Newly qualified nurse (NQN) ‘transition shock’ (Duchscher, 2009) or ‘reality shock’ (Kramer, 1974) are terms ascribed to a phenomenon of sometimes traumatic change over the first 12 months post-qualifying. The transition for these novice nurses is a complex process of socialisation, professionalisation and adaptation entwined with multiple work-related stressors (Halpin, 2015; Halpin et al, 2017).
A children's hospital within a large NHS Trust recruited more than 70 NQNs in 2017 and 100 NQNs in 2018 as part of an ambitious programme of expansion by the Trust. However, while a high proportion of NQNs is a recognised feature of acute hospitals in the UK, so is high turnover (Whitehead et al, 2013; Brook et al, 2019).
A wide range of strategies and interventions have been tried globally to support NQNs during transition, with the intention of positively affecting personal and organisational factors, such as confidence, competence, job satisfaction, retention and turnover, but none stand out as fully achieving such outcomes (Edwards et al, 2015). Preceptorship has been implemented widely across the UK as a structured approach to helping NQNs to develop both their competency and confidence during their first 12 months (Irwin et al, 2018). However, it does not have a clear pastoral role for the preceptor embedded within it to help an NQN during their transition. Equally, it does not directly assist with professional and organisational socialisation and a sense of belonging that can also promote confidence and retention of NQNs (van Rooyen et al, 2018; Devey Burry, 2020).
A number of factors led to the creation of the personal professional mentor (PPM) role and scheme in 2017 by one of the Trust's paediatric practice educators. First, there was recognition of this potentially beneficial need for pastoral care and its absence in established preceptorship. There was also recognition that many newly employed nurses had not undertaken their nurse education at the Trust, so being new to the Trust was an additional stressor for them to manage. The practice educator subsequently became the scheme lead, delivering as well as participating in the initiative.
All NQNs employed in 2017 and 2018 in the children's hospital were allocated a PPM by the scheme lead. Each PPM was one of the paediatric practice education team and an experienced nurse. Each NQN was sent an email explaining the purpose of the scheme, together with contact details of their assigned PPM. The PPM then made contact with the NQN, but it was up to the NQN to decide if they wanted to utilise their PPM allocation. If they did, then the PPM and NQN were free to decide how the relationship was going to work, such as through regular or ad hoc face-to-face meetings, and/or communicating by telephone or email. There was no set end date for the allocation, but it was suggested that it was unlikely to be needed beyond 12 months.
In 2019, when the scheme had been in operation for over a year, a formal evaluation from the NQNs' perspective was undertaken by the scheme lead. The objectives of the evaluation and the focus of this article were:
- To determine if the PPM provided the support required by the NQN
- To determine if the seniority of the PPM was a barrier or enabler of the relationship for the NQN
- To determine if the PPM scheme influenced the recruitment or retention of the NQN to the Trust
- To identify any changes required to the PPM role and scheme.
Method
Qualitative description underpinned this empirical evaluation because it was intended to be an exploration of the basic nature and shape of the scheme (Sandelowski, 2000). It is well suited to healthcare research because it allows for rich description from the participants' perspective (Colorafi and Evans, 2016).
The scheme lead emailed all NQNs who had been allocated a PPM since the scheme started in 2017 and invited them to take part in the research. The sample aim, which was achieved, was to recruit 10 NQNs. NQNs who had not met up with their allocated PPM were included in the study so that the reasons why they did not engage could be explored.
Each participant was interviewed by the scheme lead using a schedule of questions and prompts as necessary. Each interview was conducted on Trust premises, but away from the NQN's workplace, in a private meeting room. This was to ensure participant confidentiality and anonymity. All interviews were audiorecorded before being transcribed verbatim, in keeping with the desired rich description. Data were analysed using the thematic analysis six-stage framework of Braun and Clarke (2006). Consequently, themes and subthemes were produced.
Ethical approval and ethical considerations
Approval for the study was obtained from a university ethics committee, the Trust's audit department and the scheme lead's manager. The initial email advertising the study included an attached participant information sheet and participant consent form. Before starting each interview, informed consent to participate was rechecked by the scheme lead. Each participant's name and interview transcript was converted to a participant code, M1 to M10.
