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Mentorship for Pre-Registration Nursing and Midwifery Students Policy

V2.0

July 2019

Mentorship for Pre-registration Nursing and Midwifery Students Policy V2.0 of 34

Summary This policy aims to provide a clear interpretation of the Nursing and Midwifery (NMC) standards to support learning and assessment in practice (NMC 2008) for implementation at the Royal Cornwall Hospitals NHS Trust. The standards include clear requirements for organisations that support students both academically and in practice. This policy will provide clarity of responsibility to ensure that we provide high quality placements for all of our pre-registration nursing and midwifery students.


Table of Contents

Summary ............................................................................................................................ 2

1. Introduction ................................................................................................................. 4

2. Purpose of this Policy/Procedure ............................................................................. 4

3. Scope ........................................................................................................................... 4

4. Definitions / Glossary ................................................................................................. 4

5. Ownership and Responsibilities ............................................................................... 5

5.1. Role of the Sister/Charge Nurse ............................................................................ 5

5.2. Role of the Learning and Development Team ....................................................... 5

5.3. Role of Individual Mentor/Sign off Mentor .............................................................. 5

6. Standards and Practice .............................................................................................. 6

6.1. The RCHT Mentor Register ................................................................................... 6

6.2. Becoming a mentor ............................................................................................... 7

6.3. Becoming a sign-off mentor ................................................................................... 8

6.4. Maintaining status as a mentor or sign-off mentor (triennial review) ...................... 8

6.5. Maintaining status as a mentor/sign-off mentor (meeting Nursing and Midwifery Council (NMC) requirements) ........................................................................................... 9

6.6. Allocated learning time for mentor activity ........................................................... 10

6.7. Nursing and Midwifery Council (NMC) requirements to effectively support learning and assessment in practice ............................................................................................ 10

6.8. Students undertaking specialist placements ........................................................ 11

6.9. Maintaining a sufficient number of mentors in a clinical area .............................. 11

7. Dissemination and Implementation ........................................................................ 12

8. Monitoring compliance and effectiveness ............................................................. 12

9. Updating and Review ............................................................................................... 12

10. Equality and Diversity .............................................................................................. 13

Appendix 1. Governance Information ............................................................................ 14

Appendix 2. Initial Equality Impact Assessment Form ................................................. 16

Appendix 3. Mentor mapping tool .................................................................................. 19

Appendix 4. Triennial review framework ....................................................................... 28

Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We cannot rely on opt out, it must be opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the Information Use Framework Policy or contact the Information Governance Team [email protected]


1. Introduction 1.1. The Nursing and Midwifery Council (NMC) published new standards to support learning and assessment in practice in 2008 (NMC 2008). These standards include clear requirements for those organisations that support students both academically and in practice. This policy will provide clarity of responsibility, to ensure that we provide high quality placements for all of our pre-registration nursing and midwifery students. 1.2. We will not under-estimate the importance of effective mentorship for pre-registration nursing and midwifery students. A student’s fitness to practice as a registered healthcare professional is assessed by mentors in clinical placement areas. Therefore, assurance that our mentors are experienced and capable in competency assessment and fitness to practice is essential.

1.3. Whilst the NMC standards for mentorship have been in place for several years, their implementation at RCHT have been recently reviewed and local approaches to the standards have been developed in partnership with our local higher education institution (HEI) provider.

1.4. This version supersedes any previous versions of this document.

2. Purpose of this Policy/Procedure This policy aims to provide a clear interpretation of the NMC standards to support learning and assessment in practice (NMC 2006) for implementation at the Royal Cornwall Hospitals NHS Trust.

3. Scope This policy applies to all nursing staff who either provide placement areas for pre-registration student nurses or undertake the direct mentor/associate mentor role.

4. Definitions / Glossary Mentor – a registrant who, following successful completion of an NMC

approved mentor preparation programme, can supervise pre-registration students, support their development and assess their competence to practice.

Sign-off mentor - a mentor who holds additional responsibility to assess

whether a final placement student has achieved the standard of safe and effective practice required for entry onto the national NMC register.

Triennial review - a three-yearly assessment of of an individual’s ability to

maintain his/her role as a mentor and, if applicable, as a sign-off mentor. Mentor register - a list (or database) of registrants who have achieved the

criteria to become (or maintain their position as) a mentor or sign-off mentor.

Placement Development Team (PDT) - a virtual team that comprises

academic staff from Plymouth University and staff from RCHT who work closely together to co-ordinate and support student placements at RCHT.


5. Ownership and Responsibilities

5.1. Role of the Sister/Charge Nurse Ward/Department Sisters/Charge nurses are responsible for ensuring that:

the mentor register for their department is up to date and reflects current staff members

there are sufficient mentors and sign-off mentors for the agreed number of students undertaking clinical practice placements

all staff who undertake the sign-off mentor role are annotated on the Trust mentor register as a sign-off mentor

all mentors and sign-off mentors attend/complete an annual mentor update

all mentors and sign-off mentors complete a triennial review every three years and that this is communicated to the L&D team to update the Trust mentor register

adequate time for mentor activity is supported within the clinical area

work rotas enable students to work with mentor(s) for at least 40% of their time in clinical placement

student mentors are allocated prior to the start of a student placement

each student has a named mentor for the duration of their placement

sign-off mentors receive one hour per week protected time with their final placement student

support and supervision to mentors is provided to enable them to fulfil their mentoring responsibilities, assist with complex judgements and support professional development.

