mentoring new nurse practitioners to accelerate their development as primary care providers: a...

CLINICAL PRACTICE

Mentoring new nurse practitioners to accelerate theirdevelopment as primary care providers: A literature reviewSusan Harrington, DNP, APRN-BC (Practice Clinical Manager)

Emerald Physicians Services, Hyannis, Massachusetts

KeywordsAdvanced practice nurse (APN); coaching;

communication; leadership; nurse practitioner

communication; nurse practitioners; primary

care.

CorrespondenceSusan Harrington, DNP, APRN-BC, 433 West

Main Street, Hyannis, MA 02169.

Tel: 508-778-4777;

Fax: 508-778-9555;

E-mail: [email protected]

Received: April 2009;

accepted: December 2009

doi: 10.1111/j.1745-7599.2011.00601.x

Abstract

Purpose: To provide a review of the literature regarding programs for mentor-ing new nurse practitioners (NPs) to accelerate their development as primarycare providers.Data sources: A search was conducted in PubMed, Ovid, CINAHL, andCochrane Database of Systematic Reviews.Conclusions: There is currently a critical shortage of primary care providersand an aging population requiring management of chronic medical condi-tions. Although NPs are trained in health promotion, disease prevention,and medical management and are well equipped to treat patients in pri-mary care, the work can be overwhelming to the novice NP. A mentor-ing program could help the new NP further develop competencies andcapabilities as a provider. However, there is a gap in the literature concern-ing any mentoring programs for novice NPs. Nonetheless, the literature re-view has provided a mentoring definition, program models, desired charac-teristics of nurse mentors, and barriers to mentoring programs. It has alsodescribed the benefits, goals and outcomes of a mentoring relationship. Theseinsights from the literature provide a foundation for future mentoring programdevelopment.Implications for practice: A mentoring program for new NPs working in pri-mary care could accelerate productivity, increase job satisfaction, and providelongevity in the primary care setting.

Although there are an estimated 99,913 general in-ternists in this country, there is a critical shortage ofprimary care physicians (American Association of Col-leges of Medicine, 2006). Compounding the situation isan aging baby boomer population of 78 million whobegan turning 65 in 2011 and many are expected tohave chronic medical conditions (Ebell, 2008, p. 1131).The increase in chronic medical conditions for the el-derly population means more visits are needed to man-age the chronic health problems; however, there is al-ready an acute shortage of primary care providers (PCPs).Nurse practitioners (NPs) are trained in health promo-tion, disease prevention, and medical management andare well equipped to treat patients in primary care. Al-though there are potentially many new NP PCPs, theproblem involves bridging the gap between educational

preparation and the primary care setting. A model formentoring new NPs to accelerate their development asPCPs could fill this gap.

Mentoring

The term “mentor” comes from Homer’s Odyssey.Athena, the Goddess of Wisdom, disguised herself as anIthacan noble named Mentor. When Ulysses was awayin the Trojan War, Mentor served as the surrogate par-ent to Telemachus, Ulysses’ son. Mentor then guided,coached, taught, and protected Telemachus, because hewas to be the future king. Currently, mentoring is definedas a “voluntary, intense, committed, extended, dynamic,interactive, supportive, trusting relationship between twopeople, one experienced, and the other a newcomer,

168 Journal of the American Academy of Nurse Practitioners 23 (2011) 168–174 C©2011 The Author(s)Journal compilation C©2011 American Academy of Nurse Practitioners

S. Harrington Mentoring new nurse practitioners in primary care

characterized by mutuality” (Hayes, 1998, p. 525). Thementor acts as a guide, role model, teacher, and sponsor.The mentor also provides knowledge, advice, challenge,and counsel for a new role (Johnson, 2002, p. 88).

Functions of mentoring

In an analysis of interviews with mentors and mentees,Kram (1985) distinguished two functions of the mentor-ing relationship: career and psychosocial. Career men-toring concerns growth within the organization andpsychosocial mentoring promotes personal and profes-sional growth. Elements of career mentoring includesponsorship for promotions, coaching, protecting fromadverse situations, providing challenging assignments,and increasing visibility and exposure (Kram, 1985).Allen and Eby (2004) appended the list and includedpromoting professional ethics. Johnson described the ca-reer function of mentoring as “learning the ropes” (2002,p. 89).

