education Role modelling and students’ professional development Ian Felstead T eaching and learning in health and social care involve a dual relationship, conducted between two people, with the majority of learning acquired informally via role modelling (Charters, 2000).The term ‘role model’ is commonly used in various occupational fields and walks of life. It is often described as a person who exemplifies behaviour or a social role for others to emulate (Price and Price, 2009). A role model is also defined as someone who sets a positive example and whose attitudes and values are assimilated by learners (Perry, 2009). When considering professional socialisation, defined as acquiring the values, attitudes, knowledge and skills of a professional group (Roberts, 2008), it is reasonable to question whether role models are expected to establish and demonstrate the accepted norms of conduct and behaviour, not just how to do the job; patients expect to be cared for by nurses who are not only competent but also behave professionally. The Nursing and Midwifery Council (NMC) standards for preregistration nursing education stipulate that professional values must underpin education as well as practice (NMC, 2010a). It also states that the public should be confident that new nurses will act with professionalism and integrity, and that care will be provided in a compassionate, respectful way. It is therefore imperative that students are educated to develop the professional qualities necessary not only to enhance the quality of care but also to meet patient expectations. Adult nursing students are exposed to many people during training, so the influences on the development of their professionalism can be varied and complex. This article explores the concept of role modelling in relation to professional development, with particular reference to preregistration adult nursing education. The intention is to stimulate debate around issues such as role model identity and role modelling strategies, with links to teaching and the curriculum. It is hoped that nurse educators and practice staff will also become more aware of their status as role models. Role model identity Students will have a perception of what they expect a nurse to do and how a nurse should behave when they start their Ian Felstead is Senior Lecturer/Pathway Director (Adult Nursing), Department of Nursing and Applied Clinical Studies, Faculty of Health and Social Care, Canterbury Christ Church University, Kent Accepted for publication: January 2013 British Journal of Nursing, 2013, Vol 22, No 4 Abstract Patients expect to be cared for by nurses who are not only competent but also behave professionally, so students must be educated to develop professional qualities. The Nursing and Midwifery Council stipulates that professional values must underpin education as well as practice (NMC, 2010a). Much has been written on the qualities of an effective role model and the potential barriers to becoming one. This article focuses on preregistration adult nursing education and role modelling, with a slant towards the development of professionalism, as opposed to skills competence. Attention is paid to the identity of students’ role models and strategies for role modelling linked to teaching and the curriculum. Practice and academic staff have an equal stake in nurse education; for them to be seen equally as role models, there has to be a partnership approach to that education. Both practice and academic staff are able to exemplify behaviours and attitudes that directly influence the development of professionalism. This article is intended to stimulate discussion within and between nurse educators and practice-based staff about the impact their role modelling has on the development of adult nursing students’ professional practice. Key words: Role model ■ Students ■ Preregistration education ■ Professionalism programme. This may influence who they choose as a role model and influence their professional development. The primary individuals students meet are the academic staff at the university, practitioners in practice placements and peers across the theoretical and practical aspects of the course (Figure 1). Practice staff Much of the literature around role modelling by practice staff is associated with skills development and clinical competence, as opposed to the development of professionalism. Many definitions of role modelling in the healthcare professions equate effective role models with senior staff (Perry, 2009). Lewis and Robinson (2003) found in their study of student radiographers that the top nominations for workplace role models were staff in chief positions and believed this related to senior staff being ‘prominent demonstrators of clinical skills and professional conduct’. There is, however, an issue regarding whether these staff have the capacity to model behaviour for all students (Perry, 2009), given their small number and large remit. This creates the potential for a dissemination approach, whereby senior staff role model to junior staff who then facilitate students’ development (Figure 2). This would ensure that professional 223 Senior staff Junior staff Nursing student Figure 2. Role modelling continuum Practice staff Student Academic staff Fellow students from a variety of sources, such as nurses with whom the student has worked. The student’s self-evaluation can also be used. This could be expanded to include feedback from peers and patients. A potential benefit is that students may feel more confident to