RN turnover has been an area of concern for many nurse leaders. In 2021, during the COVID-19 pandemic, the national average turnover rate for staff-level RNs was 27.1%, an 8.4% increase over 2020 rates.1 Mentoring staff has been demonstrated to increase staff satisfaction and reduce turnover.2 Engaging staff to actively work to improve the quality of care can be a challenge when resources are limited. Healthcare facilities need to not only empower staff to improve care quality and seek new knowledge but provide resources to help guide them through project completion.
Mentoring has long been a valued practice in industries outside of healthcare. The positive impacts range from reduced staff turnover, increased staff satisfaction, improved self-efficacy, and lower student attrition rates.2 Mentoring also promotes team building and staff bonding. Connections formed during nurse-to-nurse interactions can lead to compassion satisfaction among team members, which has been linked to improved staff and patient outcomes.3 Research indicates that health outcomes are negatively influenced when nurses report a lack of self-efficacy, such as feeling ill-prepared to advocate on behalf of their patients.3 The significance of work satisfaction was further solidified when the Institute for Healthcare Improvement (IHI) described a new Quadruple Aim, expanding on the original Triple Aim to include the importance of attaining joy at work, thereby increasing employee well-being.4,5
Knowing that mentoring can have a positive impact on staff and patient outcomes is mitigated by the fact that many health systems operate without extraneous staff or funding. Without funding, program implementation and sustainability can appear daunting or impossible.
One positive aspect of mentoring is a reduction in staff turnover. This can equate to significant cost savings over the course of 1 year. The 2022 National Health Care Retention & RN Staffing report estimates that for each percentage point reduction in RN turnover, a hospital could save an average of $262,300 every year. The report indicates that every nurse who separates from the organization costs the hospital $46,100.1
Understanding the impact of peer mentoring on nursing attrition became an important step for refining the existing clinical ladder program at one hospital system. Could the implementation of peer mentoring into the clinical ladder program impact nursing outcomes?
To examine previous research and demonstrated outcomes related to peer mentoring in nursing, the author completed a literature search of EBSCO, CINAHL, PubMed, and ProQuest using the search term nursing in combination with each of the following search terms: peer-to-peer mentoring, mentoring, advising, and coaching. The term mentoring was used interchangeably with coaching, precepting, and advising.
The search returned 3,181 publications with only 7 partially describing the mentoring relationship defined by the author. These 7 articles described interactions between students and teachers or staff and supervisors. This pointed to a paucity of evidence related to RN peer-to-peer mentoring programs. These relationships don't match the peer-to-peer mentoring relationships described in this article.
For this program's purpose, peer mentoring is defined as a relationship between two coworkers in either equal job roles or a working relationship without supervisory or reporting authority. This type of peer mentoring program addresses a gap in the current literature.
Developing the program
The Model for Improvement is a simple quality improvement (QI) methodology developed by the IHI to help accelerate project-based QI.4 The model is characterized by four simple steps: Plan, Do, Study, Act. The IHI provides additional tools and guidance to assist users.4 The program was developed, implemented, and analyzed using the tools and strategies recommended by the Model for Improvement.
The program's goal was to engage peer mentors to help empower direct care RNs to improve patient-care quality through the design and implementation of QI and research projects. The plan was to increase direct care nurses' confidence in their decision-making abilities, improve their job satisfaction, and empower them to seek opportunities for continued learning and development.6 The program's participants were all direct care nurses. The average number of participants each year was 100. Peer mentoring was an add-on element to the existing clinical ladder program.
Understanding the limitations of available resources was important when considering how to implement the proposed program. Two nurse scientists managed the program, overseeing more than 100 QI, research, or evidence-based practice projects proposed, initiated, and implemented by direct care nurses (night and day shift). Because of competing responsibilities, these nurse scientists could dedicate only a fraction of their time to the program's oversight (25% and 10%, respectively). As more nurses became involved in the program, it became increasingly difficult to provide the guidance and mentoring they needed. In addition, the nurses were located at five acute care hospital campuses within a 50-mile radius.
The mentoring program was initially developed out of sheer necessity because two nurses couldn't be everywhere at any hour of the day when a need or question arose. In an ideal world, bringing on additional resources wouldn't be an issue, but healthcare rarely functions in that ideal world. How could we continue to provide mentoring as the number of program participants grew? After brainstorming with many current program participants, the idea of campus peer mentors became the most interesting concept to explore.
