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Mentorship programs and the novice nurse : a rapid evidence assessment Erickson, Stephanie Kyla 2015

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  MENTORSHIP PROGRAMS AND THE NOVICE NURSE:  A RAPID EVIDENCE ASESSMENT  by  STEPHANIE KYLA ERICKSON B.S.N, Kwantlen University College, 2002   A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF    MASTER OF SCIENCE   in  The Faculty of Graduate and Postdoctoral Studies   (Nursing)    THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)       August 2015  © Stephanie Kyla Erickson, 2015    ii  ABSTRACT New graduate registered nurses (RNs) experience many challenges as they transition from the role of student nurse to professional nurse.  Mentoring can support new nurses with the development of clinical nursing skills and competencies, and is linked to professionalism, nursing quality improvement, self-confidence, retention, and job satisfaction.  This rapid evidence assessment (REA) addresses how new graduate mentorship programs can be effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice.  It also reports the key elements of effective new graduate mentorship programs and reported problems in implementing new graduate RN mentorship programs. Seventeen research studies were selected for inclusion and examined using Bandura’s social learning theory.  The data from each research study was extracted using the EPPI-Centre Data Extraction and Coding Tool for Education Studies to allow for mapping and analysis.  Each research study was then scored from highest level of evidence to lowest level of evidence.  The findings were then synthesized to suggest that mentorship programs can be effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice under the right conditions.  The reported key elements of effective new graduate RN mentorship programs include mentor-mentee matching, availability of mentors, adequate training and preparation of mentors, commitment and support, and length of the mentoring relationship.  The reported problems in implementing new graduate RN mentorship programs include lack of training and preparation of mentors and mentees, availability of mentors, and mentor-mentee mismatch.     iii  PREFACE This thesis is original, unpublished, independent work by the author, S. Erickson.  There was no ethics approval required due to the nature of this work.                       iv  TABLE OF CONTENTS Abstract ........................................................................................................................................... ii Preface............................................................................................................................................ iii Table of Contents ........................................................................................................................... iv List of Tables ................................................................................................................................ vii List of Figures .............................................................................................................................. viii Acknowledgements ........................................................................................................................ ix CHAPTER 1 Introduction, Background, and Research Question .................................................. 1 1.1 Introduction .................................................................................................................. 1 1.2 Background ................................................................................................................... 2 1.2.1 Challenges for Newly Qualified Nurses ............................................................. 2 1.2.2 Attrition ............................................................................................................... 4 1.2.3 The Role of Mentorship Programs ...................................................................... 4 1.3 Research Question and Sub-questions .......................................................................... 5 1.4 Chapter Summary ......................................................................................................... 5  CHAPTER 2 Mentoring Overview, Conceptual Framework, and Definitions .............................. 6 2.1 Overview of Mentoring ................................................................................................ 6 2.1.1 Attributes of an Effective Mentor ....................................................................... 7 2.1.2 Attributes of an Effective Mentee ....................................................................... 7 2.1.3 Phases of a Mentoring Relationship.................................................................... 7 2.1.4 Types of Mentoring Relationships ...................................................................... 9 2.2 Conceptual Framework ............................................................................................... 10 2.3 Definitions .................................................................................................................. 14 2.4 Chapter Summary ....................................................................................................... 15  CHAPTER 3 Approach and Methodology ................................................................................... 16 3.1 Approach .................................................................................................................... 16 3.2 Justification ................................................................................................................. 17 3.3 Methodology ............................................................................................................... 18 3.3.1 Formulating the Question.................................................................................. 18 3.3.2 Inclusion and Exclusion Criteria ....................................................................... 19 3.3.3 Search Strategy ................................................................................................. 21 3.3.4 Data Collection ................................................................................................. 22 3.3.5 Screening and Selecting Studies ....................................................................... 23 3.3.6 Scoring .............................................................................................................. 23 3.4 Analysis ...................................................................................................................... 24 3.4.1 Critical Appraisal .............................................................................................. 24  v  3.4.1.1 EPPI-Centre Data Extraction and Coding Tool for Education  Studies .................................................................................................. 25 3.4.1.2 GSRS Weight of Evidence (WoE) Tool ............................................... 26 3.4.1.3 Maryland Scale of Scientific Methods (MSSM) Tool.......................... 26 3.4.1.4 Critical Appraisal Skills Programme (CASP) Tool .............................. 26 3.4.2 Synthesis of Findings ........................................................................................ 27 3.4.3 Communicating Findings .................................................................................. 28 3.5 Chapter Summary ....................................................................................................... 29  CHAPTER 4 Results..................................................................................................................... 30 4.1 Selected Research Studies .......................................................................................... 30 4.2 Excluded Research Studies ......................................................................................... 34 4.3 Quantitative Research Studies .................................................................................... 34 4.3.1 WoE High Level Studies................................................................................... 37 4.3.2 WoE Medium Level Studies ............................................................................. 40 4.4 Mixed-Methods Research Studies .............................................................................. 42 4.4.1 WoE and CASP High Level Studies ................................................................. 45 4.4.2 WoE and CASP Medium Level Studies ........................................................... 48 4.5 Qualitative Research Studies ...................................................................................... 49 4.5.1 WoE Medium and CASP High Level Studies .................................................. 50 4.6 Chapter Summary ....................................................................................................... 54  CHAPTER 5 Discussion ............................................................................................................... 56 5.1 Synthesis of Findings .................................................................................................. 56 5.1.1 Improving Performance .................................................................................... 56 5.1.2 Improving Satisfaction ...................................................................................... 58 5.1.3 Improving Retention ......................................................................................... 61 5.1.4 Improving Confidence ...................................................................................... 62 5.2 Key Elements of Effective New Graduate RN Mentorship Programs ....................... 64 5.2.1 Mentor-Mentee Matching ................................................................................. 64 5.2.2 Availability........................................................................................................ 65 5.2.3 Training ............................................................................................................. 66 5.2.4 Commitment and Support ................................................................................. 67 5.2.5 Length of Mentoring Relationship .................................................................... 68 5.3 Reported Problems in Implementing New Graduate RN Mentorship Programs ....... 68 5.3.1 Training ............................................................................................................. 68 5.3.2 Availability........................................................................................................ 69 5.3.3 Mentor-Mentee Mismatch ................................................................................. 70 5.4 Limitations of this REA .............................................................................................. 71 5.5 Chapter Summary ....................................................................................................... 71  CHAPTER 6 Conclusion .............................................................................................................. 73 6.1 REA Summary ............................................................................................................ 73 6.1.1 Performance ...................................................................................................... 74 6.1.2 Satisfaction ........................................................................................................ 75 6.1.3 Retention ........................................................................................................... 76 vi  6.1.4 Confidence ........................................................................................................ 76 6.1.5 Key Elements for Effective Programs .............................................................. 77 6.1.6 Reported Problems ............................................................................................ 78 6.2 Recommendations for Future Research ...................................................................... 78 6.3 Chapter Summary ....................................................................................................... 80  BIBLIOGRAPHY ......................................................................................................................... 81  APPENDIX A Excel Spreadsheet ................................................................................................ 90  APPENDIX B GSRS Weight of Evidence (WoE) Tool ............................................................... 96  APPENDIXC Maryland Scale of Scientific Methods (MSSM) Tool .......................................... 97  APPENDIX D Critical Appraisal Skills Programme (CASP) Tool ............................................. 98  APPENDIX E EPPI-Centre Data Extraction and Coding Tool for Education Studies .............. 101                vii  LIST OF TABLES Table 3.1 Categorical Ranking of Scores ..................................................................................... 24 Table 4.1 List of Selected Research Studies ................................................................................. 31 Table 4.2 Quantitative Study Details ............................................................................................ 35 Table 4.3 GSRS WoE Assessment Criteria Questions and Score ................................................ 36 Table 4.4 Mixed-Methods Study Details ...................................................................................... 43 Table 4.5 GSRS WoE Assessment Criteria Questions and Score ................................................ 44 Table 4.6 Qualitative Study Details .............................................................................................. 49 Table 4.7 GSRS WoE Assessment Criteria Questions and Score ................................................ 50                             viii  LIST OF FIGURES  Figure 2.1 Bandura’s Direction of Social Learning Processes ..................................................... 12 Figure 3.1 Confidence in Review Studies..................................................................................... 17 Figure 3.2 Stages of Synthesis ...................................................................................................... 28 Figure 4.1 Research Studies Selection Process............................................................................. 31 Figure 4.2 Publication Year of Research Studies ......................................................................... 33 Figure 4.3 Research Study Sample Size Histogram ..................................................................... 34 Figure 4.4 Quantitative Critical Appraisal Scoring ...................................................................... 36 Figure 4.5 Mixed-Methods Critical Appraisal Scoring ................................................................ 44 Figure 4.6 Qualitative Critical Appraisal Scoring ........................................................................ 50 Figure 4.7 Overall WoE Level of Evidence .................................................................................. 53 Figure 4.8 Overall CASP Level of Evidence ................................................................................ 53 Figure 4.9 Overall MSSM Level of Evidence .............................................................................. 54                    ix  ACKNOWLEDGEMENTS I offer my sincerest gratitude to my thesis committee for their time, guidance, and contributions.  I owe particular thanks to Dr. Bernie Garrett for your expertise, feedback, and always being available to answer my questions.  Additional thanks to Dr. Cathryn Jackson and Dr. Tarnia Taverner for their invaluable input and support in completing this work. To Lila a very special thanks for your unconditional support and encouragement as I completed this journey and fulfilled my dream.                  1  CHAPTER 1: Introduction, Background, and Research Question 1.1 Introduction Nursing shortage is a major concern both in Canada and across the world (Buchan & Aiken, 2008; Canadian Nurses Association [CNA], 2009).  According to the Canadian Institute for Health Information (CIHI, 2013), in 2011 there were 270,274 registered nurses (RNs) employed in Canada with 40.3% of them over the age of 50 years.  When looking at British Columbia (BC) in 2011 there were 30,151 RNs employed with 42.9% of them aged 50 years and older (CIHI).  This suggests, depending on the age of retirement that up to one third of Canada’s nursing workforce could retire from active practice within the next ten years (Maddalena, Kearney, & Adams, 2012).  The result of these experienced nurses retiring means that considerable pressure is being placed on new graduate RNs to fill the ensuing vacancies (Maddalena et al.).   In 2009 the CNA estimated that Canada currently needed 11,000 full-time equivalent (FTE) RNs to meet health care needs and anticipated that Canada will be short almost 60,000 FTE RNs by 2022.  The main causes of a nursing shortage in economically developed countries have been identified as: inadequate workforce planning and allocation mechanisms creating a mismatch between education supply and service demand; undersupply of new staff; poor recruitment, retention, and ‘return’ policies; and ineffective use of available nursing resources (Buchan & Aiken, 2008).  The CNA proposes six policy scenarios to deal with Canada’s projected RN shortage including increasing RN productivity, reducing RN annual absenteeism, increasing enrolment in nursing schools, improving the retention of practicing RNs, reducing attrition rates in RN entry-to-practice programs, and reducing international in-migration (2009). 2  This issue has also led to pressure to take on new RNs in areas that have typically not employed them in the past.  In 2011 there were 12,645 RNs employed in operating room (OR) practice, with 46.5% of them aged 50 years and older which means they need to ensure they are recruiting and retaining new RNs to meet the needs of an aging workforce (CNA, 2013).  Historically the practice of hiring a new graduate RN into a specialty area, such as the OR, has been rare but due to a nursing shortage this has become the rule, rather the exception (Baxter, 2008; Persaud, 2008).  This has resulted in the new phenomenon of RNs who have only recently graduated from nursing school entering specialty areas who have limited experience with practice skills such as time management, organization, and applying theoretical knowledge into practice (Chen & Lou, 2014).  In a complex work environment, it has been suggested that a new graduate RN may take up to one year to transition successfully into their new practice environment (Persaud; Woodfine, 2011). The stakeholders who find these issues most significant includes individuals who are responsible for recruitment and retention within health care organizations, such as directors and managers; and particularly staff  who are responsible for the orientation and mentorship of newly graduated RNs (such as clinical nurse educators).  Therefore there is a need to explore the impact of mentorship programs on the practice of novice nurses’.  1.2 Background 1.2.1 Challenges for Newly Qualified Nurses New graduate RNs experience many challenges as they transition from the role of student nurse to professional nurse (Baxter, 2010; Maddalena et al., 2012; Rheaume, Clement, & LeBel, 2011).  Some of the challenges they experience include short staffing, poor communication among colleagues, abusive or unsupportive colleagues, heavy workloads, physical and emotional 3  demands, and lack of administrative support (Maddalena et al.).  Although these challenges are not uncommon for experienced RNs, they are especially stressful for new graduate RNs and high levels of stress during the novice period may contribute to the decision to leave their place of employment (Maddalena et al.).  Some of the reasons cited for attrition from nursing include job dissatisfaction, inadequate training, lack of support, and “realty shock” (Baxter).  Other common factors influencing attrition include perceptions of unsafe patient care related to high patient acuity, unacceptable nurse-to-patient ratios, lack of support and guidance in the workplace, and unacceptable salary, benefits, or scheduling (Bowles & Candela, 2005). The first three to six months of employment for new graduate RNs can be described as the most stressful and the greatest challenge is putting what was learned in school into bedside practice (Almada, Carafoli, Flattery, French, & McNamara, 2004).  New graduate RNs demonstrate stress concerning competence, confidence, making errors, and adjusting to their new workplace environment (Almada et al.). Bowles and Candela’s (2005) research on first job experiences of recent RN graduates revealed that the newly graduated RNs did not perceive their work environment as safe, felt staffing levels were inadequate, and believed that there wasn’t enough time available to spend with their patients to provide adequate care.  Cho, Laschinger, and Wong (2006) described the sources of stress for new graduate nurses as the gap between what was learned in school and what is practiced in the workplace, the fear of making errors due to excessive workloads and responsibilities, lack of confidence in their clinical skills, and lack of mentorship from more experienced nurses.  Hunsberger, Baumann, and Crea-Arsenio (2013) identified sources of anxiety for new graduate RNs as not knowing what to do in unexpected situations, interactions with physicians, and role issues such as ambiguity and work overload.  The greatest concern for a new graduate RN was reported by Craig, Moscato, & Moyce (2012) 4  as a fear of not knowing what to do in an unexpected crisis or situation, followed by concerns about missing a key piece of information related to their patient, and their lack of experience to provide safe patient care. 1.2.2 Attrition It has been estimated that up to 69 % of new graduate RNs will leave their place of employment within their first year of practice (Baxter, 2010; Persaud, 2008).  O’Brien-Pallas et al. (2008) report that the average cost of replacing a RN in Canada is $25,000 and high turnover rates are associated with a decrease in job satisfaction, increase in likelihood of medical errors, overtime, and environmental complexity.  High turnover rates can also affect a new graduate RN personally and professionally in addition to the associated high cost to the employer (Baxter).  Bowles and Candela’s (2005) research discovered the most frequent reason why new graduate RNs left their first job as issues relating to patient care, such as the acuity of patients, unacceptable nurse-to-patient ratios, and feeling patient care was unsafe.  Another reason identified included issues with the work environment such as management issues, lack of support or guidance, and being given too much responsibility (Bowles & Candela).   1.2.3 The Role of Mentorship Programs Mentoring can be described as a way to support new colleagues with the development of clinical nursing skills and competencies, and is linked to professionalism, nursing quality improvement, self-confidence, retention, and job satisfaction (Ronston, Andersson, & Gustafsson, 2005).  Mentoring has also been identified as one successful strategy to guide and teach new graduate RNs, to develop professional growth for experienced RNs, to promote recognition of nursing as a profession, and to increase nursing retention (Young, 2009).  Mentors can also experience benefits such as increased confidence in knowledge and skills and ability to 5  provide feedback (Block, Claffey, Korow, & McCaffrey, 2005).  The presence of a mentoring program can provide multiple benefits including developing the growth of expertise in a safe environment, providing professional encouragement, modelling of professional values and leadership, modelling expertise through sharing of experiences, facilitating both professional and personal relationships, easing job transition from novice to graduate nurse, and creating support systems (Leners, Wilson, Connor, & Fenton, 2006).   1.3 Research Question and Sub-questions The focus of this thesis will be to answer the following research question:  What is the evidence that new graduate mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice?   This thesis will also answer the following sub-questions: What are the reported key elements of effective new graduate RN mentorship programs? What are the reported problems in implementing new graduate RN mentorship programs? To answer this question and sub-questions a rapid evidence assessment (REA) will be undertaken (Government Social Research Service [GSRS], 2010).  Novice nurses in this research inquiry are defined as RNs practicing within two years since graduating from nursing school. 1.4 Chapter Summary This chapter has provided an introduction to nursing shortage and its resulting impact of new graduate RNs filling ensuing vacancies.  It has also provided an overview of the challenges that newly graduated nurses’ experience, reasons for attrition from nursing, and the role of mentorship programs.  The research question and sub-questions that this thesis will answer was also introduced.  In the next chapter an overview of mentoring, the conceptual framework, and definitions used will be discussed. 6  CHAPTER 2: Mentoring Overview, Conceptual Framework, and Definitions In this chapter an overview of mentoring, the conceptual framework, and definitions used in this research study are presented. 2.1 Overview of Mentoring The concept of mentoring has been a foundation of nursing practice dating back to the times of Florence Nightingale (Barton, Gowdy, & Hawthorne, 2005).  Mentorship can be defined as “a relationship between two nurses formed on the basis of mutual respect and compatible personalities with the common goal of guiding the nurse towards personal and professional growth” (Block et al., 2005, p. 134).  Another definition of mentorship is “a long-term and one-to-one interpersonal relationship that encourages the personal and professional development of the mentee” (Chen & Lou, 2014, p. 434).   Although the concept of mentorship is a topic that is clearly defined in the nursing literature, there is some conflict about the interchangeable use of the term with preceptorship, especially in the international community (CNA, 2004; Yonge, Billay, Myrick, & Luhanga, 2007).  Some authors feel the roles are interchangeable and have been that way since the inception of this concept in nursing (Allen, 2006; Harvey, 2012) while others cite the main difference is time commitment – mentorship suggests a long-term relationship whereas preceptorship is short-term (Block et al., 2005; CNA, 2004; Wensel, 2006).  Preceptorship is more focused on assisting the novice to develop beginning practice competencies through direct supervision over a limited time period and in Canada often refers to the relationship with nursing students (CNA, 2004; Yonge et al.).  Mentoring focuses on positively influencing personal and professional growth over a longer time period and can occur within or outside the clinical setting (CNA, 2004; Wagner & Seymour, 2007). 