implementation and sustainability of the nursing and midwifery standards for mentoring in the uk
TRANSCRIPT
Nurse Education in Practice 10 (2010) 251–255
Contents lists available at ScienceDirect
Nurse Education in Practice
journal homepage: www.elsevier .com/nepr
Issues for Debate
Implementation and sustainability of the nursing and midwifery standardsfor mentoring in the UK
Margaret Andrews a,*, Melanie Brewer b,1, Teresa Buchan c,2, Alan Denne c,3, Jennifer Hammond d,4,Grahame Hardy c,5, Lorraine Jacobs c,2, Lucille McKenzie b,6, Sue West a,7
a Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU, UKb Eastern and Coastal PCT, Brook House, John Wilson Business Park, Reeves Way, Chestfield, Whitstable, Kent CT5 3DD, UKc Kent and Medway NHS and Social Care Partnership, Trust HQ, 35 Kings Hill Avenue, Kings Hill, West Malling, Kent ME19 4AX, UKd Medway NHS Foundation Trust, Medway Maritime Hospital, Windmill Road, Gillingham, Kent ME7 5NY, UK
a r t i c l e i n f o
Article history:Accepted 15 November 2009
Keywords:MentorshipNMC standardsCompetenceSustainability
1471-5953/$ - see front matter � 2009 Elsevier Ltd. Adoi:10.1016/j.nepr.2009.11.014
* Corresponding author. Tel.: +44 1227 782822.E-mail addresses: Margaret.andrews@canterbury.
[email protected] (M. Brewer), TereBuchan), [email protected] (A. Denne), Jennife(J. Hammond), [email protected] (G. Hanhs.uk (L. Jacobs), [email protected] (L. McKac.uk (S. West).
1 Tel.: +44 1233 667776.2 Tel.: +44 1622 721800.3 Tel.: +44 1732 520400.4 Tel.: +44 1634 833821.5 Tel.: +44 1227 459371.6 Tel.: +44 1233 667710.7 Tel.: +44 1227 282614.
s u m m a r y
There is growing emphasis on developing sounder processes for ensuring that nursing and midwifery stu-dents are appropriately supported and assessed in practice settings, so that they are fit to practice at thepoint of registration. To support this, the Nursing and Midwifery Council (NMC) in 2006, introduced newmandatory standards for practice education (NMC, 2006).
The standards outline mentor responsibility for developing and ensuring the practice competence ofstudents and provide a more defined statement regarding accountability for the decisions that lead toentry to the professional register (NMC, 2006, p. 6). Integral to the standards is the creation of a new rolefinal placement mentors; the ‘Sign-off’ mentor. The concept of the ‘Sign-off’ mentor is new and thearrangements for implementing a sustainable approach will be challenging for placement providers.Equally challenging for universities, is the development of a framework that can support, monitor andprovide evidence, that regulatory requirements have been met.
This paper outlines the complexities associated with maintaining mentor competence, discusses someof the challenges for Sign-off mentors and is intended to contribute to the general discussion about spe-cific aspects of the Nursing and Midwifery Council (NMC) standards and their sustainability in practice.
� 2009 Elsevier Ltd. All rights reserved.
Introduction and background
There are a number of challenges around the support of stu-dents in practice settings, especially for those following interpro-fessional programmes. This is further compounded by theprofession centric approach that many professional bodies have ta-ken to the support, supervision and assessment of student compe-tence. In 2006, the Nursing and Midwifery Council (NMC)introduced new standards for nursing and midwifery practice edu-
ll rights reserved.
ac.uk (M. Andrews), [email protected] (T.
[email protected]), Lorraine.jacobs@kmpt.
enzie), sue.west@canterbury.
cation (NMC, 2006) in the United Kingdom (UK). The standardsdemonstrate the significance of the practice component of thepre-registration nursing and midwifery curriculum and provideguidance for both mentors and the organisations responsible forpractice learning. The standards are mandatory requirements forstudents studying for each part of the professional nursing andmidwifery register.
To be eligible to act as a mentor for pre-registration nursing andmidwifery students individuals must meet the stage 1 criteria ofthe Standards to Support Learning and assessment in Practiceand to act in a mentoring capacity they must meet level 2 stan-dards. Mentors must demonstrate that they have integrated thestandard outcomes into their own practice and be able to meet cri-teria to maintain their status on the ‘active’ register. The standardsclearly outline mentor responsibility for developing and ensuringthe practice competence of students and provide a more definedstatement regarding accountability for the decisions that lead toentry to the professional register (NMC, 2006, p. 6).
