Mentoring initiative to retain community-based registered nurses in palliative care

Over the last two decades, much has been put in place by the Nursing and Midwifery Council (NMC) of the UK to support undergraduate and registered nurses (RNs). This includes clinical mentoring for nursing students; the recommendation of 3–6 months of preceptorship for newly qualified RNs in post, and ongoing clinical supervision to support registrants in clinical practice (NMC, 2019a; 2019b). These mechanisms are underpinned by the NMC's requirement for RNs to revalidate every 3 years (NMC, 2019c). Each of these support mechanisms serves a clear purpose in maintaining standards of care for patients, upholding professional standards and ensuring public confidence in the profession.

On entering employment, employers must play their part in supporting RN employees to comply with their professional requirements. They must also provide a comprehensive induction that makes clear the requirements of the organisation to support nursing employees (NMC, 2019a; 2019b).

This article describes an initiative developed by Marie Curie Nursing Service Northern Ireland (MCNS (NI)) to support its newly appointed nurses by providing them with a 3-month peer-mentoring programme designed to be responsive to the needs of each individual nurse. Part of the reason this programme was introduced was to increase the likelihood that newly appointed RNs would remain in post and go on to become established, committed employees of the service. The MCNS (NI) provides nursing care and support for patients nearing the end of their lives in a wide range of community settings, including patients' own homes.

Peer mentoring (also referred to as ‘buddying’ in some literature) is not a new concept in human resource management and employment. It has been used to twin new employees with more experienced peers to assist the former in learning their role in a non-threatening relationship of equals (Cooper and Wight, 2014). Levitan (2019) advised that there can be no better way to support and develop a new member of staff than to provide them with a buddy from the very start of employment.

Laithwaite (2017), a proponent of buddying or mentoring and peer support for what she described as new starter employees, believed that ‘… such support makes a huge difference to the speed at which new recruits manage to settle into the role.’ The author viewed the role of a mentor as a person who is willing to be a point of contact, a friendly face and a source of information and advice. Laithwaite (2017) also clarified what a buddy/peer mentor should not be, and that is a counsellor or best friend. Although the role must be responsive to the needs of the mentee, in a nursing context, it must also be underpinned by professionalism on the part of both parties.

Writing on clinical mentoring for students of nursing, Gopee (2018) recognised that they acquire and develop their clinical skills predominantly in workplace settings, and this is no less true for newly appointed RNs in community palliative care. Here, they must perfect skills in situations where peer-mentoring guidance and support is invaluable (Walsh, 2014). Vitale (2018) commented on the mentoring of RNs, advising that employers should not only recognise its value in developing their clinical skills, but also in retaining them in post.

The NMC Code's (2018) Clause 9 requires RNs to share skills, knowledge and experience for the benefit of care recipients and colleagues. Although this very likely includes peer mentoring, in relation to MCNS (NI) peer mentors sharing their skills, knowledge and experience with mentees, management decided to provide peer mentors with additional financial remuneration in recognition that this role would require commitment and additional work, including outside the mentor's working time on an ad hoc basis.

Although RNs who take up posts in the MCNS (NI) are not necessarily new to palliative care nursing, MCNS (NI) recognises that, while RNs may have had end-of-life caring experience in other clinical settings, they may not have worked for a dedicated palliative care service in patients' own homes-a role that requires lone working, often during the night, in what can be challenging and stressful situations.

In late 2014, the MCNS (NI) home nursing service manager identified that attrition rates for newly appointed RNs had become unacceptably high. In 2015 alone, nine RNs out of a total of 23 appointed left within 12 months of taking up their posts. At this time, MCNS (NI) management started discussions to establish why recently recruited RNs were leaving. Alongside this, management reviewed the terms and conditions of employment for RNs to see if any changes to working practices could account for the increased attrition. Although caring environments do evolve, managers found that little had changed over the 12-month period, with regard to the service and the needs of terminally ill patients and their next of kin, that would explain why attrition rates for recently appointed RNs were high. Further, when the terms and conditions of the RNs' employment were benchmarked against those of RNs of a similar grade in other sectors, they were found to be no less favourable. Thus, nothing could be identified to account for newly appointed RNs leaving the service.

This posed two questions: why did some newly recruited nursing staff leave the community nursing service shortly after recruitment, and what could be done to prevent this expensive loss of essential and valuable staff?

First, management held discussions with MCNS (NI) clinical managers to obtain their views on why these RNs resigned shortly after appointment. A review of exit interviews with the nine RNs who resigned in 2015 provided no insights into the reasons for them leaving. Alongside this, fact-finding discussions were held with RNs providing clinical supervision for all RNs to see if they had any understanding of the situation. From these discussions, anecdotal evidence suggested that, on commencing employment, RNs often claimed to experience feelings of loneliness and isolation in their work, which they attributed to lone working in community settings, and in not having identified experienced peers with whom to discuss issues and seek guidance and support when it was most needed.

