Developing mentors to support students in practice, Part 8 Assessment and Accountability: 3 –Accountability and Sign Off mentors
Summary
Responsibility and accountability are essential concepts that mentors and practice teachers need to explore as part of their role in supporting learning and assessment of students in practice. Mentors and practice teachers within the United Kingdom (UK) are required by the Nursing and Midwifery Council (NMC 2008a) to demonstrate that they have met NMC (2008a) Standards to Support Learning and Assessment in Practice (SSLAP). This article is part of a series of eleven which relates to these standards of which this is part 8 and the final part that considers assessment in practice. It will provide a brief recap on the history of the development of the SSLAP followed by exploration ofthe responsibility, accountability and ethical issues of the mentorandpractice teacher in relation to the assessment processalong with application of the ethical principles. The sign off mentor role as well as ‘due regard’will be discussed. The meaning of competence and partnership working when making assessment decisions will finally be explored. Much like the other two articles on assessment the issues discusseddirectly relate to the third domain and outcomes of the NMC (2008a) SSLAP named ‘Assessment and Accountability’.
Recap on the history of the development of the Standards to Support Learning and Assessment in Practice (SSLAP).
The Nursing and Midwifery Council (NMC) in 2004 published Standards for the preparation of teachers of nursing, midwifery and specialist community public health nursing. These were originally set by the United Kingdom Central Council for Nurses, Midwives and Health Visitors (UKCC) and adopted and republished by the NMC in 2002 and then again in 2004 the standards had a minor review to bring them in line with the new register (NMC 2008a). Following on from this in August 2006 the NMC (2008a) published the Standards to Support Learning and Assessment in Practice (SSLAP). This was due to a complete review of the previous standards that took place in 2003 along with consideration of the NMC (2005) consultation on fitness to practice at the point of registration. There were overlapping issues from both consultations in relation to quality and support for learning and assessment in practice (NMC 2008a). Since the publication of the SSLAP all students whom are on an NMC approved programme from September 2007 have been required to be supported and assessed in practice by the relevant practitioners who have attained the relevant qualifications (NMC 2008a). An in-depth account of the SSLAP (2008a) can be found in part one of the series named Developing Mentors to Support Students in Practice. Part 1: Standards to Support Learning and Assessment in Practice. Supervision, support and assessment of student performance remain an important part of the work of registered nurses, midwives and specialist community practitioners (Casey and Clark 2011).
The NMC (2008a) are quite clear on the roles of the mentor and practice teacherand what they are responsible and accountable for, see box 1. One of the most important roles that a mentor and practice teacher are responsible and accountable for is the assessment of a student in practice, including the student’sskills, attitudes and behaviours. Mentors and practice teachers are responsible for liaising with others to provide feedback, identify any concerns about a student’s performance and agree any action as appropriate. However, Walsh (2010) purports that assessment in practice is often not given the priority it ought to be.
Responsibility and Accountability
In accepting the role of a mentor and practice teacher, Gopee (2011 pg. 224) states thatthey are implicitly accepting responsibility and accountability for maintaining the standards of supervision and assessments. Now complete learning activity 1.
Responsibility and accountability are often used interchangeably as though they have the same meaning but this is not the case (Griffith and Tengnah 2010). Responsibility means having control or autonomy over someone or something. Griffith and Tengnah (2010) explain that nurses and midwives are responsible for their own professional practice and they decide how and what interventions are required for service users whilst taking into account the service usersbest interest.Gopee (2010) emphasises that as practitioners we are responsible for all our activities and behaviours. According to Wheeler (2012) practitioners are entrusted with and except this responsibility then they must be accountable for what they do. Gopee (2010) claims that practitioners are accountable for the activities and behaviours that are allocated or assigned to them during the course of their duties. Accountability is an obligation to give an explanation for actions and omissions (Wheeler 2012). Therefore,nurses and midwives in the role of a mentor or practice teacherare answerable for their acts or omissions and thus have a responsibility to ensure that students gain the necessary experiences to develop their professional competence (Gopee 2011). Professional practitioners are accountable to and for the service user under civil and criminal laws, also they are accountable to the profession, to the general public, to the professional regulatory body and to the employer (Gopee 2010). As well as considering accountability mentors and practice teachers need to also consider the ethical issues in relation to the learning and assessment process and the decisions they make regarding a student’s practice. Application of accountability and the main ethical principles that are essential in the assessment process will be discussed after the learning activity, therefore before reading on complete learning activity 2.