7  2.1.1 Attributes of an Effective Mentor The nursing literature appears to be in agreement about the attributes that an effective mentor should possess to ensure a successful mentoring relationship including personal attributes, professional skills and abilities, and communication skills (LaFleur & White, 2010).  Some personal attributes that an effective mentor will possess include respect, honesty, patience, openness, friendliness, enthusiasm, compassion, and flexibility (Academy of Medical-Surgical Nurses [AMSN], 2012; Fawcett, 2002; Harvey, 2012; LaFleur & White; Wagner & Seymour, 2007).  The professional skills and abilities comprise a good knowledge base, teaching and counseling ability, competence, and ability to think critically (Harvey; LaFleur & White; Wagner & Seymour). When looking at communication skills, an effective mentor should be diplomatic, a storyteller, an active listener, able to provide constructive feedback, and possess strong interpersonal skills (AMSN; CNA, 2004; Harvey; LaFleur & White; Wagner & Seymour). 2.1.2 Attributes of an Effective Mentee Although the attributes of an effective mentee are not as widely discussed in the literature, the mentee plays a key role in the success of a mentoring relationship (AMSN, 2012; Kanaskie, 2006).  Mentees should be open to receiving help and guidance from their mentor while assuming responsibility for their own learning and growth (AMSN; Greene & Puetzer, 2002; Kanaskie).  Some of the personal attributes that an effective mentee should possess include respect, honesty, energy, motivation, initiative, and a strong self-identity (Greene & Puetzer; Kanaskie).   2.1.3 Phases of a Mentoring Relationship A mentoring relationship requires thought, time, and care (Cooper & Wheeler, 2010).  The AMSN (2012) characterizes a mentoring relationship into three phases – the beginning, 8  middle, and closing.  In the beginning phase, mentors and mentees focus on interpersonal relationship building through establishing trust, engaging in meaningful dialogue, and determining learning goals (AMSN).  The middle phase is when the mentors offer specific suggestions about achieving goals; and the mentees experience enhanced self-esteem while developing and confirming new skills (AMSN).  Finally in the closing phase, the mentees feel comfortable functioning independently, achieve greater autonomy, and become empowered which results in the relationship being closed (AMSN).   Shaffer, Tallarica, and Walsh (2000) and Kopp and Hinkle (2006) describe four stages that a mentoring relationship evolves through: initiation, cultivation, separation, and redefinition.  In the initiation stage, the mentor and mentee engage in series of conversations to clarify values and establish shared interpersonal boundaries such as confidentiality and respect (Kopp & Hinkle).  The cultivation stage is a working phase in which the mentor teaches the mentee how to navigate unfamiliar environments and adjust to the new responsibilities and demands (Kopp & Hinkle).  During the separation stage, the mentee begins to practice independently and the mentor slowly takes on the role of a safety net (Kopp & Hinkle).  Finally in the redefinition stage, the mentor and mentee become equal colleagues and communication becomes peer dialogue instead of novice-expert interactions (Shaffer, Tallarica, & Walsh). Cooper and Wheeler (2010) developed a five-phase mentoring relationship model to help mentors and mentees build an effective relationship: purpose, engagement, planning, emergence, and completion.  In the purpose phase, a clearly articulated intention for the mentoring relationship is developed consisting of career vision, goals, and plans (Cooper & Wheeler).  The engagement phase focuses on the mentor and mentee determining whether their mutual goals, learning needs, and learning styles fit and then deciding to enter into a mentoring relationship 9  (Cooper & Wheeler).  During the planning phase, a mentoring action plan is developed which includes goals, action steps, resources, timelines, and evaluation of the mentoring relationship along with the expectations that the mentor or mentee have (Cooper & Wheeler).  The emergence phase is where the mentoring relationship evolves and the mentor facilitates the growth and development of the mentee through supporting, encouraging, and challenging (Cooper & Wheeler).  Finally, the completion phase is a time for celebrating accomplishments, redefining the relationship, and examining what the next steps may include (Cooper & Wheeler).   2.1.4 Types of Mentoring Relationships A mentoring relationship may be a formal or informal arrangement (AMSN, 2012; CNA, 2004; Dunn, 2014; Tourigny & Pulich, 2005).  Both formal and informal mentoring relationships can be effective as long as the mentor and mentee are committed to the relationship and agree to identify and meet the needs of the mentee (AMSN).  Formal mentoring programs are developed by an organization and usually involve establishing the mentoring objectives and duration, selecting and matching mentor-mentee dyads, and determining the frequency of time spent in mentoring activities (AMSN; Tourigny & Pulich).  The advantages of a formal mentoring program include fostering career and organization commitment along with higher levels of involvement in the nursing profession (Tourigny & Pulich).  The disadvantages may include mentor-mentee mismatch, the potential for role conflict and ambiguity, and the effects on personal learning could only be short-term ceasing at the duration of the contract (Tourigny & Pulich).   Informal mentoring is unstructured, occurs spontaneously, and based upon mutual identification and personal development needs (AMSN, 2012; CNA, 2004; Tourigny & Pulich, 2005).  An informal mentoring relationship may be either hierarchical – superior to employee or 10  peer – employee to employee (Tourigny & Pulich; Yonge et al., 2007).  The advantages of informal mentoring include mutual identification, increased potential for learning as these relationships often extend over a long period, and activities are not restricted by contracts (Tourigny & Pulich).  The disadvantages may include perceived favoritism by other coworkers, greater potential for role conflict, and lack of recognition and control by the organization (Tourigny & Pulich).   2.2 Conceptual Framework There are many different conceptual frameworks that can be applied to the concept of mentoring and could have been selected to guide this research study.  Benner’s (1984) novice to expert theory is based upon the Dreyfus Model of Skill Acquisition tool and posits that a nurse passes through five levels of proficiency in the development of a skill: novice, advanced beginner, competent, proficient, and expert.  In the progression to the expert level of proficiency, the reliance on rules and guidelines changes to intuition and decision making based upon past experiences (Benner).  Duchscher’s (2008) stages of transition theory which suggest that allowing new graduates time to adjust to what ‘is’ within a context of support that allows them to develop their thinking and practice expertise will assist them to move through the stages of professional role transition.  The initial transition to professional practice is believed to last about twelve months and during that time a new graduate nurse evolves through three stages: doing, being, and knowing (Duchscher).  Ultimately, Bandura’s (1977) social learning theory was selected as the conceptual framework to guide this research study.  Social learning theory is a perspective on learning that includes consideration of the personal characteristics of the learner, behavior patterns, and the environment (Braungart & Braungart, 2008).  It is suggested that individuals learn by observing, imitating, and modeling 11  other’s behaviors, attitudes, experiences, and consequences of behaviors (Bandura, 1977).  Considerable learning occurs when individuals take note of other people’s behaviors and what happens to them, as a result learning via role modelling (Braungart & Braungart).  For example, when applying the concept of social learning theory an experienced nurse who possesses the characteristics of clinical competence, knowledge and expertise of their practice area, self-confidence, and enthusiasm (Kaviani & Stillwell, 2000) could be used as a mentor for a less experienced nurse (Braungart & Braungart). Social learning theory was selected over Benner’s (1984) novice to expert theory and Duchscher’s (2008) stages of transition theory because its central concept is based upon role modeling which has been shown in the literature to be an important aspect of mentorship (Allen, 2006; AMSN, 2012; CNA, 2004).  As well, another key attribute for the selection of social learning theory is the impact that the mentoring relationship has on the mentor and mentee and the supportive environment that is required to be successful.  A mentoring relationship works best when both the mentor and mentee are actively engaged and collaborate to meet the goals of both individuals. Bandura (1977) defined a four-step, largely internal process that directs social learning as shown in Figure 2.1 below (Braungart & Braungart, 2008). 12  Figure 2.1 Bandura’s Direction of Social Learning Processes Source: Bandura’s Direction of Social Learning Process (Braungart & Braungart, 2008). When looking at the relationship between a new graduate RN and their mentor in the attentional phase, the mentor is the role model that the new graduate RN observes and then models their observed behavior.  Role models with a high status and competence are more likely to be observed, thus an important aspect of the mentoring relationship is to have the new graduate RN think of their mentor as a role model (Braungart & Braungart, 2008).  It may be challenging for a new graduate RN to think of their mentor as a role model when a mentoring relationship is arranged, as often found in formal arrangements, therefore the use of informal mentoring may be preferred when applying the concept of social learning theory. In the context of this research study, the retention phase would have the new graduate RN retain the observed behaviors of their mentor by imaginal and verbal systems which can then be further reinforced by rehearsal and repeated exposure (Bahn, 2001).  For example, retention of 13  observed behaviors in a new graduate RN can be aided by maintaining a reflective diary of their experiences and recording their thoughts and feelings (Bahn).   In the reproduction phase the new graduate RN will perform the tasks or actions from memory that they previously observed their mentor performing.  During this phase it is important for feedback to be provided by the mentor since individuals cannot observe their own performance (Bahn, 2001).  Feedback should be corrective and provide the new graduate RN with enough information that they can perform self-corrective adjustments (Bandura, 1977).  Feedback can also assist the new graduate RN with building their perception of self-efficacy which Bandura defines as confidence in one’s ability to take action and persist in action, thus it is an important aspect of a new RN’s practice to develop. Learning by a new graduate RN in the motivational phase focuses on whether they are motivated to perform a certain type of behavior and is influenced by vicarious reinforcement and punishment (Braungart & Braungart, 2008).  Vicarious reinforcement is the result of learning by observing the mentor’s successes and failures (Bahn, 2001).  Upon observation of the appropriate and effective management of the mentor’s successes and failures can result in valuable learning experiences for the new graduate RN whereas inappropriate or aggressive responses can greatly reduce learning (Bahn).  For example, if the new graduate RN observes their mentor engaging in a difficult conversation with another co-worker that involves yelling, the resulting outcome may be a negative impact on the new graduate RN’s learning.  Bandura (1977) suggests that some people respond to their own actions by self-reward, which can result in a great sense of pride, or self-punishment.  Mentors can encourage individualized learning to meet the needs of the new graduate RN and increase their sense of achievement but should be mindful of unrealistically high standards that can result in failure (Bahn).  One suggestion to 14  prevent these unrealistically high standards is the development of a learning contract, based on assessment of the new graduate RN’s capabilities so that realistic, measurable, and achievable goals are set (Bahn). 2.3  Definitions The following definitions are used in this research study: Competence: Refers to the potential ability and/or a capability to function in a given situation and makes one capable of fulfilling his/her job responsibilities (Schroeter, 2008). Confidence: Part of, related to, or integral to professional identity; self-confidence and self-esteem; self-concept; competency; clinical competence; critical thinking; and self-efficacy (Brown et al., 2003). Evaluation: The process of making judgments about learning and achievement, clinical performance, and competence based upon assessment data (Oermann & Gaberson, 2009). Mentee: Someone who chooses to be counseled, guided, and advised (McBurney, 2015). Mentor: Someone who serves as a career role model and actively advises, guides, and promotes another’s career and training (Mills & Mullins, 2008). Mentoring:  A nurturing process, in which a more experienced person, serving as a role model, teaches, sponsors, encourages, counsels, and befriends a less experienced person for the purpose of promoting the latter’s professional and/or personal development (Meier, 2013). Mentorship program: Provides formal, structured partnering of individuals with a prescribed list of activities or skill sets to review, orient to, or demonstrate competency in (Wilson, Andrews, & Leners, 2006). Novice or new graduate RN: An entry level RN who is a recent graduate from a recognized nursing education program (College of Registered Nurses of British Columbia [CRNBC], 2014). 15  Performance: In nursing, can be measured by competencies, nursing-sensitive quality indicators, and measures of performance on specific tasks (DeLucia, Ott, & Palmieri, 2009). Preceptorship: A formal one-to-one relationship of pre-determined length, between an experienced nurse and a novice designed to assist the novice in successfully adjusting to and performing a new role (CNA, 2004). Retention: Actions and strategies taken to keep the nurses currently employed by a hospital or organization (Westendorf, 2007). Satisfaction: Consists of a feeling of wellbeing, resulting from the interaction of several occupational aspects and may influence the worker’s relationship with the organization, patients, and family (Melo, Barbosa, & Souza, 2011).   Social learning: Behaviour is learned from the environment through the process of observational learning (Bandura, 1977). 2.4 Chapter Summary This chapter presented an overview of mentoring comprising the attributes of an effective mentor and mentee, phases of a mentoring relationship, and types of mentoring relationships.  As well, Bandura’s (1977) social learning theory was introduced as the conceptual framework guiding this research study and a list of definitions used in this research inquiry was provided.   In the next chapter the REA approach and methodology will be presented.      16  CHAPTER 3: Approach and Methodology In this chapter an overview of the REA approach, the justification for its selection, the REA methodology, and the REA analysis will be presented.   3.1  Approach An REA is a systematic review method to search and critically appraise existing research on a topic in a shorter time period, two to six months, compared with a full systematic review that normally takes a minimum of eight to twelve months (GSRS, 2010).  The REA method is especially useful to quickly gather existing evidence in a research area and determine what future research can be conducted (Boycott, Schneider, & McMurran, 2012).  An REA involves a specific and rigorous methodology, but is advantageous as it can be conducted by a single researcher (Garrett, 2012).  Healthcare particularly demands rapid access to current research to ensure evidence-informed decision making and practice (Ganann, Ciliska, & Thomas, 2010; Watt et al., 2008).  The REA method may be driven by clinical urgency and intense demands for uptake of technology, or may be determined by limited time and resources (Ganann, Ciliska, & Thomas).  When looking at an evidence hierarchy for confidence in review studies, the REA method is found just below a full systematic review as shown in Figure 3.1 below (Garrett).        17  Figure 3.1 Confidence in Review Studies         Source: Figure 3.1 Confidence in Review Studies  http://hlwiki.slais.ubc.ca/index.php/File:Evidence-review-types.jpg   Although the REA process aims to be rigorous and explicit in method, it does have some limitations over a full systematic review including the depth and breadth of the search process which is limited thereby increasing the potential of introducing bias (GSRS). 3.2 Justification  The REA method was selected for this research study since it involves a specific and rigorous methodology while possessing the ability to be conducted by a single researcher in a shorter period of time (Garrett, 2012).  A full systematic review is the most robust way to review evidence but they are time and resource consuming, often requiring a team of researchers, and outside the scope of this thesis (GSRS, 2010).  According to the GSRS, an REA will provide a balanced assessment about what is already known about mentorship and new graduate RNs by using a systematic review method to search and critically appraise any existing research.  The 18  REA method makes concessions to the breadth of the process by limiting particular aspects of the systematic review process including the question, searching of literature, screening of literature, mapping stage, data extraction, or appraisal and/or synthesis of studies (GSRS).   3.3 Methodology 3.3.1 Formulating the Question The first step in the REA method involves formulating a research question and determining whether it is an impact or non-impact question (GSRS, 2010).  According to the GSRS, the REA question should be the driver for all REA processes, a statement that can be investigated rather than a subject of interest, clear and answerable, and be worth answering.  An impact question reflects a deductive approach, and addresses “what works” inquiries.  It focuses on finding studies that investigated the population of interest, and intervention one is interested in, using a suitably rigorous method such as having one control group, and quantitatively measuring the interested outcomes (GSRS).  A non-impact question is more of an inductive exploratory question, and appropriate to answer a range of inquiries including needs, process, implementation, correlation, attitude, and economic questions (GSRS).  An REA question will lead the direction of the research, consequently having a significant effect on the conclusions and a narrower focus may limit the available evidence whereas a broader question is likely to require more extensive resources (GSRS).  As well, an REA can address more than one type of question, particularly in combining impact questions with implementation and economic questions (GSRS).   The research question posed in this research study is an impact question to identify the impact of a mentorship program on novice nurses’ performance, satisfaction, retention, and confidence as presented in chapter one.  The sub-questions are also impact questions to identify 19  the key elements of an effective mentorship program and the reported problems in implementing a mentorship program. 3.3.2 Inclusion and Exclusion Criteria The next step in the REA method involves deciding on the inclusion and exclusion criteria.  Before conclusions can be drawn from the studies that have been selected for inclusion, they need to be critically appraised to ensure relevancy and reliability of the findings (GSRS, 2010).  In order to ensure the process is rapid constraints are imposed on the inclusion criteria and may include the nature of what’s being studied, setting and population, date of research, research methods, and language of report (GSRS).  According to Gough (2007), there are three main dimensions to be considered in the appraisal of quality and relevance of studies: the methodological quality of the study, the relevance of the research design for answering the REA question, and the relevance of the study focus for answering the REA question.  The following inclusion and exclusion criteria were developed utilizing these three dimensions for this research inquiry: Inclusion criteria • Research studies written in the English language utilizing quantitative, qualitative, or mixed-methods research, selected for inclusion to avoid the introduction of a language bias and to ensure the included research studies provide a high level of evidence to answer the REA question and sub-questions. • Studies published within the past 15 years, selected for inclusion to include only the most current research. 20  • Studies that involved a one-to-one mentorship program, selected for inclusion to avoid confusion with the effect of a mentorship program if it were offered in more than one way. • Studies that included participants who were practicing RNs in their first two years of work, selected for inclusion in view of the fact that this is what the literature offers as a definition of a new graduate RNs. • Studies that were available from an electronic bibliographic database, selected for inclusion due to the time constraint of only three weeks being allotted for literature searching in this REA.  Exclusion criteria • Studies that focused on nursing students, selected for exclusion due to the fact that the learning needs of a nursing student is vastly different than that of a new graduate RN and grouping them together could have confused the results. • Studies that offered a group mentoring program, selected for exclusion to avoid confusion about the effect of a mentorship programs if it were offered in more than one way. • ‘Grey’ literature, selected for exclusion due to the time constraint of only three weeks being allotted for literature searching in this REA. • Opinion papers, abstracts, or letters to editors, selected for exclusion to ensure the included research studies provide a high level of evidence to answer the REA question and sub-questions.   21  3.3.3 Search Strategy The next step in the REA method is specifying the methods utilized for conducting the search.  An REA search strategy should be principled, planned, rigorous, taken with care and checked, explicitly reported, and grounded in the research question (GSRS, 2010).  The GSRS identifies four elements that a search strategy should employ and all elements were incorporated in this REA.   1. The first element involves what is being searched for as defined by the inclusion criteria and this is reported earlier in this chapter.   2. The second element involves including the sources that will be searched (GSRS).  To answer the research question and sub-questions identified in this REA the following electronic databases will be searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Embase, Web of Science, and ProQuest Dissertations and Theses.  Web of Science and ProQuest Dissertations and Theses will be selected to search for studies that may have never been published in a journal but involved research on mentorship and new graduate RNs. 3. The third element involves how the databases will be searched and what search terms will be used (GSRS).  The type of search strategy employed in this REA will be comprehensive or exhaustive searching which aims to identify as much literature as possible that meets the inclusion criteria (GSRS).  Comprehensive searching will be selected since this method has increased sensitivity, refers to the amount of literature that is found,  as opposed to increased specificity, refers to the amount of relevant versus non-relevant literature that is found; although clearly defined search terms can help balance sensitivity and specificity as well (GSRS).  The following search terms were selected: 22   New graduate nurse AND mentor*  Novice nurse AND mentor*  Newly qualified RN and mentor*  Mentor* of novice nurses  Mentor* of graduate nurses  New graduate nurse AND preceptor*  Novice nurse AND preceptor*  Preceptor* of novice nurses  Preceptor* of graduate nurses  Benefits of mentor*  Mentorship programs 4. The final element involves writing up the actual detailed methods of the search strategy to provide readers with the ability to see how the search was undertaken; therefore being transparent (GSRS).   Once the search strategy was defined as above, the author proceeded to search the literature for relevant studies for a period of three weeks.  Systematic literature searching includes electronic sources, print sources, and ‘grey’ literature (GSRS, 2010).  Due to the limited timeframe the searching for literature in this REA only included electronic sources and hand searching of print sources from the references of relevant research studies, which is a potential limitation that will be described further in chapter five. 3.3.4 Data Collection The next step of the REA method is data collection which involves two main components: the location and the description of the research studies (GSRS, 2010).  Studies were 23  located through searching of the electronic databases identified earlier in this chapter and through hand searching of the references of relevant research studies.  According to the GSRS, access to good library facilities is essential for the completion of a successful REA and the University of British Columbia’s (UBC) library was utilized for data collection during this step.  Once the research studies have been located the references need to be recorded through standard word-processing and spreadsheet applications or reference management software (GSRS).  The selected research studies used in this REA were catalogued using the Mendeley bibliographic database software and key elements of the work tabulated into a Microsoft Excel spreadsheet, grouped according to their research method: quantitative, mixed-methods, or qualitative (See Appendix A). 3.3.5 Screening and Selecting Studies Once the initial research studies were identified, they were screened to ensure they met the identified inclusion and exclusion criteria.  This was a two-step process that involved reviewing the abstract and then reading the full article (GSRS, 2010).  The author found that several research studies needed to be excluded after reading the full article due to conflicting definitions of a novice nurse.  The screening process can be very time-consuming and one strategy to keep the screening rapid was utilizing a time limit of three weeks for screening and selecting.   3.3.6 Scoring Each research study was scored using the GSRS Weight of Evidence (WoE) tool (EPPI-Centre, 2007), found in Appendix B, in which each study is weighted according to three dimensions with scores then ranked as either low evidence, medium evidence, or high evidence.  Quantitative and mixed-methods research studies are scored using the Maryland Scale of 24  Scientific Methods (MSSM) tool, found in Appendix C (Sherman et al., 1997).  