Building Nurse Mentoring Programs focused on Quality Improvement GHDonline Virtual Panel Discussion Sept 19-23

By Anatole Manzi | 19 Sep, 2011 Last edited by Sarah Arnquist on 19 Sep 2011

In Rwanda, the majority of primary care is delivered at health centers staffed by nurses. Nurses receive basic training in secondary school and some pursue additional training in post-secondary institutions. Traditional efforts to support ongoing nurse training have included costly centralized training workshops and sporadic supervision visits, which are often consumed by data collection and reporting.

In response to these challenges, Partners in Health (PIH) / Inshuti Mu Buzima (IMB) has collaborated with the Ministry of Health (MoH) district hospitals in two rural districts in eastern Rwanda to create the Mentoring and Enhanced Supervision at Health Centres (MESH) Program. This program, which bolsters the existing MoH supervisory structure, aims to strengthen clinical service delivery at health centres through ongoing clinical mentoring of nurses and continuous quality improvement initiatives, as well as through decentralized training of nurses. MESH mentors, who are higher level Rwandan nurses and part of the district hospital team, make approximately monthly visits to health centers, in which they provide one-on-one mentoring during patient consultations, lead teaching sessions, and help to identify and address operational and facility issues, in collaboration with health center staff.

My name is Manzi Anatole and in my capacity as the Director of the MESH Program, I have been leading this initiative. I am a Rwandan nurse with a Bachelors in clinical psychology and a Masters in Public Health and I have been working in rural primary care for almost ten years. In 2005, I joined Partners In Health as head of the Infectious Diseases Clinic at one of PIH’s supported sites in Rwanda and then worked as PIH Rwanda’s Senior Clinical Training Facilitator.

The MESH program has been in operation for under a year and continues to evolve. While we're learning as we go, we have encountered many questions that we hope the GHDonline nursing community can help us with.

Key initial questions we’d like to address include:
1. How can mentors help to empower nurses to engage in quality improvement initiatives in their own clinics? How can we train mentors to support both clinical education and systems improvements in their mentoring activities?
2. How can monitoring and evaluation (M&E) be integrated into mentoring interventions to foster effective feedback loops and nimble responses to identified problems?
3. How can mentoring programs be integrated into Ministry of Health activities and scaled to a national level, taking into consideration quality and cost issues?


We hope to hear also hear from community members about your experiences in ongoing nurse training and mentoring:
- What models of clinical mentoring are you implementing?
- What activities do mentors engage in and how do they structure their mentoring visits?
- What tools/resources do mentors use for mentoring and for M&E?
- What training do mentors receive?
- What ongoing support do mentors receive?
- What challenges are you encountering?

Attached resource:
  • Building Nurse Mentoring Programs focused on Quality Improvement (download, 14.1 KB)

    Summary: In Rwanda, the majority of primary care is delivered at health centers staffed by nurses. Nurses receive basic training in secondary school and some pursue additional training in post-secondary institutions. Traditional efforts to support ongoing nurse training have included costly centralized training workshops and sporadic supervision visits, which are often consumed by data collection and reporting.

    In response to these challenges, Partners in Health (PIH) / Inshuti Mu Buzima (IMB) has collaborated with the Ministry of Health (MoH) district hospitals in two rural districts in eastern Rwanda to create the Mentoring and Enhanced Supervision at Health Centres (MESH) Program. This program, which bolsters the existing MoH supervisory structure, aims to strengthen clinical service delivery at health centres through ongoing clinical mentoring of nurses and continuous quality improvement initiatives, as well as through decentralized training of nurses. MESH mentors, who are higher level Rwandan nurses and part of the district hospital team, make approximately monthly visits to health centers, in which they provide one-on-one mentoring during patient consultations, lead teaching sessions, and help to identify and address operational and facility issues, in collaboration with health center staff.

    My name is Manzi Anatole and in my capacity as the Director of the MESH Program, I have been leading this initiative. I am a Rwandan nurse with a Bachelors in clinical psychology and a Masters in Public Health and I have been working in rural primary care for almost ten years. In 2005, I joined Partners In Health as head of the Infectious Diseases Clinic at Rukira health center (one of PIH’s supported sites in Rwanda) and then worked as PIH Rwanda’s Senior Training Facilitator.

    The MESH program has been in operation for under a year and continues to evolve. While we're learning as we go, we have encountered many questions that we hope the GHDonline nursing community can help us with.

    Key initial questions we’d like to address include:
    1. How can mentors help to empower nurses to engage in quality improvement initiatives in their own clinics? How can we train mentors to support both clinical education and systems improvements in their mentoring activities?
    2. How can monitoring and evaluation (M&E) be integrated into mentoring interventions to foster effective feedback loops and nimble responses to identified problems?
    3. How can mentoring programs be integrated into Ministry of Health activities and scaled to a national level, taking into consideration quality and cost issues?


    We hope to hear also hear from community members about your experiences in ongoing nurse training and mentoring:
    - What models of clinical mentoring are you implementing?
    - What activities do mentors engage in and how do they structure their mentoring visits?
    - What tools/resources do mentors use for mentoring and for M&E?
    - What training do mentors receive?
    - What ongoing support do mentors receive?
    - What challenges are you encountering?

