Exemplar or facilitator: An exploration of the lived experience of nurse mentors supporting the adaptation of internationally educated nurses

Deficits in nursing workforces have led to major increases in overseas recruitment in many countries. Internationally educated nurses recruited within Ireland must complete an adaptation programme before they can practice nursing, a process contingent on the support from nurse mentors. However, it is becoming progressively difficult to identify nurses willing to act as mentors, threatening viability of overseas nurse recruitment. This research set out to address this problem by exploring the lived experiences of nurse mentors during the adaptation programme.

care system, there is also the challenge of ensuring that the recruited nurses are appropriately educated and trained.To register as a nurse sanctioned to work autonomously in Ireland, IENs must undergo an education review by the Nursing and Midwifery Board of Ireland (NMBI) to identify if there are any deficits in previous education.
Applicants are advised if they are required to complete either an aptitude test or a period of adaptation and assessment to gain entry to the NMBI register.During this assessment period, IENs are referred to by the NMBI as candidate nurses.The adaptation and assessment process requires the assessment of knowledge and skills across 'six domains of competence'. 3A critical element of the assessment process is the supervision and support of IENs in clinical workplaces by nurse mentors who monitor clinical practice, professional behaviour, interpersonal communication, teamwork and clinical competence.Worryingly, despite the importance of inducting new nurses to fill considerable gaps within the nursing workforce, it is becoming increasingly difficult to recruit nurses to act as mentors for IENs.
The importance of mentorship is widely recognised within the nursing profession.The achievement of learning goals through support and interaction with a 'knowledgeable other' is regarded as a vital component in nurse education. 4,5In Ireland, mentors act as both supporters of student nurse development and gatekeepers who assess the nurses' readiness for registration with the NMBI. 6,7Nurse mentors must be registered nurses with at least 1-year postgraduate experience.They need to have completed a preceptorship course that provides training in clinical education and assessment. 8In addition to preceptorship roles, a nurse mentor is expected to support the IENs' professional development and socialisation into Irish hospital settings.
0][11][12] The ability to establish and maintain such supportive relationships is unfamiliar to many experienced nurses, yet the quality of the mentor-mentee relationship is a critical determinant of successful outcomes for IENs who require adaptation as well as the retention of mentors. 135][16][17] In contrast, there is a marked paucity of literature exploring the experiences of nurse mentors working with postgraduate learners.
The challenge of recruiting nurse mentors is undermining efforts to provide adequate clinical support for new IENs undergoing an adaptation programme.If we are going to address the challenges of recruiting nurse mentors, we need to understand their experiences of the role and the factors that encourage or hinder their participation in mentorship.
It is well established that nurse mentors benefit greatly from formal training and development opportunities. 9,18,19It has been shown that mentor training increases nurses' confidence, self-efficacy, and competence in critical support roles such as becoming versatile in eliciting prior knowledge, providing feedback, learner assessment and exhibiting proficiency in addressing the typical problems that mentees encounter. 20,21Despite the acknowledged benefits of formal mentor development, and a strong recommendation from the World Health Organisation that organisations should focus on providing better postgraduate education for nurses, 22 the preparation and support for nurses acting as mentors in Ireland remains inadequate.Given the critical part played by nurse mentors in supporting the transition of IENs into workplace contexts in Ireland, it is important to inform the development of future mentor training and support programmes with contextual knowledge of the realities of being a mentor in Irish secondary care settings.Accordingly, this study aims to research the lived experiences of nurse mentors working with IENs undergoing a period of adaptation and assessment in an Irish hospital setting.

| METHODS
A qualitative Interpretive Phenomenological Analysis (IPA) design was employed to gain insight into the participant's experiences, attitudes and view of mentorship. 23,24IPA goes beyond the presented data and examines thoughts, emotions and underlying descriptions of individual experiences. 24This allowed the researcher to enter the participant's world and gain understanding of how participants assigned meaning and made sense of their experiences. 25,26During the interpretation phase of IPA, the author's experiences and personal views were acknowledged. 27This unique process known as the double hermeneutic approach required the author to interpret and make sense of how the participants assigned meaning to their reported experiences. 24

| Sample
A maximum variant sampling approach was applied to ensure that nurse mentors from our variety of clinical settings were included in the study. 28Criteria such as gender, years since qualification, mentorship experience and participants from a variety of clinical areas were set.Variance in the sample added generalisability and transferability to the findings.Clinical nurse managers acted as gatekeepers and distributed descriptions of the study to registered nurses known to be involved in mentorship.Twenty nursing staff who met the selection criteria volunteered to participate.Eleven nurses were then selected based on the criteria set.

