A case study on building capacity to improve clinical mentoring and maternal child health in rural Tanzania: The path to implementation

Background: Tanzania is a low income, East African country with a severe shortage of human resources for health or health workers. This shortage threatens any gains the country is making in improving maternal health outcomes. This paper describes a partnership between Touch Foundation and NYU Rory Meyers College of Nursing – Global, aimed at improving clinical mentorship and capacity among nurses and midwives at two rural hospitals in the Tanzanian Lake Zone Region. Clinical mentoring capacity building and supportive supervision of staff has been shown to be a facilitator of retaining nurses and would be possible to acquire and implement quickly, even in a context of low resources and limited technology. Methods: A case study approach structures this program implementation analysis. The NYU Meyers team conducted a 6-day needs assessment at the two selected hospitals. A SWOT analysis was performed to identify needs and potential areas for improvement. After the assessment, a weeklong training, tailored to each hospitals’ specific needs, was designed and facilitated by two NYU Meyers nursing and midwifery education specialists. The program was created to build on the clinical skills of expert nurse and midwife clinicians and suggested strategies for incorporating mentoring and preceptorship as a means to enhance clinical safety and promote professional communication, problem solving and crisis management. Results: Nineteen participants from both hospitals attended the training. Fourteen of 19 participants completed a post training, open ended questionnaire for a 74% response rate. Fifty-seven percent of participants were able to demonstrate and provide examples of the concepts of mentorship and supervision 4 and 11 months’ post training. Participants indicated that while confidence in skills was not lacking, barriers to quality care lay mostly in understaffing. Implementation also offered multiple insights into contextual factors affecting sustainable program implementation. Conclusions: Three recommendations from this training include: 1) A pre-program assessment should be conducted to ascertain contextual relevance to curriculum development; 2) flexibility and creativity in teaching methods are essential to engage students; and 3) access to participants a priori to program implementation may facilitate a more tailored approach and lead to greater participant engagement.

