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Nurse Education in Practice 11 (2011) 351e355

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Student perceptions of support in practiceq

Janice Gidman*, Annette McIntosh 1, Katherine Melling 2, Debra Smith 2

Faculty of Health and Social Care, University of Chester, Parkgate Road, Chester CH1 4BJ, United Kingdom

a r t i c l e i n f o

Article history:Accepted 4 March 2011

Keywords:Student supportMentorsPractice learning

q This paper was presented at the NETNEP 20Education Conference e Nursing Education in a Globand networking for the future, 11e14th April 2010, Sy* Corresponding author. Tel.: þ44 1244 513384; fax

E-mail addresses: j.gidman@chester.ac.uk (J. Gidma(A. McIntosh), k.melling@chester.ac.uk (K. Melling(D. Smith).

1 Tel.: þ44 1244 513386; fax: þ44 1244 381090.2 Tel.: þ44 1244 513385; fax: þ44 1244 381090.

1471-5953/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.nepr.2011.03.005

a b s t r a c t

This paper reports on a funded research project exploring perceptions and experiences of pre-regis-tration nursing students of support in practice in one Higher Education Institution in England. The studyused a mixed method approach with samples of new students (within the first six months) and finishingstudents (within the last three months). Students reported that the most important areas they neededsupport with were clinical skills, placement situations, documentation and personal issues. The mentorqualities that were valued were personal attributes, being facilitative and being knowledgeable; newlyqualified mentors and experienced students were seen as being the most supportive. Students saw theirown responsibilities as learning and gaining skills, being professional and caring for patients. The fin-ishing students also felt that accountability and teaching were part of their role. Reported challengesencompassed personal issues, including work-life balance and finances, dealing with elements such aspatient death and uncertainties in new situations. The best aspects of practice emerged as being involvedin patient care, feeling part of a team and experiencing positive support from mentors. The findingsexplicated the multi-faceted nature of student support in practice that need to be taken into accountwhen putting support frameworks in place.

� 2011 Elsevier Ltd. All rights reserved.

Introduction

This research project was funded by the Centre for Excellence inProfessional Placement Learning, University of Plymouth. Itaddressed the area of student support in practice withina pre-registration nursing programme (adult branch) in the UnitedKingdom (UK). This programme is undertaken by students witha wide range of ages, academic and socio-economic backgroundswho have diverse needs in relation to support (Jeffreys, 2007).Student retention is a major priority for Higher Education Institu-tions (HEIs) who have recognised the need to develop and optimisestudent support in order to maximise achievement and minimiseattrition (Yorke and Longden, 2004; Zepke and Leach, 2005).

Recent studies, many in professionally focused programmes(Brown and Edelmann, 2000; Jeffreys, 2007), have addressedstudents’ experiences of learning and possible reasons for leaving

10 3rd International Nurseal Community: collaborationdney, Australia.: þ44 1244 381090.n), a.mcintosh@chester.ac.uk), debra.smith@chester.ac.uk

All rights reserved.

a programme and identified several contributory factors, includingacademic, environmental and social integration issues. It is also thecase that many students have to balance academic study with thedevelopment of professional competence and integration intopractice areas (Benson et al., 2009). It is the responsibility of theHEI, in partnership with placement providers, to support studentsin all aspects of their programmes. An important aspect of this islistening to students’ views in order to gain feedback on theeffectiveness of support, through consultation and evaluation andto involve students in any improvements or innovations (McIntoshand Gidman, 2010).

This study was therefore concerned with further explicating thefactors that the students themselves see as being important forsuccess, with a specific focus on the practice experience.

Literature review

The aim of nurse education is to provide skilled and knowl-edgeable practitioners; central to this is the learning that takesplace in the practice placement area, which is designed tomake thelink between theory and practice (Burns and Paterson, 2005).Pre-registration programmes must prepare and equip studentswith the skills required for practice, whilst ensuring the develop-ment of an underpinning knowledge base to deal with thecomplexity of practice (Cope et al., 2000). However, placements aremulti-faceted, social environments and students face the additional

J. Gidman et al. / Nurse Education in Practice 11 (2011) 351e355352

challenges of integrating and becoming accepted as part of thepractice community. Cope et al. (2000) explored the processes thatstudent nurses went through during practice placements, identi-fying three significant themes; joining the community of practice,the contextualisation of learning and the support of learning inpractice.

