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Development of an orientation and mentoring program for advanced practice nurses and physician assistants

Dissertation
Author: Mathew Sorensen
Abstract:
Role-specific orientation and mentoring programs for Advanced Practice Nurses (APNs) and Physician Assistants (PAs) are scarce. Where programs for mentoring have existed, APNs have reported higher satisfaction with increased retention rates. This project surveyed 155 APNs and PAs on orientation, collaboration, performance appraisal, roles, and mentoring/networking to guide the further development of a role-specific orientation and mentoring program. The survey findings led to a task group whose purpose was to develop an orientation and mentoring program. The new program consisted of multiple opportunities for networking and collaborating with advanced practice colleagues, tracking of progress and follow-up, department education of APN and PA roles, and performance appraisal. The new orientation and mentoring program provides a framework for future initiatives. Key words : orientation, mentoring, advanced practice nurses, physician assistants, transformational leadership

Table of Contents Dedication ...................................................................................................................................... iii Acknowledgements ........................................................................................................................ iv Abstract .......................................................................................................................................... vi Chapter I: Executive Summary ........................................................................................................1 Problem ................................................................................................................................1 Purpose .................................................................................................................................2 Significance for Systems Change ........................................................................................2 Theoretical Foundation ........................................................................................................3 Stakeholders .........................................................................................................................4 Mentors ................................................................................................................................5 Summary and Conclusions ..................................................................................................6 Chapter II: Review of Literature ......................................................................................................8 Literature Related to Project ................................................................................................8 Literature Related to Theoretical Framework ....................................................................11 Summary and Conclusions ................................................................................................15 Chapter III: Implementation ..........................................................................................................16 Project Objectives ..............................................................................................................16 Design ................................................................................................................................20 Setting and Population .......................................................................................................21 Data Management Plan ......................................................................................................22 Data Analysis .....................................................................................................................23 Protection of Human Subjects ...........................................................................................23

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Outcome Evaluation Process .............................................................................................24 Proposed Budget and Timeline ..........................................................................................25 Summary and Conclusions ................................................................................................26 Chapter IV: Project Findings and Results ......................................................................................28 Introduction to Survey .......................................................................................................28 Process Analysis ................................................................................................................29 Summary and Conclusions ................................................................................................63 Chapter V: Project Summary .........................................................................................................64 Discussion of the Findings/Outcomes ...............................................................................64 Recommendations for Systems Change.............................................................................67 Program Development .......................................................................................................68 Implications for Maintaining/Sustaining Systems Change ................................................74 Future Recommendations ..................................................................................................75 Plan for Dissemination of Results......................................................................................77 Summary and Conclusions ................................................................................................77 References ......................................................................................................................................80 Appendices: A. SMDC Advanced Practice Nurse and Physician Assistant Survey ..............................84 B. NIH Protecting Human Research Participants ..............................................................92 C. SMDC IRB Approval ....................................................................................................95 D. The College of St. Scholastica IRB Approval ..............................................................98 E. SMDC Research Grant Award Letter..........................................................................102 F. SMDC General Orientation Checklist .........................................................................106

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G. APN/PA Advisory Council Brochure .........................................................................109 H. SMDC Retention Questions for Three-Month Meeting .............................................112 I. SMDC Practitioner Section/Site Orientation ................................................................114 J. SMDC APN/PA Retention Plan ...................................................................................117 K. SMDC Mentor Responsibilities ..................................................................................119 L. Project Budget .............................................................................................................121

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List of Tables Table Page 1. Survey Respondent Degree Status ..................................................................................22 2. Q5. During your Employment as an Advanced Practice Nurse or Physician Assistant at SMDC, Have You Worked in More Than One Department? .....29 3. Q8. Do You Feel The Orientation Provided By SMDC was Specific To Your Role as an Advanced Practice Nurse or Physician Assistant? ...............................30 4. Q9. Were the Physician(s) and Department Staff You Would be Working With Aware of Your Role in the Department When You Arrived? ................30 5. Q10. Do you Feel the Orientation Provided by SMDC Adequately Prepared You to Practice in Your Department? .............................................................31 6. Q11. Aside from the General SMDC Orientation, Were You Given Orientation Within Your Specific Department? .............................................................31 7. Q12. Did Your Departmental Orientation Include Time With Your Collaborating Physician to Discuss Your Role? .............................................................32 8. Q13. Did the Departmental Orientation Cover Your Role as an Advanced Practitioner Within the Department? .............................................................32 9. Q14. During The Orientation Process, Were You Connected to Other Advanced Practice Nurses or Physician Assistants Who Could be a Support at SMDC ................33 10. Q15. Was Your Collaborative Agreement Established With Your Collaborative Physician Prior to Your Arrival at SMDC? .............................................33

