In the profession of nursing, one’s academic knowledge is not enough to provide high-quality patient care. Nurses require robust communicative skills, practical experience, the ability to work in teams, and confidence. Thus, newly graduated students who enter the workforce with limited preparation may encounter many difficulties while advancing through the levels of experience. This integrative review investigates the use of mentorship as a solution to the issue of new nurses’ low professional confidence. First, the paper will discuss the present problem in more detail and talk about the significance of researching it for nurses in the United States and globally. Then, after presenting the translation science framework to guide the investigation, the paper will document the methodology of the integrative review. The paper will then describe the results of the investigation and show what information current scholarship offers for the problem. Finally, the conclusions and recommendations for further research and nursing will be considered.
Problem Statement
New nurses may experience problems when entering the workforce. Many of these issues relate to the lack of preparedness to handle the workload of nursing. Confidence can positively affect nurses’ performance and their view of the job, while the absence of this feeling leads to high rates of turnover and job dissatisfaction (Horner, 2017). However, it remains unclear which ways of gaining confidence are effective. The guiding PICOT question for this paper is “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?” The problem focuses on mentorship as a way of gaining professional confidence for new nurses, providing them with a chance to gain knowledge from experienced nurses at the practicum site.
Significance of the Practice Problem
The issue of professional confidence has an impact on nurses’ personal feelings about the job as well as their performance, healthcare organizations’ success and financial stability, and patient outcomes. Nurses represent the largest group of healthcare workers in the US and their work greatly influences the overall performance in the industry (Buerhaus et al., 2017). Low job satisfaction and high turnover rates have been connected to low levels of confidence where nurses may not feel prepared to handle their profession and quit (Horner, 2017; Jones, 2017; Salarvand et al., 2018). Thus, a hospital or a nursing home could see a lack of experienced professionals and find itself understaffed or in need to continuously search for new employees.
Turnover leads to financial problems. This further affects the organization’s performance, as the ongoing search for new workers take away time and resources. Nurses who are not confident in their choice of profession may be unsatisfied with their conditions, which negatively impacts teamwork (Salarvand et al., 2018). As older and more experienced nurses continue to retire (Buerhaus et al., 2017), it is vital for the healthcare industry to develop a program that would pass on the knowledge of these professionals to the recent graduates.
Patient outcomes are also dependent on nurses’ confidence., Nurses unsure of their choices contributes to their poor performance. It should be noted that this problem exists globally, and disproportionally affects rural areas and underdeveloped communities where the lack of resources prohibits opportunities for new nurses from gaining confidence (Penz et al., 2019). Interventions as mentorships are vital to consider in order to understand whether they should become a pillar for new nurses’ integration into practice.
Theory or Translation Science Framework
The Knowledge-to-Action (KTA) Framework is chosen for this project. According to Field et al. (2014), this approach is often used to explain and guide explorations of knowledge translation. Two components – Knowledge Creation and Action – are the basis of the KTA framework (Field et al., 2014). When moving through the several steps of Knowledge Creation, information about any particular problem becomes refined and prepared for practical use. Then, steps for Action allow one to identify barriers to implementation, plan for knowledge integration, and monitor the process of translating the knowledge into practice (Field et al., 2014). As a result, the framework offers a comprehensive plan for a person or organization to introduce theoretical information and apply it in real-life situations.
As can be observed, this framework directly corresponds with the project’s question and the intervention. By using the KTA framework, the DNP student identifies the problem (low levels of confidence among new nurses) and suggests an intervention (mentorship) for the practice site. Subsequently, the framework helps one to identify barriers to implementation, such as the ongoing COVID-19 pandemic and nurses’ resistance to change. After the intervention is implemented, the KTA framework also guides the DNP student through monitoring and evaluation of the results. In the present project, this step is accomplished through qualitative data collection and appraisal. Overall, the KTA framework applies to the project’s problem as the latter deals with knowledge transfer for newly graduated nurses.
Methodology
Review Protocol
The aim of the DNP project is to assess the effectiveness of mentorship for increasing new nurses’ confidence. Therefore, the search for studies to review focuses on research about mentorship and its use in nursing. Moreover, papers that review the factors that influence nurses’ confidence are also considered, as their conclusions may suggest the use of mentorship and other approaches as solutions. The search for suitable sources was started using the Chamberlain University online library, as it provides access to a variety of databases. The focus was on medical and nursing databases, including MEDLINE, BioMed Central (BMC) Nursing, PubMed Central (PMC), PubMed, Sage, ProQuest, and ScienceDirect. After all options in the online library were exhausted, Google Scholar was utilized to access sources from other peer-reviewed journals.
