Developing Palliative Care Physicians through Mentoring Relationships

1.1 Background Mentoring has been shown to improve resilience, sense of well-being, reduce staff turnover and to render psycho-emotional support in clinical medicine in general. Palliative care physicians face burnout, compassion fatigue and death anxiety. Whilst existing literature describes the benefit of formal mentoring programs and it’s short to medium term goals, there is a lack of data describing the relational aspects of mentoring and its long term goals in shaping a physician.


The Pressing Need for Mentoring in Palliative Care
The provision of holistic support is inextricably linked with a palliative care approach and such support is dearly required [14,15] to mitigate burnout and compassion fatigue [16][17][18][19] often in places where palliative care is in its infancy.Mentoring has been shown to improve resilience, sense of wellbeing, reduce staff turnover and to render psycho-emotional support in clinical medicine in general.Physicians who receive mentoring also report high work satisfaction and develop increased coping skills with pressures on the job [20][21][22][23].Mentoring not only transmits knowledge, skills, ethical behavior it also allows for socialization of a junior person into the profession [4,24,25,26].Successful mentoring culminates in professional independence where a mentee has matured to level which allows him/her to perform competently in his professional role, as well as be a mentor to others [4-6, 8-10,13,27-29].Yet mentoring is rarely ever a short process and often extends far beyond a relationship between a novice and a senior experienced clinician focused upon developing the novice's abilities.In most cases mentoring evolves into supportive relationships between colleagues [11,30].To address the dearth of data on the long-term effects of mentoring, this review studies the perspectives of mentors and mentees featured in editorials, perspective and opinion pieces to provide long-term views and reflections of mentoring experiences so lacking in mentoring in medicine.

Search strategy
Our review involved searches of the Cochrane, Pub med, Science Direct and ERIC databases.Editorials, perspectives articles, opinion pieces and commentaries in English or had English translations that were focused on mentoring between a senior clinician or academic to a more junior professional were included.

Selection of studies
Only editorials, commentaries and perspective pieces undergraduate and postgraduate mentoring of medical students and doctors were selected.Guided by the World Health Organization's Health Workers classification, we focused on general or internal medicine specialties.We excluded clinical specialties not associated with internal medicine such as surgical specialties, Pediatrics, Emergency medicine, Obstetrics and gynecology and Clinical and Translational Science.Articles with empirical data or qualitative data were excluded given that there were no accounts on the long-term effects of mentoring.Articles on peer, leadership, youth and patient mentoring, as were articles on supervision, advising, coaching and preceptorship we not included.

Data analysis
Two of the authors (AT, LK) carried out independent searches, retrieved and reviewed all full text articles meeting the inclusion criteria.The two authors compiled a shortlist of articles for inclusion.Three authors (AT,BL,LK) then thematically analyzed each paper independently.Consensus on these themes was achieved at the reviewers meeting.

Results
A total of 806 articles were retrieved from the initial search, using the inclusion and exclusion criteria after reading the title and abstracts 63 articles were selected.On reading the full text to evaluate whether the articles fulfilled the selection criteria, a final number of 39 articles were chosen.We identified four key themes from our analysis of the 39 papers included in this study.These include the mentoring relationship, the characteristics of the mentor, the characteristics of the mentee and advice to mentees and mentors in advancing effective mentoring relationships.We will discuss each theme in turn.

A Safe Space
A successful mentoring relationship is built on has trust [25,31,32].A good mentoring relationship creates a sense of safety for the mentee that facilitates free and open communication within the mentoring dyad [7,9,31,33].A strong personal connection is crucial to effective mentoring interactions [4,11].

Igniting the fire & Planting the seed
The long-term goal of mentoring is to facilitate effective, evidenced based, independent practice [3,5,27].The mentee is inspired and challenged to think creatively and this ignites the spark to learn and fans the flames of inquiry [24,34].Mentoring also lays the seeds of professional values and ethical principles, primarily through role modeling [3,28,32].