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Table Page 11. Q16. During the Orientation Process, Were You Informed of the SMDC Advanced Practice Council and Who Your Advanced Practice Council Representative Was? .........................................................................................34 12. Q17. The Overall Quality of the Orientation I Received Through SMDC Was? ...........34 13. Q18. Would You Have Been Interested in an Orientation Directed Specifically to Advanced Practice Nurses and Physician Assistants? ............................35 14. 19a. Benefits and Retirement ..........................................................................................35 15. 19b. General SMDC Orientation ....................................................................................36 16. 19c. Time Spent with Recruiter ......................................................................................36 17. 19d. Epic Training ..........................................................................................................37 18. 19e. Credentialing ...........................................................................................................37 19. 19f. Risk Management ....................................................................................................38 20. 19g. Reimbursement Specialists .....................................................................................38 21. 19h. Department Orientation ..........................................................................................39 22. 19h. Other Areas of Orientation......................................................................................39 23. Q20. How Often is Your Collaborating Physician Available to You? ...........................41 24. Q21. How Satisfied Are You With Your Collaborating Physician‘s Availability? .......42 25. Q22. Do You Believe You Are Primarily a Member of: ................................................42 26. Q23. Have You Had an Annual Performance Appraisal Within the Past Year? ............44 27. Q23a. Who Was Included in Your Annual Performance Appraisal? .............................44 28. Q23a (specify). ...............................................................................................................45

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Table Page 29. Q23b. The Feedback I Received From My Annual Performance Appraisal is Useful? ........................................................................................................................46 30. Q23c. When Was Your Last Performance Appraisal (For Participants Without an Annual Performance Appraisal)? .....................................47 31. Q24. My Collaborating Physician Keeps Me Informed of the Progress of My Performance? .........................................................................................48 32. Q25. Has Your Collaborating Physician Expressed Any Concern Regarding Your Scope of Practice and His/Her Liability? .............................................49 33. Q25a. If Yes, How Have These Concerns Been Addressed? .........................................49 34. Q25b. Do You View This Issue as a Barrier to Your Practice? .....................................50 35. Q26. Do You Have Any Concerns Regarding Your Own Liability? .............................50 36. Q26a. If Yes, What Are Some of the Reasons For These Concerns? .............................51 37. Q26a (Specify). ...............................................................................................................52 38. Q27. My Department Manager Understands My Role as an Advanced Practice Nurse or Physician Assistant? ..........................................................53 39. Q28. My Collaborating Physician Understands My Role as an Advanced Practice Nurse or Physician Assistant? ..........................................................53 40. Q29. I Feel My Role as an Advanced Practice Nurse or Physician Assistant is Supported at SMDC? ..................................................................54 41. Q30. My Department Gives Me Time to Educate And Mentor Other Advanced Practice Nurses and Physician Assistants (Please Exclude Preceptorship)? .....................................................................................55

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Table Page 42. Q31. I Have a Mentor at SMDC Who is an Advanced Practice Nurse or Physician Assistant? ...................................................................................................56 43. Q31a. How Was This Mentoring Relationship Started? .................................................57 44. Q31a (Specify). ...............................................................................................................57 45. Q31b. My Mentor Has the Same Type of License as I Do? ...........................................58 46. Q31b. My Mentor Has the Same Type of License as I Do? – No (Specify) Participants Responding ―No‖ Were Directed to Specify: .............................................58 47. Q31c. How Satisfied Are You With Your Current Mentoring Relationship? ................59 48. Q32. I Would Be Interested in Being a Mentor For Advanced Practice Nurses and Physician Assistants at SMDC? ...................................................................59 49. Q33. I Would Be Interested in a Networking Group of Advanced Practice Nurse and Physician Assistants at SMDC?.......................................................60

