Background
Methods
Study design
Setting
Participants
Selection and preparation
Multimodal delivery
In-person mentorship | Tele-mentoring (Project ECHO) | Smartphone App (WhatsApp) | |
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Description | On-site mentorship by multidisciplinary mentorship team to surgical team at each facility focusing on technical and non-technical skills | Telementoring sessions using a hub (mentors and international faculty) and spokes (surgical teams at 10 facilities in two regions). Open to all providers at facility | Regional WhatsApp groups including mentors and surgical teams at 5 facilities in the region |
Frequency | 2 days every 2 months | 80-min weekly sessions | As needed over 24 h, 7 days a week |
Focus | Mentorship on three tracks: clinical, data and patient pathway Facilitation on development and implementation of the Quality Improvement Action Plan Problem solving on perioperative and organizational challenges Technical support on Facility Accelerator Fund priorities Advocate on surgical priorities with facility and regional leaders | Didactic presentation on safe surgery topics Presentation of a best practice or challenging case by one facility Discussion and feedback on case by peers and mentors Promotion and dissemination of clinical updates and recommendations | Communication by mentors, mentees, and safe surgery program team Advice on management of patients Sharing of monthly postsurgical infection rates and other program indicators by each facility Sharing of successes and challenges |
Examples of mentorship activities | Side-by-side mentoring on the Joel Cohen cesarean section technique to reduce postoperative complications Coaching on the SSC in the OR by explaining why something is important and how to perform it effectively Coaching on screening, classification and management of surgical site infections during ward rounds | Presentation and demonstration on standards for sterile processing of surgical instruments Training sessions for hospital technicians and biomedical engineers covering various issues related to hospital equipment maintenance and repair Presentation on how to manage four types of post-partum hemorrhage by mentors, followed by a case presentation by a surgical team and discussion by surgical providers and mentors | Mentee in a remote facility sends a message on a patient’s condition including photos and X-ray or lab results. Mentor provides guidance on patient management Mentors share short video clip and photos demonstrating the B-Lynch procedure for the management of post-partum hemorrhage Mentees submit monthly postsurgical infections rates. Mentors provide advice on strategies for improvement. Peers cheer or send encouraging messages |
Data collection and analysis
Data collection
Data analysis
Results
Facility characteristics (N = 10) n (%) | |
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Level of facility | |
Health Centers | 2 (20) |
District Hospitals | 6 (60) |
Regional Referral Hospitals | 2 (20) |
Geography | |
Rural | 5 (50) |
Urban | 3 (30) |
Suburban | 2 (20) |
Number of inpatient beds | |
0–100 | 3 (30) |
101–300 | 6 (60) |
300 + | 1 (10) |
Average monthly major surgeries per facility | 90 |
Average number of surgical providers per facility | |
Surgeons | 0.2 |
Obstetricians/gynecologists | 0 |
Anesthesiologists | 0 |
Medical Officers performing surgery | 4.1 |
Assistant Medical Officers performing surgery | 3.7 |
Non-physicians proving anaesthesia | 2.8 |
Participant characteristics | |
Survey (N = 25) n (%) | |
Role | |
Surgical provider | 11 (39.1%) |
Anaesthesia providers | 5 (21.7%) |
Nurse | 7 (30.4%) |
Other (facility leader also a surgical provider) | 2 (8.7%) |
Years in role | |
< 1 year | 1 (4.3%) |
1–3 years | 7 (30.4%) |
3 + years | 14 (60.9%) |
Missing | 1 (4.3%) |
Present for mentorship visits | |
< 3 | 3 (13%) |
3 + | 18 (78.3%) |
Missing | 2 (8.7%) |
Interviews (N = 45) n (%) | |
Role | |
Mentees | |
Surgical provider | 12 (26.7%) |
Anaesthesia provider | 5 (11.1%) |
Nurses | 11(24.4%) |
Facility leader | 9 (20%) |
Mentor | 8 (17.8%) |
Focus Groups (N = 10) | |
Attendees per focus group (surgical providers, anesthesia providers, facility leaders) | 4–15 |
Themes and sub-themes | Illustrative Quotations* |
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Valuable elements of the mentorship intervention | |
Multimodality of the mentorship intervention | They are all valuable, because they all depend on each other and none can stand on behalf of the other. (Surgical Provider, Region 1, Facility 2) |