The RNs also identified the need for some form of signposting to make it more straightforward for new RNs to access key staff in the organisation when they had concerns or queries. Completing online mandatory training and understanding key policies and guidelines were also identified as being difficult for newly appointed RNs. Furthermore, the RNs claimed that a system of support that operated outside the normal 9 to 5 working day would be particularly useful, as most of them worked shifts over the 24-hour period. Other issues raised related to accessing general guidance on issues such as submitting personal work availability and interpreting allocation rotas, much of which required online completion. This appeared to indicate that many of the RNs found the electronic or digital side of their work particularly challenging. It also became apparent that what newly appointed RNs did not want was another formalised induction programme, but rather, the support of an identified experienced peer mentor who would be available to them for the first 3 months of their employment and who would provide them with support, guidance and the wisdom of experience on request.

The clinical managers suggested that, although the 4-day Marie Curie corporate mandatory induction programme provided for newly appointed RNs was necessary, it did not offer solutions to problems at the coalface as they arose in practice. Although not certain, the clinical managers suggested that the above factors could well have played a significant part in newly recruited RNs leaving the service soon after appointment. From these discussions, it became apparent that there was a need for a system of peer mentoring that twinned each newly appointed RN with a more experienced RN peer who would support, guide and advise them during the first 3 months of employment.

For this reason, the MCNS (NI) management team in conjunction with the RNs working within the service developed a peer-mentoring programme for all newly appointed RNs to help them make a smooth transition from appointment to confident employee, thus increasing the possibility of them remaining within the service. It was accepted that, once the peer mentoring period ended, the new RNs would then progress onto the clinical supervision support system provided for all RNs.

Development of the mentorship programme

A 3-month peer mentoring programme was developed for all newly appointed RNs on completion of the corporate induction. Each new RN would be matched with a more experienced RN peer mentor working within their geographical area. Mentors could have more than one RN mentee. The programme was to be sufficiently flexible to respond to the specific needs of each new RN. Peer mentors would be remunerated for providing this support, and it was determined that this remuneration would comprise payment for up to 8 hours of additional work, payable at their normal hourly rate in a single payment, on completion of each new RN's 3-month peer mentoring support period. The role required peer mentors to make face-to-face, telephone and other agreed contacts with their mentees on at least six occasions and to respond to mentees queries and concerns as and when they arose. Records of contacts were to be kept by both parties.

Although prescriptive in its outline, the system allowed for enough flexibility to meet the specific needs of each new RN. Management felt that committing to a peer-mentoring programme was worth the expenditure and staff time, if it demonstrated a benefit to newly appointed RNs and resulted in their staying in post.

The programme was to be monitored by the service management team to ensure a good level of consistency in mentor and mentee commitment. The record of contacts between the parties was to be made available to managers to identify any problems that needed addressing at an early stage. Feedback from both parties was to be collated to assist management in ensuring that the programme was clear, robust and genuinely supportive of the needs of newly appointed RNs.

With regard to confidentiality, every effort was to be made to ensure discussions between the peer mentor and RN were only made available to management directly involved in the programme, thus making it easier for newly appointed RNs and their peer mentors to be comfortable with the initiative. Although the mentoring programme was not designed to be about performance management, it was recognised that issues relating to performance might emerge that required other managerial intervention and support.

Evaluation and findings

The first allocation of peer mentors to newly appointed RNs commenced in early 2016. In June 2019, when the peer-mentoring programme was in place for approximately 3 years, an evaluation was undertaken. A questionnaire was developed and sent electronically to the 26 mentees who completed the 3-month mentoring programme between the beginning of January 2017 and the end of June 2019 (Box 1). A questionnaire was also developed and sent electronically to their respective peer mentors (Box 2). Each group was asked to evaluate their experiences of the peer-mentoring programme from their perspective.

Box 1.Questions asked of mentees

Box 2.Questions asked of peer mentors

Table 1 shows the number of RNs appointed to deliver the service between January 2015 and December 2019. These appointments coincided with a recruitment drive due to new RN service development rather than replacement of RN leavers. It also shows the number of newly appointed RNs who received peer-mentoring support and who left the service within 12 months of joining.

Summary of mentee responses to questionnaire based on their 3-month peer-mentoring experience

In general, the responses to the questionnaire indicated that the mentees felt the 3-month peer mentoring programme was beneficial and worked well. It provided them with an experienced, named peer mentor who was willing to meet with them and answer their queries and problem-solve on a planned and ad hoc basis. The mentees indicated that the peer-mentoring support helped them, as they were able to get answers to queries in a timely manner. They indicated that it made them feel valued and part of a team, and thus less isolated. It also helped them develop confidence in the knowledge that there was someone available day or night to address their concerns. As one mentee put it:

‘… the peer-mentoring relationship helps reduce your lack of confidence in that you can address questions to a peer mentor in a relationship of equals that does not make you feel stupid or inadequate.’

