Nurse Education in Practice 72 (2023) 103776

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

What are nurse practice assessors’ priorities when assessing student mental
health nurses? A qualitative content analysis
Joanna M Painter a, b, 1, Carmel Bond a, *, 2
a
Department of Nursing and Midwifery, College of Health Wellbeing & Life Sciences, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
b
Rotherham, Doncaster and South Humber NHS Trust, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Background: UK healthcare policy has observed over a decade of changes that has focussed on healthcare staffs’
Qualitative professional values as a marker for safe, high-quality care In 2018 the regulatory body for nursing and midwifery
Content Analysis introduced several new proficiencies, with an emphasis on physical health assessment. However, a global debate
Nurse Education
has since surfaced regarding the generification of nurse education, which has been thought to have eroded field
Psychiatric Nursing
Practice Assessment
specific skills in mental health nursing.
Aim: To explore the priorities of practice assessors, articulated within the open comments written within online
practice assessment documents.
Methods: A qualitative study was conducted, with data collected from comments made within online practice
assessment documents relating to the ongoing assessment of student mental health nurses at one UK University.
26 individual sets of assessor comments were collected. An inductive content analysis was used to explore the
nature of qualitative feedback provided to student mental health nurses, generated by mental health practice
assessors. The COREQ checklist was used for the reporting of the study.
Results: Findings demonstrated that practice assessors were prioritising two core areas or broad-based skills
categories: ‘transactional’ and ‘transformational’ competencies. Transactional competencies related to the
practical application of specific tasks. Transformational competencies were commented on more frequently and
placed emphasis on the students’ personal attributes and characteristics, and how these contribute to ‘good’
mental health nursing practice.
Conclusion: Mental health nurses prioritise assessing student nurses in relation to their personal attributes, work
ethic, and values that are congruent with humanist perceptions of mental health nursing.

1. Introduction their programme of study they are required to demonstrate increasing

levels of independence in relation to the competencies. These are
The aim of nurse education is to prepare students with the theoretical defined by the professional regulatory body, the Nursing and Midwifery
and practical knowledge to become competent, confident, compas­ Council (Nursing and Midwifery Council, 2018). Achievement of these
sionate practitioners before they enter the nursing profession (Immonen competencies is judged by a practice assessor (clinical educator) who
et al., 2019). In the United Kingdom (UK), students are required to records their appraisal of the student in a practice assessment document,
complete 2300 hours of practice, which is primarily spent in the clinical which the student shares with subsequent practice assessors. The format
environment engaging in patient care. As the student progresses through of the document currently varies amongst regions of the UK3, however,

* Correspondence to: Lecturer in Mental Health Nursing, Department of Nursing and Midwifery, College of Health Wellbeing & Life Sciences, Sheffield Hallam
University, Collegiate Crescent, Sheffield S10 2BP, UK.
E-mail address: C.Bond1@shu.ac.uk (C. Bond).
1
0000-0001-5343-4185
2
0000-0002-9945-8577
3
The current study used MYEPAD, which stands for ‘Midlands, Yorkshire & East Practice Assessment Document’. Produced collaboratively between 28 univer­
sities, the PAD was developed to ensure that student nurses are prepared to successfully meet the Future Nurse: Standards of Proficiency for Registered Nurses
(Nursing and Midwifery Council, 2018) at the point of registration. The PAD details the level of performance that students are required to demonstrate at the end of
each Part (Year) of study (See South Yorkshire Primary Care Workforce and Training Hub, 2018).