develop professional attributes not seen in their assessor but in others, in the knowledge that they will be assessed following feedback from these people. On the downside, using this method of feedback to inform assessment may generate conflicting opinions, making it difficult for the assessor to determine whose feedback is accurate. Much of the literature on role modelling in nursing concerns learning in the practice environment. This potentially has a negative impact on the 50% theory:50% practice nature of preregistration programmes as regulated by the NMC. The fact that many authors focus on the idea that the ideal setting for students to learn nursing is the practice environment may do a disservice to their academic colleagues who, through a partnership approach, are responsible for half of the students’ education and development as professionals. Academic staff Figure 1. The main people students meet behaviours are passed on from senior staff. All preregistration students should be allocated a mentor when on a practice placement (NMC, 2010a). The mentor’s role is to facilitate students’ development within the practice environment and assess their competence (NMC, 2008). However, role modelling practice and professional behaviours while judging/assessing a student create a potential conflict. Often students want to fit in, so will not challenge their mentor if they see behaviour that conflicts with their sense of professionalism, instead choosing to emulate it. A positional hierarchy in practice influences the effect of role modelling. Bandura (1977) asserts that how much the observer learns from an experience depends on the incentive and motivation to learn. Students may view the process as ‘my mentor is assessing me, so I should follow their example and do as they do’. This is despite possibly having to emulate behaviours that might be contrary to their beliefs or sense of professionalism. Students are taught that nurses should challenge practice and that they should begin to develop these critical skills during academic studies and clinical placements. However, if they see themselves as ‘the student’, they are unlikely, unless of a particularly assertive nature, to question what they see. Attempts to minimise this paradox using a 360° feedback process are already in place in many areas. This is where feedback comes from an individual’s immediate work circle, as opposed to the traditional top-down appraisal (Chartered Institute of Personnel and Development, 2012). To shift the responsibility for assessing the student away from a single mentor—as well as affording the opportunity to gain better information on skills and performance—feedback is collated 224 Initially, student nurses’ role models are academic staff (Pfeil, 1997) but, as they progress towards registration, the focus moves to nurses working in practice. This does not hold true with the notion that students enter the programme with a fixed idea of what nursing is and what they aspire to be (Chow and Suen, 2001), which would lead them to view nurses in practice as very different from university staff. Role theory suggests individuals perceive their identity in relation to groups with whom they identify closely in terms of roles (Illingworth, 2006). This means students may not think of academic staff as role models, as they may not be seen as nurses. This is despite the NMC requirement for all academic staff to engage in practice (NMC, 2008; 2010a), which students may not be aware of. Certainly, difficulties arise when academic staff are viewed as being distant from the practice of nursing, particularly in terms of credibility. With the move of nurse education away from schools of nursing into higher education, the responsibility for clinical supervision fell to mentors working in practice (Chow and Suen, 2001). It is conceivable that separating the theoretical and practical aspects between clinical settings and universities has perpetuated the idea that academics are not role models for students because of their perceived distance from nursing. Lown (2007), however, states that the ability to act as a role model to students stems from the responsibility to teach a programme with academic and practical components. This depends on how much practical component is taught in the university by academic staff. When clinical skills are taught in the academic setting, this could encourage students to view academic staff as clinically credible, particularly if this is the students’ only experience of nursing practice. However, while role play of clinical scenarios in an academic setting enables academic staff to exemplify desired behaviours, much of this is aligned to the development of psychomotor British Journal of Nursing, 2013, Vol 22, No 4 education skills. Expanding this to include role play of professional behaviours could enhance the credibility of academic staff, provided that these behaviours are replicated during practice learning opportunities. Furthermore, the development of more practice educator or lecturer-practitioner posts could help integrate theory and practice, and improve the credibility of academic staff. Lecturers have difficulty in being seen as clinically credible by some students if they are not engaged in what students see as ‘real’ nursing. This is particularly relevant when nursing is compared with medical training, where the vast majority of tutors are practising doctors. Ottewill (2001) examined undergraduate business education to establish the role of tutors in higher