There has been a long standing debate in the literature as to therole of nurse lecturers in practice settings, with research demon-strating that this often has limited impact (Lewin, 2006). In order tofacilitate learning in practice, therefore, mentorship is now widelyaccepted as the favoured approach and is considered an imperativetool for the preparation of professionals within practice. Addi-tionally, new roles to support student nurses in practice have beenpositively evaluated, for example practice placement facilitators inthe UK (Clarke et al., 2003) and practice educators in Ireland (Mallikand McGowan, 2007).

In the UK, the role of the mentor was strengthened considerablywith the introduction of specific standards by the professionalregulatory body (Nursing and Midwifery Council (NMC) 2008).These standards emphasise the assessment aspect of the role andwere developed to ensure competence at the point of registration.The role of the mentor has been widely discussed and there is anincreasing body of international empirical evidence to support itsimportance in students’ experiences of learning. The mentore-student relationship is perceived to be a valuable resource forstudents and their learning experience. Chow and Suen (2001)reported on students’ views of mentors’ roles within a universitynursing department in Hong Kong. The roles of assisting andguiding were viewed as more important than the befriending role,with the role of advising and counselling being of least importance.This suggested that, although students consider all five roles of thementor as significant, the roles that have a direct impact on clinicallearning were considered the most significant. However, the chal-lenges associatedwith this arewell recognised (Ball and Pike, 2005;Caldwell et al., 2008) and ambivalence to the role is reported (Myallet al., 2008).

A longitudinal research study carried out by Brown andEdelmann (2000) examined actual and anticipated stressors, sour-ces of stress, support and coping strategies within UK nursingeducation. The most significant, anticipated stressors includedconcern regarding competency in terms of theoretical knowledge,the balance between placement practice and academic study, andthe fulfilment of personal expectations of the role. However, inconsidering actual, reported difficulties, the findings showed thatlife-work balance and financial anxieties were the most frequentlyreported.

Several studies have considered the idea of peer-mentoringprogrammes and the ways in which such programmes may supportnew students whenmaking the transition to university and nursing.Aston and Molassiotis (2003) examined an initiative which involvedsenior students in the supervising and supporting of junior students,under the supervision of a clinical mentor. Students found thescheme to be an effective provision of support that enhancedmotivation to learn whilst also assisting in their transition to theplacement in terms of initial anxieties. In a similar study, Gilmouret al. (2007) evaluated a peer-mentoring programme designed tosupport students make the transition to higher education andnursing; data collected from focus groups illustrated that the pro-gramme had benefits for both mentors and mentees.

In considering the characteristics of a good mentor, Smith andGray (2001) reported that student nurses identified recognitionand attendance to their emotional state, assisting with theirlearning needs and career outcomes, having an ability to be flexibleand displaying empathy towards students. There appear to bediverse research findings with regard to the precise role of mentors,

with a number of authors emphasising the somewhat implicitemotional and supportive role. Myall et al. (2008) reported someambivalence in the perceptions of students andmentors in terms ofthe mentor’s role; some considered the role to encompass supportwith student issues and conducting placement audits, whereassome viewed the role to be concerned with working with studentsin the clinical environment. Further research endorsed the issuessurrounding the varying role of mentors, support and opportunitiesavailable to student nurses. Often, the level of participation andquality of the learning experience within placements seems todepend on the individual characteristics, confidence levels orpersonality of the student (Pollard, 2009).

The mentoring of students within practice is viewed asa fundamental aspect of nursing, although it has been suggestedthat lack of time and pressure of other clinical commitments canlead to difficulties which may impinge the organisation andsupervision of clinical placement programmes (Ball and Pike,2005). Mosely and Davies (2007) posited that although mentorsgenerally had a positive attitude as far as their role was concernedin terms of the interpersonal aspects, several concerns andperceived difficulties emerged. For example, mentors found itdifficult to establish effective relationships with students, providefeedback, assess students and create a learning environment.

