A focus on Placement Learning Opportunities for Student Nurses – literature review

Introduction

All student nurses are allocated clinical placements throughout their three year course, in which to develop their practical skills. Whilst in practice, they are supported by a designated mentor, who is the student’s identified lead for educational support. In this context, mentor support is provided by practitioners, who have undertaken an approved mentor preparation programme, approved by the regulatory body, the Nursing and Midwifery Council (NMC) (Nursing and Midwifery Council, 2008). The Code of Professional Conduct (Nursing and Midwifery Council, 2015) outlines a responsibility for all registered nurses and midwives, known as registrants, to facilitate the education of learners in clinical practice.

I am aware from discussions with students, and overhearing their conversations in the classroom setting that they perceive their placements to vary in quality, with some feeling they have benefitted from very strong, beneficial placements, through to others who do not feel so advantaged educationally. Some students perceive that they may have had an experience that was inequitable in comparison with peers, whilst others may comment that they don’t feel they learnt as much when comparing with previous placements. As such, I am aware that a perception exists that there are “good” and “bad” placements in the eyes of students. Having been a student myself, I am fully conversant with the fact that students will compare one placement experience with another and will also discuss their experiences with peers (Foster et al., 2014). The NMC dictates that the nursing course is built on 50% theory, and 50% clinical placements – thus ensuring that students gain an opportunity to gain experience in a range of clinical settings (Nursing and Midwifery Council, 2008). A dedicated team within the university is responsible for the allocation of a broad range of placement experiences (community and hospital) to all students on a nursing course.

Placement learning opportunities vary significantly in context, and it must be noted that no two placement settings are easily comparable. It is important to note the uniqueness of students and mentors, as all have a preferred way in which to teach and learn, and as such this factor must also be considered a significant variable.

In my mind, the key features of a work placement are to provide students with an experience similar to that of qualified status, as placements allow them to immerse themselves into the clinical setting. They are able to practice, under supervision, the skills they have been taught in the classroom setting and to develop their practice in readiness for qualification. Placements should also develop confidence and provide an opportunity to demonstrate competency to mentors.

Literature Search Process

A dual approach was taken to source literature to support the identification of a suitable research problem. Initially I undertook a systematic search of a number of recognised repositories, using specific search terms and a number of initial inclusion and exclusion criteria to ensure that the literature identified was relevant to my area of focus. Search engines included Google Scholar, the British Nursing Index (BNI) and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). This process proved very fruitful in terms of the quality and quantity of literature identified. The limited word count for this article does not permit a full overview of the search terms used and resultant number of “hits”.

Alongside this process, I also undertook what can be classified as a serendipitous search. This involved using my own knowledge of the topic area to ensure that key policy and regulatory documentation was identified, along with material that I currently use within my teaching practice. I also ensured that I followed up material found in the reference listings of articles I have read. On reflection, although this process goes against the traditional process for systematic literature searching that I am used to, it was extremely beneficial in giving assurance that I had reached saturation point as the majority of literature cited in the articles I was reading had already been covered. This provided confidence that I had not missed any key literature in the field I am focussing upon.

Literature was predominantly included if it originated in the UK, and was published within the last 15 years. Nursing is regulated differently across the globe and mentoring and placement requirements vary depending upon the country you are in.

If relevant, literature from overseas was included after careful consideration was given, if it supported the identification of a research problem by offering a perspective that varied from the UK based material. Literature was only included if it originated from credible sources, which for the majority were peer reviewed journals.

Overview of the Literature

From the outset, it became apparent that there was very little literature focussed on the “poor” placement, and particularly any that discusses the potential advantages of a perceived negative placement experience. The majority of the literature sourced has a firm focus around guidance to mentors, and how to make a placement learning experience as positive as possible.

