Background

Satisfied Registered Nurses (RNs) who enjoy bedside nursing are in increasing demand in nursing today. However, nursing has chronic problems of RN dissatisfaction and poor job retention. Since the publication of “Reality Shock: Why Nurses Leave Nursing” in 1974 by Marlene Kramer, nursing research and organizations have worked to improve the desire of RNs to remain at the bedside [3-11]. Strategies have included laws to limit patient load [3,6] recognition programs, an educational focus on decreasing stress, and increasing shift hours to provide additional days off per week for RNs. Magnet hospitals, introduced in 1983 by the American Academy of Nursing, improved statistics in attracting, and retaining nurses because of their emphasis on the importance of team orientation, open communication, strong leadership, and collaborative problem solving. Research identified these “Hospital climate” attributes as “Nursing Professional Practice Environments” and determined they were fundamental to the work environments of satisfied nurses [12]. While statistics have improved with Magnet programs [13-15], current retention levels nationally are still low especially for new RNs in their first two years. In 2019, 47.5 percent of new RNs left their job within two years [16].

Parker, et al. [17] summarizes factors influencing the graduates’ transition into their first job. These include the nature of the workplace environment, the level and nature of the support available, the amount of prior experience, the ability to learn and adapt to the workplace cultures and to accommodate their own expectations to the expectations of others. Graduates feel unprepared for the acuity of illness of the hospitalized patient [8,18-20] and alone without the support of experienced colleagues. These factors are supported throughout the literature as relevant to the experience of the new graduate [8-10,15,21,22]. Improving the transition of graduate nurses into nursing is especially important as research has demonstrated that the first two years of a nurses’ experience significantly influences their career choices [17]. The transition period, defined as the first 12-24 months, is considered the most vulnerable time during which new graduates formulate decisions about their intent to commit to the profession and/ or their organization [17]. These problems occur worldwide for nurses. International studies of nursing report similar statistics of poor RN retention and nurse dissatisfaction. High patient to nurse ratios, minimal bureaucratic response to nursing concerns, and poor support from nursing peers are specific factors resulting in dissatisfaction [15,17,22-25].

Goal of This Paper

This paper describes the implementation of a mentoring model, A Model of Caring Mentorship in Nursing (CMN) [1,2], felt by the authors of this paper to offer hope that new graduates would succeed in their first jobs feeling satisfied with their experience and accepted and supported by their RN colleagues. Satisfaction, acceptance, and support are recognized as key to job retention.

This paper has four aims:

• To describe the uniqueness of the CMN in structure and content that creates the climate and RN relationships that research has found primary to job satisfaction

• To describe the process used by the Nurse Mentoring Connection (NMC), a mentoring program helping graduates transition into nursing, to integrate features of the CMN

• To discuss the program evaluation of six nursing students who were mentees in the NMC for nine months

• To discuss features of the implementation that hold promise for mentoring success with future cohort groups

Mentoring and Preceptoring as Strategies to Increase RN Satisfaction

Mentoring and preceptoring programs have a history of mixed success improving job satisfaction and retention with experienced nurses and creating incentives for new graduates. Both strategies have helped [26-30] but failures in the operationalization of many programs have compromised their potential to improve statistics [2,9,15,17,27,31]. Mentoring programs increased significantly following the publication of Kramer’s book on reality shock [32]. Mentoring provides a context for nurse satisfaction as it focuses on the development of relationship and growth of the graduate. It promotes nurse socialization and transcends generational issues [9,15]. In a 3-year study by Latham [33] of the effect of mentoring on experienced nurses in hospital settings, mentoring improved teamwork, increased collegial support, and improved nurses’ ability to deal with conflict. Together these changes created a more positive workforce environment.

Preceptor programs replaced mentoring programs in the 1990s as an increase in patient acuity resulted in longer orientation programs for new graduates [34]. Preceptor programs matched graduates with experienced hospital RNs to decrease the graduates’ fear of being alone caring for acutely ill patients and to help graduates create relationships with experienced nurses. Unfortunately, these programs only partially resulted in increased nurse satisfaction and retention. Preceptor goals differed from mentoring. The preceptor’s focus is to make new graduates safe for independent nursing at their facility. Teaching assessment and technical skills replaced the development of emotional skills and collegial relationships as the primary goal [15,30]. Inconsistent scheduling of preceptor pairs, poorly functioning preceptors, and the failure of preceptoring to integrate graduates into the milieu were concerns expressed about preceptor programs [28]. In a review by Pasila [35] of qualitative studies assessing graduate’s first 3 years in nursing, the researcher documented the extremes in experience: “At best, preceptors created nurturing and supportive learning environments” (While) at their worst, negative experiences … resulted in nurses leaving the field” (p. 25). Experienced nurses complained of fatigue and stress given frequent requirements to precept especially when there was no reward for their effort. They felt burdened managing their assignment along with the responsibility for a graduate nurse [36].

