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Introduction
An optimal clinical learning environment for the formation of future professionals needs integrated commitment and cooperation from all those involved in the process. These include higher education institutions providing the career formation; health institutions acting as clinical field; and health professionals who undertake the role of clinical mentors, who must make compatible care demands with the requirements of clinical teaching.1-3) In relation to the concept of clinical tutor, also called preceptor, supervisor, or mentor, no consensus exists in literature on the specific functions associated to this term, which are even used as synonyms.4,5 Where agreement does exist is in the important contribution made by mentors to the formation of future professionals. In most cases, the mentor preceptor refers to the person in charge of socializing students in their professional role, facilitate the acquisition of technical skills in the clinical environment, and developing their critical thinking, that is, reaching the maximum effective learning in the clinic;2,5-7 in all, clinical mentors are models, teachers, advisors, facilitators, and evaluators.(8, 9)
In Chile, clinical mentors are especially important when nursing students are in the final semesters of their professional career, given that during that instance they must complete a 14-week clinical internship during which a clinical nurse who plays the role of mentor10 guides and evaluates them, in a one-to-one relationship. The importance of clinical mentorship when training nursing students and in achieving an optimal study learning environment has been recognized over decades in many Anglo-Saxon countries, like Canada (Canadian Nurses Association), the United Kingdom (Nursing Midwifery Council), and Spain, among others, where the phenomenon has been studied and programs have been created for mentors and directives to facilitate and provide guidelines to undertake the role.6,11-13) In Latin America and Chile, the experience related to the role of the clinical nurse mentor is hardly studied and much less is its function defined. Estimates show that in Chile an increasing number of nursing professionals are engaged in this activity, considering that in recent decades there has been a considerable increase in Nursing Schools, which are in need of these professionals.14) The objective of this study was to reveal the meaning clinical nurses give to being mentors for students from the nursing internship level.
Methods
A phenomenological study was carried out based on the postulates by Heidegger,15 considering principally that the being under study is a being there, who is within a context and environment that determine the view or essence of what it means to be a mentor for nursing students. On the other hand, it provides researchers the possibility to state their own perceptions and opinions a priori on the phenomenon, establishing that these should be recognized and evidenced to identify that which this being will effectively donate.16
Participant selection was intentioned. A letter of invitation to participate was delivered to all the clinical nurses who had gone through or were undergoing the experience of being mentors of students at nursing internship level, between September 2013 and July 2014, in hospitalized patient units from a health institution in Santiago de Chile, which acts as clinical field for diverse careers in this area. Everyone invited accepted to participate in the research.
The group size was established through the classical saturation criterion of emergent meanings according to Streubert,17 which was achieved on the sixth interview, with three more conducted to ensure the results revealed. The participants were nine women between 26 and 41 years of age, with a range between 1.5 and 18 years of work experience, and with an average of three mentorships carried out within the last two years. Information was gathered through in-depth interviews, with prior signing of the informed consent elaborated according to the precepts established in the Belmont report.18 Given that the principal investigator works in the hospital’s education area, an external interviewer was hired, a teaching professional, experienced in qualitative research and with no relationship in the health area, to conduct the interviews in a place agreed upon by both and which permitted privacy and tranquility to respond; no one else was present. The interviews were audio recorded and lasted approximately 45 min, starting with the research question: What does it mean to you to be a mentor to nursing students? During the interview, notes were not taken. No pilot tests were run, nor was the interview repeated for the participants. The researchers carried out the complete textual transcription of each of the interviews, as well as the subsequent data analysis.
Information analysis used the classic method described by Streubert and Carpenter:17) bracketing prior to starting with the interviews, which continued during the analysis stage and consisted in the personal recognition by the researchers of their biases, suppositions, and of their own experiences in relation to the theme. This was followed by careful reading and re-reading of each transcribed interview, to capture the general sense of the experience; to relate and group into units of meanings, which were accompanied with textual phrases by those interviewed to understand better the phenomenon. Thereafter, relationships were established among the essences, to group them into bigger units. Two co-researchers carried out the process independently to triangulate the information and grant reliability to the results.17 The study applied methodological rigor criteria established by Guba and Lincoln17 and the results obtained were returned to six participating nurses, to provide reliability to the interpretation of the experiences. The ethical aspects of the study were addressed according to the informed consent process19 and were approved by the ethics committee in the School of Nursing at Pontificia Universidad Católica de Chile.