The makeup of the identified literature can also be categorised for significance. The over-riding majority of identified literature was research based, having undertaken studies examining the experience of learners in practice. This was then published in credible journals. Secondly, “policy” documents were identified – these predominantly originated from the nursing regulator, the NMC (Nursing and Midwifery Council, 2008), as well as guidance from the Royal College of Nursing (RCN) based upon the regulators document and combined with advice from existing mentors (Royal College of Nursing, 2007). Finally, a number of handbooks, or toolkits covering guidance for staff involved in supporting students are concerned with the “best practice” approach (Brockbank and McGill, 2012; Shaw and Fulton, 2012).

The literature acknowledges that although in placement settings the mentor has a lead responsibility for facilitating education, there are other factors that significantly impact on the overall educational quality of the experience.

For the purpose of this review, a total of 59 articles or sources were read, and a number of key themes were evident. I utilised a matrix as recommended by Oliver (Oliver, 2012) to summarise each piece of literature and to conduct a mini thematic analysis. Upon saturation being reached, a review of the matrix enabled the identification of a number of themes that were consistent across numerous articles and sources.

The literature that was identified, as previously mentioned, all originated from credible sources – predominantly journals that are widely recognised in the field of healthcare and healthcare education. A critical approach was taken in reading each article, with a particular emphasis around critical analysis to understand what within the source was not being said. As an example, the majority of literature focussed on good examples of placements and an emphasis on positive experiences; there was a lack of literature that specifically examined the impact of negative placement experiences.

The overriding strand that ran throughout the majority of articles was the importance of the learning environment itself (Beskine, 2009; Gopee, 2011; Stuart, 2007; Walsh, 2010; Papp et al., 2003; Willis Commission, 2012; Royal College of Nursing, 2007; West et al., 2007; Burns and Paterson, 2005). Gray (2014, p65) defines the learning environment as “an interactive network of forces within clinical settings that influence students’ clinical and professional learning outcomes”. Other key foci of the literature sourced were concerned with examining relationships between mentors and mentee (Foster et al., 2014; Andrews and Chilton, 2000; Cahill, 1996; Gray and Smith, 2000; Jokelainen et al., 2011; Butler, 2012; Henderson and Eaton, 2013), and the importance of ensuring that these were effective on a professional level.

As would be expected, a considerable amount of literature exists on the assessment element of the mentor’s role, and a number of studies have been undertaken to look at the ways in which assessment is undertaken (Beskine, 2009; Aston and Hallam, 2014; Gopee, 2011; Stuart, 2007; Walsh, 2010; Robinson et al., 2012; McNair et al., 2007).

On reflection, I was surprised that there was a minimal amount of literature with a focus around the support provided by universities to mentors supporting learners in practice (Henderson and Eaton, 2013; Foster et al., 2014). Mentoring is recognised as an often challenging role, and for new mentors in particular, supporting students in practice placements can be difficult and could potentially impact upon the experience of the learner.

The Student / Learner

Perceptions

As students’ progress through their course, they will naturally compare their placements with their own previous experiences (Foster et al., 2014), and also with that of other students. It is only natural that they will perceive differences to exist between one area to the next, and likewise between the educational gain they have identified. The literature states that students will emulate and role-model qualified staff who they perceive to be good examples of the nursing profession, and will compare staff in one area to the next (Beskine, 2009; Brockbank and McGill, 2012). The literature does not highlight that practice varies in terms of standards and the evidence on which it is based, and as such role modelling can be problematic if the practice demonstrated is not current and credible.

Expectations

Student nurses will naturally expect every placement to be a positive experience, through which they can develop their knowledge and gain a greater understanding of the role of the nurse. Many will argue that placements are the way in which they develop competency, and that positive or “good” placements are the only way in which they can complete their training and qualify in a state ready for practice (Andrews and Chilton, 2000; Gopee, 2011; Jokelainen et al., 2011). The literature covered would agree with this in the main, however an Australian article (Green and Jackson, 2014) discusses the negative aspects of placements and associated mentoring. This negative aspect of placements is a weakness in the literature and needs further exploration, as there is a need to explore how student can be prepared to deal with placements that they feel are not conducive to learning and to explore the benefits of being placed in a setting that is not supportive.