    Source: Partners In Health - PIH

Replies

 

Dianne Longson Replied at 6:05 AM, 19 Sep 2011

Hello Manzi, thanks for the new discussion topic. I am looking forward to some wonderful input as we discuss this innovative project.
You have mentioned some of the activities through which mentoring functions are expressed. However I think it would be very useful if youcould answer a few more questions. Can you please delineate the conceptual foundations of your mentorship programme a little further? For example, mentorship is variously defined and dependent on context but almost universally included in any definition is the idea that it is a relational process between two individuals involving both professional and personal development for the mentee. Often, in fact usually the mentee has the power to decide whether or not to engage in any mentoring relationship.
How do you define mentorship and the mentoring relationship within your project? What are the essential functions of the mentor role in this project? What do you expect them to achieve? What personality traits or characteristics are important for mentors to exhibit if they are to carry out requisite mentoring functions and activities. Also how were mentors selected for your programme? How much choice do the mentees have in regard to the relationshhip and the programme? How do the mentees in your programme view their mentoring relationship?
Sorry Manzi there are more questions than answers here. Nevertheless I think it is very important that we all understand the basis of your programme and are discussing the same or similar things.
regards
Dianne Longson

Sheila Davis Moderator Emeritus Replied at 9:57 AM, 19 Sep 2011

Manzi,
Thanks for a starting wonderful dialogue that is so important for nurses globally.
Mentoring is an area that I think nurses have always done informally but we have not been very effective at articulating and measuring the impact of our efforts and having clear outcomes. How we meaure how effective a mentor is on impacting practice is also very important and there has been much money spent in global health on mentoring with little M&E to see if it actually worked.
Di brought up a lot of very good questions about how the mentors were chosen, who makes a good mentor , how do you define success in the mentor/mentee relationship, I will be interested in hearing your responses to her questions as well.
In developing a mentor program in South Africa in the mid-2000's when ART wa just starting there, the challenge was reliance on visiting short-term mentors which did not always prove very effective over time due to the intermittment contact and mentors coming in who did not know the context of the setting well.
I know that MESH is built on utilizing experienced Rwandan nurse mentors who know the context of clinical care in those settings well which is the key to a successful relationship.
I look forward to an interesting week discussing this topic,
Sheila Davis

Lisa Hirschhorn Replied at 10:23 AM, 19 Sep 2011

Thanks all-
I think both Dianne and Sheila bring up excellent points. I work with Manzi as the Director for M and E and Quality at PIH, as well as having served as both a mentor and a coach focusing on quality improvement and clinical skills. While there are many different interpretations, the classic definition of a mentor (actually derives from Homer and the Odyssey with Athena one of the first mentors) is someone with expertise but also who is able to bring about personal guidance beyond the technical including professional development, life skills and other areas. In some of the work which has been done, there is a greater emphasis on the coaching component (or even just coaching) which is more aimed at helping staff implement what they have learned and perform thier duties and is generally shorter term relationship. The MESH program I think also has been designed to incorporate some of the areas more traditionally viewed as supportive supervision-addressing the system issues which are often the other significant barriers to delivery of quality of care beyond individual HCW performance.

One question I have is people’s experience in mentoring and coaching the mentors regardless of whether they are coming from another setting or have been designated from within the health system being strengthened. The skills of mentoring and coaching are certainly not ones traditionally taught in pre-service training, nor something easily done through didactic lectures or readings

Lisa Hirschhorn, MD MPH
Harvard Medical School
Partners in Health

Anne Sliney Replied at 11:50 AM, 19 Sep 2011

Thank you Manzi for starting this discussion. I am so happy that this effort to establish a clinical mentoring program in Rwanda is being done within the MoH plan. The MoH of South Africa has recently produced a manual called "Clinical Mentorship for Integrated Services", which lays out the national policy on clinical mentorship - the definition, qualifications of a mentor, etc, but most importantly, has clinical competencies that must be met by the mentees. Mentors grade mentees on competency, and mentees grade themselves on confidence to perform a task or apply specific knowledge. At this point, the only fully developed competency check list (in the SA manual) is HIV focused, but certainly others could easily be developed. I hope some of my colleagues in SA will chime in with their thoughts. The Human Resource Strategic Planning Dept led the process of developing both the the manual and the Training of Mentors curriculum, but all of the training partners had significant input.
I was fortunate to vist Rwinkwavu recently, and got an overview of your mentoring program. You have paid close attention to competencies - very impressive.

Anne Sliney
Clinton Health Access Initiative

Sheila Davis Moderator Emeritus Replied at 2:26 PM, 19 Sep 2011

Thanks for your insight Anne, CHAI was a leader in making the mentorship role very in-country focused and raising the bar on expectations of mentoring program. Lisa brings up an excellent point about how good mentors become good mentors. In US nursing programs there is little emphasis on coaching and mentoring and we just had this discussion recently at the MGH Institute of Health Professions where I am on faculty. In our advanced practice curriculum there is no current content on this role, and whether formal or informal, mentoring of others is a big responsibility that all nurses have in their clinical roles. It would be interesting to hear from Manzi and others how he has successfully worked with mentors to give them those skills.
Sheila Davis
Director of Nursing
PIH

Deb Winters Replied at 2:30 PM, 19 Sep 2011

As Nurse Advisor for I-TECH, my initial work included development and implementation of basic, advanced and TOT trainings for physicians, nurses and pharmacists in Ethiopia. Recognizing that the role and expectation of nurses greatly exceeded their clinical expertise, an intensive clinical mentoring component was built into the advanced training provided to nurses. My role was to provided training, supervision and technical assistance to the multidisciplinary Field Based Teams (FBT’s) placed throughout the three I-TECH supported regions. Mentoring programs were quickly adopted by other I-TECH supported countries and my work the past several years has included training and technical assistance to mentors in South Africa and Namibia.
Currently, I am working with the clinical team in Ethiopia as we begin to transition of mentoring from the I-TECH FBT’s to individual sites and the Regional Health Bureau in each region. I am anxious to read how others are addressing the challenge of transitioning mentoring to local or regional sites, plans for M&E when transition has been completed and any information that can be shared from participants that have already gone through the transition process. The questions posted by Manzi Anatole were very thought provoking and will provide an excellent forum for the timely discussion about the importance of mentoring.

