What are nurse practice assessors ’ priorities when assessing student mental health nurses? A qualitative content analysis

Background: UK healthcare policy has observed over a decade of changes that has focussed on healthcare staffs ’ professional values as a marker for safe, high-quality care In 2018 the regulatory body for nursing and midwifery introduced several new proficiencies, with an emphasis on physical health assessment. However, a global debate has since surfaced regarding the generification of nurse education, which has been thought to have eroded field 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.


Introduction
The aim of nurse education is to prepare students with the theoretical and practical knowledge to become competent, confident, compassionate practitioners before they enter the nursing profession (Immonen et al., 2019). In the United Kingdom (UK), students are required to complete 2300 hours of practice, which is primarily spent in the clinical environment engaging in patient care. As the student progresses through their programme of study they are required to demonstrate increasing levels of independence in relation to the competencies. These are defined by the professional regulatory body, the Nursing and Midwifery Council . Achievement of these competencies is judged by a practice assessor (clinical educator) who records their appraisal of the student in a practice assessment document, which the student shares with subsequent practice assessors. The format of the document currently varies amongst regions of the UK 3 , however, will typically include: a numerical or pass/fail judgement of competence, a qualitative appraisal of professional attitudes and behaviours, opportunity for action planning for future placements, and open comments relating to overall impressions of the student's performance (Roxburgh et al., 2018).
In 2018, the NMC introduced several 'new' proficiencies 4 , with a focus on physical health assessment and monitoring. This was intended to enable all nursing fields to have a general foundational level of knowledge at the point of becoming qualified. Recent changes to the expected standards of proficiencies for future nurses  means that the workforce will inevitably comprise practice assessors who acquired their qualification prior to these revisions, and those who have become qualified within the current guidelines. Anecdotal evidence suggests that assessors who entered nursing prior to 2018 may feel ambivalence in relation to their personal competence and confidence to assess students against the new proficiencies (Warrender et al., 2023). This is supported by contemporary scholarship, which suggests that judgements made by practice assessors may be unrelated to the individual student's competence or professionalism, and more a factor of the practice assessor's confidence in their own judgement (Natterøy et al., 2023;Burden et al., 2018;Kennedy and Chesser-Smyth, 2017). However, these discussions have, thus far, failed to include the mental health practice setting (Finstad et al., 2022). This led us to question 'what might practice assessors in the mental health field be choosing to prioritise in their appraisals of student mental health nurses?'. Therefore, this study aimed to explore the priorities of mental health practice assessors by examining comments made (by assessors) within students' assessment documentation.

Background
UK healthcare policy has observed over a decade of changes that has focussed on healthcare staffs' (specifically nursing staffs') professional values, for example, treating patients with compassion, kindness, dignity, and respect as a marker for safe, high-quality care (Chaney, 2020;Francis, 2013;Willis Commission, 2012). In response to government initiatives whereby nurses' values had been questioned (Department of Health, 2012;Allen, 2015), the NMC revised the professional Code of Conduct in 2015 to include the need for all nurses and student nurses to perform compassionate care (Nursing and Midwifery Council, 2015). This focus on professional values in practice was considered vital to the (re)humanisation of our healthcare system (Straughair et al., 2019). This is of particular significance in the context of mental health, where a caring approach has, historically, been underpinned by the use of the self as a therapeutic tool (Hartley et al., 2020;Jackson-Blott et al., 2019), and whereby the formation of positive human relationships is essential for recovery and positive health outcomes in mental health care generally (Bond et al., 2022;Stacey et al., 2016).
Curriculum changes have meant there has been an increased focus on maximising opportunity to enhance students' confidence in assessing and managing health from a holistic perspective, as well as encouraging high-quality, patient-centred care through consistently applied assessment processes on students within the higher education and clinical practice setting (Health Education England, 2016;Jeppesen et al., 2017;Young et al., 2018;NHS, 2019). This has also meant that documentation, used to record progression for student nurses, has focussed on skills and competencies that are required across all fields of nursing. However, it has been argued that these changes have caused an erosion of the skills that are unique to mental health nursing (Haslam, 2023), and a generification of the curriculum, which potentially dilutes humanistic skills that are considered central to the practice of mental health nursing (Loureiro et al., 2018;Santos et al., 2018). A humanistic philosophy is viewed by services users as being characteristic of high-quality mental health care, particularly when this approach is supported within the educational environment (Horgan et al., 2021). While the emphasis on developing students' confidence in physical health skills is essential (Hennessy and Cocoman, 2018), it is thought that this may diminish some of the unique skills that services users require from mental health services, such as understanding the services user's world, and balancing conflict with risk and genuine advocacy (Connell et al., 2022). Moreover, weighting toward physical health skills development (within mental health nurse education) has caused conflict within the mental health nursing profession, compounding struggles in relation to professional identity and role definition (Raeburn et al., 2023;Warrender 2022;Hurley et al., 2022). This debate regarding 'generification' versus 'specialist' education in mental health nursing is global (Harvey, 2023;Warrender 2022). Therefore, the current study aimed to gain insight regarding what mental health nurses may perceive as important when assessing the future mental health nursing workforce.