Resilience

Refreshingly, Green and Jackson (2014) acknowledge that poor mentoring and negative placements do occur regularly in practice, and for a number of reasons. This paper led me to reflect and think about what was stated within it. Most of the literature reviewed outlines the importance of effective relationships between mentors and students (Henderson et al., 2012; Henderson et al., 2010); the need for learning environments to be set up as effectively as possible to facilitate high quality education and the guiding hands of experienced clinical and mentoring staff to ensure that the clinical education pathway of student nurses is as clear of obstructions as possible throughout the three years of training.

Theoretically, such an experience sounds very beneficial, and most students would be grateful to progress in such a manner. But is a poor placement also as beneficial to the education process? In my view, it is, as it introduces the student to the complexities of life as a healthcare professional. In reality, shifts as qualified practitioners will be challenging on a regular basis (Wallace and Gravells, 2007), and by gaining experience of challenging situations as a student, it assists in the development of building resilience and coping strategies (Papp et al., 2003).

‘Poor’ placement experiences also enable students to develop skills in resilience, and through working through challenging situations, leaves them better equipped to cope with similar situations either in future placements, or in practice as a qualified nurse. The university plays a significant part in supporting students in practice (Foster et al., 2014) and has a duty to liaise with practice colleagues if a placement learning experience has the potential to cause significant harm to the development of a student (Burns and Paterson, 2005).

Past Experiences

All students enter the course from a range of backgrounds many will have previous healthcare experience gained through previous employment in a support role, whilst others commence their nurse training with no previous experience at all. In some cases, this experience can be helpful, as an existing understanding of an area can assist the student to build upon their current knowledge base. For others, they enter a placement not knowing what they do or don’t know. The literature discusses in depth the importance of mentors and placement colleagues providing a positive, conducive setting in which all students can thrive and develop their knowledge and skills (Beskine, 2009; Royal College of Nursing, 2007; Aston and Hallam, 2014).

The motivation of students to enter the profession may also be a factor to consider – as some students could be classed as “healthy” having had little or no contact with the profession and whose motivation is to help others and care for the sick. As a result, they may have very few expectations of their placements. Others may have experience of the profession through previous employment or as a patient, and may make comparisons to first-hand experience.

Mentoring

Critique of the NMC Standards

The NMC (Nursing and Midwifery Council, 2008a) defines a mentor as one who ‘facilitates learning, and supervises and assesses students in a practice setting.’This definition is akin to frequently quoted definitions used in healthcare mentoring texts (Shaw and Fulton, 2012; Walsh, 2010; Gray, 2014) who speak of mentoring as being closely linked to skill and practice development.

As the regulatory body, the NMC have published guidance, which is frequently referred to as the “bible” for mentoring (Nursing and Midwifery Council, 2008). Idealistically, this document would provide a succinct set of instructions to mentors around how to manage a placement experience for students, and how to deal with potentially challenging situations. Unfortunately this is not provided, and the document is based around eight domains which set out the key areas of significance for mentoring students in practice placement settings.

Supporter versus Assessor

As students’ progress through their three year programme, they become more and more aware of the split responsibilities of the role of their mentors and for many, see them primarily as somebody who will judge their practice and influence the decision as to whether they will progress in their training (Bray and Nettleton, 2007). Interestingly, the study undertaken by Bray and Nettleton (2007) highlighted that the majority of mentors see their role as being fundamentally that of a teacher or supporter. Assessment is a key, but complicated process to manage for mentors, and the consequences of a wrong decision are huge for students. Stuart (2007) speaks of the importance of assessment being conducted fairly and in the best interests of students.

An observational study undertaken in a critical care setting identified the importance of the mentor offering support to students, as this led to reduced stress levels and opened up avenues for increased learning (Cochrane et al., 2008).

