Introduction

Nurses readily deliver effective, timely care during a patient’s most critical moments. Growing demands for nurses in today’s complex healthcare systems requires clinical leadership and a commitment to professional development [1]. Leadership through mentoring offers a venue of learning activities that require competent communication, critical thinking, leadership skills, and professional growth. Mentoring activities create a space for student nurses to exercise judgment and develop clinical skills necessary for a dynamic, fast paced healthcare environment. Mentoring is a reciprocal, collaborative learning relationship where the mentor is the guide, expert, and role model who helps to develop a new or less experienced mentee. Discovery, utilization of evidence, and reflection are mentoring experiences that develop transitional nurse leaders with the skills for risk taking, facing challenges, and transforming nursing care [2]. The mentor-mentee relationship connects the science of developing professionals and the science of leadership in order to enhance learning by reducing anxiety, creating a positive learning environment, boosting selfconfidence, reducing confusion, and increasing interactions in various rankings or curriculum levels.

The mentoring relationship serves to develop competent practice and performance, increases cultural capital, and promotes good citizenship through successful networking, collaboration, and support [2]. The Professional Nursing Practice Essentials for baccalaureate nursing curriculum identify ‘leadership for quality care and patient safety’ as a standard for practice and professional performance [1]. “Baccalaureate graduates can recognize, interrupt, evaluate, and correct health care errors” [1]. These leadership competencies are supported in didactic curriculum and clinical practicums where students use negotiating, collaborating, and advocating skills, creative problem solving, knowledge of healthcare system structures and finance, quality improvement, benchmarking, root cause analysis, and nursing care delivery management and evaluation. These basic leadership skills describe professional accountability. Leadership experiences through mentoring opportunities motivate students to value camaraderie, generosity, and trust in helping others be their best through teamwork. Further, colleges or universities that include strategic goals that mentor diversity and inclusiveness (Civil Discourse, Shared Values) and transformational innovation through student centered pedagogy and active learning ecosystems better serve the needs of a diverse community. Professional standards and organizational goals integrated into nursing curricula can influence mentoring opportunities, extend the value of mentoring, and advance an intellectual capacity that goes beyond the classroom into the nursing workforce. Currently, there is a paucity of research on mentoring activities in baccalaureate nursing programs linking mentoring to leadership, professional development, program standards, and strategic goals.

In this SoTL study, baccalaureate-nursing students from one Midwest College of nursing were recruited to participate in mentoring activities in order to better understand the factors that impact the mentoring experience. The following objectives directed this study: (1) Identify leadership themes from senior mentoring experiences; (2) Evaluate the senior and junior mentorship experiences; and (3) Determine how mentoring impacts leadership. The aim of this study was to create a framework for nursing practice through mentorship relationships, by building trusting teams and a commitment to culture of patient safety and quality care.

Theoretical Framework

Nurse theorist, Pat Benner, emphasized mentoring (Supporting, teaching, encouraging, challenging, coaching, advising, protecting) as foundational in the journey from novice to expert nurse. Benner’s model from Novice to Expert includes reflection and critical thinking as a means towards skill development and mastery [3]. These insightful concepts are explored and explained to guide the mentorship relationship yet may be unfamiliar even to the most accomplished nurse or faculty. Nursing curriculum that includes mentoring activities helps nurses with more experience play a vital role in motivating less experienced peers or nursing students. In addition to this mentormentee dyad is the organization’s commitment to support quality mentorship programs that include talent, energy, and resources to bolster innovation, transformation, and risk taking to achieve goals [4].

Benner identified five stages of clinical competence including novice, advanced beginner, competent, proficient, and expert [3]. Novice nurses have a limited capability to predict what might happen due to a lack of past experiences. Advanced beginners have more experiences and can recognize features of a situation. Competent nurses have skill mastery and can navigate a variety of complex situations yet lack the speed and flexibility of more experienced nurses. Proficient nurses examine the entire situation, distinguish between “Normal” and abnormal events, and can modify responses. Expert nurses make decisions instantly in response to an event using an intuitive practice. Benner’s theory concentrates on how nurses gain nursing knowledge or know-how rather than know-that thus served as an important framework for this study [5].

Summary

Mentoring activities including practicing technical skills provide mentorship experiences for nursing students entering point of care delivery in a hyper-complex nursing environment. This high accountability environment requires leadership, direct communication, and trusting teams. These essential skills are reinforced conceptually through Benner’s Novice to Expert theory and by mentorship activities that include proactive, continuous feedback in the mentorship relationship. Finally, important to mentorship programs is strategic and operational support within the organization.

