Introduction
Currently, the complex hospital setting requires new nurses to possess more that knowledge about healthcare to care for patients. According to Irwin et al. (2018), confidence in one’s professional skills is essential for new graduate nurses. However, with multiple responsibilities and new processes to learn, it is difficult for a new nurse to transition from a novice to an advanced beginner. As Ulrich et al. (2010) find, the turnover for new nurses can be high, if the hospital does not have a program to support novices. For example, one organization in the study had a “35% new graduate turnover rate” before implementing a mentorship intervention which lowered the rate of turnover to just above 5% (Ulrich et al., 2010, p. 374). These statistics show the role of a mentorship program for new hires and the healthcare industry as a whole.
By acquiring knowledge and applying it in practice, nurses also develop skills for high-quality patient care. The existing nursing research offers a classification of the stages that describe nurses’ scope of professional experience. According to Benner (1982), the levels of experience include novice, advanced beginner, competent, proficient, and expert. To start, novices are those who still attend or have recently finished a nursing school (Benner, 1982). The following stages (advanced beginner and competent) require the professional to learn standardized procedures and rules and acquire skills for independent decision-making and work structuring. A proficient nurse can make decisions based on their knowledge and precept mistakes made by other specialists. Finally, an expert nurse can see complex situations as a whole and manage co-workers to achieve the best result – these professionals guide others and can become preceptors to new specialists (Benner, 1982). As can be observed, these stages allow one to track the quality of the nurses’ grasp of the profession.
The number of nurses who struggle with confidence at the start of their career is great and this lack of self-assuredness can affect patient quality of care. “Unpreparedness of novice nurses during the process of transition to their professional role can has broad consequences for the nurse and health care system and leads to reduction of the quality of patient care” (Hezaveh et al., 2013, p. 2015). According to Hale and Phillips (2018), it is complicated for new nurses to feel equal to their co-workers, and this raises the question of whether experienced nurses’ support can guide new hires on their journey. The process of mentoring includes several stages: seeding, opening, laddering, equalizing and reframing. The first part, seeding, is the discovery of the relationship between the mentor and mentee. During opening, the professionals test their relationship – they share information and observe their changing dynamic. The third stage is laddering, during which the mentor and their protégé build a “ladder” for the latter to overcome challenges common for a new professional. Equalizing begins when the mentee starts viewing themselves as equal to mentors professionally. Finally, during the reframing phase, the mentee reflects on the relationship with the mentor and evaluates its input into their professional growth.
After passing these stages of mentoring, a new nurse can feel comfortable to start working full-time. According to the literature, mentorship programs contribute to “improved morale, higher career satisfaction, increased self-confidence, increased professional development, increased publication, obtaining more grants, and quicker promotion” (Nowell et al., 2015, p. 3). Thus, studies support the use of mentorship programs to help novice nurses’ transition into their new roles as confident nurses who are better equipped to manage the challenges of a nursing career.
As noted above, mentorship programs are considered a convenient and effective way to combat new nurses’ lack of professional confidence. A mentorship nursing program is a structured personal and professional development plan that helps novice nurses obtain confidence, job satisfaction, and retention with the assistance of an experienced or senior nurse (Regis College, 2019). To a novice nurse, the clinical setting has multiple unknowns and fears. A proper mentorship program can help minimize uncertainties that can lead to patient endangerment and new nurse dissatisfaction (Hofman & Hermandez-Romieu, 2020). According to Fleming (2017), mentorship programs help nurses gain confidence in their skills and knowledge and improve patient care.
This project aims to implement an evidence-based mentorship program that has been proven to help novice nurses transition into a thriving, competent nurses using a structured mentorship program. The chosen approach is built on the basis of the Academy of Medical-Surgical Nurses (AMSN, 2012a) Mentoring Program. The guide provided by the AMSN is designed guide nurses, promote mutuality and cooperation, increase communication skills, and provide information that helps overcome common stressors (AMSN, 2020).
A mentorship program begins with a set of established guidelines through a unique relationship between mentor and novice nurse. The mentor is someone who has had multiple years of experience in the given field of nursing and a nurse who is considered an expert in his/her field. The mentor may have prior experience as a mentor or may have had previous experience as a preceptor. However, a candidate interested in becoming a mentor must complete a two-week course that prepares them to be mentors. The purpose of pairing a novice nurse with a mentor is to cultivate a learning environment guided by an expert. Assigning a new nurse to a mentor is different than just providing a preceptor. The partnership will last for ten weeks and will be evaluated using the tools mentioned above. The success of the program will be measured using the new nurse confidence scale tool that will be reviewed at the end of the ten weeks mentorship.
Problem
This DNP project aims to address new nurses’ job confidence. On an international level, new nurses face the same issues many American nurses face when entering the workforce. One article mentions that the unpreparedness of novice nurses during the process of transition to their professional role can have broad consequences for the nurse and health care system which leads to a reduction of patient care quality (Hezaveh et al., 2013). In the US, studies have shown that low confidence leads to high turnover rates and nurses’ uncertainty in their fit for the profession (Ulrich et al., 2010). Buerhaus et al. (2017) mention that one million RNs will retire by 2030 and that “the departure of such a large cohort of experienced RNs means that patient care settings and other organizations that depend on RNs will face a significant loss of nursing knowledge and expertise that will be felt for years to come” (p. 40) Thus, it is vital for healthcare organizations to build a system that trains new nurses from the first day on the job to eliminate the knowledge gap between novices and experts.