The MSSM is a five-point scale for classifying the strength of methodologies and scores are ranked as either low evidence, medium evidence, or high evidence (GSRS, 2010).  For qualitative and mixed-methods research studies, scoring was through the Critical Appraisal Skills Programme (CASP) tool, found in Appendix D (Public Health Resource Unit, 2006).  The CASP score is based upon ten questions and ranked as either low evidence, medium evidence, or high evidence (GSRS). Table 3.1 Categorical Ranking of Scores WoE Score: Low = 3, Medium = 4-6, High = 7-9 (all studies) MSSM Score: Low = 1, Medium = 2-3, High = 4-5(quantitative and mixed-methods studies) CASP Score: Low = 1-3, Medium = 4-7, High = 8-10 (qualitative and mixed-methods studies)  3.4 Analysis 3.4.1 Critical Appraisal The key information from each research study was systematically described using a data extraction form and coding the information collected (GSRS, 2010).  The data extraction form allows researchers to identify, extract, and code information about each individual research study and the tool utilized in this research inquiry was the Evidence for Policy and Practice Information (EPPI)-Centre Data Extraction and Coding Tool for Education Studies (2007), found in Appendix E.  Using a data extraction tool allows for mapping - providing a description of each study to build up a map of the research field, and synthesis - providing information to enable synthesis such as how studies were undertaken for quality and relevance appraisal; the study findings; and reporting on aspects of individual studies (GSRS).   25  The author critically appraised the selected research studies to ensure the findings are relevant and reliable; and to separate those research studies that are higher quality from the weaker ones (GSRS, 2010).  This was a two-step process that involved the author critically appraising and scoring all the research studies at one time and then re-critically appraising and re-scoring each research study the following week.  All seventeen research studies were only critically appraised and scored by the author of this REA, which is a potential limitation that will be discussed further in chapter five.  The three main dimensions considered in quality and appraisal of studies according to Gough (2007) include: the relevance of the research design in answering the REA question, the relevance of the study focus for answering the REA question, and the methodological quality of evidence for the research study being considered, all of which were considered in this REA.  The findings of lower quality studies are to either be excluded or given less weight in the synthesis (GSRS).  All seventeen research studies included in this REA are categorized as medium evidence or high evidence based upon the WoE and CASP scores and the results are tabulated in a Microsoft Excel spreadsheet, found in Appendix A. 3.4.1.1 EPPI-Centre Data Extraction and Coding Tool for Education Studies This tool, found in Appendix E, was designed to help researchers identify, extract, and code information from a single primary research study (EPPI-Centre, 2007).  The purpose is to help reviewers obtain all the necessary information to assess the quality of a study, identify the relevant contextual information that may have affected the results, identify the contextual information that is relevant to any assessment of generalizability, and identify relevant information about the design, execution, and context of a study for the purpose of synthesizing results (EPPI-Centre).  26  3.4.1.2 GSRS Weight of Evidence (WoE) Tool This tool, found in Appendix B, assesses all research studies and includes four specific criteria for scoring: A - takes into account whether the study findings can be trusted in answering the research question(s), B - assesses the appropriateness of the research design and analysis in addressing the research question(s), C - assesses the relevance of REA topic for answering the research question(s), and D - an overall weight of evidence score (EPPI-Centre, 2007).  WoE A, B, and C can each receive a score of three for high evidence, two for medium evidence, and one for low evidence and the overall score for WoE D is either three for low level of evidence, four to six for medium level of evidence, or seven to nine for high level of evidence. 3.4.1.3 Maryland Scale of Scientific Methods (MSSM) Tool This tool, found in Appendix C, is used to appraise methodological quality of quantitative research studies and assists with identifying potential threats to internal validity (Sherman et al., 1997). It is a five-level scale: 1 – the measurement of impact of a specific intervention at a single point in time, 2 – before and after scores following an intervention, 3 – before and after scores following an intervention with a second control group, 4 – comparison between more than two groups with and without the intervention, and 5 – randomized controlled trials.  Overall MSSM scoring is either low level of evidence (Level 1), medium level of evidence (Level 2 & 3), or high level of evidence (Level 4 & 5). 3.4.1.4 Critical Appraisal Skills Programme (CASP) Tool This tool, found in Appendix D, is an appraisal method for qualitative research studies which assesses rigour, credibility, and relevance (Public Health Resource Unit, 2006).  It is based upon ten questions that receive a score of one for yes and zero for no and with the answers 27  totaled to get a final score out of ten.  Overall CASP scoring is either low level of evidence (score of 1-3), medium level of evidence (score of 4-7), or high level of evidence (score of 8-10).   3.4.2 Synthesis of Findings The synthesis stage generates the findings to answer the questions and sub-questions and allow conclusions to be drawn from the selected research studies (GSRS, 2010).  Synthesis of the results occurred through the use of the following analytical tools: EPPI-Centre Data Extraction and Coding Tool for Education Studies; WoE tool; MSSM tool; and CASP tool, described earlier in this chapter, to provide evidence that mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice.  These findings were also linked to the conceptual framework identified in chapter two as well as discussing the reported key elements of an effective mentorship program and problems in implementing a mentorship program.  Narrative synthesis described by Popay et al. (2006) as the “synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the synthesis of findings of the synthesis” (p. 5) was employed in this REA as outlined in Figure 3.2 below. 28  Figure 3.2 Stages of Synthesis Source: Figure 3.2 Stages of Synthesis http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea  3.4.3 Communicating Findings The final step in the REA method involves communicating the findings in a way that will engage with users of the research evidence (GSRS, 2010).  A written report is necessary to provide transparency and enables the readers to see how the review was conducted to provide accountability of the process of the review and its potential for replication (EPPI-Centre, 2010).  The EPPI-Centre recommends three different formats for reports: a short one page summary on the findings of the review; a short user-friendly report about 25 pages which concentrates on the findings and context of the review and gives a more thorough description of the findings; or a technical report about100 pages that includes all the fine details of the methods.  The findings in this REA are communicated through the short user-friendly report format and the results of the 29  selected research studies are presented in chapter four and the results of the analysis are presented in chapter five. 3.5 Chapter Summary This chapter presented an overview of the REA approach; the justification for its selection as an appropriate methodology; the REA methodology including identification of inclusion and exclusion criteria, search strategy, data collection, screening and selecting of studies, and scoring; and the REA analysis using quality of evidence assessment tools.  In the next chapter an overview of the included seventeen research studies along with the critical appraisal scoring and their findings will be described.               30  CHAPTER 4: Results In this chapter an overview of the final seventeen selected research studies along with their Weight of Evidence, and Maryland Scale of Scientific Methods Scores.   4.1 Selected Research Studies A total of 66 research studies were initially selected and their abstracts reviewed to screen for meeting the inclusion criteria and answering the research question and sub-questions identified in chapter 1.  Twenty-one research studies were then selected to be included in this REA but upon further review four had to be excluded due to their definitions of a new graduate RN not meeting the inclusion criteria leaving a final total of seventeen research studies for this REA.  The data from each research study was extracted using the EPPI-Centre Data Extraction and Coding Tool for Education Studies (see Appendix E), and the studies categorized according to the research approach used (quantitative, mixed-methods, or qualitative) to allow for mapping and analysis.  Each research study was then scored using the tools described in chapter three and are listed from highest level of evidence to lowest level of evidence, according to their GSRS WoE level, MSSM, and CASP scores as appropriate for the type of study.         31  Figure 4.1 Research Studies Selection Process  The list of seventeen research studies is presented below in Table 4.1: Table 4.1 List of Selected Research Studies Author Year Country Study Title Method Sample Size Almada, P., Carafoli, K., Flattery, J.B., French, D.A., & McNamara, M.  2004 USA Improving the retention rate of newly graduated nurses.  Mixed-Methods 40 Beercroft, P.C., Santner, S., Lacy, M.L., Kunzman, L., & Dorey, F. 2006 USA New graduate nurses’ perceptions of mentoring: Six-year programme evaluation. Mixed-Methods 318 Bialkowski, K. 2009 Canada Impact of mentoring on job satisfaction and retention. Mixed-Methods 21 Fox, K.C. 2010 USA Mentor program boosts new nurses’ satisfaction and lowers turnover rate. Evaluation Survey   12 32  Author Year Country Study Title Method Sample Size Grindel, C.G. & Hagerstrom, G. 2009 USA Nurses nurturing nurses: Outcomes and lessons learned. Longitudinal  129 Haggerty, C., Holloway, K., & Wilson, D. 2013 New Zealand How to grow our own: An evaluation of preceptorship in New Zealand graduate nurse programmes. Mixed-Methods 1023 Hale, R. 2004 USA Mentorship of nurses: An assessment of the first year of licensure. Descriptive Exploratory  144 Halfer, D., Graf, E., & Sullivan, C. 2008 USA The organizational impact of a new graduate pediatric nurse mentoring program.  Descriptive Survey 234 Hardyman, R., & Hickey, G. 2001 UK What do newly-qualified nurse expect from preceptorship?  Exploring the perspective of the preceptee. Longitudinal Survey 1512 Hunsberger, M., Baumann, A., & Crea-Arsenio, M. 2013 Canada The road to providing quality care: Orientation and mentorship for new graduate nurses. Mixed-Methods 3813 Komaratat, S., & Oumtanee, A. 2009 Thailand Using a mentorship model to prepare newly graduated nurses for competency. Quasi-Experimental  19 Lewis, S., & McGowan, B. 2015 UK Newly qualified nurses’ experiences of a preceptorship. Qualitative 8 Lindsey, K.S. 2000 USA Perceptions of novice nurses job satisfaction levels related to mentoring. Descriptive Comparative Survey  163 Marks-Maran, D., Ooms, A., Tapping, J., Muir, J., Phillips, S., & Burke, L. 2013 UK A preceptorship programme for newly qualified nurses: A study of preceptees’ perceptions. Mixed-Methods 44 Navarro, J. 2009 Canada The mentoring experiences and self-efficacy of new graduate nurses during transition  Descriptive Exploratory  5 33  Author Year Country Study Title Method Sample Size    from student to professional nurse.   Smith, C.B. 2006 USA The influence of mentoring on goal attainment and role satisfaction for registered nurses in acute care facilities. Descriptive Correlational  51 Wolak, E.S. 2007 USA Perceptions of an intensive care unit mentorship program. Focus Group 5  Nine of the research studies were conducted in the United States of America, three in Canada, three in the United Kingdom, and one each in Thailand and New Zealand  Figure 4.2 Publication Year of Research Studies       0 1 2 3 4 5 2000 2001 2004 2006 2007 2008 2009 2010 2013 2015 Number of Studies Year Publication Year of Research Studies  34  Figure 4.3 Research Study Sample Size Histogram  4.2 Excluded Research Studies The 49 excluded research studies did not meet the inclusion criteria and answer the research question and sub-questions.  Several of these research studies focused on new graduate RNs in a speciality practice area which meant they had been practicing nursing for more than two years and others considered new graduate RNs as those who have been practicing less than three years.  Six research studies were discovered to be based upon the same bodies of research therefore only three were selected for inclusion.  Other studies focused on group mentoring programs but the majority excluded were opinion papers rather than research studies. 4.3 Quantitative Research Studies Eight of the research studies used quantitative methods and were critically appraised using the following tools: 1. GSRS Weight of Evidence (WoE) tool, found in Appendix B. 2. Maryland Scale of Scientific Methods (MSSM) tool, found in Appendix C.    0 1 2 3 4 Number of Studies Sample Sizes Reasearch Study Sample Sizes 35  Table 4.2 Quantitative Study Details Study Author Study Approach WoE Level & Score MSSM Level & Score Lindsey, K.S. (2000)  Grindel, C.G., & Hagerstrom, G. (2009)  Komaratat, S., & Oumtanee, A. (2009)  Hale, R. (2004)  Halfer, D., Graf, E., & Sullivan. (2008) Descriptive Comparative Survey  Longitudinal   Quasi-Experimental   Descriptive Exploratory  Descriptive Survey High 9  High 8   High 8   High 8  High 7 Medium 3  Medium 2   Medium 2   Low 1  Medium 3  Smith, C.B. (2006)  Fox, K.C. (2010)  Hardyman, R., & Hickey, G. (2001)  Descriptive Correlational  Evaluation Survey  Longitudinal Survey  Medium 6  Medium 5  Medium 4  Low 1  N/A  N/A   Five quantitative research studies were scored as high WoE level of evidence and three as medium WoE level of evidence.  Four quantitative research studies were scored as MSSM medium level of evidence, two as MSSM low level of evidence, and two scored N/A which means they only used descriptive statistics.       36  Figure 4.4 Quantitative Critical Appraisal Scoring   Table 4.3 GSRS WoE Assessment Criteria Questions and Score Study Author WoE A: Methodological Quality of Study  WoE B: Relevance of Research Design for Answering REA Question WoE C: Relevance of Study Focus for Answering REA Question WoE D: Overall Score Lindsey, K.S.   High High High High 9 Grindel, C.G., & Hagerstrom, G.  Medium High High High 8 Komaratat, S., & Oumtanee, A. High Medium High High 8 Hale, R.  High High Medium High 8 Halfer, D., Graf, E., & Sullivan. High Medium Medium High 7 Smith, C.B.  Medium Medium Medium Medium 6 Fox, K.C.  Medium  Medium Low Medium 5 Hardyman, R., & Hickey, G. Low Medium Low Medium 4    0 1 2 3 4 5 6 7 8 9 Score Study Author Quantitative Critical Apprasial Scoring  WoE Score MSSM Score 37  4.3.1 WoE High Level Studies  Lindsey (2000) used a descriptive, non-experimental comparative evaluation survey design to investigate the level of job satisfaction of new graduate RNs who participated in a mentoring program versus those who did not participate in a mentoring program.  Random sampling was utilized to select the 163 RNs who took part in the study.  The instrumentation used to measure the independent and dependent variables included a Job Satisfaction Survey tool, a 20-question Likert scale, and a Quality of Mentoring tool, a 14-question Likert scale.   This researcher performed several different types of analysis to test the hypothesis involving job satisfaction and mentored versus non-mentored RNs.  An independent t-test was run using the Job Satisfaction Survey as the dependent variable and mentored versus non-mentored RN as the independent variable.  The results were statistically significant with mentored nurses having a higher total score on the Job Satisfaction Survey compared to non-mentored nurses (t = 2.66; p < .01).  Another independent t-test was conducted using question 21, a job satisfaction rating, as the dependent variable and mentored versus non-mentored RN as the independent variable.  The results were statistically significant with mentored RNs giving a higher job satisfaction rating compared to non-mentored RNs (t = 2.69; p < .01).  Finally, the author performed a cross tabulation and chi-square analysis to see if there was a statistically significant relationship between mentored versus non-mentored RNs and the question - Are you satisfied with your job?  The results of the chi-square analysis did show a statistically significant relationship between the two variables (X2 = 16.55; p < .01).   Grindel and Hagerstrom (2009) used a longitudinal design to evaluate the effectiveness of the Nurses Nurturing Nurses (N3) mentorship program whose goal was to enhance RNs’ job satisfaction and intent to stay in the agency of employment.  The purpose of the N3 program was 38  to examine the effect of a mentor-mentee program on job satisfaction, new RN confidence, intent to stay, and satisfaction with both the mentorship relationship and the program.  The instrumentation used included a Job Diagnostic Survey tool, a fifteen statement 7-point Likert scale; a Nurse Job Satisfaction Survey tool, a 26-item questionnaire using a 5-point Likert scale; and a New Nurse Confidence Scale tool, a 26-item 5-point Likert scale.  Data was collected at four different points over a twelve-month period: two weeks into the program (Time 1), at three months (Time 2), at six months (Time 3), and at twelve months (Time 4).   Repeated measures analysis of variance (ANOVA-RM) calculation was conducted on mean scores for new nurse confidence from Time 1 through Time 3 and showed a significant increase in RN confidence scores (F = 47.5; p = .000).  Job satisfaction mean scores were moderately high at Time 1 and remained stable throughout the study, therefore the ANOVA-RM results indicated no change over the first six months (F = .195; p = .824).  Intent to stay was measured at Times 2, 3, and 4; the mean scores were moderately high throughout the first six months and only rose slightly at Time 4.  The sample size at Time 4 was small and not included in this analysis, thus there was no difference between participant scores on intent to stay at Time 2 and Time 3 (t = -.38; p = .970). Komaratat and Oumtanee (2009) used a quasi-experimental, one-group time series design to study the level of nursing competency of newly graduated RNs after using a mentorship model.  Nineteen new graduate RNs took part in the program and their competency scores were measured at three times: before the experiment (Time 1), one month later (Time 2), and after the mentorship experience was completed (Time 3).  The competency scores at Time 1 and Time 2 were baseline scores before the mentorship started to document that there were no confounding variables affecting the scores.  The instrument used was the Nursing Competency Scale which 39  consisted of twenty questions with a 5-point rating scale to evaluate four dimensions: nursing, human relationship and communication, decision-making and problem-solving, and quality development and assurance. These researchers analysed the data using the Wilcoxon signed ranks test and set the significance level at 0.05.  They found that the nursing competency of new graduate RNs after using the mentorship model produced significantly higher scores than pre-experiment time one (Z = -3.831) and time two (Z = -3.825) which supports their hypothesis.  There was no difference reported in nursing competency of new graduate RNs pre-experiment between Time 1 and Time 2 (Z = -1.155). Hale (2004) used a descriptive, exploratory design that explored mentorship relationships from the perspective of new graduate RNs in their first year of licensure.  Stratified random sampling was used to select the 144 participants who agreed to take part in this study.  Of the 144 participants who responded, 82% (n = 118) reported having a mentorship relationship with 33% (n = 48) reporting a formal relationship and 49% (n = 70) reporting an informal relationship.  The Hale Mentorship Assessment for Nurses instrument was developed by the author and included 63 4-point items on a forced choice scale, four questions about mentorship, and fifteen questions about demographics. This researcher assessed the consequences of the mentorship relationship to determine if the new graduate RNs reported positive benefits from the relationship.  New graduate RNs in a mentorship relationship reported increased self-confidence (94%), competence as an RN (95%), job satisfaction (86%), and satisfaction with their nursing career (88%).  One-way ANOVA was performed by the researcher to determine whether there was any difference between formal (M = 40  157.58) and informal (M = 161.61) mentorship relationships and no statistically significant difference was found. Halfer, Graf, and Sullivan (2008) used a descriptive survey design to compare the job satisfaction and retention rates of two cohorts of new graduate RNs – one before and one after the implementation of a Pediatric RN Internship Program.  The sample consisted of 84 new graduate RNs in the pre-implementation group and 212 new graduate RNs in the post-implementation group with 234 participants responding to the surveys.  The researchers designed a job satisfaction tool which was comprised of demographic fill-in blanks, twenty-one 4-step Likert questions, and four open-ended questions.  The job satisfaction tool was mailed to all participants at three, six, twelve, and eighteen months corresponding with an RN’s time on the job.   These researchers found that the RNs’ perceptions of job satisfaction was significantly higher in the post-internship group as compared to the pre-internship group (p = .046).  Analysis on longitudinal job satisfaction was statistically significant after eighteen months of employment (p = .02) as compared to six months of employment.  Voluntary turnover rate was calculated as 12% for the post-internship group as compared to 20% for the pre-internship group and was sustained during the two-year post-intervention study period which reflects improved retention of new graduate nurses. 4.3.2 WoE Medium Level Studies Smith (2006) used a descriptive, correlational design to examine the influence of mentoring on goal attainment and role satisfaction for new graduate RNs in acute care facilities.  Both non-probability and probability sampling were utilized to select the 45 participants who took part in this study.  The instrument used was a 77-item tool developed by Bouquillon to 41  explore mentoring antecedents and functions along with measuring career outcomes (goal attainment) and job satisfaction.  Bouquillon’s tool included 73 5-point Likert questions and four open-ended questions.   This researcher analysed the data using Pearson’s r and found that there was a strong correlation between mentoring and goal attainment (r = .80; p < .001).  There was no statistically significant relationship found between mentoring and role satisfaction (r = .27; p = .071), however a statistically significant correlation between the presence of mentoring antecedents and job satisfaction was determined (r = .345; p < .05).  When Pearson’s r analysis was conducted on those RNs who have high levels of goal attainment, there was a moderate correlation found between mentoring and role satisfaction (r = .54; p < .05). Fox (2010) used an evaluation survey design to describe a pilot mentorship program that was implemented at three hospital campuses in Indiana.  Twelve pairs of mentor-mentees took part in the one-year program that required face-to-face meeting and completing evaluation forms at seven different times.  The turnover rate of first-year RNs at these hospitals was 32% in 2005 before the implementation of this mentorship program and had decreased to 10.3% by 2009 (a 21.5% decrease).   The author reported this mentoring program an overwhelming success as the retention rate of the pilot group of mentored nurses was 100%.  Satisfaction scores improved by one level (from agree to strongly agree or tend to disagree to agree) in 75% of the participants, reflecting improved satisfaction.  The mentee also reported feeling more comfortable in their roles due to the support and resources provided by the mentors. Reported key elements of an effective mentorship program include proper training for the mentor and mentee, regular face-to-face meetings, selection process to ensure personality type matching, mentors with excellent communication skills, and signing a contract. 42  Hardyman and Hickey (2001) used a longitudinal survey design to explore the expectations and experiences of mentorship from the perspectives of newly graduated nurses.  The instrumentation used was a 3-item questionnaire addressing having a mentor, the length of mentorship, and the content of mentorship.  The questionnaire was developed with a pilot cohort and 1512 newly graduated RNs took part in this study.  Data was collected via the questionnaire when the new graduate RNs became qualified and then again six months later. These researchers utilized descriptive statistics and found 97% of participants wanted to have a preceptor during their first nursing job with the preferred length of the mentorship being six months (51%) followed by four or five months in length (25%).  The aspects of mentorship found to be most important to the participants include constructive feedback on clinical skills (99%), teaching new clinical skills (99%), confidence building (95%), and helping to settle into the work environment (94%).  A reported key element of an effective mentorship program includes the duration of the program being from four to six months in length. 4.4 Mixed-Methods Research Studies Six of the research studies used quantitative and qualitative methods and were critically appraised using the following tools: 1. GSRS Weight of Evidence (WoE) tool, found in Appendix B. 2. Maryland Scale of Scientific Methods (MSSM) tool, found in Appendix C.   3. Critical Appraisal Skills Programme (CASP) tool, found in Appendix D.     43  Table 4.4 Mixed-Methods Study Details Study Author Study Approach WoE Level & Score MSSM Level & Score CASP Level & Score Marks-Maran, D., Ooms, A., Tapping, J., Muir, J., Phillips, S., & Burke, L. (2013)  Hunsberger, M., Baumann, A., & Crea-Arsenio, M. (2013)  Beercroft, P.C., Santner, S., Lacy, M.L., Kunzman, L., & Dorey, F. (2006)  Haggerty, C., Holloway, K., & Wilson, D. (2013)  Almada, P., Carafoli, K., Flattery, J.B., French, D.A., & McNamara, M. (2004)  Bialkowski, K. (2009) Mixed-Methods     Mixed-Methods    Mixed-Methods    Mixed Methods   Mixed-Methods     Mixed-Methods High 9     High 8    High 8    High 8   Medium 6     Medium 4 Low 1      N/A    Low 1    N/A   Low 1     Medium 2 High 8     High 9    High 8    Medium 7   Medium 6     Medium 7  Three mixed-methods research studies were scored as high WoE and CASP levels of evidence, one as high WoE level of evidence and medium CASP level of evidence, and two as medium WoE and CASP levels of evidence.  