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Assessment matters—mentors need support in their role

AbstractBackground: In the UK the Nursing and Midwifery Council (NMC) standards to support learning and assessment in practice state that mentors are responsible and accountable for the assessment of pre-registration nursing students in practice. This study was undertaken to explore mentors’ experience of assessing nursing students in practice post implementation of the NMC standards. Method: Five focus groups were conducted with mentors (N=35) who had assessed adult pre-registration nursing students in the previous 12 months. The focus groups were recorded, transcribed and analysed to generate categories. Results: Five categories were identified from the data: Changing roles and responsibilities; Exploring the past to understand the present; Just knowing; The odds; Time to mentor. The findings highlighted that mentors were aware of their role and responsibility for the assessment of students in practice. However, many felt this was a new responsibility and role in which they lacked experience. Some existing mentors felt that they may not have had the necessary preparation to effectively assess students in practice and identified their need for support. Conclusion: Given that mentors are expected to be competent assessors of students in practice and protect the public through gate-keeping professional registration, this study suggests that serious consideration should be given to how mentors are prepared and the ongoing support and education they receive in assessment.

Key words: Mentors ■ Experience ■ Assessment ■ Support ■ Knowing

Maggie Bennett and Brian McGowan

This�study�was�carried�out�in�a�health�and�social�care�trust�in� Northern� Ireland,� following� the� implementation� of� the�NMC� standards� (2008a).� Mentors’� experience� of� assessing�students� in� both� primary� and� secondary� care� settings� was�explored�by�using� focus�groups� to�enable� their�voice� to�be�heard.�

BackgroundPractice-based� learning� and� assessment� is� fundamental� to�nurses’� education� and� the� NMC� underlined� this� when� it�clarified� the� professional� responsibility� to� facilitate� nursing�students�to�achieve�competence�(2008a).�However,�perceived�difficulty� in� assessing� students’� clinical� practice� is� long-standing� and� has� received� much� attention� in� the� nursing�literature� from� the� perspective� of� education� providers� who�are� responsible� for� curriculum� planning� (Norman� et� al,�2002;�Bradshaw�and�Merriman,�2008;�Fitzgerald�et�al,�2010;�Holland� et� al,� 2010).� In� contrast,� McCarthy� and� Murphy�(2008)� claimed� that� the� experience� of� mentors,� who� are�accountable�for�decisions�about�competence�in�practice,�has�been�under-researched.�

The� influential� work� of� Duffy� (2003)� identified� the�concept�of�mentors�‘failing�to�fail’�and�was�instrumental�in�the�development�of�standards�to�support�learning�and�assessment�in�practice�in�the�UK�(NMC,�2008a).�The�standards�provided�a�framework�to�articulate�principles,�clarify�accountability�and�ultimately�enhance�the�quality�of�learning�in�practice�(Box 1).�As�a�result,�mentors�and�sign-off�mentors,�through�assessment�in�practice,�act�as�the�gatekeepers�to�professional�registration�and�ensure�students�are�fit�for�practice�and�purpose�at�the�end�of�a�period�of�practice�learning.�However,�several�years�after�the�issue�was�first�raised,�and�despite�implementation�of�the�standards,� it�has�been� reported� that�mentors� are� still�‘failing�to� fail’� poor� students� (Gainsbury,� 2010).� Hunt� et� al� (2012)�claimed�that�this�was�indicated�by�failure�rates�for�theoretical�assessments�in�higher�education�institutes�outstripping�failure�rates�for�practice-based�assessments�by�five�to�one.�This�is�of�major�concern�for�a�profession�that�considers�practice�to�be�its�core�element.�

AimThe�aim�of�this�study�was�to�explore�mentors’�experience�of�assessing�pre-registration�nursing�students�in�practice�in�order�to�understand�the�rewards�and�challenges�they�faced.

