Pain_Management

Reflective Commentary This essay aims to critically evaluate my role as a mentor in facilitating effective learning in the community nursing setting and reflect on my experience as a student mentor using Gibbs reflective cycle (1988) throughout the text to aid my reflection. (Please see appendix 1). I will discuss educational audit within my clinical setting and will describe how I created an effective learning environment for my student and how she was integrated into the clinical setting, critically evaluating the experience as I reflect as well as incorporating models of change. I will then move onto learning and teaching strategies, reflecting on how I applied these to help my learner. Assessment will then be discussed. This will include the application of principles and theory of assessment to my experience of being a student mentor. Lastly, the aspect of evaluation will be explored. I will critically discuss my contribution to the formal evaluation of the learning experience and evaluate my overall performance as a student mentor. When reflecting on my role as a mentor, it is apparent that educational audit forms an essential part of the mentoring process. The East of England Multi-Professional Deanery (2009) describe educational audit as a means of assuring the quality of practice placements through support and development. They maintain that auditing learning environments is an integral part of quality assurance. When preparing for my student to arrive in the clinical setting, I researched into educational audit and found that The Quality Assurance Agency for Higher Education (QAA, 2009) sets out requirements for placement learning within it’s practice code so that clinical areas have a guide to self assessing. The learning environment ties in with educational audit as the audit is what assures the quality of the learning environment. Learning in a clinical setting is just as important as university learning (Stuart 2007) as the education to become a nurse comprises of 50% theory and 50% practice (NMC 2004). The practice element brings the theory to life for the student and it is an opportunity for practical skills to be observed, practiced and retained (Beskine2009). This is supported by Race (2005) who states that you can only truly learn by doing, a person may think that they know how to perform a particular skill through theory, this can only be confirmed by practice. According to Moscaritolo (2009), ‘The clinical learning environment has been and will continue to be a large part of nursing education’ (P 18). It is therefore extremely important that the clinical setting is an environment conducive to learning. Before Zoe (my student) arrived in the clinical area I was thinking about how I could make the clinical area as student friendly as possible. Upon reflection, I was feeling apprehensive yet was looking forward to the learning experience. I decided to carry out a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of the clinical environment. The weaknesses can then be incorporated into an action plan to improve the learning environment (Welsh & Swan 2002). This analysis highlighted a lack of text books and journals for Zoe to use. According to Quinn (2000), access to information through sources such as books, journals, and the internet is a factor towards a positive learning environment. I therefore formulated an action plan and spoke to my colleagues and we were all able to increase our resources by contributing books and journals from our own personal collections. The analysis also highlighted strengths in out clinical area such as easy access to the internet and quiet rooms for study. According to Stuart (2007), the importance of the mentor in establishing a positive and conducive learning environment has grown. I feel that this is especially true in the community nursing setting because learning does not just happen in one place. For example, the NMC (2006), state that the mentor must support critical reflection and ensure there is time for discussion and explanation, so community nurses may utilise their time spent travelling with their student for this discussion (Ripley 2007). Hall (2006) adds that in the community setting the patient’s own home is often the learning environment and it provides a good variety of opportunities for learning although it must be noted that the mentor has less control over this environment. In order to create an environment conducive to learning, the learner must be assisted by the mentor to identify their learning needs (NMC 2006). On Zoe’s first day, after her orientation, we were able to draw up a learning contract so that I was aware of what she hoped to gain from her community placement. Zoe’s main objective was to obtain a competency in removal of sutures or clips. The qualities of a mentor are another important element of the learning environment (Gary and Smith 2000). This includes professional and personal qualities such as professionalism, a friendly nature, understanding, and patience (Beskine 2009). Added to this, the learner must be made to feel welcome through staff attitudes, this will help the learner to become integrated into the clinical environment (Hutchinson, 2003). Throughout the learning experience I feel that Zoe and I had a strong professional relationship and that I was an approachable and friendly mentor, enabling us to maintain a trusting relationship conducive to learning. This relationship, according to Zoe, reduced stress and anxiety. Locken and Norberg (2005) state that anxiety in students becomes reduced when mentors are able to build a good working relationship with their student and are able to work with them for almost all of their placement. Supporting this, Hughes (2005) adds that “Stress contributes to anxiety, which can in turn interfere with students’ academic performance by leading to the development of poor coping skills”. One potential