1) How can mentors help to empower nurses to engage in quality improvement initiatives in their own clinics?
From the onset, the approach to training taken by I-TECH (International Training and Education Center for Health) included discussions about the benefits of clinical mentoring following classroom-based training. Our framework for training is designed to ensure that programs result in the transfer of learning to the clinical site (for more information please visit our website www.go2itech.org.
The expanded role of nurses in resource-limited settings has resulted in the successful scale-up of HIV care and treatment. Early on in the discussions about “task-shifting”, we recognized that empowering nurses to take on this expanded role would require intensive support and encouragement. Providing them with positive feedback as well as areas for improvement was essential to validate their role as a HIV provider. Mentoring has a tremendous effect on the professional and personal growth of a new HIV provider, encouraging them to become competent providers, strong leaders and role models.
One of the key components of our mentoring approach is data collection and reporting. Mentors support and encourage the collection, review, utilization and integration of data that includes not only clinical information but systems challenges identified by the staff, administration and/or mentors. Mentors work closely with the staff to review information collected and most importantly, help them recognize and understand the importance of the findings and how the information directly impacts the care they are providing. Given the high volume of patients especially in clinics with staff shortages and burnout, mentors need to use their creative mentoring skills to engage nurses in the components necessary for successful quality improvement at their sites. One of the difficult challenges that I find when mentoring is helping nurses understand that without consistent, thorough documentation and record keeping, engaging in quality improvement activities will be more difficult, time-consuming and frustrating.







1b) How can we train mentors to support both clinical education and systems improvements in their mentoring activities?
The training program designed for I-TECH clinical mentors includes a generic curriculum that includes modules addressing: Clinical Teaching Skills, Interpersonal/communication skills and Program Orientation and M&E. Topics covered within these modules include: giving/receiving feedback effectively, rapport building, bed-side teaching, addressing systems issues, case-based learning, and helping mentee’s use data effectively. Sessions are designed based on the principles of adult learning and include a variety of participatory exercises and case-based activities designed to build confidence and skills in clinical teaching as well as how to approach a mentoring assignment. Additional topics are available and can be added to the agenda based on the needs of the country office and/or program. Curriculum has also been developed for use in refresher training that addresses complex clinical and systems mentoring issues.
The mentoring program at I-TECH Ethiopia also includes Physician and Nurse Mentor of Mentors (MoM). The MoM role is to provide support to the mentors and ensure that the clinical knowledge, skills and practice as well as system mentoring provided is optimized for the provision of standardized, high level quality of care. Specialized MoM curriculum has been developed along with specific curriculum for refresher training.
Mentors need effective, user-friendly tools to document the clinical and systems mentoring provided along with on-site training, case discussions and clinical consultations. I-TECH has developed a variety of mentoring tools that capture mentoring successes, challenges, action steps and recommendations for improvement. Mentors utilize an Issues Tracking Sheet and Observation Checklist to document specific mentoring activities and plan future visits.
Evaluating mentee’s, mentors and the Mentor of Mentors (MoM’s) has been an integral part of mentoring programs in I-TECH supported countries. Evaluation tools are available for Mentors to evaluate Mentee’s, Mentee’s to evaluate Mentors and MoM’s to evaluate Mentors. Training is provided to discuss the role of a mentor as supervisor and instruct them on completing the evaluation, providing feedback and follow-up of recommendations.
Please visit our website to access the Clinical Mentoring Toolkit developed by I-TECH that is a CD-ROM (and website) of curriculum and comprehensive tools for developing, implementing, and evaluating clinical mentoring programs.




2) How can monitoring and evaluation (M&E) be integrated into mentoring interventions to foster effective feedback loops and nimble responses to identified problems?
The M&E plan for a mentoring program should target the processes, goals and specific objectives of the mentoring program. Expected outcomes of clinical mentoring that should be tracked include: Healthcare providers knowledge and skills of comprehensive, long-term HIV care and treatment, program effectiveness and degree of the impact of clinical mentoring on improvement of maximum quality of care and improvements made at the facility level in operations and systems e.g. patient flow, record keeping, ongoing supervision of mentee’s and logistics.
Mentors that can effectively and enthusiastically present concepts of M&E and what a PDSA cycle is with examples that were done at their sites or in similar sites will help staff understand and embrace these activities rather than look upon them as extra work. M&E can be integrated during case-based discussions with the mentor pointing out clinical or systems challenges that could be explored further based on the information presented.






3) How can mentoring programs be integrated into Ministry of Health activities and scaled to a national level, taking into consideration quality and cost issues?
I-TECH has provided technical assistance and support to Ministries of Health in several country settings to implement mentoring programs. Early on in the management of HIV in many countries, it was clear that on-site follow-up mentoring and training was essential for the safe, successful and rapid scale- up of HIV/ART services. But it was also clear that each country needed to have a coordinated program based on individual country needs, specific care and treatment guidelines, standardized operating and training tools and a robust M&E program. I-TECH has provided this support and actively participates in technical working groups (TWG) to develop nationally agreed upon mentoring guidelines.
During the next phase of our grant, we are actively working with Ministries of Health as plans are being developed to transfer mentoring programs to individual sites or Regional Health Bureaus. Successful transfer of I-TECH supported mentoring programs to a national program will depend on several critical factors including:
+ support from Ministries of Health to individual hospital and clinic sites
+ collaboration between the informatics, clinical, QI and training teams at the national
and site level
+ ownership of the mentoring program at each site
+ access to current care and treatment information through distance learning and/or
on-site training
+ access to experts for clinical consultation (on-site or via mobile)
Currently, our mentors and MoM’s in Ethiopia are identifying “mentee graduates” at pilot sites where they have been providing ongoing mentoring. Mentee’s are eligible for graduation based on the results of their evaluations and recommendation from the mentor. Graduates will be utilized for clinical consultation and on-site case discussion as well as active members of the HIV and M&E teams at their sites. I-TECH mentors and MoM’s will continue to be available to the graduates for consultation and support as needed.

Lisa Hirschhorn Replied at 8:23 PM, 19 Sep 2011

Hi

In thinking about Manzi's questions-some thoughts

1) How can mentors help to empower nurses to engage in quality improvement initiatives in their own clinics? How can we train mentors to support both clinical education and systems improvements in their mentoring activities?

Mentoring is designed to not only enhance skills but also to add to professional development by teaching skills in new areas and encouraging growth. While clinical mentoring has traditionally focused on the individual and supportive supervision has focused on systems, mentoring in quality improvement (QI) needs to focus on both. Going from ensuring the quality of care for the individual patient (the one sitting in front of the nurse) to more system-based thinking, where the nurse is also interested in working with a team to ensure the quality of the systems, requires learning new skills in problem solving, measuring quality, and acting on results--skills not traditionally taught in pre-service training. In addition, while a grounding in QI theory is important, learning the practice of QI requires ongoing mentoring and coaching, not just of an individual but of a multidisciplinary quality improvement team.