| Interviews
The participants partook in single-stage semi-structured interviews.
To increase the reliability of data, an interview guide was utilised, outlining the main topics to be covered, with flexibility regarding the phrasing and order of questions.Participants were gently probed in a respectful manner to further explore their perspectives or to clarify any points made. 29Open-ended questions allowed the participants to create their own response within their culture, values and experience. 28As the author is a novice researcher, three pilot interviews were conducted.The results have been included in the study.Some of the questions were adapted following the pilot interviews to allow for deeper understanding of experiences instead of merely addressing perceptions. 28

| Data analysis
The first transcript was read several times, and annotations of interesting or important comments were assigned and compared against the audio recordings to ensure accuracy.The author used open coding to extract valuable data with an appropriate label allocated.References to the original material were recorded under each code to validate their existence within the transcript.The process was repeated for each interview.The interpretation was conducted within the context of each respondent before creating overarching themes between the accounts of different respondents. 30The themes generated from all of the interviews were grouped together to produce themes and subthemes (Figure 1).Credibility and fidelity through member checking were ensured by allowing participants to read their transcribed interview to confirm that they were accurately recorded and their views were truthfully represented.Both before and after being recorded the participants were given an opportunity to discuss any concerns. 29To enhance the analytical transparency of this research, an audit trail was maintained.

| Rigour
The credibility of IPA can be questioned because of its interactive nature and the potential for the researcher to not maintain objectivity. 28To address these concerns and add rigour and credibility to the study, the researcher kept a reflexive diary. 31The reflexive process began prior to data collection to acknowledge any personal beliefs or biases. 32By 'bracketing' preconceptions, the researcher was able to look inwards and recognise their own views to set aside what is already known. 24This allowed the researcher to gain a true understanding of the participants' experiences. 29Continuous engagement in reflexivity prevented pre-conceptions clouding new interpretations of the participant's experiences that could have influenced the findings. 33

| Ethical considerations
Ethical approval was granted by the Galway Clinical Research Ethics Committee.Formal consent and support from the Director of Nursing were agreed upon.Veracity was ensured by providing the participants with information on the purpose of the study and their right to volunteer and participate, with written consent obtained.Participants were advised that they could withdraw at any stage and were informed of the measures that ensured their confidentiality with the use of pseudonyms and storage of information. 29

| RESULTS
A sample of 11 nurses working in a variety of secondary care settings were interviewed (Table 1 outlines participant demographic).The average length of the interview was 22 minutes.The emergent themes with associated frequencies are illustrated in Table 2.The concept of team and team participation was critically important for IENs because they were expected to recognise and adopt the prevalent culturally informed values of the teams to which they were attached.Thus, the role of the nurse mentor was portrayed as being bidirectional.On the one hand, mentors supported IENs in becoming accepted members of their nurse teams, and they also expected them to demonstrate teamwork skills during their adaptation process.IEN acceptance within nurse teams was contingent on their displays of investment in being committed to teamwork and mutuality. 34

| Identifying as a mentor
The perception of the mentor role varied between participants and relied on their self-perception and understanding of mentorship.There were two distinct mentor identities evident in the participant accounts, the mentor as standard-bearer or 'exemplar' of clinical practice and the mentor as a 'facilitator' of learning.
T A B L E 1 Demographic profile of participants.The four participants' exemplar identity meant that they want to be respected as good nurses, good practitioners.
I want them to be like me, you know, I do because I think I am a good nurse.
(Participant 4) Exemplar participants viewed themselves as gatekeepers to safe practice and argued that it was their job to show candidate nurses the 'perfect' way of practicing as a nurse.The exemplar identity meant that mentors felt obliged to display high standards despite workplace pressures, and this resulted in anxiety such as leaving work with the fear that they had forgotten to teach something important.
Because I am teaching it to someone else so I have to be perfect.
(Participant 8) The exemplar identity was associated with a sense that the nurse mentor bore vicarious accountability for the candidate nurses' practice.It was evident that the exemplar identity placed considerable performative pressure on the participant mentors, which in turn threatened the sustainability of mentoring.The exemplar identity was also associated with more self-doubt, leading to comments such as 'have I done enough?'These feelings often lingered after their nursing shift had ended.There were frequent references to feeling stressed.

