Nurse Mentoring: A Scoping Review

Introduction: Mentoring programs minimize stress and anxiety in recent graduates and in newly recruited nurses, guiding their careers and enabling them to retain their skills and correctly care for patients. The objective of this scoping review is to explore and summarize the existing literature on mentoring models and programs in the clinical nursing context. Methods: The databases searched include PubMed, Embase, Cochrane Library, Epistemonikos, Cuiden, Scielo, MEDES, OpenGrey, Trove and MedNar. Published and unpublished studies worldwide that included nurse mentoring programs in a clinical context, in public and private systems and primary, secondary and tertiary healthcare settings, and articles published in English, French, Spanish and Portuguese, were included. Nurse students and training specialists were excluded. The papers were screened by two independent reviewers. In cases of discrepancy, a third reviewer made the decision. Results: Eleven studies were included. Most of them were conducted in the USA. A wide range of nurse mentoring programs were identified with highly variable characteristics. The duration of the programs and the evaluation systems were different, but the expected results matched. Conclusions: Mentoring programs need more in-depth and extensive study. In spite of their differences, they all lead to improvements for nurses, patients and organizations. A gender influence was found in our results, which could be studied in future research.


Introduction
Mentoring is defined as "Intentional mentoring relationships within the setting of a structured program that is bound by a time frame and defined objectives" [1]. It refers not only to the improvement of knowledge, but also the concept of integration within a group and an institution. There exist different forms of mentoring, but not all are the same. It may be called mentoring, a training program, or an induction program. This scoping review focuses only on nurse mentoring programs.
The first reference to mentoring in the literature was in Greece, but the first reference to specifically nurse mentoring was in England in 1960 [2]. When discussing mentoring, it is important define two essential categories: the mentor and mentee.
A mentor is a professional with important experience and knowledge who assumes the responsibility of guiding, advising, teaching and helping others to learn competency, improve their professional expertise and favor leadership. These attributes are not only about labor requirements, are about personal requirements too. Mentees' growth requires mentors to improve their trust; motivate them; and use knowledge and reflection (as important tools of learning) to teach them important strategies to resolve problems, make decisions and develop good organization capacity, always in a continuous process of evaluation, while remaining unprejudiced and being a supportive facilitator and partner.
The mentee is the person who receives the support to be able to develop their skills, as well as to achieve integration in a group or an institution. Assistance quality and security are actually important points in the context of sanitation. Mentoring programs are used in nursing practice as an essential part of the curriculum. This is completely normalized in the student context, and in certain countries in the context of sanitation, especially English ones.
Actual clinical nursing settings are complex and changing, making them a very interesting candidate for improvement in a clinical context. Nurse mentoring programs provide minimal opportunities for professionals who join new health services, ranging from new graduates to professional nurses who come from other services. The form, duration, organization, and even the impacts of mentoring programs in the literature are very diverse [3]. This review will contribute to determining which nurse mentoring models/processes exist in the clinical context, as well as their impacts and contributions to institutions and to professionals.
Mentorship, mentoring, training programs, and induction programs have been shown to be fundamental to guaranteeing adaptation and training at the healthcare level of new nurses [4], promoting quality care and integrating theoretical and practical nursing training. Nurse mentoring contributes to reducing the risk of mistakes and professional stress, and has already been shown to reduce the risks of clinical variability and staff mobility, as well as improving satisfaction [5,6].
The objective of this scoping review is to explore and summarize the existing literature on mentoring models and programs in the clinical nursing context, including their forms, duration, organization, and impacts on nursing professionals and healthcare institutions.
Review question(s): • What kinds of mentoring model or processes exist in the clinic nursing context? • What is the impact of mentoring programs on nursing professionals? • What is the impact of nurse mentoring programs on healthcare institutions?

Participants
This review included studies conducted worldwide that focused on mentoring programs directed specifically at nurses, ranging from bachelor-level nurses to those with doctorate degrees, in a clinical context. The studies primarily focused on nurse students, and academic experts or individuals other than bachelor-level nurses were excluded, with the objective of determining the impact of mentoring programs on people who have at least a bachelor 's degree.

Concept
This review considered studies in which the outcomes were related to mentoring programs for bachelor nursing in any clinical context in any country, as well as their impact on nursing professionals, and the impact of apply them in health institutions. Examples of regulatory activities included programs that explained the different methods used, the positive or negative impacts on nursing, as well as the benefits or drawbacks for institutions, like promoting quality care and integrating theoretical and practical nursing training and reducing the risk of mistakes and professional stress, having already been shown to reduce the risks of clinical variability and staff mobility, as well as improving satisfaction.

Context
This review encompassed mentoring programs in various clinical areas within public and private healthcare systems. Primary (primary care providers), secondary (specialists) and tertiary (specialized care in a hospital) settings were included. The countries selected for inclusion in this scoping review were limited to English-speaking, Spanish-speaking, French-speaking and Portuguese-speaking countries. English was selected because 95% of publications are written in this language. The rest of the languages were selected based on the knowledge of the authors.