education. He found tutors hold a position that allows strategic modelling of the attributes expected of graduates by employers. There was a focus on professionalism in its widest sense and the ability to ‘fit into the work culture’. Whether this holds true for nursing education is questionable, given academics’ limited engagement with practice discussed above. There is also the consideration that working in a practice setting exposes students to situations that cannot be replicated in a classroom (Pfeil, 1997), which inhibits some of the students’ occupational experiences. What also needs to be considered is that when students become immersed in a culture, they may replicate all practices that they witness, good and bad. The need to feel as though they fit in with the team and get on with their mentor/supervisor potentially limits their ability to discern what is unacceptable and report this via the university’s raising and escalating concerns processes. This is particularly relevant if the role model is the practitioner who will be assessing them. Teacher education, on the other hand, is unique in that educators not only teach their students about teaching but also, through their own teaching, model the role of the teacher (Lunenberg et al, 2007). The authors make a direct comparison with medical education, stating that doctors who teach medicine do not serve as role models, as they do not ‘treat’ their students. When we align this to nursing education, it is then we identify that academic staff teach about nursing practice but do not role model the actual practice of nursing. Practice-based nurses, on the other hand, are able to role model the practice of nursing but their teaching role in relation to the theoretical underpinnings of practice is less. This perhaps automatically leads to practice staff being viewed as role models by nursing students but to the potential detriment of the theory behind the practice. The nurses’ role is, however, an amalgam of education and professional socialisation in the practice setting (Illingworth, 2006) and therefore both practice and academic staff should be seen as role models. Student role models Charters (2000) maintains that much of his nursing socialisation and behaviour was not learnt at his school of nursing but by observing others in practice. His role models were the thirdyear students and staff nurses he worked with during training. He does, however, state that he ‘watched and copied’ them, which rather diminishes the concept of building one’s own professional identity and role. After all, the aim is not to create British Journal of Nursing, 2013, Vol 22, No 4 ‘clones’ but to stimulate a desire on the part of students to become role models in their own right (Ottewill, 2001). In a study examining the role of fellow students in practice learning, seniority influenced who students chose as role models (Roberts, 2008). As well as practice skills development, there was an overwhelming sense of ‘learning the ropes’ from fellow students; however, there is a disparity here, as the length of time in an area appeared to be more important than seniority when related to professional socialisation. Roberts (2008) found that elements of socialisation are not ‘taught’ by mentors, as it is expected students will just ‘know’ the cultural rules of the qualified staff. It is here that new students will pick up cues from fellow students to help them integrate into the team. This leads to the conclusion that a buddy system may be effective in integrating new students into the practice environment. Certainly, fellow students can act as role models in regard to socialisation. The NMC essential skills clusters extends this to stipulate that, at entry to the register, newly qualified graduate nurses must be able to act as an effective role model in decision-making, taking action and supporting others (NMC, 2010b). These skills must therefore be developed and demonstrated during their educational programme. Multiple exposures There is much debate regarding the influence of multiple exposures. This concerns whether students take examples from many people to build their professional identity or if there is an element of singular association. It is during their programme of study that students gain an insight into nursing then progress to a deeper understanding of it. Bandura (1977) maintains that reinforcement influences whether certain behaviour is adopted but this causes problems when students are exposed to differing practices or behaviours in similar practice situations. The nature of an adult nursing preregistration programme with the multitude of competencies that students are required to achieve and the requirements set out in the EU Directive 2005/36/EC, regarding the variety of instruction required for adult nursing students, necessitates frequent moves between practice settings, which limits reinforcement from one person.Within other fields of practice, the influence of role modelling on student development is affected by placement patterns. The provision of a ‘base placement’ that the student returns to on a regular basis during training (for example, in children’s nursing) or the allocation of particular clients (for example, in learning disability nursing) will have a different, and presumably positive, impact. The primary focus here, however, is on the education of adult nursing students and how different placements provide different role models, and these students need to be able to identify aspects relevant to their