A scoping review of mentor training programs in medicine between 1990 and 2017

ABSTRACT Effective mentoring enhances the personal and professional development of mentees and mentors, boosts the reputation of host organizations and improves patient outcomes. Much of this success hinges upon the mentor’s ability to nurture personalized mentoring relationships and mentoring environments, provide effective feedback and render timely, responsive, appropriate, and personalized support. However, mentors are often untrained raising concerns about the quality and oversight of mentoring support. To promote effective and consistent use of mentor training in medical education, this scoping review asks what mentor training programs are available in undergraduate and postgraduate medicine and how they may inform the creation of an evidenced-based framework for mentor training. Six reviewers adopted Arksey and O’Malley’s approach to scoping reviews to study prevailing mentor-training programs and guidelines in postgraduate education programs and in medical schools. The focus was on novice mentoring approaches. Six reviewers carried out independent searches with similar inclusion/exclusion criteria using PubMed, ERIC, EMBASE, SCOPUS, Google Scholar, and grey literature databases. Included were theses and book chapters published in English or had English translations published between 1 January 1990 and 31 December 2017. Braun and Clarke’s approach to thematic analysis was adopted to circumnavigate mentoring’s and mentor training’s evolving, context-specific, goal-sensitive, learner-, tutor- and relationally dependent nature that prevents simple comparisons of mentor training across different settings and mentee and mentor populations. In total, 3585 abstracts were retrieved, 232 full-text articles were reviewed, 68 articles were included and four themes were identified including the structure, content, outcomes and evaluation of mentor training program. The themes identified provide the basis for an evidence-based, practice-guided framework for a longitudinal mentor training program in medicine and identifies the essential topics to be covered in mentor training programs.


The need for this review
Growing concerns about lapses in professionalism and abuse of the mentoring process [80][81][82][83][84][85][86] have underlined the need to move mentor training from a 'learned from examples, trial and error and peer observations' approach to a more organized and regulated process [40,68,87]. A scoping review of mentoring programs in medicine is necessary to explore the potential size and scope of available literature on mentor training in published peerreviewed and prevailing grey literature [88][89][90][91][92].
With Johnson and Gandhi (2015) commenting that most senior mentors are not trained, the imperative to delineate core training elements and an effective approach to mentor training is evident. Adopting Levac et al.'s (2010) refinement of Arksey and O'Malley's (2005) framework for scoping reviews, we confine focus upon mentor training within a clearly defined mentoring approach that will better inform subsequent research projects [88,92,93]. Focus upon novice mentoring which is defined as a 'dynamic, context-dependent, goalsensitive, mutually beneficial relationship between an experienced clinician and junior clinicians and/or undergraduates that is focused upon advancing the development of the mentee' [6] also helps circumnavigate the limitations posed by mentoring's nature [1,[3][4][5][6]93,94]. Similarities between novice mentoring practices in undergraduate and postgraduate programs and novice mentoring and research mentoring in medicine which is defined as 'a dynamic, collaborative, reciprocal, and sustained relationship focused on an emerging researcher's acquisition of the values and attitudes, knowledge, skills, and behaviours necessary to develop into a successful independent researcher' allow them to be considered together [1,[3][4][5][6]95]. The six steps proposed by Levac et al. (2010) are used to organise our methods and results [90,91,93].

Stage 1: Identifying the research question
The six-member research team discussed the research question with medical librarians from the medical library at the Yong Loo Lin School of Medicine at the National University of Singapore (NUS), medical librarians at the National Cancer Centre Singapore (NCCS) and local educational experts and clinicians at the NCCS, the Palliative Care Institute Liverpool, Duke-NUS Medical School and Yong Loo Lin School of Medicine. The research question the team decided upon was 'What is known about mentor training programs in novice mentoring and what are the core elements of the mentor training program?'. All subspecialties of Surgery and Medicine as defined by the Accreditation Council for Graduate Medical Education were included in this study given their common approaches to novice mentoring [96]. Envisioning that the content of the scoping review will guide future research into mentor training, we also considered the comprehensiveness and feasibility of these tools given the longitudinal nature of the mentoring process and the mentor training program. This review adopted a PICOS format to study mentoring programs (Table 1)

