Barriers
Physical resources (care provision)
Over three-quarters of participants cited lack of physical resources, including supplies and equipment, as a barrier to care provision. Resources that were often unavailable or non-functional included autoclaves (for sterilization), gloves, labor tables, intravenous catheters, and suction bulbs.
“Here [beginning of the program], they are not using any instruments and they are conducting deliveries even without gloves.” (Age 24, 12 months mentoring)
Several participants described persistent shortages of uterotonics, antibiotics, intravenous fluids, and antihypertensive agents. When medications were out of stock, patients or their family members were asked to purchase medications from outside pharmacies or, in emergency cases, nurses sometimes purchased medications for patients.
“Once there was a patient with severe pre-eclampsia… We used to ask them to make something available, but they used to not make it available at all… Her BP was very high, so what could we do? We had to give her nifedipine. We had magnesium sulfate in that place, but what to do about nifedipine? We did not have nifedipine there. We can’t leave the patient, as her BP is so high… and how can we refer her with this high BP? We had to reduce her BP, so we went to get nifedipine from the outside.” (Age 22, 9 months mentoring)
“Drugs were not at all available, so we ourselves have to go to store, tell the MOIC [Medical Officer In-Charge] about the drugs which are missing, medicines which are missing… We have to go and speak because the nurses would say, ‘Sister, we are fed up of telling them again and again, nothing is happening.’” (Age 23, 9 months mentoring)
Facility layout (care provision and mentorship)
Mentors stated that distance between labor rooms and training rooms, where simulations were often conducted, was a common barrier to timely provision of emergency care and to mentorship.
“Our training room... it was far from the labor room... we had to see the patient and also the training too... we did not get to know when a patient came in full dilatation and her delivery was done in the ward... ASHA came and shouted at us so much, saying, ‘Did you come here to see patients or to kill them? Patient’s delivery is happening in the ward and you all are not seeing it.” (Age 22, 9 months mentoring)
Human resources (care provision and mentorship)
One-quarter of participants described staffing shortages as a significant barrier to both care provision and mentorship. They explained it was common in PHCs for a single nurse to cover the outpatient department, immunization duties, emergency room, and labor room. Further, participants stated that heavy delivery loads made it difficult to find time to conduct simulations. In addition, several explained that mentees were frequently assigned to night duty before or after training, leading to fatigue with a negative effect on work performance.
Doctor-nurse hierarchy (care provision)
Nearly three-quarters of participants stated that many doctors in PHCs failed to follow evidence-based care guidelines, citing this a major barrier to care provision. Further, doctors frequently argued with nurses who attempted to follow such guidelines.
“I think they [mentees] are not... trusting in our mean doctors... In complication management, what we are telling them [mentees], doctors are telling some other things... so they are in conflict to listen to us or the doctor.” (Age 24, 10 months mentoring)
“’Sir [speaking to doctor], this is... PPH is happening, so we have to give’... He [doctor] will tell, ‘No, no, give dexamethasone’... We told him, ‘Actually sir, let’s not give dexamethasone... What if we start RL [Ringer’s lactate] today... as it has been given in the guidelines that we should do all these steps.’ Then he [doctor] told, ‘You don’t have to teach us... we know how we should manage.’” (Age 22, 9 months mentoring)
Almost half of participants stated that doctors were unwilling to treat complications, instead instructing nurses to immediately refer such patients. Several participants felt this was due to doctors lacking of a sense of responsibility for patient care.
“If there is a complication, they [male doctors] will not see the patient. They will ask the sister and then just order... ‘Ok, you want this medication to be written, I’ll write this’… attitude is there. And if there is a female [doctor]... she will be getting so much irritated… ‘Why are you calling every time? This is not normal process, natural process. You have 35 years’ experience, do nicely.’… They are fighting with sisters like that.” (Age 22, 18 months mentoring)
“Some MOICs and some doctors have even told us in a way like, if the mentees face any problem, then refer the patient as fast as possible. If the patient dies, then it will be out of our boundary that the patient will die.” (Age 23, 10 months mentoring)
“If something happens here, the public will tell me only that, ‘You did not take care well’… Doctors also, even before we do anything, keep telling, ‘Refer the patient, refer the patient’… like this it happens here, so I feel that doctors should be more involved in patients’ care.” (Age 26, 18 months mentoring)
Over one-third of participants described doctors refusing to conduct rounds or see patients. Others stated that doctors were very slow to come even in emergency situations; for example, taking 10 to 15 minutes to attend to an asphyxiated newborn requiring resuscitation.