In response to concerns about consistency in the assessment ofstudents in practice settings and the potential for unsuitableindividuals to enter the nursing or midwifery profession, theNMC identified an enhanced final placement mentor role with
252 Issues for Debate / Nurse Education in Practice 10 (2010) 251–255
additional responsibilities (NMC, 2006, p. 32). The notion of the‘Sign-off’ mentor is new and the specific arrangements for imple-menting a sustainable approach will be challenging for healthand social care placement providers. Equally challenging for uni-versities is the development of a framework that can support,monitor and provide evidence that regulatory requirements havebeen met.
We are a group of practitioners and academics working in theSouth East of England who have an ongoing interest in the prepa-ration and development of pre-registration student mentors. Wehave lead the local implementation of the Nursing and MidwiferyCouncil (2006) Supporting learning and Assessment in Practice(SLAIP) standards, across pre-registration nursing and midwiferypractice areas. The curriculum for student nurses and midwivesis based on an interprofessional model and nursing and midwiferystudents learn and work alongside other health professional stu-dents (occupational therapy, operating department practice, radi-ography, social work). Practice placement learning takes placeacross three large acute National Health Service (NHS) Trusts, threePrimary Care Trusts, one large Health and Social Care partnershipTrust and a variety of private, voluntary and independent sectororganisations. It is therefore essential that we develop a sustain-able student mentorship model that is sufficiently flexible to meetthe various organisational needs as well as the regulatoryrequirements.
To ensure that all current mentors understood contemporarypractice education we undertook comparative mapping of the oldand the new standards, so that mentor development could initiallybe targeted at those who had not undertaken a recent update andwho arguably had the greatest need. As a result of this work manymentors now feel more empowered to assess students perfor-mance rather than relying on the University to ‘oversee’ their deci-sions. The drive to update all mentors has resulted in morementors engaging with their mentorship role. As a consequencethere have been more concerns raised about students in the earlierstages of their training and mentors are more aware of their role asgatekeepers to the profession. Mentors are beginning to have moredialogue with each other about student competence.
There are however a number of challenges that we believe war-rant further discussion and although these changes are related topractice in the UK some of the discussion is applicable to a widerinternational audience. The purpose of this paper therefore is to:
� Outline the complexities associated with maintaining mentorcompetence
� Discuss some of the challenges for sign-off mentors, particularlyin relation to student underachievement and the interprofes-sional context
� Contribute to the general discussion about specific aspects of theNursing and Midwifery Council (NMC) standards and their sus-tainability in practice
Mentor competence
During the last 10 years the number of nursing and midwiferystudents in pre-registration education in the UK has increased sig-nificantly. The NHS plan (NHS, 2000) identified staffing shortagesas a major threat to the delivery of health care and as a resultthe number of nursing and midwifery students in training, rosefrom 12,480 in 1994–1995 to 18,707 in 1999–2000, representingan increase of fifty percent (National Audit Office, 2001). Furtherincreases from 2001, means that there are now more students inpractice placement than at any other time.
In 1987 the English National Board for Nursing, Midwifery andHealth Visiting (ENB, 1987) declared that qualified nurses workingin the UK should be available in clinical areas to be teachers, men-
tors or supervisors for student nurses. These nurses quickly be-came known generically as mentors. The intention was thatmentors would smooth the progress of students during the prac-tice components of the programme by teaching, supervising andassessing their ability. In the early days of mentorship for students,there was much discussion about what the role entailed, especiallywhether mentors should assess student competence (Andrews andWallis, 1999; Barlow, 1991; Wilson-Barnett et al., 1995). Indeedthe literature focused on the supportive elements of the role andthe characteristics of good mentors (Donovan, 1990; Marriott,1991; Morle, 1990).
As the role has evolved, assessment of practice has become amajor element of the mentor role but it is one which causes mostdisquiet amongst mentors. Many take on the role of mentor will-ingly but when faced with the vagaries of the continuing assess-ment process, become overwhelmed by the responsibility,especially if they are newly qualified, trying to get to grips withcompetence in relation to their own practice, or there is little sup-port from academic colleagues for dealing with failing students.