| Facilitator identity
Contrary to the exemplar identity, six of the participants portrayed themselves as facilitators of learning.Their role was to show the IENs the way forward and to support them on their journey.There were far fewer references to role stress in facilitator identity participants' interviews.This may indicate that a facilitative approach to mentoring is more sustainable.There were frequent references indicating that the mentors wanted the IEN to develop professionally and 'be the best they could be'.This was linked to the candidate nurse achieving competence, ensuring patient safety and promoting teamwork.

| Sustainability
This theme represents the factors that both sustain and hinder the motivation to participate in mentoring.There was also a recognition that mentoring IENs required mentorship of greater intensity than that required for locally trained nurses.

| Role tensions
They identified communication challenges and cultural differences as key determinants of the additional workload.This resulted in conflicting roles for participants between being a nurse clinician and being a mentor.A lack of time often resulted in feelings of guilt or self-doubt with feelings of failing mentees.

| Mentor motivation
Although reports of feeling stressed were prevalent throughout the interviews, so were references to a positive experience.All participants referred to the positives of mentoring that ranges from personal gain to organisational benefits and patient safety.Thus, learners' educational gains and actions appeared to have a direct effect on how mentors felt about their mentorship roles.Moreover, being able to teach enhanced mentors' appreciation of their own knowledge and skills.

| Learner motivation
A critical determinant of the sustainability of the mentoring role was candidate nurses' willingness to participate in the working and learning process.If, for example, a candidate nurse appeared disinterested, it undermined the establishment of an effective mentor-mentee relationship.
If they display little interest, I really will display little interest.I will do the basics but I won't put myself further than what I can do. ( Participant's motivation to act as mentors was driven in part by the willingness of the mentee to play their part as an enthusiastic and willing learner/worker.If the learner displays a lack of interest, the mentor mirrors this with a partial withdrawal from mentorship activity.
The mentors made frequent references to the importance of feeling appreciated.There was a need by the mentors to receive recognition by both the mentee and the organisation of the additional workload and the gratitude they had when thanked.

| Socialisation
Supporting learner socialisation was an unfamiliar concept to many mentors given that the majority of the mentoring experience had been with nurses educated in Irish cultural settings.Most participants referred to the importance of supporting the integration of IENs into nursing clinical teams.This included both written and unwritten requirements of the IEN to 'survive' and become a 'credible' practitioner.The mentors had empathy and understanding of the cultural differences the IENs faced and referred to them 'fitting in', becoming part of the team and feeling comfortable and happy in Ireland.Participants felt empathy for the IENs leaving families behind creating an empathetic relationship between them.However, this adds to pressure of ensuring integration happens quickly.Supporting socialisation allows for a smooth transition period following adaptation, and the mentors frequently acknowledged some of the core components that the IENs needed to learn to establish themselves as part of the team.
This included not just clinical aspects but the importance of learning Irish culture and Irish banter to allow for rapport building with both staff and patients.
The biggest barrier to supporting socialisation was the language and communication difficulties.This also linked back to sustainability of the role with factors such as stress and lack of time being associated.
I suppose for adaptation nurses, the big difference, for me, is communication and language skills.If they do not understand the doctor, the patient, or me I always think it's very hard for them to care in a really safe and high level of care.I wouldn't have to worry about that if someone is trained in Ireland.

| DISCUSSION
This study set out to explore the lived experience of nurses acting as mentors for IENs adapting and socialising into Irish secondary care settings.A key finding was that different participants exhibited distinct forms of mentor identity.Perceiving oneself as an exemplar mentor was associated with increased stress and therefore represented a potential threat to the sustainability and effectiveness of the mentor role.On the other hand, positioning oneself as a facilitator mentor meant that participants were not trying to demonstrate perfect practice, nor did they take on the burden of responsibility for the actions of their mentees.Nyanjom 35  and historical backgrounds to relate to, leading to poor student experiences. 37,38[42] Although participants acknowledged mentorship as a professional nursing obligation, this research has shown how mentoring IENs is more complex and taxing when compared to mentoring locally trained nurses.
Participants reported that socialisation into the nursing team culture was, for them, a high priority in their role as mentors.Although there is research on professional socialisation in nursing, there is a paucity of literature examining the socialisation of IENs into existing nursing cultures in other countries.Socialisation into a new professional environment and culture is challenging for learners who are fully qualified and competent in their own cultural settings.It requires the adoption of local values, goals and standards, some of which may be antithetical to those that apply in their own country. 43The findings of this study suggest that socialisation requires mentors to be capable The sustainability of the mentorship role revealed in this study highlighted the importance of time constraints, workload pressures, understaffing and the conflicting demands of being a mentor and a service provider.16][17]46 These studies, along with the research reported here, suggest that being a nurse mentor not only requires formal training, but it also requires recognition within health services and institutions of the importance of the role and the additional workload involved. 47,48Figure 2 illustrates the relationship between mentorship practice, mentor identity and the achievement of successful socialisation and integration of IENs.