barrier in creating an effective learning experience is the personal attributes of the mentor. Although there are guidelines from NMC (2006) to support the role of the mentor, there are no rigid rules about how mentors teach in the clinical environment. Therefore the success of teaching relies on the personal enthusiasm of the individual mentor (Cardwell, Corkin, 2007). I feel that this is a true statement as it can be seen in the clinical environment that many mentors are reluctant to take students. This may be because of time constraints, work load or even that they themselves did not choose to undertake the mentorship programme but were required to by management. This is supported by Mills et al (2005) who state that the high level of commitment by the mentor required for effective learning to take place can sometimes create a challenge that can potentially be a barrier to learning. The number of students allocated to a mentor can also cause problems as mentors feel that they cannot commit enough time to each of their students (Moseley and Davies, 2008). Registering as a qualified nurse with the NMC is the first big milestone of any nursing career (Ali and Panther, 2008). So to get to this point, the NMC have published guidelines for mentors to follow and standards for students to aspire to. The most recent of these was published in 2006 and set out UK standards for professional nursing practice in relation to mentoring students. These standards are empowered by ‘The Nursing and Midwifery Order 2001’ (HM Government, 2002) and ‘The European Nursing and Midwifery Qualifications Designation Order 1996: Nurses, Midwives and Health Visitors’ (HM Government, 1996). It is clear that when a student enters the clinical environment, the area and the mentor must adapt to support the student’s learning needs. As mentioned before, our team changed the learning environment after carrying out a SWOT analysis so that materials conducive to learning were readily available for Zoe to use. The team needs to be open to change if needs arise in order to achieve excellence in practice, enhancement of learning experiences and quality assurance. A model of change which can be used in a situation such as this is Lewin’s (1951) force field analysis. According to Lewin, “An issue is held in balance by the interaction of two opposing sets of forces – those seeking to promote change (driving forces) and those attempting to maintain the status quo (restraining forces)”. So in order for any change to occur, the driving forces must exceed the restraining forces, thus shifting the equilibrium and allowing change to occur. For example within the clinical area we as mentors must realise that change can improve the learning environment, so we see a driving force which exceeds the restraining force and change happens. Zoe had expressed in her learning contract that she would like to gain a competency in removal of sutures and clips. Among other competencies that Zoe and I worked on together, I decided that I would like to focus on the removal of sutures and clips for the purpose of my mentorship course. Learning contracts help to ensure that both mentor and student take an active role in the learning that occurs (Quinn, 2000). On my third day working with Zoe after orientation and after beginning to build up a relationship with her, I arranged for her to do a VARK (Fleming, Mills, 1992) assessment in order to find out her learning style. It is important to identify a learner’s style so that material can be adapted to facilitate effective learning (McNair, 2007). I also carried out this assessment on myself. The acronym VARK stands for Visual, Aural, Read/write, and Kinesthetic (Fleming, Mills, 1992). These are different learning preferences or styles. My learning style is mostly read/write which means that I learn best having everything written down in lists etc. Zoe’s assessment showed that she has a mild kinesthetic learning preference but was also quite a visual learner. Kinesthetic learners are best taught by doing and visual learners find pictures and diagrams useful. Because Zoe and I are so different in our learning preferences, it was necessary for me to adapt my teaching so that it would best suit Zoe. The NMC (2006) developed standards which indicate that mentors should try and achieve ‘best fit’ with the level and type of learners that they come across in practice. In order for Zoe to achieve her competency set out in her learning contract, I set about planning learning experiences for her. As her VARK assessment had shown that she was a kinesthetic learner, I arranged for most of our learning experiences to be practical. Firstly, I asked her to research the subject independently to see what she could find on her own. This promotes lifelong learning as Zoe is independently accessing content which she will need to practice throughout her career in nursing (Candela et al, 2006). However, I ensured that she was able to access the correct material and that she is used to searching literature to find the most up to date and appropriate information before leaving her to complete the task. Ripley (2007) states that mentors can sometimes expect their student to independently perform a task which can make the student feel less competent than previous students and demoralised if they are not able to do this. Welsh & Swan (2002) argue that before any facilitation can take place; the learner’s prior knowledge needs to be assessed as this is the baseline for the student’s development. After Zoe had researched the subject, we went through the material and discussed it and feedback was given. The next day, Zoe and I were able to visit a patient who required removal of sutures, Consent was gained from the patient, both to carry out the procedure and also consent that he was happy for Zoe to observe. According to the NMC (2008), the student’s status should be made clear to the patient before