The peer mentors would complement the existing oversight of the two nurse scientists and would be available to offer additional resources to the other program participants. Defining a peer mentor was an easy task; selecting the right fit proved to be a much harder process.
Using the Model for Improvement during the program planning helped move the plan development along.4 The Model for Improvement isn't intended to replace an organization's existing change models but to enhance the speed at which change can occur and improve the success rate of change initiatives. Focusing on the program's goal helped drive the development of the criteria for peer mentors.
Peer mentors were selected using a very basic criterion: they needed to be engaged and interested in helping their peers.
- Were they attending the monthly program update meetings?
- Were they engaged during those meetings?
- Were they already serving as informal leaders during those meetings or on their respective units?
- Were they knowledgeable about the subject matter? Did they have a spirit of inquiry?
- And most important, were they interested in helping?
Critically appraising these qualities was essential to the mentoring program's success. Although it sounds basic, observing these behaviors and using them as a guide when inviting mentors to participate proved valuable and effective.
After peer mentors were selected, they were matched to mentees currently participating in the organization's clinical ladder. Initially, nine peer mentors were selected and represented all five hospital campuses. An important factor in selection was consideration of the night shift. Having night-shift peer mentors allowed night-shift staff to seek guidance and clarification on their individual projects during their normal working and waking hours, instead of trying to make it to a meeting held at noon.
The number of mentees for each peer mentor ranged from 8 to 11. The expectation of the peer mentoring relationships was for the mentees to complete individual QI or research projects and for the peer mentors to serve as resources or guides as the mentees progressed through these projects.
All program participants were expected to attend a monthly project update meeting. During these meetings, mentors and mentees would discuss their current projects, including successes and barriers. They would often meet outside of these meetings to discuss the mentee's progression, although these meetings weren't mandatory. Peer mentors received additional training on the various QI tools that their mentees might need to use. This training was done in separate monthly meetings where attendance wasn't mandatory.
Peer mentor program rollout
After peer mentors were selected, the initial phase of the mentoring program was rolled out. It began with brainstorming the best ways to match peer mentors with mentees, which required trial and error. It's important to embrace the idea that not all matches will work. The nurse scientists were responsible for assigning the matches and were instrumental when observing for signs of unsuccessful matches. Initial matches focused on the following criteria: campus location, shift worked, and project topic/area of interest. Although this worked for most matches, it wasn't 100% successful. It was important for the nurse scientists to be mindful of how the relationships were progressing and to listen to what was being said at the monthly meetings, and for participants to communicate when matches weren't progressing well. A challenge was identified when matches didn't want to “get someone in trouble” or “make someone mad.” Just because the participants were saying everything was okay didn't necessarily mean that it was the best match. The nurse scientists spent time during meetings and other activities observing the interactions of the matched pairs.
- How were their relationships progressing?
- Did they greet one another at meetings?
- Did they sit next to each other?
- How were they interacting during meetings?
Negative answers to these questions were subtle indications that might signify a problem. There were several instances where matches needed to be reassigned. These changes were made without fanfare or judgment.
The nurse scientists continued to act as facilitators for all program participants (peer mentors and mentees). They attended every monthly meeting and helped guide the individual projects. Scheduled at the same time every month, the meetings were a dedicated time when the mentees could discuss the progression of their individual projects. Although peer mentoring could happen during those meetings, much of the peer mentoring took place outside of the monthly meetings at times more convenient to the mentor and mentee.
The initial outcomes identified for measurement included: engagement (the percentage of members who attended the monthly meetings) and growth (the percentage of peer mentors by the end of each calendar year). These outcomes were selected because they're easy to capture.
Staff engagement improved from 66% to nearly 100% attendance at nonmandatory meetings. Mentor growth increased from 9 to 11 mentors at the end of year 2. An unanticipated outcome was that the mentors and mentees could serve as resources during the Magnet® designation and redesignation site visits. The mentors and mentees could easily articulate how and where they exemplified the Magnet model, using their experiences within the program and their specific QI or research projects. They were encouraged to talk about their projects, the barriers, the successes, and how those projects impacted patient care and the Magnet model. The only coaching needed was to give them the reassurance that their stories were important and to ask them to share those experiences with the Magnet appraisers. It became evident that these nurses were doing more than participating in a QI or research project; they exemplified the Magnet model. At the conclusion of the Magnet appraisal, appraisers said that they felt this program was an exemplar that they'd be sharing with other organizations.
