Removal of Annual Declaration and new Triennial Review Form. Originated / Modified By: Professional Development and Education Team

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1 Review Circulation Application Ratificatio n Author Minor Amendment Supersedes Title DOCUMENT CONTROL PAGE Title: Mentorship in Nursing and Midwifery Policy Version: 14.1 Reference Number: Supersedes:.14.0 Changes: Date July 2016 Notified To Summary of amendments Date: Removal of Annual Declaration and new Triennial Review Form Originated / Modified By: Professional Development and Education Team Designation: Practice Education Facilitators Ratified by: Professional Forum Date of Ratification: August 2016 All Nursing Staff and Managers Issue Date: Circulated by: dissemination and Implementation: Review Date: July 2018 Responsibility of: Professional Development and Education Team Date placed on the Intranet: Please enter your EqIA Registration Number here: 13/13 Page 1 of 32

2 Section Contents Page 1 Introduction 3 2 Purpose and scope 3 3 Roles and Responsibilities 4 4 Detail of Procedural Documents 7 5 Equality Impact Assessment 7 6 Consultation, Approval and Ratification Process 7 7 Dissemination and Implementation 7 8 Monitoring Compliance of mentorship in Nursing and 8 Midwifery 9 Standards and key performance indicators 8 10 References and Bibliography 8 11 Appendices 1. Definition of Terms 2. Standard for achieving mentor status 3. Standard for achieving and maintaining Practice Teacher status 4. Standard for Sign off status 5. Standard for annual updating 6. Standard for maintaining mentor/ sign off/ practice teacher status (Triennial Review) 7. Standard for the Management of the Live Mentor register 8. Standard for supervision of pre-registration students 9. Spoke Placement Feedback Form Page 2 of 32

3 1. Introduction Nurses and Midwives have a responsibility under the Nursing and Midwifery Council (NMC) Code of Conduct to facilitate students learning to develop their competence. This policy outlines standards, in line with the NMC Standards to Support Learning and Assessment in Practice (2008), which all nurses and midwives must comply with when assessing students on pre-registration nursing and midwifery programmes, and programmes leading to Specialist Community Public Health Nurse or Community Specialist Practitioner and Advanced Practitioner roles. Central Manchester Foundation Trust (CMFT) is committed to support learners in practice; this is reflected through the annual signing of the Learning and Development Agreement (LDA). The LDA is a quality assurance document entered into between CMFT and Health Education England (NW) which outlines our responsibilities in regard to practice learning. This policy will set out the key themes and responsibilities to ensure compliance with the NMC Standards, which will be underpinned by standards for practice to assist with compliance. 2. Purpose and scope This policy will ensure a standardised process across all CMFT Divisions to provide assurance that all mentors and practice teachers are compliant with the NMC Standards to Support Learning and Assessment in Practice. It also supports compliance with the LDA. This policy will provide a mechanism for quality assurance of mentors and practice teachers, with guidance on managing mentor development and compliance with the NMC Standards. A set of standards is included to support nursing and midwifery staff on becoming a mentor/ practice teacher, maintaining their status and providing guidance on supporting students. Inter-rater reliability will be ensured through the processes providing assurance of effective mentorship and quality learning environments. This policy applies to all mentors and practice teachers who assess and/ or support students on pre-registration nursing programmes, and programmes leading to Specialist Community Public Health Nurse or Community Specialist Practitioner and Advanced Practitioner roles. The policy also supports the recording of mentorship status on the live register of mentors. Where mentors are not able to act within their role, due to capability issues affecting their clinical practice, their status should be deactivated until such a time that they are able to undertake their mentorship duties. For this and other reasons for not acting within the mentorship role, such as secondment, change in role, long term leave, the standards for management of the live mentor register (appendix 7) should be referred to. The following Trust requirements are ensured through the processes in this policy; Page 3 of 32

4 A mentorship qualification will be a mandatory requirement for all Band 6 and 7 nurses and midwives working with the Trust Band 5 nurses must have commenced and successfully completed a Multi-Professional Support of Learning and Assessment in Practice programme before reaching the top of the Band. Band 5 midwives must successfully complete the Preceptorship programme and Multi-Professional Support of Learning and Assessment in Practice programme before consideration is given for progression from band 5 to band 6. 70% of registered nurses and midwives to hold a recognised mentorship qualification All registered mentors to complete mandatory annual updates with 100% minimum compliance across all placement areas. All registered mentors to complete a Triennial Review as part of their Revalidation process. 3. Roles and Responsibilities Chief Nurse Chief Nurse will be responsible for overseeing the implementation of the policy. The Directors of Nursing/ Deputy Directors of Nursing/Midwifery The Directors of Nursing/ Deputy Directors of Nursing/Midwifery will be responsible for ensuring the implementation of the policy through the nursing and midwifery workforce. Divisional Directors/Directorate Managers/Heads of Nursing and Midwifery The Divisional Directors/Directorate Managers/Heads of Nursing and Midwifery will be responsible for ensuring arrangements and processes are in place to support the implementation of the policy via the operational structures and local policies, across all clinical areas within the Divisions. Lead Nurses/ Matrons The Lead Nurses will be responsible for the monitoring of compliance within the policy and taking appropriate actions as required. The Lead Nurses / Matrons will be responsible for ensuring that each clinical area has sufficient numbers of mentors and sign-off mentors to support learner s needs. They will support the Heads of Nursing by undertaking audit and monitoring compliance with the Standards for practice within this policy. By monitoring mentorship numbers and competence, the Lead Nurses/ Matrons will enable the Practice Education Facilitator to facilitate the appropriate number of training opportunities. Where a mentor has been deemed as unable to carry out their mentorship duties, the Lead Nurse/ Matron will be aware of/ be involved in the decision to deactivate a mentor, particularly where there are capability issues in regards to clinical practice. Ward Managers/Team Leaders Ward Managers/ Team Leaders will be responsible for ensuring that all their staff are aware of this policy and ensure compliance with the policy in the placement areas. Ward Managers/ Team Leaders will be responsible for completing the live register and verifying all details of the mentors in their placement areas. Page 4 of 32