It is encouraging to observe more parity in this area around the balance between literature that covers both positive and negative aspects of mentoring and the relationship students have with their qualified colleagues. I have frequently reflected upon the benefits of splitting the role and having two mentors allocated, one to support and the other to assess.

Very few articles seek the views of students, and do not address any perceived difficulties from their position.

On reflection, this dual aspect of the role has infrequently been an issue for myself in a mentoring role, nor immediate colleagues. In many situations, if the mentor has been acting as a teacher and has been working with a student to develop skills in a particular area, the assessment process naturally falls within this role. It could also be highlighted, that if a student receives poor assessment results within a placement, this may potentially cloud their perception of the overall experience – irrespective of the quality of teaching received.

Benefits of shared responsibility in a larger department

As already mentioned, there are distinct advantages to the student and mentor who are based in a larger department. The responsibility for providing the guidance to students can be shared. The NMC guidance states that qualified mentors must spend 40% of practice time directly working with their student (NMC, 2008) which leaves a considerable amount of time during which a student may work with other colleagues. “Associate mentoring” is increasingly being used in practice to facilitate the educational experiences of students – as many registered nurses may not necessarily hold the mentoring qualification, but do have extensive clinical experience that will benefit all learners. Through the involvement of the whole team, expertise will benefit all learners and pressure is taken away from the qualified mentor to facilitate all learning opportunities. The literature does not discuss who should be teaching learners in practice, and this is wholly relevant to the above point. With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals.

In smaller teams, and where practitioners work autonomously, working alongside a range of colleagues is not possible. In such situations students are limited to the one mentor and can sometimes see this as a disadvantage when making comparisons to other placements.

Integration of the literature

A commission into the future of nursing education (Willis Commission, 2012) reinforces the pivotal role mentors will continue to hold in educating the next workforce generation, but does not analyse the competing roles of supporter and assessor a mentor must undertaken when carrying out the role in practice.

The literature in existence to support all those involved in educating in practice, as previously discussed, is a combination of research and advice in the form of toolkits. This is based upon the lived experiences of authors in the field of mentoring and is not necessarily research based (Wallace and Gravells, 2007; West et al., 2007; Brockbank and McGill, 2012)

The majority of the literature sourced on the mentoring element of placements is heavily biased towards the positive experience. There is a range of books and published research that discusses the “gold” standard, and provides advice on managing an effective placement experience. There is limited material that discusses the potential benefits of a negative or “poor” placement experience from a mentoring perspective. On reflection, my experiences as a mentor and as a mentee have generally been very positive – no mentor intentionally sets out to facilitate a poor placement experience for their allocated learner.

The Learning Environment

Learning cultures

A learning culture is defined by Gill(2009) as a setting in which all barriers that prevent learning from occurring are removed, and staff are rewarded for promoting learning in the setting – ultimately education should be the rule and not the exception.

It is recognised that each placement setting will differ due to the individuals that make up the team, and to the nature of the work undertaken. By default, some areas are more stressful than others due to the un-predictable nature of the setting. However, each of the above are insignificant if there is a shared culture of learning held by the whole team – if the whole team are motivated and committed to the facilitation of learning, all students should thrive.

Beskine (2009) links the environment to the staff working in an area at all levels, and discusses the importance of role modelling positive behaviour from ward manager through to cleaner. She advocates the significance of a shared philosophy towards learning, and promotes cohesive learning across a whole team, which potentially eliminates the “toxic mentor” (Green and Jackson, 2014) situation whereby one or more individuals are not keen to teach and assess students in practice. The role-model concept is supported (Brockbank and McGill, 2012) in mentoring texts as being the difference between mentoring and simply coaching an individual.

Positive and negative impacts on learning

Whilst the literature speaks generally around the learning environment as a whole, I can breakdown the focus area into separate areas of consideration: the physical environment; the individuals working within it and the philosophy held by the individuals towards learning. The physical environment will be discussed in the next section, focussed upon the work environment.

