Description: what happened.
Whilst working on a medical ward with a senior staff nurse as a mentor, I identified certain competencies which needed achieving around management of care, and negotiated these with the mentor. Accordingly, the mentor suggested that I take charge of the patient workload we had been allocated for that shift, and both prioritise the care and nursing tasks, and also attend the ward round with the medical teams, providing the nurse liaison and taking the instructions from the consultants in relation to ongoing patient care and case management.
Accordingly, I agreed on the prioritisation of patient tasks and allocated the workload to the members of staff in our team, and when the ward rounds began, my mentor and I attended. However, when the doctors communicated with us, they automatically addressed her, and although she turned to me to provide key information, they continued to chiefly communicate with her, and she did not correct this. Subsequently, she took charge of the ward rounds and I remained as an observer. At the end of the ward rounds, it should have been my role to take the instructions given and to implement them in changing care plans and in directing or implementing clinical tasks. However, my mentor continued to take charge of this for the rest of the time, giving me little opportunity to experience this aspect of the role for myself.
There is a great sense of responsibility associated with management tasks, which extends beyond being responsible for individual patients to being responsible for a group of patients, and for the actions of some staff allocated to their care. I felt very strongly motivated towards achieving management competencies, but also very nervous and concerned that I would do this effectively without compromising patient care. I felt that I was achieving well under supervision until the ward rounds, where the mentor ‘took over’ and did not discuss why she had done this. I then felt as if I was unable to fulfil my competencies, and that I must have failed in some way because she did not allow me to continue in the role.
It was very positive to take charge of some management tasks and to complete these effectively. In particular, other staff responded well to me taking on this responsibility (in liaison with my mentor), and this positive feedback gave me more confidence to continue in this role. However, the way that my mentor just stepped in and took charge during the ward rounds undermined my confidence and was very challenging to deal with. I felt that I should have been more assertive at this point, but did not feel I had the confidence to do this.
The acquisition of the complex skills associated with the staff nurse role have always been problematic (Gerrish, 2000). However, the literature seems to suggest that nurses are learning to perform this role in a rather haphazard manner,in the light of what they perceive to be inadequate preparation and lack of support (Gerrish, 2000). Bradshaw (1998) suggests that this is partly because nursing competency is only vaguely and broadly defined, which means that preparation and assessment of competency is both haphazard and unstructured. This also suggests there may be a potential safety hazard for both patient and nurse (Bradshaw, 1998). This would certainly seem to be the case here, where the inability to fully engage with management roles does not support the student in becoming competent. Baillie (1999) in an action research study of the topic found that preparation of students for their management role as staff nurses benefits from being closely linked to practical experience, with clear learning outcomes and supportive clinical staff. In this instance, staff were generally supportive, and clear learning outcomes set, but the mentor failed to follow through to meet these outcomes completely. This may have been because the mentor felt that there was a risk to patient care and safety, but this was not communicated to the student and there may have been other ways in which this could have been managed.
However, there may be other reasons for this occurrence. Cahill (1996) in a small study found there to be a type of ward culture that not only separates those with knowledge from those who need to learn, but also reinforces the position of the student through both covert and overt mechanisms of control. If such a finding were applicable in this case, then it would suggest that the mentor may have been (consciously or subconsciously) reasserting her own authority and position of power and greater knowledge. The position of student nurses may also be such that they adhere to these cultural practices in order to ensure they receive a favourable report at the end of the placement (Cahill, 1996). Lofmark and Wikblad (2001), in a study of facilitating and obstructing factors for development of learning in clinical practice, found that responsibility and independence, opportunities to practise different tasks, and receiving feedback were facilitating factors for learning. In this case, it would appear that responsibility was offered, but not fully, and it is problematic to see how a student can achieve true independence whilst being supervised.
In Lofmark and Wikblad’s (2001) study, other perceived promoting factors included perceptions of control of the situation and understanding of the ‘total picture’. Here it would have been useful perhaps if the staff nurse had explained to the student why she retained control and why she did not follow through on her promise to allow the student to take charge. Such behaviour was found in the Lofmark and Wikblad study to be one of the obstructing factors to learning, where the nurses as supervisors did not rely on the students. Other obstructing factors were supervision that lacked continuity and lack of opportunities to practise Lofmark and Wikblad, 2001). Perception of their own insufficiency and low self-reliance were drawbacks for some students (Lofmark and Wikblad, 2001), which is also true in this reflection, but these perceptions seem to be linked to the ways in which mentors and other staff perceive and interact with students. It also appears that the NMC Code of Conduct (2004) works both to support students here but also restricts their opportunities to engage in practice, due to the need to primarily protect and support the wellbeing of the patients.
The learning that has taken place here is vitally important for continued functioning and the acquisition of confidence as a staff nurse in future. Not only do ward cultures play a large part in student experiences, but relationships are the fundamental component of how nurses function in their environment. Some aspects of the nurse-mentor relationship, while perceived as challenging, may be necessary or inevitable, and it has not become clear to me through this reflection how this can be changed, other than to raise these issues honestly with mentors during initial and mid-point interviews to acknowledge them and how they will affect the learning experience.
Explore dimensions of the nurse-mentor relationship further
Raise issues of independence, power and control during initial placement interviews.
Seek out ways to develop management competencies through a variety of mechanisms and experiences.
Identify communication issues and potential means of addressing them.
Engage in more management activities, daily, until other staff members gain trust in my ability to fulfil these roles.
Attend all ward rounds to gain confidence in this area.
Engage in future cycles of reflection.
Baillie, M. (1999) Preparing adult branch students for their management role as staff nurses: an action research project. Journal of Nursing Management 7 (4), 225–234.
Bradshaw, A. (1998) Defining competency in nursing: an analytical review. Journal of Clinical Nursing 7 (2), 103–111.
Cahill, H.A. (1996) A qualitative analysis of student nurses’ experiences of mentorship Journal of Advanced Nursing 24 (4), 791–799.
Gerrish, K. (2000) Still fumbling along? A comparative study of the newly qualified nurse’s perception of the transition from student to qualified nurse Journal of Advanced Nursing 32 (2), 473–480.
Lofmark,A. Wikblad, K. (2001) Facilitating and obstructing factors for development of learning in clinical practice: a student perspective Journal of Advanced Nursing 34 (1), 43–50.
Nursing and Midwifery Council. (2004). The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics . London. Nursing and Midwifery Council.