Empowerment
The demonstration of empathy, a non-judgmental spirit and commitment to work [4,9,35] facilitates the process of self-discovery and empowers mentees [2,9,27,31,36].Care must be taken for freedom for mentees to develop in their own way and to allow them to challenge or disagree with the opinions and advice of the mentor [1,27,33,36].This requires sensitivity and attunement to a mentee's personality and needs by the mentor [24,26,27,29,33,37].

A Win-Win situation
A good mentoring relationship is reciprocal and mutually beneficial [2,3,4,6,7,30,31].Although the mentoring relationship is mentee centred, mentors often find themselves benefitting professionally and personally as a result of the process [2,4,8,10].Successful mentoring often evolves into lasting friendships as the relationship matures [11,30].This forms a platform for sharing of professional resources and acts as a launch pad for further collaborations and research opportunities [11,28,30,31].

Worth the grit and effort
Like any relationship, mentoring involves the committed investment of time, effort and self by both parties to make it succeed [26,27,31,39].This point is often tested during transitions and evolving goals and individual needs [38,39].Mentoring relationships may also be placed under strain when negative feedback needs to be administered, when personal differences arise, when addressing sensitive matter such as race and gender issues and during the separation phase when the mentee becomes independent.Working through and overcoming some of these challenges allows the relationship to mature [38].Mentors need to be supported via training and being receiving mentoring as they help their mentees [8,9,25,35].Mentees on the other hand need to be proactive, responsible and appreciative of the efforts put in by the mentor [4,9,11,27,36].

Building a legacy
Sir Isaac Newton once commented If I have seen further, it is by standing on the shoulders of giants' evincing the benefit and legacy of his mentoring experiences.Effective mentoring is an effective means of leaving a legacy for future generations [31,34].This allows us to build on the knowledge and experience of seniors who have developed the medical field thus far [4,10,28,31].
6 Characteristics of an effective mentor 6.1 Professional characteristics of an effective mentor Good mentors are experienced knowledgeable clinicians who are experts in their own fields [4,8,26,28,30,42].This stand enables mentors to provide guidance in navigating organizational structures, act as advocates for their mentee at various levels[27,29,30,37] and provide mentees with opportunities to network crucial to their professional socialization [3,4,8,26,30,34].

Personal characteristics of an effective mentor
An effective mentor is motivated, committed, genuinely interested and passionate about developing their mentee [2,8,30,34,36,42].Mentors are compassionate and sensitive of cultural differences and personal [4,9,24].By being available and responsive to the evolving needs of their mentees, demonstrating non-judgmental listening and a belief in his mentee's abilities, a mentor brings out the best in his mentee and allows him to reach his full potential [2,4,8,9,24,27,31,37,42,43].By creating a sense of safety, the mentor becomes an encourager, confidante, a sounding board, challenging the mentee to achieve to his potential and allowing himself to be challenged [2,3,8-11,24,29,31].A good mentor is secure in his position, self-aware, mature and selfconfident and this allows him to rejoice in his mentee's success rather than feeling threatened or vying with mentee for credit, or pushing forth his own agenda [3,27,28,33,35].

Advice to mentors
Mentoring is not an easy task and requires investment of time and sacrifice [2,8,24,27,34,40].As such mentors not only need training to equip and develop their skills in mentoring but also benefit from receiving mentoring themselves [8,9,25,28,35,42].The skilled helper model for individual support by Gerald Egan is a useful tool for mentors to consider with regards to facilitating problem solving for their mentees [44].Davies [9], has provided a handy acronym which encompasses the key components of mentoring.The MENTOR acronym: Manage needs, Effective communicator and feedback provider, Non-judgmental, confronting and challenging when appropriate, Trustworthy and empathetic, Offer strategies to promote selfreflection and development, Role modelling and respect.

Roles of the mentor
A mentor wears many hats and performs many roles in his duty to the mentee.Some roles of a mentor are described as follows.

Coach
A mentor ensures optimal performance of a mentee by inspiring him to reach his best potential, affirming the strengths and talents of the mentee, empowering the mentee with skills to attain greater achievement in personal and professional growth [2,9,10,11,30,34].During times of difficulties, a mentor encourages perseverance and determination, supports the mentee to overcome obstacles encountered in his journey and focuses mentees on the goal ahead [24,25,31,38].

