ABSTRACT: The role of the clinical coach in veterinary nurse practice is becoming a key aspect of professional life, underpinning student development and potentially supporting qualified staff as they advance their own clinical and professional practice. Although there is a wealth of evidence and literature surrounding mentorship in human nursing, very little published literature appears to exist for coaching or mentorship in veterinary nurse practice. This paper will outline some definitions of mentoring and coaching, the skills and attributes related to mentorship and types of assessment methods that can be undertaken in veterinary nurse practice. 

This is the first of two articles that will outline and describe the role of the clinical coach which is a relatively new concept to veterinary practice and can be perhaps most closely aligned with that of mentorship in human nursing (referred to as nursing for the remainder of the article).

In order to provide a possible framework for veterinary nurse practice, this article will refer to the published literature in relation to mentorship in nursing. Whilst the terminology may differ, the most important aspect, whether the term clinical coach or mentor is utilised, is that of providing an effective framework for supporting students in clinical practice.

In this article, the definitions of clinical coaching and mentoring, and the identification of effective coaching and mentoring practice will be discussed. In addition, some key concepts will be discussed with regard to understanding the relationship of various types of knowledge in respect of learning and assessment of students, with a brief overview of the potential gaps that can exist between theory and practice.

Background

Mentorship in nursing originated in the American industrial sector and was latterly adopted by the US nursing profession in the 1970s.1 In the 1980s, mentorship was formally introduced, largely unchallenged, to nursing in the UK, although there was little provision in the way of information or guidance on delivery.2

Gray & Smith (2000) similarly highlighted the lack of research rigor to support the success, or otherwise, of mentorship in nursing.3 Project 2000, the nursing diploma programme of the 1990s further highlighted the need for mentorship and the concept was then formally included in all educational programmes for nursing.

Mentors themselves were generally viewed as sharing their own clinical experiences, thereby enhancing their students’ skills and so often furthering their own education and learning. This shared relationship of the mentor and the student was important, since the aim was not simply to ensure they mirrored the actions of the mentor; but that a more collaborative coaching relationship’ was established, thus ensuring the student’s growth of knowledge in a safe and stimulating environment.

Defining the role of clinical coach or a mentor

In nursing, the mentor role differed from the traditional role of the existing nurse educator, which was the universal model at that time. The nurse educator role, often undertaken by an experienced nurse, taught a range of nursing skills in a relatively didactic manner. However, occasionally these skills, taught in a classroom, were disconnected from ‘real life’ clinical practice as these nurse educators frequently became deskilled.

A new approach to student development was suggested by Darling (1984), one of the US mentorship pioneers, who stated that there were, in fact, three key aspects to the mentor role – those of Inspirer, Investor and Supporter, as outlined in Figure l.1

Figure 1: Darling's (1984) aspects to the mentor role

There are a number of terms, often used interchangeably, to define and describe roles that support the mentoring or coaching role. Figure 2 outlines these terms and some of the definitions.

Figure 2: Definitions of terms used in supportive practice roles

All of these terms, of course, do little to clarify the role! In fact, the terms are so similar, that it is clear to see why ‘mentors’ and student alike could become confused as to the scope of the professional supporting their practice. Armitage & Burnard cited Hagerty (1986) who referred to this as a ‘definition quagmire’, suggested that this lack of consensus on the definition created difficulty in clarifying the role of a mentor;4 & 5 and further confused the existing roles, such as that of clinical supervision, which is distinct from mentoring.6

In relation to veterinary nursing practice, the term clinical coach is used to identify an experienced, qualified professional who undertakes to support student veterinary nurses in their placements. There are a variety of models used to undertake the role and these will be discussed later in this article. Since the majority of the mentoring concepts are generic, the terms will be used interchangeably, where appropriate, and then addressed individually where it applies to veterinary nursing.

Qualities of an effective clinical coach

So what makes an effective clinical coach? Gray & Smith’s literature review, highlighting the qualities of an effective mentor, aimed to develop a ‘checklist’ of a clinical coaches’ or mentors’ key attributes and of what is expected of them from the student’s perspective.3 They also identified those activities that constitute poor clinical coaching/mentoring practice.

For example, in one of the reviewed studies, Davies et al„ (1994) described a clinical coach or mentor as an individual who possessed appropriate professional qualities – such as being knowledgeable in the relevant clinical area.7 The clinical coach or mentor also demonstrated good communication skills and was motivated to teach and support the students.

