RANDOMIZED CONTROLLED TRIAL OF GRADUATE-TO-UNDERGRADUATE STUDENT MENTORING PROGRAM SON CHAE KIM, PHD, RN⁎,1, DEE OLIVERI, EDD, RN⁎,1, MICHELLE RIINGEN, DNP, RN, CNS-BC⁎,1, BARBARA TAYLOR, PHD, RN†,1, ⁎ AND LARRY RANKIN, PHD, RN This randomized controlled trial evaluated the effects of graduate-to-undergraduate student mentoring on anxiety, self-efficacy, academic performance, and satisfaction with nursing as a career choice among students enrolled in a nursing fundamentals course during the first semester of a baccalaureate nursing program. The nursing students assigned to the experimental group received up to 20 hours of mentoring by registered nurses who were enrolled in a graduate nursing program at the same university. The State-Trait Anxiety Inventory, Baccalaureate Student Self-efficacy Questionnaire, nursing fundamentals course performance scores, and satisfaction with nursing as a career choice were measured. One-way analysis of covariance was used for data analysis. The experimental group (n = 34) had lower trait anxiety (P = .01), higher academic performance (P = .04) and satisfaction with nursing as a career choice (P = .002) at the end of the semester compared with the control group (n = 17). There were no statistically significant differences in state anxiety and self-efficacy between two groups. Mentoring by experienced nurses appears to reduce anxiety, foster academic success, and enhance professional satisfaction among beginning nursing students. (Index words: Mentoring; Nursing students; Satisfaction; Academic success; Anxiety) J Prof Nurs 29:e43–e49, 2013. © 2013 Elsevier Inc. All rights reserved.

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URSING SCHOOL IS a stressful and intimidating environment for most beginning students. The combination of high anxiety and low self-efficacy among nursing students negatively impacts their learning process, clinical performance, and overall academic success (Cheung & Au, 2011; Watt, Murphy, Pascoe, Scanlon, & Gan, 2011). Furthermore, the shortage of nursing faculty limits the ability to provide optimal learning experience and needed remediation for some students (McGann & Thompson, 2008). This results in student dissatisfaction with their nursing program and

⁎Professor, School of Nursing, Point Loma Nazarene University, San Diego, CA. †Dean & Professor, School of Nursing, Point Loma Nazarene University, San Diego, CA. Address correspondence to Dr Kim: Professor, School of Nursing, Point Loma Nazarene University, 3900 Lomaland Drive, San Diego, CA 92106. E-mail: [email protected] 8755-7223/13/$ - see front matter 1 Zeta Mu Chapter at Large.

poor professional socialization, which may contribute to academic failure and attrition.

Background A body of literature specifies the negative effects of student stress and anxiety on academic success and retention. Not only students' clinical performance but also critical thinking abilities are negatively impacted by stress and anxiety (Suliman & Halabi, 2007). The most common stressors for nursing students include feelings of inadequacy about clinical competence, high faculty expectations, fear of making mistakes or failing, heavy academic loads, and long hours of study (Deary, Watson, & Hogston, 2003; Sawatzky, 1998; Tully, 2004). The stress level among the first-year nursing students during the initial clinical placement was shown to be higher than the stress level of even medical students (Jones & Johnston, 1997), and the nursing students' stress levels increased as they progress through the nursing program (Deary et al., 2003; Lindop, 1999). Interestingly, the baseline personality trait associated with negative coping

Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp e43–e49 © 2013 Elsevier Inc. All rights reserved.

