Mentorship part 2: assessing preregistration student nurses James Jude Vinales
The role of the mentor has been evolving since it was introduced following Project 2000 in 1986. The role that mentors of pre-registration nursing students are tasked with on a daily basis is crucial to the overall assessment of the student nurse. Assessment and the importance of the mentor’s role when assessing the students in practice will be discussed in this article. The reliability and validity of assessment and the mentor’s responsibility in assessing the competencies in the learning environment is explored, together with the roles of formative and summative assessment. The introduction of the sign-off mentor and the ongoing achievement record as part of the assessment process will also be explored. It can be argued that mentoring is not a simple task, and that there are a number of barriers to successful assessment. Key words: Assessment ■ Mentors ■ Nursing students ■ Nursing education ■ Clinical competence
T
he role of the mentor has been a major development in the assessment of student nurses in practice since the introduction of Project 2000 in 1989 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), 1986). Before Project 2000, measuring a student’s performance took the form of a task-orientated assessment, based on analysis and nursing procedures, performed by nurse teachers within the learning environment. Clinical nurses were not involved in the assessment process while in the learning environment (traditionally these were restricted to wards only). However, since Project 2000 (UKCC, 1986) nurses in practice have been educated to become mentors. Various issues arose from this shift from the nurse teacher to the mentors in the clinical setting. Not only were the nurses in practice expected to mentor students on the pre-registration courses (Nursing and Midwifery Council (NMC), 2008a; Department of Health (DH), 1999), the James Jude Vinales, Principal Lecturer in Nursing, School of Health Studies, Gibraltar Health Authority, Gibraltar Accepted for publication: January 2015
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NMC also introduced continuous assessment in practice. This caused confusion about the role of the mentor and what was expected of him or her (Philips et al, 2000; Duffy, 2003), as UK nurse education changed from being ward-based assessment (see Box 1) to Project 2000 and the continuous assessment model that remains the current model in nurse education today (NMC, 2010).
The apprentice model The apprentice model of student nurse training exposed learners to four assessments during their 3-year programme, with a written examination in their final year. The apprentice model was hospital-based, with the hospital employing the student, and nurse teachers conducting the clinical assessments. The relationship between the traditional schools of nursing and the hospital wards was very close, with students training within the hospitals themselves. Student nurses were employed where they trained, with the hospital providing the placement areas.The apprenticeship model provided competence through on-the-job training (Pratt et al, 2001). Furthermore, the apprenticeship model assumed that the wards were staffed by confident, motivated nurses who had time to pass their skills on to students (Glen and Parker, 2003), however, this was not always the case, as identified by Orton (1981).
The introduction of continuous assessment in clinical areas meant that students were constantly assessed in practice. Continuous assessment allows students to gather information in relation to specific competencies set in their learning documents (Gopee, 2008). It also ensures that student performance is assessed in real-life scenarios (Welsh and Swann, 2000). Continuous assessment potentially enables mentors in the clinical setting to assess learners’ ability on an ongoing basis, taking into account whether students are able to replicate these nursing skills.
Reliability and validity Reliability and validity of assessment is crucial in the overall assessment of clinical practice, especially if all students are to be assessed by different mentors. Reliability is often defined as whether a result can be consistently reproduced (Nicklin and Kenworthy, 2000), whether what is being measured can yield similar results when replicated (Hughes and Quinn, 2013) and an assessment that is consistent (Polit and Beck, 2004). An example of this would be if two independent mentors assessing a student came to the same conclusion on the student’s ability or competence after observing the student perform a skill in practice or their behaviour. Validity is often linked to reliability, and this is whether the assessment has measured what it is designed to measure (Nicklin and Kenworthy, 2000). Achieving both validity and reliability are essential in effective assessment (Rowntree, 1987). Mentors should be aware of these two important terms in the assessment of students in clinical practice. Mentors need to be able to assess the validity of practice and whether the student is able to reliably replicate the skill in practice. Rowntree (1987) identified that assessments made over a period of time, either by the same assessor/assessors, tend to be more reliable. However, this also depends on how mentors measure and interpret the nursing skills they are observing, and whether the mentors are subjective and reliable themselves in measuring a nursing student’s performances while on placement (Cassidy, 2009). Hence
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Abstract
Continuous assessment
British Journal of Nursing, 2015, Vol 24, No 3
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MENTORSHIP there should be parity of assessment throughout. This highlights the difficulty that mentors face in the learning environment when assessing student nurses, as a student for one mentor might not be a weak student, however, the same student might be deemed weak by another mentor. Norman et al (2002) concluded that a multi-method approach for assessing clinical competence is recommended as no single method of assessment is ideal. Having a multimethod approach will potentially reduce objectivity by allowing mentors to assess using various assessment strategies.The NMC (2008a) also encourages mentors to use a wide range of assessment methods to assess students in practice. Furthermore, using a range of assessment methods will ensure reliability in the assessment and consistency. A range of assessment methods as listed in Box 2. Although it is the mentor’s responsibility to assess students in the learning environment and decide on various methods of assessment, it is also important that other experienced practitioners are involved in the assessment of pre-registration students, as this will limit bias and can ensure transparency and fairness across assessments.
