In the years since the Nursing and Midwifery Council (NMC) launched the new national standards (NMC, 2018a), the implementation of these has affected the dissolution of traditional models of mentorship, in parallel with the emergence of new roles to support students in academic and practice environments. In the NMC's supplemental guidance, Part 2: Standards for Student Supervision and Assessment (SSSA) (NMC, 2018b), further changes to the way that students are supported in clinical practice are outlined, not only shifting focus from the formerly pivotal role of ‘mentor’, but also introducing three new roles: practice supervisor [PS], practice assessor [PA] and academic assessor [AA]. Whereas historically the NMC's proposed model of mentorship required ‘mentors’ to support any individual student in practice – as outlined in the previous Standards for Learning and Assessment in Practice (NMC, 2008) – mentorship has now become a significantly more collaborative endeavour.
Perhaps the most significant modification brought about by the new standards pertains to the preparation requirements for PAs and PSs. In contrast to the more prescriptive historical standards, which had necessitated the creation of specialised credit and non-credit-bearing programmes to prepare qualified nurses and midwives for the mentorship role, SSSA delivers a more flexible, creative and practical regulatory framework (Leigh and Roberts, 2019). Pearce (2019) suggested that, on balance, these changes succeed in constructively differentiating support and supervision from assessment. For instance, students are no longer expected to spend 40% of their placement with one trained mentor, resulting in many more registered practitioners becoming involved in mentoring student placements.
Aims
The new standards (NMC, 2018b) state that PAs must be given ongoing support along with sufficient time to develop and perform their role, while undertaking training as required. This support can take a number of forms, but must allow for the standards to be met, and for PAs to both prepare for, and contribute to, student assessment. Nevertheless, Pearce (2019) reported that educators often felt that the new standards were designed for students and not them; she also stated that there were gaps in registrants' understanding of the new roles of PA, PS and AA, which form a key aspect of the new approach. Therefore, it is vital to investigate issues informing how the student/assessor/supervisor relationship is both undertaken and supported, while seeking to improve methods of facilitating the associated preparation.
In parallel with Pearce's (2019) findings, this evaluation aims to provide a representative sample of the experiences of PAs and PSs in supporting pre-registration learners since the implementation of the new NMC standards (NMC, 2018b). The authors aim to identify the enablers and challenges that influence the new PA/PS/AA roles, with particular emphasis being placed on educators' ground-level experiences of the substantial transformations that mentorship provision has undergone over the past 4 years. Through the aggregation of qualitative feedback from educators working within the scope of the new standards, the authors aim to discern precisely which aspects are felt to be successful and which are regressive.
Method
The service evaluation underpinning this article was commissioned by Health Education England (HEE), with the purpose of undertaking a scoping exercise both to gain an understanding of the experiences of PAs and PSs in supporting pre-registration learners, and to identify the enablers and challenges that influence those roles. The study was distributed to educators across one integrated care system (ICS) within the Midlands, and consisted of an online survey that sought to explore the experiences of PAs and PSs since the implementation of the NMC standards 4 years previously. The authors extrapolate these findings to consider the national situation, under the assumption that they are broadly representative of ICSs across the UK.
Following completion of a small pilot (n=4), data from respondents were collected through the administration of an anonymous 20-item survey (n=48). The survey included both closed and open questions, requesting primarily qualitative responses in relation to educators' individual experiences of the implementation period to date. Between October and November 2021, the survey was administered online via Microsoft Forms to all PAs and PSs employed across a broad range of health and social care organisations. Respondents were asked to state the organisation by which they were currently employed, and their current educator role. Responses to the qualitative questions were then read and coded by the authors (Mayring, 2014).
Figure 1 represents the range of educator roles that respondents reported. It is assumed that some educators undertook both roles during the COVID-19 pandemic – as permitted by the NMC (2022) recovery and emergency programme standards. Respondents were also asked to stipulate their specific role(s) if they had selected ‘none of the above/other’, and these responses included supplemental roles such as educational link nurse and clinical nurse educator. The role of sign-off assessor was also cited, despite this no longer featuring in the SSSA (NMC, 2018b). All participant responses have been anonymised in the findings section.
Although the data elicited provides valuable insights into respondents' experiences and highlights pertinent issues in relation to educators' experiences locally, it must be acknowledged that this small-scale evaluation was undertaken within one ICS in the Midlands. Therefore, the findings cannot necessarily or straightforwardly be generalised to other populations, despite the participation of nursing assessors and supervisors from a range of practice areas. The authors acknowledge that the survey was conducted during winter pressures, and the COVID-19 pandemic, which may have limited participation or influenced some responses.