Literature Review

As the nurse progresses from novice nurse to expert, challenging didactic and clinical experiences are needed. The mentorship relationship is one critical aspect in this bilateral approach to learning that provides a low risk, low stress learning environment. Students are able to ‘Think with’ new concepts in the presence of their mentor who can offer perspective, explain the ‘Why,’ and lessons learned from their own experience. Intentional mentoring programs accelerate the transition of novice to expert utilizing problem-based thinking activities. A review of the current literature is presented on the following: mentoring models/tools, mentoring leadership, and mentoring communication.

Mentoring Models/Tools

The purpose of mentorship relationships is to offer direction and clarity of future responsibilities. For example, when the mentor with the desired knowledge is able to transmit that knowledge effectively and the mentee has the ability and skill to utilize the new knowledge, the dyad fit is a good one. Yet, in highly demanding nursing programs, there are high levels of stress in baccalaureate nursing students. Exposure to stressful work environments including horizontal violence, intimidation, humiliation, and excessive criticism can negatively impact coping and adaptability. Walsh, et al. [6] suggested mentors facilitate resilience principles: self-efficacy, reflection on practice, and confidence. Walsh, et al. [6] discussed reflective writing, role modeling, and utilization of peer and clinical staff support to build critical thinking skills and offset impaired performance, sickness, and high turnover. Further, mentoring relationships that support the personal and educational needs of ethnic and culturally diverse nursing students reinforces socializing mechanisms that promote diverse perspectives, skills, and interests [7]. To foster a diverse student body, an acceptance of diversity through cultural awareness must be prioritized.

Immonen, et al. [8] evaluated twelve clinical assessment checklists for formal, objective assessment of student nurses’ clinical competence. Mentor training and strong reliability and validity of the measurement tools are clinical practice standards as inconsistencies may occur in assessing skills and attitude, and mentors may not fail a student who is poorly performing [8,9]. To improve student readiness, competency, and confidence before entering professional practice, collaborative practice models are used to enhance self-directed learning, relationship building, and collaboration skills [10]. Collaborative learning utilizes clinical care and leadership roles to support real time learning; students no longer felt like an extra set of hands or were taking over for staff nurses. Collaborative teamwork accelerates student development, professional identity, and allows students to be work ready.

Mentoring Leadership

Mentoring activities including checking in, advice giving, being present, and offering constructive feedback are intentional interactions that provide personal and professional growth and leadership empowerment [11]. Women have considered mentoring to be more important than men yet there were identified consequences to absent or incongruent mentorship relationships including increased stress and retention, and decreased satisfaction and collaboration [12]. Cross, et al. [12] emphasized the need to establish a supportive inclusive environment through mentorship relationships to address gender inequality. Further, in preparing future leaders, predictors of socially responsible leadership were more significant with student mentors than being mentored by a faculty member [13].

Mentoring Communication

Formal communication skills are rarely evaluated in undergraduate nursing curriculum thus the voice of the patient can be ignored during task oriented, symptom focused assessments. Motivational interviewing and empathy training are two communicative competence styles that give patients the space to tell their story [14]. Utilizing role-play and reflection on practice, students identified where they were prejudging and deflecting hot topics. Students identified good communications strategies as active listening that incorporates pauses, resisting natural impulses to avoid unpleasant conversations, and inviting patients’ to elaborate on their experience in the midst of ill health using their own narrative [14]. Planned time for mentoring activities, including moral support and regular communication (Method of communication was not seen as important), established connectedness and built a supportive environment [15]. Further, mentoring communication requires quality feedback. Students who received specific, cognitive, justified, reinforcing, and suggestive feedback outperformed their peers [16]. Yet, it can be challenging to obtain consistent feedback from different mentors. Alliance building through cultural validation, proactive clarification, and cultural awareness were considered strategies to improve communication challenges with others from different cultural backgrounds [17].

Summary

The mentorship relationship is multifaceted yet clearly a valued practice, contributing both ethically and morally to the knowledge and skills of student nurses. This review of the literature emphasized three areas: mentoring tools/models, leadership, and communication. These themes identify components of the mentorship relationship through which the progression from novice to expert can be realized. Early socialization of the mentorship relationship, most importantly, building trusting teams, are foundational for a professional practice committed to patient safety and quality care.

Methodology

In order to study the mentorship relationship between senior and junior nursing students in the skills lab, a mixed method design was utilized combining qualitative and quantitative methods. Data were derived from 1) open-ended and close-ended survey questions and 2) senior leadership reflection papers. Below is a detailed presentation of this study’s methodology (Table 1).