The Caring Nursing Mentoring Model Is a Lived Experience of Nurse Satisfaction

Studies of nurse satisfaction have identified that caring relationships among nurses, positive work climates, and high intrinsic professional work values result in satisfied nurses and higher levels of job retention [8,9,15,21,22,29,37-39]. A Model of Caring Mentoring for Nursing (CMN) is a lived experience of caring values that are the foundation for nurse satisfaction. The model, itself a response to the Wagner’s initial failure coordinating a mentoring program [2], yielded positive results for graduate satisfaction and mentor sustainability. The model’s philosophy and foundational beliefs provided the missing pieces essential to understanding past mentoring failures: that mentoring itself needed to occur in an environment that was caring and nurse-focused. It needed to create bonds between mentors and mentees plus mentors with each other and mentees with each other [31]. It needed to promote high standards of care for patients and it needed to teach advocacy to mentors and mentees [9,12,30,31,40].

In this model, mentorship is defined as a relational development: “…Mentorship is a relational humanistic model that enriches clinical practice with a deeper holistic focus on nurturing the whole person” [2]. Relationship development is the core requirement for mentoring to be meaningful. “If the mentoring stays at the task-oriented level for either one, there will be little to build connection … mentor and mentee may walk through the motions of meeting and setting goals but with no open attempt to get to know each other…several failures in mentor-mentee relationships were due to non-commitment to the program, role overload, unrealistic expectations of mentoring, and non-valuing the opportunity, all of which resulted in failure to build relationship [2].”

Wagner, et al. [2] created “Transformative Communication” as a style of relating that focuses the mentor and mentee on each other rather than having mentors teach, advice, or problem-solve as their primary form of relating. Transformative communication incorporates reflection and requires participants to have access to feelings. Mentoring activities emphasize fun and interactive ways for mentors and mentees to learn about each other such as having a party or combining a group meeting with Sunday coffee, food and photos. In learning transformative communication, the mentor and mentee deepen their ability to relate so that the situation of “Being together…allows a more natural emergence of trust, respect, meaningful relationship, and problem sharing (p. 208)”. Transformative communication is learned over time and best through experience. The relationship itself sustains the mentoring connection resulting in desires for more experiences together rather than less. It is the bonds among members that contribute to the sustainability of the mentoring program. As stated by Ambrose [41], “True mentoring is aimed at the mentee’s development – not on solving specific problems”.

The final element for nurse satisfaction is high standards of nursing care and managerial responsiveness so nurses feel proud of the care given and are fulfilled in their reasons for becoming a nurse [21]. Satisfied nurses describe nursing units where managers listen to them and support staffing that provides time for nurses to help each other [22,42-44]. In the mentoring program, mentors modelled patient advocacy and compassionate care. Mentees learned caring behaviors [45], felt confident in the advocacy they were learning and proud of the help they received. (Table 1) pairs the job climate characteristics cited by satisfied nurses with the milieu created within the CMN program.

Development of the Nurse Mentoring Connection (NMC)

The goals of this pilot program were to test the CMN model by creating a new mentoring program that integrated the principles and techniques of the CMN. Six nursing students asked to participate in the program and at the completion of the program shared their thoughts regarding the program and their perception of the program’s effects on them as they transitioned into their first RN job. In April of 2013, the Nurse Mentoring Connection (NMC) was developed to transition graduate nurses into their first job using the foundational beliefs and implementation tools of the CMN. Implementation was done by the founding mentors of the NMC in four phases over three years. As a group, the mentors planned ways to create a climate similar to the climate conducive to satisfaction in nurses.

Phase 1 (April 2013 to October 2014): Ten founding mentors met every 2-3 months for eighteen months to develop the values that grounded the program, that is, the mission, vision, and objectives of the NMC. The goal for phase 1 was to build a team of mentors using the values and transformative communication style of the CMN. The program chair used group techniques to ensure that everyone would contribute to the final product. The critical accomplishment of these meetings was bonding of the mentors with each other and the creation of a collective passion for mentoring and the NMC. Meetings were used for teaching transformative communication, discussing mentor character traits and skills, developing leadership skills in mentors, and creating a curriculum for mentor development. The curriculum included simulation vignettes of transformative communication and films to illustrate empathy, listening skills and group mentoring. The mission and vision of the program reflect the desire for mentors and mentees of different generations and ethnic groups to bond. “The mission of the NMC was to enhance the successful transition of new nurses into their professional career. Two aims facilitate this process: the creation of a supportive network and the development of leaders and mentors through mutual learning”. The vision recognizes the diversity within nursing and asks all nurses to work together: “The vision of the NMC is a community of nurses empowering one another to achieve their potential and fulfill their passion”.