Supportive side-by-side clinical coaching | They will perform the first case and we observe and identify the gaps that they have. The second case we all scrub in together -both the mentors and the mentees – and we can perform together so in that way we can impact the knowledge through doing procedures together. (Mentor 1) |
Standardization of practices | Nowadays we hardly forget the use of the checklist. The theater staff now has a system of preparing the trays for vaginal cleansing prior whereas in the past days that was not present. Therefore, when there is a ruptured membrane you could just order for a tray that has been prepared and sterilized so it has changed the way people work. (Region 1, Facility 3, Facility Leader) |
Useful features of the mentor–mentee relationship | |
Relationship-building | If you have a mentorship relationship it has to be close. Even if you have something it can be easily shared with them. This makes it easy even to share knowledge and interest between mentors and mentees and it can increase the relationship, because you know each other even outside work and if you have something to ask you may communicate with him or her. (Region 2, Facility 4, Surgical Provider) |
Friendliness | We get feedback from mentees and most of the time, they give us feedback that they benefitted from what we offered them and the way we offered is friendly…and we participated as part of their team. And all this is because we had training before we performed mentorship compared to the formal medical training in Tanzania where there is a gap between a lecturer and a student. (Mentor 5) |
Psychological safety | It is a fine one, because someone who is not a dictator to you, you may have a conversation and you are able to exchange views. We are comfortable to admit mistake and ask questions and help. (Region 2, Facility 4, Surgical Provider) |
Mentors as part of the surgical team | The relationship is good, because when they come here we work together and they become like team members of the facility. We work together like team members for quality improvement of services. (Nurse, Region 1, Facility 4) |
Understanding of context | Mentors were trying to understand the local context and condition of the facility, and we started from the entrance gate. (Region 2, Facility 3, Nurse) |
Helpful characteristics of the mentor | |
Non-judgmental feedback | The mentors were not judgmental as in once you fail they will not judge you. So it is a conversation. They tell you something and you will ask questions and they will correct like ‘do this and you were not supposed to do this’ in a guiding manner and they give a chance to ask questions. (Surgical Provider, Region 2, Facility 4) |
Mentor experience level | I think when you bring mentors at the facility, they should be senior mentors. For example, I am a senior nurse anaesthetist. When you bring a mentor that is junior to me like someone who has been practicing for less than 6 months in the field then usually cannot add value to me. (Anaesthetist, Region 2, Facility 1) The mentors are skilled, the whole team is skilled from the surgeon, anesthetist and the nurse are all skilled so when they come and they face the challenges of the facility they can assist and tackle together with discussion. (Region 1, Facility 1, Surgical Provider) |
Accessibility of the mentor | They leave behind their numbers and they let people know that they are available so when someone is in trouble they can contact them…There was a time they [surgical team] had a fistula patient, they communicated, and they found a way forward so it has been a team. (Facility Leader, Region 2, Facility 2) |
Challenges to mentorship | |
Resistance/lack of buy-in | The challenge is some of the providers were taking this program like it belonged to those that only attended the [SS2020] training. They were not ready to involve directly on the mentorship program so sometimes you may find that when mentors come to the facility there is high effort used to get all members that are needed for the program. There is still some resistance at the facility in relation to the mentorship program. (Surgical Provider, Region 1, Facility 2) |
Shortage of surgical providers | Some of the barriers are time, because you may find people have other activities to attend to during the time of presentations/sessions…Another thing is the shortage of staff. Providers may be alone in the ward and it is difficult for them to leave patients and attend the sessions. (Focus Group Discussion, Region 1, Facility 2) |
Mentorship dose | I think the frequency can increase – at least that they should come monthly and they could stay at least if possible for a week for the mentorship. (Region 2, Facility 1, Surgical Provider) |
