The relationship between structure mentoring programs

The issue of new graduate nurse retention remains a challenge in many healthcare facilities. More than 50% of new graduate nurses leave their first employment in less than a year (North, Johnson, Knotts & Whelan 2006). Because new recruits are often faced with a variety of stressors in their beginning practice it is clear that a structured mentoring program could be of immense value. Such a program would provide technical and emotional support to nurses and so ease their transition into the unitculture.

This article provides a critical review of the literature on mentoring, especially the impact that structured mentoring programs have on the retention rates of new graduate nurses. In the first section I will explore the nature of mentorship within thenursingdiscipline. I will discuss the functions of a formal mentoring program and the chief characteristics of the mentor: mentee relationship. In the second section I will provide a critical review of the literature concerning the relationship between mentoring programs and increased nurse retention rates.

The third section explores common pitfalls that subsume in a dysfunctional mentoring program. Finally recommendations to organisations are proposed based on the review findings. Introduction Graduating from a nursing school is a considerable achievement. New graduates eagerly anticipate their first position in the ‘ real world’. The issue however of new graduate nurse retention continues to be a grave concern in many healthcare facilities. It was reported that more than 50% of new graduate nurses leave their first employment in less than a year (North, Johnson, Knotts & Whelan 2006).

New recruits are often faced with a variety of stressors associated with beginning practice. It is clear therefore, that a structured mentoring program which provides technical and emotional support to new nurses may be one of the best retention strategies for nurse administrators. This article provides a critical review of the literature on mentoring, with an emphasis on the impact that structured mentoring programs have on nursing retention rates. The first section sets up mentoring concepts and processes as identified in the literature. The second section will provide a critical eview of the literature on the relationship between structured mentoring programs and the nursing retention rate.

The third section explores common pitfalls that subsume in a dysfunctional mentoring program. The final section makes recommendations to organisations regarding a successful mentoring program. Significance New nurse graduates have many employment options. They can choose not to work in settings where they are not supported and often they take that option. Common themes emerging from the literature show that many new nurses lack both confidence and a sense of competence (Oermann & Garvin 2002).

They are afraid of making mistakes; they complain of an unsupportiveenvironment; and of being obliged to work with ‘ difficult’ colleagues (Oermann & Garvin 2002). A lack of recognition of their work as well as difficult shift-work schedules have also been identified as sources of distress (McVicar 2003). It is a sad fact that one out of every three nurses under 30 years plans to leave during his or her first year of employment (Nelson, Godfrey & Purdy 2004). The cost of such high levels of unnecessary nurse turnover is significant (Halfer, Graf & Sullivan 2008).

More significantly the resulting deficit of nursing personnel inevitably affects the quality of patient care in hospitals and can compromise patient safety (Leners, Wilson, Connor & Fenton 2006). In response to the critical issue of nursing retention, hospital managements have been urged to address the issue by developing a more congenial work environment. However, it is noticeable that mentoring initiatives are still not integrated into many healthcare organisations, despite a plethora of literature relating this with positive outcomes.

Literature search Relevant studies were identified by searching the following electronic databases: Cumulative Index to Nursing and AlliedHealthLiterature, Ovid and ProQuest. The keywords or their combinations have been utilised in the searching process. These include: mentorship, preceptorship, new graduate nurses, personnel retention, and personnel recruitment. Other literature was identified through searching the bibliographies of studies found through electronic searches, including the World Wide Web, GoogleScholar and library data systems.

Inclusion criteria included discussion/ opinion papers and articles/materials written in English. There were no particular discipline restrictions and there were also no specific date restrictions. Articles that were published after 1999 were sought. The retrieved articles were reviewed and selected based on these criteria: the relationship between formal mentoring programs and personnel retention; benefits of mentoring; new graduate transition; and possible pitfalls of mentoring. Literature review What is mentoring?