Results
This study conducted and analyzed nine in-depth interviews in which each made up a body of analysis of around nine pages. The phenomenon showed four big comprehensive categories: vocation and gratification; personal and professional challenge; big responsibility; and transmission of experience. From these categories and their corresponding units of meanings, it was possible to unveil the experience the clinical nurses attribute to being mentors to students from the nursing internship, considered a being there with their environment.
The meaning of being a mentor to nursing students is unveiled as a beneficial experience perceived internally, given that on the one hand it emerges as a vocation that offers mentors the possibility of doing something they like or for which they have aptitudes, like teaching and preparing future nurses, a condition that would be perfected over time. This vocation is perceived as a gratifying experience that emerges when seeing students grow as individuals and as future professionals, and how they feel they have contributed to this development. The mentor learns and keeps up to date with the intern, but she also transmits her knowledge to students validated in the task and the experience, which is why it is a process of mutual growth. Some testimonies related to the aforementioned: it is because of the vocation I have, which is something quite big to prepare students, thus, for me it has a very important meaning (E6); the other thing that is quite enriching is to watch them, fulfilling their stage, fulfilling their goal, and their showing what they learnt and that they learned it well (E7); so, I started with that…base, that it was going to be like mutual growth, we would both go study together… in any case, the experience has been super enriching (E4).
In addition, certain characteristics of the work environment to which the nurse mentor is exposed may determine that this function bears an important meaning as professional and personal challenge. Work overload and lack of time associated to the teaching practice; lack of tools to become mentors to students or the lack of recognition and incentives for the work they do, constitute the principal elements associated to this experience. For some of the mentors, individuals who fail to meet these challenges could lack teaching vocation, or if this role is imposed, the experience could be unsatisfactory for them and for their students: I believe that a nurse mentoring a student intern has the same care responsibilities as the colleague who is not assigned to students and, likewise, I have to dedicate time to being as professional as this colleague, but I also have to dedicate time to this student; so, how do I make this compatible? (E5); nobody has taken classes to become a mentor, no one tells you which are the items to be a mentor…, I think nobody teaches you that, it is something you learn on your own, and if you like it you get more into it, but if you don’t like it, you will be less interested! (E7).
Another relevant meaning revealed from being a mentor to nursing students is the big responsibility nurses sense during the exercise of this role. They perceive that for student interns this phase prior to practicing as professionals is a “landmark” experience, which is why they feel that a positive or negative experience influences considerably on how the students will later perceive the nursing practice. Responsibility with patients and the health staff is related to mentors feeling that they are responsible for the task, and often for the decisions made by the student interns regarding the patient. The responsibility for preparing future “good professionals” emerges as a big theme for the mentor nurses. This is revealed from two aspects they consider relevant. Firstly, the characteristics they wish to encourage in their students to turn them into “good professionals”. Secondly, the forms or teaching-learning techniques they use intuitively to achieve this purpose, where modelling fulfills a fundamental role to achieve their objectives as mentors: the ultimate responsibility, for the student and the rest of the staff, is assumed by the nurse, and in that case, you are the nurse and the mentor, you have to face things, as we say, if there is any error, or any situation (E3). We want to prepare students who are secure, empowered with a professional attitude and not with a technical attitude. Professional attitude, that is, here, I am the professional, equal to any other professional in the area and whoever it may be. Therefore, I see it as a big responsibility, not as something left to just any person… (E2); I believe, then, that it is that, exploiting the strong areas (of the intern) and reinforcing the weaker areas, that is what I do at least with my interns and it has worked till now. That is the methodology I use (E4).