Many practitioners have difficulty taking responsibility for stu-dent learning, especially making decisions about competence (Duf-fy and Watson, 2001; Duffy, 2004). A number of reasons have beenput forward by mentors for this, including lack of time, length oftime the student is on placement and a sense of personal failureif a student is deemed to have underachieved (Mulholland et al.,2005).
Assessing students is difficult, particularly those who forwhatever reason, are struggling to grasp the level of competencyrequired. Assessment strategies and competencies, usually de-signed by educationists sometimes lack clarity for practitioners,for whom the educational development of others may necessarilybe a secondary rather than primary concern. The interpretationand application of criterion based assessment tools into workingpractice, demands particular skill. This, together with the lack ofmoderation (as would be the case with theoretical assessment)means that mentors sometimes veer on the side of caution inassessing student competence. These and other concerns led tothe more recent introduction of the sign-off mentor.
There is unease amongst practitioners and educationists thatmentors may not always have the time to mentor students to anappropriate standard (Aston and Molassiotis, 2003; Jones, 2005).Carlisle et al. (1997) questions the reality of clinical staff being ableto spend time educating students in the future, as the health servicebecomes more market led. In addition, some mentors do not feelready or properly trained to teach and assess students, particularlythose that are mentoring students at a different academic level tothemselves (Andrews and Roberts, 2003; Lloyd Jones et al., 2001).Nettleton and Bray (2008) see the lack of commitment of timeand resources as being a reflection of the low importance given tothe role of the mentor and highlights this as having a negative effecton mentors, with them not getting the recognition they deserve.
To further compound this, the practice hour requirement fornursing and midwifery programmes in the UK are substantiallygreater than for other health professional programmes. The prac-tice requirement for nursing and midwifery students in the UKamounts to 2300 h, this compares to 400 for speech and languagetherapy, 1000 occupational therapy, with no regulatory require-ment for radiography students but a recognition that it should be50% of the programme. It is easy to see why nursing and midwiferyplacement areas are potentially ‘overcrowded’, with some suggest-ing that these conditions severely compromise the value that prac-tice experience offers students (Hutchings et al., 2005). Thenumber of practice hours in pre-qualifying programmes variesfrom country to country, with the UK being amongst the highest.
Not all nurses and midwives are suited to the mentoring rolebut many job descriptions/role profiles state that nurses should
Issues for Debate / Nurse Education in Practice 10 (2010) 251–255 253
have a mentoring qualification to progress, either within theirgrade or to move to the next. Nurses may be pushed into takingon a mentoring role, either as an aid to career progression, or be-cause the current one to one mentoring model relies on large num-bers of mentors to feed and maintain it. Not only is there a need forlarge numbers of active mentors but the system relies on a regularstream of ‘mentors in waiting’ to replace those who move ontoother roles. Most health care providers have a constantly changingworkforce and although there is a lack of accurate data in relationto the migration patterns of nurses across local and nationalboundaries in the UK, it is recognised that it is more difficult to re-tain locally trained staff in the South East of England (Robinsonet al., 2008).
There is little information available relating to the movement ofmentors within an organisation or to other organisations but thegaps in practice knowledge brought about by staff movement havebeen recognised as having a negative impact and something that isnot wholly recognised by workforce planners (RCN, 2006). TheRoyal College of Nursing (2007) suggest that there are still majordifficulties with stability in relation to the nursing workforce inthe UK and highlight that despite an increase of 23% full timeequivalents registering with the NMC, there are still staffing short-ages. Even allowing for the ‘political’ emphasis from the RCN tradeunion perspective, the picture is not one that easily sits alongsidethe assessment, support and supervision of students.
Similar issues with regard to mentorship have been identified inScotland. One of the findings from NHS Education for Scotland’scommissioned report ‘Evaluation of Fitness to Practice Pre-regis-tration’ (Lauder et al., 2008) indicated that while mentors werecrucial to developing students’ achievement of fitness to practice,they were hampered by a lack of time to undertake the role. Therewas recognition that the need to support students is often at a costto the mentor in terms of balancing other responsibilities espe-cially patient care. The recommendations from this report includethe need for explicit selection of mentors with possible incentivesfor those who undertake the role. A period of longer and more in-depth preparation of mentors in the first instance was alsoadvocated.