“They don’t even touch the patient... because they get paid even without touching... nobody is there to tell them... Already they are given a big position and considered in a high position... So why would they go out of the way and do hard work without any government pressure.” (Age 23, 10 months mentoring)
“[Doctors] don’t have any tension... [my] first time in Bihar, I saw two gynecologists posted in one hospital. But in that hospital also, if we are calling other after PPH... the doctor is coming after one and a half hours, where the person is going to be just collapsed.” (Age 22, 18 months mentoring)
Several participants felt that some doctors were rude and disrespectful toward nurses.
“Some doctors we have fought so much... They are making fun of us in public. They are not respecting us sometimes... we have a fight with many doctors.” (Age 22, 18 months mentoring)
“‘You can’t refer instead of me, you are not doctor... You can’t refer because you are only [a] mentor in this facility.’ Like that he was directly blaming me.” (Age 23, 18 months mentoring)
Nurse-nurse hierarchy (care provision and mentorship)
Participants described the age gap between mentors and staff in PHCs as a significant barrier to mentorship. Over half felt that older mentees commonly perceived younger mentors as lacking experience and, as a result, were resistant to learning from them. Notably, 80% of participants had no prior teaching experience and 50% had recently graduated from nursing school (Table
1).
“She [mentee] told me that, ‘I have 23 years’ experience, you were not born [at] that time I started working, so don’t teach me!’” (Age 23, 11 months mentoring)
“Like this age gap... they [mentees] used to not accept us, they used to cross question us... In starting in one of our PHCs... [mentee said] ‘These are like kids only, what they will teach us?’ But later on, when we started interacting with them... they were telling, ‘You really are teaching us new things we didn’t know.’” (Age 24, 12 months mentoring)
Several participants also discussed barriers to care provision related to seniority level and nursing qualifications. In particular, nurses with GNM degrees tended to have less respect for those with ANM degrees. As a result, some mentees were not able to practice the skills they had learned.
“We had a mentee who was really intelligent and she was of young age and she had a will to learn, and she learned all but she was not able to do her work... If she starts doing it [communication techniques], obviously, everyone will start praising her, so her senior will not allow to do her work.” (Age 24, 9 months mentoring)
Corruption (care provision)
Half of participants described various forms of corruption affecting patient care. Several stated that nurses collected money directly from patients for conducting deliveries. As a result, senior nurses often did not allow junior nurses to conduct deliveries. Participants explained that administrators commonly condoned this practice because they received a portion of these incentives.
“It’s the same ego problem, even if we tell them... in 3 weeks, you have to do this much deliveries, then they would take us to the side sometimes and say that the one who has duty, they only do, they do not let us do it... there is some issue with money, like that who does the delivery gets some money.” (Age 22, 12 months mentoring)
“If I say that, ‘We should talk to the manager that your mentee is doing like this.’ I would like to tell you that the manager is also taking money from someone, incentive from someone, so why will he stop the money... some percentage is divided, so why will they [laughs], you know, spoil their incentives.”(Age 22, 18 months mentoring)
In addition, participants described that it was common for nurses to run private clinics in their own homes to make extra money. Nurses with private clinics often prioritized these activities over their duties in the respective PHC, and many would refer patients with complications to their clinics instead of to the nearest district hospital. A monetary incentive was typically provided to doctors and MOICs to allow these practices to take place.
“It’s very common... everybody knows this.... they themselves would tell their rate, for normal delivery we take 5000, for complicated delivery we take 8000. In fact, some mentees were so... I don’t know... should I call them greedy?... There is a complication... she would say, ‘Go to my clinic, I will come.’ After the training, she would go to her clinic, and we would come to know the complication, which we had referred [to the district hospital], happened in her clinic.”(Age 23, 10 months mentoring)
Further, participants described that ASHAs received financial incentives to discourage patients from going to district hospitals and to instead bring patients to nurses’ private clinics. They stated that some ASHAs conducted vaginal exams to earn extra money, despite lack of training and being warned against this practice by supervisors in PHCs.