One mixed-methods research study was scored as MSSM medium level of evidence, three as MSSM low level of evidence, and two scored N/A which means they only used descriptive statistics.     44  Figure 4.5 Mixed-Methods Critical Appraisal Scoring   Table 4.5 GSRS WoE Assessment Criteria Questions and Score Study Author WoE A: Methodological Quality of Study  WoE B: Relevance of Research Design for Answering REA Question WoE C: Relevance of Study Focus for Answering REA Question  WoE D: Overall Score Marks-Maran, D., Ooms, A., Tapping, J., Muir, J., Phillips, S., & Burke, L. High High High High 9 Hunsberger, M., Baumann, A., & Crea-Arsenio, M. High Medium High High 8 Beercroft, P.C., Santner, S., Lacy, M.L., Kunzman, L., & Dorey, F. Medium High High High 8 Haggerty, C., Holloway, K., & Wilson, D. High High Medium High 8 Almada, P., Carafoli, K.,  Medium Medium Medium Medium 6 0 1 2 3 4 5 6 7 8 9 Score Study Author Mixed-Methods Critical Apprasial Scoring WoE Score MSSM Score CASP Score 45  Study Author WoE A: Methodological Quality of Study  WoE B: Relevance of Research Design for Answering REA Question WoE C: Relevance of Study Focus for Answering REA Question  WoE D: Overall Score Flattery, J.B., French, D.A., & McNamara, M.     Bialkowski, K.  Low Medium Low Medium 4  4.4.1 WoE and CASP High Level Studies Marks-Maran, Ooms, Tapping, Muir, Phillips, and Burke (2013) used an evaluative mixed-methods design to evaluate a mentorship program for newly graduated RNs to determine mentee engagement with the program and the impact, value, and sustainability of the program.  A total of 44 new graduate RNs took part in this study and both qualitative and quantitative data was collected through questionnaires, reflective journals, and personal audio recordings.  The questionnaire contained demographic questions, 52 4-point Likert questions, and three open-ended questions. These researchers performed quantitative data analysis utilizing descriptive statistics, t-tests, and Cronbach’s alpha to measure reliability.  Qualitative data analysis involved thematic analysis using the Framework Method by Ritchie and Spencer and then mapping the emerged themes against the findings of the quantitative data.  Findings from this study included 78% of the mentees reporting an improvement in confidence with making decisions about patient care, 70% reporting that the mentorship has enhanced their role satisfaction, 68% reporting improved competence with drug administration and 75% reporting being able to deal more confidently with problems relating to patient care.  Reported key elements of an effective mentorship program include the expertise of the mentors and the ability for choosing one’s own mentor.  46  Reported problems for a mentorship program include time commitment, conflicting shifts, not understanding the purpose of the program, and mentor-mentee mismatch. Hunsberger, Baumann, and Crea-Arsenio (2013) used a longitudinal trend mixed-methods design to examine the impact of a government-supported extended orientation and mentorship program intended to facilitate the transition of new graduate RNs to professional practice.  Quantitative data collection involved the use of an online survey asking questions about demographics, employment, and mentorship while qualitative data collection included semi-structured interviews and focus groups.  Convenience sampling was utilized to select the new graduate RNs who would take part in the interviews and focus groups, which took place via phone.   These researchers performed data analysis through the use of descriptive statistics and thematic analysis to code the interview responses into major themes and key findings. An average of 82% of new graduate RNs reported the mentorship they received as excellent, very good, or good and 90% gave the mentorship program a high rating for facilitating their transition to nursing.  The new graduate RNs reported mentorship helped them to become more confident with documentation and medication administration and were also able to integrate into the culture of the unit’s which results in increased job satisfaction.   Beercroft, Santner, Lacy, Kunzman, and Dorey (2006) used an evaluation mixed-methods design to determine whether mentoring was successful and if new graduate RNs were satisfactorily matched with their mentor, received guidance and support, attained socialization into nursing, benefited from having a role model, maintained contact with their mentor, and were satisfied with the mentorship.  A 35-item survey was completed by 318 participants but this study was only based upon eight questions pertaining to mentorship.   47  The researchers performed quantitative data analysis using descriptive statistics and logistic regression analysis.  Qualitative data analysis involved manifest content analysis to identify themes important for successful mentorship.  44% of all positively coded comments showed evidence of satisfaction that the new graduate RNs had with the mentorship.  Reported key elements of an effective mentorship program include regular face-to-face meetings, timing for the starting of the relationship, adequate training for both participants, the dedication and commitment to the relationship, and support from managers.  Reported problems for a mentorship program include lack of connection with mentor-mentee matching, not being able to choose one’s mentor, not meeting regularly, role inadequacy, and time or schedule constraints. Haggerty, Holloway, and Wilson (2010) used a longitudinal fourth generation evaluation mixed-methods design that focused on mentorship support for new graduate RNs and the nurse entry to practice program in New Zealand.  Quantitative data collection involved a questionnaire survey while qualitative data collection comprised in-depth focus groups and individual interviews.  A total of 1023 new graduate RNs participated in this study that took place over three years. The researchers identified the key issues relating to mentorship as: access to mentors, how mentors met new graduate learning needs, the importance of the mentor-new graduate relationship, mentor preparation for their role, culture of support, and development of confidence and competence.  Descriptive statistics were used and overall satisfaction from the new graduate RNs in relation to the mentors meeting their expectations increased from 64% to 71% over the three years of this study.  Reported key elements of an effective mentorship program include quality of mentor, mentor-mentee matching, access to mentors, and support of nursing 48  leadership.  Reported problems for a mentorship program include workload and acuity levels of the units, lack of mentor preparation, and having multiple mentors.   4.4.2 WoE and CASP Medium Level Studies Almada, Carafoli, Flattery, French, and McNamara (2004) used a survey mixed-methods design to determine if a newly designed mentor program provided new graduate RNs adequate education, support, and acceptance in their new role thereby increasing retention rates.  Convenience sampling was utilized to select the 40 participants who took part in this study.  A coded survey tool with yes/no questions, visual analogue scales, and open-ended questions was sent at completion of the preceptor program and three months after working independently.  The survey addressed satisfaction, reasons the new graduate RNs may have considered for leaving, and feedback for program improvements. The researchers performed quantitative data analysis and the findings indicated a high level of satisfaction with the program (visual analogue mean score 93.7).  The overall retention rate at this hospital was increased by 29% (from 60% to 89%) and the hospital’s vacancy rate was decreased 9.5% (down to 3%).  The new graduate RNs reported an increase in their level of comfort at completion of the program and a higher level of confidence and satisfaction was seen as compared to previous new graduate RNs.   Reported key elements of an effective mentorship program include the length of the program and mentor-mentee match. Bialowski (2009) used a survey mixed-methods design to evaluate a mentoring program by examining the impact of length of orientation on job satisfaction, organizational commitment, and propensity to leave.  A total of twenty-one participants took part in this study and data collection took place after three and nine months of employment.  The instrumentation used included an Organizational Commitment Questionnaire, a 15-item 7-point Likert scale; a 49  Propensity to Leave Questionnaire, a 3-item 5-point Likert scale; and the McCloskey/Mueller Satisfaction Scale, a 31-item 5-point Likert scale questionnaire. This researcher performed repeated measures analysis of variance (ANOVA-RM) and an independent samples t-test which found no significant difference exists between three and nine months of employment scores for organizational commitment, propensity to leave, and job satisfaction (F = .15; p = .70).  A series of one-way ANOVA was conducted to examine the impact of length of orientation on organizational commitment and job satisfaction and a significant difference was found between less than one month of orientation as compared to three to six months.  No significant difference was reported between propensity to leave and length of orientation.  Bivariate correlations reported a positive relationship between organizational commitment and job satisfaction (r = .83; p = <.001), which indicates that RNs who are very committed to their organizations are also highly satisfied with their jobs.   4.5 Qualitative Research Studies Three of the research studies used qualitative methods and were critically appraised using the following tools: 1. GSRS Weight of Evidence (WoE) tool, found in Appendix B. 2. Critical Appraisal Skills Programme (CASP) tool, found in Appendix D. Table 4.6 Qualitative Study Details Study Author Study Approach WoE Level & Score CASP Level & Score Lewis, S., & McGowan, B. (2015)  Navarro, J. (2009)  Wolak, E.S. (2007) Qualitative   Descriptive Exploratory  Focus Group Medium 6   Medium 5  Medium 5 High 9   High 9  High 9  50  All three qualitative research studies were scored as medium WoE level of evidence and high CASP level of evidence. Figure 4.6 Qualitative Critical Appraisal Scoring  Table 4.7 GSRS WoE Assessment Criteria Questions and Score Study Author WoE A: Methodological Quality of Study  WoE B: Relevance of Research Design for Answering REA Question WoE C: Relevance of Study Focus for Answering REA Question WoE D: Overall Score Lewis, S., & McGowan, B. Medium Medium Medium Medium 6 Navarro, J.  Medium Medium Low Medium 5 Wolak, E.S.  Medium Medium Low Medium 5  4.5.1 WoE Medium and CASP High Level Studies Lewis and McGowan (2015) used a qualitative design to examine and gain insight into what the experience of mentorship was like for newly qualified RNs.  Purposive recruitment was used to select the eight participants who took part in one-hour semi-structured, one-to-one 0 1 2 3 4 5 6 7 8 9 Lewis et al. Navarro Wolak Score Study Author Qualitative Critical Apprasial Scoring  WoE Score CASP Score 51  interviews.  Data collection and analysis followed Newell and Burnard’s Pragmatic Approach to Qualitative Data Analysis and two main categories emerged – support requirements and expectations of mentorship.  Support requirements was further organized into the themes of development of knowledge, building confidence, and time management of the process.  Expectations of preceptorship was further organized into the themes of understanding the process and understanding the preceptors’ roles.   Most of the participants reported that the mentorship enabled them to develop their confidence and further develop their knowledge and skills.  Reported key elements of an effective mentorship program include working closely together and the availability of the mentor.  Reported problems for a mentorship program include lack of time, working different shifts, unclear expectations of the process, and too much additional paperwork. Navarro (2009) used a descriptive exploratory design to describe the mentorship experiences of new graduate RNs as they transition from student to RN, how the mentorship experience shaped the perceived self-efficacy of new graduate RNs, and how the mentorship experience shaped the transition from student to RN.  Purposive sampling was used to select the five participants who took part in this study.  One-hour semi-structured telephone interviews were used for data collection and took place approximately six months post graduation.  Data analysis was completed using Hsieh and Shannon’s directed approach to content analyses and several themes were identified for each research question.  The identified themes include a formal experience, forming new relationships, the experience of relational supports, the experience of cultural supports, being encouraged, being challenged, being inspired, reframing, seeking opportunities, a commitment to goals, and discovering me. 52  All the participants in this study reported their mentors using positive verbal persuasion and encouragement which resulted in increased confidence.  The mentors also challenged the new graduate RNs to perform new skills and resulted in an increased clinical competence and the confidence to perform skills independently.  The majority of the participants reported the mentorship experience allowed for the development of their professional identity which translated into building their sense of confidence and self-worth.  Reported problems for a mentorship program include the inability to choose one’s mentor and the lack of adequate mentor training. Wolak (2007) used a focus group design to examine the experiences of mentees and mentors in a structured mentorship program.  Non-random purposive sampling was utilized to select the five mentees and six mentors who took part in this study.  The mentor-mentee pairs had been paired together at least ten months and were required to meet outside of work once a month.  Separate focus groups lasting 30 minutes were held with all the mentors and all the mentees for data collection.  Data was analyzed for specific themes using long-table methodological analysis and the following themes emerged – availability, sense of community, and support and knowledge. All the participants reported that the mentors provided the mentees with valuable knowledge and skills thus contributing to increased job satisfaction and organizational commitment.  Reported key elements of an effective mentorship program include similar work schedules for the mentor and mentee and the mentors being accessible for questions and clinical support.  Reported problems for a mentorship program include having to meet monthly outside of work and lack of enthusiasm from the mentor.  53  Figure 4.7 Overall WoE Level of Evidence  Figure 4.8 Overall CASP Level of Evidence        0 1 2 3 4 5 6 Quantitative Mixed Methods Qualitative Number of Studies Research Study Design Overall WoE Level of Evidence WoE High  WoE Med 0 1 2 3 4 Mixed Methods Qualitative Number of Studies Research Study Design Overall CASP Level of Evidence CASP High CASP Med 54  Figure 4.9 Overall MSSM Level of Evidence  4.6 Chapter Summary This chapter provided an overview of the seventeen research studies along with their critical appraisal scoring and findings.  Each research study had the data extracted using the EPPI-Centre Data Extraction and Coding Tool for Education Studies, found in Appendix E.  The research studies were grouped according to their approach – quantitative, mixed-methods, or qualitative and listed from highest level of evidence to lowest level of evidence, according to their WoE level and score.  Eight quantitative research studies were critically appraised using the GSRS WoE tool, found in Appendix B and the MSSM tool, found in Appendix C.  Six research studies utilizing both qualitative and quantitative methods were critically appraised using the GSRS WoE tool, found in Appendix B; CASP tool, found in Appendix D; and the MSSM tool, found in Appendix C.  Three qualitative research studies were critically appraised using the GSRS WoE tool, found in Appendix B and CASP tool, found in Appendix D.  In the next chapter, the findings from the seventeen research studies are synthesized to answer the research 0 1 2 3 4 5 Quantitative Mixed Methods Number of Studies Research Study Design Overall MSSM Level of Evidence MSSM Med MSSM Low MSSM N/A 55  question and sub-questions presented in chapter one.  As well, a discussion about the limitations of this REA will be presented.                        56  CHAPTER 5: Discussion In this chapter the findings from the final seventeen research studies are synthesized to explore the value of mentorship programs in more detail in the context of the literature examined, and current practice.  The reported key elements of an effective mentorship program and problems in implementing a mentorship program will also be discussed.  As well, this chapter will end with a discussion of the limitations of this REA. 5.1 Synthesis of Findings  Eight research studies utilizing quantitative methods, six utilizing mixed-methods, and three utilizing qualitative methods were included in this REA and their results synthesized to answer the following research question: What is the evidence that new graduate mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice?   5.1.1 Improving Performance Three high WoE level studies (Hale, 2004; Komaratat & Oumtanee, 2009; Marks-Maran et al., 2013) and four medium WoE level studies (Hardyman & Hickey, 2001; Lewis & McGowan, 2015; Navarro, 2009; Wolak, 2007) suggested that the use of a mentorship program improved the performance of novice nurses’ practice.  Hale explored mentorship relationships from the perspective of new graduate RN’s in their first year of licensure.  The findings of this study suggested that new graduate RN’s reported an improvement in their competence as a nurse, as a result of being in a mentorship relationship.  Komaratat and Oumtanee studied the level of nursing competency of newly graduated RN’s after using a mentorship model.  Their findings indicated that a mentorship model improved the performance of newly graduated RN’s in nursing skills, decision-making, and problem resolution.  Marks-Maran et al. evaluated a 57  mentorship program for newly graduated RN’s and their findings suggested that new graduate RN’s who took part in a mentorship program reported improved performance by increased clinical competence with drug administration, meeting the nutritional needs of patients, wound management, and other health and safety issues. Hardyman and Hickey explored the expectations and experiences of mentorship from the perspectives of newly graduated RN’s.  This study reported that teaching new clinical skills and help with settling into the work environment were important aspects of a mentorship program.  Lewis & McGowan sought to examine and gain insight into what the experience of mentorship was like for newly qualified RN’s.  Their findings suggested that a mentorship program enabled the new graduate RN’s to further develop their knowledge and skills, which translated into improved performance.  Navarro described the mentorship experiences of new graduate RN’s as they transition from student to RN.    The findings of this study suggested that mentors challenged the new graduate RN’s to perform new skills which resulted in increased clinical competence.  Wolak examined the experiences of mentees and mentors in a structured intensive care unit mentorship program.  This study reported that the mentors provided the mentees with valuable knowledge and skills which suggested improved new graduate RN performance. Several research studies offered similarities with how they measured improved performance as a result of a mentorship program.  Komaratat and Oumtanee scored nursing competency based upon nursing care, human relationship and communication, decision-making and problem-solving, and quality development and assurance while Marks-Maran et al. measured increased competence with nursing skills development, problem-solving related to patient care, and the positive impact on developing high standards of practice.  As well, Navarro’s findings focused on performance with the development of clinical skills and 58  knowledge.  In contrast, Hale measured performance through emotional functions such as communication, encouragement, and support; social functions such as advocacy and socialization; and professional role functions such as guidance, intellectual stimulation, and career direction.    Bandura’s (1977) social learning theory seems to support the improvement of performance of novice nurses’ practice with the social learning engendered in mentorship.  Bandura suggested that individuals learn by observing, imitating, and modeling other’s behaviors, attitudes, experiences, and consequences of behaviors. The mentor is role modelling for the mentee, who observes and then models their observed behavior at a later time.  The use of a reflective diary to record the new graduate RN’s thoughts, feelings, and experiences also supports social learning, and enhanced performance.  The new graduate RN can use these diary entries to reflect on their practice and develop new ways to improve their performance, especially with performing skills.  Having the mentor provide the mentee with feedback is very important during the reproduction stage of Bandura’s social learning theory and it is suggested that this can assist the new graduate RN with building their perception of self-efficacy.  An increased perception of self-efficacy can result in improved performance of the new graduate RN, thus it is important for the mentor to help develop during their mentorship relationship.   5.1.2 Improving Satisfaction Six high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013; Hale, 2004; Halfer, Graf, & Sullivan, 2008; Hunsberger, Baumann, & Crea-Arsenio, 2013; Lindsey, 2000) and three medium WoE level studies (Almada et al., 2004; Bialowski, 2009; Smith, 2006) suggested that the use of a mentorship program improved the satisfaction of novice nurses.  Beercroft et al. sought to determine whether mentoring was successful and if new 59  graduates were satisfactorily matched with a mentor; received guidance and support; attained socialization into the nursing profession; benefitted from having a role model for acquisition of professional behaviours, maintained contact with their mentor throughout the program; and were satisfied with the mentorship.  Their findings suggested that a mentorship relationship improved satisfaction for some of the new graduate RN’s as indicated by appreciation, excellence, or benefit.  Haggerty, Holloway, and Wilson provided an overview of the nurse entry to practice programs within New Zealand that focused on mentorship support for new graduate RN’s.  They suggested that the increased confidence and competence of the new graduate RN’s due to the mentorship program was linked to increased job satisfaction, which was also reported by participants as a result of the program.  Hale’s findings demonstrated that new graduate RN’s experienced increased job satisfaction due to being involved in a mentorship relationship.   Halfer, Graf, and Sullivan studied Pediatric new graduate RNs who took part in a Pediatric RN Internship Program to compare their job satisfaction and retention rates.  The reported overall job satisfaction was significantly higher in the post-internship group as compared to the pre-internship group.  Hunsberger, Baumann, and Crea-Arsenio examined the impact of a government supported extended orientation and mentorship program on the transition of new graduate RN’s to their professional role.  New graduate RN’s were provided with a “robust opportunity to integrate into the culture of the unit” (Hunsberger, Baumann, & Crea-Arsenio, p. 82) which resulted in increased satisfaction with their positions.  It was reported that mentorship enabled them to feel part of the team and created a supportive environment that improved satisfaction.  Lindsey investigated novice RN’s in their first two years of practice to determine whether mentored RN’s versus non-mentored RN’s had greater job satisfaction levels.  60  Her findings reported a statistically significant result with mentored new graduate RN’s having a higher job satisfaction than non-mentored new graduate RN’s. Almada et al. reported the findings of a study which investigated a community hospital’s implementation of an education-based mentorship program.  Their study indicated a high satisfaction rate with the experience of a mentorship program and a higher level of satisfaction was seen in the mentored new graduate RN’s as compared to non-mentored new graduate RN’s.  Bialowski sought to evaluate a mentorship program, the Vermont Nurse Internship Program, by examining the impact of length of orientation on job satisfaction, organizational commitment, and propensity to leave.  Her findings suggested an overall job satisfaction that remained constant over the nine month period of the study.  Smith examined the influence of mentoring on goal attainment and role satisfaction for RN’s who were employed in acute care facilities for less than two years.  Her findings suggested that there was a moderate relationship between mentoring and role satisfaction in those RN’s who scored above the mean for the goal attainment concept.  She also identified a significant correlation between the presence of mentoring antecedents, such as integrity, trust, willingness to engage and accept, and acknowledgment of professional responsibility, and role satisfaction.   Some of the above research studies offered differences with the length of mentorship program that improved satisfaction was based upon.  Hunsberger, Baumann, and Crea-Arsenio’s study participants took part in a three to six month supernumerary mentorship program whereas Bialowski’s mentorship program length varied from one month up to seven months.  As well, in Lindsey’s study the average length of mentoring relationship was eleven months.  In comparison, Almada et al. and Haggerty, Holloway, and Wilson’s study participants took part in eight week and six week supernumerary mentorship programs before job satisfaction was measured. 61  Improving satisfaction of a novice nurses’ practice is also supported by Bandura’s (1977) social learning theory.  A key attribute of social learning theory is that a supportive environment is required to be successful.  A supportive environment may be the result of a mentorship relationship which hopefully will increase the new graduate RN’s satisfaction with their job.  Vicarious reinforcement is very important during the motivational phase of Bandura’s social learning theory and can influence the new graduate RN’s learning.  If the new graduate RN observes their mentor having positive interactions with other coworkers or doctors, this can serve to influence their perceived satisfaction with their job and nursing unit. 5.1.3 Improving Retention Two high WoE level studies (Grindel & Hagerstrom, 2009; Halfer, Graf, & Sullivan, 2008) and two medium WoE level studies (Almada et al., 2004; Fox, 2010) suggested that the use of a mentorship program improved the retention of novice nurses.  Grindel and Hagerstrom reported the outcomes and lessons learned from a hospital-based formal mentorship program which they called, Nurses Nurturing Nurses, in which mentor and mentees worked together for twelve months to facilitate new RN transition.  