Gray & Smith also discovered that being effectively coached or mentored not only greatly improved the student’s learning experience but that such supported learning was more organised, structured and students reported that they felt that they were not just ‘tagging along’ with their clinical peers.3

Following their literature review, Gray & Smith (2000) subsequently undertook their own study by researching diploma students and discovered that initially the students felt that the clinical coach or mentor was exclusively ‘theirs’ – although this opinion evolved as the students began to appreciate the various roles of the clinical coach or mentor. The student’s dependence on the clinical coach or mentor appeared to be inversely proportional to his or her knowledge acquisition; with students quickly taking advantage of any learning opportunities.3

As the students became more skilled and staff expectations of them increased, so their reliance on the clinical coach/mentor decreased. The students in Gray & Smith’s study identified some key mentor or coaching attributes that were felt to greatly improve the student-mentor/coach experience, and are listed in Figure 3.

Figure 3: Key generic clinical coach/mentor attributes

The students also identified what constituted poor mentorship or coaching, including staff that displayed the attributes outlined in Figure 4.

Figure 4: Examples of poor mentoring or coaching practice

Mentors in nursing, and other healthcare professions, frequently have competing priorities and the clinical coaching/ mentoring role often involves an additional workload for most health care professionals (HCPs). Their other roles include clinical practice, sometimes the mentor’s own educational commitments and often managerial or other operational duties.3

Clinical coaching or mentoring commonly attracts no additional financial remuneration in the NHS and, therefore, mentors were clearly committed individuals to start with. As such, students’ views of what made a particularly ‘good’ or effective mentor are outlined in Table 1 and build on the generic mentor attributes highlighted in Figure 2.

Communication

One of the key clinical coaching attributes is that of excellent communication, forming the basis of the relationship between clinical coach and their student. Communication with students will vary but usually includes probably one – or a combination of – the following:

•   Written – handwritten, word- processed, e-mail, text, fax, and printed handouts

•   Verbal – one-to-one, groups, telephone

•   Non-verbal – body language, posture, eye contact.

The role of competence

Historically, nursing mentors assessed practice-based skills that were often task- orientated – aseptic method in wound management, injection technique, administering medications, for instance – which were frequently delivered by ‘rote’ or didactic training methods. Since this narrow approach provided only a ‘snapshot’ of student competence, it did not allow for the flexibility and patient focus that factors highly in veterinary health care, which can be easily overlooked in a single assessment.

Price (2006) identified that clinical coaches were often not fully prepared for undertaking the assessment element of their role and outlined three key areas of concern in mentor preparation as outlined in Table 2.8

Clinical coaches require a clear and transparent understanding of the ‘how’ and the ‘what’ being assessed in clinical practice, which is purposeful to both clinical coach and student. In a recent review by the Royal College of Veterinary Surgeons (RCVS) its review of veterinary nurse training proposed that training in mentorship should be via Continuing Professional Development (CPD) or formal qualification, and advised that it was overseen by an affiliated centre.9

Competence

Although clinical coaches are frequently called upon to assess competence, there appears to be no one universal definition of‘competence’. The RCVS states that in its revised training qualification, the development of competence is an aim, although there is little in the way of explanation.9 In nursing, the Nursing and Midwifery Council (NMC) loosely defines competence as ‘the skills and abilities to practise safely and effectively without the need for direct supervision’.10

In any competence-based education, clinical coaching should be clearly outlined and defined at the outset so that students are clear regarding their competences and various subsets required for successful completion of their programme of study. This premise, of course, assumes that the competences, and also skills, are easily identifiable – which is not always so easy!

In nursing, this has partly been addressed through Benner’s Model of Skill Acquisition, which identified practitioners as being competent’ as Stage 3 in her Novice-Expert model.11 & 12 Benner’s model is applicable to veterinary nurse education, stating that the competent nurse (or practitioner) was ‘typified by the nurse [or practitioner] who had been on the job in the same or similar situation for two or three years, and develops his/her actions in terms of long-range goals or plans which he/she is consciously aware’.11

Table 3 outlines Benner’s model, with the development phase also outlined.

Essentially, as practitioners become more competent and confident, and as they gain knowledge, skills and attributes, they become increasingly proficient, with the ultimate goal of attaining the level of an expert. In nursing, this model is applied to a number of nursing roles, developing models such as the Consultant Nurse, who undertake a clinical and educational/research role. These nurses are experts in their clinical field, frequently associated with a clinical specialty, such as respiratory, gastrointestinal, rheumatologic and dermatological disorders.