There is a substantial body of literature which deals with mentoring and preceptoring as discrete functions (Block, Claffey, Korow & McCaffrey 2005; Kelly 1994). To date however, the two terms continue to be used interchangeably or synonymously (Block et al. 2005). It is useful to draw some distinctions between them. Preceptorship is understood as an organised orientation program in which the nurse preceptor facilitates the integration of new staff into role responsibilities in the clinical setting for a limited period of time (Greene & Puetzer 2002).

This relationship is often viewed as one-sided and patriarchal (Leners et al. 006). In contrast, mentorship is a reciprocal relationship established between two nurses “ on the basis ofrespectand compatiblepersonalitywith the common goal of guiding the nurse toward personal and professional growth” (Block et al. 2005: 134). The relationship often occurs over a much longer period, depending on whether the agreed-upongoalshave been achieved (Andrews & Wallis 1999). Stated simply, the features of mentorship as distinct from other supporting roles in clinical settings include a strong repertoire of helper functions, reciprocal sharing and a relatively longer duration (Morton-Cooper & Palmer 2000).

Characteristics of the relationship Mentorship primarily involves a mentor and a mentee in a one-to-one relationship (Latham, Hogan & Ringl 2008). This relationship is characterised by a process of enabling, cultivating, and empowering a less experienced practitioner within the work environment (Morton-Cooper & Palmer 2000). In this longitudinal relationship, both mentors and mentees assume their own responsibilities and obligations in achieving either organisational or personal goals (Latham et al. 2008).

In this relationship, a mentor is recognised as a wiser and more experienced practitioner, who possesses certain ‘ personal’ and ‘ professional’ attributes such as good interpersonal skills, self-confidence, flexibility, knowledge, and an interest in professional growth (Kane-Urrabazo 2006: 193; Andrews & Wallis 1999: 204; Morton-Cooper & Palmer 2000). Personal attributes that have been identified as important factors to success also include good listening skills, the ability to facilitate learning and being comfortable in giving feedback (Sherrod, Roberts & Little 2008; Woodrow 1994).

The literature refers to the nurse being mentored as a ‘ mentee’, ‘ protege’, ‘ learner’, or ‘ mentoree’ (Zucker, Coss, Williams, Bloodworth, Lynn, Denker & Gibbs 2006; Hunter 2002). Referred to here simply as “ the mentee” she or he can be any nurse at a distinctive stage of his/her profession (Leners et al. 2006). The characteristics of a mentee that allow a functional mentorship to flourish include honesty; the capacity to takeresponsibility; being ready and available for feedback; following through on decisions, having a strong self-identity and a willingness to learn (Wagner & Seymour 2007; Sherrod et al. 008).

Structured mentoring program Various structures of formal mentoring programs are available across institutions (Latham et al. 2008). Broadly speaking, the structure of a mentoring program contains several stages of strategic planning (Latham et al. 2008). Initially the focus is on: establishing objectives and measurable outcomes, role delineation for mentors and mentees, establishment of criteria for involvement in mentorship and the construction of a supportive system and a surveillance system of the mentor-mentee team (Latham et al. 2008).

Those parties who are involved in this formal relationship are required to fulfil pre-determined aims, objectives and outcomes as identified by their respective supporting organisations (McCloughen, O’Brien & Jackson 2006). The second stage in which the program is implemented involves the selection of suitable mentors, the recruitment of mentees, (on both a voluntary or involuntary basis) and mentor preparation (Latham et al. 2008). Final stages include an evaluation through reflection and feedback by mentors and mentees, to determine whether specific objectives and measurable outcomes have been achieved (Latham et al. 008).