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mechanisms was a greater contributor to nursing students' attrition than their intellectual ability (Deary et al., 2003). A number of strategies to reduce students' stress and maximize learning and professional socialization have been studied. The structured tutorial supports improved self-esteem (Gammon & Morgan-Samuel, 2005); an individualized counseling program improved self-esteem and course grades (Godbey & Courage, 1994); a structured learning program decreased anxiety and increased self-efficacy (Watt et al., 2011); preceptorship increased self-efficacy (Goldenberg, Iwasiw, & MacMaster, 1997); and clinical mentorship enhanced clinical learning experiences and sense of belonging to nursing profession (Gray & Smith, 1999; Levett-Jones, Lathlean, Higgins, & McMillan, 2009). Mentoring has been identified as an important strategy in reducing students' anxiety and facilitating smooth transition into the professional roles through the supportive and encouraging relationships (Kilcullen, 2007; Nelson, Godfrey, & Purdy, 2004). In contrast to preceptorship, which encompasses the clinical supervision and performance evaluation, mentorship is a voluntary partnering relationship where the mentor provides counseling, role modeling, guiding, sharing, and nurturing friendship to promote personal and professional growth of the mentees (Chow & Suen, 2001; Moscaritolo, 2009; Ousey, 2009; van Eps, Cooke, Creedy, & Walker, 2006). In addition, the mentor– mentee dyad is a two-way partnership in which both mentors and mentees receive mutual benefits of empowering each other (Palmer, 1998). In hospital settings, mentoring of new staff nurses by experienced nurses is commonly used, and studies have shown increased retention rates, better acquisition of nursing professional identity, as well as job satisfaction (Duchscher, 2008; Fox, 2010; Weng et al., 2010). In contrast, peer mentoring studies in academic settings that used upper-level nursing student mentors have reported conflicting results on stress reduction and selfefficacy improvement for the beginning nursing students (Hughes et al., 2003; Li, Wang, Lin, & Lee, 2011; Sprengel & Job, 2004). The use of experienced nurses in academic settings to mentor the beginning nursing students has been underused (Andrusyszyn et al., 2007; Sword, Byrne, Drummond-Young, Harmer, & Rush, 2002). The potential benefits of mentoring by experienced nurses such as anxiety reduction, satisfaction with nursing as a career choice, building up confidence and self-efficacy, or academic success among the beginning nursing students have not been thoroughly studied. Furthermore, the effects of mentorship in the academic settings could not be determined with certainty because of poor study methodologies, such as lack of experimental design, randomization, or proper control groups (Sambunjak, Straus, & Marusic, 2006). These methodological limitations make it difficult to draw firm conclusions on the effects of mentoring in an academic setting.

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The theoretical framework for this study in evaluating the effects of a mentoring program was based on the self-efficacy theory (Bandura, 1997). Self-efficacy is defined as individuals' confidence in their ability to successfully complete a task. It was conceptualized that if mentors were successful in reducing mentees' anxiety level and improving self-efficacy, then the mentees will achieve academic success with greater confidence in the clinical setting and higher satisfaction with nursing as a career choice.

Methods Purpose The purpose of this study was to evaluate the effects of graduate-to-undergraduate student mentoring on anxiety, self-efficacy, academic performance, and satisfaction among nursing students in the first semester of a baccalaureate nursing program. The hypotheses for this study were that the mentored nursing students in the experimental group would have a lower anxiety level, higher self-efficacy, better academic performance, and higher satisfaction with nursing as a career choice compared with the unmentored nursing students in the control group.

Study Design and Participants A randomized controlled trial was carried out at a baccalaureate nursing program in southern California from September to December of 2009 and 2010. The volunteer students enrolled in a nursing fundamentals course were randomly assigned to either experimental or control groups. Two-to-one ratio randomization was used to double the likelihood of being mentored in the experimental group versus the unmentored students. The male and female undergraduate students in the experimental group were randomly assigned to male and female mentors, respectively, to facilitate gender-specific mentoring. The students assigned to the experimental group received up to 20 hours of mentoring by registered nurses who were in a graduate nursing program at the same university. The students in control group did not receive any mentoring. The graduate nursing students enrolled at the same university were recruited as mentors. The selection criteria for mentors included graduate students who had (a) a minimum of 2 years of experience as a registered nurse; (b) experience in preceptorship, coaching, teaching, mentoring and/or leadership; and (e) faculty recommendations.

Graduate-to-Undergraduate Student Mentoring Program The mentoring program designed by the investigators contained three different components: (a) a 2-hour mentorship training session; (b) an icebreaker session for all mentors and mentees; and (c) mentor–mentee dyad interactions. The graduate students who volunteered to become mentors and met the selection criteria attended a 2hour mandatory mentorship training session. The training

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session was led by two of the investigators and reviewed the topics of mentor–mentee dyad role expectations, mentoring phases, effective mentoring skills, interpersonal relationship building, communication skills, and conflict resolution. The mentors and mentees attended the icebreaker session to meet with each other and arrange the subsequent face-to-face meetings. On their first meeting, the mentor and mentee were required to sign a contract that included the goals for the semester, planned meeting dates, and clarification of roles and responsibilities of mentor and mentee. The mentor–mentee dyad interaction consisted of up to 20 hours of informal face-to-face interactions as well as E-mentoring methods outside the clinical setting. E-mentoring methods included telephone calls, e-mails, text messages, or Facebook interactions between the mentor and the mentee. The mentors were instructed to provide emotional support, help socialize mentees into the nursing profession, and serve as role models. However, they were not allowed to do any tutoring or help with class assignments. For each mentor–mentee meeting, the mentors were required to submit confidential written journals, discussing the contents of their meetings, barriers or facilitators of the mentoring process, and the total contact hours. The mentors were awarded a maximum of 20-hour credit toward their clinical hour requirements for their master of science in nursing degree.

established prior to incorporating this item into the study questionnaires.

