Role of the mentor in the theatre setting.
Abstract: Mentorship has been present in healthcare for many years and much has been written about it. This article will explore the role of the mentor in the operating theatre in light of the new standards of mentor preparation.

KEYWORDS Mentorship / NMC Guidelines / Students / Assessment of practice / Theatre
Subject: Mentors (Methods)
Mentors (Standards)
Surgical nursing (Practice)
Author: Harvey, Paul
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Topic: Event Code: 350 Product standards, safety, & recalls; 200 Management dynamics
Organization: Organization: Nursing and Midwifery Council
Accession Number: 300545552
Full Text: Introduction

Mentorship has been omnipresent in healthcare for many years. Gopee (2008) suggests that this concept has been evolving and developing since the early 1970s, but it was formally adopted by the nursing profession in the 1980s and subsequently by Operating Department Practitioners (ODPs) (CODP 2009). The philosophy of supporting junior colleagues and students has had many different titles and names since its inception: preceptor, assessor, supervisor and clinical facilitator to name but a few (Gopee 2008, Myall et al 2008, Ousey 2009). The term mentor has been formally used since 2000 when the United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC) stated that those who supported a student in the practice setting should use the preferred title of mentor (Myall et al 2008).

There have been many different definitions of mentors, and according to Jackson (2008) these definitions have added to the ambiguity of the role of the mentor in today's nursing press Perhaps the most clear definition is by the Nursing & Midwifery Council (NMC 2008a) who state that a mentor is a practitioner who 'has met the outcomes to become a qualified mentor and who facilitates learning and supervises and assesses students in the practice setting'. Nevertheless, mentorship is now an integral part of the nursing and other healthcare practitioners' role (Jackson 2008, Myall et al 2008, Ali & Panther 2008, NMC 2008a, Gopee 2008, CODP 2009). Indeed, Ali & Panther (2008) suggest that mentoring is an important role that every nurse and ODP has to accept at some point in their working life. It is also a part of the respective codes of professional conduct which state that nurses must 'facilitate students and others to develop their competence' and that nurses must 'be willing to share skills and experiences for the benefit of colleagues' (NMC 2008b).

Whilst ODPs have a separate code of professional standards, this essentially provides a similar outline to supervision and mentorship (HPC 2008). The concept of mentoring is also part of the NHS Knowledge and Skills Framework whereby practitioners have to assist in the development of others through a variety of learning approaches and must demonstrate these through portfolio development (DH 2004).

The role and required characteristics of a mentor

Gopee (2008) put forward several reasons as to why there is a need for mentors within the healthcare professions and these are detailed in Table 1.

* For guidance and support

* To structure working environment for learning

* For constructive and honest feedback

* For debriefing related to good/bad experience during placement

* As a link person with other areas

* As a role model

* To assess competence

* As a friend and counsellor

* For seeking answers to questions

* For protection from poor practice

* To build confidence

* For sharing learning

* It is a NMC requirement

* To keep skills and knowledge current and valid

* Linking theory to practice

* For encouragement

* To provide appropriate knowledge base for nursing interventions

* To provide a structured learning programme in placements

Table 1 The role of the mentor (Gopee 2008)

Gopee (2008) also put forward the required characteristics of a good mentor. Mentors should be people who are:

* Patient

* Open minded

* Approachable

* Good knowledge base

* Knowledge and competence is contemporary and current

* Good communication skills

* Encourager

* Self-motivated Concerned, compassionate and empathetic

* Teacher

* Counsellor

* Tactful

* Diplomatic

* Willing

* Versatile and adaptable

* Committed

* Confident

* Enthusiastic

* Advisor

* Honest and trustworthy

* Trusting

* Role model

* Non-judgmental

* Resource facilitator Build working relationships

In 2008, the NMC revised the document Standards to support learning and assessment in practice: NMC standards for mentors, practice teachers and teachers (NMC 2006) in order to support nurses working with students and especially those preparing for the mentorship role. The standards themselves did not change essentially but the means by which they could be put into practice was simplified and enhanced (NMC 2008a). The document clearly identifies a 'framework to support learning and assessment in practice' and defines outcomes for mentors to ensure clear delineators for accountability in the practice of supporting and assessing students. There are eight domains within the framework and these are detailed in Table 2. It is intended here to define each of the domains and to highlight how each aspect is met within the operating theatre environment. We also discuss how each domain is defined through being a competent and effective mentor.