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 1

Chapter I: Executive Summary Problem St. Mary‘s/Duluth Clinic (SMDC) Health System has lacked a specific orientation and mentoring program for advanced practice nurses (APNs). APNs starting employment at SMDC were included in a hospital-wide, general employee orientation. The first two years of employment within an organization have been identified as a crucial period for the establishment of a practice, feeling part of an organization, and ultimately deciding to stay employed (Mandrell, Hobbie, Deatrick, Lipman, & Hinds, 2004; Tri, 1991). Without a proper orientation and mentoring program, advanced practitioners—which included both APNs and physician assistants (PAs) at SMDC—often were sent out on their own to establish their practices, define their roles, and network with other practitioners (Mobley, Gray, & Estep, 2003). As a result, many advanced practitioners entering the SMDC system have consistently identified that they felt separated from their peers and that the task of establishing relationships was difficult (Advanced Practice Nurse and Physician [APN/PA] Retention and Recruitment Subcommittee, personal communication, September 9, 2008; SMDC, 2000, 2007). Retention of advanced practitioners within the first two years of employment at SMDC is low, especially retention of practitioners in the departments into which they were hired. In fiscal year 2007, nine APNs/PAs transferred from one SMDC department to another, in fiscal year 2008, 19 APNs/PAs transferred to different departments, and in fiscal year 2009, six APNs/PAs had made transfers. Eighty- seven percent of system transfers from one department to another were from the APN/PA group (Bussey, Heid, & Hanson, 2009). In 2008 the 19 transfers represented nearly 15% of the APN/PA group at SMDC.

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 2

Purpose The overall purpose of this project was to increase a sense of community and belonging among advanced practitioners at SMDC and thus improve retention rates by implementing a support system for the integration of advanced practitioners into the SMDC Health System. The more specific aim of this project was to develop an advanced practice orientation and mentoring program for APNs, which necessarily included PAs at this particular organization (SMDC). The project proposed to do this with a descriptive study that first collected quantitative and qualitative data from SMDC‘s APNs and PAs on current and hoped-for orientation and mentoring structures, processes, and needs, and second, convened a work group of selected stakeholders that used the collected and analyzed data to plan and develop the new orientation and mentoring program at SMDC. Significance for Systems Change This project proposed to bring about systems change within the SMDC Health System by implementing a new orientation program for advanced practitioners, which included both APNs and PAs at SMDC. Such a program has not existed in the past, and APNs and PAs were included in a general hospital orientation process that was not specific to their unique roles and responsibilities. This former orientation process was inconsistent from one department to another, resulting in some APNs and PAs receiving a strong orientation, while others lacked any formal departmental orientation before practicing at SMDC. The previous orientation process also lacked consistent follow-up of the new practitioner‘s progress. This project created a more consistent orientation process across the entire health system, ensuring a strong orientation process for every new APN and PA. As a result of this project, new advanced practitioners were assigned mentors to assist them in navigating through the orientation process, developing their

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 3

practices, and obtaining support as needed. This project responded to new APN/PA concerns of feeling isolated and alienated from their peers by providing a quarterly networking opportunity and knowledge of the APN/PA Council at SMDC. This orientation and mentoring program would provide a platform for the future implementation of competency assessments required to meet credentialing standards, should that become necessary. Without a role-specific orientation program, the implementation of such measures would be difficult due to the pending requirements of competency assessment at hire and at one year of employment. With a formal orientation process in place, these competency requirements could be integrated into the program as part of the orientation and the one-year performance evaluation, which was consistent with the competency peer review evaluation in process for physicians at SMDC. Theoretical Foundation This project was based on the theory of transformational leadership developed by James McGregor Burns (1978). His theory of transformational leadership proposed that transformation occurred when one or more persons engaged with others in such a way that leaders and followers raised one another to higher levels of motivation and morality (Burns, 1978). I believed that an orientation program with mentoring as a focus would transform those entering the system as they were mentored by those who already had established an advanced practice role at SMDC. As discussed in more detail in Chapter II, the mentoring relationships formed during orientation would emphasize Burns‘ elements of transformational leadership, idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. Of idealized influence, Burns (1978) wrote that ―transformational leaders behave in ways that allow for them to serve as role models for their followers‖ (p. 6). Burns (1978) described inspirational motivation as ―the ability for transformational leaders to behave in ways that