Instruments

Data Analyses

The following instruments were included: the State-Trait Anxiety Inventory, the Baccalaureate Student Self-efficacy Questionnaire, and a demographic data form. The StateTrait Anxiety Inventory is a 40-item tool that measures the anxiety level (Spielberger, Gorsuch, Luchene, Vagg, & Jacobs, 1983). The 20-item State Anxiety scale assesses how the respondents feel “right now at the moment” on a 4-point Likert scale, ranging from 1 (not at all) to 4 (very much so). The 20-item Trait Anxiety scale evaluates how the respondents “generally feel” on a 4-point Likert scale, ranging from 1 (almost never) to 4 (almost always). The reported Cronbach's alphas for the State Anxiety and Trait Anxiety scales were .92 and .90, respectively. For each scale, the summation score ranges from 20 to 80, with a higher score indicating a higher level of anxiety. The Baccalaureate Student Self-efficacy Questionnaire (Goldenberg et al., 1997) has 52-item questions in 12 subscales that ask the respondents to rate their level of confidence on various nursing skills and behaviors. All references on “preceptorship” in the items were changed to “mentorship” with permission. Each subscale uses a 4point Likert scale, ranging from 1 (completely lacking in confidence) to 4 (very confident). The internal consistency reliabilities have been established with Cronbach's alphas of .97 to .99 for subscales (Goldenberg et al., 1997). The student satisfaction with nursing as a career choice was assessed using an investigator-developed 10-point Likert scale item, ranging from 1 (extremely dissatisfied) to 10 (extremely satisfied). The face validity was

All data were entered into a SPSS database using the Statistical Package for Social Science, SPSS version 18.0 (SPSS Inc, Chicago, USA) and double checked for accuracy with a second person. Descriptive statistics including frequency, percentage, mean, and standard deviation were used to describe the sample characteristics. The comparisons of pretest trait anxiety, state anxiety, self-efficacy, and cumulative grade point average (GPA) between the experimental and the control groups at baseline were made by independent t test. To evaluate the effect of mentoring on trait anxiety, nursing fundamentals course performance score and satisfaction with nursing as a career choice, one-way analysis of covariance (ANCOVA) was used with pretest trait anxiety as a covariate. To evaluate the effect of mentoring on the state anxiety and self-efficacy, the respective pretest results were used as covariates in addition to the pretest trait anxiety. The baseline pretest trait anxiety was included as a covariate in all ANCOVA because of its wide-ranging impacts on beginning nursing students in the literature. The level of statistical significance was set at .05 for all data analyses.

Ethical Considerations This study was reviewed and approved by the Institutional Review Board of the university. The informed consent was waived since no more than minimal risks were involved in this study. This also assisted in maintaining the anonymity of the study participants. The completion of the study questionnaires implied participant consent. The study participants were reminded that their participation was voluntary and that they could decline to participate at any time without their course grade being affected.

Data Collection Procedures The undergraduate students who volunteered to participate in the study completed the study packet containing the Baccalaureate Student Self-efficacy Questionnaire, State-Trait Anxiety Inventory and a demographic data form for the baseline pretest data. At the end of the semester, the students in both experimental and control groups completed the same questionnaires for the posttest data as well as satisfaction with nursing as a career choice. Nursing fundamentals course performance scores were also collected. A blind code number was assigned to each student to match the pre- and posttest questionnaires.

Results Sample Characteristics A total of 76 undergraduate students were recruited; 51 and 25 were randomized to experimental and control groups, respectively. A total of 51 students, 34 in experimental and 17 in control groups, completed both

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Figure 1. Flow diagram of the study.

pre- and posttest questionnaires (67% completion rate). The study flow diagram is shown in Figure 1. The characteristics of experimental and control groups were similar (Table 1). Most were female, White, and high school graduates and had no previous health care experience. A total of 34 graduate students were recruited and selected as mentors. Most of the graduate students were female (85.3%) and White (55.9%) and had an average of 12 years of registered nurse experience. Table 2 shows the comparison of the pretest trait anxiety, state anxiety, self-efficacy, and cumulative GPA between the experimental and the control groups at baseline using independent t test. None of these differences between the two groups were statistically significant at baseline (P N 0.05).