| Limitations
Although the demographic profiles of the participants achieve maximum variance (age, gender, years mentoring, nursing experience, workplace acuity and nationality), the small sample size in one Irish hospital is unlikely to be reprehensive of the 'lived experiences' of nurse mentors in other geographical locations, and as such, similar studies in other jurisdictions should be encouraged.

| CONCLUSION
This study has shown how the sustainability of the role of the mentor is contingent on how nurses acting as mentors conceptualise their mentorship identities and how the role of the mentor is supported and recognised in clinical workplaces.Given the importance of mentorship in nursing for undergraduates, graduates and the integration of IENs, nurses should be formally trained for their roles as mentors and supported in those roles over time.It is likely that if nurse mentors are appropriately trained and supported, the problem of mentorship hesitancy would be greatly reduced.

1
Iterative process used between interviewing and interpretation.[Color figure can be viewed at wileyonlinelibrary.com] 3.1 | Mentor identity 3.1.1| Workplace culture All of the participants viewed mentorship as part of their day-to-day nursing role.They described a cultural expectation that nurses engage in mentorship, but there were considerable differences between participants in terms of how they portrayed the mentor role and the nursing values that underpinned it.Someone new comes into your working facility, I think we all have a role to play to be a mentor, to do it properly, especially in the line of work that we are doing.(Participant 1) The nursing cultures described by participants reflected the collective values of nurse teams in which they were situated.Participants described a variety of nursing values ranging from empathy, honesty, good communication, knowledgeability and being organised.Nurse teams were described as close-knit entities that had become even closer as a result of the experience of navigating the Covid-19 pandemic.I speak of instances of how important our team was and there's no bigger instance than our whole Covid-19 situation because it was each other, us as nurses that got us through the last two years.(Participant 7)

Four
of the participants described themselves as nurse standardbearers for their mentees: I suppose it means for me to be a standard-bearer.You want to teach them the skills that you have and teach them the right way of doing it.(Participant 1)

I
'm there to facilitate their learning.I'm not there to teach them anything, I'm there to facilitate because lots of them have lots of knowledge already.(Participant 7) This included describing the importance of confidence building, recognising prior knowledge and being there as a supportive and encouraging contact.I'm more concerned about building confidence, building communication, reassuring them that they can follow through in keeping the patient safe.(Participant 5) All participants referred to their frustration in relation to making time for their mentor role in the context of the demands of their primary clinician roles.I do try and give anyone I'm mentoring time but unfortunately, there just is no time for training.Some days are fine but other days it's too busy and you try your best to mentor students or new internationals, but it's just so short staffed that you're just trying to do your own work.(Participant 10) The role tensions threatened to diminish participants' willingness to engage in mentorship.As one participant put it: 'It was just so busy, I just felt like I would be better off working by myself' (Participant 10) It takes much more time because we need to explain things to them in detail [i.e. say and do] it should be more in depth in the adaptation programme.(Participant 9) It's great.You can see they are happy and they are smiling and you just think, 'Oh God, we've got there together'.I enjoy when I see the adapted nurses pushing themselves and achieving what we have been trying to do.That makes me happy.I think then, job well done.(Participant 5) Being a mentor.[Color figure can be viewed at wileyonlinelibrary.com] of supporting IENs to recognise and align themselves with features of the 'hidden curriculums' of the unarticulated norms, values and ways of doing things within nursing teams.Being capable of helping IENs to navigate the hidden curriculum within nurse teams is a critical function in enabling IENs to become credible members and autonomous practitioners in a new country.44,45Thus, if mentoring of IENs is to be sustainable, future nurse mentors need to be supported in learning how to facilitate the socialisation process of IENs into the Irish nursing culture. Themes.