5 The Ward Managers / Team Leaders will be responsible for ensuring all staff have a Triennial Review during the revalidation process demonstrating their competence to mentor and compliance with the NMC (2008) Standards to Support Learning and Assessment in Practice. The Ward Managers/ Team Leaders will be responsible for ensuring that Registrants follow the Trust policy in achieving mentorship status by undertaking an NMC approved Multi-Professional Support of Learning and Assessment in Practice programme and for inspecting the evidence of successful completion of a mentorship programme. This includes agreeing how the NMC requirements for 37.5 hours protected time for Multi-Professional Support of Learning and Assessment in Practice programmes will be met for both full and part time staff (see Appendix 2) Where nursing and midwifery staff are employed 0.4 whole time equivalent (WTE) or less, entry to the mentor preparation programme will be at the discretion of the Manager/ team leader, following consideration of the study requirements, and the staff member being able to meet the NMC Standards for mentors following completion of the programme (see Appendix 2). The Ward Managers/ Team Leaders will be responsible for ensuring that all students have an allocated mentor 2 weeks prior to the commencement of the placement. Where the student has been allocated at a late stage; the mentor will be named as soon as possible before or on the student s arrival. Where a mentor has been deemed as unable to carry out their mentorship duties, the Ward Managers/ Team leaders will discuss with/ inform the Lead Nurse/ Matron that a mentor needs to be deactivated from the live mentor register, particularly where there are capability issues in regards to clinical practice. (Appendix 7) Registrants All registrants will have responsibility for providing evidence to support their annual appraisal and demonstrate that they are achieving stage 1 of the NMC standards. The performance development plans will demonstrate a clear progression to meet stage 2 as required by the trust within this policy. Registrants will support mentors in practice in providing quality placements to students and contribute verbally to the student s assessment. Registrants must not complete the student s assessment documentation. Mentors / Sign-off mentors & Practice teachers Mentors / Sign off mentors / Practice Teachers will be responsible for ensuring that they meet the NMC standards using the processes outlined in this policy. They must demonstrate, through the Triennial Review process that they have attained and maintained the necessary competencies to support and assess learners to either NMC stage 2 or 3 as appropriate. They must complete a mentor update annually. Page 5 of 32

6 Mentors are responsible for the assessment of the student, ensuring it is conducted fairly taking into consideration inter-rater reliability. Mentors are responsible and accountable: For supervising (directly or indirectly) students 40% of the time and undertake initial, mid-point and final interviews and review the students evidence For organising and co-ordinating student learning activities in practice For supervising students in learning situations and providing constructive feedback Setting and monitoring realistic learning objectives Assessing total performance and providing evidence of student achievements Liaising with others to support learning needs and assessment (e.g. sign-off mentor, practice education facilitators, academic / personal tutors, team members) A mentor may assess in the final placement only if they have completed 2 simulations of signing off a student (usually included in the Multi-Professional Support of Learning and Assessment in Practice programme or via trust training) and/or are undergoing the final assessment to become a sign off mentor and are supervised by an established sign-off mentor. Mentors on the CMFT register prior to September 2007 remain as sign off mentors, as do those individuals identified at Trafford. Education and Development Practitioners (EDPs) and Clinical Educators (CE) Some EDPs and CEs have a role in coordinating the update of the live register and supporting staff in accessing the Multi-Professional Support of Learning and Assessment in Practice programmes. These roles are delegated as appropriate by the Heads of Nursing/ Midwifery and Lead Nurses/ Matrons. Practice Education Facilitator The Practice Education Facilitators (PEFs) have responsibility to facilitate and support the development of mentorship throughout nursing and midwifery services. This is achieved through; Ensuring that sufficient numbers of annual mentor updates are available Ensuring adequate provision of Multi-Professional Support of Learning and Assessment in Practice programmes Preparing and assessing mentors to achieve sign-off status Overseeing the maintenance of the live mentor register Supporting mentors and students during clinical placements Monitoring compliance with the policy and its standards for practice and the NMC standards Supporting Lead Nurses and Ward Managers/ Team Leaders with ensuring compliance PEFs will report to stakeholders as required via the LDA and Higher Education Institution (HEI) meetings. Page 6 of 32