1.Establishing effective working relationships

2. Facilitation of learning

3. Assessment and accountability

4. Evaluation of learning

5. Creating an environment for learning

6. Content of practice

7. Evidence based practice

8. Leadership Table 2 Domains of competency and outcomes for mentorship, Nursing & Midwifery Council 2008a

Table 2 Domains of competency and outcomes for membership, Nursing & Midwifery Council 2008a

Establishing effective working relationships during student placements

The NMC (2004) states that the mentor should 'demonstrate an understanding of factors that influence how students integrate into practice'. Arguably this could involve careful preparation and planning before the student commences on their placement. Indeed Ousey (2009) argues that mentors play a vital role in planning the students' learning experiences and thus assist the student in understanding their own learning challenges and needs during their placement. Good preparation and a full understanding of the student's needs and learning requirements will facilitate an effective and engaging student experience.

The phases of the relationship

The development of a trusting and facilitative mentoring relationship is essential in the mentoring process (Ali & Panther 2008). Learning is enhanced if the relationship is based on mutual respect and a sense of partnership and this relationship is developed over time (Mohanna et al 2004). Ali & Panther (2008) suggest that the relationship passes through three phases: initially trust and respect is built through working together, then the student learns the clinical skills and knowledge required to achieve their learning outcomes, and finally the mentoring is completed with the final assessment of practice. Essentially the three phases occurs for all mentorship relationships, but they often pass from one segment to the next imperceptibly (Ali & Panther 2008).

Initiation phase [right arrow] Working phase [right arrow]Termination phase Ali & Panther 2008

The initiation phase can be a truly stressful time. Having to start again building working relationships in a new placement is difficult.Thus, easing the student into the department will enable a smooth transition from one clinical learning environment to the next (Ali & Panther 2008). Theatre departments should therefore provide a comprehensive orientation and induction program where the students are shown around the department, their mentors are introduced and the students' learning outcomes are highlighted. This process of orientation and induction can present a feeling of a safe atmosphere whereby the student can integrate into the learning environment and learn the necessary clinical skills (Barker 2006).

Facilitation of learning

The NMC suggests that the mentor must be able to facilitate student learning through the use of varied and appropriate learning opportunities in order to integrate theory and practice (NMC 2008a). Rolfe et al (2001) suggested that the use of reflective practice greatly enhances the linkage of theory to practice and Kolb (1984) put forward his seminal idea about experiential learning as a model for clinical learning and reflection. Conversely before any reflection can occur, the student must have some 'concrete experience' to reflect and learn upon. Mentors have a duty to facilitate these concrete experiences (NMC 2008a) and, in order for the mentor to provide these learning opportunities it is essential that there is a starting point The CODP (2009) states that there should be an on-going record of student progress to assist in this process and that this should be presented to the mentor at the beginning of the placement. This will also provide the mentor with an idea of the stage of the student's learning in order to select the appropriate learning opportunity (NMC 2008a).

The operating theatre can be a fantastic clinical learning environment. However, from both personal experience and with reference to some recent evaluations of their placements, student nurses felt that there needed to be a significant shift in the way that they were managed. Several students felt that they were left to their own devices for too long and felt like 'a spare part', not working with their mentors sufficiently and perhaps more worryingly working in ways which were not relevant to their practice as nurses. This was not the case with ODP students. These observations perhaps highlight that it is not only students that need to reflect on their practice, but also mentors as learning is a lifelong process (Gopee 2008).

Students with special needs

Mohanna et al (2004) argue that teachers should not only consider the needs of the teacher in facilitating learning but also those of the different learner groups. This may be particularly important in the teaching and mentoring of students with disabilities and special needs. Both physical disability and learning disability need to be addressed in order to comply with the Disability Discrimination Act (1995) and the Special Education Needs and Disability Act (2001) as cited by Royal College of Nursing (RCN 2007).

Students are responsible for highlighting their needs in advance to the mentor, but this is not compulsory. Good communication and observation by the mentor can detect the possible problem but it is up to the student to formally highlight this and this is normally done through the Higher Education Institution prior to the student's placement.The student also needs to provide their consent if the disability needs to be disclosed to other members of the teaching team. A variety of skills and adaptations can be used to assist the 'disabled' student, for example, extra time allocated with the mentor, or overlays for dyslexic students.The mentor is able to access support themselves through the internet and the HEI if necessary.

Assessment and accountability

Duffy (2003) suggested that there needed to be a change of emphasis for assessing and mentoring students. She argued that there was evidence of mentors 'failing to fail' students whose competencies were under question. This certainly defies the NMC (2008a) and CODP (2009) standards for mentorship preparation and also contradicts the two separate codes of professional conduct (NMC 2008b, HPC 2008). Duffy (2003) states that, although sometimes the reasons for failing students prove to be difficult, the consequences of not doing so are potentially disastrous. It is imperative that nurses and ODPs understand their accountability for their assessment decisions of a student's competence. Practitioners are accountable to their professional bodies and are also accountable for the safety of future patients. The RCN (2007) states that mentors are accountable both for their professional judgements of student performance, and also for their personal standards of practice, the standards of care delivered by their students, and the standards of teaching and assessing of the student under their supervision. A mentoring relationship is therefore a very complex and demanding role and one for which nurses and ODPs should be adequately prepared (Duffy 2003).