The ‘Sign-off’ mentor; issues and challenges
The recently agreed standards to support learning and assess-ment in practice for nursing and midwifery students outline whatis expected of mentors, practice teachers and teachers for nursing,midwifery and specialist community public health nursing. Thestandards clearly articulate the responsibility practitioners havefor students in practice settings, especially in relation to their eli-gibility to enter the professional register (NMC, 2006).
The responsibility for practitioners to be the main arbiter of stu-dents’ fitness for practice in the UK has been increasing steadily((West, 2007). With the advent of the NMC standards comes thenotion of the sign-off mentor, responsibility for the final assess-ment of practice competence is very clearly in the domain of prac-titioners. Whilst it is difficult to argue the case for it not to be, thereare serious issues regarding the sustainability of such an approachand it is not wholly clear how this articulates with the overallassessment strategies for professional programmes.
Sign-off mentors are experienced practitioners who can makejudgements about the students’ suitability to be placed on the pro-fessional register; a type of ‘super mentor’. As well as meeting thementor criteria, sign-off mentors must have clinical currency andcapability in the field of practice in which the student is being as-sessed and have been supervised on a least three occasions forsigning-off proficiency at the end of a final placement. In the case
of midwifery students, ALL mentors must meet the additional cri-teria to be sign-off mentors (NMC, 2006, p. 32).
The sign-off mentor role focuses on four key activities:
(1) Providing support and guidance to students learning newskills or applying new knowledge;
(2) Acting as a resource to students to facilitate learning andprofessional growth;
(3) Directly managing students’ learning in practice to ensurepublic protection;
(4) Directly observing the students’ practice, or using indirectobservation where appropriate, in order to ensure that theNMC defined outcomes and competencies are met (NMC,2006, p. 30).
The sign-off mentor clearly has greater responsibility than thementor and as Jasper (2007, p. 224) points out, mentorship isnow placed ‘within a framework of accountability and responsibil-ity for professional standards that is implicit within the individu-als’ practice and that of the employer’. The NMC indicate that inthe final placement of pre-registration or Specialist CommunityPublic Health Nurse (SCPHN) programmes, mentors need to beeither a sign-off mentor, or be supported by a sign-off mentor orpractice teacher, in order to make a final decision on proficiency.
The key difference between mentors and sign-off mentors isaround the final assessment of practice. Mentors remain responsi-ble for the assessment of student competence with the sign-offmentor having responsibility for confirming that students havecompleted ALL practice requirements, having the ultimate respon-sibility for entry onto the professional register. Many mentors findassessment of student competence the most challenging aspect oftheir role and how sign-off mentors will adapt to the additionalresponsibility is yet to be tested. Of course this may not be seenas an additional requirement, just an extension of the final place-ment responsibility and in many cases mentors do perform thisrole for others, such as adaptation students. The main differencehowever, is that they have usually been party to all assessmentfor adaptation students and over a shorter period of time.
Issues of consistency in assessment of practice at the end stageof the programme are important and ensuring the integrity of theprocess is paramount. If sign-off mentors are responsible for thequality of mentorship within their clinical area and for the finaldecisions regarding a students’ fitness to practice, there must besome assurance that there is consistency in the approach and thestandards that sign-off mentors must attain. One way of assistingthis would be for mentors to spend time together to discuss partic-ular decisions, rather like practice assessment panels do for socialwork students.
The NMC recognise that sign-off mentors need protected timefor undertaking the role and this is acknowledged as one hourper student per week, in addition to 40% of the student placementtime. However, with no additional funding, employers will be hardpushed to support this, in any meaningful way, and there is unli-kely to be robust quality assurance mechanisms by which the com-petence of sign-off mentors is continually assessed (Andrews,2007). The NMC indicates clearly that ‘clinical commitment shouldbe reduced for mentors when they are supporting a student’ (NMC,2006, p. 30) but there is a failure to indicate how this will be imple-mented or what sanctions can be brought against non compliantorganisations.
Jones (2005) recognises that many NHS Trusts are not investingin staff to enable them to undertake mentor training or updates. Ifthis is still the case, then it will be difficult to sustain additionaltraining and updating associated with the role of the sign-off men-tor, let alone the protected time that is required to undertake the
254 Issues for Debate / Nurse Education in Practice 10 (2010) 251–255
role. As Andrews (2007) indicates, this is a fundamental issue andone which needs sensitive and urgent discussion between, educa-tionists, NHS employers and professional bodies, given the firststudents (for which this will be applied) will be qualifying in2010 or earlier in the case of conversion and eighteen month mid-wifery programmes. However, this is unlikely to happen and it willbe left to sign-off mentors to ‘carve out’ the time and to managethe consequences if they are not able to.