Table 1. Sample Characteristics at Baseline (N = 51) Characteristics Age, M (range), years Gender Female Male Ethnicity Black White (non-Hispanic) Asian/Pacific Islander Hispanic Multiethnic Highest degree earned High school Associate/diploma Cumulative GPA, M (SD) Previous health care experience None

Experimental group (n = 34)

Control group (n = 17)

20 (18–27)

20 (19–23)

32 (94.1) 2 (5.9)

17 (100.0) 0 (0)

1 (2.9) 24 (70.6) 3 (8.8) 6 (17.6) 0 (0)

0 (0) 14 (82.4) 0 (0) 2 (11.8) 1 (5.9)

31 (91.2) 3 (8.8) 3.33 (0.32)

15 (88.2) 2 (11.8) 3.28 (0.38)

22 (64.7)

13 (76.5)

Note. Values are expressed as n (%) unless otherwise indicated.

Effects of Graduate-to-Undergraduate Student Mentoring The ANCOVA model assumptions of homogeneity of variance and regression slope were met (Field, 2005). The results of the ANCOVA, showing the effects of mentoring on anxiety, self-efficacy, academic performance, and satisfaction, are summarized in Table 3. For the trait anxiety at the end of the semester, ANCOVA with pretest trait anxiety as a covariate showed statistically significant lower trait anxiety for the experimental group compared with the control group (adjusted difference = − 5.02, P = .01). For the state anxiety, the mean score at the end of the semester was numerically lower in the experimental group compared with that in the control group, but the difference was not statistically significant (adjusted difference = − 4.21, P = .08). Selfefficacy showed no difference between experimental and control groups (adjusted difference = 0.09, P = .41). For the remaining dependent variables, ANCOVA with pretest trait anxiety as a covariate showed statistically significant higher scores in the experimental group compared with the control group for the nursing fundamentals course performance (adjusted difference = 2.39, P = 0.04) and satisfaction with nursing as a career choice (adjusted difference = 1.38, P = 0.002) at the end of the semester.

Discussion Overall, this randomized controlled trial showed the effectiveness of the graduate-to-undergraduate student mentoring program. The mentored students had lower trait anxiety, better academic performance, and higher satisfaction with nursing as a career choice compared with the control group without the mentoring. The randomized controlled trial design was critical in determining one of the positive effects of mentoring in this study. Without the control group, a misleading negative conclusion would have been made regarding

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Table 2. Comparison of Experimental Versus Control Group at Baseline (N = 51)

Trait anxiety (range = 20–80) State anxiety (range = 20–80) Self-efficacy (range = 1–4) Cumulative GPA (range = 1–4)

Experimental group M (SD) n = 34

Control group M (SD) n = 17

Mean differences ⁎

T value †

P value

36.91 (8.62) 42.24 (10.28) 3.06 (0.42) 3.33 (0.32)

34.03 (5.12) 41.88 (11.58) 3.26 (0.32) 3.28 (0.38)

2.88 0.36 − 0.20 0.05

1.27 0.11 − 1.70 0.52

.21 .91 .10 .60

⁎ Experimental group–control group. T value by independent t test.



trait anxiety, since the within-group trait anxiety score improvement in the experimental group was minimal and not statistically significant (− 0.50). The positive effect of mentoring became detectable only through comparison with the control group, which showed a markedly worsening of the trait anxiety score (+ 5.20). The mentors' emotional support and encouragements through listening and sharing of the mentors' own professional and schooling experiences may have helped reduce the anxiety levels for the beginning nursing students. It is also possible that students with high levels of baseline trait anxiety at the beginning of the nursing program may have benefitted the most from mentoring by experienced nurses. In contrast to the positive effects of mentoring on reducing the trait anxiety, the effects of mentoring were not statistically significant in reducing the state anxiety in this study. Since the state anxiety measures the emotional state “at this moment” (Spielberger et al., 1983), it is likely to be a labile and less reliable measure of the longterm effects of mentoring on the students' anxiety level compared with the trait anxiety that measures how the students “generally feel.”