5.2. Role of the Learning and Development Team The Learning and Development Team is responsible for:

maintaining a ‘live’ register of mentors and sign-off mentors at RCHT

the provision of monthly mentor updates

direction and sign-posting regarding the development of mentoring skills

co-ordination of access to NMC approved mentorship courses

ensuring information/protocols regarding mentoring and sign-off mentoring is available and up to date

reviewing changes to NMC guidance and adapting protocols/information at RCHT accordingly

liaison with Plymouth University

provision of support and supervision to mentors to enable them to fulfil their mentoring responsibilities, assist with complex judgements and support professional development.

5.3. Role of Individual Mentor/Sign off Mentor All mentors/sign off mentors are responsible for:


ensuring that they meet NMC requirements for both becoming and remaining a mentor/sign-off mentor

seeking advice or clarity regarding issues pertaining to the mentorship of pre-registration nursing students

checking their status on the RCHT mentor register at least once yearly

ensuring that they understand the content of the NMC publication ‘Standards to Support Learning and Assessment in Practice’ (2008)

ensuring that allocated students work with them for at least 40% of their time in clinical placement

determining a safe level of delegation to a student and identifying levels of required supervision in order to maintain patient safety

planning and co-ordinating a student’s learning experience

completing On-going Achievement Records (OARs) in a timely manner which enables the document to be passed to the next placement

keeping sufficient records to justify and support their decisions regarding student progress/achievements.

Mentors should have access to a network of support and supervision to enable them to fulfil their mentoring responsibilities, assist them in making complex judgements regarding competence such as failing a student and to support their professional development.

6. Standards and Practice In line with NMC requirements only mentors who are annotated on the Trust mentor register may undertake the role of mentor for pre-registration student nurses. The process for becoming a mentor and the requirements to maintain a position as a mentor is outlined below. 6.1. The RCHT Mentor Register

6.1.1. The RCHT mentor register is maintained and updated by the Learning and Development Department/Placement Development Team for RCHT. Entries on this register supersede any registers held locally within departments. 6.1.2. The register contains the following details for each mentor at RCHT:

name of mentor

place of work

mentorship related qualifications

date of last annual mentor update

identification of sign off mentor status

date of triennial review

further notes where applicable.

6.1.3. In 2009 mentors were annotated to the register by virtue of their experience as a mentor. At this point they were not required to have a


mentorship qualification. From 2009 onwards new mentors cannot be annotated to the Trust mentor register without completion of the process outlined in section 6.2. 6.1.4. The mentor register is maintained as a ‘live’ document and is updated on an on-going basis to reflect changes in an individual’s status. Each departmental part of the register is reviewed annually as part of the placement education audit. The whole register is reviewed annually by the Placement Development Team.

6.2. Becoming a mentor

6.2.1. In order to become a mentor of pre-registration student nurses/midwives, registered nurses/midwives must meet the following criteria:

be registered on the same part of the register as the student

have been registered for at least one year and have developed skills, knowledge and competence beyond registration

have completed an NMC approved mentorship course

have the ability to select, support and assess a range of learning opportunities for students in their own area of practice

be able to support learning in an inter-professional environment

have the ability to contribute to the assessment of other professionals under the supervision of an experienced assessor from that profession

be able to make judgements about competence of students and be accountable for such decisions

be able to support other nurses in meeting clinical practice development (CPD) needs.

6.2.2. The registered nurse must demonstrate that he/she meets the above criteria by completing the RCHT mentor mapping tool (Appendix 3). His/her line manager must verify that the individual meets the NMC criteria and is competent to undertake the role of a mentor. A copy of the mentor mapping tool (including a copy of the applicant’s mentor qualification certificate) should then be sent to the Learning and Development Department for a final review. If the NMC criteria have been met, the individual is annotated to the RCHT mentor register. 6.2.3. NMC approved mentorship courses include the following:

HEAB 370/MENT 602/MENT 702 or equivalent from an HEI

ENB 997/8

City & Guilds 730

Certificate in Education/Post Graduate Certificate in Education.


6.3. Becoming a sign-off mentor 6.3.1. A sign-off mentor is a mentor who holds additional responsibility to assess whether a student has achieved the standard of safe and effective practice required for entry onto the national NMC register. A student nurse only requires a sign-off mentor on his/her final placement. Therefore mentors who work in clinical areas that do not support this level of student do not need to achieve sign-off mentor status. A student midwife requires a sign-off mentor in the final placement of each academic year. 6.3.2. In order to become a sign-off mentor, mentors must meet the following criteria:

meet all of the criteria identified in section 6.2 for becoming a mentor

demonstrate clinical currency and competency in the field in which the student is being assessed

possess a working knowledge of current programme requirements, practice assessment strategies and relevant changes in education and practice for the student

possess an understanding of the NMC registration requirements and the contribution a sign-off mentor makes to achieving these

possess an in-depth understanding of their accountability to the NMC for the decision they must make to pass/fail a student when assessing proficiency at the end of a programme

be supervised on at least three occasions for signing-off proficiency by an existing sign-off mentor (please note this can be done in a simulated setting for two of these occasions, one must be in practice).

