Evaluation of Outcomes
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Abdullahetal.2014MeasuringtheEffectivenessofMentoringasaKnowledgeTranslationInterventionforImplementingEmpiricalEvidence.pdf
Original Article
Measuring the Effectiveness of Mentoring as a Knowledge Translation Intervention for Implementing Empirical Evidence: A Systematic Review Ghadah Abdullah, RN, MSc • Dianne Rossy, RN, MScN, GNC(C) • Jenny Ploeg, RN, PhD • Barbara Davies, RN, PhD • Kathryn Higuchi, RN, PhD • Lindsey Sikora, BSc, MISt • Dawn Stacey, RN, PhD
Keywords
evidence-based practice,
mentorship, outcome evaluation,
professional issues/professional ethics/professional
standards, advanced
practice/advanced nursing practice,
meta-analysis
ABSTRACT Background: Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice.
Aim: To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals’ use of evidence in clinical practice.
Methods: A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of health- care professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee’s needs; and (c) involved in an interpersonal relationship as indicated by mu- tual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively.
Results: Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners’ knowledge (four of five studies), beliefs (four of six studies), and impact on organizational out- comes (three of four studies). There were mixed findings for changes in professionals’ behaviors and impact on practitioners’ and patients’ outcomes: some outcomes improved, while others showed no difference.
Linking Evidence to Action: Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.
INTRODUCTION Knowledge translation (KT) interventions are designed to sup- port the uptake of best available evidence, including clinical guidelines into practice (Straus, Tetroe, & Graham, 2013). One category of KT intervention relies on social influence, which occurs when an individual uses interpersonal interactions to influence other individuals’ or groups’ thoughts, feelings, atti- tudes, or behaviors (Eccles & Foy, 2009; Zimbardo & Leippe, 1991). Mentoring as a KT intervention uses social influence and has the potential to increase the uptake of evidence-based practice (EBP; Gattellari et al., 2005). However, few studies have included mentoring as an intervention to support the up-
take of nursing practice guidelines (Davies, Edwards, Ploeg, & Virani 2008; Gifford, Davies, Ploeg, Eldred, & Bajnok, 2013). The purpose of this paper is to examine the effects of men- toring as a KT intervention aimed at supporting the uptake of empirical evidence into clinical practice. This review offers a unique contribution to research on mentoring within the con- text of KT by identifying essential characteristics of mentoring interventions and providing an understanding of the effects of mentoring on practitioners, patients, and organizations.
Our definition of mentoring relied upon three essen- tial characteristics of mentoring that were consistently iden- tified in business and health care (Haggard, Dougherty,
284 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
Original Article Turban, & Wilbanks, 2011; Ploeg, de Witt, Hutchison, Hay- ward, & Grayson, 2008; Sambunjak, Straus, & Marusic, 2006, 2010). These characteristics were (a) mentors are more expe- rienced than mentees as related to a specific task; (b) mentors provide individualized support based on mentees’ learning needs; and (c) mentoring involves an interpersonal relation- ship as generally indicated by mutual benefit, engagement, and commitment.
Mentoring is similar to and often confused with other social influence KT interventions, such as champions, local opinion leaders, facilitation, and educational outreach visitors. According to the diffusion of innovation theory, the ways spe- cific individuals (i.e., champions, opinion leaders) interact and discuss ideas with others influence learning and adoption of change (Rogers, 2003). Educational outreach visitors as- sist healthcare professionals by providing feedback, identify- ing barriers to change, and developing tailored interventions to address these barriers (O’Brien et al., 2007). Local opinion leaders support organizational communication structures and advocate for organizational norms; they also informally influ- ence peers’ attitudes and behaviors (Flodgren et al., 2011). Fa- cilitation enables implementation processes, leading to tailored interventions, problem-solving, and team building (Dogherty, Harrison, & Graham, 2010). Mentoring focuses on mentees’ needs rather than on organizational or study program needs. Alternatively, champions are expected to support change pro- cesses by persuading and negotiating with people to adopt new innovations (Rogers, 2003). Champions may also spread in- formation about clinical guidelines via education and help to implement clinical practice guideline strategies based on orga- nizational contexts (Ploeg et al., 2010). Unlike other social in- fluence KT interventions, mentoring specifically requires men- tors to be more experienced than mentees at the specific task.
Several social influence KT interventions have been evalu- ated to determine effects on the uptake of evidence. Champions have had mixed influence on the uptake of evidence. For exam- ple, champions increased sepsis screening in ICU from 23% to 74%, but did not influence the percentage of patients treated for sepsis (Campbell, 2008). In another study, champions did not change childbirth outcomes, such as episiotomy rates (Hodnett et al., 1996). Educational outreach visitors and local opinion leaders have increased the implementation of research evidence by 6.0% and 12.0%, respectively (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012). Evidence drawn from primary healthcare settings showed facilitation moderately affected the uptake of clinical guidelines (effect size = .56, 95% CI = .43– .68; Baskerville, Liddy, & Hogg, 2012). Little is known about how expertise, individualized support, and interpersonal rela- tionships underpin mentoring as a KT intervention to support the uptake of evidence into clinical practice.
OBJECTIVES The aim of this systematic review is to determine the effective- ness of mentoring as a KT intervention designed to increase
the use of empirical evidence by healthcare professionals in clinical practice. Research questions were: (a) What are the characteristics of mentoring as a KT intervention? (b) Does a mentoring intervention alone increase the uptake of evidence compared to no intervention or compared to other interven- tion(s) without mentoring? and (c) Does mentoring as part of a multifaceted intervention increase the uptake of evidence com- pared to no intervention or compared to other intervention(s) without mentoring?