To date, hospitals and nursing homes do not have standardized guidelines that state how to train new nurses to enhance their job confidence, communicate changes, and overcome challenges. A mentorship program could help these new nurses to face various difficulties. All healthcare workers are risking their lives for others, and present and future crises urge the nursing sector to introduce mentorship programs that improve nurses’ job confidence and satisfaction (Catholic Health Initiatives, 2020).
From a global and national perspective, structured mentorship systems implemented during crises such as the coronavirus could help nurses who need initial guidance (Kofman & Hernandez-Romieu, 2020). Structured mentor programs may also increase the quality and safety of patient care (Goodyear & Goodyear, 2018). Nurses’ high job confidence is essential for hospitals because it consequently influences job satisfaction and intent to stay at the organization (Jones, 2017). Several studies support the idea that nursing confidence is tied to the new nurses intention to stay at the hospital and continue working as a nurse (Ulrich et al., 2010; Schroyer, et al., 2020; Horner, 2017). At the University of Miami hospital, the mission is to provide excellent patient care with a focus on compassion and high-quality services (University of Miami Health System, 2020a).
PICOT Question
The following PICOT question will serve as the basis for the proposed DNP project: “For new nurses in the stroke unit at the University of Miami Hospital (P), how does the implementation of the Academy of Medical-Surgical Nurses (AMSN) Mentoring Program (I), compared to current practice (C), affect new nurse job confidence (O) over ten weeks (T)?”
Literature Synthesis
Literature Search Strategy
The DNP project intends to determine whether mentorship programs are effective in increasing new nurses’ confidence. Thus, the focus of the literature search is on the use of mentorship in nursing education and its potential benefits for performance and personal view of professional skills. The investigation was conducted using the Chamberlain University online library, which included several databases. Using keywords and filters to show peer-reviewed articles that were published from 2016 to 2020, the following databases identified studies – PMC (1,842 results), MEDLINE (445 results), Sage (431 results), BMC Nursing (17 results), ProQuest (1,422 results), PubMed (36 results for articles in free access), ScienceDirect (488 results). After these resources were used, Google Scholar was added to the list of databases to search for open access articles from other platforms. The latter was chosen due to the lack of fitting articles from the selected databases, based on their methodology and focus of the investigation.
The inclusion criteria for studies covered the date of publication – articles published before 2016 were not considered. Furthermore, all studies needed to be peer-reviewed, be written in English and include primary research or systematic review. The following search terms were used: nurse confidence, nurse mentorship, and AMSN mentorship program. These terms’ variations were combined and used separately to ensure the full list of studies available for evaluation.
After reviewing the abstracts of the selected studies, twelve articles were chosen for research evidence appraisal. All pieces of research address the question of the DNP project and relate to its evidence-based intervention of nurse mentorship (Appendix A). The following synthesis of information is presented thematically, discussing the benefits of mentorship programs for new nurses that are mentioned in the selected studies. Next, the appraisal of these research pieces is presented to show the lack of knowledge and some limitations of existing scholarship. Finally, the summary of data is shown, and some ideas and needs for future studies are outlined.
Themes
It should be noted that all chosen studies discuss mentorship or similar programs as the solution to new nurses’ problems with integrating into the workforce and advancing their career. Mentorship is defined as a process during which a professional relationship between an experienced and a novice nurse is established, where the mentor passes the knowledge and skills to the mentee (Kurniawan et al., 2019). The use of this strategy is considered for multiple reasons which correspond to the most prevalent issues for new nurses. Notably, the variety in scholarship does not result in inconsistent findings – all selected studies support the use of mentorship as a highly effective intervention. However, the authors present different reasons for implementing mentorship, which can be divided into several themes.
Retention. Mentorship programs were found to positively affect retention levels among new nurses (Brook et al., 2019; Hussein et al., 2017; Jones, 2017; Salarvand et al., 2018). These studies demonstrate that most research participants regard mentoring opportunities as a positive influence on their professional knowledge and relationships with patients and peers. Such overwhelming support for this intervention suggests that a mentor-mentee relationship can have a lasting impact on recent hires and change the environment in which nurses operate. The first year of practice seems to be the most important for new nurses. During this time, a mentorship program affects nurses’ view of their capabilities and fit for the profession, which leads to greater retention (Brook et al., 2019; Hussein et al., 2017; Jones, 2017; Salarvand et al., 2018). However, the programs discussed by the scholars present a lack of social and emotional support, calling further research to look at programs that promote confidence and competence among novice nurses.
Job satisfaction. Furthermore, mentoring experiences are connected with an increase in job satisfaction (Brook et al., 2019; Havens et al., 2018; Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019). In fact, for almost half of the considered studies, the issue of job satisfaction appears as the central problem that affects nurses’ other growing concerns. In this case, mentorship is linked to autonomy, social contacts, a sense of accomplishment, and quality care (Brook et al., 2019; Havens et al., 2018; Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019). The role of a mentor-mentee relationship is highlighted as it affects job satisfaction and reduces burnout. Here, the communication between new and experienced nurses is under investigation. The authors discuss the ties between staff in the unit as a building block for higher engagement with patients and other care providers. As a result, the tight connections, high level of mutual understanding, and a clear view of one’s role in the setting lead to increased job satisfaction (Brook et al., 2019; Havens et al., 2018; Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019).