Logistical challenges | The main problem in this is the language barrier, because our country is based very much on Swahili…It would be better to have handouts and translation if possible in Swahili. Sometimes the internet is a problem and it is not stable. (Focus Group Discussion, Facility 1, Region 1) |
Perceived mentorship impact
Valuable elements of the mentorship intervention
Multimodality of the mentorship intervention
Supportive side-by-side clinical coaching
Standardization of surgical practices
Helpful features of the mentee–mentor relationships
Relationship building
Friendliness
Psychological safety
Mentors as part of the surgical team
Understanding of local context
Useful mentor characteristics
Non-judgmental feedback
Mentor experience level
Accessibility of the mentor
Challenges to mentorship
Discussion
Intervention design | |
• A multimodal mentorship intervention design using both in-person and virtual platforms can support different types of learning (e.g., tacit or explicit). The different platforms complement and reinforce each other, contributing to continuous and deeper learning | |
• Mentorship is optimized when it is part of a multicomponent intervention. Training mentees and mentors on evidence-based practices before mentorship ensures that everyone is working to implement the same standards for safe surgery | |
• A team-based approach to mentorship can provide discipline-specific mentorship (e.g., nurses mentoring other nurses), and reinforce a culture of shared learning | |
• To improve the intervention, there should be opportunities for reflection and learning. Incorporating time for bi-directional feedback, such as debriefing after each visit, at annual meetings, and evaluations can strengthen future intervention design | |
Mentors | |
• Selecting the right mentors is key. Subject matter expertise and strong interpersonal and communication skills are crucial. Selecting local mentors can facilitate cultural congruence and an understanding of context, relatability, and language. Local mentors can also train new surgical providers more frequently and engage in peer-to-peer learning to diffuse knowledge quickly and continuously | |
• Preparation of mentors should cover subject matter expertise, change management skills, and mentorship skills, such as relationship-building, communication and feedback, and effective teaching. Pairing junior mentors with experienced mentors can also be considered to strengthen mentorship skills and confidence | |
• Mentorship requires resources. Mentors need protected time away from clinical work to prepare and conduct mentorship visits as well as resources for coordination, training, and support. Options for incentivizing mentors through compensation, continuing education credits or other incentives like certification should be considered | |
Implementation | |
• A Quality Improvement Action Plan can facilitate a shared understanding about the overall improvement goals of the intervention. An action plan can lay out a clear strategy (e.g., specific actions, responsibilities, timing and means of verification) and can provide a framework for assessing progress and setting goals for the next visit | |
• Buy-in from the surgical team is essential before starting the mentorship intervention; they must understand the goals. It is especially important to address those who are less ready to change. Whole-site orientation and training and engaging facility leaders in mentorship can increase buy-in | |
• Leadership support and engagement from facilities, district and regional leaders is necessary for success. Leaders can support staff in implementing mentoring activities, release staff time, and assist in setting up QI systems. Furthermore, leadership support is crucial in sustaining surgical quality improvement. Mentorship cannot work if leadership is not receptive to it | |
• Time constraints must be considered for mentees and mentors. Health facilities in low-resource settings are often faced with staff shortages. Mentors also have competing work and personal demands. Therefore, implementation must consider providing surgical providers the time to learn and improve, timing of sessions, lowering work burden, and revamping tools for efficiency for both mentees and mentors | |
Sustainability | |
• Building a culture of mentorship is necessary for sustainability. Mentorship is a promising approach for scaling surgical quality and requires policy support to institutionalize it. Mentorship should be incorporated in the safe surgery space, linked to continuing professional development systems, and should be incorporated in the District plans and budget. Training a pool of local multidisciplinary mentors is critical for cost effectiveness and sustainability |