Objectives To identify mentors’ perspectives on strengths and weaknesses of the Training, Support and Access Model for Maternal, Newborn and Child Health (TSAM-MNCH) clinical mentorship programme in Rwandan district hospitals. Understanding the perspectives of mentors involved in this programme can aid in the improvement of its implementation. Design The study used a qualitative approach with in-depth interviews. Setting Mentors of TSAM-MNCH clinical mentorship programme mentoring health professionals at district hospitals of Rwanda. Participants 14 TSAM mentors who had at least completed six mentorship visits on a regular basis in three selected district hospitals. Results Mentors’ accounts demonstrated an appreciation of the two mentoring structures which are interprofessional collaboration and training. These structures are highlighted as the strengths of the mentoring programme and they play a significant role in the successful implementation of the mentorship model. Inconsistency of mentoring activities and lack of resources emerged as major weaknesses of the clinical mentorship programme which could hinder the effectiveness of the mentoring scheme. Conclusion The findings of this study highlight the strengths and weaknesses perceived by mentors of the TSAM-MNCH clinical mentorship programme, providing insights that can be used to improve its implementation. The study represents unique TSAM-MNCH structural settings, but its findings shed light on Rwandan health system issues that need to be further addressed to ensure better quality of care for mothers, newborns and children.
The health system in Rwanda is dominated by publicly funded healthcare facilities that include health centres, dispensaries, district hospitals, national referral hospitals and university teaching hospitals.16 Compared with the health centres, district hospitals offer services with a higher level of complexity and expertise including surgeries and complex inpatient care such as the management of high-risk cases of mothers and children that have been referred from health centres.19 Rwanda has 42 district hospitals that serve as first-line referral hospitals and receive referrals from peripheral health facilities.20 District hospitals are generally staffed by nurses, midwives and generalist physicians with basic medical training.16 Despite the limited number of specialists and resources, district hospitals are fundamental to primary care, especially in remote areas.16 The mentorship activities were conducted in neonatal, maternity and paediatric wards in the district hospitals. Through consultations with different key actors, the mentoring model was developed in early 2017. The potential mentors to be part of this mentorship model were identified and selected among experienced healthcare providers permanently working in university (tertiary) referral hospitals. Consequently, mentors had to travel to take part in mentorship activities at the district hospitals where their mentees are based. Mentors were selected by TSAM-MNCH from different professional associations in their areas of competency. The selection was based on mentors’ medical expertise, competency and willingness to transfer skills. The programme was built on interprofessional collaboration which required mentors to work in a team. Each mentoring team had five health professionals consisting of a gynaecologist/obstetrician, a paediatrician, an anaesthetist, a midwife and a paediatric nurse. This was the first mentorship model to include anaesthesia providers recognising their crucial role in the reduction of maternal, newborn and child morbidity and mortality. Each mentor was assigned two to three mentees and each mentorship visit lasted 3 consecutive days, once in 2 months. Five hospitals in the Northern Province benefited from 15 mentorship visits, while the five hospitals in the Southern Province had 13 visits each. The selected mentors received refresher courses in specific skills in their specialty and a training course on mentoring. This course on mentoring included cross-cutting themes focusing on interprofessional collaboration, gender and ethics. In addition, mentors benefited from additional training including simulation and debriefing and quality improvement. The district hospital management team was involved in the development and implementation of the mentorship model to ensure ownership of the model. This was done through the organisation of the preparatory meetings with hospitals before launching the mentoring programme. Coordination meetings with beneficiaries and implementers identified strategies to overcome the challenges encountered throughout the implementation of the mentoring. Challenges and strategies to overcome them were developed during these meetings. Before starting mentorship activities, mentees filled out self-assessment surveys to identify areas that needed improvement. These surveys facilitated the mentor’s efforts to teach effectively according to mentees’ personal needs. The mentorship activities were based on the needs of each mentee and the gaps in each hospital service. Mentors also provided an assessment to give feedback to their mentees after each mentorship visit. The mentorship model encouraged a supportive mentorship environment for the mentor–mentee relationship and allowed constructive feedback and follow-up. In addition, the mentees’ performance was determined using evaluation tools. This mentorship model allows healthcare professionals to collaborate and to cross-consult to ensure the delivery of quality care. The teaching methodologies used by TSAM-MNCH mentors included bedside teaching and case scenario discussions, as well as simulation, case presentation, ward rounds, mortality and morbidity audit, debriefing sessions and managing clinical emergencies alongside the mentees.16 Each mentor works alongside their mentee to assist with daily medical assignments and assess the performance. The whole team of mentors and mentees can occasionally collaborate depending on the medical cases. This professional collaboration is most likely to happen because the mentorship programme focuses on areas that are inter-related. After each mentorship field visit, mentors fill out reflection forms. This study was a descriptive design using a qualitative approach to assess the perspectives of TSAM-MNCH mentors on the strengths and weaknesses of the mentorship model. The study participants included 50 active mentors mentoring health professionals