Methods and ethical considerationsThis�qualitative�study�used�focus�groups�as�the�method�of�data�collection�to�gain�insight�into�the�experience�of�mentors�in�

Maggie�Bennett�is�Lecturer�(Education),�School�of�Nursing�and�Midwifery,�Queens�University�Belfast,�Belfast;�Brian�McGowan�is�Lecturer�in�Nursing�and�Academic�Lead�for�Learning�&�Teaching,�School�of�Nursing,�University�of�Ulster,�Jordanstown

Accepted for publication: April 2014

Introduction� of� the� Nursing� and� Midwifery� Council�(NMC)�standards�to�support�learning�and�assessment�in�practice� resulted� in�changes� to� the�context�of�practice-based� assessment� of� students� by� clarifying� the� role�

of� the� sign-off� mentor� and� unequivocally� allocating� the�accountability� for� such�assessment�decisions� (NMC,�2008a).�Link�lecturers,�who�were�previously�actively�involved,�are�no�longer�required�to�be�signatories�of�the�summative�assessment�of� student� nurses� in� practice.�This� led� to� questions� being�raised� about� the� validity� of� competence� assessment� and� in�particular�mentors’�experience�of�this.�

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practice.�The� focus�groups�were�designed�and�conducted� in�accordance� with� the� realist� approach� described� by�Krueger�(1994)�and�mirrored�the�discussion�format�that�the�mentors�were� familiar� with� as� part� of� their� annual� update� activities.�Ethical� approval� was� granted� by� the� Office� for� Research�Ethics� Committees� in� Northern� Ireland,� the� trust� and� the�higher�education�institute.�

Mentors�and�sign-off�mentors�with�experience�of�assessing�adult� pre-registration� nursing� students� in� the� previous�12  months� were� selected� randomly� from� the� trust� mentor�database.� Letters� of� invitation� were� sent� to� each� potential�participant� in� their� clinical� area.� In� accordance� with� the�requirements� of� informed� consent� the� letters� included�the� title� and� purpose� of� the� research� study� and� participant�information� (Munhall,� 2010).�This� outlined� the� procedures�to�be� followed� in� the� study,� including�ground� rules� for� the�focus�groups,�and�the�participant�consent�form.�The�need�to�digitally� record� the� focus� groups� to� allow�verbatim� analysis�was� highlighted.� Potential� participants� were� also� given� the�opportunity�to�ask�further�questions� from�a�member�of�the�practice� education� team� and� contact� details� were� provided�of� an� independent� advisor,� prior� to� consent.� Participants�were� informed� that� their� participation� was� voluntary� and�that�they�were�free�to�withdraw�at�any�time�without�giving�a� reason� and� without� their� rights� being� affected� in� any�way.�The� guidance� protocol� read� before� each� focus� group�reminded�participants�that�they�were�free�to�leave�the�study�at� any� point.�Written� informed� consent�was� obtained� from�each� participant� before� the� start� of� each� focus� group.�The�researcher�assured�confidentiality�of�participants’�information�by� securely� storing� the� data.� Each� participant� was� given� a�unique� identification�number� to�provide� anonymity�during�transcription� and� to� ensure� direct� quotations� were� not�attributable� to� individuals.�Arrangements� for� support� were�put� in� place� in� the� event� of� a� focus� group� causing� distress�to� any� individual.� It� was� agreed� that� the� moderator� would�provide�support�at� the�time�of�the�focus�group�and�follow-up� support� would� be� offered� from� the� practice� education�team�and�trust�occupational�health�department.�As�part�of�the�consent� process� it� was� highlighted� that� if� practice� contrary�to�the�NMC�Code�(standards�of�conduct,�performance�and�ethics�for�nurses�and�midwives)�(NMC,�2008b)�was�disclosed,�this� would� be� acted� on� as� a� professional� responsibility.� In�this� instance,� it� was� made� clear� that� confidentiality� of� the�participant�could�not�be�assured.�In�the�event�of�issues�of�staff�competence� being� raised,� it� was� highlighted� that� the� trust�policy�and�the�NMC�(2010)�guidance,�Raising concerns,�would�be�adhered�to�with�follow-up�support�if�necessary�from�the�trust� occupational� health� department.�Any� concerns� raised�in�relation�to�student�nurses�in�practice�would�be�addressed�according�to�the�higher�education�institute’s�protocol.�During�the�research�study,�none�of�the�participants�required�support�and�no�issues�were�raised�that�required�follow-up�action.�

Data collection and analysisA� total� of� five� focus� groups� (A–E)� were� conducted� with�35 participants� in� total,� which� ranged� from� five� to� ten�participants.� Each� focus� group� lasted� between� 60� and�90  minutes.� A� series� of� open-ended� questions� were� used�

across� all� of� the� focus� groups� to� explore� the� participant’s�experience� of� assessing� students� in� practice.� Each� focus�group�was� digitally� recorded� and� transcribed� verbatim.�The�transcripts� from� the� interviews� were� analysed� using� the�six-stage� pragmatic� approach� to� qualitative� data� analysis�described�by�Newell�and�Burnard�(2011)�(Table 1).�An�audit�trail�of�analysis�decisions�was�kept�and� interpretation�of� the�transcripts�was�primarily�carried�out�by�the�first�author�and�verified�by�the�second�author�to�ensure�interpretive�validity�(Cohen�et�al,�2003:�107).

Results Five�categories�were�extracted�from�the�data�(Table 2).�In�the�reporting� of� excerpts� from� the� focus� groups,� pseudonyms�have�been�used�to�protect�participants’�anonymity.

Changing roles and responsibilitiesThis� category� label� was� chosen� to� reflect� that� participants’�expressed� the� idea� that� their� role� and� that� of� others� (link�

Box 1. Summary of NMC standards to support learning and assessment in practice

■ Students on approved NMC courses supported and assessed by mentor

■ Sign-off mentors make the final assessment of practice■ Placement providers keep an up to date local mentor register■ Mentorship preparation programmes approved by NMC■ Mentors required to undertake annual updates and triennial

review ■ Ongoing achievement record to document student progress

(NMC, 2008a)

Table 1. Overview of the thematic content analysis process, stage one to six, guided by Newell and Burnard (2011)

Stage one Notes were made after each focus group regarding the topics discussed. A memo was made of any idea, theory, thought or feeling that was evoked by discussions in the group.

Stage two The transcribed data from each focus group was read through and notes made in the margins of the transcripts on general themes that appeared. The aim in general was to become immersed in the data and to get to know it very well.

Stage three In stage three, described as ‘open coding’, the transcripts were read repeatedly. Words and phrases were written in the margin of the transcripts to summarise or categorise what was said in the text. The content was categorised under headings until all aspects of it were described.

Stage four The categories to describe the data were collected together and those that overlapped were grouped under higher order codes. This stage reduced the number of categories to a manageable size and ensured the difference between them was apparent.

Stage five In this stage, the transcripts were returned to, with the shortened list of category codes. The text was coloured coded, using brightly coloured transparent ink marker pens, under the shortened list of category codes. The transcripts were cut up according to the different colour sections, reflecting the categories identified.

Stage six This resulted in the data from the five focus groups being merged together to facilitate the presentation of the findings in this qualitative report (Table 2).

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lecturers)� had� changed� in� relation� to� the� assessment� of�students�in�practice.�The�most�striking�finding�in�this�category�was�that�many�mentors�expressed�the�view�that�responsibility�for� the� assessment�of� students� in�practice�was�new�and�was�a� recent� change� in� their� role.�This�was� summed�up�by�one�mentor�who�said:�

‘I think the role of the mentor has very much changed this past number of months, you know. I just started there with a management student and I realised how much onus is actually on me as a mentor.’ (Mary, C10)

The� requirement� to� have� a� ‘sign-off ’� mentor� for� final�placement� nursing� students� created� the� myth� that� mentors�were�less�accountable�for�the�assessment�of�students.�This�idea�was�captured�by�one�participant�who�said:

‘I find people are so scared of being a sign-off mentor, but don’t realise just having a student, full stop, is putting your name on that book. You are saying they are achieving…The girls in our ward are all saying I don’t want to be a sign-off mentor.’ (Helen, D4)