6.4. Maintaining status as a mentor or sign-off mentor (triennial review)

6.4.1. The NMC requires all mentors/sign-off mentors to maintain and develop their knowledge, skills and competence as a member/sign-off mentor (NMC 2006). 6.4.2. Assurance that an individual has maintained his/her competence to be an effective mentor/sign-off mentor for pre-registration student nurses is assessed at a triennial review. A triennial review is a three-yearly assessment of an individual’s ability to maintain his/her role as a mentor and, if applicable, as a sign-off mentor. The NMC recommend that triennial reviews are undertaken as part of an individual’s normal personal development review. However they also identify that the nature of a triennial review can be determined locally. At RCHT, triennial reviews can be completed in one of two ways:

as part of an individual’s annual performance development review (PDR). This is completed by the individual’s normal performance development reviewer, or

as an additional review meeting in line with an individual’s date of annotation to the register/date of last triennial review. This may be completed by a line manager, a member of the Placement Development Team or another member of staff with delegated


responsibility form the ward/department sister/charge nurse, eg: Education Link, Deputy Sister/Charge Nurse.

6.4.3. To maintain their role as an annotated mentor or sign-off mentor, individuals must be able to demonstrate evidence that they have achieved the following NMC criteria at their triennial review:

mentored at least two students with due regard (extenuating circumstances permitting) within the three-year period

participated in annual updating - to include an opportunity to meet and explore assessment and supervision issues with other mentors. Annual updating can be done using a recognised learning package for two out of three years. Individuals must attend at least one face to face mentor update within the three-year period

explored, as a group activity, the validity and reliability of judgements made when assessing practice in challenging circumstances. This is completed as part of the face to face annual mentor update

mapped on-going development in their role against the current NMC mentor standards

been deemed to have met all requirements needed to be maintained on the local register as a mentor or sign-off mentor.

6.4.4. To facilitate this process, individuals can use the triennial review frame-work (Appendix 4) to undertake a self-assessment of their achievement and on-going development as a mentor/sign-off mentor. This also forms a basis for discussion with their triennial reviewer.

On completion of their triennial review, mentors/sign off mentors should complete the self-verification on page 8 of the triennial review document. Their line manager/reviewer should complete the recommendation box also on page 8 of the triennial review documentation. A copy of page 8 is then sent to the Learning and Development Department in order for the Trust mentor register to be updated. A copy of page 8 can also be maintained in an individual’s personal file.

6.5. Maintaining status as a mentor/sign-off mentor (meeting Nursing and Midwifery Council (NMC) requirements)

6.5.1. The mentor register is reviewed monthly by the Learning and Development Team. Mentors and sign-off mentors who do not meet the NMC criteria for completion of a triennial review and/or an annual update will be removed from the Trust register. 6.5.2. Mentors will be informed of the date that their annual update and/or triennial review is due approximately eight weeks in advance. A reminder e-mail will be sent approximately four weeks later. 6.5.3. Mentors and sign-off mentors who are removed from the register can re-apply to be re-annotated. Their application must include the following documentation:

a completed mentor mapping tool


a completed triennial review from within the last three-year period. (Mentors who have been removed from the register within their first three years of annotation must complete their first triennial review prior to being re-annotated)

evidence of attendance at a face to face mentor update

copy of certificate of mentorship qualification.

6.6. Allocated learning time for mentor activity 6.6.1. The NMC (2006, page 30) states the following:

‘The NMC recognises that nurses and midwives who are mentors are primarily employed to provide care for patients and clients. Pre-registration students have supernumerary status and can expect to be able to work with mentors. All students must be supervised at all times, either directly or indirectly. Being a mentor requires a commitment.’

6.6.2. Whilst giving direct care in the practice setting, at least 40% of a student’s time must be spent being supervised (either directly or indirectly) by a mentor/practice teacher. 6.6.3. The nature of supervision will vary from direct to indirect depending upon the:

nature of the activity the student is engaged in

evidence of their current competence

need to assess achievement of NMC outcomes or competencies for progression on the programme.

6.6.4. Mentors will use their professional judgement and local/national policy to determine where activities may be safely delegated to students and the level of supervision required. They are accountable for such decisions and for ensuring public protection. 6.6.5. They will need time, when undertaking work with a student, to be able to explain, question, assess performance and feedback to the student in a meaningful way.

6.6.6. Sign-off mentors should be allocated an additional one hour protected time per week to spend with their final placement third year students.

6.7. Nursing and Midwifery Council (NMC) requirements to effectively support learning and assessment in practice The NMC identifies the following requirements for supporting learning and assessment in practice:

every student has a named mentor(s) for each period of practice learning. The mentor should be allocated at least one week prior to the commencement of the placement

mentors should not support more than three students, from any discipline, at any point in time


40% of a student’s time in placement must be spent under supervision (directly or indirectly) by a mentor

students undertaking a final placement must also spend one hour per week as protected time with their sign-off mentor. This is in addition to the 40% supervision identified above

an on-going achievement record, including comments from mentors, must be passed from one placement to the next to enable judgements to be made on the student’s progress

placement providers (ie the Trust) are responsible for ensuring that an up-to-date local register of mentors is maintained

placement providers are responsible for triennial review of mentors to ensure that only those who continue to meet the NMC requirements remain on the local register

most assessment of competence should be undertaken through direct observation in practice

mentors should be involved, wherever possible, when competence is assessed through simulation

mentors should consider how evidence from various sources might contribute to making a judgment on performance and competence

when dealing with failing students, mentors should seek advice and guidance from a sign-off mentor or, at RCHT, the Placement Development Team.

all mentors may assess specific competencies throughout the programme

mentors must keep sufficient records to support and justify their decisions on whether a student is, or is not, competent/proficient

in the final placement of a pre-registration programme, mentors must be annotated as sign-off mentors in order to make final decisions on proficiency. A mentor can be supervised by a sign-off mentor in undertaking this task but the sign-off mentor must countersign that proficiency has been achieved.