It has been further suggested that ‘competence’ should relate to the ability to effectively perform on different occasions, not just on one occasion, and in different contexts. The ability to achieve a ‘competence’ on one specific day does not, of course, necessarily suggest that students are competent’.

This dilemma frequently causes discomfort in clinical coaches and others, who rightly feel uncomfortable in ‘signing off’ students to be competent when they have only witnessed the students performing a specific skill or competence on one occasion. The reassurance is that because they sign, time and date the event, they are merely stating that the student is component on that particular occasion and in that particular context. Competency assessment should, of course, be continuous and develop throughout the programme of study.

Knowledge and learning

In order to understand the assessment process itself, one needs to understand the core components of knowledge and learning. Bloom’s Taxonomy (1956) outlined three domains of learning that form the fundamental framework for knowledge: the cognitive, affective and psychomotor domains.13

The cognitive domain is focused on nurses’ knowledge and development of intellectual skills and often relates to such elements as knowledge, comprehension, application, analysis and synthesis of knowledge.

The affective domain centres on the way in which nurses manage the more ‘emotional’
concepts of healthcare, such as feelings, values and attitudes, amongst others.14

The psychomotor domain relates to a nurse’s skill development, which frequently requires practice and which is measurable in terms of technique, speed or execution. This ability to effectively and accurately measure, or assess, skills makes it distinctive from the other two domains. Elements of the psychomotor domain include perception, guided response and the mechanism of skill acquisition.15

Tacit and explicit knowledge

In addition to Blooms fundamental domains, the other two key ‘types’ of knowledge are ‘tacit’ and ‘explicit’ knowledge.

Tacit knowledge is often referred to as our ‘personal’ knowledge that is embedded in our own individual experiences and is essentially our personal belief system. Tacit knowledge can be difficult to articulate and is about the ‘know how’ or knowing what to do in a specific situation. An example of tacit knowledge would be the ability to perform a respiratory assessment if an animal’s condition was deteriorating under anaesthetic.

Explicit knowledge is the ‘know what’ or knowing why something is occurring. Explicit knowledge is often easier to articulate and is grounded in theory and scientific reasoning (also sometimes referred to as empirical knowledge.)

An example of explicit knowledge is the understanding of why the respiratory changes are occurring in relation to the animal’s altered pathophysiology. Explicit knowledge is easier to assess than tacit knowledge.

Assessment

The assessment of student knowledge is one of the key roles in clinical coaching. The word ‘assess’ originates from the Latin, ‘assidere, which means to ‘sit by or aside’.16 Assessing a student is about making a judgement regarding his or her progress and competence that can assist in understanding their cognitive, psychomotor and affective domains of learning.17

Clinical coaches assess students for many reasons. In healthcare, the Quality Assurance Agency (QAA) monitors and sets standards for UK Higher Education Institutes (HEIs) and helpfully define assessment in higher education as the process by which an individual’s knowledge, understanding, abilities or skills are evaluated.18

Assessments should promote student learning by providing them with constructive feedback, thereby aimed at improving his or her performance, evaluating their knowledge, understanding, abilities or skills, whilst also facilitating a mark or grade that enables a student’s level of performance to be established. Assessment of learning usually occurs at the conclusion of a period of study.18

There are of course a wide variety of methods by which to assess students and these can generally be categorised in a number of ways. However, some of the key approaches to assessment are outlined below.

Formative assessments

Formative assessments are usually undertaken during a period of study, providing feedback to the students while assisting in performance improvement. Formative assessments aim to deepen the student’s understanding of the programme’s learning outcomes and any subsequent grade or mark does not contribute to the final overall grade or award of the programme.

Formative assessments can take a number of forms – such as a quiz, short answer questions or as part of a practical assessment such as Objective Structured Clinical Examination (OSCE). Formative assessments are, therefore, assessments for learning; providing feedback to both student and mentor and ensure that the programme’s learning outcomes are being met.

Summative assessments

Summative assessments are undertaken on completion of a programme of study and the main distinction between summative and formative assessments is that summative assessment grades count towards the final overall grade for the programme of study. A summative grade will indicate the students performance against the standards set for the assessment. Summative assessments are, therefore, assessments of learning and are intended to measure learning outcomes and report those outcomes to students and tutors.