https://doi.org/10.1016/j.nepr.2023.103776
Received 27 July 2023; Received in revised form 22 August 2023; Accepted 1 September 2023
Available online 4 September 2023
1471-5953/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
J.M. Painter and C. Bond Nurse Education in Practice 72 (2023) 103776

will typically include: a numerical or pass/fail judgement of compe­ 2018). A humanistic philosophy is viewed by services users as being
tence, a qualitative appraisal of professional attitudes and behaviours, characteristic of high-quality mental health care, particularly when this
opportunity for action planning for future placements, and open com­ approach is supported within the educational environment (Horgan
ments relating to overall impressions of the student’s performance et al., 2021). While the emphasis on developing students’ confidence in
(Roxburgh et al., 2018). physical health skills is essential (Hennessy and Cocoman, 2018), it is
In 2018, the NMC introduced several ‘new’ proficiencies4, with a thought that this may diminish some of the unique skills that services
focus on physical health assessment and monitoring. This was intended users require from mental health services, such as understanding the
to enable all nursing fields to have a general foundational level of services user’s world, and balancing conflict with risk and genuine
knowledge at the point of becoming qualified. Recent changes to the advocacy (Connell et al., 2022). Moreover, weighting toward physical
expected standards of proficiencies for future nurses (Nursing and health skills development (within mental health nurse education) has
Midwifery Council, 2018) means that the workforce will inevitably caused conflict within the mental health nursing profession, com­
comprise practice assessors who acquired their qualification prior to pounding struggles in relation to professional identity and role defini­
these revisions, and those who have become qualified within the current tion (Raeburn et al., 2023; Warrender 2022; Hurley et al., 2022). This
guidelines. Anecdotal evidence suggests that assessors who entered debate regarding ‘generification’ versus ‘specialist’ education in mental
nursing prior to 2018 may feel ambivalence in relation to their personal health nursing is global (Harvey, 2023; Warrender 2022). Therefore, the
competence and confidence to assess students against the new pro­ current study aimed to gain insight regarding what mental health nurses
ficiencies (Warrender et al., 2023). This is supported by contemporary may perceive as important when assessing the future mental health
scholarship, which suggests that judgements made by practice assessors nursing workforce.
may be unrelated to the individual student’s competence or profes­
sionalism, and more a factor of the practice assessor’s confidence in their 2.1. Aim
own judgement (Natterøy et al., 2023; Burden et al., 2018; Kennedy and
Chesser-Smyth, 2017). However, these discussions have, thus far, failed This study aimed to explore the priorities of practice assessors, ar­
to include the mental health practice setting (Finstad et al., 2022). This ticulated within the open comments (in relation to 2nd year BSc mental
led us to question ‘what might practice assessors in the mental health field be health nursing students) written within online practice assessment
choosing to prioritise in their appraisals of student mental health nurses?’. documents.
Therefore, this study aimed to explore the priorities of mental health
practice assessors by examining comments made (by assessors) within 3. Method
students’ assessment documentation.
This purpose of this study was to gain insight into the subjective
2. Background views of practice assessors, and specifically identify what comments are
being made regarding mental health nursing students’ clinical practice.
UK healthcare policy has observed over a decade of changes that has Qualitative, open comments invited in the practice assessment docu­
focussed on healthcare staffs’ (specifically nursing staffs’) professional ment, in relation to values, behaviours and general conduct, offer insight