What is competence? Competence in nursing practice is paramount, as nursing standards and practice need to be delivered to a high level, safely and competently (Hengstberger-Sims et al, 2008; NMC, 2008b). Competence in nursing practice and performance includes looking at attitudes and ability and incorporates a combination of knowledge and skills (Cowin et al, 2008). The NMC describe competence as:
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‘The combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and effective nursing practice and interventions.’ (NMC, 2010: 11) The mentors in practice assess competence of the student and effectively sign off the student as competent (Butler et al, 2011) if the student performs to the required standard. However, different mentors evaluate competence in nursing students differently (Calman et al, 2002; Cassidy, 2009). Mentors assess a comprehensive range of nursing activities (Hengstberger-Sims et al, 2008). The best way to assess competence of nurses is continuous assessment (Axley, 2008). Mentors assess the student’s ability to perform tasks and skills within their learning environment. This is linked to the skills in the Essential Skills Clusters set out by the NMC in its Standards
British Journal of Nursing, 2015, Vol 24, No 3
Box 1. Four ward-based summative clinical assessments
n Medicine round n Aseptic technique n Total patient care for a day n Taking charge of the ward for a day Box 2. The following methods of assessment have been recommended by NHS Education for Scotland (2013)
n Direct observation of student performance n Working alongside the student n Reflective discussion n Oral presentation n Clinical simulation/objective structured clinical examination (OSCEs) n Reflective writing n Self- and peer assessment n Portfolio of evidence n Feedback from mentors and other health professionals
for pre-registration nursing education (2010). In it, the NMC sets out minimum requirements that students must meet in order to progress.
Formative assessment The practice assessment documents encourage mentors and students to have initial, interim and final interviews as an essential requirement in identifying areas of further development (NMC, 2008a). The initial and interim interviews are the basis for formative assessments, allowing student and mentor to identify learning opportunities for the placement (Duffy and Hardicre, 2007). The importance of formative assessment before the summative assessment is well documented in the literature (Rowntree, 1987; Welsh and Swan, 2002; Stuart, 2007; Gopee, 2008; Hughes and Quinn, 2013). It is during this stage that students are assessed in their clinical placement, and this allows the mentor to gauge the development and improvement in the student’s nursing skills (Stuart, 2007; Gopee, 2008). Formative assessment also enables the mentor and student to discuss the student’s performance and give feedback while in the clinical environment. The interim interview is therefore a vital element of the mentor’s role, allowing him or her to recognise and work with weaker students and identify how to best meet the learning outcomes of the placement, or to offer further developmental opportunities for those performing at an enhanced level. The interim interview was designed to help students develop their repertoire of skills, behaviour and attitudes in the realworld environment. It is during the formative stage of assessment that mentors need to plan and timetable progress (Phillips et al,
2000). This stage enables mentors to identify strengths and weaknesses. Those who are not progressing well or are weak and are identified on placement would therefore be required to take appropriate action to rectify and work on their weakness. Those who are progressing well should still be encouraged and motivated to further improve their care. The interim interview is important as it could be the difference between a student passing or failing their placement. Duffy (2003) points out that it is important that weak students are identified as early on in the placement as possible.The interim interview allows mentors to take appropriate action to support students once any problems are identified, rather than giving him or her the benefit of the doubt and passing them in the hope that they will improve. If weaker students are not identified, this could potentially affect the nursing profession, as more student nurses may register who are not fit to practise.
The final interview (summative assessment) The summative assessment indicates whether the learning outcomes of practice competencies have been met. It takes place at the end of the nursing education programme (Hughes and Quinn, 2013). In nursing, the summative assessments are carried out at the end of clinical placements, as well as following academic assessments subsequent to modules delivered in the approved educational institutions (AEIs). The mentor’s responsibility is to assess practice summatively, following a period of working with the student in the learning environment, verifying his or her progress and whether learning competencies and objectives have been met.
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n Leaving things to the last minute/poor time management n Difficulty with integration of theory and practice, or ineffective application n Personality problems/clashes n Problems of organisation in the practice setting n Lack of time n Student disagrees with mentor n Attitude problems (student’s or mentor’s) n Structure of learning programmes (e.g. placement is too short) n Mentor accountable and responsible for how student performs clinical interventions n Inconsistency of student performance n Student absence n Low mentor morale n Mentor changes or absence n Student appears indifferent n Student’s level of knowledge n Lack of resources n Non-cooperation or refusal of consent by the patient or service user
What is the sign-off mentor? The introduction by the NMC (2006; 2008a) of the ‘sign-off mentor’, specifies that as of September 2007, a sign-off mentor is required to make the final judgement of safe and effective practice linked to the NMC standards and proficiencies. Only once a student has been signed off will he or she be able to register with the NMC. A sign-off mentor is a mentor who has met: ‘Specified criteria in order to be able to sign off a student’s practice proficiency at the end of an NMC approved programme.’ (NMC, 2008a: 58) This means that the sign-off mentor must make the final judgement of the students practice competence after the 3-year preregistration programme. Although the AEIs provide a good character reference on completion of the pre-registration programme, the sign-off mentor provides the judgement on whether the student has met the practical element to be admitted onto the professional register. This demonstrates the vital role that sign-off mentors play in the assessment of student nurses. They also confirm that student nurses have satisfactorily met the requirements for the ‘ongoing achievement record’ (OAR). In order to become a sign-off mentor, the NMC (2008a) stipulates that the mentor must meet certain NMC criteria, and must have been supervised by a sign-off mentor on a minimum of three occasions, assessing students competencies on a student’s final placement.