Ethical Principles
Ethics is a generic term for various ways of understanding and examining the moral life (Beauchamp and Childress (2001). Butts and Rich (2013) explain that ethics is the study of ideal human behaviour and existence, focussed on understanding the concepts of and distinguishing between right and wrong. There are five widely accepted sets of principles of ethics which apply directly to mentoring. According to Gopee (2011), these include: The value of life, goodness and rightness, justice and fairness, truth telling and honesty and individual freedom; see Table 1 for how these apply to mentorship. Two other main ethical principles from Beauchamp and Childress (2001) can also be applied when supporting learning and assessment in practice; Non-maleficence and Beneficience. Non maleficence is the ethical norm that advocates no harm to service users (Wheeler 2012). Beneficence is the ethical principle in relation to ensuring that service users benefit from the caring relationship. It is about balancing the benefits against the risks, costs and ensuring that all things considered service users receive the best possible care (Wheeler 2012).
Assessment is a fundamental role of the mentor and practice teacher in order to provide support and guidance for a student’s successful development but also to prevent a failing student from becoming a registered nurse and thus safe guarding the public (Luhangaet al 2008). As stated above in accepting the role of a mentor and practice teacher, the registrant therefore has a responsibility and is accountable for their actions and omissions in relation to supporting a student’s learning and assessment in practice (Gopee 2011). One of the main responsibilities of a mentorand practice teacher is to make a judgment regarding a student’s abilitiesin practice and they are therefore accountable for the decisions they make. This approach is adopted by the NMC (2008b)and states in its code, ‘you are personally accountable for the actions and omissions in your practice and must always be able to justify your decisions’.Therefore Casey and Clark (2011) purport that it is vital the student – mentororpractice teacher relationship remains a professional partnership and one that has clear boundaries that differentiate the differing roles a mentor and practice teacher plays. There is a need to balance the supportive nurturing role with that of the assessor role in order to make objective, unbiased assessment decisions (Casey and Clark 2011). Practitioners are accountable to the professional bodies regarding the decisions they make in relation to the student’s competence. Thus there is acknowledgment by the NMC that mentors and practice teachers especially the sign off mentorwho are signing off proficiency need to recognise their additional accountability and be aware of their obligations to protect the public. Reassuringly Middleton and Duffy (2009) in their qualitative study with a small number of community nurses found that mentors appeared to be acutely aware of their accountability but did have some concerns about being held accountable.
The NMC (2008a) claims that mentors and practice teachers are responsible and accountable for assessing total performance of a student and this includes the clinical skills, attitudes and behaviours (NMC 2008a pg 19-20).Concerns have been highlighted regarding nurses being adequately prepared for their professional role (Duffy 2003, Brown et al (2012). Coupled with the recent Francis (2013) report which cites issues regarding poor nursing care and incompetence of staff within a particular trust, it is therefore imperative that mentors and practice teachers need to take into account and assess a student’s total performance which includes the knowledge, skills, attitude and behaviours. However, Gopee (2011) suggests that mentors and practice teachers do not put as much emphasis upon student’s attitude and behaviour and they appear to concentrate more on the clinical skills and knowledge. Therefore in addition to assessing the skills and knowledge mentors and practice teachers need to be assessing a student’s enthusiasm, compassion, along with the student’s attitude towards caring, dignity, respect and integrity of patients (Gopee 2011).
A mentor and practice teacher needs to consider the decisions they make regarding a student’s competence and only pass a student when there is sufficient evidence of competency. Otherwise they can knowingly or unknowingly cause harm to service users (Gopee 2010). If they are to pass to a student who is not competent this can be construed as unethical practice on their part and links to the ethical principle of Non-beneficence Moreover, according to Gopee (2010) the student could then engage with unethical clinical practice through faulty care delivery. Furthermore, this decision can also inadvertently mislead the student into believing they are competent when they are not and again can be construed as unethical (Goppe 2010).It is important to stress that mentors and practice teachers are accountable to the students and required to defend their decision making process that has taken place. More importantly this should involve disclose of information if a mentor or practice teacher is aware that someone maybe at risk of harm and they should act without delay if they believe that a student or colleague maybe putting someone at risk (NMC 2008b pg. 5). To summarise ethically practitioners owe patients a duty of care to protect them against harm (Wheeler 2012).One of the legal implications of assessments is that when a student passes the programme they are able to practice without direct supervision. Consequently,potentially allowing someone to practice who is unsupervised and not competentis technically in breach of the law (Gopee 2011). This is especially so in cases of failing to fail a student. Failing to fail is thus unethical (Gopee2010). Failing to fail and managing a failing students has been covered in more depth in a previous article named, ‘Developing mentors to support students in practice, Part 7 Assessment and Accountability; 2 –Importance of feedback and managing failing students’.