The literature agrees that the learning environment in which students are allocated clinical placements vary considerably due to the nature of the services they provide (Andrews and Chilton, 2000). Walsh (2010) notes the limitations affecting mentors and learners in that a ward or assessment unit’s primary role is to deliver healthcare, but suggests that at regular intervals the mentor and student takes a step back to review the area from their respective role in order to suggest improvement. For example, the process of giving feedback or undertaking a knowledge assessment requires a quiet area with minimal interruptions, a commonly reported issue, and sometimes the use of office space or examination rooms can be negotiated to allow such dialogue to occur. Duffy (Duffy, 2003) identified the increasingly common issue of mentors failing to fail students, but made the link to the importance of a positive learning environment in which student nurses can thrive and excel. It must also be recognised that the healthcare settings vary significantly, which for some can mean learning on a ward setting, whilst others may be in the home of a patient, or in a clinic setting (Eller et al., 2014)

Shaw and Fulton (2012) discuss another action that students often comment on as making the difference between beneficial and disadvantageous placements – a welcome and education pack. Such documents are collected by students in advance of a new practice learning experience and provides information around the work of the ward or department and some pre-reading material to support learners when they are working with mentors.

Philosophy of the wider team

For placements to be effective there is a need for the whole team to share a philosophy that education involves everybody, no matter how closely they are to be working with a learner.
With many expert practitioners working in the placement settings, there is huge educational potential for students through working alongside such individuals – irrespective of whether they hold a formal mentoring qualification.

In recent years, there has been increasing debate around the practicalities of making all registered nurses mentors (Anonymous, 2014). This is a very contentious issue, as is the suggestion that mentors should receive additional pay. I feel that a mentor requires a number of personality traits, such as patience, resilience, creativity and an interest in education that not all nurses necessarily possess. My professional opinion is that mentoring and supporting education in practice requires specialist skills, and not all staff are cut out for the role. This view is supported by the findings of the Willis Commission (2013) into the future of nursing education and discusses the complexities and demands of the mentoring role. At the current time, there is no personal selection criteria for mentors, as there is a requirement to increase the numbers of mentors in the practice setting (Anonymous, 2014).

My current role as a lecturer involves me leading tutorial sessions that outline the expectations of students prior to entering placement settings for the first time. If placement areas can be encouraged to develop and expand upon the learning opportunities available in practice with the support of the Higher Education Institutions (HEI), the benefit to students will be far reaching.
Furthermore, each HEI will have their own approach to managing the placement element of courses – and in particular the support offered and provided to students and mentors in such settings.

Conclusion

Having undertaken the literature search, and been surprised around the literature leaning towards the “gold standards”, I believe that there are advantages to exploring how students benefit from a perceived negative, or poor placement experience. There is also an understanding to be gained from students as to what their perception is of good and bad placements. By this I mean that a good educational placement experience for one student may be viewed differently by the next.

Placements are a stipulation of a nurse training programme, but also need to provide the student with opportunities to learn the role they are being prepared for. As the function and outlook of a placement varies from the outlook of a student, mentor, lecturer and workplace, it is likely that some students will perceive their experience to less than ideal. It can be argued that as the body with overall responsibility for students, the HEI must much better prepare students for placement experiences.

Having undertaken a review of this literature in this area, I perceive the following to be potential researchable problems.

1. In the eyes of nursing students, what is a good or bad educational placement experience?
2. What are the benefits to student nurses of a perceived negative educational placement experience?
3. What is the role of the university in preparing students for placement learning opportunities?

From a methodological perspective, there is scope for an ethnographical approach in order to undertake observations in practice. This would allow me to gain an understanding of the factors in a range of placement settings that contribute to the overall educational experience.

Darren Brand, Senior Lecturer, School of Health Sciences

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