The mentors feel that a fundamental part of being a mentor nurse consists in being able to transmit to the student their professional and personal experience, given that through it, students can acquire knowledge that goes beyond the classrooms. They can transmit the vocation they feel, a way of teaching, a professional posture, a way of practicing nursing, and even a way of seeing life: it is super important to transmit the attitude, the person’s attitude, and the experience. Now I am much more experienced than before, hence, my experience now is more enriching than when I started (E7). I tell them: you can sit and read books and books on nursing and techniques on nursing, but anyone can learn that; here, we go for something else, for the essence, to caring for another because I want to and because I like it (E8). This is why the mentor is so important; the students cannot be left alone, there must be clinical mentors who deliver their experience, who manage to know the students, and for students to gain trust, and for their relationship to be very close (E3).
Discussion
Mentorship is an important study topic, which is relevant in the formation of future nursing professionals8,9 and which has been addressed more from the point of view of the tasks these professionals must perform, than from what it means to be a mentor.8 This is why this study is important, given that the participants in this research share what is revealed, their environment, which - finally - will define the mentor being. The discussion described ahead is based on results from international research and on a Chilean study published in 2010, which was carried out with the same methodology in a state hospital.
Vocation and gratification
Regarding the benefits perceived by the mentors in their teaching role with students, as in this study, being mentors mainly means to them intrinsic rewards, more than extrinsic recognition.20,21Per se, being mentors to students generates satisfaction, especially if they feel they are prepared as educators, and clarity with exercising the role.13,21,22 Vocation and gratification are the starting point to create respectful, amiable, and collaborative relationships with the students, conditions studied as preponderant when conducting successful mentorships.23) In the Chilean study, the category “being there in the relationship with the students” is perceived as "a personal and professional commitment resulting in possibilities for both". This is mainly manifested in “concern for the students’ wellbeing and in understanding them within their capabilities, demonstrating consideration and patience”.24 In this close relationship, mentors learn and stay up to date with the intern, but also transmit their knowledge validated in the task performed and the experience, which is why it is a process of mutual growth.3,25 Likewise, in this study, in the vocation and gratification category, all mentor nurses feel that the relationship established with students permits mutual growth, given that they are kept up to date and gratified upon seeing the students grow through what they are capable of transmitting.
Personal and professional challenge
Another big issue extensively addressed in foreign publications, and which coincides fully with this research, are the needs, obstacles, and challenges the mentors must confront every day to perform their role. International studies highlight, among the results obtained, three relevant aspects perceived by the mentors and which are also described in this study. These are ambiguity of the role, associated to the lack of a definition of functions related to the mentorship; lack of recognition for the extra work they carry out with students, both from their co-workers and from their bosses; and work overload that leads to lack of time to properly perform their teaching duties.7,8,12,20,26,27 Although this is not the case of the nurses in this study, studies describe that these obstacles begrudge the work of the clinical mentor, finding a correlation that implies a decrease in the commitment with the mentor role.20,27 For this reason, there is increasing emphasis in the literature on the need to have real supports for the mentors, like formation programs and a mentorship model that provides tools to exert this role.7,13
In relation to recognition, as in this research, the following were considered as important incentives for the mentors: having credits for professional certification, information programs on the assignment, good relations with the Faculty, economic allocation, and access to clinical resources and available academic material.28) Small presents or certificates of gratitude were not good incentives for this group.28 Upon reviewing the literature, it is interesting to see that these same obstacles or needs of the mentors are repeated over decades, without achieving a substantial change in their opinion of their condition.
Big responsibility
It could be considered that the big roles associated to mentors are, according to Boyer, cited by Omer:9 role of protector, evaluator, educator, and facilitator. According to this, the responsibility for protection toward the patient is the most important activity and most demanding for the mentor (9. This protection is mainly aimed at not incurring in errors that affect the patient’s safety, which also results in protection toward the student. Due to this, many mentors consider the mentorship as stressful work, associated to multiple functions, which are not altogether clear.21,26 This was also described in this study, in the category of “responsibility in front of the patient and the health staff”, where mentors need to be present, directly supervise the student assigned to them, given that a medication error can have serious consequences, which is why mentors need to know their intern well. They must create a relationship based on trust and honesty, given that only under those terms, can mentors advance and feel secure with student formation.