METHODS A systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011), and reported using the PRISMA Statement (Liberati et al., 2009). The review protocol was developed a priori.
The search strategy was designed using keywords related to PICO (population, intervention, comparator, and outcomes) with inclusion and exclusion criteria (see Table 1). Eligible in- tervention studies used mentoring as a KT intervention and met the definition of mentoring.
We searched electronic databases for articles published be- tween January 1988 and December 2012. The search was limited to 1988 due to a shift toward increased use of em- pirical evidence in 1989 (French, 2002). Electronic databases searched were the Cochrane and DARE (Database of Abstracts of Reviews of Effectiveness), Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, PsycINFO, EMBASE, AHMD, ProQuest-Dissertation and Thesis Database, and Tri- als Register. A specific search strategy was developed with the librarian (LS) based on PICO for MEDLINE (see Figure S1, available with online version of this article) and adapted for other databases. Online grey literature was searched for unpub- lished studies and technical reports by organizations known to implement EBP. Journals and relevant conferences that exam- ine the effectiveness of interventions and strategies related to EBP were also searched as was a reference list of included studies and relevant review articles (see Figure S1, online).
The citations identified by the search strategy were entered into a web-based tool designed to facilitate blind screening by two independent reviewers (GA, DR). The screening process involved three phases. First, titles were screened and judged as “include,” “exclude,” or “unsure.” When at least one re- viewer rated a citation as “include” or “unsure,” it remained included. Second, abstracts were screened using the same pro- cess. Third, full-texts of citations were screened. There were no disagreements between reviewers. Authors for eight studies were contacted for additional information about the interven- tion to determine eligibility.
A standardized form was developed based on the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) data collection tool (2008). The form was pilot-tested on four randomly selected included studies and then refined accordingly. Two of four authors used the form to extract
Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. 285 C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Mentoring as a Knowledge Translation Intervention
Table 1. Study Inclusion Criteria
Criteria Included Excluded
Population Healthcareprofessionals responsible for patient care
Undergraduatemedical or nonmedical students
Intervention Mentoring to enhanceuseof evidence in clinical practice definedas:
•Focusing onorganizational or programneeds
(a)Mentormore experienced than mentee (as related to the specific task);
•Not describing or requiring a mutually beneficial relationship
(b) Individualized support basedon mentee’s needs;
(c) Interpersonal relationship as generally indicatedbymutual benefit, engagement and commitment.
Comparator Intervention group comparedwith control groupor other intervention
N/A
Outcomes Includeoneof the following: •Publishing a researchpaper
•Conceptual knowledgeuse •Obtaining grants for research
• Instrumental knowledgeuse •Attending Journal Club
•Enablers of instrumental use
• Impact (onpatients, or organizations or healthcare professionals)
Designs (a)Randomized controlled trials (RCT)
•Qualitative studies, descriptive studies
(b)Controlled clinical trials (CCT)
(c)Controlledbefore andafter studies (CBA)
(d) Interrupted time series (ITS)
(e) Pre/post test studies
Language English
data independently based on the characteristics of the studies, mentoring interventions, outcome measures, factors influenc- ing use of mentoring, and methodological quality of studies. The Cochrane Collaboration’s Tool for Assessing Risk of Bias was used to check the quality of randomized controlled trials (Higgins & Green, 2011). The quasi-experimental studies were appraised using the Critical Appraisal Skills Program (CASP) tool (Public Health Resource Unit, 2006). Disagreements were resolved by consensus.
Due to heterogeneity across study outcomes, data were an- alyzed descriptively. Study comparisons were grouped to an- swer the research questions. Findings were synthesized based
on the outcomes of knowledge use and impact (Graham, Bick, Tetroe, Straus, & Harrison, 2010). Knowledge use included (a) conceptual knowledge use (i.e., practitioner’s knowledge, understanding, attitudes/beliefs); (b) instrumental knowledge use (i.e., practitioner’s behavior or practice); and (c) enablers of instrumental use (i.e., organizational endorsement). Impact included impact on (a) the patient, (b) the practitioner, and (c) the organization.
RESULTS Of 10,669 citations, 62 were potentially eligible and 10 were confirmed eligible (see Figure 2). The 52 excluded were
286 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article
Id en
ti fi
ca ti
on Sc
re en
in g
E lig
ib ili
ty
1,889 Excluded: duplicate reports
8,746 Records excluded
62 Full test records screened
10,669 Reports identified through database searching
3,286 Embase 2,732 Medline 1,556 CINAHL
557 PsycINFO 427 Proguest D and T 116 Cochrane and DARE 77 AMED 22 Trial Register
7 Cochrane Central
8,780 Records screened
34 Records screened from database
10 Included studies
52 Records excluded: 21 non-intervention designs 17 interventions not meeting mentoring characteristics 6 interventions not examining social influence roles 6 interventions not supporting the uptake of evidence in clinical practice 2 ineligible populations
28 Records screened: ●27 from hand
searching ●1 from an
expert
In cl
ud ed
Figure 2. Flow diagram of study selection process.
nonintervention designs (n = 21), ineligible populations (n = 2), or interventions that were not examining social in- fluence roles (n = 6), not meeting mentoring characteristics (n = 17), or not supporting the uptake of evidence in clinical practice (n = 6; see Table S2, online).