Stage 2: Identifying relevant studies
Guided by librarians at the NUS' medical library and the NCCS' medical library and by local educational experts and clinicians at the NCCS, the Palliative Care Institute Liverpool, Duke-NUS Medical School, and Yong Loo Lin School of Medicine, the six members of the research team determined the inclusion and exclusion criteria of the review. The broad nature of the research question meant that pilot searches were carried out on variations of the word 'mentor training' or 'frameworks' that appeared in the title or abstract of articles in medicine. The six members of the research team reviewed the search terms and approved the inclusion/exclusion criteria in the abstract screening tool.
Guided by librarians at the NUS' medical library and the NCCS' medical library and by local educational experts and clinicians at the NCCS, the Palliative Care Institute Liverpool, Duke-NUS Medical School, and Yong Loo Lin School of Medicine, the six members of the research team determined that Pubmed, Embase, ERIC, ScienceDirect, Scopus, Google scholar databases, and a grey literature databases including OpenGrey, Trove, Mednar, Web of Science, Open Dissertations, and British Education Index databases would be used [Refer to Figure 1].
Pilot searches were carried out on variations of the word 'mentor' and 'training' that appeared in the title or abstract of articles were performed using GreyLit and PubMed databases. Applying the abstract screening tool that the research team designed, the six members of the research team independently read through the abstracts of all the articles identified in the pilot and applied the inclusion/exclusion criteria in the abstract screening tool to the abstracts retrieved. Having discussed the individual results of their pilot searches online and at face-to-face reviewers' meetings, the six members of the research team reviewed the search terms and employed Sambunjak et al.'s 'negotiated consensual validation' approach [97] to achieve consensus on the inclusion/ exclusion criteria for the search. The six members of the research team agreed that all research methodologies (quantitative and qualitative) written in English or had English translations would be included. Excluded from the review were articles that did not confine themselves to mentor training in medicine.
The search was confined to years 1 January 2000-31 December 2017 as papers before the year 2000 often conflated mentoring with supervision, role modelling, coaching, advising, networking, and/or sponsorship [1,[3][4][5][6]. There was little change to the inclusion/exclusion criteria following the pilot searches.
The finalised search strategy included the keywords: 'mentor training', 'mentorship training', 'mentoring competency', 'faculty development' AND 'medical faculty' and their combinations and used in all databases. The same keywords were used for all the databases. All allied health specialities (e.g., dietetics, nursing, psychology, chiropractic, midwifery, social work) and non-medical professions (e.g., science, veterinary, dentistry) were excluded. Mentoring training in peer, near-peer, group, mosaic, patient, family, youth, leadership, mixed and e-mentoring, role modelling, coaching, supervision, networking, and/or advising were excluded.

Stage 3: Selecting studies to be included in the review
The five members of the team adopted similar search strategies to carry out independent searches for articles about mentoring training in novice mentoring involving the agreed upon databases. All searches were carried out between the 18 July 2018 and the 18 September 2018. Using inclusion and exclusion criteria of papers agreed upon by the research team, titles and abstracts of the papers were independently reviewed by each member of the research team. To ensure concordance and consistency in the search approach, each author examined approximately 50 titles and abstracts using the same search terms, database, and the abstract screening tool and compared their results in online discussions with all the team members. Once clarity on the search terms, inclusion, and exclusion criteria were established, the reviewers proceeded to carry out their independent searches of the agreed upon databases. For the first database being searched, each member of the review team worked on the same batch of 200 titles and abstracts and compared their findings at a weekly face-to-face meeting that were supplemented by online discussions in the event consensus could not be attained and the full-text had to be downloaded and discussed by all the team members. The six-member research team used Sambunjak et al.'s 'negotiated consensual validation' approach [97] to achieve consensus on the final list of articles to be included in the scoping review [Refer to Figure 1]. All the articles from the final list of included articles were then downloaded and reviewed independently by each author for inclusion into the study. Each study team member then imported the titles meeting the inclusion criteria into EndNote, to remove duplicates, organise the references, and create their individual lists of abstracts to be studied. The individual lists were 68   discussed at research team meetings where Sambunjak et al.'s (2010) approach of 'negotiated consensual validation' [97] was used to reach consensus on a final list of abstracts to be studied.