Retention was measured at three, six, and twelve months and all participant scores were moderately high throughout the first six months and then rose at twelve months, suggesting that most respondents were going to remain in their current positions.  Halfer, Graf, and Sullivan’s findings indicated that the new graduate RN’s who took part in the mentorship program had a lower turnover rate that was sustained during the two year post-intervention period.   Almada et al. suggested that an overall increase in retention of new graduate RN’s during a fourteen month period was the direct result of their mentorship program.  Their findings also reported that the hospital’s vacancy rate was decreased due to the retention of new graduate 62  RN’s.  Fox reported the findings of a one year pilot mentorship program that sought to improve retention and turnover rates of newly graduated RN’s.  Her study suggested that the mentorship program was successful in improving the retention of new graduate RN’s due to the support and resources that the mentors provided.  Fox also reported a dramatic decrease in the turnover rate with the initiation of the mentorship program.   Fox and Grindel and Hagerstrom offered similarities with how they measured improved retention as a result of a mentorship program.  Fox measured the turnover rate of novice nurses after twelve months of starting a mentorship program whereas Grindel and Hagerstrom measured intent to stay at three times over a twelve month period.  In contrast, Almada et al. measured retention approximately six months from starting a mentorship program while Halfer, Graf, and Sullivan measured retention at four times over an eighteen month period. Bandura’s (1977) social learning theory would seem to offer a supporting framework to explain the improved retention of novice nurses’ in practice through a social supportive environment.  New graduate RN’s may not want to stay working on a nursing unit that is not supportive when their mentorship program is completed.  Vicarious reinforcement, the result of learning by observing the mentor’s successes and failures, may also influence the retention of new graduate RN’s.   5.1.4 Improving Confidence Five high WoE level studies (Grindel & Hagerstrom, 2009; Hale, 2004; Haggerty, Holloway, & Wilson, 2013; Hunsberger, Baumann, & Crea-Arsenio, 2013; Marks-Maran et al., 2013) and four medium WoE level studies (Almada et al., 2004; Hardyman & Hickey, 2001; Lewis & McGowan, 2015; Navarro, 2009) suggested that the use of a mentorship program improved the confidence of a novice nurses’ practice.  Grindel and Hagerstrom reported a 63  significant increase in RN confidence scores, particularly between initiation of the mentorship program and three months.  Hale’s findings reported new graduate RN’s increased confidence as a result of the mentorship relationship.  Moreover, Haggerty, Holloway, and Wilson’s study suggested that the structured, supportive environment that the mentorship program provided resulted in increased confidence of the new graduate RNs’ and Hunsberger, Baumann, and Crea-Arsenio’s findings indicated that mentorship increased new graduate RN’s confidence which allowed them to make decisions in a safe, protected environment.  The new graduate RN’s also reported that they became more confident about documentation as well with administering medication according to patients’ preferences.  Increased confidence was further reported in Marks-Maran et al.’s study as one sub-theme from their qualitative data.  Furthermore, their findings indicated for a majority of new graduate RN’s a structured mentorship program had the potential to build confidence and enabled the new graduates to achieve a level of confidence that they did not have upon graduating. Almada et al.’s study had new graduate RN’s reporting an increased level of comfort and a higher level of confidence when released from their mentorship program.  Hardyman and Hickey identified confidence building as an important aspect of a mentorship program by the majority of their new graduate RN participants.  Lewis and McGowan’s findings suggest that the majority of new graduate RNs expressed the view that mentorship enabled them to develop their confidence and further develop their knowledge and skills in the transition from student to newly qualified RN.  Navarro’s study participants all reported that their mentor’s use of verbal persuasion and encouragement helped foster their confidence and strengthen their belief to succeed.  Increased confidence due to the presence of the mentorship relationship was also reported when managing stressful situations and communicating effectively.   64  There were a few differences in how the research studies measured improved confidence as a result of a mentorship program.  Navarro measured increased confidence when dealing with stressful situations and being able to effectively communicate while Grindel and Hagerstrom measured increased confidence with routine nursing activities such as providing patient care, interpreting lab tests, or delegating tasks to other nursing staff.  When looking at similarities, Hunsberger, Baumann, and Crea-Arsenio measured increased confidence with decision-making and critically thinking whereas Lewis and McGowan measured increased confidence with nursing knowledge and skills. Bandura’s (1977) social learning theory appears to support improved confidence of a novice nurses’ practice.  Bandura suggests that having feedback provided by the mentor can assist the new graduate RN with building their perception of self-efficacy, which he defines as confidence in one’s ability to take action and persist in action.  Increased self-efficacy can translate into increased confidence of the new graduate RN, which may be attributed to the mentorship relationship when applying the concept of social learning theory.  The use of a learning contract can be important during the motivational phase of Bandura’s social learning theory and may result in increased new graduate RN confidence.  Through the use of a learning contract, mentors can encourage individualized learning to meet the needs of the new graduate RN and increase their sense of achievement, which in turn increases their confidence. 5.2 Key Elements of Effective New Graduate RN Mentorship Programs What are the reported key elements of effective new graduate RN mentorship programs? 5.2.1 Mentor-Mentee Matching Mentor-mentee matching was a key element of an effective mentorship program reported in three high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013; Marks-Maran et al., 2013) and two medium WoE level studies (Almada et al., 2004; Fox, 2010).  65  In the Beercroft et al. study, having a strong connection or ‘clicking’ with one’s mentor was an indication for satisfaction with the mentoring relationship.  Some mentees indicated that being able to choose their own mentor would be preferable to ensure connection.  Participants in Haggerty, Holloway, and Wilson’s study identified the matching of mentors and mentees as key to successful new graduate programs despite noting that it is an area that requires further strengthening.   Marks-Maran et al. reported that 70% of mentees would prefer to choose their own mentors. It was suggested that many mentees liked the facilitation style offered by their mentors who made them feel comfortable sharing problems and helped them become introduced to their new role. Participants in the study by Almada et al. ranked mentor-mentee matching as one of the most important aspects of a mentorship program.  All mentors were required to attend a full-day program to increase their understanding of learning styles, communication techniques, personality traits, and conflict resolution before being matched with their mentee.  Fox suggested the selection process for mentors and mentees was one of the reasons for the success of their mentorship program.  Mentors and mentees were both matched according to their personality types, educational degrees, and taking into account the shifts that each individual worked, preferring to pair those that worked similar rotations.   5.2.2 Availability Availability of mentors was a key element of an effective mentorship program reported in two high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013) and two medium WoE level studies (Fox, 2010; Wolak, 2007).  Beercroft et al.’s findings reported that meeting on a regular basis had the most impact on the success of the mentorship relationship.  For those mentees meeting on a regular basis, the majority reported that their 66  mentor provided guidance and feedback while being a stress reducer.  Haggerty, Holloway, and Wilson findings suggested that when mentors were available, new graduate RN’s reported high levels of satisfaction with meeting their learning needs.  Creative solutions were required to ensure availability of mentors such as the allocation of primary and secondary mentors or multiple mentors job sharing the  role, establishing a dedicated mentor role on a unit, or having the mentee assigned to all the mentor’s shifts. Participants in Fox’s study were required to sign a contract to ensure they understood the expectation of meeting regularly.  Mentor-mentee pairs met a minimum of seven times during the twelve month program and all meetings needed to be face-to-face, which were reported a successes of their mentorship program.  Wolak’s findings identified availability as a major theme with the context centered on being accessible for questions and clinical support.  Mentees reported that the ability to access mentors as their learning needs required rather than just during planned meetings or while working together as instrumental to their nursing practice.  The individualized attention of the mentor helped create an environment of support and trust.  It was also suggested that mentees and mentors work similar schedules for the duration of the mentorship relationship. 5.2.3 Training Adequate training and preparation of mentors was a key element of an effective mentorship program reported in two high WoE level studies (Haggerty, Holloway, & Wilson, 2013; Marks-Maran et al., 2013) and two medium WoE level studies (Fox, 2010; Navarro, 2009).  Haggerty, Holloway, and Wilson identified the quality of mentors as a key element and suggested that effective mentors need to demonstrate high levels of interpersonal and facilitation skills.  These authors also stated that the preparation of mentors was important to ensure a 67  professional relationship that supported and challenged new graduates.  In another study, with a similar focus participants indicated that the expertise of their mentor was of particular value and an important consideration for selection (Marks-Maran et al.).    Furthermore, Fox indicated proper training was a crucial element of the success of the initiation of her mentor program.  All mentors and mentees took part in a required training program together as an introduction and bonding process in which a structured agenda covered key topics relating to mentorship.  Navarro reported the importance of adequate training and preparing mentors to provide better learning experiences for new graduate nurses transitioning into practice.  She proposed formal orientation or training programs providing education regarding the impact and value of the mentor role and effective teaching, learning, and communication strategies. 5.2.4 Commitment and Support Commitment and support was a key element of an effective mentorship program reported in two high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013).  Findings from the Beercroft et al. study suggested that an important role and benefit of a mentor is the support and guidance they offer to the mentee.  To ensure success, mentors need to be dedicated and committed to spending the time required to cultivate the mentorship relationship.  They also reported that support from mangers to allow off unit times for face-to-face meetings was a key element for success.  Haggerty, Holloway, and Wilson identified a culture of support from nursing staff, especially nursing leaders, as a key component for a successful mentorship program.  Nurse leaders were reported as having a responsibility to create an environment of support for the new graduate nurse and their mentor by promoting creative solutions, inspiring colleagues, and allocating appropriate resources.  This is supported by Bandura’s (1977) social 68  learning theory which suggests that a supportive environment is a key component to having a successful relationship.    5.2.5 Length of Mentoring Relationship Length of the mentoring relationship was a key element of an effective mentorship program reported in three medium WoE level studies (Almada et al., 2004; Bialowski, 2009; Hardyman & Hickey, 2001).   Participants in the study by Almada et al. ranked length of time, one of the most important aspects of a mentorship program.  Their program included a minimum of eleven weeks of mentorship with extensions available if deemed necessary. Bialowski’s findings indicated that the new graduate RN’s who received three to six months of mentorship were significantly more committed to their organizations and more satisfied with their jobs’ thus she suggested six months as the ideal length of a mentorship program.  Participants in the study by Hardyman and Hickey reported that their preferred length of mentorship would be six months with the second choice of four to five months in length. 5.3 Reported Problems in Implementing New Graduate RN Mentorship Programs What are the reported problems in implementing new graduate RN mentorship programs? 5.3.1 Training Lack of training and preparation of mentors and mentees was a problem reported in three high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013; Marks-Maran et al., 2013) and two medium WoE studies (Lewis & McGowan, 2015; Navarro, 2009).  Beercroft et al. cited role inadequacy of both the mentor and mentee, due to inadequate training, as a problem with mentorship programs.  Their study also suggested that a number of mentees had a narrow view of mentoring and what could be gained from the relationship, and support was the only expectation from a mentoring relationship.  Haggerty, Holloway, and Wilson report that 69  many mentors are poorly prepared and were unable to attend mentor training due to workload and acuity of their nursing unit.  They also found that new graduate RN’s reported less satisfaction with the experience when having unprepared mentors despite having adequate access to them.  Marks-Maran et al. reported different understandings about the nature of mentorship which may have contributed to the lack of success of the relationship.   Lewis and McGowan referred to the lack of understanding of what the process of mentorship involved and what exactly were the mentor and mentee roles.  Some mentees assumed they would be working alongside their mentors or at least very closely together rather than working alone with support being offered from a distance.  It was also reported by some mentors that not having a clear understanding of the documentation required for mentorship became burdensome.  Lack of mentor development and training was found to be a barrier to mentorship programs (Navarro), which was reported by some study participants as negatively influencing their mentorship experience.   5.3.2 Availability Availability of mentors was a problem reported in three high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013; Marks-Maran et al., 2013) and two medium WoE level studies (Lewis & McGowan, 2015; Wolak, 2007).  Beercroft et al.’s study participants reported time and schedule constraints as reasons for not fulfilling their responsibilities, which resulted in an unsuccessful mentorship relationship.  As well, some mentors did not want to participate in the program so their dedication and commitment to the relationship was lacking.  Haggerty, Holloway, and Wilson identified the allocation of mentors as not always appropriate.  This included mentors going on planned leave at critical times, mentors taking unplanned leave, and assigned mentors who worked part-time with no 70  replacement allocated.  Furthermore, making time for meetings between the mentor and mentee due to time constraints, conflicting shift patterns, and prioritization of the mentorship meetings was reported as a challenge (Marks-Maran et al.). Lewis and McGowan reported the theme of ‘time to do’ which was described by the mentees as finding it difficult to get time together with their mentors.  This was due to busy or short-staffed wards, high patient acuity, and working different shifts.  Wolak’s participants identified the requirement of monthly meetings outside work to be inconvenient and a potential hindrance on the relationship.  Both mentors and mentees felt that impromptu meetings and discussions in the work setting were beneficial and potentially superior to outside of work meetings. 5.3.3 Mentor-Mentee Mismatch Mentor-mentee mismatch was a problem reported in one high WoE level study (Marks-Maran et al., 2013) and one medium WoE level study (Navarro, 2009).  Marks-Maran et al.’s findings suggested that some study participants did not have a valuable mentorship experience due to personality clashes and relationship issues.  Seventy percent of new graduate nurses felt that they should be able to choose their own mentor rather than one being assigned.  Navarro’s findings suggested that some mentors lacked interest in the mentees transition and learning experience which was discouraging and hindered the mentorship relationship.  This was possibly due to mentors being assigned by default rather than volunteering for the role.  The inability to choose your own mentor was identified as a negative by some participants and resulted in feeling disappointed and undervalued.  This is supported by Bandura’s (1977) social learning theory which suggests that a new graduate RN may find it challenging to think of their mentor as a role model when the mentoring relationship is arranged. 71  5.4 Limitations of this REA Several limitations were identified in the development of this REA.  The author decided to exclude ‘grey’ literature and only searched published material written in the English language for a period of three weeks, which may have led to a publication bias.  As well, due to time constraints, the searching for literature in this REA only included electronic sources and hand searching of print sources from the references of relevant research studies, which again may have led to a publication bias.  Completing a full systematic review on the topic of mentorship in novice nurses would help address this limitation but was beyond the scope of this project.   As well, all seventeen research studies were critically appraised and scored by the author of this REA, which is a potential selection limitation due to the author’s inexperience with research and all seventeen research studies were only selected by this author and no experts involved, which may have resulted in a selection bias.  This limitation again could be avoided by completing a full systematic review. Lastly, this REA only included research studies utilizing quantitative, qualitative, or mixed-methods research, selected to ensure the included research studies provide a high level of evidence to answer the REA question and sub-questions but this can also be a limitation.  There may be reported key elements of an effective mentorship program and problems in implementing a mentorship program that have only been reported in opinion papers and those results will not be captured in this REA. 5.5 Chapter Summary This chapter presented the synthesis of the final seventeen research studies to provide evidence that mentorship programs are effective in improving performance, satisfaction, retention, and confidence in new graduate RNs’ practice.  These findings were also linked to the conceptual framework identified in chapter two.  The reported key elements of an effective 72  mentorship program and problems in implementing a mentorship program were also discussed as well as any limitations that were associated with writing this REA.  The next chapter will summarize conclusions from this REA and offer recommendations for future research.                     73  CHAPTER 6: Conclusion The findings of this REA reflect a synthesis of knowledge that mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice.  The focus of this REA was to address the following research question:  What is the evidence that new graduate mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice?   This REA also attended to the following sub-questions: What are the reported key elements of effective new graduate RN mentorship programs? What are the reported problems in implementing new graduate RN mentorship programs? 6.1 REA Summary A total of 66 research studies were initially selected and their abstracts reviewed to screen for meeting the inclusion criteria and answering the above research question and sub-questions. Twenty-one research studies were then selected to be included in this REA but upon further review four had to be excluded due to their definitions of a new graduate RN not meeting the inclusion criteria leaving a final total of seventeen research studies.   Eight research studies utilizing quantitative methods, six utilizing mixed-methods, and three utilizing qualitative methods were included in this REA.  The data from each research study was extracted using the EPPI-Centre Data Extraction and Coding Tool for Education Studies (see Appendix E).  Each research study was then scored using the tools described in chapter three from highest level of evidence to lowest level of evidence, according to their WoE level, MSSM and CASP scores as appropriate for the type of study.    The findings from the final seventeen research studies were synthesized and suggest that mentorship programs can be effective in improving performance, satisfaction, retention, and 74  confidence in novice nurses’ practice under the right conditions.  Of the seventeen research articles included in this REA, none of them examined mentorship programs and its effect on all four aspects (performance, satisfaction, retention, and confidence) of a novice nurses’ practice.  This means that the positive conclusions described below were drawn from examining performance, satisfaction, retention, and confidence in isolation, thus suggesting an overall positive effect of mentorship programs on a novice nurses’ practice. 6.1.1 Performance The findings from this REA suggest that use of a mentorship program improved the performance of novice nurses’ practice as shown by three high WoE level studies (Hale, 2004; Komaratat & Oumtanee, 2009; Marks-Maran et al., 2013) and four medium WoE level studies (Hardyman & Hickey, 2001; Lewis & McGowan, 2015; Navarro, 2009; Wolak, 2007).  Although only seven of the seventeen included research studies examined the effects of a mentorship program on performance, all seven reported positive results, therefore suggesting a positive impact despite the evidence being marginal.  It was suggested that a mentorship model improved the performance of newly graduated RN’s with nursing skills, decision-making, and problem resolution (Komaratat & Oumtanee) as well as with increased clinical competence with drug administration, meeting the nutritional needs of patients, wound management, and other health and safety issues (Marks-Maran et al.). The application of a mentorship program on performance in the practice context could involve the mentor helping the new graduate RN with developing a learning plan such as a Competency, Assessment, Planning, and Evaluation (CAPE) tool.  A CAPE tool can assist a new graduate RN to meet their personal learning needs by identifying expectations which can lead to increased performance.  The mentor can also help the new graduate RN with learning nursing 75  skills through observation, role modelling, and reflection which relates to Bandura’s social learning theory.   6.1.2 Satisfaction The findings from this REA suggest that the use of a mentorship program improved the satisfaction of a novice nurses’ practice as presented by six high WoE level studies (Beercroft et al., 2006; Haggerty, Holloway, & Wilson, 2013; Hale, 2004; Halfer, Graf, & Sullivan, 2008; Hunsberger, Baumann, & Crea-Arsenio, 2013; Lindsey, 2000) and three medium WoE level studies (Almada et al., 2004; Bialowski, 2009; Smith, 2006).  The effect of a mentorship program on satisfaction was only examined in the above nine research studies, consequently suggesting a positive result where satisfaction was examined.  It was reported that the increased confidence and competence of new graduate RN’s was due to participating in a mentorship program and this was linked to increased job satisfaction (Haggerty, Holloway, & Wilson).  Furthermore, mentorship enabled novice nurses to feel part of the team and created a supportive environment that improved satisfaction (Hunsberger, Baumann, & Crea-Arsenio). In the practice context, the application of a mentorship program on satisfaction could comprise having clear expectations identified at the beginning of the relationship so both the mentor and new graduate RN are aware of their roles.  This may involve the development of a learning plan, the completion of a learning contract, or establishing explicit learning goals.  It would also be beneficial for the mentor to have an understanding of adult learning theory and different styles of learning so they best support and meet the individual learning needs of the new graduate RN.   76  6.1.3 Retention The findings of this REA suggest that the use of a mentorship program improved the retention of novice nurses as shown by two high WoE level studies (Grindel & Hagerstrom, 2009; Halfer, Graf, & Sullivan, 2008) and two medium WoE level studies (Almada et al., 2004; Fox, 2010).  Although there were only four research studies that provided evidence to support this statement, they were the only research studies from the included seventeen that addressed this aspect, thus where retention was examined the results seem to be positive even though the evidence appears to be marginal.  It was suggested that a mentorship program was successful in improving the retention of new graduate RN’s due to the support and resources that the mentors provided (Fox).  Additionally, new graduate RN’s who took part in a mentorship program had lower turnover rates hence improved retention (Halfer, Graf, & Sullivan). The application of a mentorship program on retention in the practice context could consist of a mentor helping the new graduate RN to assimilate into the work culture and develop a sense of belonging.  This may include introducing the new graduate RN to other team members both on the unit and throughout the hospital, providing a guided tour of the hospital to help the new graduate RN to become more familiar with their surroundings, and assisting the new graduate RN to adjust to a new learning environment with factors such as unit culture, management style, and workload issues. 6.1.4 Confidence The findings of this REA suggest that the use of a mentorship program improved the confidence of novice nurses’ practice as presented by five high WoE level studies (Grindel & Hagerstrom, 2009; Hale, 2004; Haggerty, Holloway, & Wilson, 2013; Hunsberger, Baumann, & Crea-Arsenio, 2013; Marks-Maran et al., 2013) and four medium WoE level studies (Almada et 77  al., 2004; Hardyman & Hickey, 2001; Lewis & McGowan, 2015; Navarro, 2009).  