Participants� described� the� variety� of� roles� they� had� with�students� such� as� guide,� friend,� supporter,� facilitator,�mentor,�assessor,� teacher,� role�model� and� influencer� that� echoed� the�work�of�Darling�(1984).�One�participant�summed�up�multiple�roles�when�she�said:

‘I was her mentor, facilitator, her everything.’ (Fiona, B4)

Changing� between� these� roles,� however,� presented�challenges.�This�was�illustrated�in�this�study�by�the�following�exchange:

‘I see a mentor as somebody that…I take them under my wing and then bring them on. And I don’t think it should be fair that maybe, after, at the end of that, if I have been given that role of

really looking after them to say, well sorry, you know you are not up to speed…’ (Ruth, A6)

‘I can see where you are coming from…taking them under your wing...and then having to do their assessment...’ (Francis, A5)

Interestingly,� only� one� mentor� in� this� study� had� personal�experience� of� failing� a� student� but� articulated� clearly� her�professional� responsibility� to� ensure� the� protection� of� the�public�when�she�said:

‘It was hard to do, nobody wants to do that to anybody but you have to think at the end of the day, if she is going out and looking after a relative of yours…she just wasn’t safe at all. I think it is part of our job to do that, it might not be nice.’ (Kate, C9)

One�of�the�key�changes�identified�by�the�participants�was�that� they� had� experienced� reduced� link� lecturer� contact�in� practice.�This� perceived� change� underscored� to� mentors�their� pivotal� role� in� assessment.�The� importance� of� taking�ownership� of� student� assessment� was� highlighted� by� one�participant�who�said:

‘I think it is going to be more important too, that we will all be mentors and assessors…there is going to be less link lecturers and I think that is going to lie with us maybe, that if there is problems that we take ownership.’ (Alice, A7)

The�need�for�support�was�summed�up�by�one�participant:

‘You did feel you had a bit of support and I think the student felt they had support as well. I just feel it was somebody else there, you just weren’t seen as doing everything.’ (Fiona, B4)

Exploring the past to understand the presentParticipants�in�the�study�reflected�on�their�own�experience�of�nurse�education�and�assessment�in�practice�as�a�benchmark�to�make�sense�of�their�current�role,�as�illustrated�by�the�following�extracts:

‘I mean, not harking back to the old days, but we would have had our surgical and medical placement in every single year, so you would have been guaranteed to be on a medical ward and surgical ward, year 1, year 2 and year 3.’ (Doris, E1)

‘I suppose I am not clear what, at what level they should be at, at the end of year 1, year 2 and year 3 and I suppose when I trained you were more clear of where you should be.’ (Ruth, A6)

Just knowingParticipants� in� the� study� described� how� first� impressions�of� students� were� important.� This� was� illustrated� by� one�participant�who�said:

‘…I think you know within the end of the first day, maybe that is judging somebody, I don’t

Table 2. Categories extracted from the data

Category Focus

Changing roles and responsibilities

■ Assessment perceived as a new role ■ Degrees of accountability ■ Mentors experienced conflict between their different roles

■ Assessment perceived as punitive ■ Role of the link lecturers

Exploring the past to understand the present

■ Difference in current education programmes from their own experience

■ Impact of change

Just knowing ■ Intuition ■ Importance of first impressions

The odds ■ Luck ■ Lack of experience and confidence in managing a failing student

Time to mentor ■ Time ■ Service pressures

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know but you do know.’ (Jane, E7)

Participants�recognised�that�their�assessment�of�students�was�often�subjective�and�as�described�by�the�following�participant:

‘I think it is how they apply themselves; in four or five days you can tell and that is not maybe the way [the higher education institute] are looking for us to do it but I mean we are all human and that is the way’. (Edel, D5)

The oddsOnly�one�participant�in�the�study�had�been�responsible�for�a�failing�student�and�the�others�felt�they�had�been�‘lucky’�not�to�have�this�experience:

‘Personally I am lucky; I haven’t had a bad student. I have been very lucky with my students.’ (Gail, C8)

In�this�study�participants’�lack�of�experience�and�confidence�impacted�on�how�they�felt�about�managing�a�failing�student.

