CNNT CASE STUDY: Importance of Mentoring in Nursing Education

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Linda Takvorian, BSN, RN, CNN

Mentoring is an essential component in educating nurses and sustaining leadership. Mentoring relationships, benefits, and examples of mentor-mentee roles in the nephrology nursing setting will be addressed. An overview of the mentoring cycle in nephrology nursing will be explained.

Mentoring in Nursing

Mentoring is a vital process in nursing; it is a means for experienced nurses to orient and to facilitate acclimation of novice nurses to their new role. This process involves the art and science of guiding another through the purposeful actions of inspiring, coaching, teaching, directing, and leading an individual to a new place of cognition (Barker, 2006: Metcalfe, 2010). One of the earliest concepts of mentoring was documented in Greek history when Athena, the goddess of wisdom, disguised herself as Mentor, a trusted family friend, and assumed responsibility for Odysseus' household for the ten years he was away during his odyssey. During the time Odysseus was away, Mentor tutored Telemachus, his son, to become a successful ruler (Allen, 2006; Holmes, Hodgson, Simari, & Nishimura, 2010). Nurses teach and help other nurses by mentoring, which is crucial to maintain competency, encourage professional expertise, and promote leadership.

Both the mentor and mentee are engaged and committed to nurturing the relationship. This nurturing relationship may be described as a covenant between the mentor, one who shares his experience and expertise, and the mentee, who looks to the expert for knowledge to contribute to personal growth, consultation, and career advancement (Blauvaelt & Spath, 2008; McCoughen, O'Brien & Jackson, 2009; Mijares, Baxley & Bond, 2013). This bidirectional relationship is complex and composed of trust and respect.

Mentoring Relationships

The mentor-mentee is a creative partnership based on trust and respect. Both parties share the responsibility for this success. Mentors are expected to role model as leaders while sustaining a professional relationship with the student (Anderson, 2011). The relationship is bidirectional in that the mentor's expectations for the mentee are: maintaining open communication, readiness to learn, and analyze the processes (Barker, 2006).

The experienced mentor serves as a role model and instructor, and may work side-by-side with the mentee for the first six weeks of employment. The mentoring relationship may occur as a result of a structured orientation program and provide a smooth transition into the workplace (Wilson, Andrews, & Leners, 2006; McCloughen, O'Brien & Jackson, 2009; Mijares, Baxley & Bond, 2013). This arrangement encourages a balance of working independently, promotes critical reasoning, and assures provision of safe-effective care while following policies and procedures.

The mentor provides direction to work independently, promotes critical reasoning, and assures provision of standardized care while guiding the mentee to follow policies and procedures. The mentee's skills are periodically evaluated during orientation. This system assures delivery of safe, effective care, and ensures patient safety. The teaching focuses on assessment, clinical reasoning, and intervention. In one case, the patient was breathing at a respiratory rate of 40 breaths per minute with an oxygenation saturation of 95% on room air. The mentor asked the mentee to visually assess the patient, the environment, and communicate with the patient. Then the mentor asked the mentee to describe what positional changes could be made to the patient's environment to improve the patient's breathing. The mentee elevated the head of the bed from 15 degrees to 40 degrees, which reduced the patient's work of breathing. This intervention assisted the patient by reducing the respiratory rate to 22 breaths per minute, which included a benefit of improved oxygenation saturation to 99%. The patient expended less energy on breathing, improved their perfusion, and reduced their anxiety.

Benefits of Mentoring

Mentoring facilitates best clinical practices and professional growth for both the mentor and mentee. A mentor must remain current with clinical policies and practices to best guide the mentee. A nurse mentor may explain changes in medication administration for an individual undergoing hemodialysis. Medications may be dialyzed or "washed out" from the patient undergoing dialysis as the blood filter works to remove toxins and excess fluid, and balance electrolytes.