Competence and skills. The third benefit of mentoring programs is their ability to increase nurses’ competences, required skills, and overall theoretical and practical knowledge necessary for the nursing profession (Hussein et al., 2017; Irwin et al., 2018; McKillop et al., 2016; Schroyer et al., 2016; Zhang et al., 2017). In contrast to single, unstructured mentoring initiatives, preceptorship programs are more effective, fostering a helping environment and influencing competence and confidence (Irwin et al., 2018; Zhang et al., 2017). Likewise, Hussein et al. (2017) and Schroyer et al. (2016) report increased self-efficacy and understanding of the nursing profession, suggesting these interventions for novices and students’ curriculums. The scope of nursing is explained to new nurses by professionals with years of experience, and it also explains the most effective ways of acquiring knowledge in the future.
Knowledge transferral happens during mentorship programs, especially in units and care centers with specific requirements (McKillop et al., 2016; Worthington et al., 2016). Scholarship – mentorship interventions positively change nurses’ attitudes toward care and their knowledge of procedures with statistically significant improvements. Mentees demonstrate the depth of the impact that a direct conversation with a mentor can make on their understanding of the issue (Hussein et al., 2017; Worthington et al., 2016).
Confidence. Finally, although researchers look at different reasons for implementing a mentoring intervention, one threat seems to connect much of the scholarship in this area – nurses’ confidence in their skills, fit for the profession, and future career development. As shown above, the majority of authors pay the most attention to one particular concern of new nurses. However, most studies either include nurses’ confidence in their variables or mention it as an integral part of the issue (Brook et al., 2019; Hussein et al., 2017; Irwin et al., 2018; Worthington et al., 2016; Zhang et al., 2017).
While looking at retention levels, Brook et al. (2019) and Hussein et al. (2017) connect the nurses’ desire to stay at their job to the mentorship opportunity, which has built the novice care providers’ confidence and fostered teamwork. In this case, the idea is presented that confidence becomes one of the pillars for nurses’ success. The existence of a mentor-mentee relationship accounts for a significant part of novice nurses’ job satisfaction rate (Brook et al., 2019; Kurniawan et al., 2019). Confidence is also considered a predictor of good performance among nurses (Kurniawan et al., 2019; Zhang et al., 2017).
The issue of gaining confidence is further linked to care provision and patient outcomes. One study concludes that “well-prepared, confident and committed newly employed nurses have the potential to improve quality of patient care and enhance patient safety” (Jones, 2017, p. 77). Confidence in nurses’ minds is related to providing fair and equitable treatment and knowing one’s scope of practice (Hussein et al., 2017; Brook et al., 2019; Zhang et al., 2017). Apart from empowering nurses to continue working, mentoring that targets confidence also improves the process of seeking knowledge and nurses’ ability to help patients. Confidence is perceived as part of nurses’ communication skills and knowledge application (Irwin et al., 2018; McKillop et al., 2016). As noted above, confidence in one’s scope of knowledge empowers nurses to continue learning and admit the inability to make an informed decision. Thus, one can see that confidence is a vital element of mentoring. Most scholars believe in the critical role of increasing nurses’ confidence to impact all aspects of care delivery.
Issues
Qualitative methodology and low levels of evidence. As can be seen from the literature summary (Appendix A), there exists a lack of high-quality evidence that would focus on new nurses’ confidence in mentorship programs. In fact, large numbers of results in databases outlined in the introductory part of this chapter do not represent the amount of evidence that could be used for a literature synthesis. Most studies had to be excluded due to them using qualitative methods, extremely small sample sizes, or cross-sectional designs. Therefore, most findings available for appraisal do not have reliable quantitative data or present only a glimpse into a mentoring intervention. In the chosen studies, similar limitations are apparent – Horner (2017), Hussein et al. (2017), McKillop et al. (2016), and Worthington et al. (2016) employ mixed methods, while only one randomized controlled study by Zhang et al. (2017) was located.
Brief discussion of confidence. Although most of the discussed studies mention confidence and link it to nurses’ performance and professional development, they do not attempt to measure the change in new hires’ confidence levels after a mentoring intervention. It should be noted that research by Worthington et al. (2016) includes individual questions about nurses’ confidence, but it presents qualitative findings that are challenging to measure. In the interviews, nurses mention confidence several times, citing the program as a root of their increased self-confidence and improved self-perception as professionals. Furthermore, Hussein et al. (2017) use a Likert scale for measuring confidence levels, but the questions and the framework are not transparent to replicate. Nurses report higher confidence levels after a mentorship program in both cases (Hussein et al., 2017; Worthington et al., 2016).
Nevertheless, the lack of attention to quantitative measurement of confidence change as a result of the mentoring program is puzzling, as most research articles discuss this aspect of nurses’ skills and aim to connect it to their findings. The presented investigations show a gap in results and support the relevance of this DNP project. While nurses’ confidence appears in a variety of studies that report great benefits of mentoring programs for nurses, none of the scholarly papers consider using developed scales to confirm their statements with results. The work by Jones (2017) mentions the AMSN mentoring program, while others talk about confidence in relation to retention, competence, communication, peer support, and patient outcomes. The role of confidence and its improvement during mentoring interventions are, therefore, challenging to overemphasize, but the quantitative measurements are visibly lacking.