‘I be nearly…nervous whenever you are getting another student. I hope they are good. I wouldn’t really want to get a bad one.’ (Helen, D4)

Time to mentorParticipants�described�the�lack�of�time�they�felt�they�had�to�work�with�students.�This�was�identified�as�a�major�challenge�and�impacted�on�assessment.�

‘I have just found in your ordinary working day you wouldn’t get time to sit down for like an hour and say this is what we have done so far, this is what we need to do next, kind of thing.’ (Sharon, A3)

The� standards� (NMC,�2008a)� require� sign-off�mentors� to�be�allocated�1�hour�protected�time�per�week�to�reflect,�give�feedback�and�keep�records�of�students’�achievements�in�their�final�placement�of�practice�learning.�

‘The protected time with the student has really made a big difference, it really has, at least a couple of hours out of work, you can get a way off the ward.’ (Dawn, E5)

Sign-off� mentors� in� the� study� felt� this� requirement� had�made�a�difference�and�supports�the�argument�that�all�mentors�should�be�allocated�protected�time�with�students�to�fulfil�their�role�(Lauder�et�al,�2008;�Beskine,�2009).�DiscussionThe� mentor’s� role� in� the� assessment� of� student� nurses� in�practice,� in� the� UK� has� been� clarified� by� the� standards� to�support� learning� and� assessment� in�practice� (NMC,�2008a).�Notably,� participants� in� this� study� felt� the� responsibility� for�the�assessment�of�students�in�practice�was�a�new�and�recent�change� to� their� role.�This� is� important,� as� Huybrecht� et� al�(2011)� argued� that� the� mentor’s� perception� of� the� role� is�undoubtedly� an� important� influencing� factor�on�his� or� her�performance.�Consequently,�the�findings�in�this�study�suggest�

that�some�mentors�may�lack�experience�in�the�assessment�of�students�and�may�have�relied�on�the�link�lecturer�to�inform�their� assessment.� Participants� also� described� the� confusion�they�experienced�between� the� supportive� elements�of� their�role�and�the�perceived�negative�aspects,�notably�that�of�being�an� assessor,� which� has� also� been� documented� by� Bray� and�Nettleton� (2007).�This,� it� could� be� argued,� was� predicated�on� mentors� having� a� narrow� understanding� of� assessment�and�its�role�in�student�development,�perceiving�it�mainly�as�a�punitive�process.�

Some�participants�acknowledged�their�tendency�to�make�a�subjective�assessment�of�students�early�in�the�placement�and�this�introduces�an�element�of�doubt�into�assessment�decisions�placed�at�the�end�of�periods�of�practice.�It�is�imperative�that�mentors�and�sign-off�mentors,�as�assessors�of�students�in�practice,�make�valid�and�reliable�assessments�based�on� the�whole�placement.�To� enable� this� they� require� an� accurate� knowledge� of� the�student’s� curriculum� and,� perhaps� more� importantly,� current�assessment�strategies,�which�may�differ�significantly�from�their�own�personal�experience�of�nurse�education.�In�addition,�this�study� suggests� that� mentors� should� explore� how� influential�student�attributes�such�as�initiative�in�practice,�perceived�level�of�interest�and�previous�experience�contribute�to�their�overall�assessment�(Duffy,�2003;�O’Callaghan�and�Slevin,�2003;�Halin�and�Danielson,�2010).