Nurses and midwives areaccountable to themselves, the publicand have a duty of care which they need to consider carefully when delegating work to someone who is not on the NMC register. Even though they may delegate the responsibility for caring for a particular service user the mentor or practice teacher remains accountable for ensuring the student performs the delegated interventions to the required standard and should ensure appropriate levels of supervision or support are in place(Gopee 2010).The NMC (2008b) affirms thatthe interest of the service user is paramount and they must come first. Thus accountability to the service user is more important than accountability to the student. It is the quality of patient care which is at stake and it is this that the mentor orpractice teacher is ultimately accountable for (Walsh 2010). Mentors and practice teachers must balance the benefits of delegating clinical interventions to students and the level of supervision required so that they ensure a service is not put at risk at any time whilst in their care, thus linking to the ethical principle of beneficence. To summarise it is around maintaining the safety of those in care (NMC 2008b pg. 5).
The NMC have introduced and enforced the SSLAP(NMC 2008a) which clearly confirms those who can support and assess students who are on an NMC approved programme that they have the relevant qualifications and are prepared to do so. More importantly the NMC have introduced the sign off mentor role who is responsible for confirming that students have met the required standards of proficiency (NMC 2008a).
Sign off mentors and Due regard
All students on a NMC Pre-registration Nursing Education approved programme are required to have a sign off mentor at their final placement only. Therefore only those mentors who support pre-registration nursing students on final placements are required to meet the sign-off criteria, All midwifery students must be supported throughout their training by a sign off mentor at all times to confirm the students’proficiency at the end of each placement and at the progression points enabling them to proceed into subsequent years. Midwives who undertake mentor preparation are required to meet the additional sign-off criteria during the programme. Post registration staff on an NMC approved Community Specialist Practitioner programme also are required to have a sign off mentor and those on the Specialist Community Public Health Programme must have a practice teacher. According to Walsh (2010) the importance of the role of the sign-off mentor is in confirming that the student is a safe and effective practitioner who has completed their practice outcomes or competencies and can be recommended to the NMC for registration. The NMC (2008a) declares that the role of the sign off mentor is to make judgements about whether a student has achieved the required standards of proficiency for safe and effective practice for entry to the NMC register. According to Gopee (2011) signing off proficiency assures an individual’s ‘fitness to practice’ and therefore the role has to be performed responsibly and accountably. Thus a mentor or practice teacher are accountable for reviewing the student’s documentation including the on-going record of achievement to ensure that the evidence provided by the student has met all the standards of proficiency (Gopee 2010). The documents are then used as evidence to confirm that the student has successfully passed the practice requirements. Gopee (2010) goes onto to claim therefore it is a must that mentors and practice teachers have an understanding of the students programme and assessment requirements and more importantly an in-depth understanding of their own professional accountability. Casey and Clark (2012) assert that sign off mentors should strengthen the quality of the practice assessment. However, Middleton and Duffy (2009) during the focus groups as part of their qualitative study found that mentors raised concerns about the implications of being a sign off mentor. Conversely, the number of focus groups and participants within the focus groups are somewhat small.
To become a sign off mentor a qualified mentor is required demonstrate that they have met additional criteria as listed in box 2. Once they have provided this evidence they can have this role annotated next to their name on the live register of mentors and practice teachers and thus are entitled to sign off a student’s proficiencies. Durham et al (2012) stress though that a sign off mentor must have the knowledge and skills to undertake a robust, equitable and fair assessment. The NMC (2008a) assert that the sign off mentor should be allowed protected time equating to one hour per week in addition to working with the student at least 40 per cent whist undertaking this role.However, the NMC recognises as part of interprofessional learning other practitioners and various placements will contribute to the students learning and assessment in practice (NMC 2008a). These practitioners will enable students to gain a breadth of experience but do not normally involve an assessment of the students practice that relates to the competencies related to the profession they intend to enter. In such placements the most appropriate person would assess the related outcomes which would be the professional who has the knowledge and experience in that area of practice. Now complete learning activity 3.
All mentors and practice teachers can assess a student’s individual competencies and skills, however, as discussed earlier only a sign off mentor and practice teacher who are on the same part or sub part of the register as the student and in the same field of practice may confirm that the student has met the relevant standards of proficiency that leads to registration or a recordable qualification (NMC 2008a). This is known as the principles of ‘due regard’ and needs to be appropriately applied. A hub and spoke approach may be used, where a student has a base or hub during a long placement, supervised and summatively assessed by a mentor or practice teacher with due regard. As part of this placement students may undertake a series of spokes overseen by a range of supervisors who then must feedback to the hub mentor or practice teacher (NMC 2007). Now complete learning activity 4