The mentor may explain to the mentee the physician's reasoning for a reduced dose of a particular medication. A dialysis patient may be dialyzed before, intraoperatively, or after surgery or a tooth extraction. In these cases, anticoagulation doses may be held or modified by the physician. The mentor may explain anticoagulation policy and when to call the physician with questions.

Leadership is sustained through mentoring. Formal training programs, internships, and preceptorships provide a foundation and the experience to prepare for leadership roles and evidence based practice (Feeg, 2008). An astute nurse manager may recognize leadership qualities in a novice nurse and informally mentor or groom the new nurse by laying the groundwork for a leadership role. A staff nurse may be asked by the charge nurse to cover breaks as preparation for promotion to a role of increased responsibility.

The mentor may give practical advice to the mentee regarding management of difficult situations. The mentee may question the mentor regarding nursing etiquette to facilitate his/her acclimation to the workplace, addressing concerns on how to approach their manager in regards to changing patient assignments or scheduling. Trusting relationships create lasting professional friendships, which contribute to staff retention.

A mentoring relationship improves communication skills. A nurse is responsible for communicating any concerns to the patient, the patient's family, and the interdisciplinary team while advocating on the patient's behalf. Teaming with an experienced preceptor may assist a novice to improve personal communication techniques. Allowing the mentee to observe, participate, and learn helps build confidence and a sense of identity.

Characteristics of a Healthy Mentor-Mentee Relationship

The mentor must be accessible and available to the mentee in order to address questions and concerns. Healthy mentor-mentee relationship are partnerships of intuitive, experienced, nonjudgmental individuals who are committed and empathetic to the mentee's learning needs (Blauvelt and Spath, 2008; McCloughen, O'Brien & Jackson, 2009). In one instance, a mentor oversaw a mentee who was assigned to the neonate intensive care unit (NICU). The mentor provided insight, guidance and direction while assisting the mentee to perform a hemodialysis treatment with a full blood prime circuit (immediate 50cc transfusion) on a 2.5kg newborn on life support with failing kidneys.

The mentor may serve as a professional role model or example for the mentee. It is essential for the mentor to think carefully before speaking or acting. The mentor's behavior influences the mentee. The mentor may indirectly influence the mentee's behavior, such as enrolling in continuing education or pursuing a nursing specialty.

Having a mentor listen to professional concerns may help the mentee to understand the stresses and adjust to the fast-paced demands in an intensive care unit, when the mentee is often new and vulnerable. The benefits of a mentor-mentee relationship for the workplace are: improved nursing staff retention, reduced isolation, increased opportunity for promotion within the workplace, less transition time for learning, and improved teaching effectiveness (Billings & Kowalski, 2008). It is essential for the mentor to be available to the struggling or overwhelmed mentee. During a busy day, there is little time for the mentee to process the events or disengage from the stress of providing care. The mentee may become emotional; realistically, it may be difficult for any nurse to accept that a patient may not do well, even though every feasible nursing intervention was performed.

The mentor may be astute and tailor the teaching accordingly to the mentee's needs in order to assist the mentee in progressing through the cycle. A novice nurse might ask an experienced nurse to hover or oversee as site care on a central venous catheter is performed. The mentee may demonstrate moving from advanced-beginner to competent when he/she is able to provide care without needing the preceptor-teacher or mentor by his/her side. As the new nurse gains experience and confidence with this particular skill, the task will be performed without assistance.

The mentor must demonstrate comportment to both the nursing profession and the responsibility of guiding a novice nurse. The mentor must be both academically and clinically proficient, to provide proper support to the mentee. Anderson describes a mentor as an experienced nurse who has completed an approved mentorship program and is qualified to support and assess students in the practice setting (2011). An approved mentoring program prepares the mentor with communication resources, assessment tools, and teaching skills, in order to provide a positive learning experience for the mentee.

The mentor must be willing and able to accept responsibility for directing and overseeing the mentee. The mentor must not only direct, but also correct and coach the mentee forward, striving for excellence. The fit mentor should exude enthusiasm, support adult learning, portray professionalism, and possess a working knowledge of workplace operations, nursing policies, procedures, and corporate mission and vision (Blauvelt & Spath, 2008; Anderson, 2011).