Aim
This study aimed to explore the priorities of practice assessors, articulated within the open comments (in relation to 2nd year BSc mental health nursing students) written within online practice assessment documents.

Method
This purpose of this study was to gain insight into the subjective views of practice assessors, and specifically identify what comments are being made regarding mental health nursing students' clinical practice. Qualitative, open comments invited in the practice assessment document, in relation to values, behaviours and general conduct, offer insight into the practice assessors' subjective priorities. This may indicate what is being perceived as important for the profession. Given that existing knowledge is lacking in the context of mental health nursing, which makes it difficult to reliably comment on the priorities of this group of practice assessors (Hughes et al., 2016;Fitzgerald et al., 2010), an inductive content analysis was justified (Krippendorff, 2018;Hsieh and Shannon, 2005).

Sampling strategy
A purposeful approach was taken to sampling, as it was understood that this would yield relevant and information-rich data (Campbell et al., 2020;Polit and Beck, 2019). Prior to collecting data, the authors discussed the selection of an appropriate sample, and sample size, with a focus on trustworthiness (Elo et al., 2014;Polit and Beck, 2014). This approach involved making decisions regarding what would be deemed appropriate to include (Neuendorf, 2017). Likely differences between the various student cohorts were discussed, including potential interference to study as a result of Covid-19, and the expectations for each cohort against the NMC Future Nurse: Standards of Proficiency for Registered Nurses . It was decided that the focus ought to be on one student cohort, at one specific placement, and the practice assessors' comments associated with that placement. Having considered these aspects of the study, and following Kyngäs et al. (2011) in Elo et al. (2014) regarding sampling in content analysis studies, practice assessors' comments found within the online assessment documents of 2 nd year BSc students, from one practice area, were purposively sampled. The authors agreed this approach would 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 convention, it is suggested (Bengtsson, 2016) a sample between 1-30 is typically sufficient to facilitate credible inferences. As such, it was agreed that a maximum of 30 practice assessment documents would be accessed.

Data collection & analysis
Qualitative data were collected from the online practice assessment documentation of second year undergraduate student mental health nurses at one UK University in the North of England. Only one NHS organisation was studied. Initially, and following guidance from Elo et al., (2014), data were collected and analysed at the same time. The purpose of this was to ensure that data saturation would be sufficient to facilitate the categorisation and abstraction process. Whilst data were being extracted, the authors engaged in continual reflexive discussion (while also noting any category types) until it was decided that no more 'new' categories were being observed. During this initial data collection/analysis phase, and throughout the remainder of the study, the authors engaged in reflexive discussion (Berger, 2015). Given the closeness of the authors to data subjects, it was important that the authors discuss their reactions to the content and make a conscious effort to refer one another back to the research context/question (Olmos-Vega et al., 2023); bearing in mind the positionality of the authors as clinical academic researchers.
Data chosen for extraction was based upon the parts of the assessment documentation where assessors can make qualitative comments. Open comments were taken directly from the practice assessment documentation onto an open Microsoft Word document. Any identifiable data, relating to either individual or organisation, was immediately anonymised and replaced with generic terms. Comments were only extracted where students were noted to have passed their placement, and no formal concerns had been raised in relation to their professional conduct or competence. This meant that 'typical' comments could be utilised to appraise the student as opposed to comments which were intended to initiate further remedial action. A total of 237 comments were extracted from the online documents, from 26 individual practice assessors. All comments were amalgamated into a single coding sheet for analysis.
After this initial data collection phase, an inductive content analysis (Elo and Kyngäs, 2008) was employed as follows. First, units of analysis were identified separately by two researchers (first and second author), through a process of immersion with the data (Polit and Beck, 2014). Second, data were openly coded by each researcher by making notes within the margins of the coding sheet. The words/segments of the text (identified by each researcher) were then "classified into smaller content categories" (Elo and Kyngäs, 2008, p. 109) and grouped according to their similarity. Through lengthy discussion, higher order categories (also known as generic categories) were identified (Fig. 1). Higher order categories were named according to the characteristics of the words/segments of text in each sub-category. Generic categories described the various subjective perspectives and priorities that were considered as consciously important to clinical practice assessors when formulating their assessment of student mental health nurses. Finally, through continued reflexive discussion, the researchers abstracted the main categories of 'transactional' and 'transformational' competencies.