Additional outcomes were more anecdotal in nature, including the leadership role assumed by mentors and increased teamwork for all participants.
- Leadership: The mentors had become the lead at the monthly campus meetings, creating agendas, taking minutes, and reporting on findings of and barriers to QI and research projects.
- Teamwork: The mentees came to the monthly meetings prepared to share the status of their projects and discuss barriers. The entire group offered suggestions and guidance, often scheduling time to meet outside of the regular meetings to discuss further and offer additional assistance.
Although it's difficult to objectively measure these outcomes, they're important to note because they demonstrate how the group evolved and shared in the projects' successes and struggles. Staff members from different floors, shifts, and even campuses banded together to work on projects that would ultimately improve patient care. Understanding how their roles were instrumental to improving the quality of patient care, they could practice knowing that they made a difference in care outcomes.
The program continued to follow the Model for Improvement as it moved into the next phase. Using brainstorming techniques to identify what had worked and what didn't work, the nurse scientists assessed the existing program. This included feedback from peer mentors and mentees. Although anecdotal feedback is valuable to drive improvement, having objective data is another important element in program appraisal. Working with the human resources department, the nurse scientist obtained reports that included rates for turnover, longevity, certification, and bachelor's of science in nursing degree. Although these aren't perfect measures, they were what was available and could offer guidance as to how the program was progressing. Waiting for perfect measures and data can't advance a quest for improvement.
Based on feedback, monthly peer mentor meetings, facilitated by a nurse scientist, were initiated to give the peer mentors time to meet with one another and discuss areas where additional support was needed. This was a time they could interact with peer mentors from other campuses, get updates, and learn more about obstacles and successes. Sometimes it helped to hear that others were having similar struggles. A consistent frustration among the peer mentors was feeling as if they were chasing their mentees. Instead of a collaborative, give-and-take relationship, the mentors felt that they were more concerned than the mentee about the progress of the mentee's project. Once this feeling was stated openly, it began a snowball discussion among the group.
It was at this point that the mentors started to share feelings of frustration and to discuss how some relationships were or weren't progressing; they sought feedback from the group. They were learning that it was okay to have these feelings, admit when they didn't know how to handle a situation, and rely on one another for support. They were becoming comfortable sharing their vulnerability with their peers. Barriers and struggles became a dedicated line item on the monthly agenda.
The data analysis was completed using reports obtained from the human resources department. Researchers identified all nurses in the mentoring program and compared this group (approximately 100 participants year to year) with all other direct care nurses within the organization. These reports were run for each calendar year. At first glance, they didn't seem impressive. Rates for certification and longevity in the workplace were similar. What was interesting was the turnover rate. Direct care RNs not involved in the program had an average turnover rate of 7.9%, whereas RNs in the program had a turnover rate of 2.6%. These results were monitored over a 4-year period beginning in 2016 and concluding at the end of 2019 (see Figure 1). A breakdown of the turnover rate each year is shown in Figure 2.
Projected turnover cost savings were calculated by comparing the turnover percentage for nurses in the peer mentoring program with the turnover rate for the nurses not involved in the program. Both groups were classified with the same job code. Using the turnover calculator from Nobscot, cost savings for 2019 are estimated at $4.4 million dollars (see Table 1). This calculation was made using the conservative estimate of 21% of annual salary. With staff levels at 8,500 direct care RNs, a turnover rate of 7.9% means that 53 staff members are terminated each month. Conservatively estimating an annual RN salary of $65,000, the cost to hire a new RN would be $13,650.7Nobscot.com requires rounding. Table 1 reflects the use of rounding to obtain the estimate. The cost-savings calculation used a 3.9% reduction in turnover to obtain a 4.0% turnover rate. This figure is higher than the current program RN turnover; it's being used as a conservative estimate.