2) How can monitoring and evaluation (M&E) be integrated into mentoring interventions to foster effective feedback loops and nimble responses to identified problems?

Monitoring activities results in large amounts of data, which have traditionally been used for reporting and not as frequently for program improvement. Ensuring that mentors are trained to understand and use existing data sources/reports, in order to focus their mentoring on activities aimed at improving quality, is a potentially invaluable expansion of traditional clinical monitoring.
Additionally, it is important to establish a practical but effective system for monitoring and evaluating the mentorship program, including regular feedback to the mentors, their supervisors and stakeholders. This should include analyzing areas for program improvement and sharing successes that may be replicated elsewhere. The indicators should be carefully chosen to reflect the primary aims of the mentoring program. They should include both process outcomes, such as adherence to guidelines by nurses and quality of care delivered, and more qualitative feedback from the mentees and clinics.

3) How can mentoring programs be integrated into Ministry of Health activities and scaled to a national level, taking into consideration quality and cost issues?

A growing number of countries are expanding more traditional supervision into the areas of supportive supervision and mentoring. Mentoring programs that have started outside of the national program need to ensure that the standards for mentoring are harmonized with those of the national program. Local and national government should be involved ideally at the start of the program design and, if not, as soon as possible to provide input and guidance as the program expands. If requirements around task assignments are different from national standards, they should be approved by the relevant ministries. If new, innovative strategies are implemented, they should be appropriately evaluated so that the Ministry for Health can determine if scaling up or adapting components of the program are warranted.
As programs are developed, understanding resource needs (staffing, training costs) and the implications for scaling up are also important. The literature on scaling up can provide some good guidance on the decisions which are critical to consider in both designing an initial mentoring program and on integrating a mentoring intervention into the national program and bringing to scale.

Lisa

Deb Winters Replied at 9:44 PM, 19 Sep 2011

Good evening everyone and thank you all for quickly beginning the discussion about this important topic. The information shared so far and interesting questions have been very thought provoking even after a long day!

Our Nurse Mentors have been providing mentoring in 3 regions of ET for the past 6yrs. We have not had the turnover I suspected and I think it is due mainly to the fact that our mentors love their work, are confident in their clinical abilities and expertise in HIV care and treatment, enjoy teaching formally (grand-rounds) or informally (bedside, case discussion) and have developed a strong relationship with not only the clinical staff but administrators/CEO's at the sites they are assigned. I knew each of these nurses before they were hired as Mentors. None of them had prior experience with mentoring but I knew when I met them that they had the qualities necessary for a good mentor e.g. clinical expertise, expert problem-solving skills, excellent working relationship with Physician/Health Officer colleagues, good communication skills etc. Several of them were already providing training to their colleagues following participation in workshops or information they found on the internet (for the few that had access). As a “Mentor of Mentors” (MoM), I was part of the team that developed our Mentoring Toolkit with generic curriculum on basic mentoring skills, interpersonal communication skills, clinical teaching skills, and program orientation. We provided our new mentors with a comprehensive orientation and I had the opportunity to provide intensive mentoring to them at their sites, share my experiences and expertise in HIV care and watch them grow in their new role. Each year Mentoring Refresher Training is also provided using curriculum that we developed to address complex areas of mentoring including clinical and systems challenges. We've also built in a significant amount of time during the training to exchange "lessons learned" and notes from the mentoring field which give the mentors an opportunity to discuss issues with their colleagues.

With our recent addition of Nurse Mentor of Mentors (NMoM), we have also developed a curriculum used during their orientation to address components of M&E and their expanded role as a supervisor (a new role for them). The curriculum incorporates cases that highlight mentoring challenges designed to elicit discussion and problem-solving. The Nurse MoM is responsible for providing technical assistance to the Nurse Mentors and FBT members for clinical and systems challenges and the NMoM also provides on-site training as requested. NMoM’s are responsible for completing the bi-annual evaluation for Nurse Mentors at their sites and assisting the Nurse Mentors as they complete evaluations for their mentee’s.

Thank you all again for sharing your thoughts and experiences. I look forward to our continued discussion over the next week.

Anatole Manzi Replied at 8:16 AM, 20 Sep 2011

Thank you all for bringing up good questions/comments and relevant viewpoints.
Lisa, Deb and others touched the questions that Di raised at the beginning of this discussion but I want to make sure that all is clear so that we can move along with specific questions mentioned at the end of my introduction.
To better understand our mentoring program, it is very important to know the context of care delivery and nurse practitioners in Rwanda that I summarized in my introduction (Including the education level for our nurses, less effective pre-service training, and low frequency of mentoring visits.)

Our goal is to change this situation and strengthen clinical service delivery through:
• Decentralized training of nurses
• Sustained, regular supervision and clinical mentoring of nurses
• Routine clinical and operations data collection for quality improvement
In addition to what Lisa shared as a definition of our mentoring and formative supervision project, our program is promoting an evidence-based practice in nursing through adhesion on national care and treatment guideline/protocols which is a big challenge in most of clinics in resource-limited settings where a routine replaced critical thinking and affected nurse decision making.

Thanks Deb for sharing your experience on mentor selection. It looks similar to the process we went through to get our team. They were nurses with at least an initial training and more than two year in the specific clinical domain (Eg: IMCI training and two year experience in IMCI was required to a mentor in that domain)
Afterward, we organized training on mentoring and formative supervision techniques. Moving forward, mentors get an ongoing training quality improvement models( eg: CQI : PDSA), adult learning methods(Presentation, Group discussions, brainstorming, reflection journey etc.) and refresher training in clinical domains as needed. I-TECH and MoH resources have been a great reference to us.