in 10 district hospitals of TSAM-MNCH clinical mentorship programme catchment area. The researcher obtained a list of TSAM-MNCH mentors with their contact information from TSAM-MNCH administration, and then selected active mentors who had completed at least six mentorship field visits on a regular basis in TSAM-MNCH assigned district hospitals. This was to ensure that mentors have sufficient knowledge and are familiar with the mentorship programme. Initially, 18 mentors were purposively selected to participate in the study. Some participants were invited over the phone while others were invited face to face by the researcher. All the invitations were in Kinyarwanda language. With different reasons, four mentors were not able to participate, thus the study sample was 14 mentors who were representative of each profession. The sample consisted of three gynaecologists/obstetricians, three paediatricians, two anaesthetists, three midwives and three paediatric nurses. These four were not replaced because we observed that saturation was reached. Saturation was reached around the ninth interview and the researcher kept collecting data to make sure that each profession is represented in the study sample since the mentorship model is built on interprofessional collaboration and every profession plays a key and unique role in the programme. The methodology followed a Consolidated criteria for Reporting Qualitative research checklist (research checklist). Qualitative primary data were collected directly from participants using one-to-one in-depth interview. The interview guide (online supplemental file 1) was made up of 15 questions that led to an hour interview between the researcher and each participant. A semistructured interview guide was developed based on the research questions by the research team. Most questions were open ended and were based on mentorship activities and the perspectives of the mentors about the TSAM-MNCH mentorship model: its strengths, weaknesses, gaps as well as areas of improvements. The interviews were electronically recorded and field notes were taken by the researcher. bmjopen-2020-042523supp001.pdf All interviews took place in the hospital offices where mentors were conducting their mentorship visits and did not interfere with mentorship activities. Two interviews were done in the local language (Kinyarwanda) due to the participants’ request and level of comfort. A Kinyarwanda interview guide that had been prepared was used for the two interviews. In general, the interviews lasted about an hour except for two interviews which lasted approximately 35 min because the participants had to abruptly leave to assist with an emergency medical case. For these two interviews, the researcher focused on questions that specifically ask for strengths and weaknesses. There were no follow-up interviews for this study. Data collection took place from mid-June to mid-July 2019. This study used framework analysis with the aim to manage and identify themes. SU transcribed all recorded interviews and translated transcripts into English where needed. This process helped the research to be familiar with the content of each interview and to get a general overview of each participant’s responses, while focusing on the relevance to the main objective of the study. Framework analysis was particularly chosen for this study because it helped the researchers to classify data in relation to the main imposed themes which are strengths and weaknesses of the TSAM-MNCH clinical mentoring model. This approach also enabled the research team to identify subthemes and to interpret data. The research team thoroughly reviewed and classified all ideas that emerged from the transcription process by focusing on the main objective as reflected in the research questions. Each participant was assigned a code and then personal identifiers were deleted to ensure confidentiality. The first set of coding process was done manually by SU and there was no use of any computer software. SU read all transcripts and conducted the first set of coding. Other members of the research team further independently reviewed the initial set of coding and suggested some additions to enhance the readability of the results. After revisions, codes were assigned to the themes and subthemes which emerged from the transcripts. Great attention was paid on quotes and statements which responded to the research themes. At the time of the study, the corresponding female researcher SU was a Master’s student at the University of Edinburgh in the School of Social and Political Science. SU is a certified qualitative research by Market Research Society. An information sheet (online supplemental file 2) was provided to participants right before starting the interviews and then a written consent form to voluntarily participate in this study was signed by both the researcher (SU) and the participant. The consent forms were signed in the hospital offices, the same location where the interviews were conducted only between the participant and the researcher. Only the researcher had access to the interview recordings and consent forms, and there was no name attached to any recording or quotation to maintain the privacy and the confidentiality of the participants. TSAM-MNCH did not know the identity of mentors who participated in the study. The researcher has only shared a final report with TSAM-MNCH with no mentors’ identities attached to it. The researcher’s occupation, experience and study purpose were communicated to all participants. The study carried no risk to the participants. bmjopen-2020-042523supp002.pdf The mentorship programme is one of the key priorities of the health sector in Rwanda.21 Therefore, the development of the research question and outcome measures were done keeping this priority in mind. This study sample was only made of mentors providing mentorship programme and there was no interaction with patients. Therefore, it was not applicable to involve patients in the design of this study. This is the same for the involvement of the patients in the recruitment process. However, since mentors are involved in the management of the patients and in the provision of health services, the results of the study will be disseminated with different stakeholders including the hospitals and the Ministry of Health as well as the mentors themselves with a view to improve the clinical mentoring programme. This will be done through different meetings at different levels.