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 4

motivate and inspire those around them by providing meaning and challenge to their followers‘ work‖ (p. 6). He further described intellectual stimulation as ―the transformational leader‘s ability to stimulate their followers‘ efforts to be innovative and creative by questioning assumptions, reframing problems, and approaching old situations in new ways‖ (Burns, 1978, p. 7). Lastly, Burns (1978) taught that individualized consideration manifested when transformational leaders paid ―special attention to each individual follower‘s needs for achievement and growth by acting as a coach or mentor‖ (p. 7). As such, transformational relationships constituted the ideal framework for an APN mentoring program. A transformational leadership framework would build a sense of community for both new and experienced APNs and thus would result in the overall improved retention and practice of APNs. Stakeholders Numerous stakeholders were involved with this project. These included the SMDC Provider Recruitment Department that oversaw orientation of new providers, including APNs and PAs; the SMDC Credentialing Department that ensured new providers met all the criteria necessary to practice at SMDC; new and graduating APNs (and PAs) who would benefit from a role-specific orientation and mentoring program; and established APNs (and PAs) at SMDC who would be enriched through their roles as mentors and through newly developed networking meetings. Other stakeholders included the SMDC Human Resources Department, which would benefit from having orientation tracked and monitored; the APN/PA Council at SMDC, which would oversee the mentoring program and assign mentors through the Retention and Recruitment Subcommittee; and individual hospital and clinic departments that would benefit from the opportunity to take a larger role in the orientation of their advanced practitioners.

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 5

Finally, important stakeholders also included the APNs and PAs who would start employment at SMDC as better informed, more comfortable healthcare providers; the SMDC physicians who would benefit from more collegial relationships established with advanced practitioners during orientation and through their necessary participation in the orientation process; SMDC administration, who would see the benefits of increased provider retention; and ultimately, the patients whom SMDC served, who would be the beneficiaries of improved healthcare outcomes. Collaborative partners in this project included Linda Wagner, director of Clinical Education; Jean Rehl, director of Physician and Provider Credentialing; Jocelyn Heid, director of Physician and Provider Recruitment; Leslie Hanson, manager of Provider Recruitment; Carrie Prudhomme, recruiter in Provider Recruitment; and Colleen Renier, statistician in the Research and Education department. Other indispensable collaborators included Kim Lakhan, PA, Chair of the APN/PA Council; Ann Bussey, Vice President of Physician and Professional Services; and Mike McAvoy, Vice President of Hospital Operations. Meetings with these individuals were held as needed. They were, along with all the collaborative partners, essential members of the working team that facilitated this project. Mentors Initially, the mentors for this project were Ann Bussey, Vice President of Physician and Provider Services at SMDC; and Tom Patnoe, M.D., President of the Duluth Clinic at SMDC. These mentors were selected for their leadership roles within the organization, their relationships with other stakeholders, and their ability to direct the day-to-day work of this project to those who had the ability to make it happen. By virtue of her position as Vice President of Physician and Provider Services, Ann Bussey had many connections within the system to issues affecting