“ASHA used to say sometimes that, ‘No, these people are doing like this. We go to DH [district hospital], so much problems occur, it is very far and it is expensive also. So, it is better it happens here. We’ll conduct your delivery’... they will tell like that... they will go to private practice like the nurses are doing now... they will tell like this... ‘You will go to there, you will spend so much money- 5000 directly... We’ll get 4000, 3000, and we’ll do everything.’”(Age 22, 9 months mentoring)
“If the ASHA does PV [per vaginal] from home and comes, they would get money for it... They were not doing it properly and that was the problem... sometimes… after doing PV only, the ASHA used to bring... so that they did not have to wait for long time, they will bring after full dilatation, will get the delivery done... they will get the money and also the patient.”(Age 22, 9 months mentoring)
One participant explained that some administrators instructed providers not to record complications occurring in PHCs. Another described how some staff working in PHCs sold government-issued equipment and commodities for personal monetary gain.
“We’ll ask them to write all the complications... but when we go after three weeks, not many complications would have occurred... Then we came to know through the nurses that MOIC and BHM [Block Health Manager] had forced them, saying, ‘Don’t write any complication. We don’t want any complication.’” (Age 22, 9 months mentoring)
“Some persons from the PHCs are getting many things from the government, they are getting many equipments, many things, but they are selling in the private areas. They are selling and getting more money from that.” (Age 22, 18 months mentoring)
Fear (care provision)
Several participants stated that nurses in PHCs feared being blamed by doctors or authorities or being punished by patients’ families if something goes wrong. As a result, nurses often refused to manage complicated patients, instead referring them to another facility.
“[Before simulation training] mentees would not even enter the delivery room... because of fear that they won’t be able to do it alone or what would happen… ‘If anything goes wrong then the public and the doctor would beat us.’” (Age 26, 18 months mentoring)
“They are afraid in some at the higher authorities... and in some local peoples... they are fearing... because if anything happens to the patient, they kill that nurse... In Bihar, many PHCs [are] like that... If complicated cases come, they are not managed.” (Age 33, 18 months mentoring)
Cultural issues (care provision and mentorship)
Participants described an overall lack of awareness about the value of medical care during childbirth in Bihar. In addition, misconceptions surrounding the use of intrauterine contraceptive devices (IUCD) were prevalent in local communities.
“People from Bihar itself, not from anywhere... they are saying like, ‘Everyone, dogs, cows are giving birth so, yes, human beings are also giving birth, there is not much to think so much to have a tension so much... We don’t need all these things.” (Age 22, 18 months mentoring)
“Even if one [woman with IUCD] has bleeding, now then, the whole village would come to know and it would become taboo… that IUCD would lead to bleeding, then cancer, this and that, even now people say the same thing, ‘No, no, no, we don’t want to put anything inside... cancer would happen’... We would give counseling you know, we would concentrate much on pre-counseling, post-counseling, then we made it as a routine after patient delivered, but still that taboo… exactly because this thing was spread in their village, that it would lead to cancer, there would be more bleeding, they can’t have child, can’t have boy child, womb would turn.” (Age 23, 10 months mentoring)
In addition, participants stated that preference for male children was common in Bihar. This led to neglect of female newborns, with some families threatening or even abusing nurses who attempted to resuscitate them.
“We have got abused while resuscitating a female baby… ‘Why do you want to give life to her?... Before we have three baby, four baby, all the four are females, and now which delivery took place, even that is female... These people who have come from outside- because of them, this happened... That sister, if she would have conducted the delivery, we would have got a male’... So, we faced all this.” (Age 23, 10 months mentoring)
Participants also discussed several cultural barriers to simulation-enhanced mentorship. They explained that, among local communities, belief that male doctors are not allowed in the labor room was widespread. As a result, some mentees felt ashamed or uncomfortable acting as patients in simulations when male staff were present. For religious reasons, some mentees refused to lie on the labor table during simulations and others were reluctant to enter the labor room. One participant described a situation where a mentee had psychosomatic symptoms after acting as the patient in a PPH simulation, which was perceived as a bad omen by fellow mentees.
“Sometimes they have rituals… Once, one mentee… it was a PPH scenario and there was bleeding, it was the artificial blood. After going home, she started having some problems like headache and knee pain… she became very scared that, ‘No, today in the PPH [simulation], I bled so much. Because of that, I had so much problem at home.’ So, all the mentees started having this thought… that this is a bad omen. With lots of difficulty we explained to them… after that, for two days, we only acted as patients then we told them, ‘Sister, it is nothing, you see, do and see. Nothing happened to us.’” (Age 24, 9 months mentoring)
Low baseline skill level (care provision and mentorship)
Participants explained that low baseline skill level among mentees, coupled with longstanding use of non-evidence-based practices, posed barriers to both care provision and mentorship.
