NURSING retention requires a multifaceted approach and continuous efforts to keep nurses at the bedside. In a community hospital, the turnover rate of registered nurses (RNs) working in medical-surgical (M/S) units has risen to 40%, which is 23% higher than the overall M/S unit national average.1 During the COVID-19 pandemic, many efforts to retain nurses diminished as leaders focused on responding to immediate organizational needs. Early reports of health care staff stressors associated with the COVID-19 pandemic such as feelings of hopelessness and helplessness were concerning.2 Nursing leaders understand that new nurses face a stressful transition into practice and the pandemic response would more than likely compound their stressors. Before the pandemic, a continual need to hire nurses has caused an annual financial impact of approximately $2 million for agency staff and approximately $62 000 to hire each new nurse, depriving the organization of resources to focus on improving patient care.3
The past year RN turnover rate for the 8 M/S units was reviewed with the chief nursing officer (CNO) and the Director of Acute Care Services (Director). Promoting nurse retention is complex and includes (a) identifying job characteristics that match nurses' interests, (b) building relationships to foster a positive work environment, and (c) offering job security by upholding the organizational vision.4 After reviewing the literature for responses to improve retention, the CNO and the Director focused on a mentorship program for newly hired RNs. The mentoring program addressed relationship building. Mentorship builds a supportive relationship that is developed between experienced nurses and newer nurses to assist in acclimating to the work environment and establishing dependable resources.5 New nurses frequently encounter a steep learning curve that may cause them to feel anxious and unprepared for the demands of the profession. The absence of a supportive relationship built through mentoring can lead to professional complications, such as poor clinical skills and a lack of effective communication skills.5 A mentorship program should focus on socializing new nurses into the work environment and developing relationships with the health care team.
The nursing administration determined that a mentorship program would be implemented to address the needs of newly hired RNs. Although the evaluation was underway in the weeks before the pandemic, the presence of the added stressor of the pandemic further supported the urgency of the need. A site coordinator (SC) was appointed, and the program was developed using a quality improvement (QI) model. The purpose of this project was to implement an evidence-based mentorship program over 12 weeks for RNs with less than 1 year of experience who are hired into an M/S unit with a long-term goal to reduce turnover rates.
A rapid review of 79 studies of health care workers in pandemic settings identified organizational support and perceived adequacy of training as important factors for reducing psychological distress.6 The vulnerability of a new graduate nurse during a pandemic situation creates unique needs. Factors that escalate turnover include the poor foundation for quality of care, lack of resources, little knowledge of hospital affairs, and workplace violence.7,8 When nurses are prepared emotionally and mentally to cope with the pressure of nursing, they will want to remain in their position, improving nurse retention.9–11 Mentoring is an intervention to promote the growth and socialization of new RNs to an organization.12,13 Edwards et al14 reported that new nurses who are mentored have an increase in confidence and clinical competence and stress levels are reduced when the new nurses met regularly with their mentor. A mentorship program should focus on promoting positive relationships, building a sound foundation for quality of care, and establishing a reliable resource for new nurses.15 An approach to implementing a mentoring program can be a formal process by having a mentee assigned to a mentor so that the mentee is aligned with the processes, procedures, and culture of the organization.15 Mentoring has a great influence on the production of high-quality nurses, allowing the mentors to elevate the nursing profession by preparing the younger generation to be clinically and emotionally competent.5,16,17 An effective mentorship program can impact the new nurses' intent to stay and job satisfaction in their current position.18,19 In summary, the best strategies for reducing nurse turnover are eliminating negative work environment factors, promoting positive relationships, and building resiliency.7,8,15
QI is using a designed set of steps or processes to apply evidence into practice.20 The QI model that was used to guide the project is Plan-Do-Check-Act. The model that was used to plan and implement the project was the Johns Hopkins Nursing Center for Evidence-Based Practice (JHNEBP) model.21 Principles from Jean Watson's theory of human caring guided this project. This theory is focused on interpersonal relationships and emphasizes the existence of individuals as free agents, determining their development through their own will.22 Watson's theory of human caring stresses self-care as a foundational component in sustaining the ability to effectively provide care.23 The principles from the theory guided the project by allowing mentors to develop supportive relationships and teach new nurses that self-care is crucial to surviving in the health care profession.24
The QI project occurred in a 300-bed, not-for-profit, community hospital located in the Midwestern United States. The project focused on 8 M/S units. Newly hired staff nurses are traditionally for 2-week classroom orientation, 2-week hospital department rotation as a part of the nurse residency program, followed by an 8- to 12-week unit orientation. The project was reviewed by a university institutional review board and the facility institutional review board. The project was reviewed and approved as an exempt QI project. An information sheet explaining the purpose of the project was provided to mentees and mentors. Signed consent was not required.