Stage 4: Data characterisation and analysis
To carry out a comprehensive review of what is known of mentor training in novice mentoring requires comparing the findings of diverse studies. This process is complicated by mentoring's nature which limits studies to mentoring programs in similar specialities, settings, healthcare and educational settings, and mentor and mentee populations. Similar obstacles have been faced with studies of mentoring approaches, the matching process that pairs mentees and mentors, Mentoring Relationships (MRs), and the mentoring culture. To circumnavigate these restrictions, studies of matching, MRs and mentoring culture have adopted Braun and Clarke's approach to thematic analysis [98] to identify consistencies across dissimilar settings, goals and mentee and mentor populations. Braun and Clarke's approach to thematic analysis [98] also circumnavigates a wide range of research methodologies present amongst the included articles which prevent the use of statistical pooling and analysis [98][99][100]. Thomas et al. (2014) also highlights that thematic analysis is necessary when studying socio-culturally influenced educational processes such as mentoring.
To evaluate the consistent elements within prevailing mentoring tools and discern the approaches that underpinned the design of these tools the fivemembers research team worked independently constructing 'codes' from the 'surface' meaning of the same 15 included articles. Thematic saturation was attained after nine articles. The coding process began with line-by-line coding, followed by focused coding 'evolving to produce categories that responded to these codes [101]. The authors discussed their analysis online and at the author's meeting to agree upon a common coding framework and code book using Sambunjak et al.'s 'negotiated consensual validation' approach [97]. Using the common coding framework and code book, the authors independently coded the articles from the 'surface' meaning of the data 'across the entire data set' and the 'detail rich' codes were grouped together to identify semantic themes [98,102]. The data was regularly reviewed to ensure all relevant excerpts were coded [98,103]. The themes, coding framework, and code book were also constantly reviewed as part of the iterative process employed within the study [3,98,103]. The authors met face-to-face and online to discuss their themes and Sambunjak et al.'s 'negotiated consensual validation' approach [97] was employed to achieve consensus on the final list of themes.
To highlight the wealth of data being reviewed, Arksey and O'Malley's (2005) descriptive-analytic method was employed [88,93,104] to help contextualize the articles being reviewed and to help the coding process. The descriptive-analytic method records information about the '"process" of each programme or intervention included in the review so that its "outcome" is contextualized and more understandable to readers' [88]. To ensure consistency in this process and comparability with prevailing reviews, the authors adapted the data charting form used by Tan et al. (2018) to chart the characteristics of all 49 articles included in this scoping review which included author details, year of publication, purpose of the study/research question, practice setting, methodology, population characteristics, and outcome evaluation (variables of evaluation, evaluation responses, and effectiveness of implementation). (Table A1) Stage 5: Collating, summarising, and reporting the results In total, 4602 titles were reviewed, 3355 abstracts were scrutinised, 232 full-text articles were identified, and 68 articles were included in this scoping review. In keeping with Arksey and O'Malley (2005) and Levac et al.'s (2010) recommendations, this section will consider the 'numerical and thematic analysis' [88,93].

Themes
Thematic analysis revealed four themes: structure, content, outcomes, and evaluation of the mentor training program.
Design of mentor-training programs pivots on three domains. The first domain relates to the host organization and its goals, curriculum, mentoring approach, support of the program and its mentoring guidelines, professional standards, and codes of conduct. The second domain relates to the mentor and their availability, motivations, interests, competencies, abilities, experiences and sometimes competing for duties [7,[9][10][11]15,17,30,46,50,95,106]. The third domain considers the trainees and their needs, motivations, goals, abilities, experiences, commitment, and desired characteristics of a mentor [7,[9][10][11]15,17,23,30,50,95,106,110]. Tillman et al. (2013) noted that to meet the mentees' desire for mentors with experience, qualifications and academic standings, most programs recruited experienced clinicians-scientists [1,[3][4][5][6]. Duration and frequency of mentor-training sessions Mentor-training was carried out in 'bursts' of two to nine sessions per month [11,78,109] or 'stretched' over six to nine months and/or over different phases of the mentoring program [76,77]. 'Burst' programs last about 2 h whilst 'stretched' programs tend to be between 6 h to two full days in duration [73,78,105]. Various combinations of 'burst' and 'stretched' sessions have been proposed although the rationale for these designs was not specified [11,40,41,76]. Fornari et al. (2014) recommended that training begins at the start of the semester to help prepare mentors for their roles and responsibilities.