Findings
In total, 75% (n=36) of respondents reported perceived benefits associated with assessing and supervising learners within the scope of the new standards. One benefit commonly emphasised is the opportunity that the practice assessment and supervision model fosters to ensure that students' learning is professionally fulfilling.
For instance, one respondent described the rewarding qualities of the opportunity to witness student development, stating:
‘… [there is] nothing as enjoyable or satisfying as … seeing them grow from nervous students to have more confidence and understanding of their role as a registered nurse.’
Respondent 10
In a similar manner, another respondent asserted:
‘… the satisfaction of watching a student grow and enhance themselves by your teaching, and watching them delivering person centred effective care that they have learnt from you … makes me feel proud.’
R24
Overall, a majority of educators experienced a palpable sense of pride and accomplishment when supporting nursing students within the remit of the new standards. Further themes that emerged from the data are presented in Table 1.
Table 1. Summary of key themes and subthemes
| Variation in levels of preparation |
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| Outdated knowledge |
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| Prohibitive workloads |
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| Role conflict |
|
Variation in levels of preparation
Most respondents positively referred to attendance at specialised training sessions to help facilitate the transition from ‘mentor’ to PA/PS, with some also referring to informative materials and online training modules provided by their organisations or practice education facilitators. For instance, one respondent stated that ‘sufficient training from the Trust enhanced the transition’ (R25) and, correspondingly, another stipulated that ‘informative material [was] provided and delivered by the practice team’ (R10). In marked contrast, 18% (n=6) said they required further training and updates in order to undertake the PA/PS role with confidence, suggesting, for example, that:
‘… an annual update/meeting would be nice to avail us of any changes/updates rather than yet finding out from the students.’
R16
Respondent 19 stated a need for ‘more training for supervisors’, which is role specific, because they ‘have not had any training or information regarding being a student supervisor’ since qualifying. Likewise, other respondents requested training specific to the required documentation, such as:
‘… further training on the workbooks particularly as we have students from a few different universities.’
R23
and further training specific to trainee nurse associates (TNAs), since this is ‘a relatively new role’ (R22).
Alongside highlighting these training deficiencies, respondents had differing overarching attitudes towards the paradigm shift. Only 9% of respondents (n=3) felt that the new NMC standards did not require improvements. One respondent strenuously raised concerns about the standards, stating their wish to ‘return to the old system!’, since
‘… it worked well before. Can't see the benefits of this new system as not all nurses should be working with students as they have no patience. Mentorship and sign off mentor [were] qualification[s] that I worked for, but I feel now it's pretty worthless.’
R12
However, other respondents differed from this view, stating that they were passionate about continuing to assess and supervise nursing students, feeling that their knowledge of the new model was continuing to improve (R18; R34).
Outdated knowledge
Within the new model, the AA role is responsible for confirming a nursing and midwifery student's achievement of proficiencies, theory and programme outcomes in the practice environment, with the PA and AA required to work in partnership to make assessment decisions (NMC, 2018b). It is therefore particularly significant that no respondents made any reference to the AA, despite AA's significant role in collating and confirming nursing students' achievement of proficiencies and programme outcomes in the academic environment and across the breadth of programmes. Nevertheless, several respondents requested that links with approved education institutes (AEIs) were enhanced, suggesting that both knowledge and the visibility of the AA role is possibly limited. This implies that there remains significant scope for strengthening links between practice teams and AEIs, via the promotion of clear lines of communication between the two roles and ensuring that educators feel supported.
Respondents also frequently referred to a variety of challenges that they had experienced while undergoing the transition from ‘mentor’ to PA/PS. One respondent asserted that the change in language adopted in the SSSA (NMC, 2018b) had been challenging. Specifically, they expressed the view that ‘… the terminology [was] the hardest thing to implement in the change’ (R26) since it differs so significantly from the terminology of the previous model. In parallel, another respondent referred to the inconsistent knowledge within practice settings in relation to the difficulty of distinguishing between PA and PS roles:
‘I completed teaching and assessment in the clinical setting in 2004. That was hard, but I felt prepared to use these skills in my workplace. I have had almost 20 years to practice this. The roles of assessor and supervisor a[re] not explicitly clear, and the programme has a lot of tweaking to go.’