The psychosocial aspect of mentoring incorporatesnumerous features. Kram (1985) described four compo-nents of psychosocial mentoring: development of the pro-fessional self, counseling, friendship, and role modeling.Allen and Eby (2004) enhanced the list of psychosocialfunctions to include developing increased competenceand self-image. Within the mentoring relationship, oneor both types of mentoring may be applicable. Nonethe-less, the career functions center on the mentee’s careerand the mentor’s position in the organization, whereasthe psychosocial function focuses on the personal devel-opment of the mentee.

Mentoring models

There are two types of mentoring relationships: for-mal and informal. The formal relationship is set upthrough the organization and the mentor and menteeare matched. Characteristically, there is formal trainingof the mentor and mentee as well as formal objectivesand program activities. In contrast, the informal mentor-ing relationship develops over time with the mentor andmentee choosing each other. Ragins and Cotton (1999)queried 1258 engineers, social workers, and journalistsand concluded that formal mentoring programs providedfewer mentoring functions and were less effective thaninformal mentoring relationships. The authors suggestedthat by training potential mentors, the formal programcan approximate an informal mentoring relationship. Ina study by Allen and Eby (2004) of 249 engineering andaccounting mentors, the mentors reported no differencein mentoring in formal, as opposed to informal, rela-tionships. However, any mentoring program should ac-

knowledge the type of model to avoid as many pitfallsas possible. Tourigny and Pulich (2005) considered thepros and cons of a formal and informal mentoring pro-gram for nurses. The formal mentoring program matchedthe mentor–mentee so that a lack of interpersonal chem-istry and/or role conflict could be minimized. Theyrecommended a formal program with trained mentors,organizational support, specific target goals, and a planfor disengagement.

Whether formal or informal in design, the mentoringrelationship may take the form of a mentoring modelsuch as apprenticeship, competency, reflective, or infor-mal (Oliver & Aggleton, 2002). The apprenticeship modelis defined as “guided supervision” (Oliver & Aggleton,2002, p. 88), much like a trainee. Within the compe-tency model, the mentor coaches, observes practice, andevaluates a definitive set of behaviors or competencies.These competencies are developed and known within thespecific professional arena. The reflective model guidesthe mentee by dialogue with a more experienced prac-titioner. This model enables mentees to develop theirprofessional identity through more than just completingtasks or attaining professional competency. The reflec-tive model encourages professional development throughpersonal growth. The informal model can be integra-tive and combine any or all of the three other models.Because mentoring is not a static activity, the informalmodel can adapt over time to the needs of the mentee.As the mentee learns the competencies of the profession,the model can adapt to a more reflective model. Thesementoring functions and models need to be clearly iden-tified in order to develop a mentoring program for newNPs in primary care.

Characteristics of the mentor

Specific characteristics of a mentor are suggested in theliterature to promote the mentoring experience. Freeman(2004) suggested that specific qualities of the mentor canoptimize the mentoring relationship to promote success-ful transition for a new NP. Five hundred and sixty-fiveNPs with 0–15 years experience named five qualificationsof a mentor. They included being an authority in thefield, an educator, a counselor, a sponsor, and having per-sonal commitment. Gibson and Heartfield (2005) addedknowledge, skills, positive attitudes, and experience asnecessary characteristics of a mentor. Although thesetraits are desirable, being a seasoned professional does notnecessarily equate with being a good mentor. A men-toring program should, therefore, include self-reflectionby the experienced NP to assess her/his skills as amentor.

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Mentoring new nurse practitioners in primary care S. Harrington

Barriers to mentoring

Despite having characteristics conducive to mentoring,other factors could cause barriers to forming an effec-tive mentoring relationship. Hayes (2005) described timefactors, scheduling limitations, and space constraints asthe most common obstacles for nursing educators in de-veloping the mentoring relationship. Greene and Puetzer(2002) cited a lack of organizational support as a barrierto mentoring. Multiple studies reported gender affectingthe mentoring functions. Allen and Eby (2004) confirmedan earlier study of Burke, Mckeen, and McKenna (1993)that mentors provide more psychosocial mentoring to fe-male than to male mentees. Therefore, the gender ofthe mentor could become a barrier for developing thepsychosocial mentoring function for male NPs. Unwar-ranted self-critique is also cited as an obstacle to effectivementoring. Johnson (2002) explained that the mentoringrelationship can be adversely affected by erroneous self-dialogue by the mentor. Examples included:

� I must be successful with all of my proteges all ofthe time.