We use a case study approach to organize our description of the program implementation and evaluation processes. Case studies are an effective method for organizing an analysis where multiple sources of data are needed to capture a phenomenon, but where the context of data collection is less structured and cannot conform to the conditions of other more structured research approaches [21, 22]. In this section, we describe the program planning efforts to establish how implementation was conducted and the analytic approach used to evaluate the program. There was no theoretical framework used to guide this study since case studies do not require them [23]. Prior to performing the six day in country needs assessment the principal investigator and remaining members of the NYU Meyers team were in constant communication with Touch Foundation via conference calls and email to organize logistics and expertise on teaching needs that could be anticipated at each hospital. The NYU Meyers team was comprised of four women with extensive international health experience, two PhD prepared nurse scientists with over 20 years’ combined experience in health services research and maternal child health and 2 Master’s prepared nursing PhD students with over 15 years’ experience in midwifery and bedside clinical care experience. IRB and/or ethical approval was deemed exempt by the home institution as it was a descriptive case study and evaluation of an educational training program and did not involve the collection of sensitive information. A strength, weakness, opportunities and threats (SWOT) analysis (Table 1) technique was used to provide a rapid assessment of each hospital and to help structure the needs assessment approach. The SWOT analysis’s intent was to provide a snapshot of short, medium and long term insights on the current situation for both the in-country partners and hospital administration based on what the assessors observed and obtained from the need assessment. It was strictly context for all parties involved with program implementation. The actual scope of the clinical mentorship and supervision program, although small, served as one component to Touch’s overarching goal to reducing maternal mortality in Tanzania. Thus, the SWOT analysis provided in this manuscript should be interpreted with caution with regard to the program described in this paper. SWOT analysis from needs assessment of Shinyanga Regional Referral Hospital The needs assessment was conducted in July 2014 over a six-day period. Once in country, the two assessors met formally with Touch Foundation personnel and provided a layout of the assessment process for the upcoming week. While the initial project sought to implement basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC) training, those plans changed due to a new policy mandated from the Ministry of Health and Social Welfare (MOHSW). The new policy specified that MOHSW is the only body that can deliver training for emergency obstetric and newborn services in accordance with the national curriculum. The NYU Meyers team was made aware of the change upon arrival for the needs assessment. Based on the findings from the needs assessment and the critical staffing shortage present at each facility, the team changed the training focus on providing and improving clinical mentorship capacity among the nurses and midwives. The final needs assessment drew from evidence-based approaches to effective maternal child health (MCH) service delivery and organizational evaluations sensitive to the dynamics of nursing personnel working in a low resource, interprofessional clinical setting. To gain an understanding of what was taking place at SDDH and SRRH specific to MCH, the NYU Meyers assessors engaged in conversations with stakeholders which included nursing, midwifery and hospital management, staff, medical directors and district health officials. Informal interviews were held with four key informants at SDDH and eight at SRRH. A semi-structured interview guide was used to elucidate information about the concerns, long term plans and needs of each facility. Team members took notes during the interviews and did not record them. Hospital and unit tours allowed the assessors to observe the realities of nursing and midwifery practice in an effort to generate potential recommendations to help deliver better patient care. Data notebooks with labor and delivery statistics were reviewed for the types of data collected by each hospital. Assessment sheets with delivery statistics were completed within one week by hospital personnel and emailed back to the NYU Meyers team. After conducting the needs assessment, the NYU Meyers team created a curriculum that encapsulated the needs of all stakeholders (Touch, hospital administration and nursing staff). The primary goal of the program was to help nurses and midwives to refresh and improve their clinical competence while incorporating principles of mentoring and clinical supervision throughout the training. Importantly, the nursing and midwifery staff determined the priorities for the clinical refresher portion of the program. Some of the clinical content that staff wanted reviewed were complications during labor and delivery such as neo-natal resuscitation and postpartum hemorrhage. The Touch Foundation was provided with drafts of the curriculum for review and feedback prior to implementation. The week-long training was designed and taught by two NYU Meyers nursing and midwifery education specialists. Clinical case studies served as the curriculum framework to discuss how mentorship and clinical teaching could be integrated into an overburdened environment to enhance professionalism and support evidenced based practice. Enhancing mentorship and clinical supervision was a central theme to all learning objectives and exercises. Using methods beyond the traditional didactic method was also key to the week-long training. Methods such as teach back, small group work, demonstrations, role plays, and low technology simulation were actively utilized. While common place in Western settings, these methods were novel to many of the Tanzanian participants. Although the NYU Meyers team tailored the curriculum to meet the needs voiced by our Tanzanian counterparts, we recognized that we were coming from a Westernized perspective and wanted to try and limit the potential for any bias in content delivery and adapt to local learning styles. Two sites in rural, northern Tanzania participated in the program. Sengerema Designated District Hospital . Established in 1959, SDDH is a 318-bed Catholic hospital that offers public services to over 700,000 people in Sengerema district. SDDH joined Touch Foundation’s Treat & Train Network in 2013 and was the first hospital to host Touch Foundation’s external clinical rotations for healthcare students. SDDH attends to over 10,000 births per year and, in 2014, was the first hospital to pilot and implement Vodafone’s MMH program. The training at SDDH occurred in August 2014. Shinyanga Regional Referral Hospital served as the second site. SRRH was built in the 1940s and is a government owned 300-bed hospital serving a catchment area of over 1.5 million people. Shinyanga has been a part of Touch’s Treat & Train Network since 2014 and is now hosting external clinical rotations for healthcare students as well as implementing the MMH program for the Shinyanga District Council. SRRH attends to almost 8000 births per year. The training at SRRH occurred in January 2015. After the needs assessment and discussion with Touch it was decided that the nurses and midwives serving in hospital administration and leadership roles, who also still practiced on the wards, were best suited to select training participants. Participants were purposively recruited for the program. The overall purpose of the training program was to prepare and engage nurses and midwives to nurture and support novice providers and students in delivering optimal care to the women and babies they serve in low resource, high intensity settings. The objectives for the training participants included: 1) defining mentoring and developing an awareness of their preexisting mentoring style; 2) developing an action plan, defining objectives and goals to enhance learning and skills acquisition for novice clinical staff; 3) utilizing essential obstetrical assessment and decision making tools in managing care; and 4) incorporating various teaching techniques to support engaged learning. Core concepts such as communication, interdisciplinary teamwork, trust building and professional leadership in relation to professional development and workforce strengthening were also reinforced. Exploring underlying care values and enhancing respectful maternity care were also subthemes that were intentionally integrated into lesson plans throughout the weeklong training. Each training, one at each site, took place over five days and were four hours per day. In addition, there was up to one hour per day allocated for clinical review of the course content. Table 2 provides a sample curriculum outline to provide context of what was taught during the training. Supplementary materials – such as theme appropriate articles – were introduced and well received by the group. Teaching and mentoring exemplars in the program emphasized how to coach and teach less experienced staff core concepts around improving patient safety for obstetric and neonatal care, including urgent care situations. Sample Program Curriculum Although the language of instruction in Tanzania is English and each facility assured the NYU Meyers team that the participants could engage in English, all pre-assessment and post questionnaire documents were in both English and Kiswahili. Clinician-champions, exemplar participants, identified by NYU Meyers educators were proficient in both spoken and written English and Kiswahili were also on hand and able to provide translation during classroom instruction. This step helped ensure there would be minimal issues related to translation.

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