6.8. Students undertaking specialist placements Students undertaking a specialist placement that is outside of their normal field of practice (eg: child health student nurses undergoing a theatre placement) may be mentored by a registered nurse from another part of the register (eg: an adult registered nurse). However, they cannot be signed off at the end of their programme by an individual who is not on the same part of the register (NMC 2011, page 57). 6.9. Maintaining a sufficient number of mentors in a clinical area

6.9.1. Other than stipulating that one mentor should only mentor up to three pre–registration students at any one time, the NMC does not provide guidance on recommended numbers of mentors in clinical placement settings. At RCHT, it is recommended that a placement area has twice the number of mentors on the register against the agreed capacity of students.


This approach enables mentors to have breaks from mentoring students on a continual cycle and takes account of staff turnover and long-term leave.

6.9.2. A placement area that has less than this agreed number of mentors (see table below) should be flagged in the mentor register report which is presented monthly to the senior nurse and midwifery committee.

Student capacity

Expected number of mentors

Number of mentors that will flag a concern about

sustainability

Number of mentors that will flag as an immediate concern

8 16 8-15 0-7 5 10 5-9 0-4 3 6 3-6 0-2

7. Dissemination and Implementation 7.1. This policy will be disseminated via the document library on the RCHT intranet site. It will also be highlighted at monthly mentor updates. 7.2. Implementation of the policy is undertaken by individual ward and department sister/charge nurses in partnership with individual mentors and the Learning and Development Department.

8. Monitoring compliance and effectiveness Element to be monitored

Compliance with criteria to become (or maintain position as) an annotated mentor/sign-off mentor on the RCHT mentor register.

Lead Ward/department sister/charge nurses in partnership with the Learning and Development Department.

Tool Yearly educational audits. Frequency Yearly educational audits in each placement area.

Yearly NMC mentor register reviews between academic lead and clinical lead in the Placement Development Team.

Reporting arrangements

Completed education audits are sent to the department education link, sister/charge nurse, PDT academic lead and Plymouth University placement audit team.

Ward sister/charge nurses receive detail of actions needed following the yearly mentor register review.

Acting on recommendations and Lead(s)

Ward sister/charge nurses, senior nurses/matrons and the Learning and Development Team will work collaboratively to ensure that recommendations/actions are completed in a timely manner.

Change in practice and lessons to be shared

Any changes to practice/lessons learned will be shared through senior nurse meetings and mentor update meetings.

9. Updating and Review This policy will be reviewed three-yearly or in line with changes to NMC standards and guidelines as published. Amendments may be made without consultation to reflect any amendments in NMC standards.


10. Equality and Diversity

10.1. Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees.

10.2. The Initial Equality Impact Assessment Screening Form is at Appendix 2.


Appendix 1. Governance Information

Document Title Mentorship for Pre-Registration Nursing and Midwifery Students Policy V2.0

Date Issued/Approved: July 2019

Date Valid From: July 2019

Date Valid To: July 2022

Directorate / Department responsible (author/owner):

Jackie Blackwell Head of Learning & Development

Contact details: 01872 255148

Brief summary of contents

This policy identifies the key responsibilities with regards to the provision of mentorship for pre-registration students of nursing at RCHT. It also outlines the criteria and processes to be followed to, firstly, become a mentor/sign-off mentor and,secondly, the actions needed to provide assurance of continued competency once annotation to the register has been achieved. The policy aims to highlight key principles for application into practice from the NMC Standards for Supporting Learning and Assessment in Practice (2008).

Suggested Keywords: Mentor, sign-off mentor, triennial review, student, mentor register

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Director of Nursing, Midwifery and AHPs

Date revised: July 2019

This document replaces (exact title of previous version):

Mentorship for Pre-Registration Nursing and Midwifery Students at RCHT V1.0

Approval route (names of committees)/consultation:

Senior Nurse/Midwife Committee/JCNC

Director/Manager confirming approval processes

Associate Director People Development

Name and Post Title of additional signatories Chair of JCNC

Not required – no changes

Signature of Executive Director giving approval

{Original copy signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Human Resources


Links to key external standards NMC Standards to Support Learning and Assessment in Practice (2008)

Related Documents: As above

Training Need Identified? No, mentor updates already provided.

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

November 2015

V1.0 Initial version Helen Lewis Head of Learning and Development

July 2019 V2.0 Policy reformatted and updated for accuracy of titles etc. No changes - full review anticipated once new mentorship standards are bedded in.

Helen Strickland HR Business Partner for Policies and Projects

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Mentorship for Pre-Registration Nursing and Midwifery Students Policy V2.0

Directorate and service area: Human Resources Learning & Development Department

New or existing document: Existing

Name of individual completing assessment: Helen Lewis Associate Director: People Development

Telephone: 01872 255148

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

The policy aims to ensure that national standards regarding the mentorship of pre-registration students of nursing and midwifery are adopted and applied to practice at RCHT.

