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"you know you have got to lift the bar a little, because you are no longer a carer or a nursing assistant, your actual on your way up to being a nurse, obviously you have got to set an exampleâ€¦" (from student F.)
I was struck by F's reflection on her own change in identity and awareness of internal drive to meet a standard. She was obviously struggling with this change process and aware of feeling vulnerable. I was surprised by her sharing this with me as she was a first year student nurse and this is a level of maturity in self awareness and reflection I might expect from a more senior student nurse or even from a newly qualified staff nurse. F. had spoken at the start of interview about trying to find her feet and perhaps feeling sensitive about things.
I responded with active listening through the rest of the interview and with an effective summary question/ statement towards the end that allowed F. to talk about moving on to her next placement. F. was voicing the possibility of having a different outlook towards a new experience; almost as if she was recognising the beginnings of long process of change in becoming a professional nurse.
In my SWOT analysis of both interviews I conducted, I saw this as the obvious opportunity for a learning moment, both for F. herself and also for myself as an aspiring future mentor. My thought during the interview was that this was a precious moment for F in becoming a nurse; and did wonder how I should respond to her verbalisation of her thoughts and feelings.
When I constructed the analysis this part stood out for me again as being a chance for myself to learn, perhaps how to become more effective as a mentor. My thoughts were how to cherish and help this kind of reflection in students in the future. I also wondered how rare these kind of conversations happened during nursing training. F. reflections that she shared with me, reminded me of my own training and how some staff nurses and charge nurses had stood out for me in the process of myself acquiring the identity as a nurse.
There was a protective element here in that I wondered how F.'s current reflective state could be nurtured and developed in her future placements. I wondered if she was aware herself of this change process and whether she would voice this in future with her mentors and tutors. It might be possible for F. and similar students to ignore and keep quiet about vulnerabilities and internalise this change process. If mentors were open to listening and gently questioning about becoming a nurse then this might facilitate growth and awareness of the nursing identity.
I considered how it might be difficult to record this type of reflection in the CAP booklet, even though the booklet explicitly encourages the use of reflection. A mentor would have to develop excellent reflective skills in order to facilitate these skills in students, and perhaps become sensitive to these opportunities for reflection arising early in the programme of nursing education.
A possibility for mentors would be to use the mid and end placement meetings with students. So that as well as assessing competencies and professional role development; there could be a place to gently discuss and reflect on identity as a nurse.
As well as this it might be possible for students to keep a reflective diary during placement and regularly meet with the mentor to discuss issues as they arose. There might be some reluctance for both mentor and student to explore these areas as this is very much about personal identity and occurs during a period of learning and developing in many different aspects as a nurse. Reflection might well be different for a very experienced and skilled staff nurse who is confident in their own capabilities and skills.
Some elements of theory relating to developing as a reflective practitioner within modern nursing will be analysed in the following section.
The path to becoming a nurse, can involve sharing feelings and asking for support and finding ways to handle emotions (Jarvis and Gibson, 2001). There can be an inherent vulnerability during the process of socialisation where the values and attitudes, that allow the nurse to function in his or her role within the health care system, are in a state of flux and change (Morton-Cooper and Palmer, 2000).
The mentor ideally should create a warm, genuine supportive relationship based on trust and sound interpersonal skills (Jarvis and Gibson, 2001). This must be fundamental to facilitating reflection upon personal and professional identity as a nurse. Gardiner (2003) introduces the idea of professional friendship to the role of being a mentor where listening, giving of recognition and challenging are added to the friend type relationship.
Some barriers to facilitating reflection on attitudes and self awareness can lie in the multi faceted role of the mentor. The mentor role is flexible and may have to cover a number of parts and elements; some of which may be contradictory. Two possibly opposing roles are informal teacher and guide and also assessor of professional competence especially with a student that is struggling or failing. So it may be difficult to add to this list that of confidant and counsellor in the broadest sense (Jarvis and Gibson, 2001).
The traditional concept of being professional could hinder openness for student nurses. There is a traditional view of keeping a professional distance and restraint in health care which may not encourage the expression of feelings and vulnerabilities for student nurses. However, Morton-Cooper and Palmer (2000) argue there is some growing evidence of the importance of developing "emotional work" as a critical element to caring, where this is described as emotional literacy, or perhaps in plain English terms as being able to express feelings appropriately, safely and effectively.
Jarvis and Gibson (2001) discuss the teacher- learner relationship as being hierarchical and the teacher having authority versus creating an inclusive, informal teaching relationship that encourages open reflection and critical thinking. There may be some difficulty for the student to reflect and be vulnerable and open about their changing identity where there is a strict authoritarian relationship (Jarvis and Gibson, 2001).
However, the nurse can develop authority based on professionalism and skills and knowledge that is legitimised by colleagues and students. This also relates to the element of mentorship in being a positive role model for student nurse (Jarvis and Gibson, 2001). Morton-Cooper and Palmer (2000) state the idea of the adult learner who directs their own learning and is in a process of becoming rather than being shaped into a role.
There are some ways to facilitate reflective practice and awareness. Donovan (2007) suggests using a formal reflective tool and a diary can be useful. Reflective discussion with peers and mentors also can be helpful. Trust is an important element in making reflection effective in clinical placement.
Levett-Jones (2007) suggests the idea of using narratives in self assessment. Case study or narratives may be more suitable to exploring practice, assessing competencies and skills. However, this could be a starting point in developing reflective skills and a language of emotional literacy. The value of narrative could lie in allowing direction by the mentor for the beginning nurse while being flexible during nursing education. There is also the value of providing a personal and persistent record for assessment and evaluation (Levett-Jones, 2007).
Some of difficulties have been examined that there may arise in developing as a reflective practitioner and how a mentor may help. There has been a short consideration of some of the possible tools such as diaries and narratives which may help in the learning process.
To be a more effective mentor, I would consider using a formal reflective tool such as Marks-Maran and Rose (1997) while mentoring students. This will be familiar to student nurses as it is used in the University of Dundee and in NHS Fife. I would try and use it more explicitly during planned learning programmes.
Further I would consider some strategies to encourage reflective discussion amongst students. Some ideas might be planned case studies involving one or more students. A structured and open discussion with a student about attitudes and professional roles may be useful at mid and end placement, although I would be tempted to arrange this after assessment and filling in competencies in the CAP booklet. I t would probably be ideal to have this at separate time as students appear to be anxious about completing their booklets.
Lastly, I may trial the use of narrative and or diaries to help with assessment of learning to see if this can promote reflection by students I will be working with.