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PROFESSIONAL

The role of the sign-off mentor


in the community setting
Karen Cooper
Karen Cooper is Lecturer in Adult Nursing, School of Health and Social Care, Bournemouth University

 Email: kcooper@bournemouth.ac.uk

N ursing is a practice-based discipline, and 50% of


current pre-registration nurse education takes
place in the practice settingacknowledging the
fact that practice experience is one of the most important
aspects of preparation for registration (Pellatt, 2006). Studies
fies that degree programmes should equip nurses and mid-
wives to work better in many settings and roles, and enable
them to draw on a wider repertoire of knowledge and skills,
including the capacity to make complex assessments, clinical
decisions and deliver therapeutic interventions in a variety of
have consistently shown that students also perceive these situations. Newly qualified nurses should be able to practice
experiences to be the most valuable aspect of their nursing safely and effectively to meet the needs of the people in
programme (Papp et al, 2003; Shen and Spouse, 2007;Wood, their care as the delivery of health-care services continues to
2010) and that experience influences their choice of future evolve (Glasper, 2010), recognising that health-care delivery
employment (Shelton and Harrison, 2011; Marshall and is continually becoming more complex and extends beyond
Shelton, 2012). It is also recognised as a valuable resource acute care settings (Lavizzo-Mourey, 2012).
in preparing students for the profession and for the acquir- The NMCs (2010a) commitment is that newly qualified
ing of knowledge, skills and attributes to become a safe and nurses will be critically thinking, caring and competent prac-
competent practitioner (Midgley, 2006; Chan and Ip, 2007; titioners, enabling the delivery of high-quality care. Nurses
Salamonson et al, 2011). will be able to meet the challenges of an ageing population,
managing long-term conditions effectively and handling the
Nursing education increased care delivery outside of the hospital setting.
Recent changes to pre-registration nurse educationas set
out in the Nursing and Midwifery Council (NMC) Standards Mentorship
(2010a)aim to equip nurses to lead and deliver care within Mentorship became integral to pre-registration education
a modern health-care system whereby the minimum aca- in the late 1980s (Andrews and Wallis, 1999) alongside
demic award for pre-registration nursing programmes is a Project 2000 and the Governments policy statement on
degree. A report by the Prime Ministers Commission on the the direction of nursing in the UK (UK Central Council
Future of Nursing and Midwifery in England (2010) speci- for Nursing, Midwifery and Health Visiting, 1986). Prior
to this, little attention was given to student learning, with
the focus being on getting the work done (Melia, 1987).
Abstract The new model of education marked a shift from training
In an move to identify nursing as an all-graduate profession, the Nursing and to educating so that a knowledgeable doer (Bradshaw and
Midwifery Council standards identified that future nurses need to be equipped Merriman, 2008) would be produced. All students have a
with the skills and knowledge to lead and deliver high-quality care. In order designated mentor who is responsible for the learning and
to have these skills within the changing context of health care, students need assessing in practice. A mentor is a nurse who has undergone
to experience care delivery across a range of community, hospital and other specific preparation and is defined as someone who facili-
settings. Students have to undertake a final clinical placement of 12weeks tates learning, supervises and assesses students in a practice
at the end of their programme, commonly called a consolidation placement, setting (NMC, 2008, p.45).
and are allocated a sign-off mentor to confirm they meet the requirements Mentorship is viewed as being pivotal to the learning
for entry to the register. Placement capacity within primary care settings experience of the student (Gopee, 2011) and an essential
continues to be a challenge alongside the need for providing a sign-off resource in supporting and facilitating the development of
mentor. This article discusses some of the challenges and opportunities of future nurses (Royal College of Nursing (RCN), 2007).
the role of the sign-off mentor and the potential impact for encouraging newly All mentors have a major role in assessing the competence
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qualified recruitment in this area. of students, ensuring they are fit for practice, purpose and
award during the programme and at the point of regis-
KEY WORDS tration (NMC, 2010a). They serve as gatekeepers to the
w Mentorship w Sign-off mentor w Consolidation placement profession (Luhanga et al, 2008), with demonstration of
w Community placements w Quality assurance competence being a requirement for entry to the NMC
register. This is a holistic concept that was defined by the

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NMC (2010a, p.11) as follows: Challenges