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 6

the advanced practitioners. She was a good resource for navigating through the system and could identify whom to talk to and what steps needed to be taken to successfully complete the project. Ann Bussey was also the administrative representative on the APN/PA Council at SMDC, which kept her abreast of current advanced practice issues. Ann Bussey was helpful in directing the project to the Provider Recruitment Department and identifying key members of the department who had previously worked on elements of orientation. Dr. Patnoe also was selected for his leadership role at SMDC. He brought a business and health system perspective to the table. Discussions with Dr. Patnoe included topics on decision- making, presentation of ideas, development of leadership skills, teamwork, and organizational processes. Dr. Patnoe provided a unique perspective to the project and was helpful in identifying the cultural and systems‘ needs of the organization. As the project developed, Leslie Hanson and Carrie Prudhomme of the Provider Recruitment Department became assets by identifying department and system needs, assisting in the development of checklists and a brochure, and pulling in other individuals as needed. Summary and Conclusions The SMDC Health System has lacked a role-specific orientation and mentoring program for APNs and PAs. Where orientation and mentoring programs have existed for advanced practitioners, such programs have resulted in successful integration into the advanced practice role and increased practitioner satisfaction (Bahouth & Esposito-Herr, 2009). The literature supports the key to retention of advanced practitioners is found in a strong role-specific orientation (Almadrones et al., 2003).The orientation process is further strengthened when linked with a mentoring program (Baggot, Hansinger, Parry, Valdes, & Zaim, 2005). The specific aim of this project was to develop a new orientation and mentoring program for APNs and PAs at

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SMDC and thereby increase retention and peer support for SMDC‘s advanced practitioners, which was its overall purpose. This was accomplished by completing a descriptive study that first collected quantitative and qualitative data from SMDC‘s APNs and PAs on current and hoped-for orientation and mentoring structures, processes, and needs, and second, convened a work group of selected stakeholders that used the collected and analyzed data to plan and develop the new orientation and mentoring program at SMDC. This project used Burns‘ (1978) theory of transformational leadership wherein both parties in a relationship learned from each other and were ―transformed‖ and improved together through a mutually beneficial relationship. Transformational relationships have been the basis of successful mentoring relationships and would provide an ideal conceptual framework for a new orientation and mentoring program for the APNs and PAs at SMDC. Stakeholders in this project were many and came from various SMDC departments with various interests and backgrounds. Stakeholders included the patients the APNs and PAs served. The mentors for this project were originally selected for their leadership roles within the organization and their knowledge of its processes. The first mentors were beneficial in identifying other helpful people within the system, and they provided direction for the project‘s initial steps. Later mentors and peers also made significant contributions.

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 8

Chapter II: Review of Literature Evidence-based literature on orientation and mentoring of APNs was limited. The Wisconsin based nursing group titled Linking Education and Practice for Excellence in Public Health Nursing (LEAP) also reported that there was a lack of available literature on nursing orientation programs (Haynes-Brokopp, 2007). Much of the available literature focused on the relationship between student and preceptor, rather than a mentoring relationship developed following graduation and/or upon hire to the APN role. The literature review for this project highlighted the available scholarship on transition to practice, orientation, mentoring, transformational leadership, and the impact that all these have had on retention of APNs. Literature Related to Project Turnover. Turnover of APNs often has been related to dissatisfaction with the job. In 2001, Misener and Cox developed the Misener Nurse Practitioner Job Satisfaction Scale to determine the level of job and role satisfaction of nurse practitioners (NPs). It was the first scale of its kind. The scale used a set of intrinsic and extrinsic factors related to job satisfaction. Intrinsic factors were those that arose from the job performance itself, including achievement, recognition, responsibility, advancement, and potential for growth (Misener & Cox, 2001). Extrinsic factors arose from the work environment including working conditions, interpersonal relationships, salary, status, security, administration, and supervision (Misener & Cox, 2001). Extrinsic factors accounted for the highest level of job dissatisfaction. Several extrinsically identified items on the scale tied into relationships with other NPs and had implications for development of a mentoring program to reduce NP turnover (Misener & Cox, 2001). In addition,