The following terms were used in the search: new nurse confidence, nurse mentorship, and AMSN mentorship program. The search phrase new nurse confidence allows one to search for studies that focus on how newly graduated professionals experience gain or use confidence. The second search term, nurse mentorship, eliminates other potential approaches to gaining confidence and makes the search more refined for the project problem. Finally, the last search phrase, AMSN mentorship program, was used to see whether some recent studies have implemented the guide that lies at the foundation of the present project. Such sources could serve as examples of previous successes or failures. The combinations and parts of these phrases were utilized (for example, new nurse and mentorship) to make sure that the largest possible number of suitable sources could be identified. It is especially vital to search for papers containing nurse confidence and mentorship together, as these search terms are the basis for the current investigation, and they connect the problem and the intervention.
Inclusion/Exclusion Criteria
The DNP student applied several inclusion and exclusion criteria during the search to narrow down the results. First, all studies published before 2016 were removed from the selection. It is crucial for investigations to collect recent data that applies to the current state of the healthcare industry and pertinent problems that nurses experience. Next, only peer-reviewed studies were allowed to ensure that the information in them is trustworthy and reliable. Studies in languages other than English were eliminated due to the DNP student’s need to focus. It should be noted that articles that contained an abstract in another language but still were written in English were accepted.
Furthermore, only papers with fully available text were considered for review. This exclusion criterion was especially relevant for such databases as Google Scholar as it contains a variety of restricted sources, while other databases present many options for accessing data through the online library. Systematic reviews and primary studies were included for review, while other types of papers, such as theoretic discussions, research proposals, and literature reviews, were excluded. Primary studies have the most robust evidence as they present an investigation into a specific question with visible results that can be appraised. Systematic reviews also collect information from primary studies, allowing one to see evidence that has been systematized and appraised.
Finally, although the DNP student did not have strict exclusion criteria for the papers’ research methodology, quantitative studies were given higher priority. The present DNP project has a quantitative methodology, which asks for previous scholarship to also have results that could be used for comparison and appraisal. However, due to the lack of sources, some mixed method studies and systematic reviews with qualitative research had to be included.
Data Analysis
After the first search for studies was conducted, each study that adhered to the inclusion criteria was reviewed. First, the DNP student examined the titles of the articles to eliminate studies that did not have any connection to the project problem. While the database’s search engine used the phrases directly connected to the topic, it could still present studies that did not contain any pertinent data. Next, the abstracts of the papers that remained were read to determine whether they contained the information that would enrich the integrative review. After these additional inclusions, the DNP student analyzed the resulting body of literature.
To ensure the quality of data and its suitability for the project, the DNP student completed the Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix A). This tool allowed one to see the main elements of each paper and determine the overall quality of evidence available for the problem under investigation. Then, the studies were explored using qualitative methods, basing the review on thematic analysis. Due to the fact that many of the selected papers had mixed methods, and the majority of them employed different approaches, it would be difficult to appraise the data quantitatively. Moreover, several systematic reviews also contained information from qualitative studies.
The DNP student combined the research from the chosen sources and divided their main findings into several themes related to the project’s question. The themes were extracted from the papers’ research findings and discussions, using both quantitative and qualitative data to make conclusions about nurse confidence and mentorship and the connection between the two concepts.
Characterization of the Body of Literature
The search of the databases with the use of search words and exclusion filters yielded a large number of studies for preliminary analysis. These included 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), and Google Scholar (more than 17,000 results, including studies without full text). The addition of Google Scholar was crucial for the project, as the DNP student quickly identified the lack of appropriate studies in the available databases. After reviewing the paper’s titles and abstracts, 15 articles were selected for the integrative review.
The journals considered for the review present a mix of national, foreign, and international publications that covers a variety of healthcare and nursing topics. The majority of journals investigate nursing specifically, such as the Journal of Clinical Nursing, Journal for Nurses in Professional Development, or BMC Nursing. Some of the publications have a narrow topic, including Plastic Surgical Nursing, the Journal of Nursing Administration, and the Journal of the Association of Nurses in AIDS Care. Several international journals include the Asian Nursing Research, Enfermería Clínica, Iranian Journal of Nursing and Midwifery Research, and the International Journal of Nursing Studies. Overall, all sources considered for the investigation come from well-established, peer-reviewed publications with interest in nursing issues nationally and worldwide.