The program duration may last one year or even longer (Morton-Cooper & Palmer 2000). Structured mentoring programs and retention success In this session, several issues regarding structured mentoring program and retention success will be addressed. First, we must ask what mentoring functions are important to retention success? Second: to what extent or in what way does mentoring contribute to the retention of new graduate nurses? Each of these questions is considered in the following section. Benefits of mentoring programs

Mentoring has been shown to provide a beneficial effect on a proteges’ job satisfaction levels and willingness to remain in an organisation (Fleig-Palmer 2009). One aspect of the mentoring relationship is the passing of knowledge from a more experienced staff (mentor) to a less experienced staff (protege) (Heartfield, Gibson, Chesterman & Tagg 2005). Research suggests that by the absorption via socialisation of specific skills to proteges is positively related to personal learning in the workplace (Sherrod et al. 2008).

This component is akin to preceptorship which also includes skill-development (Sherrod et al. 2008) and is widely accepted as a crucial orientation to new graduate nurses. Literature has linked preceptorship to a high level of satisfaction together with successful retention (Almada, Carafoli, Flattery, French & McNamara 2004; Lee, Tzeng, Lin and Yeh 2009). Anecdotal evidence shows that new graduates after completing the preceptorship program tend to seek more support, a fact which in itself would imply a strong need for good mentoring programs.

A second aspect of the mentoring relationship is the psycho-social support the mentor may provide to a mentee: support which enhances his or her sense of competence and confidence (Heartfield et al. 2005). Recent findings from a longitudinal study suggest that mentoring fosters organisational retention rates through the establishment of emotional connections between mentor and mentee, by contributing to higher level of commitment to the organisation (Beecroft, Dorey & Wenten 2007).

A substantial body of literature also supports the notion that mentorship initiatives can help new recruits transiting into the unit culture (Leners et al. 006). Positive environments can be created through frequent interaction, communicationand relational caring between different generations of co-workers (Latham et al. 2008). Such interactions can help new nurses transcend the generations, norms and values differences in a unit (Latham et al. 2008). It also can aid a new recruit in getting in touch with overt or covert culture within the practice environment (Morrow 2008). Ultimately, better patient outcomes can be achieved, which in turn can increase nurses’ satisfaction (Leners et al. 2006).

Many studies show that individuals who were mentored report higher levels of job satisfaction (Halfer et al. 2008; Krugman, Bretschneider, Horn, Krsek, Moutafis & Smith 2006; Faron & Poeltler 2007). An abundance of research studies indicates that organisations who implement mentoring programs show a consistent decrease in turn-over rate of new nurses (Hurst & Koplin-Baucum 2003; Greene & Puetzer 2002; Halfer & Graf 2006; Halfer et al. 2008; Zucker et al. 2006; Persaud 2008). Similar results are also evident in other disciplines such as Medicine, Pharmacy and Academia (Cohn, Bethancourt & Simington 2009; Sambunjak, Straus & Marusic 2006).

One report in particular highlights the benefits of mentoring. A study from the southern United States by Zucker and co-workers (2006) was done to determine the impact of an 18-month mentoring program on nurse retention in five hospitals. Prior to commencement of the program, participants completed a personality profile, to ensure successful pairing (Zucker et al. 2006). This program included topics such as communication and conflict resolution skills, co-operative learning and time-management (Zuker et al. 006)– all subjects which are normally not covered in conventional orientation programs.

At the end of the program, both parties reported that the mentoring relationship increased their knowledge and helped them become ‘ better people’ and ‘ better colleagues’ (Zucker et al. 2006). Higher levels of protege satisfaction were directly translated into increased retention. In this case, the increase was 16% (Zucker et al. 2006). Given that the high turnover rate of new recruits, mentoring program yield a significance of cost-saving to healthcare system. Research methodology/measurement issues

Admittedly, strict evidence for an improved retention rate is hampered by the small sample size of these programs (Hamilton, Murray, Lindholm & Myers 1989; Faron & Poelter 2007). Atkin and William (1995) argue that findings which result from such small purposive studies cannot be generalised. Despite numerous studies therefore which show that retention rates increase with the application of a mentorship program (Block et al. 2005), it is still difficult to draw a firm conclusion on the direct causal relationship between mentoring programs and the attained retention level.

