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Background: There are a number of factors that may contribute to high mortality and morbidity of women and newborns in low-income countries. These include a shortage of competent health care providers (HCP) and a lack of sufficient continuous professional development (CPD) opportunities. Strengthening the skills and building the capacity of HCP involved in the provision of maternal, newborn and child health (MNCH) is essential to ensure quality care for mothers, newborns and children. To address this challenge in Rwanda, mentorship of HCPs was identified as an approach that could help build capacity, improve the provision of care and accelerate the reduction in maternal and neonatal mortality and morbidity. In this paper, we describe the development and implementation of a novel mentorship model named Four plus One (4+ 1) for MNCH in Rwanda. Methods: The mentorship model built on the basis of inter-professional collaboration (IPC) was developed in early 2017 through consultations with different key actors. The design phase included refresher courses in specific skills and training course on mentoring. Field visits were conducted in 10 hospitals from June 2017 to February 2020. Hospital management teams (MT) were involved in the development and implementation of this mentorship model to ensure ownership of the program. Results: Upon completion of planned visits to each hospital, a total of 218 HCPs were involved in the process. Reports prepared by mentors upon each mentorship visit and compiled by Training Support and Access Model (TSAM) for MNCH’CPD team, highlighted the mothers and newborns who were saved by both mentors and mentees. Also, different logbooks of mentees showed how the capacity of staff was strengthened, thereby suggesting effectiveness of the model. Through different mentorship coordination meetings, the model was much appreciated by the MTs of hospitals, especially the IPC component of the model and confirmed the program ‘effectiveness. Conclusion: The initiation of a mentorship model built on IPC together with the involvement of the leadership of the hospital may be the cause effect of reduction of specific mortality and improve MNCH in low resource settings even when there are a limited number of specialists in the health facilities.
This paper aims to describe the development, implementation as well as the results of the novel mentorship model (4+ 1) for health care providers providing maternal and neonatal care in 10 hospitals located in 6 districts of Rwanda. The implementation of the model was done in three districts of Northern Province of Rwanda (Rulindo, Gicumbi and Gakenke) and 3 districts of Southern Province of Rwanda (Muhanga, Gisagara and Ruhango) These 6 districts were assigned to the TSAM project as per the Memorandum of Understanding between the project and the Ministry of Health. The mentorship model was developed in early 2017 through consultations with different key actors and is based on inter-professional collaboration (IPC) with a team of five mentors, including a gynecologist/obstetrician, midwife, pediatrician, pediatric nurse and an anesthesiologist, giving rise to the name four plus one (4 + 1) to recognize the inclusion of anesthesia provider in the mentorship model. The potential mentors were identified and selected by local experts and the Rwandan professional associations. The selected mentors received refresher courses in specific skills in their specialty and a training course on mentorship. Ten teams of five mentors provided support to mentees at their workplace in 10 district hospitals in the Northern and Southern Provinces in Rwanda. By February 2020, 15 visits of 3 consecutive days each had been conducted by the mentoring team in 5 hospitals in the Northern Province from June 2017, while 13 visits were conducted in five hospitals of Southern Province from November 2017. The model was extended to five hospitals in the Southern Province few months later after the introduction of the model in North to ensure the implementation is feasible. A coordination meeting with beneficiaries and implementers identified strategies to overcome the challenges encountered in north. The hospital management team was involved in the development and implementation of the mentorship model to ensure ownership of the model. We examined all the reports that were submitted by mentors at the end of the mentoring sessions. Information was extracted and entered into an excel database. Mentors were contacted for further information, corrective measures or clarifications if specific issues were identified from their reports. To address some of the challenges in further reducing maternal and neonatal morality in Rwanda, the TSAM project team determined that it was essential to implement novel strategies to improve patient outcomes. Thus, a mentorship model was developed to address the limitations of previous approaches to CPD. The model was built on the Rwanda Ministry of Health Guidelines Mentorship [25] with integration of additional components designated as “cross-cutting themes” (CCTs). Initially the CCTs included gender, ethics, and interprofessional collaboration (IPC). As the model was developed two additional themes were included, maternal mental health (MMH) and gender-based violence (GBV). These were added based on consultation with many stakeholders including the University of Rwanda and different professional associations to name a few and current information in Rwanda indicating the high prevalence of post-partum depression and GBV. The different steps followed are provided in Table Table11 and the core principles of the TSAM model are provided in Table Table22. Key steps followed to develop the mentorship model Core principles of the TSAM mentorship program The region of the country where the mentorship model was to be implemented was determined at the beginning of the project