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What is the ongoing achievement record? The NMC introduced the concept of an OAR, as a means of: ‘Sharing of personal information necessary to maintain continuity of assessment and to ensure safe and effective practice.’ (NMC, 2008a: 82) The purpose of the OAR is for mentors to document their comments about students and their progress to enable a judgement to be made regarding the student from placement to placement. The OAR is described as a: ‘Vehicle for sharing information regarding student progress in practice settings.’ (NMC, 2007: 3) The idea is that a mentor, at the beginning of working with a new student in the clinical setting, can discuss areas for development. The OAR presents an overall picture of the student nurse’s achievements on the programme after clinical placements, and requirements at progression points and at the end of the programme (NMC, 2010). Furthermore, the OAR and the effectiveness of the OAR are fundamental in maintaining continuity of clinical assessment in pre-registration nursing programmes (NMC, 2010). The OAR enables the mentor to document and evaluate the student’s progress at least at the interim meetings (formatively) and at the end of a placement (summatively), where strengths and any issues for development are addressed and documented for future placements and mentors. This allows the student to progress with any concern or issue highlighted during their pre-registration
programme. For example, for some students this may be lack of confidence, especially in their first placement. If the mentor in the second placement is made aware of the student’s lack of confidence in the OAR and the previous mentor’s documentation, the secondplacement mentor can help build and develop the student’s confidence. It is essential for mentors to familiarise themselves with learning objectives and the nursing curriculum that are relevant to the learning environment and the student’s level of performance.
What are the challenges associated with assessing? Challenges associated with assessing student nurses in the learning environment are long-standing (Nolan et al, 2002). Clinical assessment is complex and difficulties can arise when ensuring that it is objectively managed by mentors in practice (Price, 2007). Dolan (2003) identified that some mentors lacked motivation and had insufficient time to dedicate to assessment of student practice. Evidence suggests that mentors are inconsistent in assessing (McCarthy and Murphy, 2008; Fitzgerald et al, 2010) and hesitant when student performance is unacceptable (Donaldson and Carter, 2005). The assessment process is a crucial part of the mentor’s role; however, concerns about assessment tools exist (Duffy, 2003) and unrealistic expectations of the tools (Ousey and Gallagher, 2007). Shortages of qualified nursing staff in clinical areas have resulted in non-qualified nursing staff working with students, as in the UK there is a growing dependency on healthcare assistants (HCAs) within practice (Gillen and Graffin, 2010). There is a potential that, through having more HCAs in the learning environment, this may impact on students and student learning, as students are more likely to work with and be supervised by unqualified HCAs. Mentors need to be aware of potential barriers to effective assessment (NHS Education for Scotland, 2007).These potential barriers may hinder assessment and need to be minimised and eradicated. This means that the student will be given fair judgement in practice. With barriers in place, the mentor and student may feel they are at a disadvantage. Gopee (2008) highlighted a list of barriers to assessment following the delivery of a mentoring course, as shown in Box 3. If the mentor feels that there are barriers in place that will impede assessment, he or she should inform the ward manager in the learning environment to make alternative arrangements for the assessment, as a student must always be given a fair assessment.
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Box 3. Some potential problems with assessment
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MENTORSHIP Having enough time for students Time constraints in teaching clinical skills and clinical assessments on the ward by senior nurses has been recognised as far back as 1981 by Orton, who identified that pressures from the ward sister’s job role inevitably made them prioritise certain tasks over others. Time constraints are a major issue in mentorship and assessment and there is much literature over the years to support the use of protected time to support learners in practice (Philips et al, 2000; Duffy, 2003; Royal College of Nursing, 2007; 2012; NMC, 2008a). Orton (1981) highlighted that ward sisters might not feel confident in their teaching ability and that they were therefore unlikely to engage with students in the learning environment. This was in 1981, when the nurse-teacher supported nursing students on the apprentice model of nurse education with summative assessments. However, this was also identified by Duffy in 2003 as being a factor in nursing students slipping through the net as mentors did not feel confident enough in their own ability to summatively assess learners in practice. Price (2007) identified that when it comes to assessments in busy learning environments, clinicians struggle to find adequate time and, as a result, often question their interpretation of the assessment requirements. Furthermore, Gopee (2008) asserts that some mentors are willing to confirm that student nurses have passed their practice placement without sufficient evidence of competence.
Conclusion
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Mentors in clinical practice are crucial in pre-registration nursing programmes, as they assess student competence and fitness to practise. The assessment aspect of the mentor’s role, it can be argued, is not easy. Mentors need to recognise that the student nurse will be on a placement within the mentor’s learning environment, as a novice practitioner. Therefore, he or she will be working with experienced practitioners like the mentors to guide and help develop their skills, knowledge and understand of nursing in the real world. A mentor’s assessment is therefore salient in the standards of new registrants who will want to register with the NMC. Thus, mentors, using their ability to assess pre-registration nursing students, will BJN help to safeguard the profession. Conflict of interest: none Axley L (2008) Competency: a concept analysis. Nursing Forum 43 (4), 214–222 Butler MP, Cassidy I, Quillinan B et al (2011) Competency
