature where students had expressed feelings of exasperation by their peers' limited cultural knowledge as a result of lack of exposure to diversity (Loftin et al., 2012; Allan, 2010; Thomas et al; 2007; Amaro et al., 2006 and Yoder, 1996). The MHPs from the study expressed that due to the ever changing diverse population in the borough it was hard to keep pace with the different cultures. As stated by one MHP,
"It has become difficult to work for this Trust for one cannot communicate effectively with the service users due to language barriers."
Another MHP stated:
"I find it very hard to understand some of the accents for they are quite strong, I have to ask the person to repeat what they are saying over and over again."
Another MHP could not hide their frustration stating that:
"You expect people to at least speak and understand a good deal of English before they come here, this is absolutely ridiculous, they can read English but that is just not good enough."
Similarly, another MHP stated:
"It's not only about their culture you know, how about them learning the local culture as well?"
MHPs in the research related the need for cultural understanding from both BME students and practitioners to enable effective communication. As suggested by Loftin et al., (2012) and Amaro et al. (2006), communication is directly linked with language needs and as such students may feel alienated from their peers, especially if they are the only one on placement. Communication with peers, practitioners and service users can be more difficult when students have English as a second language. BME students have described experiencing impatience or discrimination in practice (Loftin et al., 2012 and Allan, 2010). Most participants indicated that for some BME cultures, it was considered rude to be assertive or to speak up for oneself. It can be argued that this could present with difficulties in assisting BME students with placement practice that students do not understand. As one MHP explained:
"There are times when a student needs something, but they are afraid to ask because their culture says it's rude to ask or to speak out, this can be both positive and negative"
These findings showed that the level of perceived barriers by MHPs ranged from mild moderate to severe. Similarly, the needs ranged from requiring low, medium and high intense support. Most MHPs identified and acknowledged a high level of barriers. There was need to establish and maintain supportive services for this group of students such as BME forums and support groups (Loftin et al., 2012; Allan, 2010; Amaro et al, 2006 and Chambers and Alexis, 2004).
MHPs expressed that students' personal needs could be a barrier for them whilst on placement. Several MHPs stated that the students' responsibilities for their families (caring for their loved ones) impacted on their placement outcomes. For example, one MHP summarized the feelings of most:
"These students are mature adults with family and other responsibilities, they are mothers, fathers, sisters, sons and daughters and they spent all day on placement and still have other responsibilities after placement that one cannot separate from. This leaves them with no 'me' time at all. I was once a student myself and I know how difficult it can be."
According to Amaro et al., (2006), Papadopoulous et al., (2004) and Evans, (2004), families can be both a support and a barrier for students. Some BME students were under tremendous pressure due to their family's high expectations of them. One MHP related:
"For most students having a career is everything, especially mature students. I remember while I was growing up.... all I wanted was to work hard in school and get a good well paid job. There was no room for failure at all and this put a lot of pressure on me..... In the end I did it but pheeww..... It was tough."
Family support issues were identified by MHPs as both facilitators and barriers for students. As asserted by Allan (2010) in some families, students get overwhelming support whilst in others there is limited or no support at all. Arguably in most BME families, female students struggle to balance their family responsibility and their placements. MHPs identified that family responsibilities hindered students' successful placement outcomes as some students had to sacrifice placement time in order to fulfill family responsibilities.
What assisted MHPs to cope with the barriers their students faced?
Participants indicated that although they faced barriers, there were specific factors that influenced their ability to cope with some of the student challenges during placement. They mainly mentioned:
Determination and Self Motivation
Determination and Self-motivation
Perhaps the most compelling strength that was demonstrated by all MHPs was their determination and self-motivation. Nearly all the MHPs highlighted that they desired to help and support BME students as well as other students on placement in order for them to complete their training.
One MHP expressed their tenacity which was found in most of the MHPs:
"You have to have a heart of gold in order to help someone. You spent time listening, concentrating and further listening to show that you care about the particular student.... I do everything, every single thing that I can. Students do appreciate this effort and at the end of it all you are proud of the student's success and your own as well."
Another MHP related:
"Right, I see it as my professional duty not as an extra burden. I was once a BME student and I know how it feels like to be one. I have to do it, period."
Resolve to Succeed
Most MHPs passionately described their resolve to succeed on effectively teaching and mentoring their students despite facing several barriers in their role.