Characteristics of the Studies The 10 included studies were conducted in three countries (USA, Canada, Australia) and published between 1991 and 2012 (see Table 3). Six studies were cluster-randomized con- trolled trials (RCTs), one a controlled clinical trial (CCT), one a controlled before and after study (CBA), and two were pre- and post test studies. Of six RCT studies, four randomized clusters by hospitals, one by physicians, and one by nurses. The cluster effect was not taken into account in the analysis of one RCT (Lomas et al. 1991). Seven studies evaluated the uptake of clinical practice guidelines, and three evaluated the uptake of nonguideline-based research evidence. The studies were conducted in tertiary care, community hospital, home care, or primary care. The median number of participants per study was 108.5 (range of 15 to 2,409). Seven were nursing studies and four were medical studies.
Of six RCTs, five were rated as low risk of bias and one as moderate risk of bias (see Table 3). For the CCT study, risk of bias was rated as unclear because there was insufficient report-
ing to judge risk of bias. The CBA study was rated as moderate because 70% of CASP criteria were met, while the two pre-and post test studies were rated as higher quality because 80% of CASP criteria were met (Murray et al., 2009).
Characteristics of Mentoring Interventions Of the 10 studies, five used the term “mentoring,” four “opinion leaders,” and one “academic detailing” (see Table 3). Charac- teristics of mentoring interventions varied across studies based on (a) mode of delivery, (b) frequency and length of mentoring intervention, and (c) type of mentor selection process. Mentor- ing interventions were delivered via a single approach (individ- ual or group meetings), or via mixed approach (combination of individual or group meetings, or e-mail; see Table 4). The men- toring interventions varied from 3 to 12 sessions (Median = 7.5) with each session approximately 2 hours and scheduled over 14 to 360 days (Median = 90). Some mentors were physicians nominated by their peers (Berner et al., 2003; Lomas et al., 1991; Soumerai et al., 1998). Other mentors were nurses or other healthcare professionals selected to support nurses (John- ston et al., 2007; Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Mariano et al., 2009; Masny, Ropka, Peterson, Fetzer, & Daly, 2008; Wallen et al., 2010). Only Johnston and colleagues (2007) discussed the mentor selection process, in- dicating key leaders were selected as mentors.
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Mentoring as a Knowledge Translation Intervention
Table 3. Characteristics of Included Studies (N = 10)
First author, year (country)
Design and setting
Evidence being implemented
Participants(# in intervention + comparison)
Mentoring intervention title
Study risk of bias*
Berner, 2003 (USA) ClusteredRCT in tertiary care
Unstable angina guideline
1076 (NR+NR) physicians
Opinion leaders by trained physicians
1.Unclear 2.Low
3.NA 4.Low
5.Low 6.Low
7.Low
Gattellari, 2005 (Australia)
ClusteredRCT inprimary care
Lower urinary tract symptoms guideline
277 (136 + 141) physicians
Academic detailing by physicians
1.Low 2.Low
3.NA 4.Low
5.Low 6.Unclear
7.Low
Johnston, 2007 (Canada)
ClusteredRCT in tertiary care
Pain management guideline
141 (NR + NR) nurses
Opinion leaders by trainednurses andother practitioners
1.Low 2.High
3.NA 4.Low
5.High 6.Unclear
7.Low
Levin, 2011 (USA) ClusteredRCT in homecare
Evidence- based practice
46 (22+24) nurses
Mentor by a nurse
1.Low 2.Low
3.NA 4.Low
5.Low 6.Unclear
7.Low
Lomas, 1991 (Canada) ClusteredRCT in community hospitals
Vaginal birth after cesarean section guideline
76 (38 + 38) physicians
Opinion leaders by trained physicians
1.Unclear 2.Unclear
3.NA 4.Low
5.Low 6.Low
7.Low
Soumerai, 1998; Borbas, 2000 (USA)
ClusteredRCT in community hospitals
Acute myocardial infarction guideline
2409 (Median = 43,Median = 36) physicians
Opinion leaders by physicians
1.Unclear 2.Unclear
3.NA 4.Low
(Continued)
288 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article Table 3. Continued
First author, year (country)
Design and setting
Evidence being implemented
Participants(# in intervention + comparison)
Mentoring intervention title
Study risk of bias*
5.Low 6.Low
7.Low
Masny, 2008 (USA) CCT inprimary carebut outcomespre &post only
High risk cancer guideline
41 (20 + 21) nurses
Mentor by genetic counselor
1.Unclear 2.High
3.NA 4.Unclear
5.Unclear 6.Unclear
7.Unclear
Wallen, 2010 (USA) CBA in tertiary care
Evidence- based practice
159 (94 + 65) nurse leaders
Mentor by nurses
7/10met; 2/10notmet
1/10not applicable
Mariano, 2009 (USA) Pre/post test study in tertiary care
Evidence- based communica- tion strategies with families
20 (NA + NA) nurses
Mentor by trainednurses
8/10met; 1/10notmet
1/10not applicable
Morgan, 2012 (USA) Pre/post test study in community hospital
Pressure ulcer guideline
15 (NA+NA) nurses
Mentor by expert
8/10met; 1/10notmet
1/10not applicable
Note. *StudyRiskofBiasQualityAssessmentLegend. ForEPOC: 1. allocationconcealment; 2. follow-up,professionals; 3. follow-up,patients; 4. blindedassessment; 5. baselinemeasurement; 6. reliable primary outcomemeasure(s); 7. protection against contamination. For CASP tool: 1. clear statement of aims; 2.methodology appropriate; 3. research design appropriate to address research aims; 4. recruitment strategy appropriate; 5. data collected appropriately; 6. relationship between researcher and participants considered; 7. ethical issues considered; 8. data analysis sufficiently rigorous; 9. clear statement of findings; 10. valuable research. NR = not reported;NA = not applicable.