any procedure as the rights of a patient to refuse care from a student nurse are to be respected. After Zoe had observed the skill, we discussed it in the car on our way to the next patient and after we had finished our work for the morning, I carried out a short teaching session with Zoe about removal of sutures and clips. Within the handout that I gave to Zoe (Please see appendix 2), I made sure that I added large pictures as she is a visual learner and made the session quite brief as she learns best by doing. I also managed to find some replica skin and made my own sutures so that she could practice removing them before carrying out the procedure on a patient. Within the next week, Zoe and I were able to see two more patients, one requiring removal of sutures and the other requiring removal of staples, so again Zoe was able to observe the procedure on two different patients and, after a discussion, she said that she felt confident to practice the skill on a patient. In order to maximise the learning experience, students should be allowed to practice skills instead of merely just observing (Ripley 2007). Humanistic psychologist, Rogers (1969) also states that much learning occurs through practical experience. It can also be seen within the work of cognitive theorists (Race 2005) as well as in the theory of experiential learning where Kolb (1984) suggested that we learn by experiencing a situation and reviewing what happened so that when we next come across that situation, we can apply what we learnt through experience. I ensured that patients who required removal of sutures or clips were allocated to me so that Zoe could see the theory in action. The NMC (2006), states that mentors have a duty to prioritise work to accommodate their student’s needs and Sharples et al (2007) states that in the community environment, nurses are more likely to be able to take account of their student’s needs by arranging their workload around them. After Zoe said she felt confident in the skill she was able to carry it out under supervision on a patient (removal of sutures), and a couple of days later she had the opportunity to remove a patient’s clips. Zoe carried out both skills safely, confidently, and competently. When reflecting on my teaching, a theory which is relevant is the Gestalt theory. This theory maintains that learning takes place in small stages and links are made between these stages until the whole concept is understood (Kohler, 1947). With regard to my teaching with Zoe, it also took place in stages; research, discussion, observation, and practice. I feel that adequate teaching of the subject would not have taken place if each aspect were not covered. It seemed that the teaching all came together for Zoe at the end when she was able to apply the skill to a patient. Another relevant theory is behaviourism. This puts forward the idea that we learn by responding to stimuli (Reece & Walker, 2003). Zoe did respond positively to stimuli, for example when given praise for carrying out a skill well, although it can be argued that this way of learning could be seen as pedagogic. It is clear that from the first day of Zoe’s placement, she was learning in an andragogical way. This became apparent when we were drawing up our learning contract together. She already had her objectives in mind and she knew what she wanted to gain out of her community placement. Knowles suggested that students who have entered higher education see themselves as self directed because they have made the decision that they want to learn about a particular subject. He added that to teach learners in a pedagogic way (for example spoon feeding information), would adversely affect the way they learn (1998). Knowles assumed that people who perceive themselves as self directed will not respond positively to being treated like children (1990). Andragogy recognises that adults demand to learn things that are relevant to them, and relevant to their life experiences rather than assuming they know nothing (Atherton, 2005). Please see appendix 3 for more information about andragogy. It has been long accepted that assessment of students in practice is integral to the mentor’s role, it ultimately ensures public protection and patient safety as it should be the means of deeming a practitioner as either competent or incompetent (Watson et al 2002). The importance of assessment in practice has been reiterated by the Royal College of Nursing who called for the provision of protected time for mentors and students to complete teaching and assessing (RCN 2007a). During Zoe’s learning experience, she was assessed by myself, using various methods and at various points of the learning/teaching experience. About half way through, formative assessment was carried out; this was an informal process and was mainly a discussion between me and Zoe about how I felt she was progressing and conversely how she thought she was doing. According to Walton and Reeves (2001), this is the time where problems can be picked up and resolved and also a time for personal development. At this point Zoe and I discussed her development and were both very pleased with her progress. Although one aspect noted at this point was Zoe's lack of confidence. I felt that Zoe needed to have more confidence in herself when carrying out tasks. Identifying a problem at the formative stage enables it to be rectified by the summative stage (Sharples 2007). Stuart (2007) supports this, stating that without knowledge of what has been done well or done not so well, behaviour cannot be changed and it may become rooted if it is not dealt with. The summative assessment stage is more formal and it is usually where paperwork is signed off and the learner is deemed as competent at certain skills (Walton and Reeves 2001). Zoe was assessed using her practice placement documentation and also the competencies drawn up in our learning contract. Questioning was