MHPs highlighted that peer support was an important pillar for support. They stated that other multidisciplinary practitioners at work provided them with encouragement and motivation to keep going. One non-BME MHP related how her colleagues helped her to mentor a BME student:
"My social worker colleague really supported me by taking my student on community visits and helping me in explaining some personal issues in relation to practice."
As further highlighted by Loftus and Duty, (2010), Amaro et al., (2006) and Papadopoulous et al., (2004), the significance of peers and their attitudes on cultural issues is important for successful positive outcomes for BME students. According to the MHPs, peers' attitudes and relationships with students facilitated key roles in BME students' success. Contrary to the reported incidents on some unsupportive practitioners (Loftin et al., 2012 and Papadopoulous et al., 2004), all the MHPs expressed that they received a considerable amount of emotional and motivational support from their peers.
As asserted by Hennink (2007), Amaro (2006) and Yoder (1996), these practitioners act as mentors who are supportive in providing encouragement and ongoing support. Additionally, some non-BME MHPs described receiving positive support from their BME peers. On the support and experiences with BME peers, one non-BME MHP summarized it as:
"'A' is always supportive, she takes time to explain BME issues that may relate to students on placement and she has patience, it's good to have her in the team for I don't know how some of us would have coped with some of these issues."
Other participants expressed the importance of BME forums when asked about other available support for them. BME forums for both students and practitioners may not be always available (Thomas et al., 2007 and Gardner, 2005), but these were reported by MHPs as being helpful to both practitioners and students involved. Forums were said to provide motivation, access to internet and general information on BME issues in education and practice. According to Loftin et al., (2012) and Mulholland et al., (2008) forum groups provide a safe platform for group members to identify with other practitioners and students of their own ethnicity. Additionally, forum groups provide social support and extracurricular activities. Many group members participate and act as peer mentors.
As highlighted by others, one MHP stated:
"I wish they had support groups around here like they do in Birmingham. When I was up there it was really handy. These groups are really influential and positive about experiences people share when they go there. You share good and bad experiences really."
Although MHPs stated that forums provided multicultural information that was desperately needed, not all of these groups focused on assistance for specific BME issues. A few participants had attended some of these groups and found the information unhelpful and did not attend again. From the findings, the information on the barriers and the strategies that were expressed by MHPs on how to cope with their students' challenges was overwhelming.
Internet Based Support
Another most compelling factor that participants identified was the availability of web information. Almost all of the participants reported that the intranet and internet supported them significantly in coping with some of the identified barriers. MHPs reported that access to web information on BME issues both at work and at home provided them with additional knowledge on how to work sensitively with BME groups. Practitioners cited that their work intranet provided them with guidance on equality and diversity issues at work. Additionally, the general internet information on the Equality Act (2010) provided them with statutory guidance on BME issues in the work place that enabled them to cope effectively.
What hindered MHPs from coping with these barriers?
MHPs were asked about their experiences in coping with barriers that their students faced during placement. All MHPs in the study reported different levels of challenges that they faced whilst trying to support their students. There were mixed responses regarding the level of support that was currently available from the Trust and the Universities. Problems encountered included time constraints, the unavailability of ongoing placement support from placement tutors and placement practice managers, difficulty understanding the students' placement documentation and lack of Trust support in managing their day to day work considering the fact that they had students on placement regularly.
Participants felt that the Trust was not very concerned about their roles as teachers and mentors of students. As reported by one MHP:
"Sometimes you feel like you are on your own really, the Trust does not bother to look at our case loads bearing in mind that the students are always here and demanding our full attention"
Another MHP further went on to say:
"All the Trust is concerned about is the payment by results for the Commissioners and nothing else matters, it's all about cutting costs and you wonder where we and the students come in."
All the eight MHPs reported that there were times when they had to make their own decisions based on their professional judgement and experiences. Four MHPs further reported that this would then put them in a difficult position for due to lack of knowledge and the sensitive nature of BME issues one could easily get caught up in serious personal and professional problems. All MHPs highlighted the importance of ongoing equality and diversity support when working with BME students on placement and all other students in general, as this could prompt to more tolerance and professionalism.
The following response illustrated that:
"I don't know what the equality and diversity people do in this Trust, no one talks about BME issues at all as if they do not exist, and honestly they know that there are problems especially with students. How are we supposed to cope with these issues if they don't support us?"