British Journal of Nursing, 2015, Vol 24, No 3
KEY POINTS n The introduction of continuous assessment in clinical areas means that students are continually assessed in practice n The reliability and validity of assessment in clinical practice is essential, especially if all students are to be assessed by different mentors n Using a range of assessment methods will help to ensure reliability in the assessment and consistency n Mentors assess student ability to perform tasks and skills within the clinical learning environment n Initial, interim and final interviews are essential requirements in identifying areas of development n The sign-off mentor is required to make the final judgement of safe and effective practise linked to the Nursing and Midwifery Council standards and competencies assessment methods—tool and processes: a survey of nurse preceptors in Ireland. Nurse Educ Pract 11(5): 298–303. doi: 10.1016/j.nepr.2011.01.006 Calman L, Watson R, Norman I, Redfern S, Murrells T (2002) Assessing practice of student nurses: methods, preparation of assessors and student views. J Adv Nurs 38(5): 516–23 Cassidy S (2009) Subjectivity and the valid assessment of pre-registration student nurse clinical learning outcomes: implications for mentors. Nurse Educ Today 29(1): 33–9. doi: 10.1016/j.nedt.2008.06.006 Cowin LS, Hengstberger-Sims C, Eagar SC et al (2008) Competency measurements: testing convergent validity for two measures. J Adv Nurs 64(3): 272–7. doi: 10.1111/j.1365-2648.2008.04774.x Department of Health (1999) Making a Difference. http:// tinyurl.com/l735ooz (accessed 20 January 2015) Dolan G (2003) Assessing student nurse clinical competency: will we ever get it right? J Clin Nurs 12(1): 132–41 Donaldson JH, Carter D (2005) The value of role modelling: Perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ Pract 5(6): 353–9. doi: 10.1016/j.nepr.2005.05.006 Duffy K (2003) Failing Students: A qualitative study of factors that influence the decisions regarding assessment of students’ competence in practice. http://tinyurl. com/36r8d8d (accessed 20 January 2015) Duffy K, Hardicre J (2007) Supporting failing students in practice. 1: Assessment. Nurs Times 103(47): 28–9 Fitzgerald M, Gibson F, Gunn K (2010) Contemporary issues relating to assessment of pre-registration nursing students in practice. Nurse Educ Pract 10(3): 158–63. doi: 10.1016/j.nepr.2009.06.001 Glen S, Parker P (2003) Supporting Learning in Nursing Practice: A Guide for Practitioners. Palgrave Macmillan, London Gopee N (2008) Mentoring and Supervision in Healthcare. Sage, London Hengstberger-Sims C, Cowin LS, Eagar SC, Gregory L, Andrew S, Rolley J (2008) Relating new graduate nurse competence to frequency of use. Collegian 15(2): 69–76 Hughes SJ, Quinn FM (2013) Quinn’s Principles and practice of nurse education 6th edn. Nelson Thornes, Cheltenham McCarthy B, Murphy S (2008) Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies? Nurse Educ Today 28(3): 301–13. doi: 10.1016/j.nedt.2007.06.002 NHS Education for Scotland (2013) National Approach to Mentor Preparation for Nurses and Midwives Core Curriculum Framework 2nd edn. http://tinyurl.com/ qcrx2s7 (accessed 20 January 2015) Nicklin PJ, Kenworthy N (2000) Teaching and Assessing in Nursing Practice: An Experiential Approach. Baillière Tindall, London Nolan M, Davies S, Brown J, Keady J, Nolan J (2002) Longitudinal study of the effectiveness of educational preparation to meet the needs of older people and their carers: The Advancing Gerontological Education in Nursing (AGEIN) Project. http://tinyurl.com/agrt7mc (accessed 22 January 2015) Norman IJ, Watson R, Murrells T, Calman L, Redfern S
(2002) The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students. Int J Nurs Stud 39(2): 133–45 Nursing and Midwifery Council (2006) Standards to Support Learning and Assessment in Practice: NMC standards for mentors, practice teachers and teachers. NMC, London Nursing and Midwifery Council (2007) Ensuring continuity of practice assessment through the ongoing achievement records. http://tinyurl.com/pdv9zhl (accessed 28 January 2015) Nursing and Midwifery Council (2008a) Standards to support learning and assessment in practice: NMC standards for mentors, practice teachers and teachers. http://tinyurl.com/ d3sw5ox (accessed 21 January 2015) Nursing and Midwifery Council (2008b) The Code: Standards of conduct, performance and ethics for nurses and midwives. http://tinyurl.com/5u7d24n (accessed 20 January 2015) Nursing and Midwifery Council (2010) Standards for preregistration nursing education. http://tinyurl.com/6f443py (accessed 20 January 2015) Orton HD (1981)Ward learning climate: a study of the role of the ward sister in relation to student nurse learning on the ward. Royal College of Nursing of the United Kingdom, London Ousey K, Gallagher P (2007) The theory-practice relationship in nursing: a debate. Nurse Educ Pract 7(4): 199–205. doi: 10.1016/j.nepr.2007.02.001 Philips Schostak J, Tyler J (2000) Practice and Assessment in Nursing and Midwifery: doing it for real (researching professional education. English National Board for Nursing, Midwifery and Health Visiting, London Polit, DF, Beck, CT (2004) Nursing Research Principles and Methods 7th edn Lippincott Williams & Wilkins, Philadelphia Pratt DD, Arseneau R, Collins JB (2001) Reconsidering ‘good teaching’ across the continuum of medical education. J Contin Educ Health Prof 21(2): 70–81. doi: 10.1002/chp.1340210203 Price B (2007) Practice-based assessment: strategies for mentors. Nurs Stand 21(36): 49–56. doi: 10.7748/ ns2007.05.21.36.49.c4629 Royal College of Nursing (2012) Quality with compassion: the future of nursing education. Report of the Willis Commission 2012. http://tinyurl.com/cvugp8t (accessed 20 January 2015) Rowntree D (1987) Assessing Students: How shall we know them? Routledge, London Stuart CC (2007) Assessment, supervision and support in clinical practice: A guide for nurses, midwives and other health professionals 2nd edn. Churchill Livingstone, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1986) Project 2000:A New Preparation for Practice. UKCC, London United Kingdom Central Council or Nursing, Midwifery and Health Visiting (1999) Fitness for Practice. Summary. http://tinyurl.com/kscdbzw (accessed 20 January 2015) Welsh I, Swann C (2002) Partners in Learning: a guide to support and assessment in nurse education. Radcliffe Medical Press, Oxford