There is an implicit assumption within the standards, that men-tors will be self regulated. For example, there is an indication thatmentors must achieve certain competencies in the initial prepara-tory stage but no reference is made to how competence will bemaintained, other than via an annual or ongoing update, which en-tails no assessment. The standards highlight that mentors shouldknow about the programme, be able to discuss the implicationsof changes to NMC requirements and discuss issues relating tomentoring/assessment. It is left to local placement providers todetermine any additional criteria needed for mentors to remainon the register. If left ‘unregulated’ this will lead to a disparity ofmentorship standards across the UK, which is highly problematic,given the increased accountability that sign-off mentors hold asgatekeepers to the professional register.
Currently there is variability in the recruitment of sufficientnumbers of sign-off mentors across the UK, with some NHS Trustsbeing more successful than others. If under recruitment issues arenot resolved, students will find themselves on placement without asign-off mentor or without a placement. Anecdotally, the reasonsarticulated by mentors for refusing to undertake the role are todo with not wanting to be seen as gatekeepers to the professionand a feeling that the responsibility should not sit with them. Lo-cally some mentors have expressed concerns about lack of timefor the extra commitment sign-off mentoring requires but thinkthat in practice this will make little difference to the assessmentprocess suggesting that during busy times the ‘paperwork’ willbe signed regardless.
Nursing programmes in the UK are delivered within the HigherEducation sector, mainly in Universities. If students are unsuccess-ful in any element of the programme (theoretical or practice) theyhave the right of appeal and having exhausted Universityprocedures have the right to appeal to the Office of the Indepen-dent Adjudicator (OFFA). With the new arrangements, it isassumed that the student’s right to appeal will remain. However,there is little in the literature and subsequent discussion that ad-dresses the issue from the student perspective. If the sign-off men-tor fails a student at this end stage (the end of a three yearprogramme), what rights do students have? University appealsprocesses will need to acknowledge sign-off mentors and sign-offmentors will need to be in a position to justify their decisions toappeals panels and to respond within the realms of the appealsand complaints procedures of the University and the Office of theIndependent Adjudicator.
Responsibility and accountability
Under the new arrangements area nursing and midwifery man-agers (this has been devolved to Practice Placement Facilitators insome areas) are responsible for ensuring that sign-off mentors areallocated to final placement students. Managers need to under-stand the nature of the new responsibilities for sign-off mentorsand will need to attended Sign-off mentor training, to ensure theyare aware of the new standard and how it will impact on staff,especially the requirement for protected time. The employer willbe responsible for ensuring the competence of sign-off mentorsand will need to be comfortable in challenging poor mentoringbehaviour and putting in place development programmes for those
who do not maintain their own competence. In addition, they willneed to be clear about the student and University perspective.
The notion of having sign-off mentors is intended to providegreater protection for the public. However, it could be argued thatproviding additional support at the final stage of the placementprogramme is counterproductive and that more would be achievedby addressing the real issues around mentoring students in theearlier stages. Sign-off mentors will only be able to oversee thementoring process throughout the programme trajectory if theyhave the time, support and competence to do so. Providing addi-tional ‘end on’ support may just serve to weaken the assessmentprocesses at earlier stages, as mentors may avoid the difficult deci-sions to deal with failing students, in the knowledge that there isadditional scrutiny at the final stage. If this were to happen, morestudents would complete more of the programme without beingfiltered out. This would be unjust for students, and do nothing toincrease public and professional confidence.
Concerns about ongoing competence to practice remain, giventhat the ‘sign-off mentor can only make a judgement about an indi-vidual at that moment in time, eligibility to be placed on the reg-ister, not as an ongoing endorsement. There are some who areconcerned that the sign-off mentor will be ‘blamed’ if on a futureoccasion a registered practitioner is guilty of mal practice. Whetherin reality this approach increases ‘end on’ assessment or not, it willbe seen by some, including students as such, and whether this sitscomfortably with a continuing assessment philosophy is debatable.All pre-registration nursing and midwifery programmes have someform of continuing assessment throughout the course trajectoryand the assessment of competence is ongoing, rather than a ‘oneoff’ event. If the practice assessment strategy for the programmeis working appropriately, then the additional sign-off is superflu-ous, if it is not, then the assessment strategy as a whole needs tobe re-examined. Either way, the sign-off mentor does not providethe whole solution.