All MHPs identified lack of time as one of the most significant barriers to effective mentoring of students. Practitioners highlighted that they were a quick turn over of students coming for placement and this left them without sufficient time to look after their service users. They reported that the Trust did not offer them appropriate support for their role. Students were argued to occupy most of the practitioners' time and in specific dealing with BME students was an extra difficulty. Balancing workload and having time to effectively teach or mentor BME students was challenging for practitioners. MHPs identified that workload was a major concern. Carrying on with their daily work, having contact with their service users, completing care plans, writing reports and supporting the students was difficult and time consuming (Allan, 2010 and Chambers and Alexis, 2004).
The amount of work and student support needed was overwhelming for some MHPs. This coupled with the ever changing placement and University student documentation presented serious difficulties for MHPs. One participant related the feelings of most:
"You are never prepared for a student on placement because of the amount of caseloads we have. If it was not a professional statutory requirement I don't think many would do it. Don't get me wrong, it's not that we don't want to help; it's just too much to be honest. It is even harder when you are dealing with a student who has a different culture from yours, you see what I mean."
MHPs reported having limited time to prepare themselves in time for the students. Many believed they did not receive enough support for these issues from their employer. As stated by one MHP:
"Half the time you don't even get enough notice that a student is coming. Although we do have a rota, the University does not normally send the students list on time and besides, the rota just goes quick".
The study highlighted the challenges faced by BME students on placement in mental health practice by examining both students' and practitioners' views and experiences on these issues. While the number of participants used was relatively small, together their responses painted a picture of the barriers and factors that facilitated or hindered effective BME students' placement outcomes. This can also be said to be in addition to the typical challenges faced by other students in general (Luftin et al, 2012; Amaro et al., 2006 and Yoder, 1996). This research provided an overview of research that is aimed at examining some of these barriers.
Arguably, the findings of the study indicated that successful students' placement outcomes can be complicated and there are several barriers for BME students and their mentors to overcome (Loftin et al., 2012; Beecroft et al., 2006; Amaro et al., 2006 and Yoder, 1996). Cultural issues and lack of knowledge on these issues were commonly identified by many participants in the study.
Unfortunately, for BME students these issues continue to persist today and there seems to be no great deal of change forthcoming (Thomas et al., 2007; Amaro et al., 2006 and Chambers and Alexis, 2004). Resulting from current austerity measures in the UK, the unavailability of funding in most Government departments has also affected Higher education. The departments of health and education need to work in collaboration with BME groups to facilitate the provision of funding on dissemination of information on sensitive BME issues as this would benefit this group including students. Determination and self-motivation, peer support, BME support groups were identified as facilitators for the success and achievement for MHPs (Amaro et al., 2006 and Yoder, 1996). This can then be related to the challenges BME students face as MHPs would be able to support their students effectively.
MHPs in the study expressed that their students had highlighted their reluctance to approach non-BME MHPs. The students had suggested that they had approached BME MHPs with ease but often there were not many BME MHPs available in their departments. The findings from this study may have implications on the recruitment and retention of BME MHPs in the Mental Health Trust. It may then be argued that this could significantly reduce some of the barriers faced by BME students during placement. Furthermore, findings from the study suggested that NHS organizations can have negative influence on BME students' practice experience through discriminatory practices. As such, organizations need to appreciate the influence they have on BME students learning outcomes. On the other hand, support for MHPs through information technology related to BME issues was highlighted in many of the participants' responses. As asserted by Loftin et al., (2012) the use of technology is fundamental in health care. The modern worker today needs to have at least basic computer skills in order to survive in the workplace (Loftin et al., 2012). In the study MHPs expressed that they found internet information on BME issues usefully important. This is evidence that the MHPs had some functional computer skills.
A substantial knowledge gap as noted in the study's literature review was that most studies focus on ethnic students' feelings and perceptions. There is limited literature on barriers that practitioners face in their role as teacher or mentors. In fact, similar studies may further shed light on additional barriers that historically may not have been identified by students themselves. This may then further facilitate BME students' success in practice. Identifying practitioners' participation in future research studies may likely to be difficult, but it is the opinion of the researcher that effort be made to include this population's perspective. Above all, identification of strategies that will enhance the resolve and determination of MHPs to support their students to succeed is paramount.
Findings from the study indicated that research studies show the need to raise cultural and diversity awareness among health care workers. BME students argued that they face daunting barriers in practice and there is much to be done to improve their experiences. The findings of this research highlighted the need to establish and maintain robust practice capable to aggressively address BME students' needs as well as facilitating an environment that is both welcoming and caring. The following chapter will present conclusions and recommendations for the study.