� I have to be greatly loved and respected by all ofmy proteges.

� Because I have invested so much as a mentor, myproteges should be equally hard working, equallyhigh achieving, and always eager to follow my rec-ommendations.

� My proteges must never leave or disappoint me.(p. 90–91).

Several studies of graduate education consideredbarriers to the mentoring relationship. In a study of 115graduate psychology programs, multiple obstacles weredescribed. First, there was lack of reward for the mentormonetarily, by promotions or with tenure. Only 14% ofthe programs studied offered reduced class assignments,and only 5% offered any compensation to the mentors.However, 41% of the programs did consider the men-toring experience an influence toward tenure (Dickin-son & Johnson, 2000). Wilkes (2006) also noted multi-ple barriers to mentoring in a literature review of studentmentoring and suggested peer mentoring to support thementor. Awareness of these potential barriers can helpmitigate the possible obstacles to a successful mentoringrelationship.

Benefits of mentoring

Despite the many potential barriers to mentoring,the relationship can benefit the mentee, the mentor,and the organization. For the mentee, the benefits ofmentoring have been studied in business, education,

and to a lesser degree in nursing. Mentoring has beenan effective tool for career benefits in the businessarena. In a meta-analysis, Allen, Eby, Poteet, and Lentz(2004) reported that career outcomes (compensation andpromotions) were higher among mentored persons. Jobsatisfaction, expectation for advancement, career com-mitment, and intention to stay at the current job wereall greater for mentored individuals (p. 130).

In qualitative studies, the psychosocial aspects ofmentoring, such as role modeling, counseling, and accep-tance, were considered more valuable than career men-toring. In a meta-analysis, Underhill (2005) examined theeffects of mentoring, comparing individuals who werementored to control groups of nonmentored persons. Themeta-analysis reviewed studies that had a formal or in-formal mentoring program and a comparison group ofnonmentored persons. Although much has been writtenabout the benefits of mentoring, the author found fewstudies that met the inclusion criteria. There were manycase studies and editorial commentaries about the bene-fits of mentoring but few studies that compared the out-comes of a mentored group with those of a nonmentoredgroup. Fourteen studies did, however, meet the criteriafor inclusion and they measured the outcomes of men-toring that included “organizational commitment, intentto stay, job satisfaction, tenure with the organization,number of promotions, self-esteem, perceived alternativeemployment options, income, work stress, work-family conflict, and promotion or career opportuni-ties”(Underhill, p. 295–296). The effect of mentoring wassignificant compared to the nonmentored groups. There-fore, these results suggested that mentoring did improvethe career outcomes for the mentored individuals.

In education, mentoring has been an effective tool forthe mentor and the mentored persons. Mentoring wasnoted to decrease the feelings of isolation for the men-tored and brought new insights for the mentor (Billings& Kowalski, 2008). In a qualitative study of 44 partic-ipants in a mentoring program for Head Start (Onch-wari & Keengwe, 2008), the program successfully metthe goals to improve the educators’ pedagogy. In a po-sition statement, the National League of Nursing (2006)supported mentoring to facilitate career growth anddevelopment across the span of the educators’ careerfrom the novice to the seasoned professional educatormentor.

Goals of mentoring

A mentoring program should formulate specific goalsfor the mentee. The Fellows of the American Academyof NPs (AANPs) had a 1-day “Think Tank” to outlinethe mentoring needs of students, new graduates, and

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seasoned professionals (2006). The invited group of nurs-ing professionals noted seven areas for mentoring thatcould assist new NP graduates. The items included “timemanagement and productivity, managing caseloads ofpatients, developing clinical skills, overcoming fear andanxiety, dealing with isolation, grasping the businessaspect of practice, and balancing clinical practice withpersonal responsibilities” (AANP, 2006). In a qualitativestudy in Australia of 45 general care physicians and 47NPs, the expectations of the mentee included personaldevelopment (such as increased self-confidence, shar-ing ideas, problem solving, or career development), pro-fessional relationship development (such as politics andinterdisciplinary relationship), and role development(Gibson & Heartfield, 2005, p. 58). These studies illus-trate the potential needs of the new NP and could assistthe mentor and mentee in goal setting. As a new NP en-ters practice, the mentoring relationship can help withtransition to the new NP role in primary care.

Outcomes of mentoring

The literature supports the conclusion that a mentoringrelationship with an experienced NP will benefit a newNP in primary care. The mentoring relationship can affectfour key domains of primary care practice: quality of care,productivity, job satisfaction, and longevity.