Findings
Table 1 sets out the number of times the sample met with their PPM. There was a range from never to three face-to-face meetings, although participants explained during their interviews that this did not include the email exchanges that they had also had. Thematic analysis resulted in three themes and five subthemes, as listed in Box 1.
Table 1. Number of times newly qualified nurse participant and personal professional mentor met over 12 months
| Number of times personal professional mentor met newly qualified nurse | 0 | 1 | 2 | 3 |
| Number of participants | 1 | 4 | 4 | 1 |
| Participant code | M3 | M2 | M4 | M1 |
| M6 | M5 | |||
| M9 | M7 | |||
| M10 | M8 |
Box 1.Themes and subthemes in the study
- Theme 1. Personal professional mentor (PPM): the independent, accessible, experienced confidant
- The simple but affective first meeting and beyond
- Theme 2. PPM: A new addition to the portfolio of staff support roles
- An aid to transition isolation
- Theme 3. Recommendations for PPMs and the scheme
- Showcase and promote the PPM scheme
- PPM should contact the newly qualified nurse first
- Scheduled, protected meeting times
PPM: the independent, accessible, experienced confidant
The components of the PPM role that participants appreciated were that the PPM was an experienced nurse working outside the NQN's job location, was available and accessible to the NQN, and was someone with whom it was possible to talk confidentially.
‘I like that she doesn't work on my ward. And she's experienced and I can go to her whenever, and then have that confidential discussion and the support that I would need going forward …’
M2
‘… Someone who knows the ward, but is also very separate to it, because she [PPM] doesn't work here, but understands the pressures of a newly qualified nurse …’
M10
Having the PPM located elsewhere in the Trust enabled the NQNs to talk more freely about their job location and the staff they worked with. It also enabled them to disclose with honesty their feelings and fears about being an NQN, including concerns they had about skills deficits.
‘I guess sometimes I feel like I can't necessarily talk to [my preceptor], if I have issues on the ward, because my preceptor is one of the ward, maybe it's nice to have someone outside the ward to talk to and get advice from …’
M6
‘I was struggling a little bit, so we met for a catch-up and she [PPM] helped me with some [intravenous] calculations, which was really nice.’
M1
The simple but effective first meeting and beyond
The most positively appraised first meetings were when the PPM had made initial contact with the participant by email and they meet fairly informally, away from the immediate workplace to talk. The talk generally covered who the PPM was and their background, if the participant had any immediate concerns that they wanted to discuss or if there were any practical questions on which the PPM could advise the participant.
‘She [PPM] contacted me to let me know, “I am your mentor. Let me know if we need to speak.” We had an initial meeting, which was good … we just had a chat about concerns about starting on a new ward and that kind of thing.’
M8
‘I thought it [PPM] was quite a nice idea. We got to meet … It was when I first started, so I was a bit worried, so we just spoke through some different things. [To] calm my nerves.’
M9
At present there is no prescribed format to the PPM initiative and this was reflected in the range of findings that detailed what happened after an initial meeting. Some participants made no further contact with their PPM because they did not encounter any issues that they could not self-manage. Some met their PPM for a second time and one for a third time. Other participants described how they continued their interaction with their PPM via email only. If the participant needed a quick bit of advice or guidance, emails with their PPM quickly resolved the issue. Some participants described how the PPM told them at their first meeting that they were welcome to contact them at any point in the future if they needed assistance, but the PPM was not going to mandate regular meetings.
PPM: a new addition to the portfolio of staff support roles
The PPM was seen and used by the NQN as an additional source of support, depending on the nature of the problem, concern or question.
‘I feel like my PPM worked really well and at the same time, if there was anything that I needed help with on the ward, I would go to my ward and utilise people near me. I use my clinical educators quite a lot.’
M1
‘I didn't train in this Trust, so I was completely new, so I thought it was good to have someone there to support and reassure me and give any advice that I did need, rather than just bothering people on the ward that are always busy.’
M6
‘It's just knowing that there's an additional person. So, when there's been times I've been struggling with this and that … well actually, why don't I try speaking to her [PPM] about it …’
M10
The PPM had a predominantly pastoral remit that a couple of participants likened to roles they had known and benefited from in the past.
