Mentors do it with a conscience





The nurses in my research who mentored students in their workplace knew only too well what was at stake. They had a responsibility to their patients, colleagues, the health service and their profession to do a good job and make correct judgements about students. As they worked closely with students and befriended them to an extent (in order to help them to settle in and feel comfortable to ask questions, for instance), it could feel like a betrayal of trust tell them they weren't achieving. They did not hesitate to prevent a student from progressing in their training if they judged that to be the correct decision, but nevertheless their conscience could flood them with guilt feelings. The guilt could be associated with self-doubt - could I have done more to help them learn? It was also associated with anticipating the personal impact on the student, who had invested so much in their studies and in pursuing their nursing career. However, the guilt associated with making a decision that could potentially harm patients or the profession in the future was more persuasive.

However much the mentors could rationalise their judgements and decisions, they could not escape the 'call of conscience'. Philosopher Martin Heidegger proposed that humans are never fully at-home with themselves and constantly engage in anxious self-confrontation. To an extent, we can flee from this by inauthentically identifying ourselves collectively with a group, in which case we might tot up in a more detached way our 'good' and 'bad' actions. In being authentic, true to ourselves, we accept responsibility for our actions and there is always going to be some guilt, because we can never satisfy all needs. In taking one course of action, we cut off the possibilities for another. There is always something we didn't do.

Is this at all significant when coming to an understanding of the mentor experience? It is any more than an illustration of their humanity and a small window into the complexity of this and all human endeavours? I noticed that their conscience and their guilt would be formalised, at times when they softened the blow to a student by their careful construction of feedback, or in meticulous gathering of evidence to substantiate their decisions. It would be significant in less formal ways, such as in the way the mentors built allegiances with colleagues and used them as barometers for their mentoring judgements, or where they were 'looking over their shoulders' for anticipated student appeals against their decisions or fearing malicious gossip.

Maybe all I've done is to illustrate an aspect of human nature, but perhaps when we depend so heavily on mentors in the education of our student nurses, we need to be reminded that they are human and not simply commodities that feature in a numbers game.

The mentor's journey

The metaphor of journey is commonly applied to student learning. It is easy to conceive of a student on a journey from one preliminary state of being to another, more educated state. They arrive at their destination knowing more, seeing the world from a new viewpoint and with more nuanced understanding of the world. The journey changes them. A mentor's destination might not be as clearly articulated as that of a student, or even considered at all, but they are undisputedly on a journey of transformation - they cannot fail to be affected by their relationship with a student. Perhaps, though, the extent to which they are transformed depends upon opportunities to reflect. This might occur in the company of a critical friend, through flashes of insight during practice, or in conversation with their students.

Daloz (1999), drawing on his research with adult learners in higher education, suggested that mentors do three distinct things - they support, challenge and provide vision. Mentors make intuitive judgements of when to support and when to challenge so that they provide sufficient support to enable the student to trust them and to feel confident enough to try out new things. Too much challenge can destabilise a student and cause them to retreat into a 'safe' mode which stifles development. Providing vision can be achieved, for example, by modelling the endpoint of the learning journey (when students might have aspirations to become like their mentor), or offering students ways to see the practices and ways of working that make up the tradition they are entering.

In my PhD thesis, there appear to be several journeys - the student journey that mentors dip in and out of, the mentor journey and my own journey of transformation. Any journey of this sort can be hard and forces one to leave something of the old self behind. The people around  you may also need support to recognise the journey you have travelled.

Daloz, L. A. (1999). Mentor: Guiding the Journey of Adult Learners, San Francisco, Jossey-Bass.

What did the Nursing Times survey tell us?

The Nursing Times survey (reported on 27th April) seemed to reveal some quite shocking statistics about mentors passing students who they wanted to fail.  Then, on the 11th May it was reported that the Nursing and Midwifery Council (NMC) will take "immediate action" to address the concerns the survey raised.

The front line of this action entails writing to the directors of nursing in all NHS trusts and all deans in the universities and the commisioners of the education programmes to take immediate action and remind everyone involved of their responsibilities. While this is a useful first step, one wonders whether this will have the desired effect, which is presumably to ensure that students receive adequate support in their practice placements and have a fair and accurate assessment of their achievements. 

The job that mentors have to do to support and assess students is incredibly complex and in my opinion is severely underestimated when you consider the lack of time they have in which to do the work and the lack of formal or informal recognition they seem to have from their employers of the difficult job they do.
Those who do it very well can contribute a lot to our overall understanding of just what it takes to be a skilful facilitator of learning and a fair and just assessor who can really tell who you can trust to progress towards entry to the professional register and who you can't.

Trust is like paper

Compassion in nursing

There has been a lot recently in the nursing press about the compassion in nursing agenda, especially since the final report of the Prime Minister’s Commission on the Future of Nursing and Midwifery has called for all nurses and midwives to make a pledge to provide high quality, compassionate care.  This week, it was annnounced that the first national batch of nursing students to be tested and tracked on their ability to show compassion will be arriving at Welsh universities this September.  Some nurses are indignant that anyone should assume that compassion can be measured in tick-box fashion, and some suggest that keeping cool and making hard clinical decisions in an emotionally detached way is preferable to getting too emotionally involved. Others think the problem lies in the lack of compassion that nurses feel they are offered by those in power. 