ORIENTATION AND MENTORING OF ADVANCED PRACTICE NURSES 9

the researchers indicated that extrinsic factors related to NP job satisfaction had great implications for hiring and retention of APNs (Misener & Cox, 2001). The Misener Nurse Practitioner Job Satisfaction Scale was further tested by Kacel, Miller, and Norris (2005), who studied job satisfaction through a self-administered questionnaire to 147 NPs in a Midwest state. The study found increased job satisfaction in the first year; however, after one year, job satisfaction significantly dropped (Kacel et al., 2005). NPs frequently identified extrinsic factors, such as lack of networking, collegiality, and professional growth as reasons for their job dissatisfaction, which can lead to resignation from a position and/or abandonment of the APN role altogether. Respondents to the survey confirmed the importance of extrinsic factors to retention of NPs (Kacel et al., 2005). Similarly, the Misener Nurse Practitioner Job Satisfaction Scale was used to assess the job satisfaction of 155 NPs in Arizona (Schiestel, 2007). NPs in this study also confirmed the importance of extrinsic factors in determining job satisfaction, listing collegiality, professional growth, and benefits as areas of dissatisfaction (Schiestel, 2007). Schiestel (2007) suggested that facilities employing NPs should identify areas of satisfaction for NPs that would reduce turnover and would increase awareness of the conditions and relationships that created frustration. Program development, including of mentoring programs, has been identified as a way to improve collegiality, provide networking, and assist practitioners with their transition into practice (Schiestel, 2007). Turnover of APNs has been costly. According to Mandrell et al. (2004), recruitment costs for an APN averaged $18,000 per opening, with some positions costing as much as $70,000 to fill. Reduction in turnover and increased retention of APNs thus has great implications for reducing costs and improving the financial status of an organization. For example, Banner Good

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Samaritan Hospital in Phoenix, Arizona recorded a 3.1% decline in nursing turnover one year following the development of a formal mentoring program (McKinley, 2004). In addition, New Hanover Regional Medical Center in Willington, North Carolina reduced their turnover rate from 34% to 8% after starting a mentoring program (McKinley, 2004). As of October 2008, there were approximately 20 unfilled APN positions at SMDC. Although the APN turnover rate at SMDC had not been reported at the time of this writing, available evidence suggested that development of a mentoring program at SMDC had important implications for reducing the number of open positions and retaining the APNs currently in the organization, yielding significant financial benefits. Orientation. Bahouth and Esposito-Herr (2009) developed an orientation program for hospital based NPs at the University of Maryland Medical Center in Baltimore, Maryland. Their program specifically targeted newly graduated NPs and included a 12-week orientation divided into six areas: (a) a streamlined process for completion of administrative ―startup‖ activities, (b) assignment of an NP preceptor to mentor the new employee, (c) clinical immersion for knowledge and skill development, (d) opportunities for socialization with peers, (e) identification of system resources, and (f) group mentorship in a setting focused on new NPs. Although they had not studied it during development of their orientation program, Bahouth and Esposito (2009) reported that their program ―had proven to be one of the key variables to successful integration of nurse practitioners‖ into their acute care clinical teams (p. 82). The Oncology Nursing Society (Almadrones et al., 2003) presented an abstract that showed APNs often assumed their roles upon completing advanced degrees without formal orientation to their unique roles as clinical experts, educators, consultants, and researchers. They noted that retention of APNs needed to begin with a sound orientation. Furthermore, they

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recommended a more structured orientation to APN roles and formulated a task force to develop an orientation for oncology NPs—a program that potentially could be adopted by hospitals and clinics to orient all incoming APNs. From their comprehensive search of the literature, LEAP (Haynes-Brokopp, 2007) concluded that orientation was a period of transition whose success required time and a highly structured, comprehensive plan. Baggot et al. (2005) developed an orientation and mentoring program for registered nurses (RNs). Although geared for new RNs, Baggot et al.‘s (2005) program of Preceptor Action Days (PAD) provided insight into nursing relationships formed within an orientation program. That is, orientation programs needed to include networking opportunities, which strengthened communication and collaboration. These kinds of strong relationships ensured the supportive integration of APNs into the organization (Baggot et al., 2005). One way to develop supportive relationships at orientation was through a mentoring program. Literature Related to Theoretical Framework Leadership. Transformational leadership has been identified as an effective method of mentoring. Although no nursing research or other scholarship existed on the relationship between mentoring and transformational leadership, some literature was found on the effects of transformational relationships of nursing leaders with those they led. Bass (1985) noted that transformational leaders held several behaviors in common, which they used to transform the qualities, attributes, and expertise of those they led. Raup (2008) reported that these behaviors included idealized influence, or charisma; inspirational motivation; individualized consideration; and intellectual stimulation. In order to implement these principles of transformational leadership effectively, Bally (2007) showed that there must first be an understanding of the ‗whole picture,‘