Another aspect that highlights this category is related to the responsibility assumed by mentor nurses for the proper teaching the students assigned to them. In the study by Wu,21 for the mentors, techniques, like reflexion and reasoning against clinical situations, as well as the feedback, fulfill an important role in teaching students, but they sense that a variety of evaluation methods exist that do not ensure its objectivity.21 As well as that found in this study, the mentors complain of the insufficient time they have to dedicate to education, and of the deficit in the formation of the mentors in pedagogical competencies.7,29,30 It was of interest to compare how the mentors in the present research also carried out each of these aspects (reflexion, analysis of situations, and accompaniment) in self-taught manner. They also felt that the degree of independence and learning achieved by students would not only depend on the mentor’s skills and experience, but on the student’s capacities and motivations. It is a two-way relationship, given that mentors will feel less satisfied in their role if the student is difficult or is unmotivated with the learning.22,31,32 Other research describes similar situations that highlight the lack of specific pedagogic formation and training, especially in reference to assessing student learning; due to this standardized directives are needed for the functions and a support system that backs the functions and limits the duality of roles.(7, 8, 22, 27, 33)
Transmission of experience
It is important to recognize that mentors not only feel they contribute at the technical-practical level, but also at the behavioral level, given that they also share their experiences, are models of actions to follow, and generate an ethical contribution that influences the students. This is a relevant aspect, but quite often poorly regarded.3) The second category in the study by Santos et al., (24 agrees with the aforementioned, given that nurses feel they are models for the students. This is associated to a sense of responsibility for the formation because, from it, nurses transmit “knowledge, experiences, their way of being, and their own art of care giving" for students to be good professionals in the future. These results agree with this research in the category of “transmission of the experience” in which mentor nurses state that the always accompany the students, support them, supervise them, guide, and model, thus, transmitting their teaching vocation, professional posture, a way of practicing nursing, and even a way of seeing life.
To conclude this study, mentoring of nursing students in the clinical setting has shown benefits in preparing future professionals as a valid tool to bring these students “from theory to practice”. Mentors can transmit their own professional experience, permitting students to socialize the role they will play within the multidisciplinary health staff, unadorned, but within a protected learning environment. Mentors, through this one-to-one encounter, based on trust and communication, will seek to strengthen the student’s best skills and reinforce weaknesses to, finally, manage for this future professional to acquire the tools to provide integral and founded care. The vocation of being a mentor and the responsibility for preparing “good professionals” will be the engine that drives nurses to carry out this work with dedication and professionalism and future personal and professional mutual growth will be their reward. However, there are different needs and challenges declared by mentors and analyzed in this study, which limit the adequate exercise of the teaching role. Through the phenomenological method, a vast richness of testimonies has been accomplished, permitting us to explore and delve into a phenomenon scarcely studied in Chile. Like every phenomenon, the perceptions mentors have include many appendages that have been revealed from this methodology, managing to discover a being there, defined by a setting that is not often facilitating, or propitious, but which could be overcome from the mentor’s vocation, experience, and preparation.
Based on the aforementioned, inputs are available to elaborate an intervention proposal, together with all the players involved (Health Institution, Nursing School, and mentor) to create a formal program that supports the conditions to perform this role, based on the needs expressed by the mentors in this study, enhance its benefits, and - thus - encourage and relieve the noble role of being a mentor to nursing students. Through this research, questions emerge, such as what happens to those individuals who by being mentors do not achieve gratifying experiences with students. As well as inquiring on which are the experiences of mentors with little experience (advanced beginner) who must assume the role of mentoring nursing students. It would also be interesting to ask about the experiences of student interns, as well as the rest of the health staff, about teaching in the clinical setting. This evidences the projection of the theme to continue this line of research.
Limitations in this study consisted in that the experience unveiled corresponds to nurses practicing in a hospital from a private health care network and which, additionally, was created since its origin as university clinical field.