development. Students should be encouraged to work with a variety of people and observe their approaches, abilities and conduct, to enable them to develop their own professional practice. This is supported by Bandura (1977), who indicates that learners develop skills and behaviour patterns from their experience, as opposed to a single modelled behaviour. It therefore seems feasible that students will home in on the elements of professionalism that fit their notion of a nurse and develop 225 their practice accordingly, and these could be from anyone they come into contact with. Donaldson and Carter (2005) concur, stating that observers rarely pattern their behaviour after a single source, preferring to adopt different aspects and characteristics from a variety of models. This introduces the concept of collaborative working and whether a team approach can influence a person’s professional development. When relating this to the issue of students following their primary mentor’s example, given that mentors assess competence, it can be seen that there is a benefit in students being exposed to several role models. This, however, needs to be guided by the theory of professional practice, to enable students to differentiate between the reality of practice and what would be considered as the gold standard. Students may see behaviours and conduct that, while commonplace, are not ideal. Theoretical input concerning best practice through reflection, for example, could allow students to explore these differences and become more discerning. Role modelling strategies Role modelling is often implicitly taught by example, with students unconsciously modelling nurses’ practice. Cruess et al (2008) maintain that as human beings we model ourselves consciously and unconsciously on individuals we trust and respect and aspire to be like. Embodying a role—or just playing it It is argued that role modelling should be explicit and is only effective when well planned and conducted with clarity (Price and Price, 2009). Specific role modelling sessions where issues can be switched ‘on and off ’ when the session starts and ends have been suggested. Pang and Wong (1998) say that model emulation should be a structured activity to ensure that behaviours indicative of professional nursing are brought to the students’ attention. Cruess et al (2008) state that awareness of being a role model Key points n Adult nursing students are educated to develop professional qualities to ensure they not only provide high-quality care but also meet patient expectations. n A top-down approach from senior practice staff to student nurses should be used to disseminate professional practice. n A 360° feedback process could move the responsibility for assessing a student away from a single mentor. This would enable students to build professional practice from a variety of sources, instead of feeling they should emulate the behaviour of their assessor. n Nursing combines education and professional socialisation in practice, so both practice and academic staff should be seen as role models. n Adult nursing students should not be taught to play a role but learn how to embody the nurse’s role and be professional in all they say and do. n Students should be encouraged to learn from a variety of academic and practice staff, guided by theory, to develop their own professionalism. 226 can improve the process and Wright and Carrese (2002) identified that physicians consciously think about being role models while interacting with students. This concept is, however, contentious. Awareness and planned activity give the impression of something false, and could influence role modelling behaviour. It could be argued that the student is not seeing an honest reflection of the practitioners’ attributes if they are aware they are being watched. Kenny et al (2003) said professionals were ‘embodying’ not ‘playing’ a role. Making role modelling conscious, for example where the role model is modelling a particular behaviour, gives the impression of showing the learner how to play a role. If a role model embodies role, just carrying out that role should demonstrate behaviours that the learner should emulate. Prior warning There is an element of whether learners should be advised in advance that they will be expected to model teachers’ behaviour. Bandura (1977) maintains that prior knowledge increases the attention of the observer.This is advantageous in motor skill development. When considering professionalism in respect of conduct, behaviour and attitude, this should be implicitly modelled through all interactions. Students should observe the conduct of a professional without prior discussion of what to observe; this is sometimes referred to as ‘silent’ modelling. However, given that an interaction could have a number of interpretations, the role model’s values and justification must be clear to the learner. This is an argument for structured role modelling in that, without a defined learning opportunity, the student may learn but not have the opportunity to interpret the situation fully (Charters, 2000). An opportunity to reflect and discuss the intricacies of the experience at the end of a day would go some way to address this issue. Role modelling is a very powerful educational tool that can be used to teach the ‘real world’ of nursing. Can this be true if role modelling sessions are planned? Nursing work is often unscheduled and learning in the practice setting is often spontaneous in response to patient requirements (Charters, 2000). Learning