We are observing a drastic change through mentoring and formative supervision at health centers. Moving forward we measure:

1. Training coverage
Nurses trained per sphere per health center
2. Knowledge acquisition and retention
Pre- and post-tests
3. Change in clinical practices
Assessed through observation checklists
4. Facility improvements
Also we expect to evaluate
5. Clinical outcomes
E.g. CD4, weight gain
Initially we are focusing our intervention on four clinical domain (IMCI,IMAI,ID and WH).Now we are now finalizing a protocol for a qualitative evaluation which aims specifically:

1. To describe the MESH intervention at health centers as a strategy to improve IMCI quality of care at the health center level in Rwanda.
2. To understand the acceptability of MESH by nurse mentees in the two district hospital catchment areas (Kirehe and Rwinkwavu).
3. To assess the perceived impact of MESH to IMCI quality of care at health center level in two district hospital catchment areas.
I look forward to getting back with more thoughts as the discussion goes on.

Anatole Manzi
MESH-QI Program Director
Partners In Health Rwanda

Anatole Manzi Replied at 10:58 AM, 21 Sep 2011

Hello everyone,
Thank you for sharing experience on nurse mentorship and QI programs. The discussion is very helpful and constructive. I do appreciate how systematic you have been in sharing experience and thoughts.
Moving forward I thought it would be great to share experience on challenges encountered during our mentoring programs.
I have summarized the main challenges that I have been facing so far and I am interested to hearing your experience, especially getting idea on measures to manage and prevent them:
• High attrition of nurses: especially trained &mentored nurses leave our district for many reasons (school, higher salary, etc. this is a big challenge especially for health centers in rural areas. How do you handle this situation?
• Low education level (A2 nurses: secondary level)
• Facility issues (Lack of basic equipments): For example, while mentoring nurses on physical exam, you realize that he /she doesn’t have thermometer, Blood pressure cuff, stethoscope etc.
• Internal organization and supervision: Example of staffing: you find that nurses are assigned clinical responsibilities that are not aligned with the pre-service training he/she got) or after a mentoring (eg in HIV) you find that he/she spend the rest of the week in Vaccination
• Resistance to behavior change: In spite of mentoring and training, adopting a new behavior seems critical.
• Mentor training and evaluation through accompaniment: mentoring of mentors through accompaniment, observing mentors in action etc. In our program we thought that involving a physician as a Mentor of nurse Mentors would be more effective but this has been a little bit hard to archive given that physicians are busy with clinical obligations. I would be interesting to hear more how effective is to use Nurse Mentor of Mentors that Deb mentioned. How does it work? What qualification of Nurse Mentor of Mentors?
On evaluation side, How do you evaluate mentors/how do you ensure that they are doing what they are supposed to do?
• Feedback loop and implementation of recommendations: Mentors collect much information.
We always have to communicate all findings to specific people able to take an action. We have monthly and quarterly meetings with our partners but I realized that there need to be a way to provide real time feedback. What your experience? What follow up do you make? What tools do you use?
Thanks again for the constructive inputs to this discussion.
Look forward to hearing more from you soon.

Joachim Voss Replied at 12:48 PM, 21 Sep 2011

Hello,

This discussion is quite enlightening. I am a member of the Afya Bora Consortium and we have a goal to train global health leaders in 4 African and 4 US Universities. We just completed our first pilot program focusing on 10 physicians and 10 nurses that went through a 7 month training program. The program included 6 week long in-class modules (leadership, information technology, implementation science, communication and research) and 2 three month projects in attachment sites.
Attachment sites are regional CDC offices, hopitals, MOH offices and regional NGOs.

Each fellow had a site mentor and a country mentor and it was most beneficial to the fellows and mentors if expectations were written out for the project they initiated, if they monitored success of the project, if they had at least bi-weekly contact with the mentor for a 1 hour session, and if they were able to connect to their peers.
The worst outcomes were from those fellows that isolated themselves, did nopt communicate with the mentors, and felt overwhelmed or overtasked.
In general, the nurse colleagues I talked to said that in the clinical setting they need to have some time to conduct there quality improvement projects and not have this added to their already long list of tasks. This will always lead to burnout and frustration as they will never be able to conduct the project in a staisfactory way. We learned that strong committment from the attachment sites to the projects fostered success and real implementation of change.
One of the more simple exercises that I would suggest to the colleague in Ruanda is to collect data from the rural sites of what basics are absent. This data can then be used in a visit to the MOH office or the regional health officer to see if there is a comittment from the MOH or other regional decision makers to the sites to improve conditions. Even the most dedicated mentors and mentees cannot improve practice without resources. So one of the most valuable forms of mentoring is to show nurses and nurse managers how they best can manage and search for additional resources. We just published our conceptual basis and you might be interested in the mentoring aspect of the program.
Infect Dis Clin North Am. 2011 Jun;25(2):399-409. Epub 2011 Apr 15.
The Afya Bora Consortium: an Africa-US partnership to train leaders in global health.
Farquhar C, Nathanson N; Consortium Working Group.
Greetings,

Joachim Voss

suzanne willard Replied at 1:11 PM, 21 Sep 2011

This discussion has been very good. Lots of great experiences. I have implemented qi initives in the us and throughout sub Saharan Africa. I would say the biggest challenges was not having a common understand and support for qi throughout the health system. From the funder to the government to the hospitals and all of the providers. When you put the responsibility on one area of the system you will not have any sustained success, regardless of the amount of mentoring But what you will have is frustrated and disillusioned nurses who we have worked so hard with. Our efforts must be system wide.
Sue willard