when the Memorandum of Understanding was signed with the Rwanda Ministry of Health (MoH). The MoH assigned TSAM six districts, 3 in the Northern Province (Gakenke, Gicumbi and Rulindo) and 3 in the Southern Province (Muhanga, Ruhango and Gisagara), with five district hospitals in each province (Fig. (Fig.1).1). The model was implemented first in the Northern Province and then refined and taken to the Southern Province. TSAM assigned hospitals in Rwanda. This Figure shows the location of 10 TSAM assigned hospitals where the mentorship model described under this manuscript was implemented. It was produced using ESRI 2019. ArcGIS Desktop: Release 10.7.1. Redlands, CA: Environmental Systems The development of the model involved extended consultation at multiple levels in Rwanda. The model was refined through a series of meetings with officials from the MOH, the provincial governors, the vice mayors who oversee health and social issues, local hospital leadership and administration, and health care providers at the central and local level. To facilitate collaboration, the management organization included the formation of an “Action Team”. This team brought together representatives of the professional associations; the Director Generals of TSAM assigned hospitals, and some of the senior mentors. To complete the partnership, the Action Team also included project team members from Canada with specific expertise in education and MNCH. The role of the action team was to meet regularly to design and implement the mentorship model, review and adjust the model based on the reports from the mentors, and resolve any issues arising from the implementation. A position of ‘CPD Manager’ was created to facilitate the development and implementation of the mentorship model and to provide ongoing management and leadership. This was a leadership role that required strong interpersonal skills, a high level of health care knowledge, knowledge of the local context, and experience working with multiple governmental and HCPs ‘institutions. The success of the mentorship program was dependent on the commitment and dedication of the CPD manager to coordinate mentorship activities. The manager’s role included activities such as organizing action team meetings, organizing and mentorship field visits, conducting intermittent field visits to ensure the implementation was smooth, receiving and compiling mentorship reports, sharing the reports to all parties involved to ensure challenges encountered during the visits were identified and strategies to overcome them were developed, organizing additional workshops for mentors and hospital staff and analyzing maternal, newborn and child health data from hospitals to identify trends. A workshop to review and agree on the tools to be used during the mentorship was conducted in March 2017. This workshop brought together representatives of different professional associations in Rwanda involved in mentoring, managers of TSAM assigned hospitals of the Northern Province and team members from Canada. During this workshop, existing checklists used in mentorship related to MNCH in Rwanda were reviewed and additional checklist items related to the CCT were included. A clinical mentor monthly reporting template was developed. This reporting template included documentation of near misses and critical situations encountered during mentorship visits. Two new forms were created; a form for the mentee to provide feedback to the project on how the mentor was fulfilling his/her tasks and a mentorship reporting form to be used by a mentor describing the progress of mentee. Potential national mentors were selected in partnership with the professional associations including Rwanda Society of Obstetricians and Gynecologist which is also a member of FIGO, Rwanda Pediatric Association (RPA), Rwanda Society of Anaesthesiologists (RSA) and Rwanda Associations of Midwives (RAM). This allowed the selection of competent mentors in their area of competency. Mentors were selected based on the key criteria listed in mentorship guidelines published by the MOH [26]. Using these guidelines, the characteristics of mentors should include (Table (Table33): Characteristics of a Mentor [26] Refresher training was organized for potential mentors. The objective was to provide them with updated clinical skills and to evaluate their suitability as to act as mentors. This two-day refresher training course was conducted in May 2017. The facilitators were specialists representing their professional associations. The facilitators used demonstrations, simulations, discussions, and local protocols to update the skills of the potential mentors. Following the refresher course, the Action Team selected those best suited to become mentors. In May 2017, a course on mentoring was organized for those selected to become mentors. A team of Canadian medical educational specialists and Rwandan experts facilitated the course. The course covered topics such as the philosophy of mentoring, coaching, teaching a skill, immersive learning models, change theory and changing practice, and giving feedback. The program also introduced the initial three CCTs (IPC, gender and ethics). In addition to the candidate mentors, the workshop was also attended by the Director Generals, Clinical Directors and Directors of Nursing in TSAM assigned hospitals from the Northern Province. This ensured that the hospital management team understood the mentorship model and would be able to support the mentorship team and their mentees during mentorship visits. The initial field visits were conducted the day following the completion of the training on mentoring. Each team of mentors visited their assigned hospital, facilitated by the hospital leadership. The field visits allowed mentors an opportunity to see the facilities and become familiar with the services provided at each hospital. The mentors also conducted a rapid assessment on the availability