Study Population

In 2016, at one Midwest College of nursing, a cohort of male and female baccalaureate nursing students participated in a SoTL study. Out of 152 students, 69 seniors, enrolled in a 400-level leadership course and 81 junior nursing students enrolled in a 300-level adult skills lab, participated in mentoring activities in the Adult-I skills lab for four hours during one semester. Alternate assignments were developed for deviations; one student declined to participate. Seniors were provided a mentoring quick-tip sheet, mentoring articles, and received a lecture on mentoring. Instead of step-by-step instruction from a checklist, seniors were advised to observe skills and offer spontaneous tips and tricks that prevented errors. Seniors refreshed their skills by reviewing videos and checklists available in the skills lab including sterile technique, intravenous and foley insertions, trach care, and nasogastric tube insertions. Juniors scheduled time to meet with senior mentors in the skills lab. Juniors were reassured that the mentor’s presence was one they could trust to build critical thinking, improve clinical skills, and learn to operate at their best on clinical skills.

Ethics

An Institutional Review Board (IRB) application was submitted for the protection of human subjects and approved prior to implementation of the SoTL study. The Primary Investigator (PI) completed online Collaborative Institutional Training Initiative (CITI) tests successfully on Health Information and Privacy. The data collection from this project met the Health Insurance Portability Act of 1996 Privacy Rule requirements through the use of the Safe Harbor method of de-identification resulting in the absence of information that can identify the person.

Data Collection Procedures

Once mentoring activities were completed, juniors and seniors utilized a link to a Qualtrics survey as agreed upon for being a participant in this study. The Qualtrics surveys included seven statements related to the mentorship experience and asked students whether they disagreed or not using Likert scale responses (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree). One open-ended statement was provided for more feedback. The senior reflection papers were submitted to the Canvas Learning Management System on the last day of the 400-level leadership course. Data collected for analysis was stored in a secured office, on a password-protected computer, under a locked file.

Instrument

A Delphi method was used to create open and close-ended survey statements. Open-ended responses empower respondents to bring in unanticipated information. On close-ended statements, responses are entered using the Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree). Two surveys, one to capture the mentee experience and one to capture the mentor experience, listed seven claims related to the mentorship experience, asking respondents whether they disagreed or not. One open-ended statement was added for more feedback on the mentorship experience.

Methods for Data Analysis and Verification

Qualtrics provides a statistical report of responses to closeended survey statements. The mean and standard deviation for each statement are provided. Simple bar graphs illustrate the Likert scale responses (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree) to each statement. Qualtrics reports list the narrative data on open-ended survey statements. Qualitative data from open-ended survey statements were evaluated by a team of three qualitative researchers. Dependability and confirmability checks were used to categorize survey responses as positive, negative, or neutral. Further, the three qualitative researchers coded and thematically analyzed the senior reflection papers. Dependability and confirmability checks informed direct thematic analysis and provided rich details on the mentoring and leadership experiences. A broad consensus on the process of data analysis was confirmed and interpreted as credible.

Prospective Summary

The findings from this study are presented in Chapter Four. Research findings are presented with graphs followed by a review of key themes and findings related to the research questions. These results fully describe the mentoring experience of junior and senior nursing students in one college of nursing.

Results

The results section is a presentation of data collected the three objectives: (1) Identify leadership themes from senior mentoring experiences; (2) Evaluate the senior and junior mentorship experiences; and (3) Determine how mentoring impacts leadership. The aims of this study were to illustrate how the mentorship relationship can build trusting teams, a commitment to culture of patient safety and quality, and enhance problem-solving skills. Survey responses were illustrated using descriptive statistics and graphs for close-ended statements and categories of positive, neutral, or negative for open-ended statements. Senior reflection papers were thematically analyzed and the top themes identified.

A total of 69 senior nursing students and 81 junior nursing students were surveyed based on their mentor-mentee experience after four hours in the skills lab over one semester (Figures 1,2). A higher mean score was reported for seniors (4.19+0.87, out of 5) compared to juniors (3.5+0.97) when rating the mentoring experience. The highest ranked responses on the mentoring experience most valued by seniors were: 1) strong working knowledge of skill, 2) actively involved with mentee, and 3) enhanced understanding of leadership. The highest ranked responses on the mentoring experience most valued by juniors were: 1) mentoring was valuable, 2) actively involved with mentor, and 3) senior had strong knowledge.

Open-ended statements resulted in mostly positive responses from seniors: a) the best part of the mentoring program (95%), b) what seniors learned (89%) and c) less positive remarks followed comments on making the mentoring program better (17%). Openended statements had mostly positive responses from juniors: a) the best part of the mentoring program (85%), b) comments on making the mentoring program better (58%), and c) less positive remarks on what juniors learned (44%) (Table 2).