Summary and Future Research Considerations
To sum up, the literature synthesis of recent academic scholarship reveals several ideas about nurses’ confidence and the use of mentoring programs. First, it is apparent that mentorship is highly regarded by researchers, and various studies support the use of this intervention to improve the performance and self-perception of new nurses. Second, nurses mention the improvement of confidence as an outcome of mentorship, even if the study does not center on this topic. Scholars also pay significant attention to connecting the role of confidence in helping nurses acquire knowledge and connect with patients and other nurses in a meaningful way.
However, the current state of the literature also exposes a lack of statistical data about confidence rates’ changes under the impact of mentoring programs. Although some articles briefly discuss such a tool as the New Nurse Confidence Scale, most do not aim to use this data for their conclusions. A small number of studies include some questions about confidence in their interview or a single entry in a survey. This flaw in the existing scholarship denotes an underdeveloped area of research. The focus on confidence change as an outcome of a mentoring program may open new possibilities for future research, as several authors acknowledge its fundamental role in building nurses’ competence. As a whole, the scholarship overwhelmingly supports the use of a mentoring intervention for improving new nurses’ integration into practice while also urging to consider confidence as an unexplored area.
Purpose
The DNP project aims to increase job confidence among new nurses by implementing a structured mentorship program introduced in the hospital for the first ten weeks after orientation. Specific objectives related to the DNP project are the following: prepare and implement a structured mentorship program for new nurses in the hospital, evaluate the influence of a formal mentorship program on new nurses’ job confidence in comparison to current practice, and demonstrate a positive impact on job confidence of new nurses through quantitative measures.
Evidence-Based Intervention
As shown in the literature, new nurses’ confidence can be linked to a variety of factors that affect nurses’ performance, job satisfaction, and desire to continue working in this field (Brook et al., 2019; Hussein et al., 2017; Irwin et al., 2018; Worthington et al., 2016; Zhang et al., 2017). To ensure that nurses acquire confidence in the first year of their work, a mentorship guidance program is suggested by many authors, who find this type of intervention highly useful (Brook et al., 2019; Hussein et al., 2017; Zhang et al., 2017). The DNP project will implement the Academy of Medical-Surgical Nurses (AMSN, 2020) Mentoring Program. Utilizing Benner’s Novice to Expert theoretical framework, a new nurse (mentee) will be paired with an expert nurse in the chosen hospital (mentor).
The AMSN Mentoring Program includes three separate guides for the site coordinator, mentor, and mentee. All three documents have details on the principles of a mentoring relationship, self-assessment, mentoring program plan, and necessary evaluation tools (AMSN, 2020). This guide was chosen for the intervention because it is a program that has been validated by other studies (Grindel & Hagerstrom, 2009), and it has a specific structure with tools and information for all participants to follow. Moreover, it is a program that acknowledges the unique needs of nurses in comparison to other healthcare providers, including their interprofessional collaboration, patient care, teamwork, and physician-nurse relationships. Although the guide provides more information for medical-surgical nurses, it can be adapted for other types of nursing specializations, including specialists working in the stroke unit. In fact, the guide’s acknowledgment of nurses’ specific needs according to their department makes this program highly flexible.
The content of the mentoring guide is separated into three major parts: a site coordination guide, a mentee guide, and a mentor guide. The first document describes the goals of this program and the role of each participant (AMSN, 2012c). Next, it provides checklists for the coordinator that allows one to track the timeline of the program. The mentee guide lists directions for the new nurse to follow and includes templates for background information, confidence scale, plans, guidelines, and other measurement tools to achieve set goals (AMSN, 2012a). Finally, the mentor guide starts with the directions for the experienced nurses participating in the project, a self-assessment test to see whether they are fit for a teaching role (AMSN, 2012b). The document also contains exercises for the mentor to implement and the meeting agenda and tools to use during mentor-mentee discussions.
During the first week of the project, participants (both mentors and mentees) will be recruited and informed about their rights and duties if they agree to take part in the program (Appendix H). The informed consent form will be handed out to all nurses taking part in the project. This document answers general questions about the project and addresses information confidentiality, nurses’ workload, and other potential ethical issues. Finally, it lists the contact information to ask further questions about the project and talks about the rights each participant has.
After they sign the informed consent form, the nurses will be educated about the mentoring program. This instruction is necessary to ensure that all participants clearly understand their goals during the following weeks (Appendix J). This educational offering will include a presentation that covers the importance of the mentorship program, discusses its goals, and describes the requirements for scheduling and meeting with assigned mentors, mentees, and the site coordinator. Two short presentations will take no more than 20 minutes, 10 minutes will be allotted for a Q&A section, and a short survey will be administered to ensure participants’ comprehension.
Mentors and mentees will also be introduced to the framework of the project, principles of adult learning, the continuum of nurse experience (from novice to expert), and the phases of the mentor-mentee relationship. These four questions will be discussed in the form of presentations, role play, and additional handouts. Each segment will take no longer than 15 minutes, excluding the final group discussion and five final questions to check the participants’ understanding.
To use the AMSN’s guide, the site coordinator must link the mentees with their mentors, using the self-assessment tests and new nurses’ background information. Then, mentors and mentees review their respective guides and complete initial tests that will allow one to compare the starting numbers with the results of the intervention. Most importantly, the mentees complete the Confidence Scale for New Nurses prior to the start of the intervention, but after being paired with their mentor (Appendix D). Once this data is collected, the program begins and continues over the course of eight weeks – the schedule for the intervention is structured according to the participants’ working schedule, and the AMSN guide allows for flexible meeting times for mentors and mentees. During these weeks, assigned pairs of mentors and mentees meet at agreed-upon intervals and complete exercises from the AMSN guide.