2. Policy Objectives*

Sister/charge nurses understand their responsibilities regarding the provision of mentorship for pre-registration students of nursing.

Mentors understand and can apply the NMC standards for supporting learning and assessment practice.

3. Policy – intended Outcomes*

Mentors apply the NMC standards for supporting learning and assessment in practice.

Students are supported by effective mentors who work in accordance with NMC guidelines.

4. *How will you measure the outcome?

Mentor register will show that mentors remain up to date with specific NMC standards.

Availability of mentors will correspond with agreed capacity for student placement.

5. Who is intended to benefit from the policy?

Mentors Sister/Charge Nurses Pre-registration students of nursing.

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

Senior Nurse/Midwife Committee/JCNC.

What was the outcome of the consultation?

No issues of concern identified.


Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age

Sex (male, female, trans-gender / gender reassignment)

Race / Ethnic communities /groups

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

Religion / other beliefs

Marriage and Civil partnership

Pregnancy and maternity

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

Not indicated.

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Date of completion and submission

July 2019 Members approving screening assessment

Policy Review Group (PRG) ‘APPROVED’ to be added here once reviewed at PRG.

A summary of the results will be published on the Trust’s web site.


Appendix 3. Mentor mapping tool

Student Mentor/Sign-Off Mentor

Mapping Tools


Guidance 1. Staff who undertake a mentor or sign off mentor role are required to evidence their

proficiency as set by the NMC standards (2008). The mapping process is a once only exercise for current mentors who demonstrate they meet the Standards. It is anticipated that the mapping exercise will be integrated within the annual appraisal process and personal development plan and used as evidence against the Knowledge and Skills Framework (People and Personal Development).

The attached mapping tool is divided into the following sections;

Section A

Personal Details

Section B

Competency - Mentor

Section C

Line Manager/Professional Lead Recommendation Sheet

Section D

Mapping Tool - Sign off mentor

Section E

Line Manager/Professional Lead Recommendation Sheet

Mentor Role: Please forward Sections A and C to the Placement Development Team for entry onto the Live Register on recommendation by manager/professional lead. Sign Off Mentor Role: Please forward Sections A, D and E to the Placement Development Team for verification and annotation to the Live Register.

Mentor Guidance 2. The Personal Details data sheet (Section A) is required to allow staff details to be entered

onto the electronic database for information retrieval purposes. It is important that the personal details are entered correctly as this information will be entered directly on the local register of mentors.

3. There are eight competency domains and related criteria. Staff will need to determine the

extent to which they meet each domain and indicate with a tick if the criteria is met. Staff will need to provide examples from previous experiences as a mentor to demonstrate how they meet the new competency domains. This will help inform the discussion with their line manager/professional lead.

4. On completion of the self-assessment form, staff must meet with their line manager or

professional lead to discuss the extent to which they meet the standards to enable recommendation for entry on the local register. Where a recommendation cannot be made, an action plan is jointly developed by the member of staff and line manager/professional lead to identify objectives.

5. When a recommendation has been made for mentorship status Sections A and C should

be sent to the Placement Development Team, Practice Development Department for transfer of details onto the live mentor register.


Sign off Mentor Guidance 6. There are a large number of mentors within the system who already meet the criteria to

becomesign-off mentors; these should be identified in the first instance by their line manager/professional lead.

7. If a Line Manager / professional lead considers a member of staff meets the sign off criteria

than Sections A, B, D and E should be completed. A meeting will be arranged between the proposed SOM and the Placement Development Team to discuss the extent to which the criteria is met and to annotate SOM status on the local register. Where a recommendation cannot be made, an action plan will be jointly developed to identify issues and consider how these can be achieved within a mutually agreed timeframe.

8. Current mentors who do not meet the criteria for sign-off mentors, need to be supervised by

a sign-off mentor on at least three occasions before gaining signing-off proficiency.


BIOGRAPHICAL DETAILS OF MENTORS/SIGN OFF MENTORS FOR

PRE-REGISTRATION AND SPECIALIST PRACTICE NURSING PROGRAMMES Guidance Name

Location

This is site specific e.g.RCH; WCH. SMH. Community Practice in case of Midwives

Place of work e.g. Ward/Dept

Type of placement e.g. Medical, surgical, eldercare, community

Registration Pin No. / ID No.

Expiry Date

Part(s) of the Register

Sub-Part

Recordable Qualification

Active Parts of the Register only Example Part - Nursing, Sub part – Mental Health

Other Professional Qualifications

Please list any other professional qualifications you have.

Date Mentorship Programme completed

Please enter date of programme completed

Date competent NMC Mentor Standards

Recommended by Name:

Signature:

Signature and date:

Date met NMC ‘sign-off mentor’ criteria

Recommended by Name:

Signature

I give permission for this information to be held on the Trust’s electronic database for retrieval by authorised personnel for the purposes of meeting NMC requirements for placement learning and assessment.

