The Nursing and Midwifery Council (NMC) regulates practice for nurses and midwives in the UK. It sets standards to support learning and assessment in clinical practice and the education of pre-registration nurses and midwives (NMC, 2009; NMC, 2010). The pre-registration midwifery programme requires the practice-to-theory ratio to be no less than 50% practice and 40% theory (NMC, 2008). During clinical placement, student midwives should work alongside their sign-off mentor for at least 40% of the placement (NMC, 2008). The NMC (2008) describes a mentor's role as supporting and guiding students, facilitating their learning and professional growth, and directly observing clinical practice. New standards have been received from the NMC outlining ‘assessor and supervisor’ roles (NMC, 2018a), which may change the landscape of practice learning in the future. Until new pre-registration standards are introduced in 2020, during clinical practice, student midwives develop clinical skills and care for women and their families with supervision from their sign-off mentor that reflects students' individual learning needs and stage of learning (NMC, 2018a). This provides safe and effective learning experiences while upholding public protection and safety (NMC, 2018a). In 2009, the NMC introduced mandatory clinical practice grading into the nursing and midwifery curricula, in addition to assessing competency of the essential skills clusters (NMC, 2009). Student midwives are graded by their sign-off mentor at the end of each year to ensure their practice meets these skills.
According to Chenery-Morris (2014), good mentoring helps students grow and learn, particularly where continuity of mentorship exists. However, many mentoring schemes have the potential to deliver more than they actually do in practice. This represents many of the authors' own experiences of mentorship, although this may not be the case for all student midwives. Conducting research to assess other student midwives' experiences of continuity is important, as it could be an area for improvement in the pre-registration midwifery education programme.
Literature review
The journal articles and publications used as reference material were obtained using library databases such as Library Search, Ovid, ScienceDirect and Cochrane, Google and Google Scholar. The following keywords were used in searches: ‘student midwives’, ‘continuity’, ‘mentor’, ‘preceptor’, ‘mentorship’, ‘labour ward’, ‘delivery suite’ and ‘experiences.’ While reviewing the literature, some studies included the experiences of both nursing and midwifery students, likely because both professions are regulated by the NMC. As a result of this, the search was broadened to include key words such as ‘nursing’ and ‘nursing students’ to ensure that all relevant research was found.
Journal articles published between the years 2008-2018 were used as these were relevant and up to date. Two relevant studies (Lloyd-Jones et al, 2001; Kilcullen, 2007) were excluded due to the date of publication; however, the findings of both these studies were similar to those that were included in the literature review. All but two of the journal articles in the literature review were UK-based. The exceptions are two studies based in Norway and Australia; however, the methodology and themes generated were similar to the other studies and were therefore included. Overall, eight publications were included in the literature review (Table 1). The authors of the studies included were deemed suitable to conduct their research as they were all lecturers in a faculty of health, mostly nursing and midwifery. From this, five key themes were identified: continuity, team mentorship and peer support, student-mentor relationship, grading and barriers to continuity of mentorship.
| Source | Methods and ethics | Results and analysis | Recurring themes/critique |
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| Licqurish et al (2008) |
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| Myall et al (2008) |
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| Levett-Jones et al (2009) |
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| Christiansen and Bell (2010) |
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| Kinnel & Hughes (2010) |
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| Goode (2012) |
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| Brunstad and Hjalmhult (2014) |
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| Chenery-Morris (2014) |
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Advantages;
disadvantages
Findings
Continuity of mentor
In practice, there should be coordination and continuity of support and supervision to ensure that students experience safe and effective learning opportunities (NMC, 2018a). The literature review highlighted the importance of this, with students' reporting how continuity enhanced self-esteem, motivation, confidence and skill performance (Goode, 2012; Frazer at al, 2014). Students who received continuity were likely to experience a sense of ‘belonging’ and ‘connectedness’ to the clinical area and this was thought to be necessary for an optimal learning experience (McKenna et al, 2013). Myall et al (2008) reported that this could be achieved in several ways: being welcomed into the practice environment by their mentor, being included and valued as a team member and being treated as a valid and legitimate learner. If this did not occur, it could be detrimental to student midwives' development in practice (McKenna et al, 2013). Qualitative research by Chenery-Morris (2014) exploring the importance of continuity in pre-registration midwifery education highlighted this. This study used focus groups and one-to-one interviews to elicit data and both students and mentors agreed that continuity was important to enhance learning opportunities, a sense of belonging, confidence and practice development. Mentors involved in the study also reported they felt confident grading the student where continuity existed, as they had witnessed the student's clinical practice and could identify progress more easily. Furthermore, the students felt their mark was fair and accurate when they had received continuity.
The literature review demonstrated that students' experiences of continuity varied considerably. In one study (Chenery-Morris, 2014), all 52 students worked alongside their allocated mentor for a minimum of 40% of their placement, in line with NMC pre-registration standards (2008); however, this differed for the 230 students involved in Myall et al's (2008) study. A mixed-methods approach was used to consider the role of the mentor in UK practice, using questionnaires and interviews to obtain both qualitative and quantitative data. Although 76% of students did work with their assigned mentor for at least 40% of the time, 10% of students were never allocated a named mentor, meaning that NMC requirements were not fulfilled. Furthermore, 96% of students would have liked more time with their mentor. This suggests that most students' believed that working alongside their mentor for 40% of the placement was inadequate to meet their learning requirements.