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The role of the mentor has been evolving since it was introduced following Project 2000 in 1986. The role that mentors of pre-registration nursing students are tasked with on a daily basis is crucial to the overall assessment of the student nurse. Assessment and the importance of the mentor’s role when assessing the students in practice will be discussed in this article. The reliability and validity of assessment and the mentor’s responsibility in assessing the competencies in the learning environment is explored, together with the roles of formative and summative assessment. The introduction of the sign-off mentor and the ongoing achievement record as part of the assessment process will also be explored. It can be argued that mentoring is not a simple task, and that there are a number of barriers to successful assessment. Key words: Assessment ■ Mentors ■ Nursing students ■ Nursing education ■ Clinical competence
T
he role of the mentor has been a major development in the assessment of student nurses in practice since the introduction of Project 2000 in 1989 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), 1986). Before Project 2000, measuring a student’s performance took the form of a task-orientated assessment, based on analysis and nursing procedures, performed by nurse teachers within the learning environment. Clinical nurses were not involved in the assessment process while in the learning environment (traditionally these were restricted to wards only). However, since Project 2000 (UKCC, 1986) nurses in practice have been educated to become mentors. Various issues arose from this shift from the nurse teacher to the mentors in the clinical setting. Not only were the nurses in practice expected to mentor students on the pre-registration courses (Nursing and Midwifery Council (NMC), 2008a; Department of Health (DH), 1999), the James Jude Vinales, Principal Lecturer in Nursing, School of Health Studies, Gibraltar Health Authority, Gibraltar Accepted for publication: January 2015
174
NMC also introduced continuous assessment in practice. This caused confusion about the role of the mentor and what was expected of him or her (Philips et al, 2000; Duffy, 2003), as UK nurse education changed from being ward-based assessment (see Box 1) to Project 2000 and the continuous assessment model that remains the current model in nurse education today (NMC, 2010).
The apprentice model The apprentice model of student nurse training exposed learners to four assessments during their 3-year programme, with a written examination in their final year. The apprentice model was hospital-based, with the hospital employing the student, and nurse teachers conducting the clinical assessments. The relationship between the traditional schools of nursing and the hospital wards was very close, with students training within the hospitals themselves. Student nurses were employed where they trained, with the hospital providing the placement areas.The apprenticeship model provided competence through on-the-job training (Pratt et al, 2001). Furthermore, the apprenticeship model assumed that the wards were staffed by confident, motivated nurses who had time to pass their skills on to students (Glen and Parker, 2003), however, this was not always the case, as identified by Orton (1981).
The introduction of continuous assessment in clinical areas meant that students were constantly assessed in practice. Continuous assessment allows students to gather information in relation to specific competencies set in their learning documents (Gopee, 2008). It also ensures that student performance is assessed in real-life scenarios (Welsh and Swann, 2000). Continuous assessment potentially enables mentors in the clinical setting to assess learners’ ability on an ongoing basis, taking into account whether students are able to replicate these nursing skills.
Reliability and validity Reliability and validity of assessment is crucial in the overall assessment of clinical practice, especially if all students are to be assessed by different mentors. Reliability is often defined as whether a result can be consistently reproduced (Nicklin and Kenworthy, 2000), whether what is being measured can yield similar results when replicated (Hughes and Quinn, 2013) and an assessment that is consistent (Polit and Beck, 2004). An example of this would be if two independent mentors assessing a student came to the same conclusion on the student’s ability or competence after observing the student perform a skill in practice or their behaviour. Validity is often linked to reliability, and this is whether the assessment has measured what it is designed to measure (Nicklin and Kenworthy, 2000). Achieving both validity and reliability are essential in effective assessment (Rowntree, 1987). Mentors should be aware of these two important terms in the assessment of students in clinical practice. Mentors need to be able to assess the validity of practice and whether the student is able to reliably replicate the skill in practice. Rowntree (1987) identified that assessments made over a period of time, either by the same assessor/assessors, tend to be more reliable. However, this also depends on how mentors measure and interpret the nursing skills they are observing, and whether the mentors are subjective and reliable themselves in measuring a nursing student’s performances while on placement (Cassidy, 2009). Hence
© 2015 MA Healthcare Ltd
Abstract
Continuous assessment
British Journal of Nursing, 2015, Vol 24, No 3
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 16, 2015. For personal use only. No other uses without permission. . All rights reserved.
MENTORSHIP there should be parity of assessment throughout. This highlights the difficulty that mentors face in the learning environment when assessing student nurses, as a student for one mentor might not be a weak student, however, the same student might be deemed weak by another mentor. Norman et al (2002) concluded that a multi-method approach for assessing clinical competence is recommended as no single method of assessment is ideal. Having a multimethod approach will potentially reduce objectivity by allowing mentors to assess using various assessment strategies.The NMC (2008a) also encourages mentors to use a wide range of assessment methods to assess students in practice. Furthermore, using a range of assessment methods will ensure reliability in the assessment and consistency. A range of assessment methods as listed in Box 2. Although it is the mentor’s responsibility to assess students in the learning environment and decide on various methods of assessment, it is also important that other experienced practitioners are involved in the assessment of pre-registration students, as this will limit bias and can ensure transparency and fairness across assessments.