Educator and exemplar
The mentor creates an 'easy going', blame-free environment for the mentee to develop knowledge and skills [2,3,24,39].Much of the training that mentors provide take the form of role modelling where mentors showcase professional and moral values and behaviour in clinical and academic practice [8,9,10,11,27,29,30].

Sponsor and advocate
The mentor assists a mentee in career planning, providing them with networking opportunities [3,11,27,37 40] and act as benefactors and advocates for their mentees to advance their careers and research opportunities or in the face of challenges that may arise [26,27,30,42].

Characteristics of a good mentee 8.1 Goal setting
Carl Rogers emphasizes that the mentoring relationship should be centred on a mentee's goals and propelled by the initiatives of the mentee [45].A mentee should be able to evaluate their needs, state their mentoring goals and be responsible for working toward these goals with his mentor's guidance [5,11,25,28,35].

Characteristics of a mentee
A teachable spirit is crucial to being an effective mentee as is being flexible, humble and appreciative [5,11,28,36].Mentees should be open, honest and reflective so as to facilitate open communication [5,11,25,28,33,36].

Advice to mentees
A suitable mentor can be challenging to find, selecting the right mentor is crucial [4,29,36].It is suggested that mentees identify their own educational and development needs and seek out mentors based on these [9,35,36].A single mentee may consider having multiple mentors at different points of one's career due to diverse needs and as one's professional and personal journey evolves [2,10,27,39,42].

Benefits to mentee
The ways in which mentoring contributes career progression and personal growth is described below:

Research and academia
Mentees who receive mentoring in research and academia have been shown to have increased research output and increased success in obtaining grants [1,4,6,10,13,33,42,46,47]. Through mentoring, mentees also learn the hidden rules of scholarship which they may struggle to grasp otherwise [10,46].

Being a better learner
A good mentor sparks the desire to learn in the mentee and inspires a mentee to think out of the box and intellectual curiosity [3,9,24,34,37].They also instill in the mentee a sense of history and belonging to the profession, helping the mentee to develop a strong professional identity [9,25,40,42].

Conclusion
There is little doubt that palliative care training and development would benefit from the integration of mentoring and the provision of holistic support to trainees and junior practitioners.The longterm impact of mentoring articulated in this review of mentoring perspectives, editorials, opinion pieces and commentaries infer a great many positives to mentoring practice.The key themes identified in mentoring practice resonate with many facets of Palliative Care practice and should ensure easy integration of mentoring practice within prevailing practice and training.However, there are significant gaps in the understanding of mentoring practice.Despite evidence of consistent themes within mentoring practice in prevailing mentoring practices in medicine and internal medicine there is little data on how this approach to training and support can be implemented within a multiprofessional setting.Whilst it was not the goal of this review to forward a better understanding of prevailing mentoring practice in medicine but merely to provide a better appreciation of the long-term benefits of mentoring, scrutiny of the data does suggest that there is great variance in the manner that mentoring is practiced.Similarly a lack of data of mentoring in palliative care and regnant gaps in our understanding of the viability and efficacy of mentoring novices from different professions and specialties within palliative care serve to heighten concerns about effective means of applying mentoring in palliative care.There is no evidence that the mentoring approaches employed by the various professions involved in multi-professional palliative care practice are similar and easily transferable to other settings and specialties.Growing concern about the ill effects of mentoring also necessitate careful scrutiny of prevailing practice and demand the employ of more robust and effective research methods than currently available in order to forward evidenced based practice guidelines on mentoring are required.Despite these gaps this review highlights that there is a future for mentoring in palliative care albeit with the caveat that this is only possible with context specific studies of mentoring and careful scrutiny of mentoring approaches.Thus the future of mentoring in palliative care must begin with a new chapter of study of mentoring in multi-professional settings if the undoubted benefits of mentoring are to be effectively realized within the palliative care setting.