The results obtained in this study differ somewhat from those obtained in a randomized controlled trial and a quasi-experimental study where peer group mentoring was not effective in reducing students' stress levels (Hughes et al., 2003; Li et al., 2011). It is possible that being mentored by peers in a similar academic level may create certain discomfort or embarrassment for the mentees (Moscaritolo, 2009), whereas the mentoring by more experienced graduate students in this study may have circumvented these potential issues. The support and encouragement of the experienced mentors may have played a critical role in learning the culture of nursing, professional identity, and socialization into nursing profession (Elcigil & Sari, 2008; Ousey, 2009). This may have contributed toward higher satisfaction with nursing as a career choice among the mentored students in this study. Interestingly, graduate-to-undergraduate student mentoring resulted in higher academic performance. This finding is somewhat consistent with findings of a quasiexperimental study where an individualized stress management program was effective in improving

Table 3. Effects of Mentoring on Anxiety, Self-Efficacy, Academic Performance, and Satisfaction (N = 51)

Trait anxiety ‡ Experimental Control State anxiety ‡ Experimental Control Self-efficacy § Experimental Control Academic performance || Experimental Control Satisfaction ¶ Experimental Control Note. NA = not applicable.

Adjusted difference between two groups †

P, ANCOVA

− 0.50 + 5.20

− 5.02

.01

36.76 (9.41) 40.03 (9.81)

− 5.48 − 1.85

− 4.21

.08

3.17 (0.43) 3.20 (0.39)

+ 0.11 − 0.06

0.09

.41

Pretest M (SD)

Posttest M (SD)

36.91 (8.62) 34.03 (5.12)

36.41 (8.67) 39.23 (7.95)

42.24 (10.28) 41.88 (11.58) 3.06 (0.42) 3.26 (0.32)

Mean change ⁎

NA NA

86.48 (3.69) 85.03 (5.12)

NA NA

2.39

.04

NA NA

9.15 (1.03) 8.00 (1.93)

NA NA

1.38

.002

⁎ Posttest score minus pretest score. † Experimental minus control at posttest, adjusted for pretest scores where applicable and pretest trait anxiety per ANCOVA. ‡ Scores for the state anxiety and trait anxiety scales range from a minimum of 20 to a maximum of 80, with higher score indicating higher level of anxiety. § Self-efficacy questionnaire possible range = 1–4; 4 = very confident. || Nursing fundamentals course performance score. ¶ Satisfaction with nursing as a career choice scores range 1–10; 10 = extremely satisfied.

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students' grades (Godbey & Courage, 1994). It is plausible that the mentoring fostered a nurturing environment conducive for academic success through role modeling, counseling, and coaching. The students' perceived self-efficacy was not significantly improved among mentored students in this study. This result differs from a previous study that showed preceptorship by staff nurses in a clinical setting had improved self-efficacy (Goldenberg et al., 1997). These differences are likely due to the mentoring that occurred outside the clinical environment in this study.

Study Limitations There were certain limitations in this study. First, owing to the nature of the mentoring intervention, the ability to carry out a blinded randomized controlled trial was impractical. Second, the dropout rate of 33% (loss of 25 of 76) at posttest could have impacted the validity of the study results. Because of the smaller number of available mentors, some were assigned to two mentees each, which may have contributed to the mentee dropouts. However, there were no statistically significant differences in baseline characteristics between the participants completing the study versus the dropouts, indicating a reduced likelihood of skewed results arising from the dropouts (data not shown). Third, the quality of mentoring may not have been consistent among mentor–mentee dyad and was not closely monitored. The differences in quality as well as quantity of face-to-face versus E-mentoring methods may have resulted in inconsistent experiences among the mentees. Fourth, the sample size was relatively small in spite of the fact that the data were collected over two school academic years. A priori power analysis was not performed, but the effect sizes were large enough to be detectable in this study with a small sample size. Mentoring studies of this design from a single institution are logistically difficult to include large sample sizes because of the inherent small number of graduate students available as mentors in most academic institutions. Finally, this study was conducted at a single academic institution, which could limit the generalizability of the findings. Additional future studies are needed to confirm this study's findings and to determine the baseline characteristics of students who might benefit the most from mentoring. The quality of interactions between the mentors and mentees as well as the effects of the mentor–mentee compatibility upon the outcomes need to be further explored. The longitudinal follow-up of the students to determine long-term effects of mentoring may be also useful.

Conclusion In this study, the graduate-to-undergraduate student mentoring program reduced undergraduate students' trait anxiety, improved their satisfaction with nursing as a career choice, and resulted in better academic performance. However, prior to implementation of such a mentoring strategy, further studies are needed to confirm

the results as well as to identify those students who might benefit the most from mentoring by experienced nurses.

Acknowledgments This study was funded by Research and Special Project grant (RASP 12–1372) from Point Loma Nazarene University.

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Randomized controlled trial of graduate-to-undergraduate student mentoring program.

This randomized controlled trial evaluated the effects of graduate-to-undergraduate student mentoring on anxiety, self-efficacy, academic performance,...
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