What is competence? Competence in nursing practice is paramount, as nursing standards and practice need to be delivered to a high level, safely and competently (Hengstberger-Sims et al, 2008; NMC, 2008b). Competence in nursing practice and performance includes looking at attitudes and ability and incorporates a combination of knowledge and skills (Cowin et al, 2008). The NMC describe competence as:
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‘The combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and effective nursing practice and interventions.’ (NMC, 2010: 11) The mentors in practice assess competence of the student and effectively sign off the student as competent (Butler et al, 2011) if the student performs to the required standard. However, different mentors evaluate competence in nursing students differently (Calman et al, 2002; Cassidy, 2009). Mentors assess a comprehensive range of nursing activities (Hengstberger-Sims et al, 2008). The best way to assess competence of nurses is continuous assessment (Axley, 2008). Mentors assess the student’s ability to perform tasks and skills within their learning environment. This is linked to the skills in the Essential Skills Clusters set out by the NMC in its Standards
British Journal of Nursing, 2015, Vol 24, No 3
Box 1. Four ward-based summative clinical assessments
n Medicine round n Aseptic technique n Total patient care for a day n Taking charge of the ward for a day Box 2. The following methods of assessment have been recommended by NHS Education for Scotland (2013)
n Direct observation of student performance n Working alongside the student n Reflective discussion n Oral presentation n Clinical simulation/objective structured clinical examination (OSCEs) n Reflective writing n Self- and peer assessment n Portfolio of evidence n Feedback from mentors and other health professionals
for pre-registration nursing education (2010). In it, the NMC sets out minimum requirements that students must meet in order to progress.
Formative assessment The practice assessment documents encourage mentors and students to have initial, interim and final interviews as an essential requirement in identifying areas of further development (NMC, 2008a). The initial and interim interviews are the basis for formative assessments, allowing student and mentor to identify learning opportunities for the placement (Duffy and Hardicre, 2007). The importance of formative assessment before the summative assessment is well documented in the literature (Rowntree, 1987; Welsh and Swan, 2002; Stuart, 2007; Gopee, 2008; Hughes and Quinn, 2013). It is during this stage that students are assessed in their clinical placement, and this allows the mentor to gauge the development and improvement in the student’s nursing skills (Stuart, 2007; Gopee, 2008). Formative assessment also enables the mentor and student to discuss the student’s performance and give feedback while in the clinical environment. The interim interview is therefore a vital element of the mentor’s role, allowing him or her to recognise and work with weaker students and identify how to best meet the learning outcomes of the placement, or to offer further developmental opportunities for those performing at an enhanced level. The interim interview was designed to help students develop their repertoire of skills, behaviour and attitudes in the realworld environment. It is during the formative stage of assessment that mentors need to plan and timetable progress (Phillips et al,
2000). This stage enables mentors to identify strengths and weaknesses. Those who are not progressing well or are weak and are identified on placement would therefore be required to take appropriate action to rectify and work on their weakness. Those who are progressing well should still be encouraged and motivated to further improve their care. The interim interview is important as it could be the difference between a student passing or failing their placement. Duffy (2003) points out that it is important that weak students are identified as early on in the placement as possible.The interim interview allows mentors to take appropriate action to support students once any problems are identified, rather than giving him or her the benefit of the doubt and passing them in the hope that they will improve. If weaker students are not identified, this could potentially affect the nursing profession, as more student nurses may register who are not fit to practise.
The final interview (summative assessment) The summative assessment indicates whether the learning outcomes of practice competencies have been met. It takes place at the end of the nursing education programme (Hughes and Quinn, 2013). In nursing, the summative assessments are carried out at the end of clinical placements, as well as following academic assessments subsequent to modules delivered in the approved educational institutions (AEIs). The mentor’s responsibility is to assess practice summatively, following a period of working with the student in the learning environment, verifying his or her progress and whether learning competencies and objectives have been met.
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n Leaving things to the last minute/poor time management n Difficulty with integration of theory and practice, or ineffective application n Personality problems/clashes n Problems of organisation in the practice setting n Lack of time n Student disagrees with mentor n Attitude problems (student’s or mentor’s) n Structure of learning programmes (e.g. placement is too short) n Mentor accountable and responsible for how student performs clinical interventions n Inconsistency of student performance n Student absence n Low mentor morale n Mentor changes or absence n Student appears indifferent n Student’s level of knowledge n Lack of resources n Non-cooperation or refusal of consent by the patient or service user
What is the sign-off mentor? The introduction by the NMC (2006; 2008a) of the ‘sign-off mentor’, specifies that as of September 2007, a sign-off mentor is required to make the final judgement of safe and effective practice linked to the NMC standards and proficiencies. Only once a student has been signed off will he or she be able to register with the NMC. A sign-off mentor is a mentor who has met: ‘Specified criteria in order to be able to sign off a student’s practice proficiency at the end of an NMC approved programme.’ (NMC, 2008a: 58) This means that the sign-off mentor must make the final judgement of the students practice competence after the 3-year preregistration programme. Although the AEIs provide a good character reference on completion of the pre-registration programme, the sign-off mentor provides the judgement on whether the student has met the practical element to be admitted onto the professional register. This demonstrates the vital role that sign-off mentors play in the assessment of student nurses. They also confirm that student nurses have satisfactorily met the requirements for the ‘ongoing achievement record’ (OAR). In order to become a sign-off mentor, the NMC (2008a) stipulates that the mentor must meet certain NMC criteria, and must have been supervised by a sign-off mentor on a minimum of three occasions, assessing students competencies on a student’s final placement.