One immediate challenge is ensuring that enough sign-off
the combination of skills, knowledge and attitudes, mentors are made available to students in their final place-
values and technical abilities that underpin safe and ment. Glasper (2010) identified that this was a challenge for
effective nursing practice and interventions. trusts, and difficulties have been experienced in coordinat-
ing three people (the student, the trainee sign-off mentor
As Black (2011) has highlighted, the absence of any one of and the observing sign-off mentor) to meet together, par-
these elements can mean failure in the final placement. ticularly in community settings (Robinson, 2013).
It has been shown that effective mentoring and supervi- In response to these difficulties, the NMC (2010b) has
sion of students contributes to a positive experience that clarified that future sign-off mentors have to be signed off
enhances students learning (Brammer, 2008). Effective men- on at least three occasions, but the first and second supervi-
toring has been shown to benefit individualsboth student sions could be undertaken by a variety of other methods
and mentorin fostering professional growth in knowledge, (for example, simulation or role play) determined by local
skills, attributes and practice (Carr, 2008; Nettleton and Bray, education providers. The final supervision for signing off
2008; Casey and Clark, 2011) and is essential in developing proficiency remains the same and must be with an actual
the future generation of nurses (RCN, 2007). The Willis student in practice.
Commission (2012) report clearly identified the importance The NMC (2008) also set the requirement for the sign-
of high-quality mentorship when discussing the future of off mentor in relation to the time needed to reflect, give
nurse education, and observed that students believe their feedback and document students achievements in the cur-
placement experiences to be directly related to the quality rent placement. The NMC (2008) requirement for all stu-
of their mentorship. dents is that, when giving direct patient care in the clinical
setting, 40% of the time is spent being supervised directly
Sign-off mentor or indirectly by a mentor. In addition to this 40%, when
The NMC (2008) agreed mandatory requirements for nurs- students are in their final placement, the sign-off mentor
ing, whereby sign-off mentors who have met additional is required to undertake a minimum of 1 hour per week
criteria (Box 1) must make the final assessment of practice. A of protected time with the student (Gopee, 2011). This is
sign-off mentor is: to ensure that any decision on the students proficiency
is not unexpected.The standards allow that the time may
a nurse or midwife designated to sign off pro- be reduced later in the placement as the student becomes
ficiency for a particular student at the end of more confident and competent. The issue of time con-
a programme must have been supervised on at straints has been documented as an issue (Rooke, 2013),
least three occasions for signing off proficiency by acknowledging the emotional aspects involved if students
an existing sign-off mentor or practice teacher. are underachieving in the final placement. Rookes (2013)
(NMC, 2008, p.7) evaluation of the role identified some concerns that deci-

Nurses are required to confirm that they have met all the
requirements for safe and effective practice for entry to Box 1. Criteria for sign-off mentor
the register, being fit for practice, purpose and award (Platt, w Identified on the local register as a sign-off mentor or a practice teacher
2002). This is defined as follows:
w Registered on the same part of the register
w Fitness for practicestudents have developed the requi-
site skills for professional registration w Working in the same field of practice as that in which the student intends
w Fitness for purposestudents are fit for employment, to qualify
including attendance w Clinical currency and capability in the field in which the student is being
w Fitness for awardstudents have met the required aca- assessed
demic standards. w A working knowledge of current programme requirements, practice
Judging this requires an overall decision to be made, assessment strategies and relevant changes in education and practice for
informed by evidence from a variety of sources and docu- the student they are assessing
mented in the ongoing achievement record, together with w An understanding of the NMC registration requirements and the contribu-
the mentors own observations of working with the student. tion they make to the achievement of these requirements
The sign-off mentor has to be undertaken once all of the
w An in-depth understanding of their accountability to the NMC for the deci-
hours of the programme have been completed. This is done sion they must make to pass or fail a student when assessing proficiency
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in order to address situations where students had previously requirements at the end of a programme
passed their proficiencies, had hours outstanding or where
w Been supervised on at least three occasions for signing off proficiency by
concerns were raised. an existing sign-off mentor, two of which can be undertaken by simulation
Robinson et als (2012) report on sustaining mentorship
identifies some key skills and desirable attributes for a sign- Source: NMC (2008)
off mentor (Table1).