It should be noted that the original program developed by the AMSN is much longer than the project – it spans over one year. However, the project under investigation does not have such a long timeframe, which requires the program to be scaled down to eight weeks. The AMSN guide’s flexible scheduling opportunities allow mentors and mentees to meet at any time intervals, which makes this adaptation possible.
During weeks two-nine, the intervention takes place, and nurses work together to share knowledge and integrate new hires into the unit. As the scale of the intervention is smaller than that suggested by the AMSN, which offers a 12-month program, the progress is tracked by the site coordinator in two-week intervals (as opposed to three- and six-month gaps). In this case, the role of the site coordinator is assumed by the DNP student, who meets with the mentor-mentee dyad on a biweekly basis. Conversations are held one-on-one to ensure that mentees and mentors are comfortable discussing their experience and reporting any problems that may arise during the intervention. Mentors and mentees also meet on a set schedule that they design following their own available time and the guide’s specifications. During their meetings, they use tools from the guide and follow the developed agenda.
New nurses have the ability to ask practice-related questions, discuss procedures, and request advice on any topics with which they may struggle in their workplace. The AMSN guide provides several sections to which mentors and mentees can pay attention: interpersonal skills, management skills, and organizational skills. Interpersonal skills include relationship building, conflict management, feedback, assertiveness, and assertiveness. To improve one’s management capabilities, mentors may discuss motivation, delegation, organizational culture, networking, team building, and self-management. Finally, the meeting topics can revolve around project and time management and professional goal setting for mentees.
The dyads will be given the freedom to choose which themes are the most important or pressing to mentees in this particular working environment. The focus on the individual interests of the new nurses makes this intervention tailored to each specific case and allows mentees to avoid talking about information they know well. However, it also means that one cannot predict the topics that will become the most prevalent among nurses. The site coordinator-dyad discussions will be semi-structured, using surveys and tests provided in the AMSN guides as the main guideline.
On the tenth week of the project, the mentees complete the confidence scale again, as well as the Job Satisfaction Scale and Intent to Stay in the Job Survey (Appendices K-L). The DNP student meets with the participants for the last time and offers to discuss additional feedback that may be used to adjust future projects. Mentors fill in the Assessment of the Relationship with the Mentee and Mentoring Program Satisfaction Survey – they are also provided with an opportunity to provide feedback (Appendices E-F). These surveys are used to form some final outcomes of the program and assess its success in the unit.
Translational Science Model or Theoretical Framework/Change Model
The translational science model selected as the underpinning for this DNP project is the Knowledge-to-Action (KTA) Framework. This framework was developed in Canada by Graham and colleagues in 2004 (Xu et al., 2020). KTA is a concept that systematically explains how to take actions having knowledge. The Knowledge-to-Action (TKA) process has two components: knowledge creation and Action (World Health Organization, n.d.). Researchers report the TKA framework is frequently cited and widely utilized and integral to knowledge translation (Field et al., 2014). The model’s primary tenets include identification of the problems, adaptation of knowledge, assessment of barriers to knowledge use, selection of intervention, monitoring the implementation, evaluating outcomes, and sustaining knowledge use for future utilization (Field et al., 2014).
The TKA model has seven tenets. The first stage is identifying the problem, which is the job confidence among new nurses. Lack of proper training for new graduate nurses can decrease the job confidence of new members of the healthcare team. This issue brings the process to the second stage, which is to adapt the knowledge into the local context. This can be achieved by recognizing there is a need to adopt a mentorship program at the University of Miami Hospital’s stroke unit. The third stage identifies any barriers that may present themselves in the implementation of a mentorship program. Some of the identified obstacles are the current situation with the global pandemic COVID, leadership motivation, and the nurse’s resistance to change. To overcome these barriers, the DNP student will work closely with the identified stakeholders to determine how to establish this given mentorship program. The fourth stage in this project is the implementation stage. During this stage, the DNP student will launch the mentorship program using the AMSN Mentoring Program that focuses on the Knowledge-to-Action (KTA) Framework (Washington University in St. Louis, 2019).
To help the program succeed, the DNP student will launch the fifth stage of the project to monitor and evaluate the mentorship program through surveys and patient feedback. This is vital to understand the strong and weak aspects of the nurses’ activities and work on them appropriately. This stage is pivotal as it helps identify issues that can be modified to help the program reach completion. Evaluation of the outcomes will occur during the sixth stage using the New Nurse Confidence Scale tool to evaluate the success of the mentorship program. Information gathered will be given to staff members and administrators to reveal the project’s success. The final stage in this project is to establish sustainability within the stroke unit. This will be accomplished by raising awareness about the problem, educating key stakeholders, empowering staff, and creating new protocols to continue the mentorship program for years to come.
Organizational Setting
The organizational setting for this DNP project is the stroke unit at the University of Miami Hospital. The typical client is a patient with neurological problems, aged 55 and above, residing in the hospital vicinity. Typical areas of treatment include the brain, spinal cord, cranial, nerves, muscle, and heart. Most of these patients also suffer from high blood pressure, obesity, high cholesterol, and diabetes. The number of patients seen annually is 1500 with strokes and 35,000 in the whole Department of Neurology (University of Miami Health System, 2020b). The unit of the hospital sees many uninsured patients as well as those on Medicaid, Medicare, and private insurances.