Team mentorship and peer support
The literature review identified that continuity was valued more by first-year students. Studies showed that a lack of continuity during initial placements and a failure to connect with the placement area as a result could have long-term effects on students' progress (McKenna et al, 2013; Chenery-Morris, 2014). Midwives found that mentoring students early in their training was demanding and intense, with one mentor reporting:
‘I do find sometimes the first years are quite challenging especially when you have to prompt them … when you've got a first year it's like 6 or 7 weeks every shift with you and it is a lot.’
A number of mentors reported that having students shadow them constantly meant it was difficult to fulfil their own role effectively and this was considered to implicate both students and themselves (Myall et al, 2008). Co-mentoring first year students is reported as a possible resolution, as students would still have a sense of belonging and experience continuity, while mentors could have a break from the intensity associated with mentoring a student every shift (Chenery-Morris, 2014). The NMC also states how students should have:
‘Opportunities to learn from a range of relevant people in practice learning environments, including service users, registered and non-registered individuals, and other students as appropriate.’
Kinnell and Hughes (2011) suggested that involving other members of the multidisciplinary team in the student learning experience could enhance team dynamics and cohesion. Students would also have access to a range of learning opportunities to meet their individual needs. Students in third year, who are preparing for practice, were reported to value the opportunity to work alongside other midwives and members of the multidisciplinary team; therefore continuity appeared to be less important until grading of practice. Working with other midwives was shown to enhance learning by taking students out of their comfort zone so they could expand their skill repertoire and develop their own style of midwifery, through a variety of different practices (Goode, 2012; Chenery-Morris, 2014; Brunstad and Hjalmhult, 2014).
Peer support by senior students is an alternative method to reduce pressure on mentors. A interpretative qualitative study by Christiansen and Bell (2010) explored the effectiveness of peer learning partnerships and found that support from senior students minimised the feelings of ‘social isolation’ experienced by first-year students, helping them cope with challenges and concerns, and reducing the rate of students leaving the programme. The partnership was also beneficial for senior students as it helped them gain confidence for registered practice.
Student-mentor relationship
Myall et al (2008) identified how relationships between mentors and students were found to affect student learning, and concluded that expert teaching was essential for developing midwifery students' skills and knowledge. Mentors identified as supportive, helpful, realistic and providers of ‘hands-on’ practice and feedback were valued by students as they enhanced the quality of clinical placements and students' learning. In the study, 87% of the 161 students reported having a good relationship with their mentor. This appears to be a large number, however the sample was only 10% of the students who were invited to take part in the study. Because of this, it could be argued that the results were not representative of the student population; however, the questionnaires were reviewed and analysed to ensure they included students from different branches and year groups. This meant the sample was representative of the student population as a whole. Students also sought opportunities to work alongside mentors who inspired the philosophy they admired, rather than becoming socialised into a midwifery culture that was different to the programme philosophy (Licqurish et al, 2008). Overall, a positive relationship between students and their mentor was a fundamental part of student midwife success, and mentors with helpful qualities were found to enhance students' education.
Grading
A poor student-mentor relationship, often due to lack of continuity, could be considered detrimental to practice development and the grade that student midwives were awarded. The problem of establishing and sustaining effective student-mentor relationships has been documented in nurse education (Webb and Shakespeare, 2008). Chenery-Morris (2014) demonstrated that students with a better relationship with their mentor were able to discuss their progress and areas for improvement in order to be awarded a higher grade. This was supported by Brunstad and Hjalmhult (2014), who conducted a qualitative study using grounded theory to explore midwifery students' learning experiences on the labour ward. Student midwives felt that they had to be accepted by their mentor before they could begin the learning process and that access to learning was only enabled through acceptance. Once the relationship was established, the students felt comfortable and reassured that skill and learning opportunities would be provided. Issues with grading could be addressed by students being proactive and taking responsibility for their own learning, ensuring they are asking for feedback regarding ‘progress towards, and achievement of proficiencies and skills’ (NMC, 2018a: 12; NMC 2018b) and seeking relevant support from the student link if they are concerned.
Barriers to continuity
Although students desired mentorship continuity, the literature review indicated that organisational and contextual constraints imposed on mentors affected the quality of students' placement experience. These included workload, staff shortages, lack of support from university link lecturers and the staff-to-student ratio (Myall et al, 2008; Barry et al, 2016). Because of this, students were often used as an extra pair of hands because they were recruited into helping, rather than being given time and attention for learning. In some cases, the students felt like a burden or inconvenience, resulting in some considering withdrawing or taking a break from their programme of study (Myall et al, 2008). Lack of mentor continuity could have a negative effect on placement experience, learning and completion of the essential skills clusters. It appears that the NMC requirement to work alongside a sign-off mentor for 40% of the placement may be unrealistic in the reality of the clinical setting.
Conclusion
There is a paucity of literature that explores experiences of continuity of mentorship alone and what affect this has, and there is particularly little research that is up-to-date. However, there was a considerable body of literature looking at what student midwives valued in a student-mentor relationship and how positive student-mentor relationships improved students' learning and placement experience. In the light of these findings, it is clear that a lack of continuity affects all aspects of student midwives' experiences of the labour ward. Moving forward, good mentor practice should focus on continuity and the possible introduction of co-mentoring where a student is mentored by at least two midwives. This would remove the intensity of mentoring a student every shift for the midwife, while maintaining continuity and a sense of belonging for the student. Grading would also be less problematic as the team of midwives would be able to discuss the student's progress together and provide feedback. This would mean that student midwives would be provided with safe, effective and inclusive learning experiences (NMC, 2018), working with different named midwives to enhance their practice and skills development, without the anxiety of starting a shift without knowing who their mentor is or whether they will have their skills validated.