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sions may be left for the sign-off mentor, rather than address- on the mentoring relationshipbut reinforces that it is
ing concerns at an earlier stage. This would support Duffys essential for any feedback to be specific, timely, and both
(2003) findings, which showed that students may be given verbal and written.
the benefit of the doubt, with responsibility and account-
ability being passed on to other parties. Community nursing scenario
Middleton and Duffy (2009) also found that there were Within the community setting, students can work with
concerns regarding the emphasis placed upon the sign-off several members of the team, which enhances the learning
mentor in terms of accountability and the feeling of being opportunities, broadens experiences and enables students
pressurised that resulted. Glasper (2010) also highlights the to greater exposure of practitioners expertise (Lofmark et
reliance on the sign-off mentor who sanctions the students al, 2008). However, this can mean that the mentor has less
entry onto the NMC register. However, Blacks (2011) study control and that potential conflict can occur (Hall, 2006).
found that although anxiety was present, mentors were able This reinforces the need to ensure there are clear objec-
to manage this situation when they felt it was morally right. tives and opportunities for feedback to be obtained by all
The most important factor was wanting to be a mentor and involved, including patients and carers. Miller and Archer
commitment to ensuring fitness to practice, offsetting the (2010) reinforce the importance of any assessment proc-
barriers of time and support. ess, emphasising the need for multi-source feedback to
It therefore seems that clear documentation regarding be obtained. This enhances the rigour of assessment and
how the student is progressing is essential, particularly at the reduces subjectivity.
mid-point interview. This documentation is vital for any
student, both for their own development and as evidence for Caseload and accountability
any appeals or fitness-for-practice proceedings. Heaslip and One challenge identified by Middleton and Duffys (2009)
Scammell (2012) found in an evaluative study that student study with regard to mentoring students within the com-
and mentor perceptions did not always match in terms of the munity setting was the problem of students having a smaller
feedback given. Clynes and Rafferty (2008) also found that caseload, and the need to balance accountability with
feedback was often given towards the end of the placement, students developing skills as autonomous practitioners. It
meaning that students found it difficult to make improve- was found that the allocation of a caseload appeared to be
ments in the time remaining. Clynes (2008) recognises that dependent on students ability and stage of the programme,
giving feedback is challengingparticularly as it can impact the mentor themselves and also on the caseload and patients
needs. Therefore, assessment and development of the stu-
dents competence requires skilful planning.
Table 1. Skills and desirable attributes for
sign-off mentors
Lone workers
Skills Desirable attributes Hall (2006) also highlights the complexity in acknowledging
Good communication and interper- Having an interest and aptitude for being a lone worker and not having easy access to colleagues
sonal skills teaching for advice. McVeigh et al (2009) acknowledge that effective
and equitable mentor support is much more challenging
Supporting the student in skill Being self aware and reflective
development within a community setting due to a reduced number of
available mentors, and this can lead to people feeling isolated
Providing constructive feedback Being fair, consistent, encouraging and unsupported. Support is provided for mentors by the
and thoughtful towards students academic institution and local trust initiatives such as place-
ment support facilitators, learning advisors and link lecturers
Identifying areas that need further Having a high level of commit- (Carr, 2008), alongside mentor updates and support groups.
development ment in view of the requirement
of a 1-hour meeting every week
Mentors need to identify the support mechanisms available
throughout the placement within their own area, which will enable knowledge, skills
and experience to be shared.
Prioritising and planning action Keeping aware of changing staff
with students carefully considering circumstances so that new The NMC (2008) identifies that the mentor is account-
their progress sign-off mentors could be able for their decision to allow the student to work inde-
developed to maintain capacity pendently, and Brown (2013) reinforces the need for careful
Managing difficult situations such consideration regarding how this is applied in a community
as behaviour regarded as setting. The NMC (2011) discusses the benefits of indirect
unacceptable by the third year supervision in facilitating students to work more independ-
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To be able to stand back and ently, developing their confidence and skills. They also give
recognise that students who guidance in terms of the caseload being well defined, ensur-
appear overconfident might be ing that the mentor or supervisor is easily contactable and has
covering up a lack of competence the ability to delegate supervision to another colleague. The
Source: Robinson et al (2013, p.1067) mentor remains accountable for such decisions and must
ensure public protection.