The effect of a mentorship program on confidence was only examined in nine of the seventeen included research articles but where it was examined the results appear positive, therefore indicating a positive effect on confidence.  It was suggested that the structured, supportive environment that a mentorship program provided resulted in increased confidence of the new graduate RNs’ (Haggerty, Holloway, & Wilson).  Moreover, a majority of new graduate RN’s in a structured mentorship program had the potential to build confidence and enabled the new graduates to achieve a level of confidence that they did not have upon graduating (Marks-Maran et al.) as well as mentorship increased new graduate RN’s confidence which allowed them to make decisions in a safe, protected environment (Hunsberger, Baumann, & Crea-Arsenio). In the practice context, the application of a mentorship program on confidence could include the mentor assisting the new graduate RN to perform nursing tasks and skills that they are already competent with independently and providing supervision with more challenging activities.  The mentor can provide support through frequent constructive and supportive feedback and also encouraging the new graduate RN to self-reflect which may enhance their confidence.  Starting the mentorship program with adequate orientation that incorporates the objectives, expected outcomes, and clearly identified roles could also assist with confidence. 6.1.5 Key Elements for Effective Programs The reported key elements of effective new graduate RN mentorship programs include mentor-mentee matching, availability of mentors, adequate training and preparation of mentors, commitment and support, and length of mentoring relationship.  Mentor-mentee matching included having a strong connection, the ability to select one’s mentor, and working similar rotations.  Availability of mentors included meeting on a regular basis, allocation of primary and 78  secondary mentors, and working similar schedules.  Adequate training and preparation of mentors included high levels of interpersonal and facilitation skills and formal orientation or training programs.  Commitment and support included support from mangers to allow off unit times for face-to-face meetings and a culture of support from nursing staff, especially nursing leaders.  Length of mentoring relationship suggested six months as the ideal length of a mentorship program. 6.1.6 Reported Problems The reported problems in implementing new graduate RN mentorship programs include lack of training and preparation of mentors and mentees, availability of mentors, and mentor-mentee mismatch.  Lack of training and preparation of mentors and mentees included role inadequacy of both the mentor and mentee, different understandings about the nature of mentorship, and being unable to attend mentor training due to workload and acuity of the nursing unit.  Availability of mentors included time and schedule constraints as reasons for not fulfilling their responsibilities, the allocation of mentors as not always appropriate, and making time for meetings between the mentor and mentee.  Mentor-mentee mismatch included personality clashes and relationship issues, mentors being assigned by default rather than volunteering for the role, and the inability to choose your own mentor. 6.2 Recommendations for Future Research The literature search conducted for this REA revealed there is not a huge body of high level of evidence research being conducted on mentorship programs for new graduate RNs.  Many of the original 66 research studies were excluded due to being opinion papers rather than high evidence research studies which indicate a need for further work in this area, such as focused evaluation studies that explore the effect of mentorship programs on performance, 79  satisfaction, retention, and confidence in the novice nurse.  It was interesting to note that although much of the opinion nursing literature reported that mentorship improves retention of RNs, this REA only found four research studies to provide evidence.  Nursing shortage is a major concern across Canada with an anticipated shortage of almost 60,000 FTE RNs by 2022 (CNA, 2009), therefore it is recommended that future research includes further high methodological quality research on mentorship and its effect on retention of new graduate RNs.  This could include comparative studies that study the effect of mentorship programs along with another variable, such as an extended orientation or residency program, on the retention of new graduate RNs. Another recommendation for future work would be to explore the effects of a mentorship program on all four aspects (performance, satisfaction, retention, and confidence) of a novice nurses’ practice in one high evidence research study.  The author of this REA was not able to find any research study that examined performance, satisfaction, retention, and confidence at the same time; thus indicating a need for further research.  This could include a comparative study that individually compares each aspect on a novice nurses’ practice to determine which variable is most influenced by a mentorship program. A further recommendation for future work is on mentorship and its effect on retention in experienced RNs in a new practice area.  Experienced RNs in a new practice area can also face challenges such as short staffing, poor communication among colleagues, abusive or unsupportive colleagues, heavy workloads, physical and emotional demands, and lack of administrative support which may result in the decision to leave a practice area (Maddalena et al.).  The average cost of replacing a RN in Canada as $25,000 and high turnover rates are associated with a decrease in job satisfaction, increase in likelihood of medical errors, overtime, 80  and environmental complexity (O’Brien-Pallas et al.), thus retention of experienced RNs is also crucial to ensure adequate supply of RNs in Canada.  6.3 Chapter Summary This final chapter has provided a summary of the evidence that suggests mentorship programs are effective in improving performance, satisfaction, retention, and confidence in novice nurses’ practice under the right conditions.  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Rapid Evidence Assessment Toolkit. Retrieved  January 12, 2015 from http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance Greene, M.T., & Puetzer, M. (2002). The values of mentoring: A strategic approach to retention  and recruitment. Journal of Nursing Care Quality, 17(1), 63-70. Grindel, C.G. & Hagerstrom. (2009). Nurses nurturing nurses: Outcomes and lessons learned.  MedSurg Nursing, 18(3), 183-94. 85  Haggerty, C., Holloway, K., & Wilson, D. (2013). How to grow our own: An evaluation of  preceptorship in New Zealand graduate nurse programmes. Contemporary Nurse, 43(2),  162-71. Hale, R. (2004). Mentorship of nurses: An assessment of the first year of licensure. Available  from ProQuest Dissertations & Theses Global. (305103039). Retrieved from  http://search.proquest.com.ezproxy.library.ubc.ca/docview/305103039?accountid=14656 Halfer, D., Graf, E., & Sullivan, C. (2008). The organizational impact of a new graduate  pediatric nurse mentoring program. 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Marks-Maran, D., Ooms, A., Tapping, J., Muir, J., Phillips, S., & Burke, L. (2013). A  preceptorship programme for newly qualified nurses: A study of preceptees’ perceptions.  Nurse Education Today, 33(11), 1428-34. McBurney, E.I. (2015). Strategic mentoring: Growth for mentor and mentee. Clinics in  Dermatology, 33(2), 257-60. doi:10.1016/j.clindermatol.2014.12.019 Meier, S.R. (2013). Concept analysis of mentoring. Advances in Neonatal Care, 13(5), 341-5.  doi: 10.1097/ANC.0b013e3182a14ca4 Melo, M.B., Barbosa, M.A., Souza, P.R. (2011). Job satisfaction of nursing staff: Integrative  review. Revista Latino-Americana Enfermagem, 19(4), 1047-55.  Mills, J.F., & Mullins, A.C. (2008). The California nurse mentor project: Every nurse deserves a  mentor. Nursing Economic$, 26(5), 310-5. 87  Navarro, J. (2009). The mentoring experiences and self-efficacy of new graduate nurses during  transition from student to professional nurse. Available from ProQuest Dissertations &  Theses Global. (276267757). Retrieved from http://search.proquest.com.ezproxy.library.ubc.ca/docview/276267757?accountid=14656 O’Brien-Pallas, L., Tomblin, G., Shamian, J., Li, X., Kephart, G., Laschinger, H., Smadu, M., McGillis, L., D’Amour, D., Gallant, M., Hayes, L., Lee, J., Lee, N., & Liu, Y. (2008).  Understanding the costs and outcomes of nurses’ turnover in Canadian hospitals. Author:  Ottawa. http://nhsru.com/publications/understanding-the-costs-and-outcomes-of-nurses-turnover-in-canadian-hospitals/ Oermann, M.H., & Gaberson, K.B. (2009). Evaluation and testing in nursing education. New  York: Springer Publishing Company. Persaud, D. (2008). Mentoring the new graduate perioperative nurse: A valuable retention  strategy. Association of periOperative Registered Nurses Journal, 87(6), 1173-9. Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., Britten, N., Roen, K.,  & Duffy, S. (2006). Guidance on the conduct of narrative synthesis in systematic  reviews. Retrieved March 26, 2015 from http://www.lancaster.ac.uk/shm/research/nssr/research/dissemination/publications/NS_Synthesis_Guidance_v1.pdf Public Health Resource Unit. (2006). Critical Appraisal Skills Program (CASP). Retrieved  March 26, 2015 from http://resources.civilservice.gov.uk/wp-content/uploads/2011/09/Qualitative-Appraisal-Tool_tcm6-7385.pdf Rheaume, A., Clement, L., LeBel, N. (2011). Understanding intention to leave amongst new  graduate Canadian nurses: A repeated cross sectional survey. International Journal of  88  Nursing Studies, 48, 490-500. doi:10.1016/j.ijnurstu.2010.08.005 Ronsten, B., Andersson, E., & Gustafsson, B. (2005). Confirming mentorship. Journal of  Nursing Management, 13(4), 312-21. Schroeter, K. (2008). Competence literature review. Competency & Credentialing Institute.  Retrieved April 10, 2015 from http://www.cc-institute.org/docs/default-document- library/2011/10/19/competence_lit_review.pdf Shaffer, B., Tallanco, B., & Walsh, J. (2000). Win-win mentoring. Dimensions of Critical Care  Nursing, 19(3), 36-8. Sherman, L. W., Gottfredson, D., MacKenzie, D., Eck, J., Reuter, P., and Bushway, S. (1997). Preventing crime: What works, what doesn’t, what’s promising. National Institute of  Justice. Retrieved March 26, 2015 from https://www.ncjrs.gov/pdffiles/171676.PDF Smith, C.B. (2006). The influence of mentoring on goal attainment and role satisfaction for  registered nurses in acute care facilities. Available from ProQuest Central; ProQuest  Dissertations & Theses Global. (305327278). Retrieved from  http://search.proquest.com.ezproxy.library.ubc.ca/docview/305327278?accountid=14656 Tourigny, L., & Pulich, M. (2005). A critical examination of formal and informal mentoring  among nurses. The Health Care Manager, 24(1), 68-76.  Wagner, A.L., & Seymour, M.E. (2007). A model of caring mentorship for nursing. Journal for  Nurses in Staff Development, 23(5), 201-11. Watt, A., Cameron, A., Sturm, L., Lathlean, T., Blamey, S., Facey, K., Hailey, D., Norderhaug,  I., & Maddern, G. (2008). Rapid reviews versus full systematic reviews: An inventory of  current methods and practice in health technology assessment. International Journal of Technology Assessment in Health Care, 24(2), 133-9. 89  Wensel, T.M. (2006). Mentor or preceptor: What is the difference? American Journal of  Health-System Pharmacy, 63(17), 1597. Westendorf, J.J. (2007). The nursing shortage: Recruitment and retention of current and future  nurses. Plastic Surgical Nursing, 27(2), 93-7. Wilson, V.W., Andrews, M., & Leners, D.W. (2006). Mentoring as a strategy for retaining racial and ethnically diverse students in nursing programs. The Journal of Multicultural  Nursing and Health, 12(3), 17-23. Wolak, E.S. (2007). Perceptions of an intensive care unit mentorship program. Available from  ProQuest Central; ProQuest Dissertations & Theses Global. (304832833). Retrieved from  http://search.proquest.com.ezproxy.library.ubc.ca/docview/304832833?accountid=14656 Woodfine, P. (2011). Taking a novice nurse under your wing. Nursing, 41(9), 53-5. Yonge, O., Billay, D., Myrick, F., & Luhanga, F. (2007). Preceptorship and mentorship: Not  merely a matter of semantics. International Journal of Nursing Education Scholarship, 4(1), 19-32. doi: 10.2202/1548-923X.1384  Young, L.E. (2009). Mentoring new nurses in stressful times. Canadian Operating Room  Nursing Journal, 27(2), 6-7, 14-5, 29-30.        90  APPENDIX A: Excel Spreadsheet Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Lindsey, K.S. (2000) Descriptive Comparative Survey Is there a difference in job satisfaction levels between novice nurses who have been mentored versus those who haven't been mentored? Varied between participants 163 Significant relationship between mentoring and job satisfaction. High 9 Medium 3   Grindel, C.G. & Hagerstrom. (2009) Longitudinal A 12-month mentorship program wherein the mentor and mentee would work together to facilitate the transition of the new nurse to professional nursing practice and implement career goals of the mentee.  12 month mentorship program 129 Significant relationship between mentoring and job satisfaction.  No relationship between mentoring and intent to stay and confidence. High 8 Medium 2   Komaratat, S., & Oumtanee, A. (2009) Quasi-Experimental This research was conducted to study the level of nursing competency of newly graduated nurses after using a mentorship model. 1 month program working together 19 Significant relationship between mentoring and nursing competence (performance). High 8 Medium 2   Hale, R. (2004) Descriptive Exploratory  To explore mentoring relationships from the perspectives of the new graduate nurses and assess the consequences of the mentorship relationships (positive benefits). Varied between participants 144 Significant relationship between mentoring and confidence, competence, and job satisfaction. High 8 Low 1   91  Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Halfer, D., Graf, E., & Sullivan, C. (2008) Descriptive Survey A descriptive study to compare the job satisfaction and retention rates of two cohorts of new graduate nurses: one before and one after implementation of a Pediatric RN Internship Program.  Not described 234 Job satisfaction higher in post group and lower turnover rate (sustained for 2 years). High 7 Medium 3   Smith, C.B. (2006) Descriptive Correlational This quantitative study examined the influence of mentoring for RNs who have been employed in acute care facilities for the first time for less than 2 years. Varied between participants 51 Significant relationship between mentoring and role satisfaction with high levels of goal attainment and mentoring antecedents and job satisfaction Medium 6 Low 1   Fox, K.C. (2010) Evaluation Survey A pilot mentoring program was initiated to reduce the turnover rate of newly hired registered nurses.  1 year program 12 Satisfaction scores improved by one level (from agree to strongly agree or tend to disagree to agree) in 75% of the participants, reflecting improved satisfaction.  The mentee also reported feeling more comfortable in their roles due to the support and resources provided by the mentors.  Medium 5 N/A  92  Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Hardyman, R., & Hickey, G. (2001) Longitudinal Survey A longitudinal, questionnaire survey exploring the expectations of preceptorship from the perspective of newly qualified nurses. Not described 1512 The aspects of preceptorship found to be most important to the participants include constructive feedback on clinical skills (99%), teaching new clinical skills (99%), confidence building (95%), and helping to settle into the work environment (94%). Medium 4 N/A   Marks-Maran, D., Ooms, A., Tapping, J., Muir, J., Phillips, S., & Burke, L. (2013) Mixed-Methods This article presents the evaluation of a preceptorship programme for newly qualified nurses to determine preceptee engagement with the preceptorship programme, and the impact, value, and sustainability of the programme from the preceptees' perspective.  Not described 44 Findings from this study included 78% of the mentees reporting an improvement in confidence with making decisions about patient care, 70% reporting that the preceptorship has enhanced their role satisfaction, 68% reporting improved competence with drug administration and 75% reporting being able to deal more confidently with problems relating to patient care.  High 9 Low 1 High 8 93  Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Hunsberger, M., Baumann, A., & Crea-Arsenio, M. (2013) Mixed-Methods A trend study design was used to examine the impact of extended orientation and mentorship on the transition of new graduate nurses to professional practice over a 3-year period.  3-6 month program 3813 Mentor helped to be more confident with documentation and medication administration High 8 N/A High 9 Beercroft, P.C., Santner, S., Lacy, M.L., Kunzman, L., & Dorey, F. (2006) Mixed-Methods The aims of the study were to determine whether mentoring was successful and if new grads: were satisfactorily matched with a mentor; received guidance and support; attained socialization; benefitted from having a role model; maintained contact with mentor; and satisfied with mentorship.  Not described 318 Appears mentors could be instrumental in retention of new grads by increasing confidence High 8 Low 1 High 8 Haggerty, C., Holloway, K., & Wilson, D. (2013) Mixed-Methods This article provides an overview of nurse entry to practice programmes in New Zealand and the key findings on new graduate's confidence and competence.  6 weeks with preceptor 1023 Overall satisfaction and increased competence and confidence due to program High 8 N/A Medium 7 94  Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Almada, P., Carafoli, K., Flattery, J.B., French, D.A., & McNamara, M. (2004) Mixed-Methods Will a newly designed preceptor program provide NGNs adequate education, support, and acceptance in their new role as staff nurses and thereby increase retention rates? 8 weeks with preceptor 40 Retention rate increased from 60 to 89% and mean scores for satisfaction 93.7% Medium 6 Low 1 Medium 6 Bialkowski, K. (2009) Mixed-Methods To evaluate a mentoring program by examining the impact of length of orientation on job satisfaction, organizational commitment, and propensity to leave. Up to 7.5 month long program 21 Significant difference between mentorship/orientation of < 1 month and 3-6 months Medium 4 Medium 2 Medium 7 Lewis, S., & McGowan, B. (2015) Qualitative What was the experience of preceptorship like for newly qualified registered nurses in a healthcare trust? Not described 8 Preceptorship enabled them to develop their confidence and further develop their knowledge and skills Medium 6   High 9 95  Author & Year Study Design Purpose/Aims Intervention Length Participants Outcomes/Findings WoE Level & Score MSSM Level & Score CASP Level & Score Navarro, J. (2009) Descriptive Exploratory The purpose of this study was to: describe the mentorship experiences of NGNs as they transition from student to RN, describe how the mentorship experience shaped the perceived self-efficacy of NGNs, and describe how the mentorship experiences shaped the transition from student to RN.  Varied between participants 5 All the participants in this study reported their mentors using positive verbal persuasion and encouragement which resulted in increased confidence.  The mentors also challenged the new graduate nurses to perform new skills and resulted in an increased clinical competence and the confidence to perform skills independently.   Medium 5   High 9 Wolak, E.S. (2007) Focus Group The purpose of this study was to examine the experiences of mentees and mentors in a structured mentorship program.  Paired together at least 10 months 5 All the participants reported that the mentors provided the mentees with valuable knowledge and skills thus contributing to increased job satisfaction and organizational commitment.   Medium 5   High 9  96  APPENDIX B: GSRS Weight of Evidence (WoE) Tool  Weight of Evidence A: Taking account of all quality assessment issues, can the study findings be trusted in answering the study question(s)?  High Evidence               Score of 3 Medium Evidence          Score of 2 Low Evidence                Score of 1   Weight of Evidence B: Appropriateness of research design and analysis for addressing the question, or sub-questions, of this specific REA  High Evidence               Score of 3 Medium Evidence          Score of 2 Low Evidence                Score of 1   Weight of Evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample and measures) for addressing the research question, or sub-questions, of this specific REA  High Evidence               Score of 3 Medium Evidence          Score of 2 Low Evidence                Score of 1   Weight of Evidence D: Overall weight of evidence  High Evidence               Score of 7 - 9 Medium Evidence          Score of 4 - 6 Low Evidence                Score of 3   Source: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit.http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-ssessment/how-to-do-a-rea     97  APPENDIX C: Maryland Scale of Scientific Methods (MSSM) Tool Increasing Methodological Quality for Impact Studies   Level 1  Observed correlation between an intervention and outcomes at a single point in time. A study that only measured the impact of the service using a questionnaire at the end of the intervention would fall into this level.   Level 2  Temporal sequence between the intervention and the outcome clearly observed; or the presence of a comparison group that cannot be demonstrated to be comparable. A study that measured the outcomes of people who used a service before it was set up and after it finished would fit into this level.   Level 3  A comparison between two or more comparable units of analysis, one with and one without the intervention. A matched-area design using two locations in the UK would fit into this category if the individuals in the research and the areas themselves were comparable.   Level 4  Comparison between multiple units with and without the intervention, controlling for other factors or using comparison units that evidence only minor differences. A method such as propensity score matching, that used statistical techniques to ensure that the programme and comparison groups were similar would fall into this category.   Level 5  Random assignment and analysis of comparable units to intervention and control groups. A well conducted Randomized Controlled Trial fits into this category.   Source: Sherman et al. (1997). Preventing crime: What works, what doesn’t, what’s promising. National Institute of  Justice. Retrieved March 26, 2015 from https://www.ncjrs.gov/pdffiles/171676.PDF     98  APPENDIX D: Critical Appraisal Skills Programme (CASP) Tool This assessment tool has been developed for those unfamiliar with qualitative research and its theoretical perspectives. This tool presents a number of questions that deal very broadly with some of the principles or assumptions that characterise qualitative research. It is not a definitive guide and extensive further reading is recommended.  How to use this appraisal tool  Three broad issues need to be considered when appraising the report of qualitative research:  Rigour: has a thorough and appropriate approach been applied to key research methods in the study?  Credibility: are the findings well presented and meaningful?  Relevance: how useful are the findings to you and your organisation?  The 10 questions on the following pages are designed to help you think about these issues systematically.  The first two questions are screening questions and can be answered quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions.  A number of italicised prompts are given after each question. These are designed to remind you why the question is important. Record your reasons for your answers in the spaces provided.  Screening Questions  1. Was there a clear statement of the aims of the research?    Yes No  Consider:  – what the goal of the research was  – why it is important  – its relevance  2. Is a qualitative methodology appropriate?       Yes No  Consider:  – if the research seeks to interpret or illuminate the actions and/or subjective experiences of      research participants  Is it worth continuing?  Appropriate research design 3. Was the research design appropriate to address the aims of the research?  Consider:  – if the researcher has justified the research design (e.g. have they discussed how they decided  99    which methods to use?)  Sampling 4. Was the recruitment strategy appropriate to the aims of the research?  Consider:  – if the researcher has explained how the participants were selected  – if they explained why the participants they selected were the most appropriate to provide      access to the type of knowledge sought by the study  – if there are any discussions around recruitment (e.g. why some people chose not to take  part)  Data collection 5. Were the data collected in a way that addressed the research issue?  Consider:  – if the setting for data collection was justified  – if it is clear how data were collected (e.g. focus group, semi-structured interview etc)  – if the researcher has justified the methods chosen  – if the researcher has made the methods explicit (e.g. for interview method, is there an      indication of how interviews were conducted, did they used a topic guide?)  – if methods were modified during the study. If so, has the researcher explained how and  why?  – if the form of data is clear (e.g. tape recordings, video material, notes etc)  – if the researcher has discussed saturation of data  Reflexivity (research partnership relations/recognition of researcher bias) 6. Has the relationship between researcher and participants been adequately considered?  Consider whether it is clear:  – if the researcher critically examined their own role, potential bias and influence during: - formulation of research questions - data collection, including sample recruitment and choice of location  – how the researcher responded to events during the study and whether they considered the      implications of any changes in the research design  Ethical Issues 7. Have ethical issues been taken into consideration?  Consider:  – if there are sufficient details of how the research was explained to participants for the reader  to  assess whether ethical standards were maintained  – if the researcher has discussed issues raised by the study (e. g. issues around informed  consent or confidentiality or how they have handled the effects of the study on the participants  during and after the study)  – if approval has been sought from the ethics committee 100  Data Analysis 8. Was the data analysis sufficiently rigorous?  Consider:  – if there is an in-depth description of the analysis process  – if thematic analysis is used. If so, is it clear how the categories/themes were derived from  the data?  – whether the researcher explains how the data presented were selected from the original  sample to demonstrate the analysis process  – if sufficient data are presented to support the findings  – to what extent contradictory data are taken into account  – whether the researcher critically examined their own role, potential bias and influence  during analysis and selection of data for presentation  Findings 9. Is there a clear statement of findings?  