NC Public Health NurseNC Public Health NurseMentoring Orientation materialsMentoring Orientation materials

Retention problems exist in all of nursing but are particularly problematic in public health

Nurses entering governmental public health nursing positions appear to have knowledge deficiencies in areas such as:

• Population focus• Epidemiology• Health education• Advocacy• Case management

Background

• Challenges exist attracting, recruiting and retaining public health nurses

• Public health nursing workforce is aging • The cost of turnover in one position is @ 75% of

the annual salary of that position.

BackgroundBackground

COPE (Committee on Practice and Education) of NC Association of PHN Administrators has been looking at recruitment and retention issues affecting the specialty field of Public Health Nursing. Mentoring has been identified as an effective tool in assuring the successful transition of nurses to public health.

What is Mentoring?What is Mentoring?

Mentoring is a deliberate pairing of a more skilled or more experienced person with a less skilled or less experienced one, with the mutually agreed goal of having the less skilled person grow and develop specific competencies.

(Murray, 2001)

What is Mentoring?What is Mentoring?

Mentoring is a personalized one-on-one approach to learning grounded in a personal and professional relationship between a mentee (the learner) and the mentor (the teacher).

(Goldman & Schmalz, 2001)

Definition of MentoringDefinition of Mentoring

• A teacher and educator• “be available to help

learn a new topic or area”

• Support• “support person…in a

nutshell”

• A resource“go to person”

• A guide and leader• “coaching-building on

big picture”

• Experienced• “someone to show you

the ropes”

• Role model• “ someone you trust and

respect”

• Mentoring

• Precepting

They Are Different!They Are Different!

Preceptor Mentor

View of Intern Views intern as a prospective co-worker Views intern as a colleague

Conceptual focus Focuses on practice based learning Focuses on personal development

Prior knowledge Assumes intern has necessary content knowledge

Theory/PracticeDemonstrates the

incorporation of theory in practice

Identifies unwritten work-place policies and practices

Learning experiencesSuggests useful learning experiences to help intern

achieve learning objectives

Encourages intern to determine learning experiences to achieve

objectives

Ethical concerns Identifies actual ethical concerns

Strengths/ weaknesses Helps intern become aware of strengths and weaknesses

Progress evaluation Provides intern with an evaluation of professional progress

Intern self-evaluation Identifies usefulness of self-evaluations

Strongly encourages intern to participate in self-evaluation

Role model Views oneself as a professional role model

Views oneself as a personal role model

Duration of relationship Recognizes relationship with intern is limited

Views the relationship with the intern as indefinite

Preceptor vs. MentorPreceptor vs. Mentor

To Mentor• Shares their successes and achievements with the mentee• Practices interpersonal and management skills• Expands horizons• Gains insight from mentee’s background• Reenergizes own career• Enlists an ally in promoting the organization’s well-being• Increases network of colleagues• Recognizes and increases skills in leadership & coaching• May reduce turnover and additional work

Benefits of MentoringBenefits of Mentoring

To Mentee• Gains an active listening ear• Receives valuable direction• Learns a different perspective• Gains from mentor’s expertise• Receives critical feedback in key areas• Develops sharper focus• Learns specific skills and knowledge• Gains knowledge about the organization’s culture &

unspoken rules• May reduce turnover and additional work

Benefits of MentoringBenefits of Mentoring

Mentor• Introduces population-based nursing concepts• Ensures two-way open communication• Assists in establishing parameters of partnership• Provides as much career path information as possible• Shares information about career opportunities and

resources• Shares information about own job and resources• Provides encouragement

Responsibilities

ResponsibilitiesMentor - cont’d

• Monitors and provides sensitive feedback and guidance

• Follows through on commitments• Acts as a role model• Respects confidentiality of information shared by

mentee

Mentee• Is willing to learn and grow• Accepts advice and provides mentor with feedback• Takes on new challenges• Remains available and open• Is proactive in relationship• Identifies goals• Accepts responsibility for own development• Demonstrates commitment to the relationship