Senior nursing students completed a reflection paper on their mentoring experience with juniors in the clinical skills lab. Detailed, highly individualized written experiences were reviewed and qualitatively shaped the findings presented in this section. Five themes emerged from the mentoring experiences of seniors in their reflection papers: 1) mentoring created a connection and the opportunity to share knowledge and skills, 2) good communication skills are key, 3) mentoring needs to be expanded starting in the sophomore year, 4) teaching the mentees required prep-work and a thorough review of skills, and 5) mentees are going through the same experiences as the mentors have already (Figure 3).

Theme One

Keep it simple prep work. Mentors highly valued “Refreshing” or “Brushing Up” on lecture notes, articles, quick tip sheets, videos, websites, and other materials in order to facilitate teaching, be well “Received,” and be informative. One senior was skeptical at first, stating “[I] wasn’t certain of [my] own abilities” however the experience “Raised [my] confidence and increased my knowledge on skills from one year ago.” Another senior “Did not know what to expect” because mentees were older. In the clinical lab, students must practice basic skills such as nasogastric tube insertion, intravenous and Foley insertion, master the sterile field, and much more. Realizing the world is a more complex place, one mentor stated, “Hospitals should do this,” and another senior added, “It’s good to know what future job mentors go through as we prepare to enter our real jobs.” While nursing students strive to maintain their knowledge and skills, they will constantly struggle against external pressures, demands, and deadlines. Mentoring gives students, a chance to control of what is done and how it should be done.

Theme Two

Mentees are just like me. Self-motivated mentors develop strategies to teach their peers in spite of their struggles. Mentors reflected on how mentees were sleep deprived, stressed, and anxious, yet eager to learn and desired less stress. Making silly mistakes required “Grace and Patience” that can only be offered by someone who has already walked down that path. One senior advised, “Each student struggles when applying what is learned in the classroom [to the clinical setting]”. Mentees needed “Support and encouragement,” not “Intimidation” or being “looked down upon”. Achievement can occur in either context however, in a more positive environment, one that nurtures/supports learning, motivation, creativity, and curiosity can inspire professional development and growth.

Theme Three

Be approachable with open communication skills. Mentors identified themselves as a “Resource” person for students, someone with “Tips and Advice”, and one who provided clear rationale. The nursing skills lab is not well understood when looking at each individual part however senior mentors are positioned to look at the whole skills experience with a tangible wisdom. One senior stated, “[I] didn’t give away answers or boss [students] [I] provided tips and advice on how to improve skills”. Another senior directed, “Focus on SimMan. We have to explain procedures to our patients”. Someone else “Identified strengths and acknowledge weaknesses that needed improvement”. Other seniors reflected, that having the right “Attitude” is everything, expectations should be “Less Daunting” so students can relax and learn, and “Seeing juniors succeed was the greatest part”.

Theme Four

Redefined through knowledge and skill sharing. Contributing to another’s personal growth involves responsibility, flexibility, and empowerment. Beyond the confines of the classroom, the clinical lab is a zone where students thrive when practicing solving problem skills that will reduce human suffering. “There is nothing wrong with asking questions,” one mentor stated. Another senior advised that “the difficulties are well worth it and there is an end in sight”. One mentor showed a fellow left-handed student how to perform skills right-handed and another senior examined how “different perspectives”, reflection, and rethinking are key to learning a new skill. Engineered on relationship building, mentorship provides information in a comfortable setting so that every student has an equal chance to learn new skills and become proficient.

Theme Five

Expand student mentoring. Effective mentoring supports student learning. Seniors voiced that mentoring should “Start earlier [in skills lab]”, continue to expand into “Pathology” and “Pharmacology” courses, be offered in leadership courses during the senior year, or be offered as extra credit. The current research supports positive outcomes from mentoring and based on this group of senior mentors, a positive impact for both mentors and mentees was highly praised. On sharing knowledge and skills, one senior described: “The mentoring program implemented was also a chance to really solidify leadership skills and clinical skills that the seniors will be utilizing most as we transition into full-fledged nurses”. To support good communication skills, one senior writes, “Being able to encourage and help these students in order for them to retain these skills felt great knowing that this would ultimately put them as ease as well as benefit future patients”. Frequently expressed was the need to expand the mentoring program; one senior added, “The mentoring program [should] help freshman and sophomores prepare for clinical and maybe even have the mentors be involved in simulation days.” Regarding the preparation work required, one senior wrote, “I reviewed the check off sheets and videos my 310 check off sheets. I found it helpful to look at my own personal notes and tips I had written down, it made me remember how stressful these demos can be”. When commenting on sharing the same experiences, one senior writes: “I had their same fears and troubles, but was able to still make it to where I am now seemed to put them at ease”. For nursing students, the mentoring experience has created meaningful dialogue and open communications instrumental in understanding the range of contexts and barriers that influence change.