The mentor often anticipates the learning needs of the mentee. In this example, the mentor explained the process of hemodialysis delivery to a newborn and guided the new nurse through the process. Mentoring may require helping the mentee to recognize clinical challenges and apply clinical reasoning. This journey may be a slow repetitious process, but human knowledge and behavior may be modified through teaching and learning (Holmes, Hodgson, Simari & Nishimura, 2010).

One mentoring-based challenge is teaching the mentee how to holistically care for the patient. In this situation, we examine a teenager undergoing chemotherapy. The caring paradigm includes the patient, parents, and siblings, while integrating culturally competent care and providing developmentally appropriate communication into the daily framework or care plan. In this case, the nursing goal would be to communicate with the parents three small goals planned for the day: have the patient out of bed and sitting on a chair as tolerated, provide self- care (brush his teeth, wash his face), and take in nutrition (eat more than 20% of his meal). The interventions are to work with dietary staff to have popsicles and ice-cream available when the patient wants a snack. The nurse will explain to the patient and parents the importance of adequate nutrition and hydration during chemotherapy.

Teaching the mentee how to recognize adverse drug reactions in the pediatric patient is also crucial. The nurse is the last individual to assess the patient and double check medication orders. In many instances, a nurse will call to the medical team to question and confirm a particular prescription or dosing protocol. The experienced nurse recognizes potential problems; the novice nurse is learning what to recognize as a problem. Beyond having a willingness to learn, the mentee must be career focused, willing to accept criticism and remain committed to the relationship's outcome (McCloughen, O'Brien & Jackson, 2009). The mentor may recognize a patient problem and calmly teach the mentee how to provide care and respond to an adverse drug reaction.

The mentor must become familiar with a mentee's learning history. This process assists the mentor to better understand challenges or recognize upcoming pitfalls and remediate any deficiencies. The mentor must be able to analyze the mentee's learning style and optimize the learning experience (Riley & Fearing, 2009).

Mentoring Cycle

The mentee may pass through five levels of proficiency during their acquisition and development of skills: "novice, advanced beginner, competent, proficient and expert." (Benner, 2004). A mentor may delineate these stages by recognizing a mentee's milestones in clinical practice. A mentee starts as a novice, and gains experience learning and communicating with their mentor. The novice mentee passes to advanced-beginner mentee, and, eventually with time, the mentee may progress and acquire sufficient skills to become an expert practitioner and mentor.

Methods of mentoring are broad. Some mentors adhere to a rigid meeting schedule with goals, research and defined expectations. They anticipate problems and guide the mentee through challenges using methodologies such as transformational learning, remediation, and peer mentoring (Riley & Fearing, 2009; Jacobson & Sharrod, 2012).

In one example, a new nurse was assigned to perform hemodialysis on a newborn with her mentor as a guide. According to Barker, the mentor should engage in a process that delivers constructive feedback and nurtures a sense of professional identity (2006). The seasoned nurse partnered with the new nurse for the entire case from start to finish. This partnership assured that correct neonatal supplies were available, the physician's hemodialysis orders correlated with the most current patient's assessment and clinical snapshot, and quality delivery of care and documentation occurred. In this situation, the mentor provided clinical oversight, shared her experience, and thus minimized the high risk associated with the procedure.

Mentoring may involve assigning the mentee tasks or research to facilitate learning. It may also involve traditional and nontraditional learning techniques, as appropriate for the mentee. Holmes, Hodgson, Simari, and Nishimura describe three models of mentoring. The first model describes the mentor as asking questions to expose the mentee to a broader vision of a particular topic. For example, the mentor could ask the mentee to describe the pathophysiology of hepato-renal syndrome in patients waiting for a live transplant and the nursing care of this patient population. The second model involves assigning learning tasks to the mentee, and the third requires the mentee to study and observe a subject, and take notes (2010). All three approaches enable the mentor to assess the professional scope and academic capabilities of the mentee.

