Microsoft Word - Crownew.docx 43 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 MENTORSHIP FOR NURSING IN A RURAL AREA: A PROGRAM FOR SUCCESS FOR WORKING WITH DIVERSE POPULATIONS Karine Crow, RN, PhD 1 Margaret M Conger, RN, MSN, Ed.D. 2 Ursula Knoki-Wilson, BSN, MSN, MPH, RN 3 1 Associate Professor, Coordinator, American Indian Program. School of Nursing, Northern Arizona University, karine.crow@nau.edu 2 Emeritus Professor, School of Nursing, Northern Arizona University, Margaret.conger@nau.edu 3 Nurse-Midwifery & Community Liaison, Office of CEO for Chinle Comprehensive Health Care Facility; Co-Founder and President of Navajoland Nurses United for Research, Service and Education, Inc. (N- NURSE), tywils56@frontiernet.net Keywords: Rural/Frontier Nursing, Mentorship, Preceptorship, Culture, American Indian ABSTRACT Rural areas often face severe nurse shortages that result in many challenges to health care agencies located there. Of particular concern is the need for preparing nurses from urban areas to the realities of rural practice. The Navajoland Nurses United for Research, Service, and Education, Inc. (N-NURSE) developed a culturally based mentorship program entitled the Navajo Nursing Pathway of Mentorship to meet this need. The program is used to support nurses in their transition to rural practice. The newly hired nurses attend a workshop and can be assigned a mentor who serves as a cultural bridge builder to assist them with their transition to rural practice in a culturally diverse area. INTRODUCTION Rural areas often face severe nurse shortages that results in many challenges to health care agencies. The lack of a stable workforce provides not only poor coordination of services but also leads to decreased optimum care. The reasons for nurse shortages in rural areas are many. Not the least of these reasons is the lack of comfort with rural culture on the part of nurses coming from urban areas. Nurses coming into rural areas from urban settings are often culturally unfamiliar with the population they will be serving. In addition, nurse researchers are coming to realize that practice in a rural area requires a broad knowledge and skill base not normally required in an urban setting. They also need to be able to practice very independently and have a strong sense of self- reliance (Britten, Hahn, & Ragusa, 2003). However, many nurses in rural areas, educated at the associate degree level, need to develop the leadership skills taught at the baccalaureate level (Pierce, 2007). To prepare nurses for practice in a rural area, strategies must be developed to overcome these barriers. Some nursing programs have developed specific course work to teach rural nursing (Pierce, 2007). However these are not common enough to meet the 44 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 challenge. Another approach is to provide a strong mentorship program for newly recruited nurses to a rural setting. LITERATURE REVIEW Needs of Rural Nurses In a study by Conger and Plager (2008), challenges faced by new MS nurses working in rural settings in Northern AZ were examined. Many of these graduates experienced frustration in learning their new role in the rural community. Both the location and the new cultural environment provided unique challenges to those coming from urban areas. Those that experienced a sense of disconnectedness tended to return to an urban area. They identified the need for better preparation for working in the rural area. Cultural dissonance was a huge factor in their adjustment to their new environment. Those who lacked understanding of the cultural norms found it difficult to be accepted by the community. One of the nurses described learning that you can’t use the ‘anglo” interrogation method to obtain information from the client. Instead, the patient’s story had to emerge. Learning patience to wait for the reason why the patient was seeking health care was important. Many of the nurses talked about the sense of isolation experienced. One described it as “its lonely out here”. Another troubling factor was the loss of anonymity they had known when living in a urban area. They had nowhere to “hide” from the population they served. Because of their outsider status, they felt cut off from the inner working of the community. Hegney (2003) reports that the experience of the first 12 months of the new nurse in a rural setting will be significant to the nurses’ success in the community. During this time special effort is needed to support them. A mentor who is culturally connected to the community can be the guide needed to help socialize the new nurse to the cultural norms of the community providing support during the adjustment period. Mentoring Nurses new to the rural environment need role models. Many hospitals provide a preceptor to newly employed nurses. The preceptor can be helpful in learning about the work setting. But when the nurse is new to the culture, more than a preceptor is needed. This need can be met through a mentorship program. Even though the terms preceptor and mentor are used interchangeably, there are differences. A preceptor is one who assists the new nurse in the role transition to the new assignment. It tends to be task oriented, time limited, and is focused on the work. In the nursing literature there are a number of examples of the use of the term mentor in which the actions described would be better termed preceptor. This often happens when the relationship is between a staff nurse and a nursing student. Heale, Mossey, Lafoley and Gorham (2009) describe the use of mentors to work with individual students in a clinical setting. In this situation, the nurse is actually better described as a preceptor guiding the student’s clinical experience. In Britain, a similar model is found. Beskine (2009) describes the role of the mentor for the nursing student to be accountable for the students learning. His/her role is to orient the student to the clinical environment, 45 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 assess the student’s progress, and evaluate the student’s performance including failing the student if warranted. Similar use of the term mentor is found in clinical settings with nursing