Trustworthiness
The authors acknowledge their position as insiders in relation to the topic under investigation (Chavez, 2008). With a combined clinical and academic experience of approximately 56 years, the researchers regard their perspectives, tacit experience, and knowledge as relevant for the determining of categories and subcategories in this study (Elo et al., 2014). This insider position is, therefore, considered to be a strength of the study and beneficial to the interpretive and analytical process (Patton, 2001). The study is reported according to the COREQ checklist (Tong et al., 2007).

Ethical considerations
Ethical approval was granted by the host organisation on 15 th May 2023 (ID: ER53538781). Before proceeding with the study, the research team confirmed with the Data Protection Officer (DPO) that the activity complied with legal processes and GDPR standards (Data Protection Act, 2018). As a courtesy, data subjects were informed about the study, prior to data collection, and were provided with contact details of the research team (and DPO).

Findings
Findings demonstrated that practice assessors were prioritising two broad-based skills categories. Firstly, assessors were commenting on learners' transactional competencies in relation to the practical application of specific tasks (and the tools used to undertake those tasks e.g., mental state assessment, risk assessments) that would be needed to become competent mental health nurses (Fig. 1). This concerns what the student knows and the performance of tasks to be assessed. The second core priority was a focus on the fundamental categories of transforming into or 'becoming' a mental health nurse. This involves 'how' the student demonstrates positive personal values and characteristics when using the tools and applying them in practice (Fig. 2). In terms of the number of comments made, the second core category appeared to be given much more weighting. There was also greater depth, quality, and richness in the data within this category.

Transactional competencies
Comments were made on specific skills that were transactional in nature. The language used here was more perfunctory, and related to an assessment of what the student understood against the task that was being performed. These comments were organised into two generic categories. The first generic category was related to all fields of nursing i. e., those competencies which all nurses must achieve in respect of the Annex B proficiencies.
"Has partook in physical health observations, he has been able to complete ECGs with a basic understanding".
"He has been able to complete physical observations with prompts and has taken an interest into ECGs under supervision".
"Has been excellent regarding taking physical observations and raising any concerns".
Assessment of the student's competency in relation ECGs and the taking of physical observations featured heavily within the data. However, assessors appeared to be prioritising mental health field specific skills. The latter were referenced frequently, as shown in the subcategory notations in Fig. 1.
"Is developing her skills base in relation to mental health assessment and administering depot medication".
"Starting to display knowledge within mental health act paperwork".
"Displays some knowledge in response to some of the learning which was set for him around the Mental Health Act (1983) and medication".
Practice assessors were clearly focussed on the core tasks and tools used in mental health nursing. In this category, practice assessors did not directly comment on a student's failure to achieve a specific competency, or pass comment on a student's lack of knowledge. Rather, assessors' language was reflective of this being a work in progress and not a failure to achieve as such.
"Is starting to display knowledge within mental health act paperwork".
"[student name] has been completing MSE which she needs to continue to complete to build up her knowledge base on how to assess risk and how to assess mental states effectively".
Mental health specific skills were more developmental, whereas, the 'all-fields' specific competencies were more finitely referenced and formulaic in the language that was used to comment.