Population Description
The anticipated population for this DNP project is 10-15 new registered nurses hired during the first half of 2020. Inclusion criteria for nurses in this study are newly hired registered nurses in the stroke unit, less than one month out of orientation, less than one-year nursing experience, and willing to be mentored. Traveling or agency nurses, non-nurses, nurses who have been out of orientation for a period longer than one month, nurses in orientation, and those who are unwilling/unable to be mentored will be excluded from the study.
Preceptors are not a part of the population, but due to the controlled nature of the project, some inclusion criteria apply to them as well. Mentors need to have at least five years of nursing expertise in the stroke unit, previous experience in preceptorship/mentorship, and willingness to mentor. Exclusion criteria for preceptors are traveling or agency nurses, non-nurses, and those nurses who have less than five years of nursing experience in the stroke unit.
Considerations and Challenges for Implementation
The project requires substantial time from employees as it asks them to make time for additional meetings, discussions, and planning. As such, the lack of time is the first potential challenge for the implementation. According to Havens et al. (2018), nurses experience continuous time constraints, especially in units with a high number of emergency situations or incoming patients. To overcome this problem, nurse mentees will be allowed to allocate some time at the end of the shift to devote to their planning of the mentorship agenda and completing surveys. Moreover, they will be encouraged to discuss appropriate meeting times with mentors that will not significantly affect the workload of the experience nurses and themselves.
As the AMSN Mentoring Program requires a significant number of mentors to participate, the lack of human resources may arise as another obstacle to completion. Nurses have a busy schedule which demotivates them from additional initiatives (Havens, et al. 2018; Ortiz, 2016). Consequently, when the nursing staff has resistance to change, the DNP student will emphasize the value of mentorship with the help of hospital executives. According to Salam and Alghamdi (2016), resistance to change is a problem in many spheres; however, in nursing, it affects not only the professional but also the patient. The DNP student and hospital leadership will work diligently in explaining the benefits of a mentorship program. A lunch and learn session with staff and administrators will present the mentorship program in detail.
A lack of motivation is another issue from which the results of the project can suffer. Intrinsic and external motivation are essential in the learning process, and if the team fails to participate in the process of mentorship with a complete understanding of its benefits, the results may not demonstrate the full potential of the program (Kodama & Fukahori, 2017). The investigator will discuss the programs’ benefits and introduce it in a way that represents value to all members involved will help with the resistance. Lack of motivation is eliminated with this format, and more nurses will be eager to participate (Kodama & Fukahori, 2017). The University of Miami Hospital employees are open to evidence-based practice; therefore, there will not be any significant objections.
Outcomes
The measurable outcome for this proposed project is an increase in new nurses’ confidence after participation in a structured, evidence-based mentorship program. The data collection process will focus on measuring novice nurses’ confidence prior to and after the mentoring program. For this, the New Nurse Confidence Scale (Appendix D) will be administered pre- and post-intervention – all mentees participating in the program will receive the form to complete, and the data will be collected online. This tool is a part of the AMSN mentorship program; the survey contains 26 questions that assess the level of confidence on a 5-point Likert scale, from “not at all confident” to “very confident.” The New Nurse Confidence Scale has been validated by the AMSN (2012a) and the study by Grindel and Hagerstrom (2009). The data analysis of the present project will include internal reliability measurement, using Cronbach’s alpha.
Additionally, the mentees will complete the Assessment of the Relationship with the Mentor Form and the Mentoring Program Satisfaction Survey at the end of the project to ensure the high quality of the mentorship program and gain additional insight into the usefulness of the intervention (AMSN, 2012a). As such, the surveys will be administered to the novice nurses during week 10 of the project, together with the posttest completion of the New Nurse Confidence Scale. These tools use the same measurement system as the New Nurse Confidence Scale – a 5-point scale, with the Assessment of the Relationship with the Mentor Form having a separate point, “not applicable.” All measurement tools are available through the AMSN mentorship program toolkit (Szalmasagi, 2018). The statistical evidence of these tools is provided by the AMSN as well, and the internal reliability of the surveys (alpha) will be measured prior to presenting results.
Data Management Plan
The present project is quasi-experimental, with a pretest-posttest design. New nurses’ confidence lies at the center of the project’s investigation, and the AMSN Mentoring Program uses the New Nurse Confidence Scale to assess this factor. Thus, the results of this survey are the main sources of data that indicate nurses’ level of confidence before and after the evidence-based intervention program. As the mentees have to be chosen to participate, and the sample has inclusion criteria, this project cannot be considered fully experimental. The New Nurse Confidence Scale used in the program allows one to compare findings pre- and posttest. Hence, the investigation employs a one group pretest-posttest design, since a control group is not separated from the whole sample (Grimshaw, 2000).
The structured mentor program offered by the AMSN serves as the independent variable for this project. In produces nominal data since the main question here is whether the nurses completed the program or not. Here, no measurement is needed as all nurses in the sample will complete the program. The dependent variable is the nurses’ level of confidence. The latter is calculated using the New Nurse Confidence Scale which is a survey consisting of 26 statements (AMSN, 2020). Nurses assess their agreement with the scale’s statements using the 5-point Likert scale, from “not at all confident” to “very confident.” Then, the items are summed to calculate a total score ranging from 26 to 130, which means that the dependent variable produces interval data (Grindel & Hagerstrom, 2009).