also used, according to Nicholl & Tracey (2007), questioning facilitates learning by requiring the student to actively participate and acquire a deeper understanding of the subject. After the teaching session I asked Zoe to complete a quiz in order to assess how much she had learnt, but my main method of assessment was observing Zoe carry out the skill. It is important when assessing to consider the validity and reliability of the assessment methods used. Quinn (2000) states that validity is concerned with how well assessment works and ensuring that the assessment measures what it is intended to. For example removal of sutures cannot be assessed by discussion only as I, as the assessor cannot be assured that Zoe is competent at the skill before it is actually performed. Reliability is concerned with the consistency of measurement (Quinn 2000). For example, ensuring that students are assessed fairly, in the same manner and objectively. However I feel that sometimes an amount of professional judgement is required in order to assess effectively. According to Norman et al (2000), there is a lack of research into the validity and reliability of assessment tools. A hugely prominent issue within assessment is the reluctance of mentors to fail some students (Duffy 2003). Watson and Harris (1999) found that 46% of mentors acknowledged that some students were being passed in their practice placements when their performance was not up to standard. To me, this is a worrying figure because these incompetent students that are being passed as ‘competent’ are our future nurses. Mentors are accountable to the NMC for their decision in assessing student nurses and the responsibility should be taken seriously (NMC 2006). Duffy (2003) outlines a procedure for managing failing and weak students and emphasises that action can be taken to help them improve once their problems have been identified. The third stage of Gibbs reflective cycle is evaluation which leads onto analysis, conclusion and action plan (Gibbs 1988). Upon reflection I feel that overall, the learning experience was extremely positive as Zoe was able to achieve her competencies within an environment conducive to learning which was extremely encouraging to witness. Although after analysing the experience it is apparent that there are some further aspects which I could have incorporated into my teaching. Zoe gave me feedback on my performance as a mentor and made some very encouraging and positive comments. She felt that she was integrated into the learning environment and felt part of the team. She was also pleased to fulfil her learning objectives and said that she enjoyed the way teaching took place as I took into consideration her individual learning style. One point which she made was that she would like to have been given an induction pack before her placement so she felt less anxious about coming into the community after only having hospital placements. I feel that this would have made a big improvement on the learning experience. In response to this I drew up an action plan, so in future when I have students I will incorporate an induction pack. The RCN (2007) recommends providing new students with an induction pack as it will prepare the student for the placement ahead. Quinn (2000) supports this by stating it is vital to help students prepare for placements as the community setting is so different to the ward setting that students are used to. When giving Zoe feedback , I always ensured that I ended on a good note. This technique is known as the ‘praise sandwich’ (Hinchcliff 2004). It consists of giving not so good feedback between positive feedback. For example, when telling Zoe that she needs to improve her confidence, I first said that she is progressing well and ended saying I was very pleased with her overall performance. When reflecting on what I found difficult about the learning experience, I found self assessment quite difficult but using Gibbs reflective cycle helped me through this and I have identified that my self assessment skills need to be developed in order to provide the best teaching possible. Diekelman (2004) argues that abilities essential to today’s nurse are self assessment, peer assessment, and lifelong learning. Through witness testimony of my colleagues, I was encouraged by positive feedback and also pleased with the comments in my practice document given by my mentor facilitator. Although I have taken on board comments to try to relax when giving teaching sessions as the anxiety can sometimes rub off on the audience, as my colleague found. After much reflection, analysis, and evaluation of the entire learning experience, the importance of mentorship has been reiterated to me again and again and it is clear that nursing would come to a stand still without mentors who can facilitate an environment and personality conducive to learning. The increased emphasis from the government on providing care in the community has also made mentoring students in this setting increasingly important (Ripley 2007). It can be seen that the mentorship role can highlight both weaknesses and strengths in the mentor and also aid in quality care delivery (Hall 2006). I am looking forward to further developing my role as a mentor and contributing to the education of our future nurses. To conclude, I am pleased that I undertook this course as I can see that what I have learnt will greatly affect my practice and not only benefit myself and the students that I take but also my team as I understand the importance of clinical audit and the effect that it has on the learning environment. As I have learnt from this course, teaching is extremely integral to nursing as you are not only teaching nurses-to-be but also patients, family, friends, and colleagues. Mentorship reiterates lifelong learning for me and has highlighted the importance of keeping myself updated in my field of nursing. Word Count: 3868.