Table 1: -
|Current annual turnover ratio:
|Improved turnover ratio:
|US voluntary turnover rate∗:
|Employee savings∗∗ =
|Your dollar savings =
∗US National Voluntary Turover Rate for last 12 months ending October 2015 as reported by the US Bureau of Labor Statistics.
∗∗Number of additional employees retained
Additional outcomes were observed when including promotion and publication rates and the percentage of program participants pursuing higher education: 20% of program participants received promotions, 10% initiated advanced schooling or higher education, and 30% had their individual project results published in nationally recognized journals or disseminated at national and regional conferences.
When implementing a peer mentoring program, it's important not to wait for perfect measures to evaluate its success. Identify what you can measure and start there. Seek better metrics as they become available. The following metrics might be helpful:
- Staff satisfaction data: Does your organization currently measure staff satisfaction? If so, obtain a copy of the questions and survey your program participants. How does their satisfaction compare to the organization as a whole?
- Turnover or attrition rates: This can be linked to cost savings. Many organizations have a value associated with the cost of turnover per staff member. Find out what that number is. You can reach out to your finance department to help guide you on turnover cost (by percentage point reduced or per RN).
- Degree completion rates: We found that several program participants had begun and finished school during their course of participation. Although we hadn't collected this information in the beginning, we added it as the program progressed.
- Staff engagement: Decide how you want to define engagement. One option is to compare how many program participants versus non-participants are in leadership roles. Leadership roles could include acting as a chairperson for a unit-based or organizational-level council or committee or serving on a professional board. You could also explore the promotion rate. Is the rate of promotions higher among nurses in your mentoring program than among those not participating in the program?
The success of this program relies on the engagement of the direct care nurses involved. Providing a forum to succeed required patience and time. The program and the availability of related data evolved over several years. At the end of the fourth year, data were no longer available because of a change in the human resources tracking systems following hospital mergers. The program was disbanded in March of its fifth year, which is the reason limited data are available for analysis. The merger of several hospitals required the many campuses to regroup and develop plans that would allow staff program participation across all campuses. In addition, because the peer mentoring program ceased operating prior to the COVID-19 pandemic, results may be different in this postpandemic nursing world.
Originally conceived out of necessity, this program evolved into a forum that empowered staff-level nurses through promotions, advanced education, and dissemination in journals and conferences. Outcomes were positive. A 2.6% turnover rate among RNs in the mentoring program illustrates the value of peer mentoring in reducing turnover. These direct care nurses just needed word of encouragement to say “yes, you can do this!” Success can be accomplished without adding staff or obtaining additional funding.
More important, 53% of the Magnet document focuses specifically on the direct care nurse. Having a program that provides numerous projects and many engagement opportunities for staff would have significant value to an organization seeking Magnet recognition or redesignation.
This process provided many takeaways for leaders looking to implement a similar program:
- A “good” nurse doesn't necessarily make a good mentor. Relationship-building is key!
- Developing a program shouldn't be completed overnight or in a silo. It's a slow process that will take on many shapes as it evolves.
- How you envision the program at the beginning may not be what it looks like at the end.
- Be comfortable with change. Know that a good program will morph as new information or learnings are presented.
- Involve key stakeholders; these are the boots-on-the-ground staff doing the actual job.
- Never wait for perfect measures or data. QI requires working with what you have today.
Identify outcomes, practice patience
A program that encourages and supports nursing staff can be developed with limited to no additional funding. Although anecdotal feedback can be helpful to illustrate some level of outcomes, having objective data that present a potential for significant cost savings or staff engagement is more powerful. Identifying outcomes at the start of the program is preferred, but program implementation shouldn't be delayed waiting to find the “perfect” way to measure those outcomes.
Some may argue that the cost-savings calculations are high. Regardless of how you calculate the cost savings, thousands of dollars are lost every time an RN leaves the organization. What's not accounted for in the cost-savings calculation is the impact of an engaged RN who's driven to improve patient outcomes. Mentoring can be successfully accomplished without adding to your staff or budget, and a mentoring program can reduce RN turnover. Although this program involves nursing staff, it can be used for other staff members as well.
Research has clearly demonstrated that nurses who feel empowered and are satisfied with their jobs will stay with an organization. Even when empowerment and job satisfaction aren't measured specifically, a lower turnover rate might indicate success in those other outcomes. A successful program won't happen overnight; be patient and give it time to evolve.