Out of the 15 selected studies, 12 are primary studies, and 3 are systematic reviews. All primary studies use the quantitative methodology in full or partially, as 4 papers employ mixed methods to answer their research questions. A significant number of fully qualitative studies was eliminated, which suggests a lack of quantitative data related to the project problem. One randomized controlled trial (RCT) that considered an intervention similar to a mentorship and new nurses’ confidence was found, which denotes a dearth of high-quality data in the field.
Similarly, the systematic reviews chosen for this project also contained qualitative data along with fully quantitative studies, which presented a barrier in using quantitative methods for the integrative review. The DNP student had to use qualitative methods of analysis, identifying themes by finding key terms, and mapping out the connections between the papers’ main ideas in relation to the present project’s question. Among the systematic reviews, the data was appraised based on its presentation, quality according to the Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool, and the conclusions made by the reviews’ authors (Appendix B).
As noted above, the main weakness of the sources is the lack of RCTs in the selected pool. Although many other sources are quasi-experimental, there are some nonexperimental studies present in the integrative review, which exposes the low quality of available evidence. The full elimination of qualitative data was near impossible if one were to collect at least 15 studies for the investigation. It is possible that the DNP student could find more papers that would enrich the topic in older studies, but their inclusion would undermine the quality of the examination as it would present potentially outdated data. However, the central strength of the collected scholarship is that it has clear thematic connections between mentorship programs and their positive benefits for new nurses. Quantitative and qualitative investigations considered in the review seem to support the problem considered in the present project and provide much information about how mentorship, confidence, job satisfaction, and other concepts correlate.
Findings Synthesis
The integrative review of the studies revealed five major themes that arose from the selected papers. The majority of studies are concerned with appraising the various benefits of mentorship. Out of these papers’ analysis, four of the five themes can be identified – retention, job satisfaction, competence, and confidence. The combination of these themes is connected to nurses’ confidence by the authors, many of whom do not focus strictly on one benefit of mentorship over others. Finally, the fifth theme is the connection between confidence and nurses’ performance and other aspects of their success in the practice site. The summary of findings presented at the end of this segment shows the limitations of the current research and shows how the synthesis of the papers can be used further.
Mentorship benefit: retention. One of the most obvious themes that connect a large portion of the available scholarship is retention levels among new nurses. Mentorship programs lower the rates of turnover for new nurses (Brook et al., 2019; Hussein et al., 2017; Jones, 2017; Salarvand et al., 2018). Mentorship opportunities connect nurses with much experience with newly graduated specialists, who enter the workforce and are overwhelmed with the amount of pressure they face every day (Hussein et al., 2017; Jones, 2017). As a result, many of them begin doubting themselves and their fit for nursing. This leads to high rates of turnover, as new nurses often do not just change jobs but leave the profession entirely (Jones, 2017; Salarvand et al., 2018).
Mentorship programs help new graduates understand their role in nursing and to accept the challenge of becoming a professional in the field (Brook et al., 2019; Hussein et al., 2017; Jones, 2017; Salarvand et al., 2018). For example, many new employees realize the higher capabilities and better see the ways to deal with the lack of knowledge or stress of the job (Brook et al., 2019; Hussein et al., 2017). The discussion is focused on nurses’ retention in the first year of practice, with specific attention to their self-realization as a nurse. Many nurses lack emotional and social support outside of mentorship programs, which leads to high turnover and other issues, especially low confidence and competence.
Mentorship benefit: job satisfaction. Another positive outcome that comes from mentorship programs is increased job satisfaction (Brook et al., 2019; Havens et al., 2018; Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019). Many of the papers reviewed in the previous segment also consider job satisfaction as a benefit of mentorship programs, relating nurses’ ability to understand their fit for the profession to the desire to stay and their overall enjoyment of their job. However, job satisfaction as a consequence of mentorship is also linked to nurses’ sense of accomplishment and an increase in patient care quality (Brook et al., 2019; Havens et al., 2018; Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019).