Modes of delivery
One-off orientation program. Most programs mandate attendance of orientation programs and most supplemented these programs with either webbased, face-to-face, and/or peer training [109].
Lunchtime sessions. Lunchtime sessions focused on sharing personal experiences and ideas in small groups of four to five individuals [77], interactive case-based discussions or seminars [11,77,105,108].
Role-plays. Role-plays were used to demonstrate mentoring skills [105] and constructive peer feedback [76].
Small group discussion. Consisting of 6-14 participants small group discussions focused on teaching approaches [77], grant writing [11] and fostering mentor relationships, independence and work-life balance [40], challenges to communication, promoting mentoring of women and under-represented groups, reflections [78], and problem-solving [11,105].
Seminars. Schmidt et al. (2010) ran six seminars on the required skills and roles of the mentor [107] whilst Feldman et al. (2012) employed 10 case-based seminars over 5 months delivering skills-based exercises, case discussions and 'key information relevant to all mentors'. The 'Entering Mentoring' seminar discussed strategies, created a forum for discussions and provided an opportunity for reflection [40,41,43].
Workshops. Workshops last a day or two and were more didactic [40] and theoretical [111], addressed practical issues [73] or special interest topics [73,78,105,108,111], updates to the program, interpersonal, communication, organizational, diversity training and knowledge and skills training, and guidance to new mentors [11,12,17,45,110,112]. Johnson and Gandhi (2015) reported improved mentoring competencies, self-efficacy scores and confidence in dealing with diversity following a 2-day workshop.
Forum. Open forums allowed mentors to discuss their experiences and review changes to the program [32].
Mentoring for mentors. Having new mentors shadow and then mentored by senior mentors provides training and support for new mentors [11,113,114]. Though pairing mentors to mentees was primarily mentee-initiated and based on research and career interests and/or skills [113], Bland et al. (2015) reported that matching resulted in higher research activity while Shollen et al. (2014) found that menteeinitiated matching resulted in increased career satisfaction. A combined matching process has been proposed as a means of reducing mismatches and failed relationships [115,116]. Feldman et al. (2012) reported the use of an online platform to facilitate the creation of mentoring networks that provide mentees with specific, accessible and timely support [117][118][119].

Training content
The importance of appropriate training content is underlined by evidence that up to 15% of mentoring relationships failed as a result of mentors not understanding their obligations [115]. Only three [120] mentor training programs were 'field tested' [11,40]. The topics covered were determined by the program developers and the 'general' [73,74,78,109] and 'specific' needs of the mentors [77]. Selection of 'specific' mentoring topics was informed by the particular needs, context, and goals of the mentoring program, the mentor's experience and knowledge on the topic, the characteristics and needs of the mentee and the problems faced by mentees, mentors, and mentoring relationships within the program [11,77,114]. In the clinical research setting, for example, mentors were trained to promote interdisciplinary research, research design, grant writing [77], clinical research skills, and preparation of articles for publication [95,121].
The topics covered in general mentoring skill training include communication skills [122], aligning expectations [11,78,95,109], establishing and overseeing compliance of codes of conduct, standards of practice, timelines and the roles and responsibilities of mentors and mentees [71], assessing professional development [114], and mentoring progress [78,95,109]. Additional topics include promoting professional development, handling difficult scenarios, challenging mentees effectively, nurturing mentoring relationships [12], addressing diversityrelated issues [45,123], fostering independence [40,46,73,77,78,97,105,111], role modelling, networking, career advising and guidance on publications, promotions, departmental politics and addressing psychosocial issues [114,119]. Pfund et al. (2014) adapted the Entering Mentoring [124] program that focuses on maintaining effective communication, aligning expectations, assessing understanding and diversity, fostering independence and professional development and articulating a mentoring philosophy and plan [16] to the clinical research setting and found an improvement in competencies in all domains.
General teaching skills training include how to deliver curriculum content, use of educational tools and new approaches [78], demonstration of practical skills through role-play and case discussions [77,78,105], debriefing and providing and receiving feedback [46,77,111]. Other topics also include interpersonal, motivational, coaching, research, selfefficacy, networking, ethics, disciplinary, teaching and technical skills training [95], active listening, building relationships, career guidance, and cultural sensitivity [16,27,95,112].
Augmenting the mentor training program Many programs augment mentor training programs with the peer, near-peer, online [120], 'functional' (skills based or project-based mentoring) [29,113], mentoring committees and mentoring networks. Mentor consultation services and mentoring committees [11] provide mentees with the additional mentor and peer mentor support whilst mentoring networks [29] provide a mix of peer and faculty support. Online services [122,125] provide mentors and mentees with supplemental resources including information on best mentoring practices and links to resources, such as mentoring agreements and individual development plans.
Peer support network A support framework for mentors during the training such as the Peer-Onsite-Distance model helps mentors network and support one another [46].

Obstacles to mentor-training programs
The main obstacles to mentor training programs are a shortage of trained mentors, a lack of appreciation of mentor training and a lack of time, funding and accountability in designing and coordinating the mentor-training program [27,30,115,121,122,126]. The role of the host organization in supporting these programs also remain poorly elucidated [27,115,122,127].