7 Professional Development and Education Administrators The Professional Development and Education Administrator will be responsible for the day to day maintenance of the live mentor register and provide reports under the guidance of the Practice Education Facilitators. They will provide administrative support for the Multi-Professional Support of Learning and Assessment in Practice programmes and mentor updates. 4. Detail of Procedural Documents This policy is supported by a number of documents that detail the required standards for practice in mentorship and practice education. These are available in the Appendices Standard for achieving mentor status Standard for achieving and maintaining Practice Teacher status Standard for Sign off status Standard for annual updating Standard for maintaining mentor/ sign off/ practice teacher status (Triennial Review) Standard for the Management of the Live Mentor register Standard for supervision of pre-registration students 5. Equality Impact Assessment. The Trust is committed to promoting Equality, Diversity and Human Rights in all areas of its activities. The EqIA registration number is 13/ Consultation, Approval and Ratification Process This policy has been reviewed by the Nursing and Midwifery Education Forum with approval sought from Professional Nursing Forum. The policy was approved and ratified by the Professional Nursing Forum in August This policy will be reviewed two yearly by the PDE Team. 7. Dissemination and Implementation 7.1 Dissemination Dissemination of this policy is detailed within the Implementation Plan. 7.2 Implementation of Procedural Documents See updated Implementation Plan. Page 7 of 32

8 8. Monitoring Compliance of Mentorship in Nursing and Midwifery Compliance with this policy will be monitored by the Lead Nurses/ Matrons. The PDE Team will provide compliance reports three times per year to assist the Lead Nurses/ Matrons. Process for Monitoring Compliance and Effectiveness The Lead Nurses/ Matrons are responsible for monitoring compliance with the Mentorship in Nursing and Midwifery Policy at Divisional and Corporate level. This will be completed on a three times per year basis and reported to the Professional Nursing Forum. The following will be monitored for compliance: 70% of registered nurses and midwives to hold a recognised mentorship qualification All registered mentors/ practice teachers to complete mandatory annual updates with 100% compliance across all placement areas. All registered mentors/ practice teachers will comply with Triennial Review requirements with 100% compliance across all placement areas 9. Standards and Key Performance Indicators KPIs This policy supports the NMC Standards for Learning and Assessment in Practice (2008) which all mentors and practice teachers must adhere to. The policy links to the following Quality, Innovation, Productivity and Prevention (QIPP) outcomes: Quality Prevention Productivity 10. References and Bibliography Nursing and Midwifery Council (2008) Standards for Learning and Assessment in Practice: NMC standards for mentors, practice teachers and teacher London NMC Nursing and Midwifery Council (2010) Standards for Pre-registration Nursing Education London NMC Nursing and Midwifery Council (2011) Advice and supporting information for implementing NMC standards for pre-registration nursing education London NMC. Page 8 of 32

9 11. Appendices 1. Definition of Terms 2. Standard for achieving mentor status 3. Standard for achieving and maintaining Practice Teacher status 4. Standard for Sign off status 5. Standard for annual updating 6. Standard for maintaining mentor/ sign off/ practice teacher status (Triennial Review) 7. Standard for the Management of the Live Mentor register 8. Standard for supervision of pre-registration students 9. Spoke Placement Feedback Form Appendix 1 Definition of Terms Registrant Stage 1 Registrants are registered nurses and midwives who have not completed a mentorship programme. Stage 1 of the NMC Standards reflects the requirements of The Code: Professional standards of practice and behaviour for nurses and midwives (NMC, 2015) Mentor Stage 2 A mentor is a registrant who has achieved the required knowledge, skills and competence through completion of a recognised Multi-Professional Support of Learning and Assessment in Practice programme. This qualification is recorded on the local register held by placement providers. Sign-off Mentor Stage 2 A sign off mentor is a mentor who has met the additional criteria and undertaken 3 supervised sign off assessments, as per the NMC Standards. A sign off mentor is required to sign off competency of final placement nursing students, Community Specialist Practitioner (CSP) students and all midwifery placements. Practice Teacher Stage 3 A practice teacher is a registrant who will have previously fulfilled the requirements to become a mentor, and, has received further preparation to achieve the knowledge skills and competence required to meet the NMC defined outcomes of a practice teacher by undertaking and successfully completing an NMC approved practice teacher preparation programme and having completed the prescribed preceptorship and supervision by an experienced practice teacher. The NMC (2008) recommend that the presence of a practice teacher is desirable for supporting learning and assessing registrants studying for general nursing specialist practice qualification or for registration as an advanced nurse practitioner. Page 9 of 32