The interprofessional perspective
The issue of mentorship in relation to interprofessional pro-grammes is complex, especially as professional bodies do not rec-ognise the value of other professionals in the summative elementsof the practice assessment process. On interprofessional pro-grammes, students learn and practice together, yet the summativeassessment of their competence, even for generic aspects, can onlybe undertaken by someone qualified in the same professional do-main. Even with the development of ‘role emerging’ placements,where students are not placed with a supervisor from a like profes-sion, the summative assessment is conducted by the ‘long arm’supervisor, i.e. supervision provided by an off-site registered pro-fessional, rather than the practitioner providing the day to daysupervision.
In health professional programmes such as, occupational ther-apy and physiotherapy the practice educator (mentor equivalent)is responsible for assessing and grading student practice compe-tence. This is done by a range of practice educators throughoutthe programme trajectory. There is no final assessment ‘sign-off’and the final assessor is not required to meet any other additionalcriteria to undertake this role, as is the case for the sign-off mentorin nursing and midwifery practice. It is interesting to note that reg-ulatory and professional bodies for the allied health professionshave not to date seen it necessary to introduce additional require-ments, of those responsible for assessing students. Both the Collegeof Occupational Therapy and the Chartered Society for Physiother-apy have an accreditation process for educators, which provideprofessional recognition to the role of the Practice Placement Edu-cator and acknowledges the educator’s professional development.
Issues for Debate / Nurse Education in Practice 10 (2010) 251–255 255
This is reassessed over a period of time to demonstrate that thepractice educator has continuing commitment to practice educa-tion; however this process does not assume the educator takeson additional roles or responsibility.
Allied Health Professionals are accountable to the regulatorybody, the Health Professions Council (HPC) for the student’s fitnessto pass the practice component and it is the University that as-sumes the accountability for the theoretical part, with the overallresponsibility of recommending a student for registration oncetheoretical and practice elements have been achieved. It is there-fore the educator’s responsibility to assess practice skills in linewith the validated programme assessment strategy and the HPCcompetency frameworks. Despite these requirements, educatorsare only expected to have completed the University training pro-gramme and attend an update under the recommendations ofthe Professional body. It is not clear if there is greater concern fromthe NMC about nursing and midwifery practice and what the basisfor this is, or if the HPC is in some way less than diligent. Eitherway, the rationale for such differing approaches to the assessment,supervision and support for student in practice is hard tounderstand.
There are a growing number of pre-registration interprofes-sional programmes in the UK and attempts to develop a unified ap-proach to supervision and assessment of students is long overdue.Whilst professional and regulatory bodies voice similar concernsabout pre-registration practice and protection of the public, thereis little evidence that this is translated into common standardsand approaches. The recommendations from many high profile re-ports indicate the major errors in health care have usually occurredwhen professionals have not worked together (Kennedy, 2001;Laming, 2003). By developing uni-professional approaches to thepreparation of the next generation of professionals does little toaddress this. The development of interprofessional practice learn-ing is hampered by this uni-professional stance and moves us moreaway from the collaborative practice models that all professionsare striving to work towards. Although the professional bodiesmay not yet be at a stage to support interprofessional assessment,a unified approach to the assessment, supervision and support ofstudents in practice settings would be helpful.
Conclusion
Growing emphasis on developing sounder processes for ensur-ing that nursing and midwifery students are appropriately sup-ported and assessed in practice settings, so that they are fit topractice at the point of registration are welcome. With this as thebasic premise the NMC published new standards for nursing andmidwifery practice education.
The standards outline the requirements for practitioners actingas mentors, with the creation of a new role for those mentoringstudents on their final placement; the ‘Sign-off’ mentor. The newarrangements present both practitioners and the organisationswithin which they work with significant challenges concerningaccountability, implementation and consistency.
This paper has attempted to raise some of the issues to be con-sidered in both the implementation and evaluation of the arrange-ments to support and assess student nurses and midwives inpractice settings prior to entry to the professional register.
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