Types of Sources
This scoping review considered all of the information included in any of the databases and the grey literature for unpublished documents, trying our best to capture reality in the most reliable way. The reviewers decided to keep the source of information "open" to allow for the inclusion of any and all types of studies. Otherwise, important information could be lost.

Methods
The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a protocol, registered on the Open Science Framework platform (http://osf.io/uh7q2?view_only=3c7eec1ccbed4798a7e4223472d551c2 (accessed on 1 March 2021)). The Joanna Briggs Institute (JBI) methodology for scoping reviews was followed [6].

Search Strategy
The search strategies were developed by an experienced medical librarian (MGC) and peer reviewed by another librarian (CCA) according to best practice recommendations [7]. The search strategies used Boolean operators, truncation terms and keywords, identified using medical subject headings (MESH, via the US National Library for Medicine MESH browser), and Embase subject headings (EMTREE, via Embase.com (accessed on May 2020)). The reproducible search strategy for PubMed can be found in Table 1. To identify potentially relevant documents, a comprehensive literature search was conducted using the most impactful bibliographic databases: MEDLINE (PubMed), Embase (via Embase.com (accessed on May 2020)) and Cochrane Library. We also searched in additional databases, including Epistemonikos, Cuiden (Index Foundation), Scielo (Scientific Electronic Library Online) and MEDES (Medicine in Spanish), as well as in some grey literature databases for unpublished documents: OpenGrey, Trove and MedNar. Finally, we used the search engine Google Scholar. All searches were run in May 2020. The analysis time was arduous, which prolonged the investigation, ending in October 2022. No time limits were applied to the search strategy. The studies were limited to those published in English, French, Spanish and Portuguese.

Source of Evidence Screening and Selection
The final search results were exported into Mendeley, which was used to manage the references and remove duplicates. The Rayyan [8] citation management platform was used to screen and review the articles. Rayyan is largely intuitive to use, with significant potential to lighten the load of review authors by speeding up this part of the process. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria for the review. Any disagreements that arose between the reviewers were resolved by a third reviewer guided by the inclusion criteria. The full texts of potentially relevant evidence were retrieved for further review against the inclusion criteria.

Data Extraction
The data extraction process followed a predefined data extraction form based on the review protocol. Data were extracted from papers included in the scoping review by three independent reviewers. There was no need to contact the authors of the papers for missing or additional data. Any disagreements that arose between the reviewers were resolved through discussion and consensus.

Analysis and Presentation of Results
A data extraction table based on recommendations from the JBI Reviewer's Manual [6] and specified in the review protocol, registered in the Open Science Framework platform, was used. The information extracted included standard information (title, author, year of publication, language, country of origin and study design).
During data extraction, it was found that the information related to the characteristics of the nurse mentoring programs was highly variable. For this reason, a second table was created to facilitate the description of the mentoring model/processes that exist in the clinic nursing context. The information added included the hospital's name and features, program, duration, participants, objectives, development, outcomes and measurement tools.

Search Results
The database searches identified 1521 records. In total, 71 additional records were identified through other sources. A total of 52 duplicates were removed, leaving 1540 records. A further 1153 were not relevant, as determined by the initial screening of titles and abstracts. A total of 387 articles were retrieved in full text. Of these, 376 were excluded. A total of 11 records were included in this review. The results of the search are presented in a Preferred Reporting Items for Systematic Reviews and Metanalyses extension for Scoping Reviews (PRISMAScR) flow diagram [9] (Figure 1).

Inclusion of Sources of Evidence
Eleven articles met the inclusion criteria and were included in this review. The articles included nine journals, eight of which were nursing journals [10][11][12][13][14][15][16][17][18]. The publication dates ranged from 1992 to 2021. Of the 11 included articles, only one was published prior to 2006 [10] and most of them were published later, and we did not find any differences between the 2000s and the 2010s in terms of the number of publications. All of the articles were written in English. The articles were categorized by country of origin; most of them were conducted in the USA [10][11][12][13][16][17][18][19], one in Canada [14] and one in Taiwan [19]. The countries of origin of the included papers are shown in Figure 2.
A wide range of nurse mentoring programs were identified with highly variable characteristics. Most of them were developed in third-level hospitals, and only one of the studies reported data from long-term-care facilities and community organizations [14]. Only the program in Taiwan was developed in a public hospital [19]; the rest were developed privately. Regarding the types of programs, there were programs created specifically for the studies. "Norton Navigators" [11] and "Nurses Nurturing Nurses" [13] are structured programs that were widely named in the literature on this subject and were recognized by researchers throughout the selection process of the articles. The duration of the programs was very diverse, from eight weeks [16,18] to eighteen months [11], as was the number of members in the groups created. Only one of the studies included the same number of mentors as the number of mentees [18] . A few programs were developed with external support from sources such as universities or nursing associations [13,17].