Sent from my iPad

Deb Winters Replied at 3:33 PM, 21 Sep 2011

Hello everyone and thank you for another great day of sharing your mentoring experiences and posting important questions for further thought. Sue, you pointed out an area that is on the radar for many of us; buy-in and ownership. The FMOH/Prevention and Control Office in Ethiopia developed National Guidelines for HIV/ART Clinical Mentoring in 2007. I-TECH was one of the members of the Mentoring Working Group and the FMOH looked to us for guidance on the development of the national program, orientation materials and mentoring tools. From early on, mentoring was seen as a vital component of quality HIV care and this is also stated in the Introduction of the guidelines: “Even though many factors govern HIV service quality, a well designed and coordinated clinical mentoring process is taken as an immediate option of interventions to achieve the desired quality of HIV care/ART”.
Our transitioning plans to the local sites and Regional Health Bureau are in line with the National Guidelines so our hope is that any reservations that hospitals have to taking on the mentoring program will be addressed at the Regional and National level. Successes, challenges and findings from the Supportive Supervision visits will be communicated to the FMOH and discussed at the ongoing working group meetings. As I continue to work with our FBT’s during the transition, I will be using my eyes and ears (not just reviewing what they put on their monthly reports!) to look for early warning signs of potential difficulties both from the providers as well as administration.
Without these layers of support, ongoing supervision and evaluation you are absolutely correct…..we will not only have frustrated and disillusioned nurses but nurses who will continue to experience the effects of burnout that exists and ignored. We have embraced the success of task-shifting in many countries but as a HIV provider for the last 24yrs I rely on my physician mentors/colleagues more than ever to effectively deal with the complex, chronic and long-term management of HIV Disease. The experienced nurses who are providing high quality HIV care and treatment need to know who they can call for a clinical consultation, case discussion and updated information and new providers must have the benefits of mentoring as they begin their careers. If not, we will continue to face the challenge of rapid turn-over as well as issues surrounding quality of care.
As far as the questions about equipment and staffing that Manzi posted, I will tell you that these are continued challenges that are reported by our FBT members and ones that I have seen first-hand during my MoM visits. Staff will show us the inventory slips for equipment delivered at the clinic or for the ward e.g. masks, gloves but the drawers are empty and no-one is wearing a mask in the TB ward. One of the areas that is addressed during the National Nurse Prescriber and Mentoring training is Leadership and Advocacy (L&A). When staff complain to us about the lack of equipment, rotating schedules or any other clinical or systems challenge, mentors using their best problem-solving skills with mentee’s and avoid trying to give solutions or handle the problem from their level. For our Nurse Prescribers in particular, the role of leader is not one that they are comfortable with even after completing their advanced HIV training or attending the many L&A programs offered by the FMOH and/or NGO’s. Mentors are there to guide and support them through the problem-solving process and provide technical assistance if needed.
For staffing, this has been and continues to be a challenge in many of our sites. Experienced Nurse Prescribers rotated to the Medical or Surgical Ward due to shortages, replaced with a newly trained nurse who has never prescribed ARV’s without supervision! This seems to be a challenge that I hear about from many of my colleagues. I will say that over the past year or longer, I do not hear about this as much as when I first started mentoring in Ethiopia. The complexity of this disease and all too frequent examples of mismanagement has reinforced the importance of having experienced HIV providers in the clinic. This is where the importance of ongoing M&E projects, communicating results at the Multidisciplinary Team Meetings and holding staff accountable are also essential components of a successful HIV program.
I am off to a meeting but will check in for further discussion points later tonight. Thank you again for the opportunity to contribute to this valuable discussion.
Deb Winters

Celia Reddick Replied at 5:06 AM, 22 Sep 2011

Thank you to everyone who has commented so far. To follow up on questions of nurses' education level and decentralization of training to the health centers: Manzi and I have been working together within PIH's training department to offer mentors intentional, focused instruction on training techniques. Most mentors and nurses have been exposed to didactic training techniques throughout their formal education; we hope to support ongoing learning for adult learners through participatory training methodologies. Each month, mentors receive formal instruction in adult learning strategies, and ongoing observation and mentorship in the health centers, as they facilitate trainings for nurses. We are hoping that these strategies will build mentors' teaching competencies, increase nurses' learning, and also improve the quality of health center based training more generally. Would very much like to hear thoughts and experiences from others about training mentors to be effective educators!

suzanne willard Replied at 7:06 AM, 22 Sep 2011

One tool that I have used effectively is the importance of a teach back with peers. This is giving individual an opportunity to do their mentoring in a supportive environment with the mntte there providing feedback. You can also do this with a cohort of mentees who support each other, thus designing a learning environment that continues to be supportive to each other. Giving the group a road map to sustainability of these efforts is also valuable with the mentor doing frequent check ins to keep the enthusiasm going. This also allows them to experience the quality improvement methodology. Small steps that effect change!

Sue Willard
Clinical Associate Professor
Rutgers University
Newark, NJ

Marik Moen Replied at 11:39 AM, 22 Sep 2011

It was such a pleasure to log on and find familiar names. (To those I know: Amakuru y'all?) Manzi's last posting gets at the heart of challenges we all face in global nurse mentoring activities. I will submit 2 posts in response.
Personal experience (in Rwanda and Haiti) and close collaboration with nurse mentor colleagues (in 8 countries in Africa and Caribbean under University of Maryland PEPFAR projects) reveal same issues.
1. High attrition of nurses: The phenomenon: once nurse's capacity is increased, that talent may leave. It happens all over the world. Data and resources for retention exist- using both carrots (monetary, continuing education, other benefits), and sticks (contracts stipulating employee must stay for x amount of time after receiving training or pay certain fee, other penalty.)
• Focusing on working conditions, addressing some of the issues listed in #3 and #4 below- creating better work environments by working with institutions to improve to human resources management (hiring, assignment, evaluation, promotion policies) and equipping nurses to actually do scope of work can help-- but is not easy. Even then, people leave for greener pastures for personal needs, professional development. The attached is very interesting article: Mathauer, I & Imhoff, I (2006). “Health worker motivation in Africa: The role of non-financial incentives and human resource management tools.” Human Resources for Health. 4. 1-24
“HRM tools that may affect motivation. World Health Organization: Working Together for Health. WHO Report 2006.
• supervision schemes
• recognition schemes
• performance management
• training and professional development
• leadership
• participation mechanisms
• intra-organizational communication processes”
• My first nurse manager adopted the acceptance philosophy that nurse capacity/talent is transient. She felt the spirit and presence of highly motivated and skilled/trained nurses would carry the whole unit while they were there. She even encouraged seeking learning opportunities- and the unit built a reputation as being a good work environment where personal and professional growth was encouraged. This attracted new staff who were just waiting for a position as soon as another nurse moved on.
While holding up standards and expectations of nurses, if we can also assure ongoing mentoring and educational opportunities, it won't allow us to keep those we have trained, but may make them stick around longer and encourage others to join us and give their best during the brief time they are with us. Not an ideal solution- and, of course, the countries (especially the rural areas) where we work have great nursing shortages-but it is one strategy.
Marik Moen
Asst. Prof., University of Maryland School of Nursing, Baltimore, MD