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What is the ongoing achievement record? The NMC introduced the concept of an OAR, as a means of: ‘Sharing of personal information necessary to maintain continuity of assessment and to ensure safe and effective practice.’ (NMC, 2008a: 82) The purpose of the OAR is for mentors to document their comments about students and their progress to enable a judgement to be made regarding the student from placement to placement. The OAR is described as a: ‘Vehicle for sharing information regarding student progress in practice settings.’ (NMC, 2007: 3) The idea is that a mentor, at the beginning of working with a new student in the clinical setting, can discuss areas for development. The OAR presents an overall picture of the student nurse’s achievements on the programme after clinical placements, and requirements at progression points and at the end of the programme (NMC, 2010). Furthermore, the OAR and the effectiveness of the OAR are fundamental in maintaining continuity of clinical assessment in pre-registration nursing programmes (NMC, 2010). The OAR enables the mentor to document and evaluate the student’s progress at least at the interim meetings (formatively) and at the end of a placement (summatively), where strengths and any issues for development are addressed and documented for future placements and mentors. This allows the student to progress with any concern or issue highlighted during their pre-registration
programme. For example, for some students this may be lack of confidence, especially in their first placement. If the mentor in the second placement is made aware of the student’s lack of confidence in the OAR and the previous mentor’s documentation, the secondplacement mentor can help build and develop the student’s confidence. It is essential for mentors to familiarise themselves with learning objectives and the nursing curriculum that are relevant to the learning environment and the student’s level of performance.
What are the challenges associated with assessing? Challenges associated with assessing student nurses in the learning environment are long-standing (Nolan et al, 2002). Clinical assessment is complex and difficulties can arise when ensuring that it is objectively managed by mentors in practice (Price, 2007). Dolan (2003) identified that some mentors lacked motivation and had insufficient time to dedicate to assessment of student practice. Evidence suggests that mentors are inconsistent in assessing (McCarthy and Murphy, 2008; Fitzgerald et al, 2010) and hesitant when student performance is unacceptable (Donaldson and Carter, 2005). The assessment process is a crucial part of the mentor’s role; however, concerns about assessment tools exist (Duffy, 2003) and unrealistic expectations of the tools (Ousey and Gallagher, 2007). Shortages of qualified nursing staff in clinical areas have resulted in non-qualified nursing staff working with students, as in the UK there is a growing dependency on healthcare assistants (HCAs) within practice (Gillen and Graffin, 2010). There is a potential that, through having more HCAs in the learning environment, this may impact on students and student learning, as students are more likely to work with and be supervised by unqualified HCAs. Mentors need to be aware of potential barriers to effective assessment (NHS Education for Scotland, 2007).These potential barriers may hinder assessment and need to be minimised and eradicated. This means that the student will be given fair judgement in practice. With barriers in place, the mentor and student may feel they are at a disadvantage. Gopee (2008) highlighted a list of barriers to assessment following the delivery of a mentoring course, as shown in Box 3. If the mentor feels that there are barriers in place that will impede assessment, he or she should inform the ward manager in the learning environment to make alternative arrangements for the assessment, as a student must always be given a fair assessment.
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Box 3. Some potential problems with assessment
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MENTORSHIP Having enough time for students Time constraints in teaching clinical skills and clinical assessments on the ward by senior nurses has been recognised as far back as 1981 by Orton, who identified that pressures from the ward sister’s job role inevitably made them prioritise certain tasks over others. Time constraints are a major issue in mentorship and assessment and there is much literature over the years to support the use of protected time to support learners in practice (Philips et al, 2000; Duffy, 2003; Royal College of Nursing, 2007; 2012; NMC, 2008a). Orton (1981) highlighted that ward sisters might not feel confident in their teaching ability and that they were therefore unlikely to engage with students in the learning environment. This was in 1981, when the nurse-teacher supported nursing students on the apprentice model of nurse education with summative assessments. However, this was also identified by Duffy in 2003 as being a factor in nursing students slipping through the net as mentors did not feel confident enough in their own ability to summatively assess learners in practice. Price (2007) identified that when it comes to assessments in busy learning environments, clinicians struggle to find adequate time and, as a result, often question their interpretation of the assessment requirements. Furthermore, Gopee (2008) asserts that some mentors are willing to confirm that student nurses have passed their practice placement without sufficient evidence of competence.
Conclusion
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Mentors in clinical practice are crucial in pre-registration nursing programmes, as they assess student competence and fitness to practise. The assessment aspect of the mentor’s role, it can be argued, is not easy. Mentors need to recognise that the student nurse will be on a placement within the mentor’s learning environment, as a novice practitioner. Therefore, he or she will be working with experienced practitioners like the mentors to guide and help develop their skills, knowledge and understand of nursing in the real world. A mentor’s assessment is therefore salient in the standards of new registrants who will want to register with the NMC. Thus, mentors, using their ability to assess pre-registration nursing students, will BJN help to safeguard the profession. Conflict of interest: none Axley L (2008) Competency: a concept analysis. Nursing Forum 43 (4), 214–222 Butler MP, Cassidy I, Quillinan B et al (2011) Competency