Methods

The aim of the study was to explore the perceptions and expe-riences of nursing students regarding support in practice settings.The research used a mixed method approach: a questionnaire wasdesigned to elicit the perceptions and experiences of students andfocus groups were used to further explore themes arising from thequestionnaire data. Questionnaires were developed from a Facultytool used to investigate student support in academic settings,revised using the findings of the literature review. Question designincluded open items to elicit respondents’ views without prompts,including ranked questions. Pilot work, carried out with a sample ofstudents not involved in the study, indicated that the datawould bevalid, although some refinements and additions were made inresponse to feedback.

Ethical approval

Full ethical approval was granted by the HEI’s ethical approvalcommittee. All respondents were fully informed about the nature ofthe project and their involvement, including their right to with-draw without prejudice at any time. Data collection was under-taken by a research officer and assistant, rather than academic orpractice staff in order to avoid any influence being exerted on therespondents. Confidentiality was maintained throughout the study.Datawere stored securely and password protectionwas ensured forall computer-based data.

Data collection

The population was student nurses undertaking an adult pre-registration nursing programme in the Cheshire and Merseysideregion of England. The sample was drawn from starting and fin-ishing students in one HEI. For the questionnaire completion,students were accessed at the end of a timetabled session inconsultation with lecturing staff. The study was explained andvolunteers recruited to complete the questionnaire at that time.The starter students (n ¼ 174) were within the first six months ofcommencement and had undertaken practice experience; theirquestionnaires focussed on their expectations of support thatwould be required throughout their programme. The finisher

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students (n ¼ 98) were in the final three months of their pro-gramme, with their questionnaire focussing their experiences ofpractice support. A total of four focus groups was undertaken tofurther explore the data obtained from the questionnaires (twowith starter students (n ¼ 15) and two with finisher students(n ¼ 20)). These were facilitated at a location and time which wasconvenient for the respondents and lasted for approximately 1 h.The interviews were audio-recorded with the students’ consent.

Data analysis

The questionnaire data were quantitatively analysed using Excelspreadsheets to elicit descriptive statistics (closed questions) andqualitatively analysed to produce themes (open questions). Thefocus group interviews were transcribed verbatim, coded andrecurrent themes identified, in line with three interrelated aspectsof qualitative data analysis identified by Miles and Hubermann(1994): data reduction, data display and conclusion drawing. Thefinisher students had left the HEI when the data had been analysed,therefore it was not possible to return the interview data torespondents for verification. To overcome this limitation, thethemes were verified by four experienced researchers.

Questionnaire findings

Ranked responses were incorporated to elicit students’perceptions of priorities in relation to support in practice.Respondents were required to identify the three most importantareas in relation to their expectations (starters) and experiences of(finishers) support during practice placements.

The first-rankedmost important source of support in practice bystarters (39%) was academic staff. Mentors were ranked a closesecond overall (37%) and family and friends a distant third (5%).In contrast, 67% of the finishers ranked mentors as the mostimportant source of support in placements, while lecturers wereranked second (15%), and both groups ranked support and teachingas the most important support from peers third (6%).

Both groups of students (37% of starters and 40% of finishers)identified clinical skills as the most important element for whichthey thought they would need support. Starters then rankedplacement documentation as second (23%) and personal issuesthird (20%). However, the finishers ranked two aspects of secondequal importance; placement situations (16%), including adjust-ment to the placement and becoming part of a team; and place-ment documentation (16%). Other areas identified were linkingtheory to practice and personal issues.

In relation to the responsibilities of mentors, both groups ofstudents ranked teaching and support as themost important (65%ofstarters and 71% of finishers) and personal attributes (for example,friendly, patient, approachable, understanding, honesty, respect andenthusiasm)as themost important qualities (66%of starters and67%of finishers). In terms of their own responsibilities, 44% of thestarters identified personal aspects to be of prime importance (forexample, being professional, confidentiality, timekeeping, enthu-siasm, motivation, reliable, responsible and knowing own limita-tions). Learning and gaining skills were ranked second (38%) andpatient care third (16%). In contrast, the finishers ranked learningand gaining skills as highest (41%), with patient care second (34%)and personal responsibilities as third (15%). This group also identi-fied accountability and teaching other students as responsibilities.