staff members when the term preceptor would be more appropriate. Mentoring is often used to describe a relationship in which a more experienced nurse works with a new nurse to develop clinical skills. Mariano, et al. (2009) describes a mentoring program in which the mentor is utilized to assist staff nurses to develop skill in the use of evidence-based practice. Aid with goal development is also stressed, but the goal development is related to the new nurse’s interest and use of evidence-based practices. A program to promote oncology nursing skills through use of mentors described by Marble (2009) and Hurst and Koplin-Baucum (2005) denotes the role of mentor as a coach, guide and teacher. Mentorship is designed to promote both psychosocial and instrumental development of the nurse new to the assigned clinical area. In the vocational literature, a mentor is described as having a larger role. In addition to assisting the new employee in the tasks of the new role, the mentor is more focused on supporting him/her in the new environment. The role is designed to help the mentee learn about the new organization with the aim of developing culture competency. The mentor can also assist the mentee to develop a career path in this new setting. Sawalsky and Enns (2009) describes the psychosocial role of the mentor as one who role models, counsels, and supports the mentee to promote professional advancement. Such mentoring was found to be a positive force for recruiting and retaining nursing faculty in academic settings(Singh, Ragins, & Tharenou,2009). Singh et al. (2009) found that mentoring was a positive predictor for the promotion, achievement expectations, and turnover intentions of the mentees. Gibson (2004) states even though there is no consistent definition or common description of mentoring, it is commonly used to enhance the career success of a new employee. Several elements included in its purpose are to improve the socialization, orientation and aid the mentee in gaining access to informational networks in the work environment. Gibson (2004) identified several themes common to the mentoring experience. The mentee viewed the mentor as one who cared about the mentees best interests and provided a feeling of connection. Providing insight into how things were done in the work environment was cited as being very important. Anderson and Ramey (1990) list five roles of a mentor (a) educator, (b) sponsor, (c) coach, (d) counselor, and (e) confronter. Kram (1983) states career and psychosocial development are the primary responsibilities of a mentor, not skill acquisition. Using the broader definition of mentoring, the focus of a mentoring program should be to prepare the mentor to support the mentee in developing psychosocial skills and cultural knowledge necessary to be successful in the new environment. Programs focused on skill acquisition are better described as preceptorships. In light of the voluminous literature on the need for mentors for newly hired employees, programs for developing mentor/mentee relationships should be considered an important goal for all organizations. RURAL AREA MENTORSHIP PROGRAM Need for Program A rural area that has a great need for a mentorship program is in Northern AZ with the American Indian population. The Navajo Tribe, one of the largest American Indian 46 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 groups in the United States residing in a geographical area approximately the size of WV, is located in the Four Corners region. The majority of the people are in AZ, but tribal lands extend into UT and NM. Much of this area is considered frontier.. The health care systems consist of Indian Health Service (IHS) hospitals and clinics as well as tribally owned facilities. The IHS hospitals lie in remote areas on several American Indian Reservations serving a culturally unique population. These health care facilities are chronically understaffed. The IHS system in the area reports a 20-45% vacancy rate and the average age of these nurses is 46. Furthermore, the number of nurse vacancies doubled between 2007 and 2008 (“Nursing Shortages”, 2008). A large number of nurses working in these facilities come from urban areas with little or no cultural knowledge about the people they will serve. Many of them are there to “pay back” time in underserved area required for having accepted scholarships from the federal government during their school years. However, the need for a culturally appropriate approach is essential to rendering effective and responsible services to clients (Campinha-Bacote, 2007). Nurses new to the Navajo culture have a “steep learning curve” in developing cultural competence. Navajoland Nurses United for Research, Service, and Education, Inc. The Navajoland Nurses United for Research, Service, and Education, Inc (N- NURSE is an example of a non-profit organization that was an outgrowth of a grant provided by the William Randolph Hearst Foundation “Mentorship for Nursing Careers in the Navajo Nation” 2003-2006. N-NURSE prepares both potential mentors and mentees working on or near the Navajo Reservation, with the IHS and health care centers in Northern AZ. Nurses from this group have developed a workshop that combines a mentorship/mentee program and a cultural orientation program for nurses new to the area. Its purpose is to prepare new nurses for the realities of practice in this rural environment that serves a large American Indian population. The workshop participant has the option to continue with a mentor after the conclusion of the workshop. The mission of N-NURSE (n.d.) is “to embrace cultural harmony by giving voice to nurses”. The group “shares wisdom, nurtures mentorships, partnerships, and research for quality Navajo health” (N-NURSE Inc., n.d.). The program entitled “Navajo Nursing Pathway of Mentorship © 2004” has a strong component on guiding cultural aspects of health care for developing an authentic mentoring relationship. It is particularly suited to helping more junior Navajo nurses balance their traditional worldviews with the western nursing worldviews. It is also helpful for nurses new to the Navajo culture to adapt their nursing practices to meet the cultural traditions of the