Quality of care

Although there are no specific studies regarding men-toring NPs and improved quality of care, peer review isregarded as a means to improving quality care for ad-vanced practice nurses. Briggs, Heath, and Kelley (2005)reviewed the literature regarding peer review for ad-vanced practice nurses. They developed three categoriesfor this review: structure, process, or outcome. Structureinvolved analysis of practice patterns and activities per-formed. In primary care, the practice pattern is stable dueto specific scheduled patient visits. The time allocation forthe patient visit is predetermined. Process review involvesthe actions of the NP such as ordering treatments or tests.Outcome measures are based on accepted recommenda-tions of experts in the field.

Process and outcome measures were studied for qualityof care in the outpatient setting. Chart review was usedin a study of 15 NPs at the Veterans’ Affairs Medical Cen-ter for process evaluation, which revealed with poor in-terrater reliability (Sheahan, Simpson, & Rayens, 2001).Interrater bias, as well as inability to differentiate qualitymanagement, were cited as causes of low reliability forthe measurements. In another study of process and out-come measures, physician and NP charts from eight insti-

tutions were reviewed (Smith, Atherly, Kane, & Pacala,1997). The outcome measures had higher interrater re-liability than the process measures. Five outcome mea-sures had fair to good reliability (> 0.40) and none of theprocess measures had reliability > 0.40. In outcome mea-surement, however, the results can be skewed because itis hard to differentiate decisions made by NPs from thosemade by physicians. Although outcome measurement isconsidered more reliable, it is difficult to measure for NPspracticing in a collaborative primary care practice.

As the new NP strives for quality of patient care, thementoring relationship can provide a venue for present-ing process and outcome review results. Sheahan andassociates (2001) reported that 70% of the NP partic-ipants preferred verbal and not written evaluations oftheir charting. A formative evaluation of the new NP viachart audit during the mentoring process could providevaluable feedback as part of the mentoring process.

Productivity

Through an effective mentoring relationship, the newNP may increase productivity and job satisfaction within ashorter adjustment period. Brown and Olshansky (1997),for example, noted that for new NPs in the first yearof practice, the NPs who had a supportive environmentwere better able to increase their productivity in primarycare. There were no further studies retrieved that showeda correlation between productivity and mentoring. Fur-ther studies are needed to assess the productivity of NPsas a result of a mentor relationship in primary care.

Job satisfaction

There are many studies that document the job satis-faction of NPs. In a study of 147 NPs, Kacel, Miller, andNorris (2005) evaluated job satisfaction using the MisenerNP Job Satisfaction Scale. They found 72% of respon-dents to be minimally satisfied to satisfied (Kacel et al.,2005, p. 30). These findings support the previous work ofKoelbel et al. (1991), Strickland and Hanson (1995), andKleinpell (1997). New NPs with 0–1 years of experiencehad the highest job satisfaction in all areas but all scoresdeclined in every category up until 8–11 years of expe-rience. The authors postulated that the high job satisfac-tion rate for NPs with no experience may be related tofinishing school and gaining employment with increasedpay. The study was done in the Midwest and results can-not be generalized as a result of varying state practiceregulations of NP autonomy. Although the authors sug-gested that mentoring may help the mentor and menteeincrease their job satisfaction, there were no other studiesfound related to this subject.

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Longevity

There is currently a critical shortage of PCPs and NPspracticing in this setting can help to fill this gap. How-ever, the NPs need to stay in primary care and not moveinto other areas of practice. In a similar situation, hospi-tals have experienced a shortage of nurses in the past.In response to high attrition rates of hospital RNs, theCalifornia Nurse Mentor Project was a 3-year pilot pro-gram developed to improve patient care through greaterretention of nurses (Mills & Mullins, 2008). Greene andPuetzer (2002) found that nurse recruits who participatedin the mentoring program at a Midwestern hospital hadhigher retention rates than for those nurses without aprogram. In consideration of the acute shortage of PCPs,a long-term goal of the mentoring relationship will belongevity in primary care practice.