of services, staff, and key equipment. Another important goal of the initial field visit was ensuring that the staff of the district hospital understood the philosophy and purpose of the mentorship visits. Prior to the initial field visits, a document was developed and presented to the mentors for guidance while on the field visit. The recommendations in the guiding document included meeting key administrative staff, basic data gathering on the assigned district hospital including availability of staff and equipment, and information about the population served. After a successful design phase, the first mentorship team visits were organized for the five hospitals in the Northern districts in June 2017 and then in five hospitals of South in November 2017. By the end of February 2020, a total of 15 visits and 13 visits of 3 consecutive days had been conducted by each team. Although there was initial concern about the feasibility of having the five mentors visit as a team this proved not to be problematic. On occasion when one team member could not be available, an experienced mentor replaced that team member for the visit. As much as possible the model emphasized the one-on-one aspect of mentoring with the expectation that the mentor would work with the same mentee on each visit. This was an early challenge but as the hospital leadership and the mentees grew to appreciate the mentor-mentee relationship this issue was less problematic. During the mentoring period, different key activities were carried out (Table 4). Key activities carried out by mentors during the mentorship field activities A key element of the mentoring was that the mentors were not to be considered an extra staff member during the visit but were there to mentor and support their mentees. Upon completion of each visit, the team of mentors provided the feedback to not only mentees but also to the entire hospital staff during the staff meeting on the last day of the visit. The feedback was also provided to the hospital management team with suggestions about what has to be changed and what support is needed by the hospital management team to support the changes. Finally, the team completed their reports, which were then reviewed by the TSAM mentorship manager. The reports were reviewed and analyzed to monitor the mentorship process as well as to maintain a record of activities during mentorship and the feedback was provided to the mentors and hospital management team. Once the program was functioning in the Northern Province, the experience gained was used to implement the program in the hospitals assigned to TSAM in Southern Province; Gakoma, Gitwe, Kabgayi, Kibirizi and Ruhango. To ensure the mentorship approach was running smoothly and experiences were shared, quarterly evaluation meetings were organized. These meetings brought together the Director Generals, Clinical Directors and Directors of Nursing from hospitals benefiting from the mentorship visits as well as TSAM team members involved in the mentorship program. The goal was to share the key messages from the reports of the mentorship visits, discuss the successes and challenges, and to develop strategies to overcome challenges. In addition, mentorship evaluation was always on the agenda of the Action Team meetings. Standardized questionnaires were developed that allowed participants to evaluate all the workshops and courses. Recognizing that a single workshop on mentoring was not sufficient to build the skills and confidence of mentors, additional workshops were planned. These additional workshops often included the hospital leadership as well. The first one provided in-depth training by Rwandan and Canadian experts on the CCTs. The second workshop offered was on Maternal Perinatal Death Surveillance and Response (MPDSR) and Continuous Quality Improvement (CQI). The MPDSR is one of the key processes to reduce preventable deaths and an activity to be conducted during mentorship. The workshop was attended by all the mentors and each district hospital was invited to send an additional 3 people from their staff. During the workshop, the mentors and hospital staff worked as a team to develop a potential CQI project that could be done in their hospital. The workshop was facilitated by a CPD team from both Canada and Rwanda, and staff from the Rwanda Biomedical Center, who supervise the death audit process. An additional workshop MPDSR and CQI was organized for the hospital management team recognizing that this team must be supportive of the two processes. An additional workshop was conducted to expand the CCTs from the original 3 themes of ethics, gender and IPC to include MMH and GBV. The latter 2 themes are an important initiative of the MOH. The final workshop in the series covered the use of simulation and debriefing to strenghnen the capacity of mentors in transferring the knowledge and skills to their mentees. This workshop reinforced aspects of team functioning and improving team communication and emergency care. The content included development of simulation scenarios and skill stations using mannequins and debriefing after a simulation. Other topics were suggested by mentors such as leadership training and statistical education to support local evidence-based decision making. It was not possible within the time frame of the project to include all topics. However, the philosophy of providing ongoing skill development for mentors was well received. In addition to regular updates the workshops provided an opportunity for the mentors to get together informally and exchange their experiences. The final piece of the model development was implementation of a “Train-the Trainer’ approach to ongoing training of new mentors. The mentorship teams enthusiastically embraced this and have conducted workshops on clinical and mentorship skills for new mentors to expand the team of available mentors.
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