“Yes, actually really it’s very bad things. The practices they are using... to initiate cry in baby... They are applying oil and tapping.” (Age 24, 18 months mentoring)
“The problem is with the malpractices they follow from the last 20 years... they have learned some wrong practices, and society has given them a good name.” (Age 24, 9 months mentoring)
Resistance to change (mentorship)
Finally, participants described how resistance to change made mentorship challenging, especially at the beginning. In some cases, mentees refused to participate in training sessions due to arrogance and disinterest.
“One of our facilities... it was one of our worst facilities actually... because the mentees, the administration, all were very rigid... rigid as in their behavior, in the system they didn’t want to change. In everything, there was an excuse.” (Age 23, 10 months mentoring)
“[Mentees] would be sitting around saying, ‘It is not our duty hours, so why should we work?’ At the beginning, they used to think like that only… Some of them did not change at all... like, ‘I know everything, I don’t need to learn.’” (Age 22, 9 months mentoring)
Facilitators
Improved skills and confidence through training (care provision and mentorship)
All participants agreed that training and mentorship improved providers’ skills and confidence, particularly with regard to managing common obstetric and neonatal complications, and that this was a key facilitator of evidence-based care provision and successful mentorship.
“The first time they [mentees] were going [into the] labor room... they will say, ‘I can’t do delivery... never I would I have been doing,’ and now they are calling us, they are managing PPH, they are managing pre-eclampsia, they are managing eclampsia, they are managing birth asphyxia.” (Age 22, 18 months mentoring)
“A lot of changes have occurred in their knowledge and their practices. Earlier, in the beginning, mentees used to be a lot behind, they used to feel scared that, ‘We can’t do this, we can’t do this’... I mean they were scared to talk to MOIC... ‘Sir, how will we refer this patient?’ or ‘How will we do?’... they started doing everything by themselves very well… everything!” (Age 22, 9 months mentoring)
“[Previously] they are not bothering about the patient is bleeding or baby is not crying, anything they are not taking it serious[ly] because they are telling, ‘It’s luck, it’s her luck or the baby’s luck, he is going, he is not alive, so what to do with them’... But after that, we have seen that they have managed... complications about birth asphyxia, meconium or PPH.” (Age 24, 10 months mentoring)
All participants agreed that simulation was a valuable aspect of training, particularly for teaching mentees how to manage complications seen less frequently in PHCs, such as shoulder dystocia and pre-eclampsia. The majority of participants felt that simulation was more effective than other training methods; however, they stressed the importance of providing lectures and skills stations to improve understanding of new content areas prior to conducting simulations in those areas.
“Simulations… I think this is a very great idea... teaching somebody who has experience of 25 to 30 years and now we have to change his practice… After doing simulation, they’ll [mentees] learn how we are doing and what else we can do... Because if we are teaching them like, ‘You have to do this, this, and this,’ they’ll not understand, they’ll not even do that thing. But after doing simulation, they’ll remember all we have done… so we have to do these things in real life also.” (Age 23, 11 months mentoring)
“I’ll frankly say, after the lunch, my mentees will sleep for classroom training... But when we do the simulation, they [say], ‘Oh my god! What scenario will she give? What scenario?’... their mind starts working.” (Age 22, 18 months mentoring)
“In college, we used to read from books and, by reading, we would learn something and forget something. But here practically when we did things… we understood it deep, as in what it is. I didn’t have to open [a] book and read… to learn why is it like this, practically we did and the concept got cleared… I think simulation is better than anything because theory, anything would not go in their mind.” (Age 23, 9 months mentoring)
Nearly all participants felt that doctors should also participate in training in order to ensure they are aware of current, evidence-based guidelines for obstetric and neonatal care. One explained that doctors in some PHCs participated in a clinical guidelines workshop that was very helpful because, after the workshop, doctors started listening to the nurses and asking questions.
“When we ask[ed] them something or had to refer, then they [doctors] used to tell by themselves that, ‘No, no, we should not do this.’ For example, like when there is an asphyxiated baby, they say, ‘There is no role for dexamethasone here’... And that oxytocin should not be given before. In the beginning… they used to order to give misoprostol and methergin after every delivery. After that, they came to know and they used to say, ‘No, no, there is no role of that and we should give only oxytocin.’” (Age 22, 9 months mentoring)
In addition, several participants felt that nurses who are not participating in the mentoring program should be included in training when possible. Related suggestions included pairing mentees with non-mentee nurses during work shifts and incorporating a short training session for both at the beginning of the mentoring period to cover basic skills, such as measuring vital signs and using a partograph.