values, for example, treating patients with compassion, kindness, dig­ into the practice assessors’ subjective priorities. This may indicate what
nity, and respect as a marker for safe, high-quality care (Chaney, 2020; is being perceived as important for the profession. Given that existing
Francis, 2013; Willis Commission, 2012). In response to government knowledge is lacking in the context of mental health nursing, which
initiatives whereby nurses’ values had been questioned (Department of makes it difficult to reliably comment on the priorities of this group of
Health, 2012; Allen, 2015), the NMC revised the professional Code of practice assessors (Hughes et al., 2016; Fitzgerald et al., 2010), an
Conduct in 2015 to include the need for all nurses and student nurses to inductive content analysis was justified (Krippendorff, 2018; Hsieh and
perform compassionate care (Nursing and Midwifery Council, 2015). Shannon, 2005).
This focus on professional values in practice was considered vital to the
(re)humanisation of our healthcare system (Straughair et al., 2019). This 3.1. Sampling strategy
is of particular significance in the context of mental health, where a
caring approach has, historically, been underpinned by the use of the A purposeful approach was taken to sampling, as it was understood
self as a therapeutic tool (Hartley et al., 2020; Jackson-Blott et al., that this would yield relevant and information-rich data (Campbell
2019), and whereby the formation of positive human relationships is et al., 2020; Polit and Beck, 2019). Prior to collecting data, the authors
essential for recovery and positive health outcomes in mental health discussed the selection of an appropriate sample, and sample size, with a
care generally (Bond et al., 2022; Stacey et al., 2016). focus on trustworthiness (Elo et al., 2014; Polit and Beck, 2014). This
Curriculum changes have meant there has been an increased focus on approach involved making decisions regarding what would be deemed
maximising opportunity to enhance students’ confidence in assessing appropriate to include (Neuendorf, 2017). Likely differences between
and managing health from a holistic perspective, as well as encouraging the various student cohorts were discussed, including potential inter­
high-quality, patient-centred care through consistently applied assess­ ference to study as a result of Covid-19, and the expectations for each
ment processes on students within the higher education and clinical cohort against the NMC Future Nurse: Standards of Proficiency for
practice setting (Health Education England, 2016; Jeppesen et al., 2017; Registered Nurses (Nursing and Midwifery Council, 2018). It was
Young et al., 2018; Nursing and Midwifery Council, 2018; NHS, 2019). decided that the focus ought to be on one student cohort, at one specific
This has also meant that documentation, used to record progression for placement, and the practice assessors’ comments associated with that
student nurses, has focussed on skills and competencies that are required placement. Having considered these aspects of the study, and following
across all fields of nursing. However, it has been argued that these Kyngäs et al. (2011) in Elo et al. (2014) regarding sampling in content
changes have caused an erosion of the skills that are unique to mental analysis studies, practice assessors’ comments found within the online
health nursing (Haslam, 2023), and a generification of the curriculum, assessment documents of 2nd year BSc students, from one practice area,
which potentially dilutes humanistic skills that are considered central to were purposively sampled. The authors agreed this approach would
the practice of mental health nursing (Loureiro et al., 2018; Santos et al., ensure that data were reflective of students that were being assessed at
the same stage of the course, against consistent expectations. Regarding
sample size in content analysis, and given there is no established
4
New proficiencies included chest auscultation, venepuncture, intravenous convention, it is suggested (Bengtsson, 2016) a sample between 1-30 is
canulation, ECGs, and knowledge of pharmacokinetics (See NMC, 2018). typically sufficient to facilitate credible inferences. As such, it was