R8
These responses suggest that, from the perspective of a large proportion of the educators tasked with undertaking these same roles, the three key roles in the new NMC standards are still not sufficiently explicit.
A further 15% of respondents (n=4) referred to various transitional challenges relating to the new mandatory practice documentation, suggesting, for instance, that ‘getting up to speed with the new documentation was quite hard’ (R21). Similarly, another respondent expanded that:
‘… it requires more … paperwork and as the students also at times look for guidance from us, that makes me a bit uncertain. Although I do confer with other assessors to check if I am on the right track.’
R1
There was also a recurring hesitancy expressed as to which skills learners are authorised to perform.
‘I also find it complicated to know exactly what a student is permitted to do while on placement, such as venepuncture for example. I do feel there should be a section that covers clinical skills and outcomes with clear definition of exactly what a student is permitted to learn/observe while on placement’
R21
These gaps in knowledge strongly suggest the need for further preparation and training around the roles outlined in the new guidance and local policy reviews.
Prohibitive workloads
Wider issues were also raised pertaining to time constraints inhibiting the ability to expend sufficient time to support learners in the current landscape. As one respondent summarised:
‘Short staffing and high patient acuity, together with meeting the needs of the patients and the organisation, has [sic] proven difficult to enable sufficient time to discuss, teach and complete student documents and interviews’
R12
Significantly, 22% of respondents (n=8) specifically referred to their current role limiting their capacity to assess or supervise students. For instance, one ward manager reported:
‘I often get pulled away from clinical duties, which means students get put with other members of the team’
R10
Similarly, Respondent 30 stated that they were often inhibited by ‘demands on my time as a band 6 nurse in charge’. Another respondent stated that their manager had felt that they would not be capable of undertaking a PA role in addition to their regular duties (R29). These barriers were further compounded by shift patterns that impacted on educators ‘working directly with students’ (R5). In addition to the above issues, Respondent 7 also cited numerous specific organisational constraints and barriers that impede the quantity of students that educators can assess or supervise at their institution.
Meanwhile, one quarter of respondents (n=8) referred to either requiring protected time or needing a reduced workload, in order to support their assessor/supervisor role. For these respondents, supervision only became possible ‘by having specific time set aside (paid for by my employer) to be with my student’ (R9). Another referred to having protected time to support students, but related this solely to the completion of documentation, stressing the importance of:
‘… having specified time to complete paperwork away from the ward area that is not in our own time.’
R7
Correspondingly, Respondent 26 asserted that there should be
‘protected time for both students and assessors. Instead, much of the assessments are completed after a shift or a day off – allowing for no interruptions.’
In addition to the need for protected supervisory time, 26% of respondents (n=7) referred to themes relating to either needing ‘more time available to spend with students one to one’ (R15) or ‘more assessors … to give assessors a break in between students’ (R10).
Role conflict
Considering current workload pressures associated with the COVID-19 pandemic, it was not unexpected that educators frequently cited workload constraints as a barrier to effective learner assessment and supervision. Indeed, participant responses were frequently permeated by themes pertaining to role conflict, and having insufficient time to assess students in clinical practice. The data indicated that staffing shortages and a general lack of available educators in some placement areas, alongside PAs and PSs being absent through sick leave, had introduced considerable vulnerability in learner assessment and supervision provision over the past 2 years. PAs commonly reported that they lacked protected time amid their high workloads, and indicated that completing student assessment documentation had only exacerbated workloads.
Respondents also referred to having witnessed institutional practices that had negative impacts on student experiences, such as learners being used inappropriately to bolster thin staffing numbers, or instances where there were more students than PAs and PSs. For instance, one respondent reported:
‘It has been difficult to give students the normal standard of placement due to unit pressures … so there may be more students than assessors/supervisors occasionally.’
R26
Although Respondent 19 informed:
‘Time constraints on the ward have become worse over the years and at times I feel that the students get used as a pair of hands rather than a learner.’
Discussion
This evaluation aimed to gain both an understanding of PAs' and PSs' ground-level experiences in supporting pre-registration learners and to identify the enablers and challenges that influence these roles since implementation of the updated standards published 4 years previously (NMC, 2018b). Although the preceding published literature has focused on improving the understanding of the PA and PS roles (Hoy and George, 2018; Drayton and Edmonds, 2020), there is no published research to date exploring the transition from the traditional role of mentor to that of PA/PS. Four years on from implementation of the NMC standards (2018b), the findings reported in this article provide insight into the contextual characteristics experienced by PAs and PSs when performing these roles, particularly in relation to the benefits and challenges they experience, while offering methods that may facilitate the associated preparation: for example, further preparation and training around the PA/PS/AA roles and associated documentation, specified time to complete paperwork, and protected time or a reduced workload to support the assessor/supervisor role.