Consider:  – if the findings are explicit  – if there is adequate discussion of the evidence both for and against the researcher’s  arguments  – if the researcher has discussed the credibility of their findings (e.g. triangulation, respondent  validation, more than one analyst.)  – if the findings are discussed in relation to the original research questions  Value of the Research 10. How valuable is the research?  Consider:  – if the researcher discusses the contribution the study makes to existing knowledge or      understanding (e.g. do they consider the findings in relation to current practice or policy, or      relevant research-based literature?)  – if they identify new areas where research is necessary  – if the researchers have discussed whether or how the findings can be transferred to other      populations or considered other ways the research may be used   Source: Public Health Resource Unit, England (2006). Critical Appraisal Skills Program (CASP).  Retrieved March 26, 2015 from http://resources.civilservice.gov.uk/wp-content/uploads/2011/09/Qualitative-Appraisal-Tool_tcm6-7385.pdf    101  APPENDIX E: EPPI-Centre Data Extraction and Coding Tool for Education Studies  Purpose and use of this tool   This tool is designed to help those conducting systematic reviews on educational topics identify extract and code information about a particular research study that is to be included in a systematic review.   It is designed to help the reviewer obtain all the necessary information to    assess the quality of the study or its internal validity  Identify the relevant contextual information that may have affected the results obtained in the specific study   Identify the contextual information about a study that will be relevant to any assessment of the generalizability of findings in the individual study   Identify relevant information about the design , execution and context of a study for the purpose of synthesizing (bringing together) results from all the studies that are included in a particular review   The tool is designed to be used to extract data from a single primary study. That is the report(s) of a piece of research i.e. not a review (systematic or otherwise), a scholarly paper, treatise or opinion piece.    The study may be reported in more than one paper for which a single data extraction is completed        Each separate study included in a review will require a separate data extraction   For the purposes of producing a ‘map’ review groups will usually include questions from sections A,B,C, D, E (if relevant), G.    Questions B2 and G3 must be included in the coding questions for the map  Additional questions used will depend on the purpose of the map and the type of review.  The questions to be used should be agreed with the funder and the EPPI-Centre prior to starting coding  Other sections and questions are completed only on studies included in the ‘in-depth review’    102  Section A: Administrative Details Use of these guidelines should be cited as: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit. A.1 Name of the reviewer A.1.1 Details  A.2 Date of the review A.2.1 Details  A.3 Please enter the details of each paper which reports on this item/study and which is used to complete this data extraction. (1): A paper can be a journal article, a book, or chapter in a book, or an unpublished report. A.3.1 Paper (1) Fill in a separate entry for further papers as required. A.3.2 Unique Identifier: A.3.3 Authors: A.3.4 Title: A.3.5 Paper (2) A.3.6 Unique Identifier: A.3.7 Authors: A.3.8 Title:  A.4 Main paper. Please classify one of the above papers as the 'main' report of the study and enter its unique identifier here. NB(1): When only one paper reports on the study, this will be the 'main' report.  NB(2): In some cases the 'main' paper will be the one which provides the fullest or the latest report of the study. In other cases the decision about which is the 'main' report will have to be made on an arbitrary basis. A.4.1 Unique Identifier:  A.5 Please enter the details of each paper which reports on this study but is NOT being used to complete this data extraction. NB A paper can be a journal article, a book, or chapter in a book, or an unpublished report. A.5.1 Paper (1) Fill in a separate entry for further papers as required. A.5.2 Unique Identifier: A.5.3 Authors: A.5.4 Title: 103  A.5.5 Paper (2) A.5.6 Unique Identifier: A.5.7 Authors: A.5.8 Title:  A.6 If the study has a broad focus and this data extraction focuses on just one component of the study, please specify this here. A.6.1 Not applicable (whole study is focus of data extraction) A.6.2 Specific focus of this data extraction (please specify)  A.7 Identification of report (or reports) Please use AS MANY KEYWORDS AS APPLY. A.7.1 Citation Please use this keyword if the report was identified from the bibliographic list of another report. A.7.2 Contact Please use this keyword if the report was found through a personal/professional contact. A.7.3 Handsearch Please use this keyword if the report was found through handsearching a journal. A.7.4 Unknown Please use this keyword if it is unknown how the report was found. A.7.5 Electronic database Please use this keyword if the report was found through searching on an electronic bibliographic database.  In addition, if the report was found on an electronic database please use ONE OR MORE of the following keywords to indicate which database it was found on:  aidsline For AIDSLINE  104  appsocscience For Applied Social and Abstracts  artscitation For the Arts and Humanities Citation Index  aei For the Australian Education Index  bei For the British Education Index  bibliomap For the EPPI-Centre's specialist register of research  cabhealth For CABhealth  cei For the Canadian Education Index  ceruk For CERUK  cinahl For the CINAHL  cochranelib For the Cochrane Library  dissabs For Dissertation Abstracts  dislearn For the Distance Learning Database  eduabs For Education Abstracts 105   educationline For Education-line  embase For EMBASE  eric For ERIC  healthplan For Health Planning  healthpromis For HealthPromis  intbibsocsci For the International Bibliography of the Social Sciences  langbehrabs For Linguistic and Language Behaviour Abstracts  medline For MEDLINE  psycinfo For PsycINFO  regard For REGARD  sigle For SIGLE  socscicitation For the Social Science Citation Index  106  socservabs For the Social Services Abstracts  socioabs For Sociological Abstracts  spectr For the Social, Psychological, Educational & Criminological Trials Register  A.8 Status Please use ONE keyword only A.8.1 Published Please use this keyword if the report has an ISBN or ISSN number. A.8.2 Published as a report or conference paper Please use this code for reports which do not have an ISBN or ISSN number (eg. 'internal' reports; conference papers) A.8.3 Unpublished e.g. thesis or author manuscript  A.9 Language (please specify) A.9.1 Details of Language of report Please use as many keywords that apply  If the name of the language is specified/known  then please use the name as a keyword. For example: Dutch  English  French  If non-English and you cannot name the language:  non English     Section B: Study Aims and Rationale  B.1 What are the broad aims of the study? Please write in authors’ description if there is B.1.1 Explicitly stated (please specify) 107  one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Other, more specific questions about the research questions and hypotheses are asked later.  B.1.2 Implicit (please specify) B.1.3 Not stated/unclear (please specify)  B.2 What is the purpose of the study? N.B. This question refers only to the purpose of a study, not to the design or methods used.  A: Description Please use this code for studies in which the aim is to produce a description of a state of affairs or a particular phenomenon, and/or to document its characteristics. In these types of studies there is no attempt to evaluate a particular intervention programme (according to either the processes involved in its implementation or its effects on outcomes), or to examine the associations between one or more variables. These types of studies are usually, but not always, conducted at one point in time (i.e. cross sectional). They can include studies such as an interview of head teachers to count how many have explicit policies on continuing professional development for teachers; a study documenting student attitudes to national examinations using focus groups; a survey of the felt needs of parents using self-completion questionnaires, about whether they want a school bus service.  B: Exploration of relationships Please use this code for a study type which examines relationships and/or statistical associations between variables in order to build theories and develop hypotheses. These studies may describe a process or processes (what goes on) in order to explore how a particular state of affairs might be produced, maintained and changed. B.2.1 A: Description B.2.2 B: Exploration of relationships B.2.3 C: What works? B.2.4 D: Methods development B.2.5 E: Reviewing/synthesising research  108   These relationships may be discovered using qualitative techniques, and/or statistical analyses. For instance, observations of children at play may elucidate the process of gender stereotyping, and suggest the kinds of interventions which may be appropriate to reduce any negative effects in the classroom. Complex statistical analysis may be helpful in modelling the relationships between parents' social class and language in the home. These may lead to the development of theories about the mechanisms of language acquisition, and possible policies to intervene in a causal pathway.  These studies often consider variables such as social class and gender which are not interventions, although these studies may aid understanding, and may suggest possible interventions, as well as ways in which a programme design and implementation could be improved. These studies do not directly evaluate the effects of policies and practices.  C: What works A study will only fall within this category if it measures effectiveness - i.e. the impact of a specific intervention or programme on a defined sample of recipients or subjects of the programme or intervention.  D: Methods development Studies where the principle focus is on methodology.  E: Reviewing/Synthesising research Studies which summarise and synthesise primary research studies. 109  B.3 Why was the study done at that point in time, in those contexts and with those people or institutions? Please write in authors’ rationale if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation.  B.3.1 Explicitly stated (please specify) B.3.2 Implicit (please specify) B.3.3 Not stated/unclear (please specify)  B.4 Was the study informed by, or linked to, an existing body of empirical and/or theoretical research? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. B.4.1 Explicitly stated (please specify) B.4.2 Implicit (please specify) B.4.3 Not stated/unclear (please specify)  B.5 Which of the following groups were consulted in working out the aims of the study, or issues to be addressed in the study? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Please cover details of how and why people were consulted and how they influenced the aims/issues to be addressed.  B.5.1 Researchers (please specify) B.5.2 Funder (please specify) B.5.3 Head teacher/Senior management (please specify) B.5.4 Teaching staff (please specify) B.5.5 Non-teaching staff (please specify) B.5.6 Parents (please specify) B.5.7 Pupils/students (please specify) B.5.8 Governors (please specify) B.5.9 LEA/Government officials (please specify) B.5.10 Other education practitioner (please specify) B.5.11 Other (please specify) B.5.12 None/Not stated B.5.13 Coding is based on: Authors' description B.5.14 Coding is based on: Reviewers’ inference  B.6 Do authors report how the study was funded? B.6.1 Explicitly stated (please specify) 110  B.6.2 Implicit (please specify) B.6.3 Not stated/unclear (please specify)  B.7 When was the study carried out? If the authors give a year, or range of years, then put that in. If not, give a ‘not later than’ date by looking for a date of first submission to the journal, or for clues like the publication dates of other reports from the study. B.7.1 Explicitly stated (please specify ) B.7.2 Implicit (please specify) B.7.3 Not stated/unclear (please specify)  B.8 What are the study research questions and/or hypotheses? Research questions or hypotheses operationalise the aims of the study. Please write in authors' description if there is one. Elaborate if necessary, but indicate which aspects are reviewers' interpretation. B.8.1 Explicitly stated (please specify) B.8.2 Implicit (please specify) B.8.3 Not stated/ unclear (please specify)     Section C: Study Policy or Practice Focus  C.1 What is/are the topic focus/foci of the study? C.1.1 Assessment (please specify) C.1.2 Classroom management (please specify) C.1.3 Curriculum (see next question below) C.1.4 Equal opportunities (please specify) C.1.5 Methodology (please specify) C.1.6 Organisation and management (please specify) C.1.7 Policy (please specify) C.1.8 Teacher careers (please specify) C.1.9 Teaching and learning (please specify) C.1.10 Other ( please specify) C.1.11 Coding is based on: Authors' description C.1.12 Coding is based on: Reviewers' inference  111  C.2 What is the curriculum area, if any? C.2.1 Art C.2.2 Business Studies C.2.3 Citizenship C.2.4 Cross-curricular C.2.5 Design & Technology C.2.6 Environment C.2.7 General C.2.8 Geography C.2.9 Hidden C.2.10 History C.2.11 ICT C.2.12 Literacy - first languages C.2.13 Literacy - further languages C.2.14 Literature C.2.15 Maths C.2.16 Music C.2.17 PSE C.2.18 Phys. Ed C.2.19 Religious Ed. C.2.20 Science C.2.21 Vocational C.2.22 Other C.2.23 Coding is based on: Authors' description C.2.24 Coding is based on: Reviewers' inference  C.3 What is/are the educational setting(s) of the study? C.3.1 Community centre C.3.2 Correctional institution C.3.3 Government department 112  C.3.4 Higher education institution C.3.5 Home C.3.6 Independent school C.3.7 Local education authority C.3.8 Nursery school C.3.9 Other early years setting C.3.10 Post-compulsory education institution C.3.11 Primary school C.3.12 Pupil referral unit C.3.13 Residential school C.3.14 Secondary school C.3.15 Special needs school C.3.16 Workplace C.3.17 Other educational setting C.3.18 Coding is based on: Authors' description C.3.19 Coding is based on: Reviewers' inference  C.4 In which country or countries was the study carried out? Provide further details where relevant e.g. region or city. C.4.1 Explicitly stated (please specify) C.4.2 Not stated/unclear (please specify)  C.5 Please describe in more detail the specific phenomena, factors, services or interventions with which the study is concerned. The questions so far have asked about the aims of the study and any named programme under study, but this may not fully capture what the study is about. Please state or clarify here. C.5.1 Details        113  Section D: Actual Sample If there are several samples or levels of sample, please complete for each level D.1 Who or what is/ are the sample in the study? Please use AS MANY codes AS APPLY to describe the nature of the sample of the report. Only indicate a code if the report specifically characterises the sample focus in terms of the categories indicated below D.1.1 Learners Please use this code if a population focus of the study is on pupils, students, apprentices, or other kinds of learners D.1.2 Senior management Please use this code if a sample foci of the study is on those with responsibility in any educational institution for the strategic leadership and management of a whole organisation. This will include the person with ultimate responsibility for the educational institution under study. In the school setting, the term 'headteacher' is typically used ('principal' in the U.S.A., Canada and Australia); the term 'principal' is often used in a college setting, the term 'vice-chancellor' in a university setting. D.1.3 Teaching staff Please use this code if a sample focus of the study is on staff who teach (or lecture) in a classroom/lecture-hall setting D.1.4 Non-teaching staff Please use this code if a population focus of the study is on staff who do not teach, but whose role within the educational institution is administrative/ organisational, e.g. equal opportunities coordinators, other support staff D.1.5 Other educational practitioners Please use this code if the sample focus of the study includes representatives from other educational bodies, including interest/advisory groups; school governing bodies and parent support groups D.1.6 Government Please use this code if the sample focus of the 114  study is on representatives from government or governing bodies e.g. from the DfES (Department for Education and Skills), BECTA (British Educational Communications and Technology Agency), LSDA (learning and Skills Development Agency, formerly FEDA - Further Education Development Agency) etc. D.1.7 Local education authority officers Please use this code if a sample focus of the study is people who work in a local education authority D.1.8 Parents Please use this code if the sample focus of the study refers to the inclusive category of carers of 'children' and 'young people', which may include natural parents/mother/father/adoptive parents/foster parents etc D.1.9 Governors Please use this code if the sample focus of the study is on members of the governing body, which may include teachers or parents. They play a role in the management and vision of the educational institution D.1.10 Other sample focus (please specify)  D.2 What was the total number of participants in the study (the actual sample)? if more than one group is being compared, please give numbers for each group D.2.1 Not applicable (e.g. study of policies, documents etc) D.2.2 Explicitly stated (please specify) D.2.3 Implicit (please specify) D.2.4 Not stated/ unclear (please specify)  D.3 What is the proportion of those selected for the study who actually participated in the study? Please specify numbers and percentages if possible. D.3.1 Not applicable (e.g. review) D.3.2 Explicitly stated (please specify) D.3.3 Implicit (please specify) D.3.4 Not stated/unclear (please specify)  115  D.4 Which country/countries are the individuals in the actual sample from? If UK, please distinguish between England, Scotland, N. Ireland and Wales, if possible. If from different countries, please give numbers for each.  If more than one group is being compared, please describe for each group. D.4.1 Not applicable (e.g. study of policies, documents, etc.) D.4.2 Explicitly stated (please specify) D.4.3 Implicit (please specify) D.4.4 Not stated/unclear (please specify)  D.5 If the individuals in the actual sample are involved with an educational institution, what type of institution is it? For evaluations of interventions, this will be the site(s) of the intervention.  Please give details of the institutions (e.g. size, geographic location mixed/single sex etc.) as described by the authors. If individuals are from different institutions, please give numbers for each. If more than one group is being compared, please describe all of the above for each group. D.5.1 Not applicable (e.g. study of policies, documents, etc.) D.5.2 Community centre (please specify) D.5.3 Post-compulsory education institution (please specify) D.5.4 Government Department (please specify) D.5.5 Independent school (please specify age range and school type) D.5.6 Nursery school (please specify) D.5.7 Other early years setting (please specify) D.5.8 Local education authority (please specify) D.5.9 Higher Education Institution (please specify) D.5.10 Primary school (please specify) D.5.11 Correctional Institution (please specify) D.5.12 Pupil referral unit (please specify) D.5.13 Residential school (please specify) D.5.14 Secondary school (please specify age range) D.5.15 Special needs school (please specify) 116  D.5.16 Workplace (please specify) D.5.17 Other educational setting (please specify) D.5.18 Coding is based on: Authors' description D.5.19 Coding is based on: Reviewers' inference  D.6 What ages are covered by the actual sample? Please give the numbers of the sample that fall within each of the given categories. If necessary refer to a page number in the report (e.g. for a useful table).  If more than one group is being compared, please describe for each group  if follow-up study, age of entry to the study D.6.1 Not applicable (e.g. study of policies, documents etc) D.6.2 0-4 D.6.3 5-10 D.6.4 11-16 D.6.5 17 to 20 D.6.6 21 and over D.6.7 Not stated/unclear (please specify) D.6.8 Coding is based on: Authors' description D.6.9 Coding is based on: Reviewers' inference  D.7 What is the sex of the individuals in the actual sample? Please give the numbers of the sample that fall within each of the given categories. If necessary refer to a page number in the report (e.g. for a useful table).  If more than one group is being compared, please describe for each group. D.7.1 Not applicable (e.g. study of policies, documents etc) D.7.2 Single sex (please specify) D.7.3 Mixed sex (please specify) D.7.4 Not stated/unclear (please specify) D.7.5 Coding is based on: Authors' description D.7.6 Coding is based on: Reviewers' inference  D.8 What is the socio-economic status of the individuals within the actual sample? If more than one group is being compared, please describe for each group. D.8.1 Not applicable (e.g. study of policies, documents etc) D.8.2 Explicitly stated (please specify) D.8.3 Implicit (please specify) 117  D.8.4 Not stated/unclear (please specify)  D.9 What is the ethnicity of the individuals within the actual sample? If more than one group is being compared, please describe for each group. D.9.1 Not applicable (e.g. study of policies, documents etc) D.9.2 Explicitly stated (please specify) D.9.3 Implicit (please specify) D.9.4 Not stated/unclear (please specify)  D.10 What is known about the special educational needs of individuals within the actual sample? e.g. specific learning, physical, emotional, behavioural, intellectual difficulties. D.10.1 Not applicable (e.g. study of policies, documents etc) D.10.2 Explicitly stated (please specify) D.10.3 Implicit (please specify) D.10.4 Not stated/unclear (please specify)  D.11 Please specify any other useful information about the study participants. D.11.1 Details     Section E: Programme or Intervention Description  E.1 If a programme or intervention is being studied, does it have a formal name? E.1.1 Not applicable (no programme or intervention) E.1.2 Yes (please specify) E.1.3 No (please specify) E.1.4 Not stated/ unclear (please specify)  E.2 Content of the intervention package Describe the intervention in detail, whenever possible copying the authors' description from the report word for word. If specified in the report, also describe in detail what the control/ comparison group(s) were exposed to. E.2.1 Details  E.3 Aim(s) of the intervention E.3.1 Not stated E.3.2 Not explicitly stated (Write in, as worded by the reviewer) E.3.3 Stated (Write in, as stated by the 118  authors)  E.4 Year intervention started Where relevant E.4.1 Details  E.5 Duration of the intervention Choose the relevant category and write in the exact intervention length if specified in the report  When the intervention is ongoing, tick 'OTHER' and indicate the length of intervention as the length of the outcome assessment period E.5.1 Not stated E.5.2 Not applicable E.5.3 Unclear E.5.4 One day or less (please specify) E.5.5 1 day to 1 week (please specify) E.5.6 1 week (and 1 day) to 1 month (please specify) E.5.7 1 month (and 1 day) to 3 months (please specify) E.5.8 3 months (and 1 day) to 6 months (please specify) E.5.9 6 months (and 1 day) to 1 year (please specify) E.5.10 1 year (and 1 day) to 2 years (please specify) E.5.11 2 years (and 1 day) to 3 years (please specify) E.5.12 3 years (and 1 day) to 5 years (please specify) E.5.13 more than 5 years (please specify) E.5.14 Other (please specify)  E.6 Person providing the intervention (tick as many as appropriate) E.6.1 Not stated E.6.2 Unclear E.6.3 Not applicable E.6.4 Counsellor E.6.5 Health professional (please specify) E.6.6 parent  119  E.6.7 peer E.6.8 Psychologist E.6.9 Researcher E.6.10 Social worker E.6.11 Teacher/lecturer E.6.12 Other (specify)  E.7 Number of people recruited to provide the intervention (and comparison condition) (e.g. teachers or health professionals) E.7.1 Not stated E.7.2 Unclear E.7.3 Reported (include the number for the providers involved in the intervention and comparison groups, as appropriate)  E.8 How were the people providing the intervention recruited? (Write in) Also, give information on the providers involved in the comparison group(s), as appropriate. E.8.1 Not stated E.8.2 Stated (write in)  E.9 Was special training given to people providing the intervention? Provide as much detail as possible E.9.1 Not stated E.9.2 Unclear E.9.3 Yes (please specify) E.9.4 No     Section F: Results and Conclusions In future this section is likely to incorporate material from EPPI reviewer to facilitate reporting numerical results F.1 How are the results of the study presented? e.g. as quotations/ figures within text, in tables, as appendices F.1.1 Details  F.2 What are the results of the study as reported by the authors? Before completing data extraction you will need to consider what type of synthesis will be undertaken and what kind of 'results' data is required for the synthesis  F.2.1 Details  120  Warning! Failure to provide sufficient data here will hamper the synthesis stage of the review.  Please give details and refer to page numbers in the report(s) of the study, where necessary (e.g. for key tables) F.3 What do the author(s) conclude about the findings of the study? Please give details and refer to page numbers in the report of the study, where necessary F.3.1 Details     Section G: Study Method  G.1 Study Timing Please indicate all that apply and give further details where possible  -If the study examines one or more samples but each at only one point in time it is cross-sectional  -If the study examines the same samples but as they have changed over time, it is a retrospective, provided that the interest is in starting at one timepoint and looking backwards over time  -If the study examines the same samples as they have changed over time and if data are collected forward over time, it is prospective provided that the interest is in starting at one timepoint and looking forward in time G.1.1 Cross-sectional G.1.2 Retrospective G.1.3 Prospective G.1.4 Not stated/ unclear (please specify)  G.2 when were the measurements of the variable(s) used as outcome measures made, in relation to the intervention Use only if the purpose of the study is to measure the effectiveness or impact of an G.2.1 Not applicable (not an evaluation) G.2.2 Before and after G.2.3 Only after G.2.4 Other (please specify) 121  intervention or programme i.e. its purpose is coded as 'What Works' in Section B2 -  If at least one of the outcome variables is measured both before and after the intervention, please use the 'before and after' category. G.2.5 Not stated/unclear (please specify)  G.3 What is the method used in the study? NB: Studies may use more than one method please code each method used for which data extraction is being completed and the respective outcomes for each method.  