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J.M. Painter and C. Bond Nurse Education in Practice 72 (2023) 103776

agreed that a maximum of 30 practice assessment documents would be categories” (Elo and Kyngäs, 2008, p. 109) and grouped according to
accessed. their similarity. Through lengthy discussion, higher order categories
(also known as generic categories) were identified (Fig. 1). Higher order
3.2. Data collection & analysis categories were named according to the characteristics of the words/­
segments of text in each sub-category. Generic categories described the
Qualitative data were collected from the online practice assessment various subjective perspectives and priorities that were considered as
documentation of second year undergraduate student mental health consciously important to clinical practice assessors when formulating
nurses at one UK University in the North of England. Only one NHS their assessment of student mental health nurses. Finally, through
organisation was studied. Initially, and following guidance from Elo continued reflexive discussion, the researchers abstracted the main
et al., (2014), data were collected and analysed at the same time. The categories of ‘transactional’ and ‘transformational’ competencies.
purpose of this was to ensure that data saturation would be sufficient to
facilitate the categorisation and abstraction process. Whilst data were 3.3. Trustworthiness
being extracted, the authors engaged in continual reflexive discussion
(while also noting any category types) until it was decided that no more The authors acknowledge their position as insiders in relation to the
‘new’ categories were being observed. During this initial data collec­ topic under investigation (Chavez, 2008). With a combined clinical and
tion/analysis phase, and throughout the remainder of the study, the academic experience of approximately 56 years, the researchers regard
authors engaged in reflexive discussion (Berger, 2015). Given the their perspectives, tacit experience, and knowledge as relevant for the
closeness of the authors to data subjects, it was important that the au­ determining of categories and subcategories in this study (Elo et al.,
thors discuss their reactions to the content and make a conscious effort 2014). This insider position is, therefore, considered to be a strength of
to refer one another back to the research context/question (Olmos-Vega the study and beneficial to the interpretive and analytical process
et al., 2023); bearing in mind the positionality of the authors as clinical (Patton, 2001). The study is reported according to the COREQ checklist
academic researchers. (Tong et al., 2007).
Data chosen for extraction was based upon the parts of the assess­
ment documentation where assessors can make qualitative comments. 3.4. Ethical considerations
Open comments were taken directly from the practice assessment
documentation onto an open Microsoft Word document. Any identifi­ Ethical approval was granted by the host organisation on 15th May
able data, relating to either individual or organisation, was immediately 2023 (ID: ER53538781). Before proceeding with the study, the research
anonymised and replaced with generic terms. Comments were only team confirmed with the Data Protection Officer (DPO) that the activity
extracted where students were noted to have passed their placement, complied with legal processes and GDPR standards (Data Protection Act,
and no formal concerns had been raised in relation to their professional 2018). As a courtesy, data subjects were informed about the study, prior
conduct or competence. This meant that ‘typical’ comments could be to data collection, and were provided with contact details of the research
utilised to appraise the student as opposed to comments which were team (and DPO).
intended to initiate further remedial action. A total of 237 comments
were extracted from the online documents, from 26 individual practice 4. Findings
assessors. All comments were amalgamated into a single coding sheet for
analysis. Findings demonstrated that practice assessors were prioritising two
After this initial data collection phase, an inductive content analysis broad-based skills categories. Firstly, assessors were commenting on
(Elo and Kyngäs, 2008) was employed as follows. First, units of analysis learners’ transactional competencies in relation to the practical appli­
were identified separately by two researchers (first and second author), cation of specific tasks (and the tools used to undertake those tasks e.g.,
through a process of immersion with the data (Polit and Beck, 2014). mental state assessment, risk assessments) that would be needed to
Second, data were openly coded by each researcher by making notes become competent mental health nurses (Fig. 1). This concerns what the
within the margins of the coding sheet. The words/segments of the text student knows and the performance of tasks to be assessed. The second
(identified by each researcher) were then “classified into smaller content core priority was a focus on the fundamental categories of transforming

Fig. 1. Transactional Competencies, Categories and Sub-Categories.

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J.M. Painter and C. Bond Nurse Education in Practice 72 (2023) 103776