Navajo clientele. The Navajo Nursing Pathway of Mentorship” utilizes a culturally congruent basis for working with the Navajo population. A cultural norm for the Navajo population is reflected in this statement: “Before one begins any activity, one must enter into one’s silence” (Knoki-Wilson, 2006). This is an idea that is culturally foreign to most in western society. The Navajo Nursing Pathway of Mentorship workshops include using Navajo health beliefs to promote a mentorship/mentee paired relationship between an experienced, culturally knowledgeable nurse with a more junior nurse moving into the Navajo area or an American Indian nurse who is returning to the reservation following nursing education in an urban area. The purpose of the mentorship is to develop understanding and provide a more culturally congruent interface with the Navajo while helping the mentee formulate and follow their career development, which may be in 47 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 education, job changes, etc. The mentor knowledgeable about the Navajo culture serves as a cultural bridge builder, a person who guides the mentee through interchanges with Navajo clients. The mentor establishes rapport with the mentee so that the pair can identify a plan to provide opportunity for the mentee’s development. The mentee’s learning habits and opportunities for professional development are discussed. Both the mentor and mentee are enriched by the association. To develop a culturally congruent mentor/menteeship program both language and symbol of the people being addressed are essential. The Navajo Nursing Pathway to Mentorship model utilizes language and symbols of Navajo philosophy (Fig 1). Figure 1: Navajo Nurse Mentorship Pathway Used with permission from N-NURSE (Knokie-Wilson et al., 2004). The six mountains, sacred to the Navajo people that surround the Navajo Nation form the theoretical framework. They are Mount Blanc on the East, Mount Taylor on the south, Mount Hesparus on the north, the San Francisco Peaks on the west and the door way Mountains Huerfano and Gobernador Knob. The mentor/mentee enter the pathway from the East and cognitively follow the six sacred mountains for their developmental journey along the cardinal directions (East, South, West, North, East) and completing a cycle in the East again. In Navajo East is located at the top of the page. Progression of growth as a mentor and mentee follows Benner’s (1984) Novice to Expert clinical concept. Beginning in the east, the mentor/mentee is at the novice stage. Moving to the south the mentor/mentee is at the advanced beginner stage. In the west the nurse who has developed social competence can be considered at the proficient stage. The north represents the nurse at the expert level. Using the traditional Navajo view of the stages of life moving from east to north, the mentor and mentee emerge through the east doorways practicing nursing competence and completing a pathway cycle. 48 Online Journal of Rural Nursing and Health Care, vol. 11, no. 2, Fall 2011 RESULTS OF THE MENTORSHIP EDUCATION PROGRAM Nursing students enrolled in the American Indian Program of the School of Nursing of Northern Arizona University participated in the Navajo Nursing Pathway of Mentorship workshops in 2009.. Even though the majority of these students are American Indian, they found that the program provided them with information that enhanced their ability to provide culturally relevant nursing care. They stated that this is what they had hoped they would receive in nursing school. Other individuals who have participated either as a mentor or mentee have expressed that this program re-enforced their own beliefs,if they have been away from the area awhile, or provided cultural understanding of how to work more “in harmony” with the populations found in Northern AZ. Both the rural and indigenous populations are addressed in a more culturally congruent manner after participation in this program. For example, from the persepective of a layperson, anatomy and physiology may be understood from that of the sheep since these are the main type of live stock raised in the area and explanations can be provided using this background. Assumptions are not made that the patient “doesn’t care” if an individual does not come into a clinic “on time” or at the first sign of disease or injury due to the fact that distances and transportation have to be considered; cost of transportation, who will care for animals while gone; are there “elderlies” and small children that have to be cared for if one leaves, etc. Time, distance, beliefs and understanding of using both indigenous and western ways are seen as congruent cultural interventions for the population being served. Moreover, this mentor/menteeship program has provided a mechanism for helping those not from the area to feel more comfortable working in this setting and remaining in the area. In addition to the workshop, there is opportunity for nurses new to the area to be paired with a mentor to continue the cultural learning. This support provides the needed reinforcement for a successful transition to rural/frontier nursing with a culturally unique population. CONCLUSION The N-Nurse organization provides an example of a culturally congruent model for a mentor-mentee relationship for nurses working with the Navajo and rural population to follow. While it is more specific to this cultural group, the concept of utilizing appropriate philosophy, beliefs, practices, language and symbols can be applied to other cultural populations. Such culturally appropriate models can be used to assist and socialize nurses new to an environment. Congruent with the literature and the N-NURSE example, a focus for all organizations would be to develop a mentor/mentee program that encompasses the psychosocial skills and cultural knowledge necessary for adaptation to a new work setting and environment. In implementing such a program, a more stable workforce and increased optimum of care for the population would result. REFERENCES Anderson, R.T., & Ramey, R. (1990). Women in higher education: Development through administrative mentoring. In L.B. 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