Transformational competencies
In this category, comments were more expansive, language was more effusive, predominantly values based, and demonstrated a clear passion for the mental health nursing field. The students' values and attitudes to learning were dominant in the assessors' comments. This was interpreted as assessors appreciating enthusiastic learners who have values that are closely aligned with the broader perceptions of mental health nursing.
"Has a fantastic attitude to learning and has been an absolute pleasure on this placement so far. She is approachable and is willing to do what she can to develop herself and others. She is proactive in her learning and shows the true values of an aspiring nurse".
"He has noted how important communication is, even in regards to small gestures with patients e.g., using manners when asking patients to do something. After discussions with [student name] he has noted how communication is a founding principle within nursing" In the transformational category, there was much more emphasis on students' personal attributes and characteristics, and how these contribute to 'good' nursing practice. In the example given below, the student's commitment to the profession has been emphasised by referencing the challenging nature of the student's personal circumstance.
"Is a great communicator, it is clear that she has experience in working with patients. She has a confident and compassionate manner. [student name] has impressed us with how eager and conscientious she is, despite juggling the many pressures of her own life".
There were numerous references to the core values that are considered integral to mental health nursing such as, empathy, compassion, and therapeutic relationship building. In terms of the therapeutic relationship, there were several examples where assessors referred to the therapeutic relationship and the student's underpinning values. Contrary to the transactional competencies, where the language use related to these skills being developed and built on (and then achieved), transformational characteristics (personal attributes, values and work ethic) were commented on in an interrelated way and described as inherent to the person.
"Has been demonstrating a good approach to patient care and had made appropriate reference to how patients can and should be treated. She has shown a down to Earth attitude to individuals we have seen and noted how this can be used to build a therapeutic bond".
"I have observed [student name] speaking sensitively with patients and asking questions appropriately to enable her to build a therapeutic relationship".
"Has displayed a humanistic approach towards patient care and recognises the importance of treating each patient as an individual".
The data clearly evidences that, where the values and attributes considered integral to mental health nursing were potentially in deficit, assessor comments were focussed on this being a concern.
"Has lacked a positive go-get-it attitude….I have spoken to this student about this simply not being acceptable….concerns have been discussed…he is aware he needs to enhance his personalisation skills and to have a more positive attitude whilst on placement showing willingness to engage" "Has been able to complete physical observations with patients, although currently does appear to struggle at times with conversations with patients and manners when asking patients to do things. This has been feedback from other members of the team. I believe from reading his pebble pad [student name] is aware he needs to enhance his communication skills within the nursing industry to be able to build a rapport with his patients in the future, to make them feel safe and comfortable" It is clear from the data that physical skills are being considered. However, much more emphasis is placed on the context within which those skills are delivered, with greater value being placed on communication and caring attitude over the specifics of the skill. Overall, value is placed not on the specifics of the skill being assessed, but how the student has delivered that skill in the context of a respectful, personcentred, and compassionate approach.