Failing students

Managing a failing student arguably should never reach a point of surprise for the student, the mentor or the higher education institution. Gopee (2008) argues that there could be many reasons as to why the student struggles, and the RCN (2007) states that those having difficulties should be identified early enough to provide sufficient opportunity for them to improve through careful management, support and supervision.

Preparation of mentors

Gopee (2008) states that one of the most fundamental aspects of mentorship is the assessment of clinical learning and competence. Mentors need to be prepared to train for this through the mentorship preparation programmes (NMC 2008a, CODP 2009) and to maintain this competence through mentoring and assessing at least two students annually over a three year period-the triennial review (NMC 2008a).

Student assessment

A multitude of approaches can be used to assess a student's clinical learning and application of knowledge to practice, e.g. direct observation, simulation, objective structured clinical examinations (OSCE), reflective discussions, and the setting of selective pieces of written work (RCN 2007).However, the RCN (2007) suggests that the student's performance should also be continually assessed whilst carrying out the routine day-to-day activities through either formal or informal approaches or, as Gopee (2008) suggests, formative or summative assessments. The NMC (2008a) states that 'most assessment of competence should be undertaken through direct observation in practice' thus demonstrating the student's competence in the practice setting. If some experiences offer themselves only infrequently, then other forms of assessment could be used. In order for the assessments to be deemed appropriate they should be valid and reliable (Gopee 2008). The validity of an assessment refers to the degree to which the assessment appraises what it is meant to assess. The reliability of an assessment however is where the assessment can be repeated consistently to gauge competence (Gopee 2008).

FvniRntinn of Fnnrning

Gopee (2008) states that the evaluation of learning is important to ensure that mentoring praxes are and remain effective and also to highlight areas that need improvement. Evaluation should include both the student and the mentor (Light & Cox 2001) which could lead to a more reflective teacher in the clinical setting.McNair et al (2007) suggest that evaluation can be undertaken in a variety of methods, from formal questionnaires to informal discussions. Within the mentor-student relationship evaluation is often carried out informally in order to gain some indication as to the effectiveness of the learning. The placement as a whole should be formally evaluated as this will have a significant impact on future student placements. The lack of a recognised evaluation process perhaps indicates an assumption that all is well (McNair et al 2007). However, in personal practice, there often does not seem to be any formal evaluation. As previously mentioned, several student nurses recently have discussed their feelings as to how they felt their placement had gone, and this certainly revealed areas that need evaluating further by the teaching team.

Creating an environment for learning

The RCN (2007) states that a student's clinical learning environment is one of the most important aspects of their clinical education in preparation to become nursing professionals. Arguably, not only does this impact on the physical environment but also on the learning ethos within the practice placement. Indeed McNair et al (2007) suggest that a 'learning environment is not just the physical area but the attitudes of staff'. It therefore should be an integral part of any mentor's role that making the students feel welcome and part of the theatre team will enhance their learning opportunities and assist them in achieving the required outcomes. This is further supported by Department of Health (2006) report that poor quality clinical placements are often characterised by unwelcoming environments and students not being valued as members of the teams.

Context of practice

The NMC (2008a) states that mentors should 'contribute to the development of an environment in which effective practice is fostered, implemented, evaluated and disseminated'. An effective way that this statement can be adopted is through role modelling. Morton-Cooper and Palmer (2000) as summarised by AM and Panther (2008), suggest that the importance of an observable image that clearly demonstrates good practice and effective skills and is someone to emulate, cannot be overestimated. Indeed, Donaldson and Carter (2005) argue that the perceptions of students on role modelling within the clinical environments were very positive as it gave them something to observe and to practice.

In order to be an effective role model the mentor must have high standards, must be able to demonstrate these high standards consistently, and must have good attitudes and beliefs regarding the role of their relevant profession in the wider context of healthcare (Murray & Main 2005). Indeed Gopee (2008) categorically states that mentors should be 'aware of their impact as role models on students' learning of skills and professional attitudes'. Armstrong (2008) states, however, that role modelling is not just about observing practice, but also includes considered linkage between practical skills acquisition and the underpinning knowledge that relates to the skills, i.e. closing the theory-practice gap.

The NMC (2008a) states that professional boundaries set for students need to be flexible for providing interprofessional care.

Interprofessional learning has been put forward for many years (Baker et al 2008) and is deemed valuable in that it aids the education of all professions within healthcare to give them a good basis of understanding in caring for patients through actively sharing information, knowledge and expertise.