Characteristics of Instruments Twelve instruments measured knowledge use and impact (see Table 5). Of 12 instruments, 6 reported reliability and validity, 1 reported reliability only, and 5 had no psychometric proper- ties reported. Only two instruments were used in more than one study, and they were based on the Transtheoretical Model of Health Behaviour Change and the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model (i.e., EBP Implementation and the EBP beliefs scales; Melnyk, Fineout-Overholt, & Mays, 2008). One reliable and valid in-
strument was used to assess barriers and enablers influencing mentoring.
Multifaceted intervention With mentoring Versus Without mentoring (n = 1).
Instrumental knowledge use. Compared to a multifaceted intervention without mentoring (i.e., educational meetings combined with educational materials, and audit and feed- back), physicians who received mentoring as part of the same kind of multifaceted intervention improved use of antiplatelet
Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. 289 C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Mentoring as a Knowledge Translation Intervention
Table 4. Characteristics of Interventions (N = 10 studies)
First author, year Groups Intervention description
Delivery approach Intervention frequencyand length
Berner, 2003 Intervention group 1
Mentoring Group NR
Coordinator or administrative educational meetings (e.g., reviewof guideline, study design, implementation strategies)
Once NR
Coordinator or administrative educational materials
NR NR
Audit and feedback
NR 2audits + 1 feedback
group2 Coordinator or administrative educational meetings (e.g., reviewof guideline)
Once NR
Coordinator or administrative educational materials
NR NR
Audit and feedback
NR 2audits + 1 feedback
Control None
Gattellari, 2005 Intervention Peer coaching sessionsby mentors
In person via telephone
3 sessions over 2months
Patients’ educational materials
Written + in person discussionwith patients
One session
Practitioners’ educational materials (e.g., guidelines, the GreatDebate)
Audiotape/video/written 3 timesover 3 months
Audit and feedback
In person Pre&post audit, each audit over 6 weeks + 3 feedbacks over 2months.
(Continued)
290 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article Table 4. Continued
First author, year Groups Descriptionof intervention
Delivery approach
Frequency and lengthof intervention
Control Practitioners’ educational materials (i.e., guidelines)
Written Once
Johnston, 2007 Intervention One-on-one coaching sessionsby mentors
In person 10 sessions per participant. Most coaching 14–25days.
Audit and feedback
In person 10audit and feedbacks during intervention + 2audits, once at 2weeksand onceat 6 months after intervention completion.
Practitioners’ educational materials
Written+ verbal
Asneeded
Control Audit and feedback
NR At least 4 audits per nurse, per monthduring intervention + 2audits, once at 2weeksand onceat 6 months after intervention completion.
Levin, 2011 Intervention Mentoring In person + e-mail
12 sessions. 2 hour sessions, weekly over 12 weeks.
Practitioners’ educational meetings (i.e., EBP)
Group 4 sessions. 1 hour sessions, weekly over 4 weeks.
Practitioners’ educational materials
Written NR
Massmedia (i.e., poster)
Written NR
(Continued)
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Mentoring as a Knowledge Translation Intervention
Table 4. Continued
First author, year Groups Descriptionof intervention
Delivery approach
Frequency and lengthof intervention
Levin, 2011 Control Practitioners’ educational meetings (i.e., physical assessment)
Group 4 sessions. 1 hour sessions, weekly over 4 weeks.
Lomas, 1991 Intervention group 1
Mentoring Groupand in person
Approximately 12 sessions over 12 months.
Practitioners’ educational materials (e.g., guideline, information sheets)
Written Twice over 5 months
Practitioners’ educational meetings
Group One session
Group2 Local consensus process on the criteria of conducting caesarean section
Group NR
Audit and feedback
Group + mailed
1 audit + 3–4 feedbacks.
Control Practitioners’ educational materials (i.e., guideline)
Written Once
Morgan, 2012 Post Mentoring Group 5 sessions. Approximately 2hours per session, over 6 weeks.
Practitioners’ educational materials
Written 5 times
Wound champion taught revised medical form
NR NR
Pre None
(Continued)
292 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article Table 4. Continued
First author, year Groups Descriptionof intervention
Delivery approach
Frequency and lengthof intervention
Mariano, 2009 Post Mentoring In person 5months
Massmedia (i.e., posting study updates)
Written 5months
Pre None
Masny, 2008 Intervention Mentoring In personby telephoneor e-mail
3 sessions. One session monthly over 3 months, beginning immediately after pre-course.
Practitioners’ educational meetings
Telephone 3 sessions. One session monthly over 3 months.
Practitioners’ educational materials
E-mail 3months
Control None (waitlist control)
Soumerai, 1998 Intervention Mentoring Group 7months
Practitioners’ educational materials
Group 7months
Establish system change (e.g., revising protocols)
NR 7months
Audit and feedback
Group Twice
Control Audit and feedback
Mailed Twice
Wallen, 2010 Intervention Mentoring In personor group
7months
Practitioners’ educational meeting
Group (in-personand via internet forum)
2days
Control None
Note.NR= not reported.