10 Teacher Stage 4 A teacher is a registrant who has received further preparation to achieve the knowledge, skills and competence required to meet the NMC defined outcomes of a teacher by undertaking and successfully completing an NMC approved teacher preparation programme. The NMC teacher standard is mandatory for those registrants based in higher education, who support learning and assessment in practice settings for students on approved NMC programmes. Live Mentor Register The placement provider is responsible for holding a register of all qualified mentors, including sign-off mentors and practice teachers demonstrating that they have met the NMC requirements for these roles to remain on the register. Triennial Review The NMC require that each mentor and practice teacher undergo a Triennial (three yearly) review of their knowledge, skills and competence to ensure that only those meeting the NMC Standards remain on the Live Mentor register (Appendix 6). Team mentorship Where members of the practice team work with the student and provide feedback to the named mentor, ensuring inter-rater reliability. Co-mentorship Co-mentorship is the joint mentorship and assessment of a student by 2 mentors. This is advised where mentors work part time. Inter-rater Reliability Inter-rater reliability is when the mentor discusses and assures themselves of a valid and reliable assessment of a particular student, within the mentorship team. Hub Placement Where the Mentor/Placement Educator is based and where the formative and summative assessment takes place Spoke Placement Supervised and observational practice adding breadth and cross field exposure to the students experience. Direct supervision When the student is working close to their mentor, practice teacher or educator, to be directly observed and monitored. Indirect supervision Where the student works more independently, but their mentor, practice teacher or supervisor is easily contacted and provides the level of support needed to ensure public protection. Indirect supervision helps students develop confidence and independence. It is suitable for students who are more experienced and where activities can be delegated safely and responsibly. Page 10 of 32

11 Mentors will need to use their professional judgment to decide where activities may be safely delegated to students and the level of supervision required. They can also choose to delegate supervision to a colleague or someone from another profession. They are accountable for such decisions and for ensuring public protection. They should adhere to local working policy and procedures. (NMC 2011) Appendix 2 CMFT Standard for achieving mentor status Introduction This standard explains the process of becoming a mentor and explains the routes available to achieve mentor status. The successful completion of this programme will be a mandatory requirement for any registered nurse/midwife undertaking the role of a mentor for pre-registration nurses/midwives. (NMC, 2008) It is a Trust requirement for 70% of eligible registrants to hold a mentorship qualification. Scope This standard applies to registrants in practice areas where students attend placement, either as a hub or a spoke. Standards Identifying new mentors Ward managers/ team leaders will identify registrants to complete the programme, ensuring their service meets the requirements of the policy. This will be in liaison with the PEF as necessary to ensure areas are prioritised by need. It is also a requirement that spoke placement areas have mentors available to support students and support the provision of feedback to the student s hub placement mentor. To be eligible for entry on a Multi-Professional Support of Learning and Assessment in Practice programme, nurses and midwives must have completed a minimum of 12 months full time or equivalent part time experience and have passed through the Foundation gateway of the Band 5. Where nursing and midwifery staff are employed 0.4 whole time equivalent (WTE) or less, entry to the mentor preparation programme will be at the discretion of the placement manager, following consideration of the study requirements, and the staff member being able to meet the NMC Standards for mentors following completion of the programme. Programmes Multi-Professional Support of Learning and Assessment in Practice programmes for registered nurses/midwives must be NMC approved (NMC 2008).There will be a number of programme options available to staff, these will include in house academic credit bearing programme, offered in partnership with local Universities, and a noncredit bearing programme, also programmes taken directly with the Universities. Page 11 of 32

12 The credit bearing programme is offered at HEI Levels 5, 6 and 7 and requires submission usually of an assignment and portfolio. The programmes are advertised widely throughout the Trust and University websites. The non-credit programme is delivered by the PDE Team, under a licence from the University of Bolton. Assessment is through completion of a portfolio assessed at HEI Level 5. When undertaking the programme, registrants must have access to an experienced and qualified mentor for supervision and support. They must also have the appropriate opportunities to support students in practice. Registrants will be entitled to 37.5 hours timetabled, protected study time, in order to undertake the Multi-Professional Support of Learning and Assessment in Practice programme irrespective of the route of study (NMC 2008). Managers /Team Leaders will agree how this requirement will be met for both full and part time staff to ensure continuity of service needs. Entry onto the live mentor register Upon receipt of confirmation of successful completion of the programme, registrants will be annotated as mentors on the register. See standard for management of the live register. (Appendix 7) Conclusion It is important that new mentors are trained to ensure that the Trust can meet the requirements of the LDA and to ensure that we can provide high quality learning experiences for students. Following completion of the programme it is the mentor s responsibility to ensure they adhere to this policy and the NMC Standards. Appendix 3 Standard for achieving and maintaining Practice Teacher status Introduction This standard provides guidance for mentors identified to take on the role as Practice Teacher. A practice teacher is a registrant who has met the NMC requirements as a mentor and has received further preparation to achieve the skills, knowledge and competence required to meet the NMC outcomes for a practice teacher. (NMC 2008) The NMC requires all students undertaking a programme leading to registration as a specialist community public health nurse (SCPHN) to have a named practice teacher. Scope This standard applies to health visitors and school nursing staff who have been identified by team managers/ clinical leads to undertake the training. Page 12 of 32