Discussion
The aim of this study was to examine what the current priorities of clinical practice assessors are when assessing mental health nursing students. This is an area where there is currently little understanding and is where this paper contributes a better understanding of 'what' is being prioritised for the future mental health nursing workforce, by those who work in clinical practice, and are responsible for assessing student mental health nurses. While it is clear 'what' is being written about, as we have described in this study, ascertaining whether a conscious decision was made to choose these comments over others is not certain.
Given recent changes to the expected standards of proficiencies for future nurses , an argument has surfaced which proports the generification of mental health nursing, and a diminishing focus on humanistic skills that are viewed as central to the profession (Loureiro et al., 2018;Santos et al., 2018). Our findings demonstrate that humanism continues to resonate with mental health professionals who are clearly passionate about the future of mental health nursing, moving forward with a humanistic approach at the core of the profession.
A key anxiety regarding the Nursing and Midwifery Council's (2018) educational standards, is that the fundamentals of the mental health nursing role, such as therapeutic relationship building, are not captured or focussed upon in practice assessment documentation. This is because these documents routinely place more emphasis on specific proficiencies relative to physical health skills (Warrender et al., 2023). However, what is clear in the data is that when assessing students outside of mandatory proficiency tick boxes, nurses consistently and assertively assess students against the values and skills associated with humanist concepts of mental health nursing. This is reflected within the data, for example, there were frequent references to person centredness, compassion, and therapeutic relationships. There were also recurring comments to mental health nursing specialist knowledge, key legislation such as the Mental Health Act (2007/1983), and other assessment tools that are commonly used in mental health nursing practice. This suggests that nurses are placing emphasis on the qualities and skills associated with the provision of high-quality mental health nursing care, which has been a source of frustration amongst nursing students and academics since the NMC endorsed curriculum changes in 2018 (Nursing Times, 2023). It is possible that, despite the generic nature of the practice assessment documentation, mental health nurses are finding a way around this structure to ensure that the distinct work of mental health nurses is foregrounded.
Physical health proficiencies were not referenced very often in the current study, however, when they were, the most frequently referenced skills were EGC's and physical observations. This is reflective of the most common core skills exercised within a mental health setting. Given that the Annex B proficiencies have only been within the nursing curriculum for a short period of time, existing mental health nurses may have not yet acquired the necessary competency in their training They may, therefore, not feel able to adequately assesses new student nurses. Accordingly, it is possible that the comments do not necessary reflect the priorities of assessors, but more so reflect the aspects of practice that they feel competent to assess. The assessor may feel that it is a priority for the student to be able to undertake physical health skills, but due to an absence of knowledge/competency, they do not comment on this. Therefore, to better understand why the comments were made, as well as the practicalities and decision making involved, the first-person perspectives of practice assessors would need to be ascertained.
The debate regarding continued dissatisfaction with the lack of mental health field specific skills, and theory specific knowledge, within the higher education syllabus is ongoing (Connell et al., 2022;Nursing Times, 2023), and ways in which to address this have begun to surface (Harvey, 2023). However, in terms of evidence to support the need for the humanist elements of mental health nursing to be better represented and distinguished as specialist skills (within the practice assessment document), this paper is the first to offer a research response. Findings of the current study reflect an obvious and consistent focus on prioritising, or at least choosing to focus on in their assessments of students, relational skills specific to the mental health field of practice. It could be argued that these should, therefore, be reflected within the practice assessment documents. However, for this to be achieved, and for this revision to be actioned by the , these elements would need to be better distinguished in the curriculum.

Strengths and limitations
The application of content analysis in this study has enabled contemporary insights regarding interactions between student nurses and practice assessors to be obtained using unobtrusive means. However, while the data is highly topical in nature, and representative of contemporary debate in nurse education, the findings are limited by temporality. Regardless of this limitation, the authenticity of the findings is illustrated by the range of realities presented (Elo et al., 2014); 237 comments were collected from 26 individual practice assessors, which has provided a diverse range of in-depth data to draw from.
The research team have a wealth of knowledge relating to the context from which the comments have been obtained (clinical practice and nurse education in practice), which adds credence to the interpretative process. However, the structure of the practice assessment document interface steers assessors to prompt on specific areas, for example, assessors are directed to comment on knowledge, skills, attitudes, and values. There is a final section, 'the ongoing achievement record (OAR)' where assessors record a summary of the student's strengths. Since some of the data were collected from sections that are explicitly prompted, this may have influenced the results. Therefore, it would have been beneficial to have followed up with practice assessors, using interviews to understand more about assessors' rationalities around inputting comments in relation to our findings.
Only one organisation was studied, in one location in the North of England. It is, therefore, difficult to comment on the transferability of the findings to similar organisations in other geographical locations. For future research, we plan to examine comments made by practice assessors in the adult nursing field to explore what practice assessors are prioritising, using the transactional/transformational framework derived from this study as a guide for comparison. The transferability of the findings from the current study could also be tested by repeating this study within the same filed of practice, using a different placement area.

Conclusion
In the clinical learning environment, mental health nurses (who are trained to assess student mental health nurses in practice) are prioritising transformational aspects of learning that contribute to students 'becoming' a mental health nurse. This focussed on personal attributes, work ethic, and values that are congruent with humanist perceptions of mental health nursing. Their assessment seems to be informed by a strong sense of professional identity.

Ethical approval
This study was approved by Sheffield Hallam University Research Ethics Committee (ID: ER53538781) on 15 th May 2023.

Declaration of Competing Interest
None.

Appendix A. Supporting information
Supplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2023.103776.