Only� one� participant� in� the� study� reported� having�experience� in� managing� a� failing� student.�The� importance�of�mentor�preparation�and�training,�particularly�in�managing�a� failing� student� was� highlighted� by� Duffy� (2003)� and�although� this� is� now� included� in� mentorship� preparation�programmes,� many� existing� mentors� may� not� have� had�formal� preparation� or� experience� of� managing� a� failing�student� in�practice�because�of� the�capacity�to�map�previous�experience.�Duffy� (2003)� identified� that�mentors�who�were�not�adequately�prepared�lacked�confidence�in�assessment�and�could� be�more� inclined� to� give� students� the� benefit� of� the�doubt.�The� future� training� and� support�of� existing�mentors�needs�to�prepare�them�for�their�role�in�a�fail�scenario.�Duffy�(2003)� also� highlighted� that� time� constraints� and� service�pressures�contributed�to�the�‘benefit�of�the�doubt’.�The�need�for�mentors�to�have�time�with�students�to�fulfil�their�role�is�well�documented�and� is� a�key� recommendation� in�a� recent�independent�review�of�nurse�education�(Bradbury–Jones�et�al,�2007;�Lauder�et� al,�2008;�Beskine,�2009;�Willis�Commission�on�Nursing�Education,�2012).

Hunt� et� al� (2012)� identified� that� failure� rates� for� theory�modules�exceeded�practice-based�assessments�by�five�to�one.�This� raises� the� question:� why?� Consequently,� relatively� few�mentors�have�had�experience�of�dealing�with�a�fail�scenario.�Rather� than� this� being� a� matter� of� luck,� the� assessment�tools�available� to�mentors�have�been�questioned�along�with�the� concept� of� clinical� competence� assessment� as� a� whole�(Norman�et�al,�2002;�Watson,�2002).�Norman�et�al�(2002)�in�a�study�to�test�the�validity�and�reliability�of�selected�nursing�and�midwifery�competence�assessment�tools,�identified�that�very�few� students� fail� practice-based� assessments.�This� calls� into�question�the�validity�and�reliability�of�assessments�by�mentors�and�more�work� is� required� to� ensure� that� this� is� addressed.�Yanhua�and�Watson�(2011)�found�in�a�literature�review�that,�

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although� a� coherent� definition� of� competence� did� seem�to� be� emerging,� there�was� still� a�way� to� go�with� regard� to�consistency�in�definition�of�the�concept�and�its�validity�and�recommended�an�international�effort�to�address�this.

LimitationsOnly�mentors�and�sign-off�mentors�for�adult�pre-registration�nursing�students�were�included�in�this�study.�Although�some�of�the�findings�may�provide�insight�that�may�be�transferable,�it�is�likely�there�will�be�specific�issues�for�mentors�and�sign-off� mentors� in� the� other� fields� of� nursing� and� midwifery.�Furthermore� as� only� mentors� with� recent� experience� of�assessing� a� student� were� purposively� selected� for� the� study,�mentors�who�have�not�assessed�a�student�in�the�last�year�may�have�additional�issues�not�explored�here.

ConclusionThis� study� suggests� that� the� standards� to� support� learning�and� assessment� in� practice� (NMC,� 2008a)� have� increased�awareness�among�participants�of�their�role�and�accountability�for� assessment.� However,� it� is� of� concern� that� participants�perceived�the�assessment�of�students�as�a�new�role�and�one�in�which�they�were�not�practiced.�Participants�sometimes�failed�to� move� forward� and� were� judging� current� students� while�referring� to� the�curricula� that�governed� their�own� training.�Assessment� that� was� described� as� intuitive� was� present,�which� could� be� interpreted� as� evidence� of� the� application�of�experience�but�caution�is�advised�that�this�is�not�used�to�obscure� judgmental� attitudes.� Participants� felt� that� student�performance� was� inherent� in� the� person� and� regarded�students� as�‘good�ones’� or�‘bad� ones’.�The� findings�were� all�contextualised�in�the�milieu�of�practice�that�was�represented�by� pressure� of� time.�This� study� suggests� that� evaluation� of�update�activities�available�for�mentors�is�required�to�determine�if�they�address�the�issues�identified,�with�a�particular�emphasis�on�the�validity�of�assessment�tools�and�decisions.�� BJN

Conflict of interest: none

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KEY POINTS

nMentors are aware of their role and accountability for the assessment of students in practice

nMany mentors lacked experience and confidence in the assessment of students in practice

nThis study found that mentors felt that failing a student was punitive and thus may have avoided it

nMentors need support in practice to discuss the validity and reliability of their assessment decisions

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