into or ‘becoming’ a mental health nurse. This involves ‘how’ the student a failure to achieve as such.
demonstrates positive personal values and characteristics when using
“Is starting to display knowledge within mental health act
the tools and applying them in practice (Fig. 2). In terms of the number
paperwork”.
of comments made, the second core category appeared to be given much
more weighting. There was also greater depth, quality, and richness in "[student name] has been completing MSE which she needs to
the data within this category. continue to complete to build up her knowledge base on how to
assess risk and how to assess mental states effectively".
4.1. Transactional competencies
Mental health specific skills were more developmental, whereas, the
’all-fields’ specific competencies were more finitely referenced and
Comments were made on specific skills that were transactional in
formulaic in the language that was used to comment.
nature. The language used here was more perfunctory, and related to an
assessment of what the student understood against the task that was
4.2. Transformational competencies
being performed. These comments were organised into two generic
categories. The first generic category was related to all fields of nursing i.
In this category, comments were more expansive, language was more
e., those competencies which all nurses must achieve in respect of the
effusive, predominantly values based, and demonstrated a clear passion
Annex B proficiencies.
for the mental health nursing field. The students’ values and attitudes to
“Has partook in physical health observations, he has been able to learning were dominant in the assessors’ comments. This was inter­
complete ECGs with a basic understanding”. preted as assessors appreciating enthusiastic learners who have values
that are closely aligned with the broader perceptions of mental health
“He has been able to complete physical observations with prompts
nursing.
and has taken an interest into ECGs under supervision”.
“Has a fantastic attitude to learning and has been an absolute plea­
“Has been excellent regarding taking physical observations and
sure on this placement so far. She is approachable and is willing to do
raising any concerns”.
what she can to develop herself and others. She is proactive in her
Assessment of the student’s competency in relation ECGs and the learning and shows the true values of an aspiring nurse”.
taking of physical observations featured heavily within the data. How­
“He has noted how important communication is, even in regards to
ever, assessors appeared to be prioritising mental health field specific
small gestures with patients e.g., using manners when asking pa­
skills. The latter were referenced frequently, as shown in the sub-
tients to do something. After discussions with [student name] he has
category notations in Fig. 1.
noted how communication is a founding principle within nursing”
“Is developing her skills base in relation to mental health assessment
In the transformational category, there was much more emphasis on
and administering depot medication”.
students’ personal attributes and characteristics, and how these
“Starting to display knowledge within mental health act paperwork”. contribute to ‘good’ nursing practice. In the example given below, the
student’s commitment to the profession has been emphasised by refer­
“Displays some knowledge in response to some of the learning which
encing the challenging nature of the student’s personal circumstance.
was set for him around the Mental Health Act (1983) and
medication”. “Is a great communicator, it is clear that she has experience in
working with patients. She has a confident and compassionate
Practice assessors were clearly focussed on the core tasks and tools
manner. [student name] has impressed us with how eager and con­
used in mental health nursing. In this category, practice assessors did not
scientious she is, despite juggling the many pressures of her own
directly comment on a student’s failure to achieve a specific compe­
life”.
tency, or pass comment on a student’s lack of knowledge. Rather, as­
sessors’ language was reflective of this being a work in progress and not There were numerous references to the core values that are

Fig. 2. Transformational Competencies, Categories and Sub-Categories.

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J.M. Painter and C. Bond Nurse Education in Practice 72 (2023) 103776