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KEY POINTS n The introduction of continuous assessment in clinical areas means that students are continually assessed in practice n The reliability and validity of assessment in clinical practice is essential, especially if all students are to be assessed by different mentors n Using a range of assessment methods will help to ensure reliability in the assessment and consistency n Mentors assess student ability to perform tasks and skills within the clinical learning environment n Initial, interim and final interviews are essential requirements in identifying areas of development n The sign-off mentor is required to make the final judgement of safe and effective practise linked to the Nursing and Midwifery Council standards and competencies assessment methods—tool and processes: a survey of nurse preceptors in Ireland. Nurse Educ Pract 11(5): 298–303. doi: 10.1016/j.nepr.2011.01.006 Calman L, Watson R, Norman I, Redfern S, Murrells T (2002) Assessing practice of student nurses: methods, preparation of assessors and student views. J Adv Nurs 38(5): 516–23 Cassidy S (2009) Subjectivity and the valid assessment of pre-registration student nurse clinical learning outcomes: implications for mentors. Nurse Educ Today 29(1): 33–9. doi: 10.1016/j.nedt.2008.06.006 Cowin LS, Hengstberger-Sims C, Eagar SC et al (2008) Competency measurements: testing convergent validity for two measures. J Adv Nurs 64(3): 272–7. doi: 10.1111/j.1365-2648.2008.04774.x Department of Health (1999) Making a Difference. http:// tinyurl.com/l735ooz (accessed 20 January 2015) Dolan G (2003) Assessing student nurse clinical competency: will we ever get it right? J Clin Nurs 12(1): 132–41 Donaldson JH, Carter D (2005) The value of role modelling: Perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ Pract 5(6): 353–9. doi: 10.1016/j.nepr.2005.05.006 Duffy K (2003) Failing Students: A qualitative study of factors that influence the decisions regarding assessment of students’ competence in practice. http://tinyurl. com/36r8d8d (accessed 20 January 2015) Duffy K, Hardicre J (2007) Supporting failing students in practice. 1: Assessment. Nurs Times 103(47): 28–9 Fitzgerald M, Gibson F, Gunn K (2010) Contemporary issues relating to assessment of pre-registration nursing students in practice. Nurse Educ Pract 10(3): 158–63. doi: 10.1016/j.nepr.2009.06.001 Glen S, Parker P (2003) Supporting Learning in Nursing Practice: A Guide for Practitioners. Palgrave Macmillan, London Gopee N (2008) Mentoring and Supervision in Healthcare. Sage, London Hengstberger-Sims C, Cowin LS, Eagar SC, Gregory L, Andrew S, Rolley J (2008) Relating new graduate nurse competence to frequency of use. Collegian 15(2): 69–76 Hughes SJ, Quinn FM (2013) Quinn’s Principles and practice of nurse education 6th edn. Nelson Thornes, Cheltenham McCarthy B, Murphy S (2008) Assessing undergraduate nursing students in clinical practice: do preceptors use assessment strategies? Nurse Educ Today 28(3): 301–13. doi: 10.1016/j.nedt.2007.06.002 NHS Education for Scotland (2013) National Approach to Mentor Preparation for Nurses and Midwives Core Curriculum Framework 2nd edn. http://tinyurl.com/ qcrx2s7 (accessed 20 January 2015) Nicklin PJ, Kenworthy N (2000) Teaching and Assessing in Nursing Practice: An Experiential Approach. Baillière Tindall, London Nolan M, Davies S, Brown J, Keady J, Nolan J (2002) Longitudinal study of the effectiveness of educational preparation to meet the needs of older people and their carers: The Advancing Gerontological Education in Nursing (AGEIN) Project. http://tinyurl.com/agrt7mc (accessed 22 January 2015) Norman IJ, Watson R, Murrells T, Calman L, Redfern S
(2002) The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students. Int J Nurs Stud 39(2): 133–45 Nursing and Midwifery Council (2006) Standards to Support Learning and Assessment in Practice: NMC standards for mentors, practice teachers and teachers. NMC, London Nursing and Midwifery Council (2007) Ensuring continuity of practice assessment through the ongoing achievement records. http://tinyurl.com/pdv9zhl (accessed 28 January 2015) Nursing and Midwifery Council (2008a) Standards to support learning and assessment in practice: NMC standards for mentors, practice teachers and teachers. http://tinyurl.com/ d3sw5ox (accessed 21 January 2015) Nursing and Midwifery Council (2008b) The Code: Standards of conduct, performance and ethics for nurses and midwives. http://tinyurl.com/5u7d24n (accessed 20 January 2015) Nursing and Midwifery Council (2010) Standards for preregistration nursing education. http://tinyurl.com/6f443py (accessed 20 January 2015) Orton HD (1981)Ward learning climate: a study of the role of the ward sister in relation to student nurse learning on the ward. Royal College of Nursing of the United Kingdom, London Ousey K, Gallagher P (2007) The theory-practice relationship in nursing: a debate. Nurse Educ Pract 7(4): 199–205. doi: 10.1016/j.nepr.2007.02.001 Philips Schostak J, Tyler J (2000) Practice and Assessment in Nursing and Midwifery: doing it for real (researching professional education. English National Board for Nursing, Midwifery and Health Visiting, London Polit, DF, Beck, CT (2004) Nursing Research Principles and Methods 7th edn Lippincott Williams & Wilkins, Philadelphia Pratt DD, Arseneau R, Collins JB (2001) Reconsidering ‘good teaching’ across the continuum of medical education. J Contin Educ Health Prof 21(2): 70–81. doi: 10.1002/chp.1340210203 Price B (2007) Practice-based assessment: strategies for mentors. Nurs Stand 21(36): 49–56. doi: 10.7748/ ns2007.05.21.36.49.c4629 Royal College of Nursing (2012) Quality with compassion: the future of nursing education. Report of the Willis Commission 2012. http://tinyurl.com/cvugp8t (accessed 20 January 2015) Rowntree D (1987) Assessing Students: How shall we know them? Routledge, London Stuart CC (2007) Assessment, supervision and support in clinical practice: A guide for nurses, midwives and other health professionals 2nd edn. Churchill Livingstone, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1986) Project 2000:A New Preparation for Practice. UKCC, London United Kingdom Central Council or Nursing, Midwifery and Health Visiting (1999) Fitness for Practice. Summary. http://tinyurl.com/kscdbzw (accessed 20 January 2015) Welsh I, Swann C (2002) Partners in Learning: a guide to support and assessment in nurse education. Radcliffe Medical Press, Oxford
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