The same issues were identified as the most challenging by thestarters andfinishers: personal issues such as childcare andfinancialdifficulties andplacement related issues suchasdealingwithpatientdeath, emergency situations, lack of support and uncertainty in newsituations. These factorswere reported by some students as reasons

why theyhadconsidered leaving theprogramme. Theopenquestionabout the best aspects of placements elicited the same three themesfor both groups, with patient care, including interactions, buildinggood relationships and taking responsibility for patientsmentionedmost frequently. Gaining practical experience and skills and feelingpart of the team, with positive support were also mentioned by thetwo groups.

Focus group findings

The findings of the questionnaire data were used to develop theinterview schedule for the focus groups, which were then tran-scribed verbatim. Following coding and analysis of the data, sixrecurrent themes were identified:

1. Personal issues2. Mentors3. Peers and newly qualified nurses4. Competence and assessment5. Uncertainty of student nurse role6. Being part of a team

These are presented below with verbatim quotations to illus-trate each theme.

Personal issues

Life-work balance, finance, shift patterns, travelling to place-ments and childcare were all identified as issues. Financial prob-lems were highlighted, particularly by single parents within thegroups, and these had led some to consider leaving the programme.

I could do with taking a job on but then that means even lesstimewith my little boy and I’ve got hardly any time now. I find itreally difficult financially. (Starter)

A few students also described difficulties in keeping up withacademic requirements, reporting problems in relation toworkloadand their family life.

Mentors

Students described a range of experiences of mentor support,with supportive mentors having a positive impact on students’perceptions of their experiences. Support was generally perceivedto be either very good or not good at all as exemplified by thefollowing quote:

Some people are naturally good mentors e somearen’t (Finisher)Experiences of negative attitudes from mentors were reportedby some: They say it’s not their duty ewe’re not paid to do this,we’re paid to look after patients. (Finisher)

Respondents considered that mentors should be voluntary andeven suggested that there should be a system to ‘vet’ them becauseif they did not want to take on the role this would have a detri-mental effect on their students:

They shouldn’t be a mentor if they’ve got no time forstudents (Starter)

Students recognised that increased student numbers have putpressure onto placement providers and the difficulties for mentors,in terms of lack of time and other commitments, and their need forsupport in their roles. There were examples of positive experiences

J. Gidman et al. / Nurse Education in Practice 11 (2011) 351e355354

where students had been assigned a ‘back up’ mentor who workedwith them when the mentor was not on duty.

Peers and newly qualified nurses

Support from experienced students and newly-qualified nurseswas highly valued by students who considered these individuals asbeing enthusiastic and motivated, both in their practice and in theirattitudes to students. They also considered that they were moreapproachable and had less time constraints than more experiencednurses:

It’s always good to have a third year around because she’ll turnaround and say listen this is a really good area to gointo (Starter).I learned more on my first placement off the nurse who had justqualified and she’d been literally weeks on the ward (Starter).

Competence and assessment

Although both sets of focus groups raised the issue of clinicalskills and developing confidence in patient care, this was particu-larly notable in responses from the finisher students. Theydescribed a range of both positive and negative experiences and itwas apparent that the mentor and the culture of placement itselfhad an impact on the nature of these.

The mentors all sat down together and structured for thestudents coming in and what outcomes they should be meeting,what they should be doing and I think that’s reallygood (Starter)

Both groups discussed the difficulties in achieving all compe-tencies within the documentation. Some students felt that it wasthe mentors’ responsibility to plan their learning. Other studentsrecognised that they needed to show initiative, but one respondentcautioned:

But that [initiative] just comes with experience though, youcan’t do that in your first year (Finisher)

Uncertainty of student nurse role

Although students recognised the need to develop caring skills,for some, there appeared to be confusion about their role in this.

They say don’t do anything you don’t think you are supposed tobe doing and then they ask you to do something and you’re like,am I allowed to do this or am I not allowed to do this (Starter)

It was evident that students valued being accepted as part of theteam. However, there were examples of instances in which this didnot happen, for example:

Whenwe’re seen as more of a pest.it makes you feel a burden.It’s important to hear your name [not] “the student” (Finisher)

Discussion

The findings from this study can be seen to support previousresearch in this area and offer further insights into the multi-factorial process of supporting students in practice.