Attached resource:
  • Health worker motivation in Africa: the role of non-financial incentives and human resource management tools (download, 324.9 KB)

    Summary: It was such a pleasure to log on and find familiar names. (To those I know: Amakuru y'all?) Manzi's last posting gets at the heart of challenges we all face in global nurse mentoring activities. I will submit 2 posts in response.
     Personal experience (in Rwanda and Haiti) and close collaboration with nurse mentor colleagues (in 8 countries in Africa and Caribbean under University of Maryland PEPFAR projects) reveal same issues.
    1. High attrition of nurses: The phenomenon: once nurse's capacity is increased, that talent may leave. It happens all over the world. Data and resources for retention exist- using both carrots (monetary, continuing education, other benefits), and sticks (contracts stipulating employee must stay for x amount of time after receiving training or pay certain fee, other penalty.)
    • Focusing on working conditions, addressing some of the issues listed in #3 and #4 below- creating better work environments by working with institutions to improve to human resources management (hiring, assignment, evaluation, promotion policies) and equipping nurses to actually do scope of work can help-- but is not easy. Even then, people leave for greener pastures for personal needs, professional development. The attached is very interesting article: Mathauer, I & Imhoff, I (2006). “Health worker motivation in Africa: The role of non-financial incentives and human resource management tools.” Human Resources for Health. 4. 1-24
    “HRM tools that may affect motivation. World Health Organization: Working Together for Health. WHO Report 2006.
    • supervision schemes
    • recognition schemes
    • performance management
    • training and professional development
    • leadership
    • participation mechanisms
    • intra-organizational communication processes”
    • My first nurse manager adopted the acceptance philosophy that nurse capacity/talent is transient. She felt the spirit and presence of highly motivated and skilled/trained nurses would carry the whole unit while they were there. She even encouraged seeking learning opportunities- and the unit built a reputation as being a good work environment where personal and professional growth was encouraged. This attracted new staff who were just waiting for a position as soon as another nurse moved on.
    While holding up standards and expectations of nurses, if we can also assure ongoing mentoring and educational opportunities, it won't allow us to keep those we have trained, but may make them stick around longer and encourage others to join us and give their best during the brief time they are with us. Not an ideal solution- and, of course, the countries (especially the rural areas) where we work have great nursing shortages-but it is one strategy.
     Marik Moen
    Asst. Prof., University of Maryland School of Nursing, Baltimore, MD

    Source: University of Maryland School of Nursing - Nurses for Global Health

    Keywords: mentoring, quality improvement

Marik Moen Replied at 11:46 AM, 22 Sep 2011

2. Low education level (A2 nurses: secondary level)
• We have found that training programs have had to be revised and extended to accommodate the lower levels of nursing education and practice in many situations. And one-off trainings do not work (to generalize) as you know, mentoring and repeated technical assistance and ongoing training is necessary (for ALL of us).
• Most countries are advancing their nursing education programs (a long-term solution) but for those already in practice, and existing faculty in nursing education, adjusting expectations and methods has been necessary. Again, this is not easy given time-and resource-limited grant-funded programs- and when you want to improve practice and patient care ASAP.

3. Facility issues (Lack of basic equipments): For example, while mentoring nurses on physical exam, you realize that he /she doesn’t have "x" BIG problem--
• Building the voice and presence of nurses to assure they can cogently represent, advocate for nurses’ needs at the table during budget discussions (worked pretty well in western Rwanda.)
• Knowing cost, quantity of item, Linking need for item (usually these are not costly things) to patient outcomes, or improving service function, and improving site level indicators, etc. helps.

4. Internal organization and supervision: Example of staffing: you find that nurses are assigned clinical responsibilities that are not aligned with the pre-service training he/she got)...
• Wow. In autonomously run health care organizations, we the outside mentors or trainers are constantly frustrated by our protégés being assigned elsewhere. Working with site leadership to advocate for importance of appropriately trained staff in appropriate positions- and linking this to improved outcomes (for PBF or other reportable data) could help. But it is tough -esp. with turnover and shortages described above.
•Training more of site staff for broader coverage. If you have the resources.
•Encouraging site leadership to take human resources and health care org. management trainings- (If such a thing exists, but these are becoming more available as monies shift to institutional strengthening)
5. Resistance to behavior change: In spite of mentoring and training ...
•Tough. Incentives and penalties -if you have site level leadership buy-in and can develop, implement staff performance evaluation plan.
•Getting at root of why resistance exists and addressing that if possible— Please refer to reasons for low motiviation in article (above posting).
6. Mentor training and evaluation through accompaniment: use of Nurse Mentor of Mentors
•We have had challenges working with physicians as mentors too. They are too busy and a few look on mentoring nurse as not very estimable assignment- unfortunately.
•If you can retain well trained, motivated nurses and have the luxury of time and ability to build them into mentors of nurses, I think this works best. - as Deb Winters described.
7. How do you evaluate mentors/how do you ensure that they are doing what they are supposed to do?
•“objective evaluations” using tools with indicators (defined by tasks and knowledge, attitudes, etc.) that you expect them to demonstrate in their teaching and practice and guidance of others. I may have your own at PIH and I-Tech has examples to build from.
•“subjective evaluations” are very valuable to evaluate mentors but time-consuming and must be done right: structured interviews or focus groups with mentees, other site level staff , staff of your organization, peers mentors (usually these are separate focus groups or interviews).
8. Feedback loop and implementation of recommendations: real time feedback.
• Short of staying at a site forever- informing as many relevant people as possible as soon as possible and indicating how they all will be held accountable for expected changes.
• Really following up on information, instructions, and requests given via call or follow-up visit (if not by same person, by colleague) within ASAP. This is difficult with our commitments but key to progress and makes the relevant people feel they are valued, important part of team- if done appropriately. (Supervision that is supportive not punitive/controlling.)