The Academy of Medical-Surgical Nurses (AMSN) published a mentoring program in 2012 for nursing staff working in the M/S specialty.25 This program offers guides for the SC, mentors, and mentees.25 The guides include tools to assist with mentor-mentee meeting planning, assessing the relationship, and impacting the menteesʼ intent to stay in the position. An SC was assigned to implement the AMSN program. The responsibilities of the SC, mentors, and mentees were reviewed with the Director. The program was implemented in May 2020 with group 1 mentor-mentee pairs. On the basis of the prior yearʼs number of new hires in May, June, and July, 15 mentors would be needed. The managers of the M/S units and the Nurse Residency Program coordinator met with the SC and identified 20 RNs who were hired within the last 1 to 2 years. Mentors with 1 to 2 years' experience were selected since they could relate to the current health care state as the organization has had a change in CNO and moved into a new facility in the past 5 years. Mentors must have been RNs functioning at or above expectation on their annual evaluation and in no disciplinary action. The SC contacted the 20 selected nurses, explaining the program and expectations electronically and in person. Of the 20 nurses, 15 agreed to become mentors as new nurses were hired into their units. Once identified, the SC met with each mentor individually to review the mentor and mentee guide, discuss expectations of being a mentor, when to contact the SC if issues arise, completion of the background information sheet, and allow opportunity for questions. After new hires were confirmed, the SC then contacted the mentors with the names and start date of their mentee.
Mentors were not offered any additional compensation for agreeing to become a mentor. The CNO approved that the mentors could use this as an example of “exceeds” job expectations on their annual evaluation or they could use mentoring to meet one criterion of the clinical advancement program (CAP). Both could increase hourly compensation if all requirements were met for the CAP and the mentors met other job expectations.
The SC met with the new hires during their first week of hospital orientation and provided a mentee guide to each new RN. The mentoring program was explained, and the name of their mentor was given along with the mentor background information sheet. Once the new RNs reached the nursing unit, the mentors met with them at minimum biweekly and when possible weekly. All mentees were also paired with a preceptor for their unit orientation period. After the mentees began orientation on the units, the SC rounded to speak with the mentor-mentee pairs on week 1, week 3, week 6, and week 9. In group 1, 5 RNs were hired into the M/S units who all had less than 1 year of acute care experience, with 4 being new graduates. Within the first weeks of the orientation period, 2 mentees left the program before working with their mentor.
Four measures were used to evaluate the effectiveness of the program: (a) the Intent-to-Stay survey, (b) the Job Satisfaction Scale, (c) the Mentor Program Satisfaction survey, and (d) the Mentee Program Satisfaction survey. The Intent-to-Stay survey has 15 questions measured on a 7-point Likert scale (1, strongly disagree, to 7, strongly agree). Grindel and Hagerstrom26 report the development of the Intent-to-Stay survey was part 3 of Hackman and Oldham's Job Diagnostic Survey, which measures employees' personal feelings, and the Cronbach α for this study was 0.68. The Job Satisfaction scale has 26 items measuring the degree of satisfaction on a 5-point Likert scale that includes categories related to Maslow's hierarchy of needs and Hertzberg's modification of needs, and the previously reported Cronbach α was 0.87.26
The Mentor Program Satisfaction survey has 9 questions measuring the degree of satisfaction on a 5-point Likert scale of (1, little, to 5, much) satisfaction regarding working with the mentee, professional development, and communication.26 The Cronbach α was reported as 0.95.26 The Mentee Program Satisfaction survey has 12 questions measuring the degree of satisfaction on a Likert scale of (1, little, to 5, much) satisfaction regarding professional and personal development, communication with others on the health care team, and working with the mentor. The previously reported Cronbach α for this study was 0.96.26 Data analysis included comparing results of the Mentor Program Satisfaction with the Mentee Program Satisfaction and the Intent-to-Stay survey and Job Satisfaction scale. The AMSN allows users to utilize and customize all information and tools as appropriate for their organization.25
A total of 3 mentees were enrolled in group 1. Group 2 has a total of 4 pairs of mentor-mentees, followed by group 3 with 5 pairs. Data for group 2 and group 3 are in progress. Three mentors completed the satisfaction survey with a mean of 33 (range, 25-40) (SD = 7.55). Three mentees completed the program satisfaction survey with a mean of 49 (range, 36-58) (SD = 11.53). Three mentees completed the Intent-to-Stay survey with a mean of 67.33 (range, 66-68) (SD = 1.15). Three mentees completed the Job Satisfaction scale with a mean of 88.33 (range, 84-94) (SD = 5.13); reversed scoring was used on questions 13 and 14.