Students identified personal issues, life-work balance and timemanagement as the main reasons that they had considered leavingthe programme (Brown and Edelmann, 2000). The findings,therefore, support the requirement for HEIs to provide effective

support to meet the widening participation agenda. The data alsosupport the view that, within nursing programmes, there areadditional pressures on students who have to balance academicstudy and the achievement of practice competencies (Benson et al.,2009). However, in addition to these aspects, this current study hashighlighted the increased pressure on students whilst on place-ment, which confirms the need for HEIs and practice placements towork together to support students in all aspects of their pro-grammes (McIntosh and Gidman, 2010).

The data support the existing body of literature which identifiesthatmentors are themain source of support for students during theirpracticeplacements,withamore limitedroleplayedbyacademic staff(Lewin, 2006). It was interesting to note that the starters anticipatedthat lecturing staff would be more important as a source of supportthanmentorsand thatpeersupportwasasyet largelyunrecognisedasa valuable resource, as identified by the finishers. This is noteworthy,in the light of earlier findings by Aston and Molassiotis (2003) whoresearched a system of peer-mentoring to support new studentnurses. They concluded that it provided an effective support mecha-nism; it assisted the transition of new students into practice andenhanced theirmotivation to learn.Gilmouretal. (2007)alsoreportedpositive outcomes from peer mentorship strategies, with newstudents gaining a range of personal benefits.

The students in this study clearly expected that mentors wouldhelp them to learn and to develop skills during their practice place-ments, supporting the earlier findings of Chow and Suen (2001).The data highlighted themajor impact that the quality ofmentorshiphad on students’ perceptions of their practice experiences andconfirm the prime importance ofmentors’ personal attributes (Smithand Grey, 2001). The requirement for mentors to be adequatelyprepared and updated for their roles has been strengthened signifi-cantly in theUK in recent years (NMC2008).However, thedata in thisstudy suggest that, in addition to thispreparation, it is imperative thatmentors are also enthusiastic and committed to supporting students.The findings showed that students recognised that, timewas amajorconstraint for mentors, which affected the quality of support, in linewith Ball and Pike (2005).

It was evident from the data that the focus of learning forstudents in practice was primarily on competence and thecompletion of assessment documentation. It is important thatnursing students are prepared for their roles as skilled andknowledgeable practitioners within the increasingly complexcontext of health care (Burns and Paterson, 2005). It appears, fromthis study, that students adopted a narrow perspective in relation tocompetence, viewing it from a clinical skills perspective. This hasimplications for the development of practice assessment docu-mentation and for the preparation of both mentors and students inrelation to the concept of competence in professional education.

Students were aware of their own responsibilities for learning inpractice and there appeared to be a link between students’ sense ofbelonging to the practice team and their enthusiasm and motiva-tion to learn. Some students reported negative experiences, inwhich they felt a hindrance and they resented being referred to as“the student”. This supports Pollard’s (2009) view that students’level of engagement and quality of the learning experience aregreatly influenced by their own individual personality, attributesand confidence. Placements are becoming more diverse andcomplex in nature and students have additional challenges inrespect of integrating into, and being accepted by, a wide range ofpractice teams throughout their programmes.

Recommendations for practice

� This study has highlighted the additional pressure experiencedby student nurses when completing practice placements. This

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confirms the need for a collaborative approach between HEIsand placement providers to develop effective support systems.

� Support systems should include preparation and support ofmentors and students and the development of peer mentorprogrammes.

� This study indicates the need for a more holistic approach tocompetence within pre-registration nursing programmes.

The authors acknowledge that support for student nurses in thepractice learning environment is multi-faceted and a further paperis planned to report the perspectives of mentors.

Conclusion

This study was conducted in one HEI in the UK and the findingsare therefore limited in their generalisability. However, the accor-dance shown with other research studies indicates that thesefindings have a wider international applicability and can be used tounderpin strategies to support students in practice settings. Inaddition, the new insights into the perceptions of the value of peersupport, the tendency of students towards a narrow perspective oflearning and competence and the increased pressure on studentswhilst on placement should be taken into account when consid-ering student support. Ensuring students have the best supportpossible is a crucial element in optimising the student learningexperience, promoting student progression and reducing attrition.The many factors highlighted in this paper need to be addressed inorder to ensure appropriate frameworks are put in place for thesupport of students in practice.

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