13 Standards The identified health visitor or school nurse will complete the practice teacher programme at the identified University. Upon successful completion of the programme the practice teacher will be entered onto the mentor register as a practice teacher. Following successful completion of the programme the practice teacher will undertake a period of preceptorship, supported by an existing sign off practice teacher. This will include supervised sign off of at least one SCPHN student. This period of preceptorship will usually be for one year, but will be determined locally as necessary. Following completion of the preceptorship period, practice teachers can be annotated as a sign off practice teacher. They must continue to receive support from experienced practice teachers until the first triennial review. Practice teachers will have met the criteria for sign off status as part of their preparation. NMC practice teachers are responsible and accountable for: Organising and co-ordinating learning activities, primarily in practice learning environments for pre-registration students, and those intending to register as a specialist community public health nurse (SCPHN) and specialist practice qualifications where this is a local requirement. Supervising students and providing them with constructive feedback on their achievements. Setting and monitoring achievement of realistic learning objectives in practice. Assessing total performance including skills, attitudes and behaviours. Providing evidence as required by programme providers of the student s achievement or lack of achievement. Liaising with others (e.g. mentors, sign-off mentors, supervisors, personal tutors, the programme leader, other professionals) to provide feedback and identify any concerns about the student s performance and agree action as appropriate. Signing off achievement of proficiency at the end of the final period of practice learning or a period of supervised practice Practice Teacher annual updating will be achieved as per the standard for annual updating (Appendix 5). Triennial review will be completed in accordance with the Standard for maintaining mentor/ sign off/ practice teacher status (Appendix 6). Page 13 of 32

14 Conclusion Adherence to this standard will ensure on going quality of practice placements and assessment. It is the responsibility of practice teachers to ensure they meet the required NMC Standards and maintain their skills and knowledge. Team leaders and Clinical Leads are responsible for ensuring that practice teachers are appropriately prepared and are competent to support the relevant students. Appendix 4 Standard for Sign off status Introduction The NMC require that any decisions about whether a student has achieved the required standards of proficiency for safe and effective practice for entry to the register must be made by a sign off mentor. This standard details the criteria for sign off status and how this can be met. Scope These standards apply to all mentors and Practice Teachers in CMFT who are required to mentor and assess students at the end of their nursing/midwifery programme. Standard Criteria for sign off status Only sign off mentors and practice teachers that are on the same part of the register and in the same field of practice can sign off students to confirm they have met the requirements for entry to the register. All midwife mentors are required to gain sign off status. The stages which require a sign off mentor are: Student nurses require a sign off mentor at the end of the programme Student midwives require a sign off mentor at all progression points Community Specialist Practitioner students require a sign off mentor throughout the programme Sign off mentors will be annotated on the live mentor register and meet the following criteria: Have clinical currency and capability in the field of practice in which the student is being assessed Met the NMC requirements to remain on the live mentor register Have a working knowledge of the current educational programme requirements, practice assessment strategies and relevant changes in education and practice. Have an understanding of NMC registration requirements and the contribution they make in meeting these requirements Page 14 of 32

15 An in depth understanding of their accountability to the NMC for decisions to pass or fail a student at the end of a programme Achieving sign off status The NMC states sign off status can be achieved by being supervised on 3 occasions of signing off proficiency by an existing sign off mentor, however, this can be a lengthy process. The NMC allows 2 of the supported sign off occasions to be completed through simulation. Mentors can achieve sign off status via the following routes; New mentors will complete 2 simulations during their mentorship preparation programme, they will then sign off a student in practice under supervision of a sign off mentor. Where no sign off training is provided the new mentor should contact the relevant PEF for their area Existing mentors who have not undergone sign off training will complete 2 simulations when required, the details of this training is available via the PDE Team, they will then sign off a student in practice under supervision of a sign off mentor Once the mentor has completed all 3 supervised occasions, they must complete the sign off verification form (Form A), with each occasion being signed by the PEF or experienced sign off mentor undertaking the supervision. Form A should be signed by the mentor s line manager who will then send a copy of the form to the relevant PEF, who will then annotate the live register. A copy will be kept in the mentor s personal file. Maintaining Sign off status Sign off mentors should maintain their status by referring to the standard for maintaining mentor/ sign off/ practice teacher status (Appendix 6) and standard for annual updating. (Appendix 5). Conclusion Sign off mentors are crucial to the assessment of proficiency at the relevant progression points as detailed above. Maintenance of this status is a mandatory requirement in line with other standards for practice within this policy document. Page 15 of 32

16 Form A Sign off mentor verification form Mentor name (print) Placement area Date Multi-Professional Support of Learning and Assessment in Practice programme completed Please describe each sign off support occasion Experience / Simulation Number One (Include the programme, part of register, details about the stage the student is at on the programme, and proficiency level attained/state if a scenario) Experience/ Simulation Number Two (Include the programme, part of register, details about the stage the student is at on the programme, and proficiency level attained/state if a scenario) Experience/ Number Three (Include the programme, part of register, details about the stage the student is at on the programme, and proficiency level attained/state if a scenario) Page 16 of 32