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Mentoring as a Knowledge Translation Intervention
medication within 24 hours of admission (M = 20.2% vs. M = –3.9%, p = .02; Berner et al., 2003). There was no difference in heparin use, ECG within 20 minutes of arriving in emergency, beta-blockers during hospitalization, and antiplatelet medica- tions at discharge.
Multifaceted intervention With mentoring compared to sin- gle intervention Without mentoring (n = 5). Conceptual knowledge use. Compared to educational mate- rials alone, physicians exposed to mentoring as part of a multi- faceted intervention reported improved knowledge of prostate cancer screening (M = 6.1/7, 95% CI = 5.9 – 6.3 vs. M = 4.8/7, 95% CI = 4.6 – 5.0, p < .001), and changes in their beliefs re- garding medico-legal risk concerning prostate-specific antigen (PSA) screening (odds ratio = .31, 95% CI = .19–.51, p < .001; Gattellari et al., 2005). In another study, there was improve- ment in physicians’ knowledge of vaginal birth after cesarean section (M = 6.3% vs. M = 46.2%), and more care provided in agreement with the guideline recommendations (M = 54.4% vs. M = 39.7%; Lomas et al., 1991).
Compared to educational meetings, nurses who received mentoring as part of a multifaceted intervention had increased beliefs in EBP (F1, 15 = 3 3.105, p < .001) and had sustained beliefs at 9 months post intervention (F1, 15 = 7.335, p = .016; Levin et al., 2011). No differences were reported in nurses’ knowledge. Compared to audit and feedback, mentoring as part of a multifaceted intervention improved nurses’ knowledge of pain management (p < .0001; Johnston et al., 2007).
Instrumental knowledge use. Compared to educational ma- terials alone, physicians exposed to mentoring as part of a mul- tifaceted intervention reported improvement in their skills for supporting patients’ informed decision-making (M = 45.7/55, 95% CI = 44.2–47.2 vs. M = 37.2/55, 95% CI = 35.5–38.8, p < .001), and increases in their provision of written and ver- bal information to men before making decisions about PSA (M = 28.4/35, 95% CI = 27.8–29.0 vs. M = 23.9/35, 95% CI = 23.1–24.7, p < .001; Gattellari et al., 2005). Physicians ordered fewer PSA tests (risk ratio = .52, 95% CI = .38–.75, p < .0004), but not because they were significantly influenced by their perceptions of medico-legal concerns (Gattellari et al., 2005). Physicians who received mentoring as part of a multi- faceted intervention increased participation in a trial of labor rate (M = 38.2%, 95% CI = 30.6–45.7 vs. M = 28.3%, 95% CI = 23.0–33.7, p < .007), showed changes in practice in de- livering women after cesarean section (M = 30.9% vs. M = 23.1%), and more often offered a vaginal birth trial (M = 74.2%, 95% CI = 63.1–85.2 vs. M = 51.3%, 95% CI = 43.5–59.2, p < .002; Lomas et al., 1991).
Compared to educational meetings, nurses who received mentoring as part of a multifaceted intervention improved implementation of EBP (F1,15 = 10.39, p = .006) and sus- tained implementation at 9 months post-intervention (F2,30 = 5.85, p = .007; Levin et al., 2011). Compared to au- dit and feedback, mentoring as part of a multifaceted intervention increased physicians’ prescriptions of aspirin
(Median = +.13 vs. –.03, p = .04) and beta-blocker medica- tions (Median = +.31 vs. +.18, p = .02) for patients with acute myocardial infarction (Soumerai et al., 1998), and improved uptake of pain management guidelines as evidenced by en- hanced nurses’ pain assessment documentation (15% to 58%, p < .0001 vs. 24% to 9%, p < .001; Johnston et al., 2007). There was no difference in the use of thrombolysis and lido- caine medications (Soumerai et al., 1998) or in the administra- tion of analgesia and nonpharmacological measures (Johnston et al., 2007).
Impact on patients. Compared to educational materials only, physicians exposed to mentoring as part of a multifaceted inter- vention showed improvement in infant patients’ Apgar scores at 5 min (M = .9%, 95% CI = .0–.6 vs. M = 1.2%, 95% CI = .0–2.4, p < .0001), and higher rates of vaginal births for patients (M = 25.3%, 95% CI = 19.3–31.2 vs. M = 14.5%, 95% = 10.3–18.7, p = .003; Lomas et al., 1991). This study also reported no statistically significant difference in infant Apgar scores at 1 min, rates of unscheduled cesarean sections, and in maternal and infant deaths.
Impact on practitioners. Compared to educational materi- als only, physicians exposed to mentoring as part of a mul- tifaceted intervention improved preference to share decision- making with patients about PSA screening (odds ratio = .11, 95% CI = .04–.31, p < .001; Gattellari et al., 2005). There was also a decrease in physicians’ decisional conflict regarding PSA screening decisions (M = 25.4/45, 95% CI = 24.5–26.3 vs. M = 27.8/45, 95% CI = 26.6–29.0, p < .0002; Gattellari et al., 2005).
Compared to educational meetings, nurses who received mentoring as part of a multifaceted intervention showed no dif- ference in group cohesion, job satisfaction, and nurses’ work- load (i.e., time and effort) post intervention or at 9 months (Levin et al., 2011).