The New Nurses Confidence Scale (AMSN, 2012a) will be administered electronically with data being exported to a comma-separated value file and transmitted to the statistician for analysis. Due to the observations being measured prior to and after the intervention study identification numbers will be assigned. The number of participants will be reported for each time period (nominal variable: preintervention and postintervention). As a result, the evidence-based intervention created by the AMSN yields two sets of data from the nurses who completed the New Nurse Confidence Scale before and after the program’s completion. The comparison of these two data sets is the statistic that is interpreted in the QI’s results.
Mean (standard deviation) and median (interquartile range) of the New Nurses Confidence Scale (interval data) will be calculated for both periods of time (Academy of Medical-Surgical Nurses, 2012a). Dependent variables were tested for normality using normal probability plots and the Anderson-Darling, Shapiro-Francia, and the Shapiro-Wilk normality tests (Anderson & Darling, 1954; Shapiro & Francia, 1972; Shapiro & Wilk, 1965). The Anderson-Darling test is the recommended empirical distribution function test by Stephens compared to other tests of normality giving more weight to the tails of the distribution than the Cramer-von Mises test (Stephens, 1986). The Shapiro-Francia test was chosen because of its known performance and the Shapiro-Wilk test was chosen because it is one of the best-known tests for normality (Shapiro & Wilk, 1965).
To measure the change in nurses’ confidence after the intervention, the investigator will use the dependent-sample t test. As Gerald (2018) explains, the dependent -sample t test is most often selected for investigations with a pretest-posttest design, where two sets of data are connected to each other, since they originate from one group of participants. In this case, the first group of scores is calculated from pretest scores of the New Nurse Confidence Scale, and the second group is taken from the nurses’ posttest scores of the New Nurse Confidence Scale.
Owning to the dependence of the data a one-sided test [paired t test or Wilcoxon Signed Rank test; (Student, 1908; Wilcoxon, 1945)] will be used to identify an increase in confidence (Wilcoxon, 1945). The dependent sample t test detects an increase (or decrease) in means and the Wilcoxon Signed Rank test examines whether there is a shift (increase or decrease) in location due to the intervention (Hollander & Wolfe, 1999). Since there was an interest in scores increasing after the intervention a one-sided test was used instead of a two-sided test. As a result, the tests should demonstrate a change in the level of the new nurses’ confidence.
Project Management Plan and Gantt Chart
The intervention will be the implementation of the Academy of Medical-Surgical Nurses (AMSN) Mentoring Program. Using Benner’s Novice to Expert theoretical framework, a novice mentee will be paired with a proficient or expert mentor.
Week 1: Recruitment of participants (mentors and mentees), signing of informed consent, education on the structured mentorship program, assignment of a mutually agreed upon 8-week schedule will be created, the mentees will complete the New Nurse Confidence Scale. During the first week, blueprints will be distributed among the nurse, and the nurse educator will establish training sessions with employees. The executives will give a presentation to staff members with the value of the necessity of adjustments. Week 2: the implementation of the intervention in the practicum site.
Weeks 2-9: Biweekly check-ins with the DNP student and the mentor/mentee to assure cooperation between the pair and to answer any questions. Weeks 2-9 will also be used to encourage nurses to be held accountable for meetings with mentors and to track them further with regular meetings. It is also essential to evaluate the initial data and feedback to make changes if needed.
Week 10: Mentors will complete the Assessment of the Relationship with the Mentee and Mentoring Program Satisfaction Survey. The mentees will complete the New Nurse Confidence Scale, the Assessment of the Relationship with the Mentor Survey, and the Mentoring Program Satisfaction Survey. Week 10 will also be dedicated to the analysis of data and feedback gathered and the presentation of the intervention’s central results.
Proposed Budget
The project requires significant resources that will be used in the implementation project phase; they will be indicated in the attached budget plan. The financial expenditures are associated with the work of the compliance committee which includes one nurse, quality team member/statistician, project manager, and a nurse educator. Members of the committee will facilitate project plan execution to improve new nurses’ job confidence and evaluate data on the project implementation and a level of successful application. Members of this team will be paid their average salary to help nurses follow the mentorship principles and undergo extensive training and interactions with mentors. Human resources will be needed to encourage medical professionals to be involved in the project. To address this, the time of the management team and executives should be used to educate people; it is expected that they will do it without additional expenditures because they are interested in enhancing job confidence among nurses. To evaluate results gathered during the project implementation, a Statistician will be used. Finally, other materials, such as conference rooms, paper, printers, laptops, and projectors, will be needed to create a presentation and guidelines and show it to the hospital’s employees to communicate changes indicated in the budget.
The sources of finance will be initially found internally through institutional budget support expected to provide the most significant investments. Among other sources, grants can be found to help with the launch of the project in the hospital because foundations may sponsor such studies to research COVID-19 related concerns and job improvement initiatives. The hospital executives can present a project implementation plan to targeted scholarship and funding organizations and get additional support. The project is non-profit, and benefits are not expected to be monetary. Instead, they should indirectly increase the quality of healthcare services and job retention levels among new nurses of the hospital.