Evaluating mentor-training programs
Investment in time and resources demand evaluation of mentor training programs. Yet many prevailing assessment tools are limited to pre-and post-assessments and self-rated tools [45,74,76]

Surveys
Anonymized mentor surveys have been used to identify the most and least effective parts of the training program, changes in the participants' views over the course of the program, and suggested improvements for future training sessions [77,78]. Surveys also assess participants' satisfaction, the abilities of the facilitator or presenter [105,108], the relevance of the teaching material and extent to which the training objectives were met [76][77][78]. Surveys 6 months after the program [77,108] or at the latter part of a 6-month-long training program [76] are used to capture changes to the mentor's life and work [76], mentor competency, and mentoring effectiveness [108]. The Mentoring Competency Assessment measures changes [12,41,122,125] in communication, aligning expectations, assessing understanding, addressing diversity, and fostering independence [69,125].
The Mentorship Knowledge Test assesses contentspecific knowledge [103] whilst Lau et al. (2016) compared baseline and post-workshop mentorship competencies.

Stage 6: Undertaking consultations with key stakeholders
Stakeholders were consulted on the findings of this scoping review. To highlight the strength of the data to garner and to underline the critical nature of the findings, a quality appraisal of the articles was carried out using the Medical Education Research Study Quality Instrument (MERSQI) and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) ( Table A1). Whilst scoping reviews are not traditionally associated with quality assessments, the pool of papers identified in the searches were deemed sufficiently robust to undergo quality assessments. To contextualise the findings, the stakeholders were presented with the table created as part of Arksey and O'Malley's (2005) descriptive-analytic method [88].
This contextualised and quality appraised data enhanced discussions with stakeholders and garnered their views on the relative importance of a mentor training program, the cost-effectiveness and viability of implementing the findings and also aided input into focus for future studies.

Discussion
This scoping review highlights the increasing importance placed upon mentor training [95] in novice mentoring [7][8][9][10][11]15]. However, despite evidence that mentor training improves knowledge, skills and attitudes and the need to support mentors in diverse settings [7,[9][10][11]15,17,27,30,50,95,106,121] to meet the changing needs of their mentees [7,9,10,15,17,30,50,106], adoption of mentor training programs has not been uniform particularly in clinical medicine, and informal mentoring programs. This scoping review also sketches the range of available mentor training programs and their content and approaches, the domains being evaluated and the key obstacles to effective mentor training. In so doing, this scoping review highlights the variability in the construct, content and focus of mentor training programs which inevitably impacts practice and oversight of mentoring programs, relationships, and processes [128].
Whilst it was our intention to appreciate the scope of available literature and tools on mentor training in novice mentoring, it is evident that this mere sketch albeit an expansive one lacks depth [128]. This limitation is largely the result of incomplete reporting of prevailing mentor training approaches, the contents of these programs, the manner that the training and the trainees are evaluated and how the program is able to provide effective support for mentors in training. Further limitations to this review lie in this scoping reviews' adoption of a pragmatic approach that balances practicality and available resources and focuses upon publications in English and those that had English translations. A further limitation to the generalizability of the findings of this scoping review is the presence of a small pool of papers included in this scoping review and the preponderance of American and European papers that limit their global impact. Reliance upon self-rated scales [41] and tools still rooted in 'Cartesian reductionism and Newtonian principles of linearity' [129] that fail to consider the evolving nature of the mentoring process [1,[3][4][5][6] also underline the need for a systematic reviews.
However, despite these limitations, this scoping review was carried out with the required rigour and transparency advocated by Arksey  We believe the findings of this scoping review will be of interest to educators and program designers in undergraduate and postgraduate settings and will help inform the design of future mentor training programs.
The lack of consensus and gaps in evidence on the best approach, necessary content, quality assessment of the programs and evaluation of the competence of mentors following training, also underscore the need for a systematic review of mentor training in medicine.

Directions for future research
Actualising a consistent mentor training program depends on evaluations of the mentoring process. To facilitate this goal, a critical area for future study must be a design of effective tools to assess mentoring competencies and efficacy longitudinally and holistically. It is only thus, can mentoring in medical education develop to its full potential. this manuscript This paper is dedicated to the late Dr S. Radha Krishna, whose advice and insights were critical to the conceptualization of this review.

Disclosure statement
No potential conflict of interest was reported by the authors.