Another link is the reduction of burnout, which often leads to dissatisfaction and stress (Havens et al., 2018; Penz et al., 2019). The professional relationship between the mentor and the mentee gives the latter an opportunity to inquire about difficult subjects, which lowers stress without removing the authority of the new nurse over the decision-making process. Mentorships facilitate tight bonds between the nurses in the department, as many mentors and mentees also work together outside of the mentorship program (Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019; Zhang et al., 2017). This leads to better professional relationships, collaboration, and nurses’ satisfaction with their job (Horner, 2017; Hussein et al., 2017; Kurniawan et al., 2019; Zhang et al., 2017). Notably, the view of job satisfaction is multifaceted, focusing on professionals’ relationships and their knowledge and experience rather than financial or organizational issues.
Mentorship benefit: competence. The competence of nurses is described as the combination of professional skills, theoretical and practical knowledge, and the overall understanding of nursing duties (Hussein et al., 2017; Irwin et al., 2018; McKillop et al., 2016; Schroyer et al., 2016; Zhang et al., 2017). Mentorship programs are found to be highly effective in increasing nursing actualization (Hussein et al., 2017; Schroyer et al., 2016). In particular, the helping environment of mentorship relationships positively impacts the acquisition of practical knowledge (Irwin et al., 2018; Zhang et al., 2017). Furthermore, as noted in previous themes, mentorship increases nurses’ autonomy and self-realization, which also makes them feel more competent (Hussein et al., 2017; Irwin et al., 2018; McKillop et al., 2016). Thus, the ideas of job satisfaction and retention are closely connected to competence. This feeling ensures that nurses understand what they are doing and that they are educated and ready to tackle difficult tasks.
As older, more experienced nurses transfer their knowledge to new hires, they focus not on theory but on lived experiences and the particular needs to work in the specific environment (Irwin et al., 2018; Rizany et al., 2017; Schroyer et al., 2016). However, this transfer may not happen outside of mentorship programs that encourage nurses to share information and answer questions that they may not consider otherwise (Irwin et al., 2018; Zhang et al., 2017). As an outcome, nurses engage in conversations that urge both mentors and mentees to bridge the divide between novices and advanced professionals and increase informational sharing in the unit.
Mentorship benefit: confidence. Finally, the last benefit discussed in the papers is confidence. There exists a great lack of studies that specifically address the improvement of nurses’ confidence through mentorship programs. Although confidence appears in most papers, it is not measured quantitatively. In contrast, it is handled in an obscure way that is difficult to replicate. For example, most studies rely on qualitative measures or self-reporting or do not present any numeric confirmations of increased confidence levels among mentees (Brook et al., 2019; Hussein et al., 2017; Irwin et al., 2018; Worthington et al., 2016). One study by Zhang et al. (2017) offers a quantitative measurement and finds that self-confidence increases dramatically among newly graduated nurses who finish a mentorship program. Other papers show great increases in confidence, but these conclusions are based on nurses’ words during interviews or the authors’ assumptions about nurses’ overall satisfaction with mentorship as a whole.
The role of confidence in nursing. The previously discussed positive outcomes are interconnected with confidence in most papers, as confidence is almost never discussed separately from other factors that influence nurses’ behavior on the job. Thus, confidence links the majority of papers as a thread that supports new nurses’ ability to gain knowledge, communicate with mentors, enjoy their profession, and understand their role in the healthcare industry (Brook et al., 2019; Hussein et al., 2017; Irwin et al., 2018; Kurniawan et al., 2019; Worthington et al., 2016; Zhang et al., 2017).
The desire to stay at one’s site (retention) is linked by scholars to professional confidence, which new nurses rely on to fulfill their duties (Brook et al., 2019; Hussein et al., 2017). Job satisfaction relies on their self-realization, which is found to be inherently connected to self-confidence (Brook et al., 2019; Kurniawan et al., 2019). Confidence is also a part of competence as it is associated with successful communication and nurses seeking knowledge (Jones, 2017; Zhang et al., 2017). Therefore, confidence plays a crucial role in extracting all other benefits from mentorship. Without this personal aspect, many other advantages of working with experienced nurses seem challenging to achieve (Brook et al., 2019; Hussein et al., 2017; Irwin et al., 2018). For example, in rural nursing or in conditions of high pressure, the lack of job resources hampers new nurses’ ability to develop professional confidence (Makarem et al., 2019; Penz et al., 2019; Rizany et al., 2017). This finding emphasizes the role of robust mentorship programs in increasing confidence levels and positively affecting all other outcomes for new nurses.