Refresher training and increased training frequency (care provision and mentorship)
One-quarter of participants recommended refresher training and increased training frequency to improve both care provision and mentorship, explaining that mentees commonly forgot what they had previously learned following the three-week gaps between monthly mentoring visits.
“They [mentees] say, ‘Sister, if this... training is done again or revision is done, then we will completely remember it.’ So, I asked that [mentee], ‘What happened now?’ Then she said... ‘Sister, you have taught us pulse or anything, but if we do not know the basic then what do we do?’ One mentee even said that, ‘It was 30 years already and I still did not know how to measure BP [blood pressure].... I used to feel very ashamed, but due to this training, I learned many basic things that I used to feel shy about to do.’” (Age 24, 9 months mentoring)
“When we leave one facility and go to the other and go back to that facility after three weeks, then some changes happen again. If the gap is reduced, then it will be so much better... because some changes start occurring during the week, but after that the training gets completed, and then they forget those things in the three-week gap. Then again, after three weeks, we have to start from bringing about new changes.” (Age 26, 18 months mentoring)
One mentor discussed use of unplanned follow-up visits during non-mentoring weeks to motivate mentees who were not practicing, additionally noting the value of employing a combination of strictness and kindness to promote behavior change.
“We used to go see what is happening... We thought that no follow up was happening at night of the third week, so they used to go at any time be it night, morning, or evening and they got used to it that people will come for visit at any time and if something is not done, they would be scolded… We had to be strict with them because, with love, we could only change the behaviors... We decided that I would be strict one and sister the loving one... so that they could share their problem with her... and I am strict, so they would be a little scared… At least they should be scared of one and other one should be good.” (Age 22, 9 months mentoring)
Establishment of strong mentor-mentee relationships (care provision and mentorship)
Almost half of participants discussed the value of establishing strong relationships, based upon mutual respect and trust, with mentees. Role modeling and companionship were also seen as key components in building such relationships.
“When we were given the ToT [training of trainers], then we were told that we have to maintain good relationship no matter how because, if it is maintained, then only they would listen to you... In the first week, any of the days, we used to do cleaning, organizing, and seeing this, that the mentors are doing it even though they come and go in big cars, means in spite of being in a better position they are doing it, then we should also be doing it... We all used to eat together, feed each other, we never thought anything otherwise.” (Age 22, 9 months mentoring)
Participants also described the importance of being approachable and promoting open communication with mentees.
“They [mentees] used to call us ma’am, actually, in starting but later we told them no use of this ma’am and all because we are really a facilitator, not a teacher... so that whatever doubts and whatever they have, they can come to us.” (Age 24, 12 months mentoring)
“In the beginning, it took a lot of time to develop a relationship… then after that, so much more… They [mentees] started sharing everything with us like, ‘All these things are happening here’… and if there was any complication in the night, also, they used to call us freely that, ‘Sister, there is a case like this, what should we do?’” (Age 22, 9 months mentoring)
Administrative support (care provision)
Nearly three-quarters of participants discussed the importance of administrative support for improved care provision, particularly with regard to repair of broken equipment and replenishment of out-of-stock supplies and medications. One mentor recommended assigning experienced administrators to cover PHCs whose staff had not yet received mentoring.
“We used to tell our district manager to come in this QI [quality improvement] meeting, as the gaps were more... the district manager was also not taking things seriously... When the feedback started going, then everyone started taking things seriously... When the QI meeting was there, then the MOIC felt guilty that in his PHC things were not available.” (Age 22, 9 months mentoring)
Nursing supervision and feedback (care provision)
Several participants discussed the importance of nursing supervision and provision of performance feedback by local governmental employees, particularly during non-mentoring weeks (when mentors were not present), to encourage mentees to practice newly learned skills.
“They [mentees] will practice during the mentoring week, but during the non-mentoring week, they will not practice until their own superiors create pressure... One thing is there should be some pressure from the administrative level. That does not happen. So, I mean, only during the mentoring week, they learn well, they understand well at that time itself. But later when we come again, we had to revise the same chapter again.” (Age 24, 9 months mentoring)
One participant suggested appointing the most skilled and knowledgeable mentee at each PHC to serve as leaders, supervising other mentees and providing feedback to program staff.
“The best mentee should be made the leader, so that they can supervise and should report what is not going on... this can help in sustaining [the effects of training].” (Age 26, 18 months mentoring)