Inclusion of Sources of Evidence
Eleven articles met the inclusion criteria and were included in this review. The articles included nine journals, eight of which were nursing journals [10][11][12][13][14][15][16][17][18]. The publication dates ranged from 1992 to 2021. Of the 11 included articles, only one was published prior to 2006 [10] and most of them were published later, and we did not find any differences between the 2000s and the 2010s in terms of the number of publications. All of the articles were written in English. The articles were categorized by country of origin; most of them were conducted in the USA [10][11][12][13][16][17][18][19], one in Canada [14] and one in Taiwan [19]. The countries of origin of the included papers are shown in Figure 2.    Descriptive studies were the most common research design identified [4,10-13, [16][17][18]. Further details of the characteristics of the included articles are shown in Table 2.  All mentoring programs were orientated toward new nurses, with few/no programs with different objectives, and ranged from improving job environments and increasing retention to improving the evidence based on practice or determining the satisfaction and organizational commitment of new nurses. One study used a mentoring support to facilitate evidence-based practice [15]. Regarding the development of the programs, this was the section in which we found more variability, but all of the programs agreed on a promotion period, the pairing of recent nurses with experience nurses, and a final evaluation.
The results of the programs were varied, as were their objectives. Regarding the impact on nursing professionals, seven studies talked about the enhancement of nursing [4,10,[13][14][15]18,19]. Regarding impact on healthcare institutions, at least seven studies pointed to the improvement of the retention of nurses [4,[11][12][13][16][17][18], two of the studies talked about economic savings [4,11] and only one talked about higher patient satisfaction [11]. In addition, one more talked about the learning and application of and challenges and barriers to succeeding in implementing evidence-based practice [15].
The measurement tools were all different. Further details of the characteristics of the nurse mentoring programs are shown in Table 3.   HealthForceOntario services were used to e-mail all newly graduated nurses. To participate in the Nursing Graduate Guarantee, employers and New Graduated Nurses had to register on a Web-based employment portal created by HealthForceOntario. Including 3 to 6 days of general orientation; clearly defines the roles of newly graduated nurses, mentors, and orientation leaders; and ensure the use of a learning plan by and New Graduated Nurses and mentors Supervision is generally one-to-one. In some cases, however, the and New Graduated Nurses rotates to a different unit for increased clinical exposure, and thus is supervised by more than one mentor Mentorship increased the new graduate nurses confidence and allowed them to make clinical decisions in safe, protected environment. The program provided vital support and helped new graduate nurses move from students to practicing nurses.
Focus groups were held with employers (they were contacted by e-mail) and individual interviews were conducted with newly graduated nurses and mentors.  The registered nurses were introduced to the emergency department through a 10-week orientation, where they followed their assigned preceptors through the department s guidelines. After this period, they were paired with seasoned emergency department nurses. The mentoring program consisted of direct observational oversight, weekly meetings between mentors and mentees, frequent visitations with stakeholders and data collection and analyze. During the first week, they worked on the same shift but managed their own patients. The last 2 weeks of the program were intended for electronic mentoring.

Discussion
Mentoring programs are frequently used to retain professionals in centers or in zones with difficult access or with problems with generational relief, as is the case in New Zeeland, where it is practically required to perform programs that allow for fast adaptation and immersion in the practice, to ensure that there are problems with having nurses in theses contexts.
Generalist and specialist nurses benefit from these programs, because they allow them to grow quickly in all of the situations [20]. In addition, in special situations such as the pandemic, mentoring programs have allowed for the training of new nurses, decreasing pressure, improving security and increasing retention in institutions [17].
Mentoring programs in large hospitals contribute to increased nurse allegiance and reduce mobility and turnover, making these hospitals more attractive to new professionals [21,22]. These programs allow for internal and sustainable changes in organizational culture, which is very complicated, especially in big hospitals [23]. In addition, manager nurses would benefit from these kinds of programs both in terms of the incorporation of new elements in the management of teams and for organization as a whole [24]. Regarding gender, in this field, the female binomial is the most representative, where most mentors and mentees are women. There have been observed differences with the masculine approach, except in promotion in the workplace. The feminine approach improves clinical skills but does not require competitiveness for professional development or promotion within the field.
Mentoring programs have the biggest influence on clinical professionals, who see increases in their professional growth and more security in their own abilities [23], as well as new nurses [25]. However, nurses who are going to be mentors also need to develop abilities and strategies to effectively communicate their knowledge and experience to mentees, with a manner of professionalism and trust that does not lead to confusion about their roles.

Conclusions
There are important heterogeneity in all of the studies' aspects, including the program duration, number of participants and objectives, as well as the structures and evaluations tools. These results suggest that mentoring programs need more in-depth and extensive studies. In spite of their differences, they all lead to improvements for nurses, patients and/or organizations.
All mentoring programs aim to support the transition of graduate or experienced nurses to new service areas. Mentoring programs improve practice and retention, enhance nurse performance and create a supportive and positive work environment.
The impact on institutions' organization is positive, decreasing mobility, leading to references and making hospitals attractive to new professionals, enabling new leaders to be found in the organizations and promoting professional development. All of these factors are creating a global and lasting change in organizational culture, which is especially complicated in large hospitals.
The feminine approach improves clinical skills but does not require competition for development or promotion within the profession. This finding suggests that it would be interesting to study or contemplate, in future studies, a gender perspective and its impact in mentoring.

Conflicts of Interest:
The authors declare no conflict of interest. In addition, the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.