Signed Date

Section A


Domain 1: The mentor should demonstrate how they orientate students to the learning environment and how they establish effective working relationships with students

Domain 2: The mentor should demonstrate how they keep up to date with students’ learning objectives, facilitate students’ integration of learning in theory and practice and help students critically reflect on their learning experience

Mentor Please tick

if achieved

Mentor Please tick

if achieved

1. Establishing effective working relationships

1.1 Developing effective working relationships based on mutual trust and respect

2. Facilitation of Learning

2.1 Use knowledge of the student’s stage of learning to select appropriate learning opportunities to meet their individual needs

1.2 Demonstrate an understanding of factors that influence how students integrate into practice settings

2.2 Facilitate the selection of appropriate

learning strategies to integrate learning from practice and academic experiences

1.3 Provide on-going and constructive support to facilitate transition from one learning environment to another

2.3 Support students in critically reflecting upon

their learning experience in order to enhance future learning

Domain 3: The mentor should demonstrate how they have worked with students to assess the student’s development and progress throughout the placement.

Domain 4: The Mentor should demonstrate how they have assisted students to reflect on and illustrate how they have contributed to the professional development of others

Mentor Please tick

if achieved

Mentor Please tick

if achieved

3. Assessment and accountability

3.1 Foster professional growth, personal development and accountability through support of students in practice

4. Evaluation of learning

4.1 Contribute to evaluation of student learning and assessment experiences, proposing aspects for change where applicable

3.2 Demonstrate a breadth of understanding of assessment strategies and ability to contribute to the total assessment process as part of the teaching team

4.2 Participate in self and peer evaluation to facilitate personal development and contribute to the development of others

3.3 Provide constructive feedback to students and assist them in identifying future learning needs and actions

3.4 Be accountable for confirming that students have met or not met the NMC competencies in practice i.e. at the end of the Common Foundation Programme (Nursing).

Form B Section B: COMPETENCY DOMAINS Name:


Domain 5: The mentor should demonstrate how they have contributed to the creation of a learning environment in the clinical area

Domain 6: The mentor should demonstrate the strategies used to ensure the delivery of safe and effective care, involvement with inter-professional working and their involvement with practice developments to promote learning

Mentor Please tick if achieved


5. Creating an environment for learning

5.1 Support students to identify both learning needs and experiences that are appropriate to their level of learning

6. Context of practice

6.1 Contribute to the development of an environment in which effective practice is fostered, implemented, evaluated and disseminated

5.2 Use a range of learning experience, involving patients, clients, carers and the professional team to meet defined learning needs

6.2 Set and maintain professional boundaries that are sufficiently flexible for providing inter-professional care

5.3 Identify aspects of the learning environment which could be enhanced, negotiating with others to make appropriate changes

6.3 Initiate and respond to practice development to ensure safe and effective care is achieved and an effective learning environment is maintained

5.4 Act as a resource to facilitate personal and professional development of others

Domain 8: The Mentor should demonstrate their leadership abilities in managing the practice placement and providing learning opportunities for students

Domain 7: The Mentor should demonstrate strategies used to support students in the use of evidence-based practice



8. Leadership

8.1 Plan a series of learning experiences that will meet students defined learning needs

7. Evidence based

7.1 Identify research and evidence-based practice relating to their area of practice

8.2 Be an advocate for students to support them accessing learning opportunities that meet their individual needs, involving a range of other professional, patients, clients and carers

7.2 Contribute to strategies to increase or review the evidence base used to support practice

8.3 Prioritise work to accommodate support of

students within their practice roles

7.3 Support students in applying an evidence base to their own practice

8.4 Provide feedback about the effectiveness of learning and assessment in practice

Name:


Mentor self-verification On completing the competency self-assessment, mentors should confirm they have demonstrated achievement of all the NMC domains and meet the competency requirements of the NMC standards to support learning and assessment in practice. I declare that I meet the NMC mentor requirements Yes No (please circle) Mentor Signature: _________________________________________ Date: ________________________________ If the mentor has identified competency domains which still require to be developed these should be identified in the Action Plan below and more fully discussed with the line manager at the verification meeting.

Line Manager/Professional Lead Recommendation I have read the mentor’s self-assessment documentation and held a follow -up discussion with the mentor. As the mentor’s line manager/professional lead, I confirm that I am/am not (please delete, as relevant) satisfied that ____________________ meets the NMC competence domains required to support students on placement, including relevant updating within the last year. I am recommending/not recommending (please delete, as relevant) the mentor for entry on the local register of mentors. Signature of Line Manager: ___________________________________ Position: ____________________________ Date: _____________________________________ Location: ____________________________ Mentor’s Action Plan (Please identify which mentor competency domains require further development)

Section C


In addition to being verified as meeting the NMC standards as a mentor, if you consider you meet the NMC criteria as a sign off mentor, the following self-evaluation form must be competed and verified by the Placement Development Team.

Criteria Please initial if Achieved

Provide examples from previous experience as a Mentor to demonstrate HOW you have achieved these. (See guidance notes).

1. I am an experienced mentor and have mentored at least 2 students within the last 3 years.

2. I have knowledge and understanding of the specific programme relating to the student and have clinical currency and capability in my field of practice.

3. I have experience of working with student nurses/midwives or post registration students and currently confirm their capability for safe and effective practice.

4. I have the ability to manage students with competency difficulties to enable them to improve their performance and capabilities for safe and effective practice.

5. I have had relevant on-going professional development relevant to my role as a sign-off mentor incorporated into my PDP.