Table 1:Budget
Ethical Issues and Considerations
Approval to conduct this DNP project will be sought from the Institutional Review Board (IRB) at Chamberlain University. IRB approval at the practicum site is not required for quality improvement projects. Participation in the research is strictly voluntary without monetary benefits of involvement, and evaluation forms for mentors and mentees will be anonymous. All volunteers will receive comprehensive information about the future research, objectives; Q&A session will be held to answer questions of volunteers. Mentors and mentees will get specific guidelines to follow to establish the mentorship program and its aims. Volunteers will sign an informed consent (Appendix H) to participate in the study and to provide data to project executors and Chamberlain College of Nursing management team. Informed consent and the questionnaires for the study will be stored electronically in a secured database of the college for seven years. The informed consent will be distributed separately to chosen volunteers after the introduction and Q&A session to ensure that they agree to participate freely.
Results
Sample: This portion should describe in detail the setting, the target or accessible population, the number contacted, the percentage participating, and the details of who participated. For inferences, an analysis of the representativeness of your sample characteristics should be done by comparing your sample to your accessible or target population. These data is best presented in tables detailing those demographic details that are important to the study. An analysis of the demographic data is required.
Table 2
Note: [Place all tables for your paper in a tables section, following references (and, if applicable, footnotes). Start a new page for each table, include a table number and table title for each, as shown on this page. All explanatory text appears in a table note that follows the table, such as this one. Use the Table/Figure style, available on the Home tab, in the Styles gallery, to get the spacing between table and note. Tables in APA format can use single or 1.5 line spacing. Include a heading for every row and column, even if the content seems obvious. A default table style has been setup for this template that fits APA guidelines. To insert a table, on the Insert tab, click Table.]
Findings: This portion provides an interpretation of the major findings in the context of the overall purpose of the project. Present the statistical analyses of your primary outcome and process measures. Discuss how your major findings provide new knowledge or support previous findings that you found in the literature. Note how these findings add to the body of knowledge on this topic and support or expand on the theoretical framework you provided in Chapter I. There should be a clear relationship between the theory that drove the project to the findings presented and analyzed.
Figures Title
For more information about all elements of APA formatting, please consult the APA Style Manual, 6th Edition.
Discussion
This is where you can, and should, express your opinions regarding the results, implications, recommendations and the strengths and limitations of your project. Every study has strengths and limitations, so these should be stated.
If your results are similar to those found in previous studies, you may cautiously infer the results beyond your population and setting. However, if your results are completely different and/or contradict previous studies, you should let the reader know that these results cannot be used beyond the study population and setting.
Recommendations
Recommendations based on the findings should be for the nursing profession and society in general, and to specific nursing leaders as mentioned in the significance portion. A summary of the major findings concludes the findings and interpretations portion with a transitional paragraph introducing the recommendations portion. Recommendations should follow the same logical flow as the findings and interpretations. Include a narrative of topics that need closer examination to generate a new round of questions. Be sure to make specific recommendations for leaders in the nursing field and policy makers. Recommendations for future research should be detailed and extensive. This is a key area that students often fail to elaborate. What could other researchers do with the new information to find out more gaps as indicated by the new results? New doctoral learners often look in this portion for ideas on problems that remain to be solved so elaborating with detail leaves a legacy to new doctoral students to continue.
Conclusions and Implications for Nursing Practice
Conclusions should relate directly to your purpose and project question. They are generalizations that loop back to the existing literature on your topic. For each conclusion you make, cite the sources that support or contradict your findings. The conclusion should represent the contribution your practice project has made to the body of scientific knowledge on this topic and relate this to the significance of the project, which is always, in some way, to improve nursing practice. Conclusions indicate what is now known regarding nursing practice when your results and results from prior literature are considered together. Implications for nursing should report findings in Section I not reported by any other literature. Why should nursing leaders care? Meanings of any gaps or similarities to literature are critically analyzed and discussed for every unusual finding. What do the findings mean to nurse leaders, and would society care about the results?
Plans for Sustainability
Explain what will be done to sustain the project over time. What strategies will you put into place for the practicum site to ensure the project has ongoing evaluation and modification as needed to ensure its success after your implementation phase is complete?
References
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Appendices, Tables, and Figures
Appendix A
- Johns Hopkins Nursing Evidence-Based Practice.
- Appendix G: Individual Evidence Summary Tool.
- © The Johns Hopkins Hospital/ The Johns Hopkins University
Practice Question: For new nurses in the stroke unit at the University of Miami Hospital, how does the implementation of the Academy of Medical-Surgical Nurses (AMSN) Mentoring Program, compared to current practice, affect new nurse job confidence over ten weeks?
Date: 10.16.2020
Attach a reference list with full citations of articles reviewed for this Practice question. © The Johns Hopkins Hospital/ The Johns Hopkins University
Appendix B
- Site Letter of Support
- N/A-Virtual Case Study
Appendix C
Project Schedule
Appendix D
The New Nurse Confidence Scale (AMSN, 2012a)
Appendix E
Assessment of the Relationship with the Mentor (AMSN, 2012a)
Appendix F
Mentoring Program Satisfaction Survey (AMSN, 2012a)
Appendix G
These tools are part of the AMSN Mentorship Program, no permission necessary.
Appendix H
Informed Consent
Appendix I
Budget
Appendix J
Plan for Educational Offering
Appendix K
Job Satisfaction Scale (AMSN, 2012a)
Appendix L
Intent to Stay in the Job Survey (AMSN, 2012a)