Phase 2 (January to June 2015): The mentors knew they needed a mentoring process that encouraged socialization along with didactic information. They needed a climate where mentees could relax and feel safe rather than feeling shy and overwhelmed by experienced mentors. They started the program using group mentoring. Six nursing students, entering in their final semester of the baccalaureate program, volunteered to be in the NMC. The students and mentors were divided into two groups: 3 mentees and 5 mentors for each group. Meetings were monthly for 2 hours/ meeting and usually held in the home of a mentor. There was an unstated expectation that all would attend each group. The meeting date/time for the next month’s meeting was decided at the end of each meeting. The mentors had learned transformative communication during their initial two years together. The mentees learned it in responding to the mentors and through the group discussions. In group mentoring, mentors and mentees were peers. The mentees set the agenda through questions regarding situations experienced during the month. Mentors shared facilitation of the group and used silence when needed to motivate mentees to provide the topics for discussion especially at the beginning of the meeting. The designation of groups as families created a milieu that was respectful, nurturing, and comforting. This atmosphere enabled mentors and mentees to get to know each other over time.

The groups were a hit. Surrounded by at least two peers and with mentors careful not to monopolize the conversation, mentees became increasingly open, attended regularly, called their groups their families and loved learning in the homes of the mentors. Mentors and mentees grew closer as the months progressed. Confidentiality, respect, active support, honest feedback to mentees’ questions and practice techniques such as scenarios helped mentors and mentees grow. Positive feedback from mentees and mentors supported the feeling that everyone was learning and enjoying themselves. One mentee stated, “(The) program helped to normalize my fears and anxieties. It provided wonderful conversations and words of wisdom from RNs at all levels”.

Phase 3 (June to October 2015): The mentees graduated in May 2015. Their focus moved to passing NCLEX and finding a job. The family meetings ceased and the mentors presented a series of enrichment programs focused on communication and relationship development for mentees in their first job: (1) working with MDs; (2) working with experienced nurses; and (3) working with patients & families defined as difficult. Upon being hired for an RN job, the mentees were invited to select a mentor for their first year of employment. Five selected mentors. The sixth mentee felt well supported by her job peers and decided to wait on selecting a mentor. Of the five mentees, three received individual mentoring for 6 to 12 months. The other two mentees had obtained jobs outside California. They found it difficult to sustain the mentoring relationships using Skype.

Description of The Participants

The six participants joined the program in October of 2014. They had heard of the program from a brief presentation done by the primary author at a meeting of a student nursing organization. They were all entering the final semester of their baccalaureatenursing program at a large west-coast university. The students were female and in their 20s. Ethnographic backgrounds included Caucasian, Middle Eastern, and Mexican. Three participants were interested in pursuing pediatrics and three adult nursing.

Participant Involvement in The NMC Program

The students attended a formal “Orientation of Mentees” event put on by the mentors soon after they joined the program. They submitted questionnaires sent to them by the mentoring program asking them to self-assess their level of readiness for their first job and their expectations for joining the NMC. Mentoring was started the following January. Students attended the monthly meetings and built relationships with their peers and mentors. They appreciated hearing the stories of their peers as much as the sharing from mentors. Once the students graduated and passed the California Registered Nurse Licensing Examination (NCLEX), there were multiple demands for their time and the graduates experienced the pressure of job application, interviews, and orientations.

In the meantime, the mentors continued attending educational programs and program development as they evolved into a supportive, enthusiastic group for each other. This development was critical for sustaining mentors in the coming busy months of individual mentoring and attending a monthly processing group to help them work with the challenges of individual mentoring. At the completion of the nine months of mentoring (6 group mentoring meetings and 3 months of enrichment lectures), the mentees were asked to help evaluate the program. Questions started with a self-assessment of their readiness for their first job in areas of confidence, technical skills, personal strengths, and areas of weakness. Mentees were asked to rate and explain their overall experience with the program, to recount what they felt they had gained from the mentoring, what they had enjoyed most and least about the program and what was most meaningful to them regarding the program.