Perioperative care is most definitely a multiprofessional arena of healthcare. Not only are there nurses working within the operating theatres, but there are also surgeons, anaesthetists and ODPs.However, despite the interprofessional working practices within the operating theatres, only a mentor on the same register as the student can formally assess and sign off the student as competent (NMC 2008a).Nevertheless, associate mentors can be from any registered body, as long as they do not finally assess the student. This situation is well illustrated in the theatre department as ODP students are taught and supervised by nurses, and vice versa and expertise is passed through all the professions.However, for the process to be successful mentors and other supervisory staff need good communication to ensure that valid and reliable assessments are made.

Evidence based practise (EBP)

The concept of practice being evidence-based has been around the nursing profession for many years (NMC 2008b, Gopee 2008). Indeed Dale (2006) as written by Gopee (2008) argues that EBP has shifted the way of working from a more traditional, routine practice to a more scientific method. As a result the mentor now needs to be aware of the availability of the extensive healthcare research and needs to pass this on to their students, thus disseminating the knowledge and shaping the future practitioner's ideals, knowledge and healthcare wisdom (Gopee 2008).Scullion (2002) as quoted by Gopee (2008) suggests that there are many opportunities available for mentors to access evidence and research and then to pass this on to their students, examples of which include journal clubs, writing articles and poster presentations. This can however raise problems, as nursing has a history of poor reading habits and a negative attitude towards research (Timmins et al 2012). One way to encourage EBP in students is by the use of reflective practice. Jasper (2003) suggests that engaging in reflective practice is associated with the improvement of the quality of care, stimulating personal and professional growth and closing the gap between theory and practice. This of course should apply not just to the students, but to their mentors too. Mentors need to reevaluate their practice as a mentor continually to ensure that they remain fresh and up-to-date in their supervision and assessment of students, especially in a dynamic field such as healthcare.

Leadership

Gopee (2008) suggests that 'careful planning of own work and prioritising are key features of the mentor's leadership role towards achievement of placement competencies, along with acting proactively to avert the contemporary problems of assessments, and dealing with those that do occur'. This means that the mentor should make sure that they achieve the maximum experience and exposure for their student within their field of care, in order to ensure that the student's competencies are achieved. There must also be careful management of students that have difficulties, through proactive administration of the placement with the use of interviews and meetings (Jokeiainen et al 2011).

Sometimes, placement outcomes cannot be met within the confines of the mentor's sphere of practice. Therefore careful consideration is required to explore other areas either within the intra-professional field or further afield working with other professions [inter-profession]. Indeed, Baker et al (2008) argue that working and learning with other healthcare professionals allows an insight into their working practices once qualified and prepares students well. This certainly occurs within the operating theatres as not always can certain concepts and skills be ascertained by one mentor, but associate mentors can facilitate this. It is important to point out that, whilst there may be areas of a student's documentation that needs to be fulfilled, the mentor must stay within their own scope of practice and not be prepared to sign a student as competent in a different professional area. To do so would be to disregard both the NMC (2008a) standards for mentorship and the NMC (2008b) code of practice.

In conclusion, it is clear that the role of the mentor is not an easy one. The task revolves around two key characteristics, namely being a good role-model and being an active facilitator of learning. It is highly complex and carries a great deal of responsibility and accountability. Indeed, mentorship formulates the new generation of healthcare professionals and therefore poor mentorship can lead only to a dearth of dedicated, knowledgeable and competent practitioners of the future.

References

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by Paul Harvey

Correspondence address: Paul Harvey, Burton Hospitals NHS Foundation Trust, Queens Hospital, Belvedere Road, Burton on Trent, DE13 ORB. Email: paulharvey@burtonft.nhs.uk

About the author

Paul Harvey

RN (Adult), BSc (Hons), PGCE

Staff Nurse, Recovery, Burton Hospitals NHS

Foundation Trust

No competing interests declared
* For guidance and support
  * To structure working environment for learning
  * For constructive and honest feedback
  * For debriefing related to
  good/bad experience during placement
  * As a link person with other areas
  * As a role model
  * To assess competence
  * As a friend and counsellor
  * For seeking answers to questions lo
  * For protection from poor practice
  * To build confidence
  * For sharing learning
  * It is a NMC requirement
  * To keep skills and knowledge current and valid Linking
  theory to practice
  * For encouragement
  * To provide appropriate knowledge base for nursing
  interventions
  * To provide a structured learning programme in placements
  Table 1 The role of the mentor (Gopee 2008)


1.Establishing effective working relationships
  2. Facilitation of learning
  3. Assessment and accountability
  4. Evaluation of learning
  5. Creating an environment for learning
  6. Content of practice
  7. Evidence based practice 8. Leadership Table 2 Domains of competency
  and outcomes for mentorship, Nursing & Midwifery Council 2008a
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