Mentoring program development

Preprogram considerations

The first step in forming the mentoring relationshipis to contemplate potential ethical issues. Because therelationship involves overlapping roles and an emo-tional, complex bond with unequal power, careful con-sideration of possible pitfalls is warranted. In 2003, theAssociation for Australian Rural Nurses began the Men-tor Development and Support Project (Mills, Lennon, &Francis, 2007). Over a 2-year period, 101 nurses par-ticipated in training workshops for mentoring novicerural nurses in Australia. The program emphasizedpotential conflict within the relationship includingboundaries of the mentor. The boundaries were empha-sized in the program to avoid toxic relationships thatcould be harmful to the mentor or the mentee. Johnson(2002) recommended two approaches to avoid harmfulmentoring relationships with graduate students. First, hesuggested self-reflection of the mentor to ask:

� Is the professor role negatively compromised?� Is the professor exploiting the student?� Is the professor increasing the probability of being

exploited?� Is the professor’s behavior interfering with the pro-

fessional roles of other faculty? (p. 91).

Second, he recommended applying ethical code guide-lines to the relationship by “structuring the relationship,providing informed consent, avoiding all sexual intima-cies with current or former proteges, and giving carefulattention to interruption and termination of mentoring”(p. 91). Barker (2006) advocated planning for mentoringrelationship by evaluating for compatibility. These sug-gestions could be applied to an NP mentored relationship

to ensure ethical outcomes and avoid harmful relation-ships.

Training mentors

A mentoring program for new NPs in primary carerequires experienced NPs who are trained in the newmentor role. Two studies addressed the training of men-tors for healthcare providers. Ramani, Gruppen, andKachur (2006) reported that a half-day workshop at the11th Ottawa International Conference on Medical Edu-cation in Barcelona in 2004 yielded 12 suggestions fordeveloping effective mentors. Topics included definingthe mentor role, supporting and challenging mentees,maintaining professional boundaries, and reserving timefor mentoring. Other areas of interest were genderawareness, recognition and reward for mentors, peermentoring, mentor support, mentor forum to expressproblems, and program evaluation (Ramani et al., 2006).Another example is provided by the Military Nurse Corpsthat developed a 6-h workshop (Blankenbaker, 2005) totrain senior military nurses for mentoring new nurses.That program curriculum included defining the men-toring role, goals, benefits, and barriers for the mentor.Other topics included principles of adult learning, andmentee role definition (Blankenbaker, 2005, p. 123). Theprogram incorporated the basic concepts of mentoring;however, the literature review revealed no further stud-ies regarding implementation of the program. There wereno further studies that addressed components of a mentortraining program for healthcare practitioners.

Mentoring program

The literature review revealed no formal mentoringprograms for new NPs entering practice. In education,however, Hayes (2005) examined the precepted NP stu-dent relationship. She suggested journaling as a meansfor student mentees to assess their personal needs andgoals. The student mentee could describe desired accom-plishments, why the goals were important, and how theywould achieve the goals. In counseling pharmacy stu-dents, White (2007), a Pharmacy Leadership Coach, sug-gested journaling to detail goals, action plan, measurablemilestones, and a timeline (p. 1258). Reflective questionsinclude:

� What is your definition of success?� What excites you?� What is the most challenging part of your current

position?� If you could change something about your career,

what would it be?

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� What do you want your professional legacy to be?� In what ways do you think you inhibit reaching

your potential? (White, 2007, p. 1259)

There were no further studies regarding mentoring pro-grams for new NPs entering any field of practice.

Conclusion

As the population ages, even more PCPs will be neededto fill the expanding void of PCPs. There is already a crit-ical shortage. If future healthcare reform steers in the di-rection of expanded health care coverage, where will thePCPs come from? Physicians are increasingly opting forspecialty areas (Massachusetts Medical Society, 2008) sothat a major resource becomes the NP. The NP can pro-vide primary care. Although the literature supports thatNPs provide care that is equal to that of physicians forhealth outcomes, patient satisfaction, and healthcare uti-lization, the work can be overwhelming to the noviceNP provider. Studies show that new NPs benefit fromrole clarification as well as support with role transition.A mentoring program could help the new NP further de-velop competencies and capabilities as a PCP. However,there is a gap in the literature concerning any mentoringprograms for novice NPs. Nonetheless, the literature re-view has provided a mentoring definition, program mod-els, desired characteristics of NP mentors, and barriers tomentoring programs. It has also described the benefits,goals, and outcomes of a mentoring relationship. Theseinsights from the literature provide a foundation for thementoring program development. Still, more research isneeded to study the effect of a mentoring program onquality of patient care, productivity, job satisfaction, andlongevity of the NP in primary care.

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