considered integral to mental health nursing such as, empathy, health nursing, moving forward with a humanistic approach at the core
compassion, and therapeutic relationship building. In terms of the of the profession.
therapeutic relationship, there were several examples where assessors A key anxiety regarding the Nursing and Midwifery Council’s (2018)
referred to the therapeutic relationship and the student’s underpinning educational standards, is that the fundamentals of the mental health
values. Contrary to the transactional competencies, where the language nursing role, such as therapeutic relationship building, are not captured
use related to these skills being developed and built on (and then ach­ or focussed upon in practice assessment documentation. This is because
ieved), transformational characteristics (personal attributes, values and these documents routinely place more emphasis on specific proficiencies
work ethic) were commented on in an interrelated way and described as relative to physical health skills (Warrender et al., 2023). However,
inherent to the person. what is clear in the data is that when assessing students outside of
mandatory proficiency tick boxes, nurses consistently and assertively
“Has been demonstrating a good approach to patient care and had
assess students against the values and skills associated with humanist
made appropriate reference to how patients can and should be
concepts of mental health nursing. This is reflected within the data, for
treated. She has shown a down to Earth attitude to individuals we
example, there were frequent references to person centredness,
have seen and noted how this can be used to build a therapeutic
compassion, and therapeutic relationships. There were also recurring
bond”.
comments to mental health nursing specialist knowledge, key legislation
“I have observed [student name] speaking sensitively with patients such as the Mental Health Act (2007/1983), and other assessment tools
and asking questions appropriately to enable her to build a thera­ that are commonly used in mental health nursing practice. This suggests
peutic relationship”. that nurses are placing emphasis on the qualities and skills associated
with the provision of high-quality mental health nursing care, which has
“Has displayed a humanistic approach towards patient care and
been a source of frustration amongst nursing students and academics
recognises the importance of treating each patient as an individual”.
since the NMC endorsed curriculum changes in 2018 (Nursing Times,
The data clearly evidences that, where the values and attributes 2023). It is possible that, despite the generic nature of the practice
considered integral to mental health nursing were potentially in deficit, assessment documentation, mental health nurses are finding a way
assessor comments were focussed on this being a concern. around this structure to ensure that the distinct work of mental health
nurses is foregrounded.
“Has lacked a positive go-get-it attitude….I have spoken to this
Physical health proficiencies were not referenced very often in the
student about this simply not being acceptable….concerns have been
current study, however, when they were, the most frequently referenced
discussed…he is aware he needs to enhance his personalisation skills
skills were EGC’s and physical observations. This is reflective of the most
and to have a more positive attitude whilst on placement showing
common core skills exercised within a mental health setting. Given that
willingness to engage”
the Annex B proficiencies have only been within the nursing curriculum
“Has been able to complete physical observations with patients, for a short period of time, existing mental health nurses may have not yet
although currently does appear to struggle at times with conversa­ acquired the necessary competency in their training They may, there­
tions with patients and manners when asking patients to do things. fore, not feel able to adequately assesses new student nurses. Accord­
This has been feedback from other members of the team. I believe ingly, it is possible that the comments do not necessary reflect the
from reading his pebble pad [student name] is aware he needs to priorities of assessors, but more so reflect the aspects of practice that
enhance his communication skills within the nursing industry to be they feel competent to assess. The assessor may feel that it is a priority
able to build a rapport with his patients in the future, to make them for the student to be able to undertake physical health skills, but due to
feel safe and comfortable” an absence of knowledge/competency, they do not comment on this.
Therefore, to better understand why the comments were made, as well
It is clear from the data that physical skills are being considered.
as the practicalities and decision making involved, the first-person
However, much more emphasis is placed on the context within which
perspectives of practice assessors would need to be ascertained.
those skills are delivered, with greater value being placed on commu­
The debate regarding continued dissatisfaction with the lack of
nication and caring attitude over the specifics of the skill. Overall, value
mental health field specific skills, and theory specific knowledge, within
is placed not on the specifics of the skill being assessed, but how the
the higher education syllabus is ongoing (Connell et al., 2022; Nursing
student has delivered that skill in the context of a respectful, person-
Times, 2023), and ways in which to address this have begun to surface
centred, and compassionate approach.
(Harvey, 2023). However, in terms of evidence to support the need for
the humanist elements of mental health nursing to be better represented
5. Discussion
and distinguished as specialist skills (within the practice assessment
document), this paper is the first to offer a research response. Findings of
The aim of this study was to examine what the current priorities of
the current study reflect an obvious and consistent focus on prioritising,
clinical practice assessors are when assessing mental health nursing
or at least choosing to focus on in their assessments of students, rela­
students. This is an area where there is currently little understanding
tional skills specific to the mental health field of practice. It could be
and is where this paper contributes a better understanding of ‘what’ is
argued that these should, therefore, be reflected within the practice
being prioritised for the future mental health nursing workforce, by
assessment documents. However, for this to be achieved, and for this
those who work in clinical practice, and are responsible for assessing
revision to be actioned by the Nursing and Midwifery Council (2018),
student mental health nurses. While it is clear ‘what’ is being written
these elements would need to be better distinguished in the curriculum.
about, as we have described in this study, ascertaining whether a
conscious decision was made to choose these comments over others is
5.1. Strengths and limitations
not certain.
Given recent changes to the expected standards of proficiencies for
The application of content analysis in this study has enabled
future nurses (Nursing and Midwifery Council, 2018), an argument has
contemporary insights regarding interactions between student nurses
surfaced which proports the generification of mental health nursing, and
and practice assessors to be obtained using unobtrusive means. How­
a diminishing focus on humanistic skills that are viewed as central to the
ever, while the data is highly topical in nature, and representative of
profession (Loureiro et al., 2018; Santos et al., 2018). Our findings
contemporary debate in nurse education, the findings are limited by
demonstrate that humanism continues to resonate with mental health
temporality. Regardless of this limitation, the authenticity of the find­
professionals who are clearly passionate about the future of mental
ings is illustrated by the range of realities presented (Elo et al., 2014);

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