Results

Given the small sample of six mentees, the researchers expected random answers with minimal repetition in the responses. However, unsolicited there was significant consistency in the answers of the mentees to the broad general questions resulting in identification by each participant of the following three themes:

Theme 1. The mentoring program normalized my fear and anxieties about starting my first job.

“It allows me different views & perspectives which is nice because sometimes my views can be self-destructive” Mentee 6

“The program helped to normalize my fears & anxieties. It provided wonderful conversations & words of wisdom from RNs at all levels.” Mentee 5

“The mentoring program has helped me keep things in perspective, that I am currently a brand new RN and that I need to be more flexible/easier on myself.” Mentee 2

Theme 2. The mentoring program gave me a feeling of being supported versus being alone.

“Mentoring meetings feed my soul & my mind … They also provide emotional support during those trying times. Hence why I cry in nearly every meeting.” Mentee 6

“I think the family meetings helped me realize that I wasn’t alone in what I was feeling …” Mentee 3

“The mentoring program validated & supported my feelings. It made me feel like I was not alone in my struggles & successes of being a new nurse.” Mentee 1

It gave me support …mentors actually understood what I was going through … I have a sense of belonging…” Mentee 4

Theme 3. It (the program) resulted in the creation of deep relationships.

“What I enjoyed most about mentoring was the deep relationships with different mentors & mentees.” Mentee 1

“I love meeting up with everyone & bringing up great topics of discussion, & being able to hear everyone’s point of view. (I loved) connecting with everyone in the group” Mentee 2

“Most meaningful was members being very understanding. Also, very welcoming. It is very beautiful when we all share our stories.” Mentee 4

Six months following the evaluation, individual interviews were done with five out of six mentees to see whether there was individual agreement with the summary statement of each theme. All five mentees agreed that the three themes resonated with them. The sixth mentee was unable to meet given illness in the family.

Discussion

The purpose of this study was to implement a mentoring program based on Wagner’s “A Caring Nursing Mentoring Model”. The goal was to contribute to the satisfaction of graduate nurses in their first RN job hoping that this would improve retention of graduate nurses in bedside nursing. Our experience with the mentees suggested a series of steps: The importance of the mentoring program is in effecting the experience of new graduates so that the relationships they develop with experienced nurses are satisfying and helpful. Preparing mentees to work comfortably with experienced nurses and to seek their help as often as needed is part of that process. The group mentoring meetings seemed to promote comfort with experienced RNs as mentees witnessed RNs with different levels of experience discuss their concerns and heard their suggestions for working with their peers. Workshop exercises and scenarios where mentees role-play the struggles they are experiencing in preceptorships helped mentees gain competency in relating to experienced staff. By the end of graduate’s first year in their job, the graduates need to be gaining in self-competency within an environment that is comforting and contributes to their confidence as a nurse.

The study objectives for the graduates were for them to enter their first jobs feeling connected with their RN mentors, feeling more secure versus frightened and reassured that they would have the mentoring help needed to succeed in their first job. Each mentee had worked on communication skills that fostered positive relationships and a beginning capacity to advocate for themselves when needed. An interesting finding was that each of the mentees was less reassured about her general knowledge and skills as a nurse at the end of the program when compared with her self-assessment at orientation. Research regarding graduate self-assessment when compared with school faculty assessment and employer assessment would say this latter assessment by the graduates was more realistic of themselves [15,18,19,20,30]. Two unexpected positive findings regarding the structure of the program was the value of group mentoring and our decision to begin mentoring during the students’ final semester. For all mentees, the time spent developing deep relationships with peers and mentors, processing fears and anxieties, learning communication skills and listening to how experienced RNs problem-solve added to their confidence and, for some, provided a sense of empowerment. The three mentees that said the experiences added to confidence but not necessarily empowerment already were exceptionally secure with themselves and were forthright in obtaining learning experiences. The three that felt the 6 months had empowered them were much shyer students who needed encouragement.

Beginning the mentoring during the students’ final semester was helpful as the anxiety of preceptorship was similar to the anxiety experienced when graduates began their first job. In both experiences, graduates must figure out how best to work with experienced RNs, manage the demands of multiple tasks and increases in workload, and how to function as a team member as a nurse in charge of patients. Mentees brought these issues into the group mentoring meetings. They worked to develop these skills before starting their first job. The mentoring leadership felt they had successfully implemented the foundational themes of the model. Mentees described these themes as they talked about what the program had given to them. Implementation felt surprisingly easy despite there being a significant amount of work. In implementing the program, the leadership (NMC Board) created the climate of the model through kinship, modeling high standards for success, being passionate about the success of mentors and mentees and in using transformative communication. Kinship between the mentors was felt by the mentees and encouraged a climate of learning, courage, and growth for both mentors and mentees.