‘It was quite good, because obviously at university you're allocated a personal tutor, that's kind of like someone that you can go to and talk to about things that aren't always to do with work-related things. So I suppose, as being a NQN it's like a progression of that. And yeah, it was helpful.’
M8
An aid to transition isolation
There were features of transition shock evident in the feelings expressed by some participants. They made reference to poor confidence, feeling overwhelmed, feeling daunted and nervous, especially when they started their first job and in the initial few months. Through talking with their PPM these feelings were expressed in a supportive and confidential arena and the PPM was able to help the participant manage and work through the feelings as opposed to continuing with them unabated, in isolation.
‘I think it's mainly support, because when you are newly qualified, you really need that. You don't feel confident. I felt I wasn't very confident. I kept comparing myself with the others. But, after having a chat with my PPM, I was reassured because she advised me on what to do, and that has been very helpful.’
M2
Recommendations for PPMs and the scheme
Overall, the participants commended the initiative. No participants suggested that it was not beneficial and should be discontinued. However, participants did make recommendations to help both the role and the initiative evolve.
Showcase and promote the PPM scheme
The PPM role and initiative should be showcased more within the Trust and publicised externally to the Trust. Participants would have liked a good understanding of the PPM role before they started their job. They also felt that it would help the PPM and staff within the Trust to understand the role and how it differs from other existing roles. It had the potential to attract NQNs to apply for a job at the Trust.
‘That was one of the reasons I decided to come here [to the Trust] … because no other position that I interviewed for actually offered the professional mentorship programme, and that was a deciding factor for me, to have that additional support that was more like pastoral support. And as I was new to London, and [had] lots of stress going on, as well as being a newly qualified nurse.’
M10
PPM should contact the newly qualified nurse first
The PPM should make the first contact with the NQN. Participants commented on feeling overwhelmed with their new qualified status, new job, new Trust and with lots to undertake and learn. It was too much to also remember to contact this unknown person and arrange to meet them to use them for support as well.
‘I think, maybe instead of us [NQNs] being an initiator after the first meeting, it might be nice for you [PPMs] to email. I know it's our choice whether we take the support or not, but I think, sometimes, you can be so bogged down with everything that you're getting on with, you just forget about all the different support systems that are out there.’
M9
One participant who did not meet their PPM said:
‘I think I was reluctant to approach them, having never met them … I thought, what if I get the wrong person, what if they don't want to meet me? I don't really know what they do. So I think if they contacted me, then I probably would have done more with it.’
M3
Scheduled, protected meeting times
Some participants thought that there should be designated, protected, mandatory time allocated to a PPM to meet up with the assigned NQN. There was evidence of the prolonged struggle some participants had to meet with their PPM because of opposing shifts or the unpredictable nature of nursing care and workload.
‘Just like emailing took a while for us to both check our emails anyway, and then when we finally did, it was trying to find a designated time to do that … ward life is very unpredictable …’
M7
Discussion
The participants in this study articulated some classic NQN personal feelings and descriptors of transition such as fluctuating confidence and feeling overwhelmed. This illustrated that they were typical of NQNs in their first qualified employment. The results of the evaluation of the PPM scheme demonstrated that participants felt that they benefited from it. The use of qualitative description provided a rich explanation for how and why participants benefited.
The results showed that the PPMs did have a new and important role to play for the NQNs. The PPM was an experienced nurse who was knowledgeable about the situation, yet independent from the NQN's workplace. This gave the PPM status for the NQN and they could be confident that the PPM was a person whom they could approach with simple, functional questions and more personal, complex emotions, trusting that this person was someone they could speak to in confidence, to help them navigate whatever they were going through. The PPM was the independent, accessible, experienced confidant and an aid to help offset transition isolation. This is different to the role of the preceptor who, while similar in that they can also help build confidence and competence (Irwin et al, 2018), is still a person within their work environment with an assessing component to their role. The preceptor role does not have the same independent status to enable the NQN to feel able to disclose to or confide in the preceptor. The risk to the NQN is that they may be viewed as failing to cope or perform as a qualified nurse. Therefore, the title and role of the PPM constitutes a new addition to the portfolio of staff support roles.