6. I understand the NMC registration requirements and the contribution made by me as a mentor to meet these requirements.

7. I fully understand my professional accountability in relation to the decision to pass, defer or fail a student when assessing proficiency requirements at the end of a programme.

8. I have knowledge and understanding of the support available for sign off mentors in making these decisions.

9. I have knowledge of the support available to students in relation to decisions made around their proficiency.

Document amended by permission of NHS Education Scotland from their document Transitional Guidance for Sign-Off Mentors (2007)

Sign-off mentor self-verification On completing the mapping self-assessment, sign-off mentors should confirm they have demonstrated achievement of all the NMC domains and meet the competency requirements of the NMC standards to support learning and assessment in practice.

I declare that I meet the NMC sign-off mentor requirements for Midwifery/Nursing/Other Yes No (please circle) Mentor Signature: _________________________________________ Date: ________________________________

If the sign-off mentor has identified requirements which still require to be developed these should be identified in the Action Plan below and more fully discussed when meeting with the line manager

Form D Section D Mapping as a Sign-off Mentor


Learning and Development Recommendation of Sign-off Mentor I have read the sign-off mentor’s self-assessment documentation and held a follow -up discussion with the mentor. As the Placement Development Team representative I confirm that I am/am not (please delete, as relevant) satisfied that he / she meets the NMC competence domains required to be annotated in the local register as a sign-off mentor. I am recommending / not recommending (please delete, as relevant) the mentor for entry on the local register of mentors as a sign-off mentor. Signature of Academic Lead___________________________________ Date: _____________________________________ Location: ____________________________ Where a recommendation cannot be given please identify which criteria have not been met and indicate the actions and timeframe agreed with the mentor to enable the criteria to be met and arrangements made for supervision on three occasions by a sign-off mentor.

Section E


Appendix 4. Triennial review framework

Mentorship at RCHT

Triennial Review

A record of mentor activity providing evidence of compliance with NMC standards to support learning and

assessment in practice

Name

Place of work

Date of triennial review

Expected date of next triennial review


1. Introduction The Nursing and midwifery Council ‘Standards to support learning and assessment in practice’ (NMC 2008) require all nursing mentors, who are annotated on the local mentor register, to undergo a triennial review. This is a three‐yearly review of an individual’s ability to maintain their role as a mentor and, where applicable, as a sign‐off mentor. Although the NMC recommend that the review is incorporated into yearly performance development reviews, a local decision can be made regarding the best process for completion. At RCHT, triennial reviews can be completed in one of two ways:

a) as part of an individual’s annual performance development review. This is completed by the individual’s normal performance development reviewer

b) as an additional review meeting in line with an individual’s date of annotation to the register. This may be completed by a line manager, a member of the Placement Development Team or another member of staff with delegated responsibility from the relevant ward sister/charge nurse, eg: Education Link.

To maintain their role as an annotated mentor or sign‐off mentor, individuals must be able to demonstrate evidence that they have achieved the following criteria: mentored at least two students within the last three‐year period participated in annual updating mapped on‐going development in their role against current NMC standards.

This document provides a framework in which individuals can undertake a self‐assessment of their achievement and on‐going development as a mentor. As such, it forms a basis for discussion with their triennial reviewer. 2. Record of mentoring students In this section the mentor should identify the occasions when he/she has mentored students. It is not essential to keep details of students’ records but if mentors choose to do so they must gain the student’s consent.

Date of student placement Year/cohort of student and university

Clinical area/department

Eg 3rd Jan 31

st March 2012 3

rd year Adult Nursing student, 2009 cohort

Plymouth University Kernow ward

3. Record of Annual Updating In this section the mentor needs to identify the dates when he/she undertook each annual mentor update during the last three years. This can be a face‐to‐face session or an on‐line update. The purpose of annual updating is to ensure that mentors have the following: up‐to‐date knowledge of the pre‐registration programme from which students are placed in to

practice ability to discuss the implications of changes to NMC requirements an opportunity to discuss issues related to mentoring, assessment of competence and fitness for

safe and effective practice.


Date of mentor update Type of update eg face to face/on line

Location of update

4. Continuing professional development in relation to the eight domains outlined in ‘Standards for

Learning and Assessment in Practice’ (NMC 2008) Mapping professional development activity against the eight domains may be viewed by mentors as part of their usual professional portfolio development. Individual mentors can identify how they collate this evidence although, as previously stated, details of student records can only be included with the consent of the student and should be anonymised. This section provides a framework for mentors to demonstrate their experience, learning and development against each of the eight standards.

NMC Domain 1 – Establish effective working relationships Demonstrate an understanding of factors that influence how students integrate into practice

settings. Provide on‐going and constructive support to facilitate transition from one learning

environment to another. Have effective professional and inter‐professional working relationships to support learning

for entry to the register.

Examples of evidence may include: student learning contracts, student testimonies, teaching plans, PDPs, student orientation pack, reflection on self. Write an account of how you meet this domain and provide any examples of evidence

NMC Domain 2 – Facilitation of Learning Use knowledge of the student’s stage of learning to select appropriate learning

opportunities to meet individual needs. Facilitate the selection of appropriate learning strategies to integrate learning from practice

and academic experiences. Support students in critically reflecting upon their learning experiences in order to enhance

future learning.

