The Manitoba pilot project, Enhanced Orientation for Nurses New to Long-Term Care, lasted 18 months and involved three sites in the Winnipeg Regional Health Authority. It was developed to address the reality that individuals entering long-term care have more complex needs than in the past and that it is often difficult to recruit and retain nurses to work in this care setting. This mentorship program included 11 mentors and 12 protégés. As well, six clinical workshops were developed and held for a total of 390 participants. Protégés reported a positive effect on their transition to the workplace and their confidence levels, and mentors reported building their mentorship skills. The program has been expanded within the Winnipeg Region and to other health regions in the province and in Canada.

Background

Demands on long-term care are growing as people are living longer and the needs of individuals who enter care are becoming more complex. At the same time, it is often more difficult to retain and recruit nurses in the long-term care sector. The seriousness of the situation has been underscored by several recent reports (e.g., CHA 2009; Silversides 2011). According to Linda Silas, president of the Canadian Federation of Nurses Unions:

We cannot afford to undervalue the role of nurses in long-term care. There is no lack of research indicating that nursing care is strongly correlated to better patient outcomes. … What better way is there to honour our elders than providing them with the care they deserve? (CHA 2009: 8)

Many people think of personal care homes as a supportive place for the elderly to live as they grow older. But increasingly, these facilities are housing residents who have complex care needs and require a high level of professional care and support. Residents often have multiple medical issues, sometimes have psychological challenges, and in many cases have dementia, which causes progressive cognitive decline. Indeed, it has been said that long-term care facilities are now providing "acute care for the elderly." A more experienced health workforce is required as the elderly account for a growing proportion of the population and, owing to greater longevity, more of them are living with multiple illnesses and degenerative conditions. Recognizing these issues, the Winnipeg Regional Health Authority (WRHA), Manitoba Health and the Manitoba Nurses Union collaborated to pilot this project at three of the 38 long-term care facilities in the WRHA.

Objectives

The project was designed to provide nurses new to long-term care with a better understanding of the needs of the long-term care resident population in order to improve care, enhance the work experience and create a positive work environment. As well, the project aimed to create a collaborative working partnership – outside of the normal labour relations and collective bargaining environment – between the Manitoba Nurses Union, Manitoba Health and the WRHA in order to address specific and urgent nursing workforce retention and recruitment issues. Because of the profile and needs of individuals who are now being admitted into care, nurses (and residents) benefit from further education for nurses. To that end, high-quality orientation workshops were created on a range of subjects (including conditions such as dementia and delirium, as well as assessment skills), and the nurse mentors received education to develop and enhance their mentoring skills. Another purpose was to provide some consistency in long-term care orientation programs in Manitoba, which currently vary from two days to less than two weeks and tend to be specific to an individual facility.

The objectives of the program were to

• improve retention of nurses in long-term care by providing better orientation;
• enhance the profile of long-term care as a desired workplace;
• develop greater capacity for nursing leadership, training and support within a long-term care facility;
• develop an inter-professional component to the long-term care orientation program; and
• enhance the geriatrics-related knowledge and skills of healthcare providers who are new to long-term care.

Overview: Design and Planning

A full-time project coordinator was hired in January 2009 to manage and oversee the pilot implementation. The project coordinator was contracted for an 18-month period (January 2009 to June 2010). Project planning began in February 2009. Various levels of administrative support were also required throughout the project for start-up (ordering equipment, arranging office space and so on), receiving registrations and answering questions about the clinical workshops, and collating the workshop evaluations and pre-/post-test responses.

Content experts were engaged to assist with the development of some of the workshop materials. Some of the content experts were employees of the WRHA and undertook the work as part of their jobs, while outside consultants were hired to develop and deliver certain portions of the clinical workshops. The project coordinator developed and delivered the mentoring workshops and one of the clinical workshops as part of her role. A graphic design company was hired to assist with the layout, design and printing of the workshop materials.

Twenty-three nurses took part in the mentorship component of the pilot – 12 nurses new to long-term care (protégés) and 11 mentor nurses who were experienced in the area. Of the 12 protégés, nine were new graduates, while the other three had worked in other settings; eight were licensed practical nurses (LPNs) and four were registered nurses (RNs). Of the mentors, two were LPNs and nine were RNs. One mentor was lost to attrition when she took a job at a non-participating long-term care facility.

Implementation

At the beginning of the pilot, the 12 protégés were matched with an experienced nurse from their personal care home so that the mentors could provide support and guidance. In September 2009, the nurse mentors attended a one-day workshop designed to enhance their mentoring skills. A week later, both mentors and protégés attended a one-day orientation workshop so that they could meet their partners, discuss expectations of the mentoring relationship and review tools, such as a goal-setting template, a problem-solving framework and mentoring relationship evaluations, that might be helpful throughout the mentoring journey.

Mentoring activities took place between September 2009 and April 2010. Some mentoring relationships extended beyond the project timeframe based on the protégé's needs or the development of close bonds. The frequency of the mentor–protégé meetings varied based on individual work schedules. The pairs often met for coffee or lunch during worked shifts or had contact by phone.