Impact on organization. Compared to educational materials only, patients of physicians exposed to mentoring as part of a multifaceted intervention had shorter hospital stays (M = 46.6% days vs. M = 32.2%, p < .0001; Lomas et al., 1991). Compared to educational meetings, nurses who received men- toring as part of a multifaceted intervention had a 50% lower attrition or turnover rate, while the control group continued to have a 35% attrition or turnover rate (Levin et al., 2011).
Multifaceted Intervention With Mentoring Compared to No Intervention (n = 5 studies). Conceptual knowledge use. Compared to no intervention, nurses exposed to mentoring as part of a multifaceted inter- vention had increased beliefs in EBP (M = 57.2%–62.6% vs. 58.0%–58.2%, p = .025; Wallen et al., 2010) or no difference (Mariano et al., 2009). Nurses also had improved perceptions of organizational culture and readiness for EBP (M = 77.2%– 89.5% vs. M = 80.9%–82.9%, p = .025; Wallen et al., 2010). Instrumental knowledge use. Compared to no intervention, physicians exposed to mentoring as part of a multifaceted
294 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article Table 5. Characteristics of Instruments (N = 13 Instruments)
Outcomes measure
Instruments Reliability Validity
Knowledge PediatricNurses’ Knowledgeand AttitudesSurvey RegardingPain [J]
Cronbach’s alpha = .72 and .79 [J]
�
Aknowledgeand attitude survey [S]
NR NR
Obstetricians’ survey [Lo]
NR NR
OrganizationalCulture andReadiness for System-Wide Implementation of EBP (OCRSIEP) scale [W]
Cronbach’s alpha = .93 to .94 [W]
NR
Belief/attitude EBPBeliefs Scale*
[Le,Ma,W] • Internal consistency = >.85 [Le]
�
•Cronbach’s alpha = .90 to .92 [W]
Aknowledgeand attitude survey [S]
NR NR
Obstetricians’ survey [Lo]
NR NR
Useof evidence
ThePainManagement ExperienceEvaluation [J]
NR NR
EBP Implementation Scale [Le,Ma,W]
• Internal consistency = >.85 [Le]
�
•Cronbach’s alpha = .90 to .92 [W]
Obstetricians’ survey [Lo]
NR NR
Practitioner outcomes
GroupcohesionScale [Le,W]
• Internal consistency = .73–.83 [Le]
�
•Cronbach’s alpha = .81–.89 [W]
Job satisfaction questionnaire [W]
Cronbach’s alpha = .84-–.88 [W]
�
Index ofWork Satisfaction [Le]
Cronbach’s alpha = .80-–.90 [Le]
�
TheProviderDecision ProcessAssessment Instrument [G]
NR NR
Intention to Leave Scale [W]
NR NR
(Continued)
Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. 295 C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Mentoring as a Knowledge Translation Intervention
Table 5. Continued
Outcomes measure
Instruments Reliability Validity
Barriers and enablers
Barriers toResearch UtilizationScale [Mo]
Cronbach’s alpha = .89 [Mo]
�
Aknowledgeand attitude survey [S]
NR NR
Note. *Based on The Transtheoretical Model of Health Behaviour Change, and the Advancing Research and Clinical Practice Through Close Collaboration Model (Melnyk et al., 2008). G = Gattellari, 2005; J = Johnston, 2007; Le = Levin, 2011; Lo = Lomas, 1991; Ma = Mariano, 2009; Mo = Morgan, 2012; S = Soumerai, 1998;W = Wallen, 2010.NR = not reported. � = done.
intervention showed improved use of antiplatelet medication within 24 hours of admission (M = 15.8% vs. M = –.4%, p = .01; Berner et al., 2003). The number of nurses who sought clinical support from mentors increased from 17 to 26 nurses at 3 months, and 33 at 6 months (Masny et al., 2008). There were no differences in the use of ECG within 20 min of arriving in emergency, beta-blockers during hospitalization, heparin use, and antiplatelet medications at discharge (Berner et al., 2003). Two studies reported no difference between groups of nurses’ uptake of nonguideline-based research evidence into clinical practice (Mariano et al., 2009; Wallen et al., 2010).
Impact on practitioners. Compared to no intervention, nurses exposed to mentoring as part of a multifaceted inter- vention had increased self-efficacy for cancer risk counseling skills over time (p < .001; Masny et al., 2008). The other mul- tifaceted study that included mentoring found no difference in nurses’ job satisfaction, group cohesion, or intention to leave their positions and profession (Wallen et al., 2010).
Impact on organization. Compared to no intervention, nurses exposed to mentoring as part of a multifaceted inter- vention had no difference in retention (Wallen et al., 2010). Nurses’ participation in mentoring as part of a multifaceted intervention also led to a 5% reduction in the prevalence of hospital acquired pressure ulcers (Morgan, 2012).
Barriers and Enablers Influencing Mentoring Of 10 studies, four reported barriers and four reported enablers to mentoring (see Table S6, available with online version of this article). The barriers identified were staff resistance and shortage, staff lack of time, lack of knowledge and skills related to guideline recommendations, and inadequate guidance from mentors. The enablers identified were leadership support, staff involvement, and available mentors.