17 This mentor has / has not completed each of the 3 supervised assessments following completion of a preparation for mentorship programme. Only when the 3 supervised assessments are completed can the mentor be given sign-off mentor status. To be annotated as a sign off mentor the mentor has: Occasion 1 Occasion 2 Occasion 3 Completed a supervised sign-off assessment Demonstrated clinical currency and capability in the field of practice in which the student is being assessed Demonstrated a working knowledge of the current programme requirements, practice assessment strategies and relevant changes in education and practice for the students being assessed Can discuss the NMC registration requirements and the contribution made to meeting these requirements Can discuss their accountability to the NMC for the decisions made to pass or fail a student when assessing proficiency requirements at the end of a programme Line Manager (Print name): Date: Signature: Mentor (Print name): Date: Signature: Sign off mentor (print name) Date: Signature: Copy to be retained by line manager for audit purposes and by mentor within portfolio Page 17 of 32

18 Appendix 5 Standard for annual updating Introduction To be maintained on the local register, mentors, sign off mentors and practice teachers are required to have evidence of annual updating. This must include having met with other mentors to explore assessment and supervision issues, including the validity and reliability of judgements made when assessing in challenging circumstances. Scope These standards apply to all nursing and midwifery mentors and practice teachers within CMFT who work within practice areas that provide hub or spoke placements to students. Standard Mentors, sign off mentors and practice teachers are subject to triennial review which must have evidence that the mentor/ practice teacher has participated in annual updating which includes an opportunity to meet and explore assessment and supervision issues with other mentors/practice teachers (NMC 2008). Mentors/ practice teachers should also engage in a group activity which explores the validity and reliability of judgements made when assessing practice in challenging circumstances. The annual updating requirements can be met by completing the following: Face to face mentor update within CMFT E-learning online via these links: Dates for the face to face sessions are published on the Student Support in Practice website and cascaded by the PDE Team. The PDE Team will be informed of attendance on all options via register or return slip and will be recorded on the live mentor register. Practice Teachers will attend a yearly update with the Programme Team for the programme they are supporting. The HEI will inform the PDE Team of attendance and will be recorded on the live mentor register. Conclusion It is the responsibility of every mentor, sign off mentor and practice teacher to adhere to the NMC Standards. It is also the responsibility of the manager to ensure that all mentors, sign off mentors and practice teachers are meeting the requirements of completing an annual update and the live register is updated. Page 18 of 32

19 Appendix 6 Standard for maintaining mentor/ sign off/ practice teacher status (Triennial Review) Introduction This standard provides guidance for mentors and practice teachers assisting them to maintain their status in line with the NMC Standards for Learning and Assessment in Practice (2008). Mentors and practice teachers within CMFT are required to follow the Triennial Review process. Scope This standard applies to all nursing and midwifery mentors and practice teachers within CMFT who work within practice areas that provide hub or spoke placements to students. Standards The mentor/ practice teacher will maintain a portfolio of evidence to demonstrate compliance of meeting the NMC standards. Verification of this is achieved through completion of a Triennial Review form (Form B) as part of the Revalidation process. Progression towards Triennial Review should be discussed at the mentor s annual appraisal with completion of Form B at the Revalidation Reflective Discussion/ Confirmation meeting. Form B will be kept in the personal file to inform the mentor register. At the end of one triennial review cycle, the mentor will commence a new 3 year cycle during which they will comply with these standards. Examplars of evidence to support mentors and practice teachers to meet the NMC Triennial review can be found in Form C. Issues Issues which prevent the mentor from achieving the requirements should be avoided. If this is not possible, an action plan will be instigated to support the mentor/ practice teacher to achieve the requirements. The mentor has not mentored 2 students in 3 years or the practice teacher has not mentored 1 student in 3 years Use a co-mentoring approach Review the placement capacity to ensure an adequate number of students are placed in the area Rotate students around all mentors in the area Ensure all mentors have equal opportunity to mentor Develop an action plan to ensure the mentor achieves this requirement Mentor to complete a log of involvement and collaboration in student assessment where they have not had full responsibility for the student i.e. senior staff or spoke placements (Form D) Page 19 of 32

20 The mentor/ practice teacher has not completed an annual update Ensure mentor is aware of what constitutes an update and the dates/ options available Ensure mentors book onto updates/ access online updates in advance of due date Ensure mentors are able to access updates during work time The mentor is not able to demonstrate the required competence Ensure the mentor has the time and resources to be able to collect/ collate evidence. The triennial review part of the form should not be signed if the mentor is not able to demonstrate they have met the NMC Standards. The manager should identify which areas the mentor is not showing competence in and agree an action plan with the mentor. The action plan should be reviewed and signed off when complete. The Practice Education Facilitator for the area should be informed of issues regarding mentorship. The mentor can remain on the mentor register for the period of the action plan. Where there are specific concerns regarding capability or conduct in relation to the NMC Standards, Line Management and HR may need to be informed. At this point the mentor should be deactivated from the register. (See Standard for the management of the live mentor register (Appendix 7) Page 20 of 32