Responsibilities

• Is willing to spend a minimum of two hours/month with mentee

• Is committed to attending mentor training and yearly updates of training

• Exhibits characteristics such as:

Key Considerations

CoachingMotivatingLeadership

SharingEncouragingWilling to share knowledge & expertise

• Is committed to the mentoring process

• Has the ability to create a learning environment

ListeningAdvisingProficiency in practice

Mentors

• Is a new employee, where new is defined as a nurse who is new to working in a public health agency or a nurse who is in a new role in a public health agency

• Has a working knowledge of career goals and objectives

• Is willing to set aside time to meet with mentor

• Is committed to participating

• Is open to suggestions and feedback from the mentor

Key Considerations Mentees

A Few Concepts AboutA Few Concepts AboutPublic Health NursingPublic Health Nursing

Public Health Nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences.

(APHA, Public Health Nursing Section, 1996.)

What is Public Health Nursing?What is Public Health Nursing?

Public Health•Population based•Grounded in social justice•Focus on greater good•Focus on health promotion and prevention•Does what others cannot or will not•Driven by the science of epidemiology•Organizes community resources •Long-term commitment to the community

Cornerstones of PH Nursing, Minnesota Department of Health , revised 2007

Nursing•Relationship based •Grounded in an ethic of caring •Sensitivity to diversity •Holistic focus •Respect for the worth of all •Independent action

Cornerstones of Public Health NursingCornerstones of Public Health Nursing

Population-based care vs.

Population-based Care• Goal is an overall healthy population• Might involve health-improvement goals for a

community or sub-set of a community that are many years (even a generation) away

• Primary intervention strategies are provision of information, education, and communication.

• Collaborates with other community groups to advocate for policies that will allow and encourage healthy behaviors

• Uses community health data to plan strategies, based on the specific demographics, strengths, and weaknesses of a particular community

• Has a broad awareness of the environment’s impact on health. This includes such things as safe food and water, sidewalks in good repair, availability of transportation, housing quality, etc.

Individual Medical Care•Goal is a healthy person•Primarily focuses on current patient conditions, and prevention of onset of new conditions in a particular person•Primary strategies are biological (medication, surgery, for example), with information and education as a supplement•Advocates for services for specific patients, and for exceptions or adaptations to policies to accommodate those patients•Uses medical research to determine the most appropriate care for a particular patient•Recognizes the impact of environment on specific patients with specific conditions. This might include presence of respiratory triggers for patients with lung diseases, or availability of appropriate food for diabetics.

Individual Medical care:

Population Focus

• Individuals present in clinic with communicable disease—treat individual

• Identify population needs for disease– Preventing transmission– Communicating to your population– Providing treatment

• Example: Ringworm

Vulnerable Populations

Health Disparities

Health Literacy

Definition of Vulnerable Populations

• Greater risk for poor health status and/or problems with access to health care

• Higher probability of illness and worse health outcomes than others.

• Multiple risk factors interact to limit resiliency.

Resource limitations• Economic (poverty and link to hazardous environments and in adequate nutrition)• Educational (ability to understand health information and make informed choices) • Social (support system)• Health status (physical, biological, psychological)• Health risk (lifestyle, environmental)

Vulnerability is Multidimensional

Differences in quality of care and health outcomes by age, gender, race, ethnicity, education, income, disability, sexual orientation or geography due to:

• Patient level factors (e.g., biology, behaviors)

• Provider-level factors (e.g., stereotyping)

• System factors (e.g., lack of insurance)

• Social and political factors

Health Disparities

Vulnerable population groups are most likely to experience health disparities in access to care, quality of care and health outcomes.

Connecting the Terms

Health Literacy

"The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions".

• From Healthy People 2010

Institute of Medicine A Prescription to End Confusion

“Ninety million people in the United States, nearly half the population, have difficulty understanding and using health information”

How can nurses make a difference?