Summary of the findings. Mentorship has been considered by a variety of authors in order to improve new nurses’ integration into the workforce. Such programs have many benefits for nurses and organizations, and the consensus is that mentorship is one of the best ways to help new graduates effectively use their knowledge and receive new skills vital for the profession. At the same time, the dearth of information about the effect of mentorship on increasing confidence levels is apparent. The majority of studies include confidence as one of the most important factors for nurses’ retention and job satisfaction, but most fail to present any quantitative investigation into the influence of the intervention on it.
Implications for Nursing Practice
The integrative review shows that the separate discussions of mentorship interventions and the role of confidence for nursing are abundant. The benefits of mentorship are discussed in quantitative and qualitative studies, and authors consider a variety of outcomes that new nurses may expect after completing a mentoring program. Similarly, the idea that confidence positively influences nurses’ retention, job satisfaction, self-actualization, competence, and other vital elements of the profession permeates the scholarship. However, there exists a clear dearth of quantitative evidence of whether mentorship increases the level of confidence among new nurses. For this reason, the present project, which aims to measure this influence in a quantitative way, is highly relevant to the current state of nursing practice.
It is vital to concentrate on the connection between mentorship and new nurses’ confidence to show another benefit of this intervention and to present evidence that can be easily replicated in a different setting. This project is intended to impact the meso-level of the healthcare system, as it deals with nurses’ tools and expertise and the state of practice in relation to the use of scientific evidence. The DNP student aims to show evidence of the mentorship programs’ effect on confidence levels. Another goal is to demonstrate a way for nurses to acquire the necessary skills to deliver high-quality patient care and create meaningful professional relationships.
Moreover, the findings of the project can also influence the macro-level of the healthcare industry that considers policy in healthcare and nurses’ education and professional growth. For example, as this level is concerned with continuing education, the paper may show that mentoring acts as a part of the educational system, helping new graduates to transfer from a strictly academic experience into practice. The findings may present strong arguments for future financial choices, possibly supporting investments into mentorship programs for all units in the hospital under investigation as well as other healthcare organizations.
Conclusions and Contributions to the Professions of Nursing
The integrative review shows that there exists a consensus on the role of mentorship programs for newly graduated nurses. Mentoring programs are found largely to be highly effective in helping new nurses to understand their role in healthcare (Kurniawan et al., 2019; Schroyer et al., 2016; Zhang et al., 2017). More than that, mentorship leads to lower rates of turnover (Brook et al., 2019; Hussein et al., 2017), higher job satisfaction (Brook et al., 2019; Irwin et al., 2018), and increased competency among new nurses (Hussein et al., 2017; Brook et al., 2019; Zhang et al., 2017). Thus, this intervention should be considered as a vital strategy for helping new nurses find their place in practice.
However, the scholarship also reveals that confidence serves as a foundation for many of the positive outcomes of mentorship, but it is not considered in research in much detail (Horner, 2017; Hussein et al., 2017; McKillop et al., 2016; Worthington et al., 2016). This finding makes the project question relevant to the contemporary problems that new nurses face. The investigation into the impact of mentorship on confidence levels should become a significant addition to the existing scholarship and consider whether the effectiveness of this intervention is connected to professional confidence levels in the same way as previous scholarship implies.
Recommendations
The findings of the integrative review point to several recommendations for research and practice that one can suggest. First, the overwhelming support for mentorship as a strategy of improving new nurses’ integration into the workforce leads one to argue that opportunities for having a mentor should be given to all new hires. Academic education is a vital part of the profession, but it is challenging for recent hires to adapt to the stressful environment of the healthcare system when they start working. Thus, education should not be treated as a strategy exclusively linked to learning institutions, and hospitals and nursing homes should offer mentorship programs as a part of new nurses’ experience.
In research, the lack of quantitative studies and the overall focus on low-quality evidence calls for a new investigation into the effect of mentorship on nurses’ confidence and the role of professional confidence on nurses’ performance. In particular, the integrative review shows that confidence is considered as a part of other studies but not as a separate aspect that significantly influences nurses’ performance. Moreover, the lack of RCTs reveals an unbalanced focus on mixed methods and qualitative studies that, while showing an interesting side of the discussion, do not allow for easy reproduction. Thus, one cannot transparently see how mentorship influences new nurses’ confidence and how the level of confidence may also be important for nurses’ performance and new of their profession.
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/Johns Hopkins University. May not be used or reprinted without permission.