Examples of evidence may include: formative assessments, written feedback from students, learning contracts, reflection on experience, student evaluation Write an account of how you meet this domain and provide any examples of evidence


NMC Domain 3 –Assessment and Accountability Foster professional growth, personal development an accountability through support of

students in practice. Demonstrate a breadth of understanding of assessment strategies and the ability to

contribute to the total assessment process as part of the teaching team. Provide constructive feedback to students and assist them in identifying future learning

needs and actions. Manage failing students so that they may enhance their performance and capabilities for safe and effective practice or be able to understand their failure and the implications of this for the future.

Be accountable for confirming that students have met, or not met, the NMC competencies in practice. As a sign off mentor confirm that students have met , or not met, the NMC standards of proficiency in practice and are capable of safe and effective practice.

Examples of evidence may include: Attendance at annual mentor update, reflection on personal accountability, student assessments, reflection on student assessments, testimony form colleagues, discussion at workshop/meeting relating to accountability, liaison with PDT Write an account of how you meet this domain and provide any examples of evidence

NMC Domain 4 – Evaluation of Learning Contribute to evaluation of student learning and assessment experiences – proposing

aspects for change resulting from such evaluation. Participate in self and peer evaluation to facilitate personal development and contribute to

the development of others.

Examples of evidence may include: Participation in department educational audit, participation in supervision/Coaching, student testimony, personal reflection, formative and summative assessments Write an account of how you meet this domain and provide any examples of evidence

NMC Domain 5 – Creating an Environment for Learning Support students to identify both learning needs and experiences that are appropriate to

their level of learning. Use a range of learning experiences, involving patients and the professional team to meet

defined learning needs. Identify aspects of the learning environment which could be enhanced – negotiating with

others to make appropriate changes.


Act as a resource to facilitate personal and professional development of others.

Examples of evidence may include: Learning contracts, participation in education audit/actions that arise, student testimony, student evaluation, Development and support of other staff in the dept. Development of student resources Write an account of how you meet this domain and provide any examples of evidence

NMC Domain 6 – Context of Practice Contribute to the development of an environment in which effective practice is fostered,

implemented, evaluated and disseminated. Set and maintain professional boundaries that are sufficiently flexible for providing inter‐

professional care. Initiate and respond to practice developments to ensure safe and effective care is achieved

and an effective learning environment is maintained.

Examples of Evidence may include: Can demonstrate positive role modelling – student evaluation, personal reflection, demonstrates examples of sharing own knowledge. PDR, Dept based development of practice. Testimony from colleagues. Contribution to policy development Write an account of how you meet this domain and provide any examples of evidence

NMC Domain 7 – Evidence Based Practice Identify and apply research and evidence based practice to their area of practice. Contribute to strategies to increase or review the evidence base used to support practice. Support students in applying an evidence base to their own practice.

Examples of evidence may include: Knowledge of new guidance /polices that relate to specialty and development of patient care. Knowledge of national guidance and drivers, participation in link roles, undertaking further study, reflection journal articles, participation in discussion at meetings, personal reflection, student testimony Write an account of how you meet this domain and provide any examples of evidence


NMC Domain 8 – Leadership Plan a series of learning experiences that will meet students defined learning needs. Be an advocate for students to support them accessing learning opportunities that meet

their individual needs – involving arrange of other professionals, patients and carers. Prioritise work to accommodate support of students with their practice roles. Provide feedback about the effectiveness of learning and assessment in practice.

Examples of evidence may include: Contribution to student teaching, dissemination of information , record of meetings with students and relevant others, involvement in ward/dept educational audit, support of colleagues to develop mentorship skills, Evidence of time management, student testimony, personal reflection Write an account of how you meet this domain and provide any examples of evidence

References

NMC (2008) Standards to support Learning and Assessment in Practice. http://www.nmc‐uk.org/Publications/Standards/ NHS Suffolk, Suffolk County Workforce Group (December 2010) Triennial review – Framework of evidence to support mentors in meeting the NMC standards to support learning and assessment in practice Lincolnshire Partnership NHS Foundation trust (2009) Triennial Review Guidelines for Mentors


5. Triennial Review Self Verification Having completed the framework in this document, the mentor should confirm the following:

Triennial review components Name and Signature Date

I have attended three mentor updates during the last three years (one per year)

I have mentored at least 2 learners during the last 3 years

I have discussed aspects of mentorship within a formal group setting on at least one occasion in the last three years (This could be during a mentor update or a divisional meeting)

I have evidence of continuing professional development in relation to the eight domains highlighted in ‘Standards to support learning and assessment in practice’ (NMC 2008)

6. Recommendation for Continuation as an annotated mentor/sign off mentor Following a discussion with the mentor, the line manager, placement development team member or delegated person should complete the following:

I have discussed the mentor’s development with him/her on _______________ (date) and reviewed the evidence contained within this document. I confirm that I am /I am not (Please specify)satisfied that he/she meets the NMC standards to continue supporting students in practice I recommend /do not recommend (Please specify) that ______________________________(name) remains on the RCHT NMC register as an annotated mentor/sign off mentor (please specify) Name of Reviewer_____________________________________________ Role________________________________________________________ Signature_____________________________________________________ Date________________________________Ward/Dept__________________ Notes

On completion a copy of page 8 of this document should be filed in the individual’s P file and a second copy should be forwarded to

the Learning and development Department in order for the Trust register to be updated.