The mentees all indicated that they would recommend peer-mentoring support for all nurses newly appointed to the MCNS.

Summary of peer mentor responses on providing the 3-month peer-mentoring programme

In June 2019, 19 newly appointed RNs completed their 3-month peer-mentoring programme, and the seven peer mentors who supported them were asked to complete an online questionnaire on how valuable they thought it was for the new RNs.

The mentors said that meeting new RNs at an early stage was useful because it allowed them to establish a system of peer support. They felt that it was important for them to share their experiences and knowledge of palliative care provision in the community with their mentees as it helped establish a team. The new mentees adopted individual ways of contacting mentors, and this was viewed as desirable by mentors. Three mentors identified their role as enriching their own knowledge and believed it gave them a fresh perspective on their work.

Overall, the peer mentors commented that mentoring was a good experience and that they had enjoyed every aspect of it, facing no challenges. Although it placed increased pressure on their workload-and this was especially true when a mentee required an exceptional amount of support to develop confidence and competence-it was something they were happy to provide.

Support provided by peer mentees ranged from being a role model to being a teacher and a friend. Others commented that the mentee role required them to answer queries and listen to issues about a difficult shift and caused them to recognise their own needs and limitations with regard to mentoring. They also found that new RNs needed help recognising when and whom to contact in a range of different circumstances.

All mentors were clear on what they expected of newly appointed RNs. One mentor commented that:

‘Supporting a mentee required significant commitment from the mentee, including a willingness to identify learning needs and being open to acquiring new skills, especially IT.’

They said it was important for them to emphasise the need for mentees to seek timely advice and direction so as not to risk exceeding their competence. The mentors expected mentees to develop good working relationships within the nursing teams rather than working remotely. The mentor's roles included advising mentees to work within the charity's policies and protocols.

Having a dedicated one-to-one approach to peer mentoring was considered very effective by both mentors and mentees. Skype and other IT communication systems were important to peer mentoring, although these could not always be used by both parties or even relied upon in networks with poor internet service. Face-to-face or telephone contact was still the preferred method for all respondents. Peer mentors also helped new RNs to access the IT system to be able to demonstrate their availability for work, book holidays and complete required online learning.

Overall, the peer mentors commented that the mentoring role was positive, interesting and valuable, and that they enjoyed it. It was also considered by both parties that actual face-to-face meet-ups were the key to success.

Conclusion

The implementation of the 3-month peer mentoring programme has been shown to have impacted positively on the retention of newly recruited RNs to the MCNS (NI) over a period of 3 years. It has provided each newly appointed RN with an identified, experienced RN peer mentor who is remunerated for providing them with guidance, support and advice as and when required. This system of support is managed within a formal framework and records of contacts are kept by each peer mentor so that it can be evaluated for its effectiveness over time and value for money. To date, this peer-mentoring support programme has been successful in retaining RNs, and it has been rolled out to all newly appointed Marie Curie RNs working in the community within the Northern Ireland region.

Finally, peer mentoring is a very different system of support for newly appointed RNs, as it provides for a more responsive, unique experience compared with that provided by a corporate induction programme or ongoing clinical supervision. Although the latter two are important, peer mentoring encourages the development of good working relationships that enhance team work and collaboration. It also helps reduce the sense of isolation and stress for newly appointed RNs that can be part of lone working and can lead to the loss of an organisation's most vital and expensive resource: its staff. Remunerating RN peer mentors to provide 3 months of peer mentorship support for newly appointed RNs requires of them commitment, flexibility and fast-paced responses to queries, as and when they arise. Thus, in MCNS (NI) management's view, it is indeed money well spent.

KEY POINTS

• Lone working for newly appointed registered nurses (RNs) in community palliative care can be lonely, isolating and challenging
• Putting a 3-month peer mentoring support programme in place can keep newly appointed RNs in post and help them make the transition from new employees to confident practitioners
• Providing a financial incentive for peer mentors means that they are compensated for their time, support and experience and are valued members of staff.

CPD REFLECTIVE QUESTIONS

• Do newly appointed registered nurses (RNs) working in community palliative care need support from a peer mentor for a ‘defined period of time’ even if they have previous clinical experience?
• Should RN mentors receive financial remuneration for providing peer mentoring support that is additional to their roles?
• How does peer mentoring of newly appointed nurses in community palliative care sit alongside induction programmes and clinical supervision?