DISCUSSION This systematic review is the first known synthesis of studies that measure the effectiveness of mentoring as a KT interven- tion. Ten studies of varying methodological quality evaluated
the effectiveness of mentoring as part of multifaceted inter- ventions. Only one study, with low risk of bias, compared a multifaceted intervention with mentoring to the same kind of intervention without mentoring. This study showed mixed ef- fects for practitioners’ behavior, with one outcome improving and others showing no difference (Berner et al., 2003). The other nine studies with mentoring as part of a multifaceted intervention showed various effects on practitioners, patients, and organizations. Of these nine, the study with consistently positive outcomes and low risk of bias used mentoring in com- bination with practitioners’ and patients’ educational materials, as well as audit and feedback (Gattellari et al., 2005). Overall, interventions with mentoring did not produce worse outcomes than controls or alternate intervention(s). Differences in in- tervention characteristics, such as mentoring length and fre- quency, may have an effect on the mixed findings observed in these studies.
Our findings can be compared and contrasted with other studies evaluating mentoring within health care. Unlike our mixed findings, some studies showed that mentees exposed to mentors consistently increased knowledge, skills, and use of EBP (Melnyk et al., 2004; Sambunjak et al., 2006). Mentor- ing was also consistently useful for enhancing mentees’ per- sonal and professional development (i.e., job satisfaction and productivity), and organizational outcomes (i.e., retention and recruitment; Kashiwagi, Varkey, & Cook, 2013; Melnyk, 2007). However, similar to our findings, other studies found that the use of mentoring in medical practice had mixed impacts on patients’ outcomes (Augestad et al., 2013; Birch, Asiri, & de Gara, 2007).
Mentoring interventions supported the uptake of some clin- ical guideline recommendations in studies with unclear to low risk of bias (Berner et al., 2003; Gattellari et al., 2005; Johnston et al., 2007; Lomas et al., 1991; Masny et al., 2008; Soumerai et al., 1998). However, mentoring interventions were only shown to support the uptake of nonguideline-based research evidence in one of three studies with moderate to high quality (Levin et al., 2011; Mariano et al., 2009; Wallen et al., 2010). Nonguideline-based research evidence was often more general
296 Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Original Article and not necessarily targeted to specific issues, whereas guide- line recommendations were often framed specifically around an issue, which allowed for better implementation or mea- suring of targeted outcomes (Turner, Misso, Harris, & Green, 2008). With so few studies evaluating nonguideline-based re- search evidence, it is difficult to make conclusions.
Outcomes related to conceptual and instrumental knowl- edge use, impact on practitioners, and barriers and enablers influencing mentoring were measured using various instru- ments. No instrument was used to measure mentor–mentee interaction or skills. Overall, thirteen instruments were used, with psychometric properties reported for only seven instru- ments. Furthermore, only three studies used the same in- struments (Levin et al., 2011; Mariano et al., 2009; Wallen et al., 2010). Using consistent instruments can facilitate com- parisons across studies, potentially enhancing understanding of the effectiveness of mentoring (Tian, Atkinson, Portnoy, & Lowitt, 2010).
Our understanding of mentoring within the KT context im- proved with the identification of three further characteristics. First, mentoring involves regular meetings over a period of time. Although studies showed regular meetings enhanced mentees’ outcomes, there was little explanation of how meet- ings were organized (Sambunjak et al., 2010). Second, men- toring can be delivered via different approaches: individual or group meetings or e-mail. One of our included studies found that mentoring through individual meetings via telephone en- hanced all measured outcomes (Gattellari et al., 2005). Men- toring delivered using a combination of individual and group meetings also improved most outcomes (Lomas et al., 1991). Consistent with other research, mentoring delivered using in- dividual meetings enhanced practitioners’ outcomes (Ploeg et al., 2008). Third, mentoring involves a selection process to match mentees and mentors. Physician mentors were se- lected via peers in most medical studies, while nurses’ and healthcare professionals’ mentors were selected via key leaders in one nursing study. The extent to which selection processes affect relationships and the uptake of evidence into practice is difficult to conclude from this review. Similar findings around selection process were reported in studies examining the effect of opinion leaders’ interventions on the uptake of evidence in different healthcare settings (Flodgren et al., 2011; Grimshaw et al., 2006).
Interestingly, few of the studies reported on mentor– mentee relationships. Given that a key element of mentoring intervention is the relational aspect (LaFleur & White, 2010), understanding characteristics of mentor–mentee relationships could improve the uptake of evidence into practice. In addition, few studies reported on mentors’ knowledge and skills regard- ing mentoring strategies and innovations. Research needs to identify effective mentor behaviors and strategies that can be used to meet mentees’ individualized needs.
The act of mentoring was not consistently called mentoring in the included studies. Studies used the terms “mentoring,” “opinion leaders,” and “academic detailing.” All terms met our
definition of mentoring. The lack of a clear and well-defined taxonomy for mentoring and other social influence roles within the context of KT made determining study eligibility more challenging, as mentoring and other concepts were used syn- onymously. Our findings about concept confusion were sim- ilar to findings in literature reviews on facilitation (Dogherty et al., 2010) and on different concepts or roles used to support the uptake of EBP (Thompson, Estabrooks, & Degner, 2006). For example, facilitation was called different terms (e.g., “link nurses,” and “opinion leaders”; Dogherty et al., 2010). A tax- onomy of social influence roles would contribute to conceptual clarity.
Barriers hindering the success of mentor–mentee relation- ships highlighted in this review included staff resistance and shortage, lack of time, lack of knowledge and skills about guide- lines, and inadequate support from mentors. These barriers are consistent with those identified in other studies exploring barri- ers to mentoring within the context of EBP (Gifford et al., 2013; Melnyk et al., 2004; Ploeg et al., 2008). Barriers not identified in this systematic review, but that may be relevant, include lack of incentives for mentors and lack of organizational pro- cesses to support mentees incorporating their knowledge about mentoring in organizations (Ploeg et al., 2008). Our findings about enablers (i.e., leadership support, and staff and mentor involvement) are consistent with others who identified provid- ing educational sessions with experts and supporting mentees to practice learned skills as enablers (Melnyk et al., 2004; Ploeg et al., 2008).