This is due to the limited amount of information provided with respect to evaluation tools, sample size, mentor styles as well as the lack of a comparison group in the available studies (Gagliardi, Perrier, Webster, Leslie, Bell, Levinson, Rotstein, Tourangeau, Morrison, Silver & Straus 2009; Greene & Puetzer 2002; Hurst & Koplin-Baucum 2003). In addition, the outcomes of these studies may be affected by: differences that exist in a mentor-mentee relationship; the program’s aim and function; and the frequency of interaction between mentor and mentee (Jacobi 1991; Beecroft et al. 2007).

Lack of strong quantitative data may prevent the establishment of a positive colleration between mentoring programs and retention rates. Furthermore it can be argued that retention strategies such as mentorship (which are deemed appropriate in one hospital) may not work in another (Jacobi 1991). Atkin and William (1995) point out that the findings might only show that mentors and mentees’ experience during mentorship was relatively new to them. In spite of all critiques, no one however has doubted the overall value that mentoring programs have for mentees, mentors as well as for organisations (Block et al. 2005).

The existing mentoring studies on nursing which are linked to retention rates include cross-sectional and longitudinal components (Halfer et al. 2008). In contrast, empirical studies with correlational design, contain data which are only collected for a single point of the study and are subject to a limited amount of participants (Caine 1989; Fagan & Fagan 1982). Quasi-experimental design is therefore recommended (Jacobi 1991). In such studies data is collected from a group of participants who receive mentoring programs together with another non-receiving group, at multiple points throughout the study (Jacobi 1991).

Until today, it is not known how long the mentorship effect takes to emerge, in this instance, nor how long it will last (Jacobi 1991). Pure experimental research has value in determining the relationship between mentoring and retention of new graduates (Jacobi 1991) but not many current studies can afford to adopt such a strict approach to measuring the cause and effect of mentoring programs and retention rates. Pitfalls of a structured mentoring program Despite numerous of benefits gained from a mentoring relationship, the desired outcome such as retention not always achieved.

Several types of problems that might occur in mentoring include:- Selection of mentors A number of authors note that inequity in the selection of mentors can be problematic to the success of a mentoring program (Greene & Puetzer 2002; Andrews & Wallis 1999). Andrews and Wallis (1999: 206) state that ‘ some of the nurses are not mentors by choice’, as they dare not reject their selection by the nursing manager. The mentor selection criteria have not been made clear and explicit (Andrews & Wallis 1999).

Sometimes, an experienced staff nurse does not have the attributes to become a good mentor (Greene & Puetzer 2002). Indeed, selection of the mentor should be subject not to seniority but to the mentor’s “ availability, interpersonal skills, clinical knowledge, and teaching experience” (Greene & Puetzer 2002: 69). An optional basis may also be used (Atkin & William 1995). An inadequate mentor who lacks strong values, or good personal and professional attributes and who exhibits unwarranted behaviours can be a liability (Kane-Urrabazo 2006).

Such behaviours can include negative feedback or a lack of respect towards the mentee and can result in decreased self-esteem in the new recruit (Kane-Urrabazo 2006; Woodrow 1994). These behaviours are also known as ‘ joy stealing’ (Heinrich 2007, cited in Driscoll 2009: 8). The consequence of this will be frustration for either or both mentor and mentee (Kane-Urrabazo 2006). Poor mentoring can drive the newly employed staff away (Kane-Urrabazo 2006; Woodrow 1994). It is therefore imperative that a formalised selection criteria for mentors should be identified.

Compatibility Many proteges complain of being enmeshed in a dysfunctional relationship with their mentor (Feldman 1999). This is likely to occur if there is ‘ forced matching’ when a less experienced nurse is assigned to be with a mentor pre-selected from experienced staff nurses (Morton-Cooper & Palmer 2000: 46). Given the closed relationship between mentor and mentee, there is a risk of this relationship becoming destructive (Woodrow 1994). Empirical studies have identified this issue (Fenske 1986).