Reflection in Mentoring

The mentor and mentee must engage in sincere dialogue as they review their goals and reflect on how to achieve them. Mentors promote bi-directional communication, ongoing insight, reflection, critical thinking, clinical reasoning and clinical decision making in open discussion (Barker, 2006; Holmes, Hodgson, Simari & Nishimura, 2010, Wilson, Andrews & Leners, 2006).

The mentee may require a review on the relationship of electrolytes and fluid balance in critical care patients. The mentor may review case studies and pathophysiology with the novice nurse to improve his/her critical reasoning decision processes. Sepsis, or systemic bacterial infection, presents a challenge for new nurses. The patient's blood pressure usually drops precipitously while fluid output slows (urine output slows) and capillaries leak fluid into the tissues, which results in a fluid overloaded patient. Metabolic waste builds in the body, triggering a cascade leading to multiorgan system failure. Often, the retained fluid pools in the lungs causing pulmonary edema, shortness of breath, increased heart rate and an inadequate perfusion of oxygen to the tissues, acidosis, ischemia. Recognizing the signs and contributing factors to sepsis in a timely manner are crucial determinates of an individual's survival.

Mutual trust, caring, and in some instances confidentiality, provide a scaffold for the mentor-mentee relationship. Understanding the expectations and limitations will determine its success. McCloughlen, O'Brien, and Jackson located four mentoring themes: the connection (which is based on the partnership), the degree of mutual regard or respect, professional boundaries, and honoring the characteristics that contribute to self (2009). Examples of two common characteristics shared by nurses are varying degrees of altruism and ethics.

Barriers to Mentoring

Not all mentor-mentee relationships are successful. Barriers to a successful mentor-mentee relationship may be due to lack of faculty sensitivity, lack of academic preparation, cultural miscommunication, feelings of isolation, fear of failure, difficulty in establishing peer relationships, and lack of professional role models (Wilson, Andrews & Leners, 2006). Problems may occur if the mentor or mentee are unable to maintain the commitment or lose communication due to responsibilities or a career change (Billings & Kowalski, 2008).

The relationship will not survive if it is one sided or grossly imbalanced. Both parties must participate and contribute to its success while maintaining a focus on the goal—mentee success. Open communication or scheduled meetings using traditional face-to-face meetings, email, texting, internet, or virtual meetings contribute to the relationship's success.

Mentoring is an interactional process. There may be "bad mentors" in every field (Darling, 1985, p. 44). Failure to communicate or miscommunication may result in a termination of the relationship. Barker describes the four categories of toxic mentors as "avoiders, dumpers, blockers, and destroyers" (2006, p. 56). These behaviors may sabotage a mentee's professional development. The avoider is unavailable for the mentee. The dumper does not guide or assist but instead leaves the mentee overwhelmed in a time of need. The blockers control and sabotage the mentee by withholding crucial information. The destroyers and criticizers may exclude the mentee in a meeting or event, or embarrass the mentee. These relationships harm mentees and strip them of confidence.

It is the responsibility of the mentee to abandon a harmful partnership and seek out a more suitable mentor. Mentors have differing personalities, and not every partnership will break apart without issues. Incivility is not tolerated in the workplace, nor is a behavior model for nurses.

Mentoring is an ongoing active process. A successful mentor-mentee relationship may be based on open communication and mutually agreed upon with a written contract. It is vital that the mentor and mentee communicate realistic expectations and goals. A successful, mutually-beneficial mentor-mentee partnership requires reflection, and maintains a responsibility to examine the direction of the relationship to uphold a holistic, positive and civil attitude. The mentor serves as an experienced guide and provides the mentee with direction and insight to assist the mentee in achieving his or her goals. Successful mentors nurture mentees, who eventually develop into leaders and become mentors themselves.

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