• Identification (outreach and case finding)• Linking to health services (case manager)• Developing or revising programs to meet their needs• Educating them on how to promote health• Providing direct care• Advocating for programs and services to meet their needs

CULTURAL DIVERSITY:

Gabriela ZabalaOffice of Minority Health and Health DisparitiesNC Department of Health and Human Services

Forest Toms, PhDTraining Research & Development, Inc. , Hickory, NC

Goal

To build the foundation for culturally appropriate health services capable of serving an increasingly diverse population.

“When we think…

of Culture, we think of mainstream America; but when we think

of Diversity the tendency is to think of minority groups.”

“American Culture”

• White middle-class values• Dominant culture• Mainstream culture• European – American (Anglo)

ASSUMPTIONS & APPROACHES TO DIVERSITY

• DIVISIVE/PANDORA’S BOX• ONLY BLACK/WHITE• NOT AN ISSUE• SHOULD TREAT EVERYONE THE SAME• RESOURCES• ALREADY DEALT WITH

“Why” of Diversity

What’s In a Name?• African American – Black, Africans, Carribeans• Hispanic/Latino – Mexican, Puerto Rican, Cuban,

Salvadorian, Ecuadorian, Argentinan, Honduran, Dominican, etc

• European/Anglo – White

• American Indian – Native American, Alaska Native, Aleutian

• Asian – Chinese, Filipino, Korean, Japanese, Vietnamese, Cambodian, Laotian, Hmong, Pacific Islander (Polynesian, Melanesian, Micronesian)

USUS Population Composition 1990 - 2050

75.6

60.5

52.8

11.8

13.1

13.6

9.1

18.9

24.5

2.8

6.7

8.2

0.7

0.8

0.9

0 10 20 30 40 50 60 70 80

American Indian

Asian/Pacific IslandHispanic

Black

White

Percentage of US Population

2050

2030

1990

Source: U.S. Census Bureau

American Indian

Asian/Pacific IslandHispanic

Black

White

American Indian

Asian/Pacific IslandHispanic

Black

White

“What” of Diversity

Dimensions of Diversity

• Primary– Largely unchangeable human differences– Inborn– Influence our early socialization

• Secondary– Can be changed– Differences we acquire, discard and modify

throughout our lives

Primary Dimensions of Diversity

Sexual/AffectionalSexual/AffectionalOrientationOrientation

UnchangeableDifferences

AgeAge

RaceRace

PhysicalPhysicalAbilities/QualitiesAbilities/Qualities

GenderGenderEthnicityEthnicity

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Secondary Dimensions of Diversity

EducationalBackground Geographic

Location

Income

Marital Status

MilitaryExperience

HouseholdComposition

ReligiousBeliefs

Work Experience

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CultureCulture• Behavior patterns, arts, beliefs, institutions, and

all other products of human work and thought

American Heritage Dictionary, 1991

• A view of the world and a means of adapting to the world

Bilingual Health Initiative Task Force, 1994

• Is reflected in, and influences beliefs and values, communication styles, health beliefs and practices

Culture Helps Us…

Organizes Our Physical And Social Interaction

Forms Our Identity

Shapes Our Understanding And Perceptions

Culture DefinesFamily Roles

Family Relationships

Family Structure

Attitudes And Practices

Styles Of Communication

Beliefs

Beliefs and Values• What we are used to thinking and doing• What we feel or know is right, good, important• Complex concepts with many dimensions• Influence all other area of life and activity• Affect how people think, feel, act• Can cause conflict if people’s beliefs and values are not incorporated in health recommendations

Overview of BeliefsComparison of Common Values

Anglo-Americans– Mastery over nature

– Personal control over the environment

– Doing-activity

– Time dominates

– Human equality

– Individualism/privacy

– Youth

– Self-help

– Competition

– Future orientation

– Informality

– Directness/openness/honesty

– Practicality/efficiency

– Materialism

Other Ethnocultural Groups– Harmony with nature

– Fate

– Being

– Personal interaction dominates

– Hierarchy/rank/status

– Group welfare

– Elders

– Birthright inheritance

– Cooperation

– Past or present orientation

– Formality

– Indirectness/ritual/”face”