As is implicit in the new framework of assessment and supervision underlying the new standards (NMC, 2018b), the current generation of nurses play an invaluable role in the preparation of the future nursing workforce. Nevertheless, since national data regarding workforce shortages emphasise an urgent need to recruit and educate non-medical health professionals (Department of Health and Social Care (DHSC), 2021), there is an acute requirement to carefully manage workforce expansion within practice learning, in order to continue to provide adequate supervision and assessment to student practitioners.
PA, PS and AA educators are integral to students practice learning experiences, having a significant influence on the quality of placements, and students' sense of belonging and their scope for learning. This article demonstrates that PAs and PSs are committed to undertaking their practice education role and that preparing the future workforce is a source of satisfaction and pride for educators. However, respondents also reported some negative experiences, suggesting that there are a number of unresolved challenges associated with assessing and supervising students, which are frequently linked to inconsistent knowledge and preparation, workforce implications and role conflict.
According to the NMC (2018a), all PAs and PSs should receive adequate preliminary and ongoing preparation to adopt their respective roles and prevent those taking on such roles from feeling ill-prepared and unsupported. Leigh and Roberts cautioned back in 2018 that appropriate arrangements should be made by AEIs and practice partners to adequately prepare PAs and PSs for their imminent roles. Although respondents in this survey positively reported on the training they had received, there were frequent examples of deficiencies in their preparation and persistent gaps in knowledge. Leigh et al (2019) emphasised the challenges associated with the transformation of long-standing mentoring traditions, advising that the requisite time and effort to ensure that this should not be underestimated and subsequently further preparatory, transitional and ongoing training is warranted.
Survey respondents described various learning methods for preparation ranging from training days provided by organisations and AEIs to online guidance/training, workbooks and independent study. Although these diverse approaches meet the requirements of the NMC standards (2018b), which permit greater independence of assessment and offers potential for greater innovation (Leigh and Roberts, 2018; Knight et al, 2021), this lack of consistency in content has resulted in varied levels of preparation. Furthermore, robust transitional and preparatory arrangements have been established across some regions in the UK to ensure that PAs and PSs are adequately prepared (Pearce, 2019), yet the findings from this survey indicate that there are discrepancies nationally. Despite the fact that training requirements for supervisory and assessment are no longer stipulated, as a governing body, the authors recommend that the NMC should implement more standardised preparation for PAs and PSs. Furthermore, appropriate training resources need to be created and distributed widely to fill gaps in knowledge about the model, and to enable educators to perform their specific roles sufficiently, while that ensuring nursing students can meet their practice learning outcomes.
The development of the AA role to work alongside the PA/PS provides a collaborative approach to practice assessment (NMC, 2018b). However, it was interesting to note that the AA role was not referred to in this survey, despite respondents appealing for stronger links with AEIs. According to Drayton and Edmonds (2020), despite little research to date on the role of the AA, a key challenge associated with the role is managing communication between the university and nursing students' practice placement sites. Although electronic assessment documentation is one method that can be used to resolve any communication issues between PAs, PSs and AAs (Smith and Cambers, 2017), the findings of this survey have established that PAs' and PSs' knowledge of the documentation system is also limited. A focus on ensuring clear lines of communication between the PA and AA roles is key to the assessment process and make certain that they feel supported by affiliated AEIs. The authors therefore support Smith and Cambers' recommendation that training and support is seen as essential, alongside further exploration to consider how links can be developed further between practice and AEIs.
The responsibility for supervision and assessment of students is positioned with practice educators who are required to manage the demands of patient care delivery alongside their supervisory role. Respondents in this survey reported that they lacked protected supervisory time, set against high workload pressures, and indicated that completing student assessment documentation had added to their workload. Role conflict has been an issue frequently reported by (formerly titled) mentors in previous studies (Myall et al, 2008; Newton et al, 2017; Harrison-White and Owens, 2018; Panda et al, 2021), with assessors reporting often feel overwhelmed by the amount of work associated with their role (Hughes et al, 2019). Due to the lack of protected time this results in PAs and PSs using their own time to adequately undertake their role, despite previous recommendations for a crucial review of the issue to ensure practice educators are protected from excessive clinical workload when supporting learners (Newton et al, 2017).