A=Please use this code if the outcome evaluation employed the design of a randomised controlled trial. To be classified as an RCT, the evaluation must:  i). compare two or more groups which receive different interventions or different intensities/levels of an intervention with each other; and/or with a group which does not receive any intervention at all AND ii) allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences to the different groups based on a fully random schedule (e.g. a random numbers table is used). If the report states that random allocation was used and no further information is given then please keyword as RCT. If the allocation is NOT fully randomised (e.g. allocation by alternate numbers by date of birth) then please keyword as a non-randomised controlled trial  B=Please use this code if the evaluation compared two or more groups which receive different interventions, or different intensities/levels of an intervention to each G.3.1 A=Random experiment with random allocation to groups G.3.2 B=Experiment with non-random allocation to groups G.3.3 C=One group pre-post test G.3.4 D=one group post-test only G.3.5 E=Cohort study G.3.6 F=Case-control study G.3.7 G=Statistical survey G.3.8 H=Views study G.3.9 I=Ethnography G.3.10 J=Systematic review G.3.11 K=Other review (non systematic) G.3.12 L=Case study G.3.13 M= Document study G.3.14 N=Action research G.3.15 O= Methodological study G.3.16 P=Secondary data analysis  122  other and/or with a group which does not receive any intervention at all BUT DOES NOT allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences in a fully random manner. This keyword should be used for studies which describe groups being allocated using a quasi-random method (e.g. allocation by alternate numbers or by date of birth) or other non- random method  C=Please use this code where a group of subjects e.g. a class of school children is tested on outcome of interest before being given an intervention which is being evaluated. After receiving the intervention the same test is administered again to the same subjects. The outcome is the difference between the pre and post test scores of the subjects.  D=Please use this code where one group of subjects is tested on outcome of interest after receiving the intervention which is being evaluated  E=Please use this code where researchers prospectively study a sample (e.g. learners), collect data on the different aspects of policies or practices experienced by members of the sample (e.g. teaching methods, class sizes), look forward in time to measure their later outcomes (e.g. achievement) and relate the experiences to the outcomes achieved. The purpose is to assess the effect of the different experiences on outcomes.  F=Please use this code where researchers compare two or more groups of individuals on the basis of their current situation (e.g. 16 year old pupils with high current educational performance compared to those with average 123  educational performance), and look back in time to examine the statistical association with different policies or practices which they have experienced (e.g. class size; attendance at single sex or mixed sex schools; non school activities etc).  G= please use this code where researchers have used a questionnaire to collect quantitative information about items in a sample or population e.g. parents views on education  H= Please use this code where the researchers try to understand phenomenon from the point of the 'worldview' of a particular, group, culture or society. In these studies there is attention to subjective meaning, perspectives and experience'.   I= please use this code when the researchers present a qualitative description of human social phenomena, based on fieldwork  J= please use this code if the review is explicit in its reporting of a systematic strategy used for (i) searching for studies (i.e. it reports which databases have been searched and the keywords used to search the database, the list of journals hand searched, and describes attempts to find unpublished or 'grey' literature; (ii) the criteria for including and excluding studies in the review and, (iii) methods used for assessing the quality and collating the findings of included studies.  K= Please use this code for cases where the review discusses a particular issue bringing together the opinions/findings/conclusions from a range of previous studies but where the 124  review does not meet the criteria for a systematic review (as defined above)  L= please use this code when researchers refer specifically to their design/ approach as a 'case study'. Where possible further information about the methods used in the case study should be coded  M=please use this code where researchers have used documents as a source of data e.g. newspaper reports  N=Please use this code where practitioners or institutions (with or without the help of researchers) have used research as part of a process of development and/or change. Where possible further information about the research methods used should be coded  O=please use this keyword for studies which focus on the development or discussion of methods; for example discussions of a statistical technique, a recruitment or sampling procedure, a particular way of collecting or analysing data etc. It may also refer to a description of the processes or stages involved in developing an 'instrument' (e.g. an assessment procedure).  P= Please use this code where researchers have used data from a pre-existing dataset e.g. The British Household Panel Survey to answer their 'new' research question.    Section H: Methods-Groups  H.1 If Comparisons are being made between two or more groups*, please specify the basis of H.1.1 Not applicable (not more than one group) 125  any divisions made for making these comparisons Please give further details where possible  *If no comparisons are being made between groups please continue to Section I (Methods - sampling strategy) H.1.2 Prospective allocation into more than one group e.g. allocation to different interventions, or allocation to intervention and control groups H.1.3 No prospective allocation but use of pre-existing differences to create comparison groups e.g. receiving different interventions or characterised by different levels of a variable such as social class H.1.4 Other (please specify) H.1.5 Not stated/ unclear (please specify)  H.2 How do the groups differ? H.2.1 Not applicable (not in more than one group) H.2.2 Explicitly stated (please specify) H.2.3 Implicit (please specify) H.2.4 Not stated/ unclear (please specify)  H.3 Number of groups For instance, in studies in which comparisons are made between group, this may be the number of groups into which the dataset is divided for analysis (e.g. social class, or form size), or the number of groups allocated to, or receiving, an intervention. H.3.1 Not applicable (not more than one group) H.3.2 One H.3.3 Two H.3.4 Three H.3.5 Four or more (please specify) H.3.6 Other/ unclear (please specify)  H.4 If prospective allocation into more than one group, what was the unit of allocation? Please indicate all that apply and give further details where possible H.4.1 Not applicable (not more than one group) H.4.2 Not applicable (no prospective allocation) H.4.3 Individuals H.4.4 Groupings or clusters of individuals (e.g classes or schools) please specify 126  H.4.5 Other (e.g individuals or groups acting as their own controls - please specify) H.4.6 Not stated/ unclear (please specify)   H.5 If prospective allocation into more than one group, which method was used to generate the allocation sequence?  H.5.1 Not applicable (not more than one group) H.5.2 Not applicable (no prospective allocation) H.5.3 Random H.5.4 Quasi-random H.5.5 Non-random H.5.6 Not stated/unclear (please specify)  H.6 If prospective allocation into more than one group, was the allocation sequence concealed? Bias can be introduced, consciously or otherwise, if the allocation of pupils or classes or schools to a programme or intervention is made in the knowledge of key characteristics of those allocated. For example, children with more serious reading difficulty might be seen as in greater need and might be more likely to be allocated to the 'new' programme, or the opposite might happen. Either would introduce bias. H.6.1 Not applicable (not more than one group) H.6.2 Not applicable (no prospective allocation) H.6.3 Yes (please specify) H.6.4 No (please specify) H.6.5 Not stated/unclear (please specify)  H.7 Study design summary In addition to answering the questions in this section, describe the study design in your own words. You may want to draw upon and elaborate on the answers already given. H.7.1 Details     Section I: Methods - Sampling Strategy  I.1 Are the authors trying to produce findings that are representative of a given population? I.1.1 Explicitly stated (please specify) I.1.2 Implicit (please specify) 127  Please write in authors' description. If authors do not specify, please indicate reviewers' interpretation. I.1.3 Not stated/unclear (please specify)  I.2 What is the sampling frame (if any) from which the participants are chosen? e.g. telephone directory, electoral register, postcode, school listings etc.  There may be two stages - e.g. first sampling schools and then classes or pupils within them. I.2.1 Not applicable (please specify) I.2.2 Explicitly stated (please specify) I.2.3 Implicit (please specify) I.2.4 Not stated/unclear (please specify)  I.3 Which method does the study use to select people, or groups of people (from the sampling frame)? e.g. selecting people at random, systematically - selecting, for example, every 5th person, purposively, in order to reach a quota for a given characteristic. I.3.1 Not applicable (no sampling frame) I.3.2 Explicitly stated (please specify) I.3.3 Implicit (please specify) I.3.4 Not stated/unclear (please specify)  I.4 Planned sample size If more than one group, please give details for each group separately.  In intervention studies, the sample size will have a bearing upon the statistical power, error rate and precision of estimate of the study. I.4.1 Not applicable (please specify) I.4.2 Explicitly stated (please specify) I.4.3 Not stated/unclear (please specify)  I.5 How representative was the achieved sample (as recruited at the start of the study) in relation to the aims of the sampling frame? Please specify basis for your decision. I.5.1 Not applicable (e.g. study of policies, documents, etc.) I.5.2 Not applicable (no sampling frame) I.5.3 High (please specify) I.5.4 Medium (please specify) I.5.5 Low (please specify) I.5.6 Unclear (please specify)  I.6 If the study involves studying samples prospectively over time, what proportion of the sample dropped out over the course of the study? If the study involves more than one group, I.6.1 Not applicable (e.g. study of policies, documents, etc.) I.6.2 Not applicable (not following samples prospectively over time) 128  please give drop-out rates for each group separately. If necessary, refer to a page number in the report (e.g. for a useful table). I.6.3 Explicitly stated (please specify) I.6.4 Implicit (please specify) I.6.5 Not stated/unclear (please specify)  I.7 For studies that involve following samples prospectively over time, do the authors provide any information on whether, and/or how, those who dropped out of the study differ from those who remained in the study? I.7.1 Not applicable (e.g. study of policies, documents, etc.) I.7.2 Not applicable (not following samples prospectively over time) I.7.3 Not applicable (no drop outs) I.7.4 Yes (please specify) I.7.5 No  I.8 If the study involves following samples prospectively over time, do authors provide baseline values of key variables, such as those being used as outcomes, and relevant socio-demographic variables? I.8.1 Not applicable (e.g. study of policies, documents, etc.) I.8.2 Not applicable (not following samples prospectively over time) I.8.3 Yes (please specify) I.8.4 No     Section J: Methods - Recruitment and Consent  J.1 Which methods are used to recruit people into the study? e.g. letters of invitation, telephone contact, face-to-face contact. J.1.1 Not applicable (please specify) J.1.2 Explicitly stated (please specify) J.1.3 Implicit (please specify) J.1.4 Not stated/unclear (please specify) J.1.5 Please specify any other details relevant to recruitment and consent  J.2 Were any incentives provided to recruit people into the study? J.2.1 Not applicable (please specify) J.2.2 Explicitly stated (please specify) J.2.3 Not stated/unclear (please specify)  J.3 Was consent sought? Please comment on the quality of consent, if J.3.1 Not applicable (please specify) 129  relevant. J.3.2 Participant consent sought J.3.3 Parental consent sought J.3.4 Other consent sought J.3.5 Consent not sought J.3.6 Not stated/unclear (please specify)     Section K: Methods - Data Collection  K.1 Which variables or concepts, if any, does the study aim to measure or examine? K.1.1 Explicitly stated (please specify) K.1.2 Implicit (please specify) K.1.3 Not stated/ unclear   K.2 Please describe the main types of data collected and specify if they were used to (a) to define the sample; (b) to measure aspects of the sample as findings of the study? Only detail if more specific than the previous question K.2.1 Details  K.3 Which methods were used to collect the data? Please indicate all that apply and give further detail where possible K.3.1 Curriculum-based assessment K.3.2 Focus group interview K.3.3 One-to-one interview (face to face or by phone) K.3.4 Observation K.3.5 Self-completion questionnaire K.3.6 self-completion report or diary K.3.7 Examinations K.3.8 Clinical test K.3.9 Practical test K.3.10 Psychological test (e.g I.Q test) K.3.11 Hypothetical scenario including vignettes K.3.12 School/ college records (e.g attendance 130  records etc) K.3.13 Secondary data such as publicly available statistics K.3.14 Other documentation K.3.15 Not stated/ unclear (please specify) K.3.16 Please specify any other important features of data collection K.3.17 Coding is based on: Author's description K.3.18 Coding is based on: Reviewers' interpretation  K.4 Details of data collection instruments or tool(s). Please provide details including names for all tools used to collect data, and examples of any questions/items given. Also, please state whether source is cited in the report K.4.1 Explicitly stated (please specify) K.4.2 Implicit (please specify) K.4.3 Not stated/ unclear (please specify)  K.5 Who collected the data? Please indicate all that apply and give further detail where possible K.5.1 Researcher K.5.2 Head teacher/ Senior management K.5.3 Teaching or other staff K.5.4 Parents K.5.5 Pupils/ students K.5.6 Governors K.5.7 LEA/Government officials K.5.8 Other educational practitioner K.5.9 Other (please specify) K.5.10 Not stated/unclear  K.5.11 Coding is based on: Author's description K.5.12 Coding is based on: Reviewers' inference  131  K.6 Do the authors' describe any ways they addressed the repeatability or reliability of their data collection tools/methods? e.g. test-re-test methods  (where more than one tool was employed, please provide details for each) K.6.1 Details  K.7 Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/methods? e.g. mention previous piloting or validation of tools, published version of tools, involvement of target population in development of tools.  (Where more than one tool was employed, please provide details for each) K.7.1 Details  K.8 Was there a concealment of which group that subjects were assigned to (i.e. the intervention or control) or other key factors from those carrying out measurement of outcome - if relevant? Not applicable - e.g. analysis of existing data, qualitative study.  No - e.g. assessment of reading progress for dyslexic pupils done by teacher who provided intervention  Yes - e.g. researcher assessing pupil knowledge of drugs - unaware of whether pupil received the intervention or not. K.8.1 Not applicable (please say why) K.8.2 Yes (please specify) K.8.3 No (please specify)  K.9 Where were the data collected? e.g. school, home K.9.1 Educational Institution (please specify) K.9.2 Home (please specify) K.9.3 Other institutional setting (please specify) K.9.4 Not stated/ unclear (please specify)    132  Section L: Methods - Data Analysis  L.1 What rationale do the authors give for the methods of analysis for the study? e.g. for their methods of sampling, data collection or analysis. L.1.1 Details  L.2 Which methods were used to analyse the data? Please give details (e.g., for in-depth interviews, how were the data handled?)   Details of statistical analyses can be given next. L.2.1 Explicitly stated (please specify) L.2.2 Implicit (please specify) L.2.3 Not stated/unclear (please specify) L.2.4 Please specify any important analytic or statistical issues  L.3 Which statistical methods, if any, were used in the analysis? L.3.1 Details  L.4 Did the study address multiplicity by reporting ancillary analyses, including sub-group analyses and adjusted analyses, and do the authors report on whether these were pre-specified or exploratory? L.4.1 Yes (please specify) L.4.2 No (please specify) L.4.3 Not applicable   L.5 Do the authors describe strategies used in the analysis to control for bias from confounding variables? L.5.1 Yes (please specify) L.5.2 No L.5.3 Not applicable  L.6 For evaluation studies that use prospective allocation, please specify the basis on which data analysis was carried out. 'Intention to intervene' means that data were analysed on the basis of the original number of participants, as recruited into the different groups.  'Intervention received' means data were analysed on the basis of the number of participants actually receiving the intervention. L.6.1 Not applicable (not an evaluation study with prospective allocation) L.6.2 'Intention to intervene' L.6.3 'Intervention received' L.6.4 Not stated/unclear (please specify)  L.7 Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? L.7.1 Details  133  e.g. using more than one researcher to analyse data, looking for negative cases. L.8 Do the authors describe any ways that they have addressed the validity or trustworthiness of data analysis? e.g. internal or external consistency, checking results with participants.  Have any statistical assumptions necessary for analysis been met? L.8.1 Details  L.9 If the study uses qualitative methods, how well has diversity of perspective and content been explored? L.9.1 Details  L.10 If the study uses qualitative methods, how well has the detail, depth and complexity (i.e. the richness) of the data been conveyed? L.10.1 Details  L.11 If the study uses qualitative methods, has analysis been conducted such that context is preserved? L.11.1 Details     Section M: Quality of Study - Reporting  M.1 Is the context of the study adequately described? Consider your previous answers to these questions (see Section B):  why was this study done at this point in time, in those contexts and with those people or institutions? (B3)  Was the study informed by, or linked to an existing body of empirical and/or theoretical research? (B4)  Which groups were consulted in working out the aims to be addressed in this study? (B5) M.1.1 Yes (please specify) M.1.2 No (please specify)  134   Do the authors report how the study was funded? (B6)  When was the study carried out? (B7) M.2 Are the aims of the study clearly reported? Consider your previous answers to these questions (See module B):  What are the broad aims of the study? (B1)  What are the study research questions and/or hypothesis? (B8) M.2.1 Yes (please specify) M.2.2 No (please specify)  M.3 Is there an adequate description of the sample used in the study and how the sample was identified and recruited? Consider your answer to all questions in sections D (Actual Sample), I (Sampling Strategy) and J (Recruitment and Consent). M.3.1 Yes (please specify) M.3.2 No (please specify)  M.4 Is there an adequate description of the methods used in the study to collect data? Consider your answers to the following questions (See Section K)  What methods were used to collect the data? (K3)  Details of data collection instruments and tools (K4)   Who collected the data? (K5)  Where were the data collected? (K9) M.4.1 Yes (please specify) M.4.2 No (please specify)  M.5 Is there an adequate description of the methods of data analysis? Consider your answers to previous questions (see module L)   M.5.1 Yes (please specify) M.5.2 No (please specify)  135  Which methods were used to analysis the data? (L2)  What statistical method, if any, were used in the analysis? (L3)  Did the study address multiplicity by reporting ancillary analyses (including sub-group analyses and adjusted analyses), and do the authors report on whether these were pre-specified or exploratory? (L4)  Do the authors describe strategies used in the analysis to control for bias from confounding variables? (L5) M.6 Is the study replicable from this report? M.6.1 Yes (please specify) M.6.2 No (please specify)  M.7 Do the authors state where the full, original data are stored?  M.7.1 Yes (please specify) M.7.2 No (please specify)  M.8 Do the authors avoid selective reporting bias? (e.g. do they report on all variables they aimed to study, as specified in their aims/research questions?) M.8.1 Yes (please specify) M.8.2 No (please specify)     Section N: Quality of the Study - Weight of Evidence  N.1 Are there ethical concerns about the way the study was done? Consider consent, funding, privacy, etc. N.1.1 Yes, some concerns (please specify) N.1.2 No (please specify)  N.2 Were students and/or parents appropriately involved in the design or conduct of the study? Consider your answer to the appropriate question in module B.1 N.2.1 Yes, a lot (please specify) N.2.2 Yes, a little (please specify) N.2.3 No (please specify)  N.3 Is there sufficient justification for why the study was done the way it was? N.3.1 Yes (please specify) N.3.2 No (please specify)  136  Consider answers to questions B1, B2, B3, B4 N.4 Was the choice of research design appropriate for addressing the research question(s) posed? N.4.1 yes, completely (please specify) N.4.2 No (please specify)  N.5 Have sufficient attempts been made to establish the repeatability or reliability of data collection methods or tools? Consider your answers to previous questions:   Do the authors describe any ways they have addressed the reliability or repeatability of their data collection tools and methods (K7) N.5.1 Yes, good (please specify) N.5.2 Yes, some attempt (please specify) N.5.3 No, none (please specify)  N.6 Have sufficient attempts been made to establish the validity or trustworthiness of data collection tools and methods?  Consider your answers to previous questions:  Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/ methods (K6) N.6.1 Yes, good (please specify) N.6.2 Yes, some attempt (please specify) N.6.3 No, none (please specify)  N.7 Have sufficient attempts been made to establish the repeatability or reliability of data analysis? Consider your answer to the previous question:  Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? (L7) N.7.1 Yes (please specify) N.7.2 No (please specify)  N.8 Have sufficient attempts been made to establish the validity or trustworthiness of data analysis? Consider your answer to the previous question:  Do the authors describe any ways they have addressed the validity or trustworthiness of data analysis? (L8, L9, L10, L11) N.8.1 Yes, good (please specify) N.8.2 Yes, some attempt (please specify) N.8.3 No, none (please specify)  N.9 To what extent are the research design and N.9.1 A lot (please specify) 137  methods employed able to rule out any other sources of error/bias which would lead to alternative explanations for the findings of the study? e.g. (1) In an evaluation, was the process by which participants were allocated to, or otherwise received the factor being evaluated, concealed and not predictable in advance? If not, were sufficient substitute procedures employed with adequate rigour to rule out any alternative explanations of the findings which arise as a result?  e.g. (2) Was the attrition rate low and, if applicable, similar between different groups? N.9.2 A little (please specify) N.9.3 Not at all (please specify)  N.10 How generalisable are the study results? N.10.1 Details  N.11 In light of the above, do the reviewers differ from the authors over the findings or conclusions of the study? Please state what any difference is. N.11.1 Not applicable (no difference in conclusions) N.11.2 Yes (please specify)  N.12 Have sufficient attempts been made to justify the conclusions drawn from the findings, so that the conclusions are trustworthy? N.12.1 Not applicable (results and conclusions inseparable) N.12.2 High trustworthiness N.12.3 Medium trustworthiness N.12.4 Low trustworthiness  N.13 Weight of evidence A: Taking account of all quality assessment issues, can the study findings be trusted in answering the study question(s)? In some studies it is difficult to distinguish between the findings of the study and the conclusions. In those cases, please code the trustworthiness of these combined results/conclusions. N.13.1 High trustworthiness N.13.2 Medium trustworthiness N.13.3 Low trustworthiness  N.14 Weight of evidence B: Appropriateness of research design and analysis for addressing the N.14.1 High 138  question, or sub-questions, of this specific systematic review. N.14.2 Medium N.14.3 Low  N.15 Weight of evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample and measures) for addressing the question, or sub-questions, of this specific systematic review N.15.1 High N.15.2 Medium  N.15.3 Low  N.16 Weight of evidence D: Overall weight of evidence  Taking into account quality of execution, appropriateness of design and relevance of focus, what is the overall weight of evidence this study provides to answer the question of this specific systematic review? N.16.1 High N.16.2 Medium N.16.3 Low     Section O: This section provides a record of the review of the study  O.1 Sections completed Please indicate sections completed. O.1.1 Section A: Administrative details O.1.2 Section B: Study aims and rationale O.1.3 Section C: Study policy or practice focus O.1.4 Section D: Actual sample O.1.5 Section E: Programme or intervention description O.1.6 Section F: Results and conclusions O.1.7 Section G: Methods - study method O.1.8 Section H: Methods - groups O.1.9 Section I: Methods - sampling strategy O.1.10 Section J: Methods recruitment and consent O.1.11 Section K: Methods - data collection O.1.12 Section L: Methods - data analysis O.1.13 Section M: Quality of study - reporting 139  O.1.14 Section N: WoE A: Quality of the study - methods and data O.1.15 Section N: WoE B: Appropriateness of research design for review question O.1.16 Section N: WoE C: Relevance of particular focus of the study to review question O.1.17 Section N: WoE D: Overall weight of evidence this study provides to answer this review question? O.1.18 Reviewing record  O.2 Please use this space here to give any general feedback about these data extraction guidelines O.2.1 Details  O.3 Please use this space to give any feedback on how these guidelines apply to your Review Group's field of interest O.3.1 Details     Source: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit. Retrieved March 26, 2015 from http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-ssessment/how-to-do-a-rea  

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