Mentor Impact on Student Nurse Experience

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