how to react in those unscheduled times is vital and not necessarily something that can be recreated.This, again, would appear to be more role play than role modelling. Role modelling and the curriculum The moral sense of nursing cannot be taught but can be caught (Pang and Wong, 1998). There is a general sense in the literature that role modelling is a basic component of the educational process (Ettinger, 1991). Students learn by following the example of their educators. Those educators, who are afforded respect by nature of their authority, are able to influence the development of students’ skills, competence and professionalism. The intricacies of professionalism are not necessarily outwardly discussed and debated but exemplified through the educators’ behaviours, actions and attitudes. The downside to this is that when someone in authority displays negative behaviours, these could be considered as acceptable professional responses and emulated by the learner. This in turn becomes a reflection of the profession that forms the students’ view (Ettinger, 1991). British Journal of Nursing, 2013, Vol 22, No 4 education In their study of physician role models, Wright and Carrese (2002) maintain that these people foster professional values in trainees—specifically attitude, behaviour and ethics—and exemplify a ‘standard of excellence’ that learners should imitate. Illingworth (2006) agrees and makes the distinction that while competence is an important aspect of the role and is enhanced through professional development, role modelling is also important for changing attitudes. The contextual elements of curricula are well documented in the literature. The formal, informal and hidden curricula have a varying impact on role modelling (Cruess et al, 2008). The formal preregistration curriculum is set by the NMC education standards and competencies (NMC, 2010a). Learning within this sphere appears to be heavily influenced by the enthusiasm and commitment to learning and teaching by tutors. This has been evidenced by student evaluation where statements such as ‘the tutor was motivated and enthusiastic, making us want to learn’ are relatively common. The informal curriculum is arguably most aligned to role modelling and, more specifically, the development of professionalism. It is highly interpersonal and very powerful (Cruess et al, 2008). The informal curriculum concerns the elements of a role that can be observed but are not explicitly defined, such as behaviour, attitude, values and communication, so is closely linked to attitudes in the delivery of the formal curriculum. Organisational and/or cultural influences lead to the hidden curriculum, which is often defined as unintentional learning. An example of this is where work pressures in practice areas limit the time available for staff to spend with students (Hopkins, 2000, cited in Pellatt, 2006). This could lead to compromised supervision of students, as this may be rushed. Despite this, the most appropriate way for students to learn what it means to be professional is to see this in action. The didactic nature of teaching in universities makes it difficult for students to see professionalism and expectations in a meaningful way (Ettinger, 1991). This is not to negate the vital aspects of learning that take place in academic settings, such as graduate skills, critical thinking and research awareness (Perry, 2009). Within universities, the way that business is done has much influence. Tutors set expectations of work patterns and behaviour that will potentially influence the development of the students’ professionalism. A culture of starting work early and finishing late and answering emails in the evenings and at weekends, for example, serves to demonstrate that this is how a professional is expected to deliver services, when these may be unrealistic expectations. Lown (2007) says that the primary objective of the staff in her faculty is to develop behaviours that reflect the highest professional standards. Academics often find it difficult to teach professional behaviours, but it is maintained that it is their actual behaviours that teach more to students by way of role modelling. Conclusions This article hopefully provides some food for thought around role modelling and how it may or may not influence the development of professionalism in nursing students. The intention is that the ideas presented will stimulate discussion British Journal of Nursing, 2013, Vol 22, No 4 within and between academic and practice-based staff, raising awareness of role modelling and its influence. Several people influence the development of professionalism in student nurses. Recommendations include: ■■ Guidance by academic staff, by way of theoretical input, should be provided to steer students in the right direction and encourage them to draw on elements from several people to build their own professional identity. ■■ To remove the incentive to simply follow what their mentor does, a 360° feedback process should be introduced by practice staff, if this is not already in place. ■■ A buddy system should be considered to assist students’ integration into the practice setting and allowing them to concentrate on developing their professional role. Further debate is needed on whether role-modelling should be a conscious activity where the student is told in advance that they will be expected to follow someone’s example, as there are strong arguments to support and reject this approach. 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