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Quality assurance the experiences of community nurses in mentoring a


As discussed by Robinson et al (2013), the rigour applied to student prior to registration. They found that having
assessment processes within higher education, such as second longer placements whereby students had the opportuni-
marking, external examiners, assessment boards and modera- ties to consolidate their practice provided benefits for
tion is not always seen to be as robust within the practice all involved. In such cases, this provided the opportunity
setting. While recognising that assessment and moderation to influence and support students prior to entering the
processes can be subjective activities, Schroder et al (2011) register, as well as enhancing personal mentoring skills
support a moderation process where opportunities for shared through assessment, feedback and documentation. Rookes
interpretations can be discussed with a move towards shared (2013) recent evaluation has shown that the introduction
understanding and setting good practice guidance. This has of a sign-off mentor has been viewed positively, ensuring
been undertaken locally, with practitioners and academic a robust mechanism for students confirmation of entry to
staff identifying good practice and giving feedback. It has the register and safeguarding the public. Robinson et al
enabled comparisons across a variety of practice settings, (2012) also emphasised that mentoring a student in their
which has informed part of a moderation report and has consolidation is valuable in terms of being able to support
been used for mentor updating. students in the transition and helping them to get ready
Some issues that have arisen when reviewing sign-off for the role of registered nurse. Sign-off mentors play a
mentor documentation relate to clarity and understand- pivotal role in guiding students during the final placement
ability. When reviewing documents, at times there is no clear where safe passage into the nursing profession is ensured
audit trail, particularly when students are underperforming, (Bourbonnais and Kerr, 2007).
with limited justificatory comments being given for the final
assessment. Development plans when issues have been iden- Community placements
tified are also not always evident. The NMC (2010a) has argued that the current pre-
registration programmes have greater opportunities for
Clarity of written confirmation practice learning in primary care. There is a need to
The sign-off mentor also needs to ensure that the written promote district nursing as a dynamic career pathway for
confirmation at the end of the placement clearly confirms nurses who want to make a difference and offer a quality
that the student has met all the requirements for entry to service to patients and carers in the community (Bennett
the register. All too often, the documentation is vague and and Nicholson, 2013). This is reflected in the RCN (2012)
subjective, with terms such as will make a good staff nurse report on the community nursing workforce and the
in the future being used where it might be questioned how urgent need to build future capacity.
long in the future this might be! The NMC (2008) requires One way to do this would be to promote the provision
confirmation that both practice and theory have been suc- of final consolidation placements in the community set-
cessfully achieved and that the student is considered profi- ting and the availability of employment for newly qualified
cient in meeting the competencies that have been set for nurses. Baglin and Rugg (2010) found that the majority
safe and effective practice. Sign-off mentors and/or practice of students were still undertaking placements within the
teachers are not required to directly inform the NMC of the acute trust setting. This may partly be due to traditionalist
practice assessment. The programme leader, or lead midwife attitudes that students need to get acute experience prior
for education, confirms to the approved education institution to a role within the community setting, which may in
assessment board that both the theoretical, practice elements turn influence students beliefs about their employability.
and good health and character have been achieved on com- Marshall and Shelton (2012) and Shelton and Harrison
pletion of the programme. These parties are therefore reliant (2011) discuss several myths and misconceptions about
on the quality of the practice documentation. students being unable to secure posts in the community
This also determines whether the student can be support- which again influence their potential choice of a consoli-
ed in repeating their consolidation placement (in a different dation placement.
area) if it has been identified that they have the potential to
meet the required competencies but had not achieved this at
the first attempt. This has been successful in several respects:
for some students, facilitating a further consolidation place- KEY POINTS
ment has resulted in achievement of the final practice assess- w The sign-off mentor role is challenging and complex, but is necessary for
ment and entry to the register. For a small number it has not students transition to registered practice
been achievable but has demonstrated a rigorous, fair process w Quality assurance processes can be enhanced through effective
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in terms of quality assurance. feedback, support and documentation ensuring students are fit for practice,
purpose and award
Opportunities w Community placements offering a consolidation placement and a sign-off
Limited research has been undertaken on supporting mentor can promote future recruitment upon qualification
students in their final placement within the commu-
nity. However, Middleton and Duffy (2009) explored

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