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which was demonstrated by recognizing the close interrelationships among leadership, mentorship, and organizational culture. Furthermore, reinforcement of leadership styles was essential to nurse retention (Raup, 2008). Failla and Stichler (2008) found that transformational leadership style was associated with higher levels of job satisfaction, resulting in improved retention. Robbins and Davidhazir (2007) maintained that healthcare organizations should evaluate individual nurse managers on units to promote transformational leadership qualities, which would result directly in staff satisfaction, staff retention, and patient satisfaction. In the case of mentoring, a transformational leadership style was one way to guide APNs through their first few years in an organization. As emphasized by Stordeur, Vandenberghe, and D‘Hoore (2000), transformational leaders believed that intellectually stimulating relationships were key to staff development, since such relationships encouraged a higher level of performance through analysis and exploration of practice. Bally (2007) found that the mentoring responsibilities of teaching, counseling, confirmation, accepting, friendship, protection, coaching, and sponsorship were clearly consistent with leadership behaviors. Finally, Murphy (2005) reported that transformational leaders empowered, encouraged, and motivated those whom they mentored. Mentoring. In a series of publications, Hayes (1998, 2001, 2005) disseminated a wealth of information about mentoring relationships in nursing, reporting that mentoring has long been viewed as an intense relationship between novice and expert that promoted the newcomer‘s success and socialization to the role. Mobley et al. (2003) defined mentoring as a process of guiding students in ―organizing their knowledge, acquiring appropriate skills, and critically thinking about diagnosis and management of health issues‖ (p. 51). Among others, Hayes (1998,

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2005) defined mentoring as a ―voluntary, intense, committed, extended, dynamic, interactive, supportive, trusting relationship between two people, one experienced, and the other a newcomer, characterized by mutuality‖ (p. 525; p. 442). Furthermore, mentoring was fulfilled through ―teaching, socializing, providing opportunity, sponsoring, coaching, guiding, protecting, advising and counseling, encouraging, inspiring, challenging, role modeling, supporting, and befriending‖ (Hayes, 1998, p. 525; Hayes, 2005, p. 442). Mentoring relationships in nursing often have manifested in the form of student-preceptor relationships in graduate nursing programs where students learned the skills of the profession from clinical preceptors in arranged relationships (Hayes, 1998). After graduation from APN programs, mentoring became a relatively new concept again. One study addressed the issue. In a study of 565 NPs following graduation, Freeman, Baker, and O‘Hara (2004) found that only 35% had a mentor. Of these, 6% were approached by the mentor for mentoring, 23% individually sought out a mentor, and 36% did not exactly know how their mentoring relationship started. This study highlighted the lack of mentoring following graduation and the need for formalized mentoring programs. However, it left a void in terms of the effects of mentoring on advanced practice satisfaction and retention, as did other research on mentoring programs. Some literature has looked at the characteristics of a mentoring relationship and how it should be structured. Barker (2006) cautioned that the mentoring relationship did not need to be an arranged relationship; rather, it needed to be carefully structured so that it was a long-term relationship, free from destructive behaviors, and beneficial to both parties. Nevertheless, the most successful mentoring relationships were arranged. In the United Kingdom, a standard practice has been to establish mentoring relationships between graduating APNs and physicians.

Full document contains 136 pages
Abstract: Role-specific orientation and mentoring programs for Advanced Practice Nurses (APNs) and Physician Assistants (PAs) are scarce. Where programs for mentoring have existed, APNs have reported higher satisfaction with increased retention rates. This project surveyed 155 APNs and PAs on orientation, collaboration, performance appraisal, roles, and mentoring/networking to guide the further development of a role-specific orientation and mentoring program. The survey findings led to a task group whose purpose was to develop an orientation and mentoring program. The new program consisted of multiple opportunities for networking and collaborating with advanced practice colleagues, tracking of progress and follow-up, department education of APN and PA roles, and performance appraisal. The new orientation and mentoring program provides a framework for future initiatives. Key words : orientation, mentoring, advanced practice nurses, physician assistants, transformational leadership