Mentors and protégés also attended a series of six day-long workshops between October 2009 and April 2010 that were based on topics of clinical relevance to the care of individuals in long-term care. The workshop topics were:

1. Geriatric Assessment/Changes with Aging; Atypical Presentation of Illness and Infection; Medication and Aging/Polypharmacy
2. Dementia/Delirium/Depression: Differentiation and Management; The Brain and Behaviour: Supportive Dementia Care Strategies; Communication and Dementia
3. Behavioural Responses in Dementia: Assessment, Intervention and Psychotropics; Prevention of Abuse and Neglect; PIECES Overview: A Model for Collaborative Dementia Care
4. Pain Assessment and Management; End-of-Life Care; Fall Prevention and Management; Least Restraint Philosophy/Restraint Reduction Strategies
5. Everyday Leadership and Communication Skills for LTC: Critical Thinking and Prioritization; Clinical Presentation Skills; Integrating Best Practice; Communication Techniques; Conflict Management Strategies
6. Nutrition and Hydration; Swallowing and Communication Difficulties; Oral Health; Pressure Ulcer Prevention; Continence/Incontinence Assessment and Management

A total of 390 staff attended the six clinical workshops. The majority of attendees were nurses, but others included registered dietitians, social workers, occupational therapists, speech–language pathologists, a chaplain and a patient safety officer. Each workshop, developed by experts in the various subject areas, was repeated twice. Interactive sessions included PowerPoint presentations, activities and case studies. At each session, a participant's handbook was distributed.

Challenges

At the project's three sites, the number of recently hired (or about-to-be hired) nurses new to long-term care was lower than expected. This challenge was addressed by including nurses new to long-term care who had been hired up to six months before the starting date of the project. Still, the number of participants was, at 23 (11 mentors and 12 nurses who were new to long-term care), lower than the 30 nurses anticipated in the original proposal.

A challenge that was anticipated – arising from the fact that the mentorship allowance (part of the current Manitoba Nurses Union contract) did not apply when protégés were experienced but new to long-term care and not new graduate nurses – did not have an impact on the project. The restricted application of the mentoring allowance was discussed during the recruitment process but did not deter those nurses who stepped forward as volunteer mentors to the protégés who were not new graduates.

Outcomes

An enhanced orientation program, including a curriculum of best practice clinical information, was developed and implemented. All of the workshop evaluations were positive, and pre- and post-tests showed significant uptake in knowledge. Participants believed the workshops offered crucial foundational knowledge for nursing staff who work in long-term care.

The project as a whole was evaluated as part of the national RTA evaluation. It was not possible to measure the effects of this particular project on nurse retention and recruitment, given the short timeframe and small study size. However, the project supported positive workplace improvements, including mentorship and professional development opportunities, which are known to promote retention and recruitment (Greene and Puetzer 2002; Hurst and Koplin-Baucum 2003; O'Brien-Pallas et al. 2001; ) Similarly, it was difficult to measure just how much the project enhanced the profile of long-term care as a desirable place to work; more time is needed to reach staff in other sectors about the existence, benefit and ongoing availability of this program.

Protégés revealed in focus groups that the enhanced orientation program had a positive effect on their transition into their new jobs and on their confidence level in the work setting. The mentors enhanced their leadership abilities and reported that they appreciated the opportunity to improve their mentoring skills and share their experiences and knowledge with the new nurses, while at the same time feeling supported as mentors.

The project sought to develop an interprofessional component in the orientation program and, based on their evaluation reports, the staff from disciplines other than nursing who attended the clinical workshops said the experience was positive. Multiple-choice tests administered to all the workshop participants before and after the clinical workshops showed a measurable improvement in knowledge of key concepts.

A program guide for this enhanced orientation was developed, and copies were printed for distribution to stakeholders to promote the sustainability and transferability of the project. The program guide contains all of the educational material and electronic files required to reproduce the Enhanced Orientation Program for Nurses New to Long-Term Care.

Lessons Learned

• The project clearly filled an important need. Response was very positive, and attendance at the clinical workshop series was beyond expectations. Many nurses indicated that they had come in on a day off, or taken a vacation day, in order to attend.
• The pilot sites' managers should have been involved in the mentoring education so that they understood the process and were prepared to support both the mentor and protégé in the mentorship experience. For a mentoring program to be successful, the management team and front-line manager need to be supportive and involved in monitoring the relationships. They must also be prepared to act as a sounding board or intervene as needed. As well, the mentors require support throughout the mentoring process. It also would have been helpful to hold a second session with the mentors at the mid-point of the project in order to continue to build mentorship skills and provide an opportunity to discuss the progress of the mentoring relationship.
• Mentors and protégés reported difficulties finding time to meet if they did not both work on the same unit. In future, it would be best to link nurses who work on similar units or rotations, when possible, in order to facilitate face-to-face meetings.

Sustainability and Transferability

The Winnipeg Regional Health Authority's Personal Care Home Program agreed to continue with the Enhanced Orientation for Nurses New to Long-Term Care, and will include other staff at personal care homes in the WRHA. The WRHA is also interested in expanding the mentorship and education component of the program to other sites within the WRHA. In June, 2011, the Manitoba's premier announced funding to permanently implement the enhanced orientation program in long-term care facilities across the province.

The program has spread in Manitoba beyond the Winnipeg Region. The Parkland Regional Health Authority in western Manitoba has adopted the RTA mentoring education materials to its mentorship program and has started to use the material to train mentors, new nurse graduates and managers. Another rural health region in Manitoba has also expressed interest in adapting the project's mentoring education materials to its mentorship program, and the Department of Health and Wellness in Prince Edward Island has begun to implement the enhanced orientation program's clinical workshop series in all public and private long-term care facilities in that province.

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