Other assessment methods include informal and formal assessments. Informal assessments are, as their title suggests, less structured and can include observation, inventories, checklists, performance and portfolio assessments, participation, peer- and self-evaluation, and discussions. By contrast, formal assessments are more structured and include such activities as written exam papers, Multiple Choice Questions (MCQs) and also OSCEs.

Table 4 outlines some assessment methods, categorised by written and practical approaches, commonly utilised in healthcare programmes.

Continuous assessment

Continuous assessment is a common feature of healthcare programmes. It utilises a variety of methods, usually administered throughout the programme against a number of learning outcomes. Continuous assessment has its advantages in assisting in developing both the student s confidence whilst assisting in their awareness of such development.

The disadvantage of continuous assessment (and perhaps of any assessment) is the fact that it is only as good as the assessor and the assessment itself. This issue, combined with the regular – often daily – scrutiny of the students performance may feel threatening to some students.17 Table 5 further outlines some other advantages and disadvantages of continuous assessment.

Assessment reliability and validity

With any form of assessment, it is important to ensure that the assessment has both high reliability and validity. Good assessments are both highly reliable and valid. Reliability refers to the consistency of an assessment; a reliable assessment is one that consistently achieves the same results with the same (or similar) cohort of students.

Various factors affect reliability, such as ambiguous questions and vague grading instructions or assessment criteria. 

Similar to a ruler that is marked incorrectly, it will always give the same (but incorrect) measurement, so it can be said to be very reliable, but not very valid.

A valid assessment is one that measures exactly what it is designed to measure.

For example, it would not be valid to assess a students infection control skills through a written assessment alone. A more valid method of skill assessment would also need to include a practical demonstration of hand washing and aseptic techniques associated in wound care.

Validity can be compared to asking random individuals to tell the time without looking at a clock. The answers will vary between individuals but the average answer is probably close to the actual time. Therefore, the combination of written and practical assessment approaches will achieve a higher level of validity.

The theory-practice gap

Having identified elements of assessments, it is worth a brief review of the concept of the ‘theory-practice gap’. This is literally the potential breach between the theoretical frameworks and concepts
and clinical practice.

A study by Corlett’s (2000) explored the theory-practice gap from the perspective of teachers, student nurses and the clinical preceptors.19 It appeared that basic communication skills were a common problem, in that it was not that qualified staff lacked the appropriate knowledge, but that the application of theory to practice in some situations was often challenging.

Although some of the tutors in Corlett’s study reportedly felt this gap’ was actually beneficial, by encouraging students to develop problem-based learning and reflective skills; not surprisingly the students did not share this view, reportedly feeling frustrated by this gap’.

Having identified this theory-practice gap, how best to close or at least reduce this gap is an important issue. Corlett’s study also identified three key areas through which this could be done – through improved communication, information sharing and collaboration.

In addition, students may only experience or realise the theoretical relevance of the taught aspect of their course retrospectively, only realising the significance of this learning at a later date. Often at the time of learning, for example a session on pathophysiology or pharmacology, this theory can appear idealistic and decontextualised, particularly if not delivered in sequence with an appropriate clinical placement.

Corlett also argued that the theory- practice gap is actually inevitable and an area that students are required to manage until such time as they have sufficient knowledge and experiential understanding to ‘fit’ the various aspects of theory and practice together for themselves.

To put this into context with the two different types of knowledge identified earlier – the ‘know that’ and the ‘know how’ of the tacit and explicit knowledge. The ‘know that’ is knowledge learnt from lectures, literature, articles and textbooks and the ‘know how’ from the clinical placement experience – that all-important experiential setting where students actually undertake the task themselves.

Nursing has overcome some of these challenges through the Lecturer Practitioner (LP) role. A LP is a joint appointment between the education provider and the clinical practice. LPs have the ability to teach the academic knowledge, is up-to- date with current, local clinical practice whilst maintaining the permanent link with the education provider.

Conclusion

Experiences of clinical coaching or mentorship can be good or bad, with all points in between. However, whilst really good support of student practice may appear elusive, it can be hugely valuable for both student and clinical coach.

Clinical coaching is relevant to veterinary nursing students, both at undergraduate and postgraduate levels. It is important and necessary for students but perhaps equally important for qualified veterinary staff, many of whom are frequently overlooked in their requirements for support as they develop as practitioners in their own professional careers.