21 Form B Triennial Review Declaration of Competence for Mentors / Sign-off mentors / Practice Teachers In order to comply with the NMC standards to Support Learning and Assessment in Practice, please complete this form on a 3 yearly basis (aligned to your revalidation date) and maintain a portfolio to demonstrate how you have met the standards. To be completed as part of your Revalidation Reflection Discussion / Confirmation meeting Name of Mentor:.. Ward /department:.. Working in the role of (circle): Mentor Sign-off mentor Practice teacher Evidence of Achievement Yes No Additional information when required I have completed a mentor Dateupdate in the last 12 months I have mentored the required number of students in the last 3 years? (The Triennial Review NMC requirement is 2 students in 3 years for mentors and 1 student in 3 years for Practice Teachers) NMC Developmental Framework to support learning and assessment in practice Achievement of the following NMC (2006) standards for mentors 1. Establishing effective working relationships 2. Facilitation of learning 3. Assessment and accountability 4. Evaluation of learning 5. Creating an environment for learning 6. Context of practice 7. Evidence based practice 8. Leadership This Registrant has/ has not demonstrated that they meet all the requirements of the NMC Standards to support learning and assessment in practice (2008) and have updated their knowledge and skills in relation to Mentorship / sign-off mentorship proficiencies. Line Manager (Print name): Signature: Date: Page 21 of 32

22 Mentor (Print name): Signature: Date: Copy to be retained by line manager for audit purposes and by mentor within portfolio. Action Plan to be completed if Triennial Review not achieved Objective Action Completion date Mentor (Print name): Signature: Manager (Print name): Signature: Copy for mentor portfolio, copy for personal file Page 22 of 32

23 Exemplars of evidence to meet the NMC Triennial Review. NMC Standards Establishing effective working relationships Develop effective working relationships based on mutual trust and respect Demonstrate an understanding of factors that influence how students integrate into practice setting Provide on-going and constructive support to facilitate transition from one learning environment to another Facilitation of learning Use knowledge of the student s stage of leaning to select appropriate learning opportunities to meet individual needs Facilitate selection of appropriate learning strategies to integrate learning from practice and academic experiences Support students in critically reflecting upon their learning experiences in order to enhance future learning Assessment and accountability Foster professional growth, personal development and accountability through support of students in practice Demonstrate a breadth of understanding of assessment strategies and the ability to contribute to the total assessment process as part of the teaching team Provide constructive feedback to students and assist them in identifying future learning needs and actions, managing failing students so that they become fit for safe and effective practice or be able to understand their failure and the implications of this for their future practice Be accountable for confirming that students have met the NMC standard of proficiency and are fit for safe and effective practice Evaluation of Learning Contribute to evaluation of student learning and assessment experiences, proposing aspects for change resulting from such evaluation Participate in self and peer evaluation to facilitate personal development and contribute to the development of others Form C Evidence suggestions Documents used to welcome students and evidence of mentors Participate in the orientation process of a new student or staff member, photocopy orientation checklist. Work with the student and/or others to complete a practice document for the student. Photocopy anonymous document. Reflective Piece on experience with students Evidence of spoke placements used by student List of multidisciplinary team members (MDT) Initial and mid-point meetings with student keep copy of documents Reflection on a teaching session undertaken Complete a risk assessment of the ward / clinic area in regards to students needs i.e. disability. Write a short reflection on giving feedback, including actions taken. Actively engage in and have a working knowledge of the student assessment documentation. Provide copies of completed student assessment documentation at varying levels of learning. A short piece of reflection recording the handling of unsatisfactory or satisfactory progress by the student. Copy of student assessment Attend educational meeting, use minutes as evidence. Obtain a student evaluation and devise/ update the action plan Reflective piece evaluate your role as a mentor Copy of student assessment Attend educational meeting, use minutes as evidence. Liaison with other professionals, services and or agencies regarding the student experience for example specialist services for spoke placement. Participate in the completion of the ward educational audit. Page 23 of 32