Furthermore, the results showed that NQNs potentially understood the remit of the PPM role because it mirrored roles with which they were familiar as an undergraduate. At university, most NQNs would have had a personal tutor for the duration of their education, a role that has a major pastoral component like the PPM (Gidman, 2001; Christensen et al, 2019). This familiarity could be important in utilising the PPM because the NQNs already had an understanding of what such a role could offer them.
There are parallels between this PPM scheme and international mentor/mentee programmes for NQNs. These programmes use a variety of strategies such as: matching mentor to mentee, mentor/mentee working in the same area or a different area, and the mentor having or not having an assessment component to their role (Zhang et al, 2016; Devey Burry et al, 2020). The outcome of a systematic review into successful interventions to reduce turnover and increase retention of NQNs suggested there was some evidence to support a multifaceted programme having both preceptor and mentor components (Brook et al, 2019). However, the findings of the present study mirror the outcome of Edwards et al (2015), that anything an employing Trust does to show they understand NQN transition concerns and needs, coupled with having initiatives in place to help NQNs, will be an attractive feature for an NQN as they consider where they want to work.
The findings of this evaluation show that it is important to ensure that staff within the Trust know about the PPM role and that it is publicised externally, so potential applicants know that the role exists. The findings also show that the PPM should initiate first contact and be proactive in scheduling periodic meetings because NQNs often lack confidence during transition, which may hinder them from taking the lead on making arrangements or asking for help.
Implications for practice
The PPM scheme was an inexpensive strategy to provide NQNs with an additional, named, experienced nurse whom they could access for pastoral support during the often turbulent months of transition. The evaluation has demonstrated the benefits of the scheme for paediatric NQNs, but the scheme can easily be applied to other fields of nursing and healthcare organisations. The scheme started by utilising paediatric practice education nurses as PPMs. To scale up the scheme, all interested, experienced nurses across an organisation could be prepared and employed as PPMs to support NQNs.
Further research
Quantitative exploration of important workforce variables such as absenteeism, retention, turnover and job satisfaction could be included in a future, larger, longitudinal evaluation of the scheme. Further research into the socialisation and pastoral needs of NQNs would aid understanding to develop more strategies to help nurture and retain this vital sector of the workforce.
Limitations
It is acknowledged that all the NQNs knew that the scheme lead created as well as ran the PPM scheme. Therefore, this may have exerted an influence on who chose to participate and what they chose to reveal during the interview with the scheme lead. However, participation in the evaluation was voluntary and ongoing feedback on the scheme had been encouraged since the start.
Conclusion
The PPM role and scheme was envisioned as an additional support strategy to provide pastoral support to a large number of newly recruited paediatric NQNs in a large children's hospital. The scheme was co-ordinated by the practice education team, and it was straightforward to assign experienced nurses who were not from the same work environment as their NQNs. The relationship enabled NQN concerns, emotions or knowledge deficits to be disclosed in a confidential, supported way. It had the added potential of aiding professional and organisational socialisation and a sense of belonging as the NQNs navigated their transition. The scheme and role is an inexpensive way of using the wealth of experience that already exists within the workforce to support and nurture the forthcoming generation.
KEY POINTS
- Newly qualified nurses (NQNs) can experience a stressful transition, with the risk that it is so overwhelming and distressing that they leave their job or even the profession
- This study investigated whether the pastoral support of an experienced nurse mentor could help nurture and retain them within the workforce
- The major findings of this study, using thematic analysis, were that the personal professional mentor (PPM) was an independent, accessible, experienced confidant for NQNs and their role constituted a new addition to the portfolio of staff support roles
- Active pastoral support from the PPM could counteract feelings of transition isolation in NQNs
- A PPM scheme is easy to set up, inexpensive to run and has the potential to scale up, given the number of experienced nurses who could participate without adversely impacting on their other job commitments
CPD reflective questions
- After reading the article, consider the feelings and fears that a newly qualified nurse (NQN) may experience in the first few months of starting their first job after graduating
- What sort of pastoral support is available in your workplace and how would you offer this to an NQN?
- If you where the personal professional mentor for an NQN who became distressed during one of your meetings, how would you manage the situation?
- What services exist in your organisation and local community to help with work-related physical, mental and emotional issues?