Indeed, a proposed review of the veterinary nursing awards plans to ‘concentrate on providing quality mentorship and work experience’.20

Author

Lynda Sibson msc rgn rscn

Lynda began her nursing career in Surrey, later training at Great Ormond Street Hospital and working as a paediatric nurse. She then became a practice nurse in a GP surgery and after qualifying as a nurse practitioner, worked in a nurse-led minor treatment centre in central London before joining a telemedicine organisation and completing her Masters Degree in Advanced Healthcare Practice. More recently, Lynda was a principal Lecturer at the University of Hertfordshire, developing and running some advanced practitioner and paramedic programmes, and is now a nurse consultant with her own consulting company, Sibson Consulting Ltd, www.sibsonconsulting.com

To cite this article use either

DOI: 10.1111/j.2045-0648.2010.00037.x or Veterinary Nursing Journal Vol 26 pp 168-175

References

1.   DARLING. L. A. W. |1984| What do nurses want in a mentor? Journal of Nursing Administration Oct, 42-44.

2.   LOADS, D., BROWN. M.. MCKENZIE. K. and POWELL, H. (2006) Developing mentorship through collaboration. Learning Disability Practice 913): 16-18.

3.   GRAY, M. A. and SMITH, L. N. 120001 The qualities if an effective mentor from the student nurse's perspective: findings from a longitudinal qualitative study. Journal of Advanced Nursing 32161: 1542-1549.

4.   ARMITAGE, P. and BURNARD, P. 119911 Mentors or preceptors? Narrowing the theory-practice gap. Nurse Education Today. 11 13): 225-229.

5.   HAGERTY, B. 119861 A second look at mentors. Nursing Outlook 34 II): 16-24.

6.   DONOVAN, J. 11990) The concept and role of mentor. Nurse Education Today 1014): 294-298.

7.   DAVIES, H NUTLEY. S. and MANNION, R. 120001 Organizational culture and health care quality. Quality Health Care 9: 111-119.

8.   PRICE. B. I2006I Addressing problematic behaviour in learners. Nursing Standard 20 I40I 47-48.

9.   Royal College of Veterinary Surgeons I2009al Future veterinary nurse training model. London. RCVS.

10.   Nursing & Midwifery Council 12008) Standards of Conduct, Performance & Ethics. London. NMC.http://www.nmc-uk.org/aArticle.aspx? ArticlelD=3056&Keyword=performance

11.   BENNER. P, 120011 From Novice to Expert: Excellence and Power in Clinical Nursing Practice. (Commemorative Edl. London, Sydney: Prentice Hall.

12.   DREYFUS. H. and DREYFUS. S. (2000) Mind Over Machine. The power of human intuition and expertise in the era of the computer New York: Free Press.

13.   BLOOM, B. S. (1956). Taxonomy of Educational Objectives. Handbook I: The Cognitive Domain. New York: David McKay Co., Inc

14.   KRATHWOHL, D. R.. BLOOM, B. S. and MASIA, B. B. 11973). Taxonomy of Educational Objectives, the Classification Goals. Handbook II: Affective Domain. New York. David McKay Co.. Inc.

15.   SIMPSON. E. J. (1972) The Classification of Educational Objectives in the Psychomotor Domain. Washington DC. Gryphon House.

16.   BROWN, L. (2003) Shorter Oxford English Dictionary. (5th Ed) Oxford. Oxford University Press.

17.   HAND. H. 120061 Assessment of learning in clinical practice. Nursing Standard 21(4): 48-56.

18.   Quality Assurance Agency (20061 Code of practice for the assurance of academic quality and standards in higher education. Section 6: Assessment of students. QAA. Mansfield http://www.qaa.ac.uk/academicinfrastructure/codeofPractice/section6/COP_AOS.pdf

19.   CORLETT, J. 120001 The perceptions of nurse teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurse Education Today 20(6|: 499-505.

20.   Royal College of Veterinary Surgeons I2009bl In the frame VN awards review. VN Standard Aug: 3.

Further reading

Royal College of Nursing 12007] Guidance for mentors of nursing students and midwives An RCN toolkit. London.

RCN.http://www.rcn.org.uk/data/assets/pdfJile/0008/78677/002797.pdf

Veterinary Nursing Journal • VOL 26 • May 2011 •