I'm not so sure that being compassionate excludes calm, somewhat emotionally detached decison-making.  I think that nurses need to find a balance between being able to empathise with patients and be responsive to their emotional needs alongside the more fact-based clinical reasoning.  Surely, in the end, it's about knowing how to treat people as people and not "conditions in a bed".  Some of the best nurses I know do this juggling act incredibly skilfully and seemingly without effort, but no doubt they are paddling furiously under the surface.  Then, there are some nurses who are incredibly compassionate with patients but pay less attention to the emotional needs of their colleagues.

In my recent work on trust as revealed by the mentors in my PhD study,  I had a glimpse into just how complex all of this is.  Trust is essential for cooperative teamwork.  Nurses want and need to be trusted both by their patients and their colleagues - and although trust judgements are partly made in terms of cold facts ( can I rely on this person to do the job properly?), trust is also about emotional connections with people (if I reveal my personal or professional vulnerability, will this person respect that and respond appropriately?).  Psychological safety is crucial if nurses are to maintain a no-blame culture and learn from clinical mistakes. The less trust there is in the workplace, the more errors and near-misses will be swept under the carpet and the system will struggle to improve.

Trust and interdependence

Trust relationships in the world of the mentor seem to feature a marked interdependence. I'll consider this with respect to the relationships between mentor-student, mentor-university link, mentor-colleague and mentor-patient.

In the mentor-student relationship, the interdependence is concerned with the mentor depending on the student to practise in a responsible and reliable way (do no harm to patients) and to report back to peers and university staff in a way that is fairly representative of the experience they have had on placement, and that is respectful of some of the difficulties and subtleties of professional practice. The student depends on the mentor to show them good practice, open doors to learning experiences (make them available, e.g. access to patients and other professionals), and to assess their performance fairly.

In the relationship between the mentor and the university link person, the mentor depends on the university link person/people to provide the right information and training/updating when needed, and support and back-up in cases of difficult student-related issues. They also depend on the university sending students in manageable numbers and appropriately, in terms of matching learning needs to the practice area. Mentors rely on the university to prepare students appropriately for their forthcoming practice experiences. The university depends on mentors to provide the appropriate practice experience, communicate with them as necessary, and assess students appropriately.

In the relationship between the mentor and their immediate colleagues, the mentor depends on colleagues to show goodwill, cooperation and support towards the student, and to deputise in their absence. Mentors often depend on the opinions of and evidence provided by colleagues in assessing the capabilities of students. As having a student may be seen as competing or interfering with day-to-day practice, the mentor also relies on colleagues to be tolerant and accepting of their position and responsibility. There is probably less dependence in the other direction, unless colleagues are also mentors, in which case giving support can be reciprocated mentor-to-mentor. In some senses, then, the relationship between mentors and close colleagues could be unbalanced or unidirectional in terms of dependence.

With patients, mentors depend on patients allowing students to take part in their care. Patients depend on the mentors to delgate and supervise appropriately to deflect risk of harm.

Where there is obvious interdependence, this must be different to situations where the mentor is more dependent, for example, on colleagues to provide support. Where does trust come into this? Is it easier to make yourself vulnerable, knowing that the other can also be vulnerable?

How do nurses negotiate multiple trust relationships in their mentoring roles?

Trust exists in relationships with patients, colleagues, managers, and relevant professional bodies. Indeed, the first item in the Nursing professional code of conduct is that “The people in your care must be able to trust you with their health and wellbeing” (Nursing and Midwifery Council, 2008). The code further stipulates that nurses have an obligation to work collaboratively in teams and behave in such a way as to uphold the reputation of the profession.

Trust is thought to be important for cooperative behaviour. Workers are said to trust others when they have optimistic expectations of them and are willing to be vulnerable and take a risk with regard to the other fulfilling their expectations (Rousseau, Sitkin, Burt, & Camerer, 1998; Whitener, 1997). The relationships between mentors and students and with their work colleagues seem to call for a consideration of collegial trust. Collegial trust operates on an interpersonal level and carries an expectation of the other person working with professional integrity and doing what is expected (Jackson, 2008; Sullivan, Francis, & Hegney, 2008).

The data in my study reveals a complex web of relationships that mentors negotiate. With their work colleagues, they sometimes need to advocate for their mentoring activities and the presence of students in the workplace, or they may need to confide in colleagues about aspects of their mentoring practice, or delegate to them for supervision of and judgements about their student. With the partner university, it is important to them that their judgements and concerns about students are taken seriously, but also that their goodwill in taking students and making the effort to support students is recognised and not taken for granted. With students, they make efforts at befriending in order to put students at ease, and to foster a sense of trust that enables disclosure by the student. Such disclosures can be seen as essential for supporting reflection on practice. However, this befriending must be tempered by the requirement of mentors to assess students' practice, determining their eligibilty to progress in their training, or even to progress onto the professional register. With regard to patients, mentors are protective, seeking to reduce any risk associated with students providing care. They also require patients to cooperate with the student, and accept that some patients will refuse care by a student.