24 Creating an environment for learning Support students to identify both learning needs and experiences that are appropriate to their level of learning Use a range of learning experiences, involving patients, clients, carers and the professional team, to meet defined learning needs Identify aspects of the learning environment which could be enhanced negotiating with others to make appropriate changes Act as a resource to facilitate personal and professional development of others Context of practice Contribute to the development of an environment in which effective practice is fostered, implemented, evaluated and disseminated Set and maintain professional boundaries that are sufficiently flexible for providing interprofessional care Initiate and respond to practice developments to ensure safe and effective care is achieved and an effective learning environment is maintained Evidence based practice Identify and apply research and evidence based practice to their area of practice Contribute to strategies to increase or review the evidence base used to support practice Support students in applying an evidence base to their own practice Leadership Plan a series of learning experiences that will meet students defined learning needs Be an advocate for students to support them accessing learning opportunities that meet their individual needs, involving a range of other professionals, patients, clients and carers Prioritise work to accommodate support of students within their practice roles Provide feedback about the effectiveness of learning and assessment in practice Copy of student assessment document Evidence of Sign off Mentor development Spoke placement list Contribution to action plan following student evaluation Acting as preceptor or mentor to other staff Attendance at education meetings etc. Reflection on assessment process To be able to access and implement guidance on disability support. Documents used to welcome students Copy of students induction checklist (placement doc) Attend educational meeting, minutes as evidence. Reflective piece on experience with students Contribute to the development of an environment in which student learning is fostered, evidence by positive evaluations. Give a short reflective account of a teaching session, relating to a clinical practice speciality. Evidence of spokes used by student Identify a piece of evidence based practice within your area and discuss how you would share this with students Evidence of sharing evidence based practice with student- teaching session plan, evaluation, student reflection Provide evidence that teaching is based on local and national policy. Identify the methods used to disseminate research used within your particular area. i.e. record any meetings or minutes from an MDT meeting / educational update. Evidence of spokes available Use of collaborating with MDT Copy of student assessment documents Review placement Educational audit and update any action plans or make notes of further development Act as Education Link Attend education meeting Evidence of contact made with PEF or University Review completed evaluation forms related to the student experience; formulate an action plan improving any areas where change is required. Evidence examples of students shadowing you for management experience. Page 24 of 32

25 Form D Log of involvement and collaboration in student assessment Date Description of activity Evidence Example - observed year 3 student managing reflection clinic. Feedback to mentor Example - completed student assessment in partnership with Practice Teacher Log of involvement and collaboration in assessment of student competency Page 25 of 32

26 Appendix 7 Standard for the Management of the Live Mentor register Introduction The NMC Standards introduced the requirement that an up to date local register of current mentors and practice teachers is held and maintained by placement providers. CMFT have a live register of mentors, which is held by the Professional Development and Education team. The NMC require the register to be kept up to date and maintained, with mentors added/ removed as necessary. Scope The mentor register will include registrants, with all mentors and practice teachers annotated, in practice placement areas which provide hub or spoke placements. Some staff will not be included, e.g. team leaders/ specialist nurses, this will be agreed locally by the Head of Nursing. Standards Management of the register The register will be managed centrally by the PDE team, however, ward managers/ team leaders will be responsible for supplying accurate information regarding mentor annual updates, staff absence, movement of staff etc. when requested to do so. This will occur in a timely manner to ensure the PDE team and Universities have the correct information to assist in allocation and capacity reviews. Who will be annotated on the register? All registrants in areas which provide hub or spoke placements will be entered onto the register. Where nurses do not support students due to the nature of their role, they will not be included on the register; this will be agreed locally by the Head of Nursing. This may include; Heads of Nursing Lead Nurses Matrons Clinical leads and team/ ward managers Certain specialist nurses i.e. safeguarding team Certain Nurse Practitioners To be annotated as a mentor, the registrant must have successfully completed an NMC recognised Preparation for Mentorship programme. Multi-Professional Support of Learning and Assessment in Practice programme Preparation for Mentorship/ Education in Practice module ENB 997/998 Specialist Community Public Health/ Community Specialist Practitioner programmes which incorporated NMC approved mentorship module ( ) Post Graduate Certificate/ Diploma of Education recognised by the NMC Community Practice Teacher ENB 603 Page 26 of 32

27 Mentors with City and Guilds 730/7, who were entered as a mentor on the register in Sept 2007, having previously acted as a mentor, can remain on the register. To be annotated as a sign off mentor, the mentor must have completed the requirements set out in the standard for sign off status. (Appendix 4) To be annotated as a practice teacher for Specialist Community Public Health students, the mentor must complete an NMC recognised programme and then complete the required preceptorship period of one year and have signed off one further student under supervision of an experienced practice teacher. Deactivation and reactivation of mentors from the register Mentors can be deactivated from the register for a number of reasons. This process assures the NMC and university partners of quality and capacity. Deactivation of a mentor will occur when the mentor is unable to meet the NMC requirements or act in the role of mentor. This may be due a number of reasons; The mentor is subject to performance monitoring or capability policy actions and the manager feels it is not appropriate for the mentor to support students Change in role Lack of opportunity to mentor Long term leave (maternity, sickness, secondment) The mentor has not met all the requirements for triennial review Deactivation will be carried out by the PEF following confirmation from the ward manager/ team leader or lead nurse or clinical lead by receipt of the Deactivation of mentor form (Form E). The mentor s/ practice teachers mentorship qualification will remain on the register; however, they will be annotated as a registrant or where agreed, removed from the register, usually if they have changed role. Where deactivation has occurred, an action plan to support the mentor/ practice teacher to meet the NMC Standards will be instigated with relevance to their particular circumstances. The action plan will provide assurance of mentor development. A mentor/ practice teacher can be reactivated when they can evidence, via the action plan, that they can meet the NMC Standards. The ward manager/ team leader will complete the reactivation part of the deactivation form and send to the PEF when this is the case. Conclusion Only mentors and practice teachers who can evidence full compliance with annual updating and the Triennial Review can mentor students. Failure to comply with the policy, may lead to instigation of the de-activation process. Page 27 of 32

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