Limitations

The small N of this mentee group allows a thoughtful reflection regarding the impact of this mentoring program. The themes were the same for each mentee providing additional weight to the findings. The next step is to repeat this study with a much larger group of mentees.

Recommendations for Further Research

The feelings of support and development of strong RNto-RN relationships indicated by the themes are consistent with components nurses personally identify as being instrumental to their concept of high job satisfaction [9,17]. In addition to research with larger study groups, research also needs to include comparison studies of graduates transitioning into first jobs with and without the 6 months of mentoring while still a student. It is plausible to assume that starting first jobs with the boost in confidence, bonds with peers and RN mentors and with less fear given experiences that normalized fear would significantly contribute to competency and feeling accepted by job colleagues versus feeling scared, alone and, at times, tolerated rather than desired.

The Failure of RNs to Bond with Each Other

The failure of nurses to bond with each other is frequently cited as a primary issue in studies where RN retention is poor. In studies of nurses happy in their jobs, bonding correlates with satisfaction and is cited by nurses as a factor central to their job retention.

Research has documented that nurses’ relationships with each other are central to their job satisfaction but there is less research focused on why nurses are unhappy with each other. Why do nurses bully each other, “Eat their young” and refuse to help one another? The failure to bond is complex and may have more to do with the context, empowerment, and distressing job issues shared by nurses more than the “likeability” nurses have with each other. In an analysis of the decline of a mentoring program [31], failed relationships between experienced nurses and their student nurse mentees was the central finding. The program ran seven years (1997 to 2004) starting with 120 nursing students and 60 experienced nurses. It was one-third the original size when it ended. Communication with mentors and mentees revealed that the pairs often had difficulty genuinely connecting with each other. Cancellation of an appointment was interpreted as “she doesn’t really like me” or “I don’t think I am really helping her” instead of simply a missed appointment. Experienced nurses drove long distances to attend mentoring meetings with their mentees demonstrating that they do care about their new colleagues but a majority of pairs failed to bond. This is reminiscent of Wagner, et al. [2] finding that mentor-mentee relationships that never progress beyond the task-oriented level fail as they are unable to meet the needs of one or both participants. Is it possible that the context including the workload and fast pace of bedside nursing interferes with the ability of nurses in hospitals to connect with each other in a manner satisfying to both?

The statistics on retention issues for hospitals published in the 2020 NSI National Health Care Retention & RN Staffing Report [16] suggest that a connection exists between the failed relationships of new RNs and the hospital environment. The report states, “In 2019, turnover of RNs in the average hospital was 15.9%”. Adding the percentages of average RN turnover from 2015 through 2019, the average hospital would turn over 82% of their RN workforce (p. 6). What is equally concerning is that similar statistics exist for all hospital employees: “Consistent with previous surveys, first year turnover continues to outpace all other tenure categories. When looking at the range of those employees who terminated with ‘less than one year of service’, this group can make up 58.9% of a hospital’s total turnover. When expanding this to include all employees with less than two years of service, the range jumped to 91.5% (p. 10)”. The statistics suggest that something is missing from hospital environments that is serious enough that people leave within their first two years. Perhaps RN retention is related more to hospital issues than to strictly RN issues.

The NSI report concludes that improving these statistics will require improving relationships: “The value hospitals place on their people will have a direct correlation to their commitment, confidence, and engagement. Enhancing culture and building programs to reinforce theses values is critical to driving retention. Hospitals believe that retention is a ‘key strategic imperative’, yet are slow to translate this into a formal strategic plan. (They recommend a) focus on strategies that enhance culture and eliminate those that do not (p. 13).” “A Model of Caring Mentorship for Nursing” focuses on creating an environment and process that develops and sustains relationship. Cultural considerations are critical as caring doesn’t exist in an atmosphere of intolerance. Judgments erode when people come to know each other. Hurt feelings give way to pleasure and teamwork replaces the solitude of nurses not engaged with each other. Respect and caring make people interested in seeing each other. This model could be a plan for improving relationships for all hospital employees.

Implications for Nursing Focusing On Issues of International Relevance

This study supports the idea that graduate nurses involved with experienced nurses in an environment of support results in positive relationships and vulnerability where issues affecting good patient care are discussed and mentees gain courage and competency in relating to experienced nurses. The implementation strategies utilized in this study and the success of the program in meeting important needs of the mentees could be utilized by international nursing organizations. They are strategies of communication, management that values the ideas of its RNs and effective leadership by nurses who have high patient care standards and caring values for patients and all staff.

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