Significant time constraints and role conflict inhibiting the ability to expend sufficient time to support learners in the current supervision landscape can also negatively impact the learner experience. These instances are consistent with previous findings reported by Keeping-Burke et al (2020), which established that staffing constraints can result in learners having limited role models, receive insufficient feedback and missed learning opportunities. Two of the predominant challenges associated with the preceding ‘mentorship’ model were negotiating student access to adequate mentorship arrangements and, in instances where such arrangements were inadequate, students' supernumerary status being eroded (Harrison-White and Owens, 2018). However, several reports have emphasised that exposure to unsupportive placement experiences and staff shortages that affect student supervision are key reasons cited for placement-related attrition in nurse education (Eick et al, 2012; HEE, 2018). Furthermore, Hughes et al (2019) postulated that workload and time pressures can result in some assessors passing students who are performing at a borderline level. Although this issue is enduring, and role conflict forms a theme inseparable from the other key findings from this survey, the authors acknowledge that it is difficult to ascertain to what extent this will remain an issue outside COVID-19 pandemic conditions. However, it is notable that previous articles have recommended that workload should be decreased when students are working alongside practice educators due to the time required to invest to provide effective assessment and supervision (Henderson and Eaton 2013; Newton et al, 2017).
In terms of policy implications, the authors recommend that PAs' and PSs' concerns related to time constraints for student assessment during working hours are considered, with targeted efforts to promote protected time. This is significant because the Education and Training Tariff (DHSC, 2021) aims to ensure that providers are reimbursed consistently for the training placements they provide, that placements are high quality and ensure learners have the appropriate supervisory teaching and support as defined by the NMC. Furthermore, the completion of a practice learning educational audit between AEIs and practice learning partners to monitor the capacity, resources and quality of all practice placements to meet statutory and professional body requirements is a contractual requirement (Royal College of Nursing, 2017). Therefore, it is essential that action is taken in areas in which staff need support to maintain, improve and develop the quality of the learning environment. This would help guarantee that nurses of the future are provided with meaningful, effective practice learning opportunities, and that PAs and PSs are suitably prepared to perform their respective roles in line with the new NMC standards.
Finally, the authors note that it would be helpful to compare these findings with those from other ICSs to confirm that the findings on PA/PS preparation are generalisable across the UK higher education and practice landscape. In particular, future research involving PAs and PSs from other regions or ICSs is required, to expand knowledge about their preparatory needs and experiences since implementation of the new standards, while simultaneously attempting to determine whether these issues have endured beyond COVID-19. Therefore, the authors recommend that the HEE continues to invest in assessing the efficacy of the PA/PS model by commissioning similar scoping reviews.
Conclusion
The quality of practice learning environments is integral to providing safe and inclusive places in which students can experience and learn, healthcare. How we supervise and assess students in practice is crucial to ensure our future workforce is fit for purpose. This evaluation offers practice partners and AEIs the opportunity to review how practice learning educators are prepared and supported and how the Standards of Supervision and Assessment (NMC, 2018b) can be implemented through innovation and collaboration. This can ensure that nurses of the future are provided with meaningful, effective practice learning opportunities and that PAs and PSs are suitably prepared to perform their respective roles.
KEY POINTS
- The survey provides a detailed overview of the experiences of PAs and PSs in supporting pre-registration learners since the implementation of the new NMC standards. Most educators experienced a palpable sense of pride and accomplishment when supporting nursing students within the remit of the new standards
- Persistent gaps in knowledge emphasise the need for further preparation and consistent training around the roles outlined in the new standards for student supervision and assessment
- Role conflict is an issue for many PAs and PSs, who often have insufficient time to assess students in clinical practice
- The NMC should set the requirement for more standardised preparation for PAs and PSs regionally and nationally, with protected supervision time
CPD reflective questions
- Consider how you prepare and maintain current knowledge and expertise that is relevant for the proficiencies and professional programme outcomes
- As a PA/PS, consider how you communicate and collaborate in assessment decision-making with academic assessors (and vice versa), and reflect on how your own current practice can be enhanced
- Identify the local support mechanisms available to you to help develop and maintain emotional resilience and personal support strategies for this role