– Idealism

– Spiritualism

Culture and Healthcare

Patients

Health Status – Minority Groups

High risk for :– Heart disease, diabetes, cancer,

homicides, infant mortality – African Americans

– Stroke/diabetes, MVA, infant mortality American Indian

– Diabetes, MVA, homicide - Hispanics

– Diabetes - Asians/Pacific Islanders

• Teen pregnancy– African Americans– American Indians– Hispanics

Barriers to Health Services

• High rates of poverty• Unemployment• Cost of care• Lack of insurance• Location and hours of

services• Lack of transportation• Lack of information• Language• Cultural differences

between providers and clients

Visions of a Culturally Competent Healthcare System

Definition of Cultural Competence

• The process is ongoing and continuous.

• Cultural competence is a dynamic, developmental process and a state towards which we should strive, it takes a long-term and consistent commitment to achieve.

• It is not something that comes to the individual, the agency, or the system through a one-shot, quick-fix approach.

Cultural Competency ContinuumCultural destructiveness -- attitudes, policies, and practices that are harmful to cultures and hence to

individuals within the culture.

Cultural incapacity -- the system or agencies lack(s) the capacity to help minority clients or communities. There is much bias.

Cultural blindness -- the system and agencies provide(s) services with the belief that they are unbiased. The premise is that services are universally applicable.

MOVING TOWARDS THE GOAL

• There must be a willingness and courage to confront all the feelings and attitudes that cultural competence and change indicate for the individual, the agency, and society in general.

• As Pinderhughes (1989) states, the multicultural staff engages in dialogue about their differences in perceptions and experiences.

OUTCOMES

• Failure to provide the opportunity to understand and process these differences among a multicultural staff can produce two outcomes:

• staff will cover over the conflict in perceptions and orientation and block off the confusion, frustration, and strong feelings.

• conflict can erupt and staff will become burned out and fatigued.

BEFORE TAKING ACTION• Agencies should understand cultural dynamics

and the significance of cultural identify for themselves, their clients, and their work together.

• Opportunities for sharing and dialogue must be built into the structure of the agency or organization seeking to become

more culturally competent.

UNDERSTANDING THE AGENCY ENVIRONMENT

As part of the agency’s commitment, it should be recognized that cultural diversity and cultural competence require an understanding of the sociopolitical environment in which an agency operates.

Nurse Mentoring RelationshipNurse Mentoring RelationshipGetting StartedGetting Started

Keeping Momentum GoingKeeping Momentum Going

Once matched, the pair should write up a formal mentoring agreement to clarify their roles with one another. This agreement can determine the framework of the relationship.

Mentoring Agreement

• Schedule first meeting within one week of matching • Review goals and objectives • Discuss goals and objectives and activities • Complete mentoring agreement• Exchange contact information and schedules as necessary• Maintain twice monthly contacts• Check in with contact person to share progress• “Close” the relationship after designated time

Getting Started

Keeping Momentum Going

• Beyond goals in contract• Discuss networking opportunities, NC Public

Health Nursing• Teach mentee about day-to-day LHD

operations• Schedule visits or shadowing opportunities to

other LHD clinics and services• Focus on work-life balance issues

• Plan• Keep mentoring a priority• Acknowledge / deal with conflicts

Work Issues

Overcoming Barriers

Barriers– Time– Other priorities– Role tensions– OTHERS?

Solutions– Set a calendar– Nurse supervisor

support– Facilitate approaching

supervisor– OTHERS?

Crisis Management

• Changing from individual to population focus

• Addressing health department priorities

• Problem solving

Health Department Priorities

• Require staff adjustments– Job priorities– Work schedules– Implementing protocols

• Priority changers– Communicable disease outbreak– Weather events (hurricanes, floods)– Influx of immigrants

Health Department Problem Solving: Exercise

• Ethical dilemmas– Client treatment– Work performance

• Potential dilemmas

• What are your health dept policies and protocols on these issues?

• How should you be involved to work with mentee?

Additional Resources

• Nurse Mentoring Manual• Website—NC Public Health Nursing http://www.ncpublichealthnursing.org