Summary

In this SoTL study, nursing students evaluated the mentoring experience where seniors mentored juniors on Adult-I skills in the skills lab for four hours over one semester. The data collected were based on student responses to open and close-ended survey statements and senior reflection papers. Senior nursing students evaluated the mentoring experience more positively than juniors. Juniors and seniors had survey responses that satisfied positive, negative, and neutral feedback illustrating strengths and opportunity areas. Five themes emerged from senior reflection papers: 1) mentoring created a connection and the opportunity to share knowledge and skills, 2) good communication skills are key, 3) mentoring needs to be expanded starting in the sophomore year, 4) teaching the mentees required prep-work and a thorough review of skills, and 5) mentees are going through the same experiences as the mentors have already.

Discussion, Implications, and Recommendations

The purpose of this SoTL study was to better understand the complexities of the mentoring experience from juniors and seniors who participated in mentoring activities for four hours during one semester at one college of nursing. This SoTL project achieved its aims: to determine the impact of the mentoring experience by analyzing quantitative and narrative data from surveys and reflective papers. Additionally, senior nursing students completed mentoring activities on 6 skills with junior nursing students. Finally, the findings support the benefits and barriers of this mentoring program. Seniors critiqued the mentoring activities more positively than juniors; mentor-mentee narratives reflected positive, negative, and neutral comments; and the process of reflection on practice produced five themes related to support the mentorship program (Similar experiences, training/prep work, expand mentoring, communication, mentoring/work). Overall, the nursing students rated the mentorship experience as positive.

Implications

Mentoring builds an ongoing culture of knowledge sharing and increases the opportunities to improve good communication, problem solving, and enhance clinical leadership skills that promote inclusive behaviors and advance the professional image of nurses. The skills lab can offer a supportive environment for learning yet to optimize the mentorship relationship student feedback must be incorporated and used to organize and improve upon original processes. Mentorship activities inside and outside of the clinical lab can be offered to all nursing students as a oneto-one mentorship relationship supports retention and satisfaction in nursing programs. The methodology of this SoTL study did not include directly observed mentorship activities by the researchers that may have offered additional insight on facilitators and barriers not considered by junior or senior students. Further, mentors did not utilize evaluation tool to provide feedback to the mentees on their clinical performance yet both did complete reflections on their mentorship activities and progression. Mentorship activities allow for nursing students to utilize an intuition in relates to each stage of expertise. By trusting one’s intuition in his or her daily practice, expert status can be realized. It is crucial to foster the conditions that support professional development and empowered leadership.

Conclusions and Recommendations

This SoTL study illuminated the importance of the mentorship relationship, mentorship programs, and mentoring activities. Nurse faculty who champion mentoring programs do realize the freedom and innovation that exists in its development and overlapping avenues to expand and improve its implementation. Supported by nurse colleagues, professional standards, and university strategic goals, faculty can provide mentoring activities where strong problem-solving skills morph into a culture of networking, professional development, and collegial opportunities [18].

Based on this preliminary SoTL study, one recommendation is to continue mentoring activities and expand the mentoring program to include freshman and sophomore nursing students. Nursing faculty can pair courses and students at different levels, develop mentoring activities, and capture the value added from the mentoring experiences of students by post hoc surveys and reflection papers. However, context (Setting) and culture (shared language, values, norms), impact the mentoring experience and it is important to appreciate and inform mentoring programs, activities, and training accordingly. Moreover, without effective and efficient lab scheduling and skills training, mentoring activities are compromised.

A second recommendation is for nursing faculty to normalize mentoring activities. Standard mentorship activities with mentor training and varying levels of mentor-mentee experiences should be an essential component in nursing programs. Student mentors should meet as a group, learn from each other, and feel involved and fully engaged, as this is the collaborative environment representative of the nursing profession. Yet, it is recommended to avoid a prescriptive, unilateral approach to mentoring programs as there are several strategies (Peer, study partners, faculty mentor, groups, informal, formal) from which to choose [11].

Finally, all health professions schools should incorporate collaborative mentoring activities into curricula and clinical experiences. This SoTL study deserves replication in other settings, including clinical settings in hospitals or outpatient clinics. The results of this SoTL study should create an impetus for other comprehensive mentoring programs, activities, and training.

Acknowledged Contributor

Sarah Koch

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