In a community hospital, nurse retention was a challenge, which was further exacerbated by the presence of the global pandemic. The hiring and retention of new graduate nurses were identified as a priority need by the organization. According to the local Board of Nursing, there were 4000 to 5000 students who would complete their nursing education during the pandemic and due to testing sites being closed, these graduates would not be able to enter the workforce. Therefore, the Board of Nursing temporarily suspended the rule of requiring licensure by passing the National Council of State Boards of Nursing's licensure examination for RNs. New graduates were granted a license for a defined period provided that a background check and evidence of nursing education program completion was submitted.27 In May 2020, the organization was able to hire 3 RNs into the M/S units under this rule. These 3 nurses entered the health care organization during a pandemic response with a nontraditional completion of their nursing program; developing a connection with these mentees was vital to socialize them into the work environment and to impact the mentees' intent to stay and job satisfaction.28
At 3 months, mentees' mean program satisfaction scores (M = 49, SD = 11.53) are trending slightly higher than the previously reported means for the same period (M = 36.5, SD = 12.8).26 Intent to stay is slightly lower (M = 67.33, SD = 1.15) than the previously reported data (M = 72.7, SD = 7.3), while the current mentees' job satisfaction was trending higher (M = 88.33, SD = 5.13) than the previously report results (M = 75.4, SD = 11.3). The initial trends are encouraging when considering the influence of the pandemic on frontline nurses and the work setting.
When the project was being planned, the facility had 8 functioning M/S units. As a result of the pandemic, the inpatient census dropped dramatically and 3 of the units were closed. The staff was temporarily reassigned to other units. After 10 weeks, 2 of the units had reopened. One of the units would not reopen as an M/S unit. All staff members from the permanently closed unit were reassigned to another unit. However, 1 original mentor-mentee pair did not get reassigned to the same unit, resulting in reassigning one of the new RNs with a new mentor.
Early research has identified that the risk of posttraumatic stress disorder for frontline nurses caring for COVID-19 patients increases from 6% before the pandemic to 62% after caring for patients during the pandemic.29 The need to better understand how to prevent long-term risk for frontline nurses is evolving. Coupling newly hired nurses with a mentor is a first step toward developing a support system.
The sustainability plan for the mentorship program entailed each M/S manager assuming the responsibilities of the SC for his or her respective unit. Mentoring is designed to foster relationship building by providing a supportive and nurturing work environment.30 The Director assumed the responsibility to hold each manager accountable to continue the program. The Director developed a plan to collect and evaluate the menteesʼ intent to stay, job satisfaction, and turnover data as defined in the program guide.
IMPLICATIONS FOR PRACTICE
The program guide instructs the SC to round on the mentor-mentee pair at week 3, week 6, and week 9. A concern identified when planning the program was that many of the mentees were hired into night shift but would orient to day shift for a few weeks, having time to meet with their mentors was a challenge. When the mentor-mentee pairs were established, matches were made on the basis of the unit and shift assignment. During rounding, the SC found that the mentees hired in group 1 who had mentors on night shift did not have much opportunity to meet with their mentor. The SC worked with the managers for group 2 and group 3 new RNs hired into night shift to ensure they were scheduled on days that the mentor was working nights. This allowed more opportunities to meet with their mentor.
Those implementing a mentoring program and following the AMSN program will have to allow time for frequent rounding and a flexible schedule, especially when mentor-mentee pairs work night shift. The SC found that making rounds on nights was most effective when completed at least 1 hour before the end of the shift so that the pairs had sufficient time to discuss the progress of their relationship building.
During program planning, the SC role will need to be established and determine whether this SC role will be for the long term or handed off to another role. In this implementation, the SC was established for the initial implementation and then handed off to each unit manager. To improve the sustainability plan, each unit manager could have been involved earlier in the implementation process to be better prepared to continue the program.
The mentoring program was marketed to each M/S unit manager and the potential mentors identified during planning. To increase the number of potential mentors selection and allow tenured nurses to engage in their professional development, the program could have been marketed to all M/S nurses, explaining the reason and why being a mentor is essential in acclimating new nurses to the organization during a pandemic.
Recognition of mentors was completed on an individual basis by the CNO, the Director, and the SC presenting each with a certificate of appreciation and lapel pin. As a result of the pandemic and maintaining safety, no group photographs or luncheon was able to be held. In the future, a more meaningful mentor-mentee recognition event could be held such as a breakfast or luncheon and take a group photograph for marketing purposes.
The limitations of this project included being implemented at one community hospital, only being implemented on the M/S units, and having a small number of participants. A larger-scale project using the same mentoring program guides could be implemented at a large health care organization in many types of nursing departments to determine the impact of new nurses' intent to stay and job satisfaction and ultimately determine how implementing a mentorship program impacts RN turnover.
The findings from the mentoring program surveys provide insight for nursing leaders to use an evidence-based mentoring program and implement a superior program in their organization. Retention of nurses in M/S units is a challenge that nursing leaders face nationwide.1 With nurse retention being such a complex concept following an evidence-based approach to address factors that affect nurse retention is critical to secure nurse staffing to provide high-quality care and meet the needs of the organization and community. Developing supportive relationships early in nurses' careers can affect their intent to stay and ultimately the RN turnover rate.
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