LIMITATIONS Three key limitations of this systematic review and of the in- cluded studies should be considered. First, we conducted a thorough systematic search using broad eligibility criteria, but relevant studies may have been missed due to concept confu- sion. Second, available studies included minimal description of mentoring interventions. Third, we may have missed relevant studies by restricting the search to English articles; however, KT studies were most likely to be conducted in English-speaking countries (Moher, Pham, Lawson, & Klassen, 2003).
IMPLICATIONS AND CONCLUSIONS Few studies have included mentoring as a KT intervention. Those studies that include mentoring have done so as part of a multifaceted KT intervention. This review helps to fill the gap in research by identifying characteristics essential to mentoring as a KT intervention aimed at supporting the uptake of evidence into clinical practice. Mentoring as part of a multifaceted inter- vention had various effects on practitioners, patients, and orga- nizations, although none were negative. Further, one of the ten studies clearly showed that mentoring, not the other elements of the multifaceted intervention, had changed some practition- ers’ behaviors. However, based on the studies reviewed, it is difficult to determine the effect of mentoring specifically on the uptake of evidence into practice.
Worldviews on Evidence-Based Nursing, 2014; 11:5, 284–300. 297 C© 2014 The Authors Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing
Mentoring as a Knowledge Translation Intervention
Our review suggests several implications for further re- search, education, and clinical practice. Research is needed to understand mentoring apart from other interventions. There is a need to identify factors used to address individual mentee needs, and to explore the nature of mentor–mentee relation- ships and their influence on supporting the uptake of evidence. Further, studies need to better report on the mentoring inter- vention and psychometric properties of instruments to facili- tate comparability across studies.
Mentoring has commonly been employed in clinical nurs- ing education and in organizational change efforts (Huybrecht, Loeckx, Quaeyhaegens, De Tobel, & Mistiaen, 2011). In or- ganizational settings, expert clinical educators and advanced practice nurses are positioned to act as mentors. They fre- quently provide tailored interaction with nurses via different approaches to enhance staff’s involvement, knowledge, beliefs, and skills and to decrease their resistance and turnover rate. A better understanding of mentoring could allow experts to cre- ate effective KT interventions aimed at enhancing the uptake of evidence in clinical practice. WVN
LINKING EVIDENCE TO ACTION When planning for mentoring to support the uptake of ev- idence into practice, clinical educators, advanced practice nurses, and others positioned to be mentors should con- sider the following:
� Plan regular meetings with mentees over a period of time.
� Deliver mentoring using the most appropriate ap- proach (e.g., individual and/or group meetings, telephone, e-mail).
� Establish a selection process to match mentees and mentors.
� Mentoring as a KT intervention may be com- bined with other KT interventions (e.g., educa- tional meetings and materials, audit, and feed- back).
� Research is needed to determine the impact of mentoring on professional and patient outcomes, and the influence of the mentor–mentee relation- ship on outcomes.
Author information
Ghadah Abdullah, Doctoral candidate, School of Nursing, Fac- ulty of Health Sciences, University of Ottawa, Nursing Best Practice Research Centre, Ottawa, ON, Canada; Dianne Rossy, Advanced Practice Nurse, Geriatrics, The Ottawa Hospital, Ot- tawa, ON, Canada; Jenny Ploeg, Professor, School of Nursing, Faculty of Health of Sciences, McMaster University and Sci-
entific DirectorAging, Community and Health Research Unit, Hamilton, ON, Canada; Barbara Davies, Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Co-Director, Nursing Best Practice Research Centre, Ottawa, ON, Canada; Kathryn Higuchi, Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Nursing Best Practice Research Centre, Ottawa, ON, Canada; Lindsey Sikora, Health Sciences Research Liaison Librarian, Health Sciences Library, University of Ottawa, Ottawa, ON, Canada; Dawn Stacey, Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Scientist, Ot- tawa Hospital Research Institute, Ottawa, ON, Canada.
Ghadah Abdullah doctoral studies are funded through a scholarship from the King Abdulaziz University Hospital. The funders played no role in study design, collection, analysis, interpretation of data, writing of the report, or in the decision to submit the paper for publication. They accept no responsibility for the contents.
The authors acknowledge Anton Saarimaki, the Ottawa Hospital Research Institute (for developing the web-based screening tools used for the systematic review), Julie Wu, the Ottawa Hospital Research Institute, and Janet Jull, doc- toral candidate at University of Ottawa (for duplicate data extraction).
Address correspondence to Ghadah Abdullah, School of Nursing, Faculty of Health Sciences, University of Ottawa, Nursing Best Practice Research Centre, 451 Smyth Rd, 1118- B, Ottawa, Ontario, Canada, K1H 8M5; [email protected]
Accepted 23 May 2014 Copyright C© 2014, Sigma Theta Tau International
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doi 10.1111/wvn.12060 WVN 2014;11:284–300
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site:
Figure S1. Search strategy. Table S2. Characteristics of Excluded Studies (N = 52 Studies). Table S6. Barriers and Enablers to Mentoring (N = 5 Studies).
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