Common themes that emerge are: failureof the mentor or mentee to maintain confidentiality of private information, mentee abuse of the relationship in which the mentor’s resources are exploited for personal advantage, mentor abuse of the enthusiasm and goodwill of the mentee by making use of his/her as a personal helper or assistant (Hunter 2002). Eventually varying degrees of injurious consequences to mentor, mentee and organisation can develop if not properly monitored (Feldman 1999). The literature has identified that mentees would have better opportunities for growth if mentees were able to select the mentors (Woodrow 1994).

Opposition to this suggests that matching is not as important as meeting regularly for a successful mentoring relationship (Beecroft, Santner, Lacy, Kunzman & Dorey 2006). Training for mentors Undoubtedly, a mentor is the key person in the success of a mentoring relationship. However, several studies have shown that most mentors feel deficient in their role as mentor because their training consisted of learning “ on the job”, and by “ watching how other people do it” (Andrews & Wallis 1999: 205-206).

There are some institutions providing formal mentor training to guide the mentor along (Hurst & Koplin-Baucum 2003). An evaluation study done by Jinks and Williams in 1994 (cited in Andrews & Wallis 1999: 205) found those who undertake a formal course with exams felt significantly more able to undertake the role. A formal mentoring course commonly would examine the phases in mentorship, recognising different adult learning styles and personality traits, provide techniques in dealing with conflict and effectively help to manage the relationship with the mentee (Hurst & Koplin-Baucum 2003; Block et al. 00. In spite of these improvements, the majority of the course content was still perceived as inadequate by mentors’ (Andrews & Wallis 1999).

Additionally, those who had left school for a significant period of time, might feel the lack of a theoretical background leading to doubts as to whether they possess sufficient preparation to be a mentor (Andrews & Wallis 1999). Woodrow (1994: 813) argues that the ideal of mentorship might be undermined by ‘ token mentorship’, in which mentors are unable to perform true mentor functions. Recommendation

It is important for hospital managers who prepare and support nurses as mentors to develop a greater understanding of mentoring from the mentor’s perspective (Atkin & Williams 1995). Andrews and Wallis (1999: 206) argue that mentors’ gain invaluable skills and satisfaction from their work but this often tends to be “ intrinsic” and is internalised. Several authors believe that administrative support through financial compensation, staffing and schedule flexibility, title andleadershiprecognition can act as motivators for experienced staff (Greene & Puetzer 2002).

Such measures would make mentors more likely to commit and sustain in this longitudinal relationship (Greene & Puetzer 2002). In addition, on-going mentor support through a mentor-support group may be helpful in maintaining the momentum (Latham et al. 2008). Latham et al. (2008) had further examined a university-hospital partnership mentoring program. The program included a component of mentor support as part of the program follow-up. It offered an opportunity for mentors to vent about the difficulties they were facing, and share the successful experiences in the mentorship.

A mentor support group can clearly help management to monitor the mentorship progress and develop a strategy to tackle emerging problems (Latham et al. 2008). Conclusion It is important that healthcare organisations not continue to take the nurse retention issue lightly. The provision of an effective mentoring program structure is the appropriate response. This is essential in helping clinical entry nurses make a smooth transition into the working environment and at the same time benefit experienced nurses to achieve a higher level of professional development.

Such a program can also help the organisation transcend a multitude of problems by creating a positive environment where every staff member may enjoy working. In order for an effective mentoring program to be carried out, organisations must: allocate sufficiently experienced staff to act as mentors; provide flexible staffing and scheduling; give quality training to mentors; and support the mentors through various means by title recognition, wage adjustment and support groups.

In turn the program can help organisations increase retention and reduce turn-over for nurses, particularly new graduate staff. It can thus achieve better patient outcomes and increase nurse’s job satisfaction. By providing a structured mentoring program for new nurses’careerdevelopment and advancement, we can help to improve the longevity of active nursing careers and also help to alleviate the problem of current nurses’ retention.