Maggie Sullivan Moderator Replied at 5:15 PM, 22 Sep 2011

This is such an important and dynamic conversation. I have to agree with Marik. I didn't know anything about nursing education outside of the US until I traveled. And the academic training of nurses varies widely, even within the US. It is vital to have an accurate understanding of the educational background and health literacy of nurse mentees. There are a lot of overlaps (my book of nursing diagnoses, ie "patient knowledge deficit in...," was instantly recognized in rural Puebla, Mexico), but I have also made many mistaken assumptions about what nurses already know. There are many things to learn from each other. For example, a vocationally-trained nurse in Guatemala does MVACs (manual vacuum aspirations)and trained the local physician. Not to mention learning culturally appropriate concepts and behaviors from in-country nurses. But anecdotally (if that's a word), I have learned to ask many questions about local nursing education and basic fund of knowledge before launching into nurse-trainings and mentorship.

The other challenge is in talking to nurses from other countries about the role and scope of practice of nurse practitioners. NPs have a level of preparation and scope of practice that does not exist in many other countries. So when I work with nurses (in Latin America), it is a challenge for them, let alone patients, to understand that I'm a nurse, not a doctor. I enjoy the peer-to-peer mentor relationship, but this difference can get in the way.

I think it's important to keep in mind that mentorship does not necessarily or exclusively mean one person teaching the other. There needs to be some degree of reciprocity.

Lisa Hirschhorn Replied at 10:00 PM, 22 Sep 2011

Thank you all for the great insights and experieence. the approach that eventually most/all nurses will move on I think raises the importance of mentoring not jst the individual but also the team. This appraoch is one which was integrated into MESH to include the approach of building caapcity within the site to identify and address system gaps (similar to the QI work Sue described) as well as individual mentoring as a potentially more sustainable approach to ensuring quality of care delivered and received. Maggie also brings up a critical and often neglected side of an effective mentoring relationship-the role and responsibilities of the mentee. I would also propose that when the mentor is from a different country, that the mentoring (receiving and giving)is truly a two-way street.

Sheila Davis Moderator Emeritus Replied at 9:34 PM, 25 Sep 2011

What a great discussion, thanks so much to everyone who took the time to contribute and to Manzi and the other moderators. Although the offical discussion has ended, I hope we can continue to discuss nurse mentoring and the importance of this as a mutually beneficial collegial relationship.

Vanessa Redditt Replied at 12:22 AM, 26 Sep 2011

Thank you all for this dynamic discussion!

Our final panelist, Dr. MUKENDI KAZADI from the Botswana Harvard AIDS Institute for HIV Research, was unable to participate on the online discussion last week, unfortunately. Below are his responses to Manzi's initial discussion questions.

1) How can mentors help to empower nurses to engage in quality improvement initiatives in their own
clinics? How can we train mentors to support both clinical education and systems improvements in their
mentoring activities?


a) Mentors can help to empower nurses through:
•Training in quality management
•Imparting them with required skills for improvement through coaching and mentoring
•Advocating on behalf of nurse mentees whenever necessary
•Facilitating "best practice" sharing sessions

b)Training mentors to support both clinical education and system improvements in their mentoring
activities:
•Train them as trainers, mentors and or coaches
•Train them as trainers in quality management. Aspects of quality of care and organizational quality
should be included.
•Provide access to continuous medical education


2) How can monitoring and evaluation (M&E) be integrated into mentoring interventions to foster
effective feedback loops and nimble responses to identified problems?

•Develop from the onset an M&E component for the mentoring program with a well defined set of
performance and quality indicators.
•Equip mentors with the necessary skills to conduct monitoring and evaluation activities

3)How can mentoring programs be integrated into Ministry of Health activities and scaled to a national
level, taking into consideration quality and cost issues?

•Usually Ministry of Health staff members are very busy with management and programmatic issues and as
a result, it may be difficult for them to be mentors.
One way would be for Ministry of Health to provide leadership, play a coordination and supportive role
while the infrastructure for mentoring should be built at the district level.
•Mentors can come from within the healthcare system instead of those outsourced because they are familiar
with the system and have a network of relations that could play to the advantage of the program. They
will be more easily accepted.

Anatole Manzi Replied at 7:13 PM, 28 Sep 2011

I wanted to thank all participants for your fantastic contributions to this panel discussion over the past week. I hope this exchange continues—there is much we can continue to learn from one another! Below, I’ve summarized some highlights from the discussion so far and some additional thoughts from my own research on this topic.

In Rwanda, as in many resource-limited settings, the majority of primary care is delivered at health centers staffed by nurses. Delivering quality care is often limited by both facility challenges and the performance of health providers. Implementing nurse mentoring and quality improvement initiatives is an important strategy to improve care, particularly in sub-Saharan Africa where patient care is being shifted from physicians to nurses, especially in HIV care and treatment (Kanchanachitra et al. 2011).

Partners In Health, in collaboration with the Rwandan Ministry of Health, launched the Mentorship and Enhanced Supervision at Health centers (MESH) Program in Kirehe and Southern Kayonza districts in 2010. While early results show promising benefits of this intervention, we have faced many challenges in implementing and growing this program. During this five day online discussion, experts in the domains of clinical mentoring and quality improvement have shared their experiences and reflections on mentoring activities, M&E data utilization for effective mentoring, mentor selection and training, and ongoing support for mentors.

Highlights:

 Mentoring contributes to nurses’ professional development by teaching skills in new areas and encouraging growth. Mentoring has the potential to sustainably contribute to high-quality clinical care (WHO 2005).
 A mentoring approach that leads to improved quality of care must focus on both individuals through side-by-side teaching and on systems through supportive supervision.
 In addition to the tailored clinical training, mentors need to receive hands-on training in supportive supervision techniques, approaches to adult learning, and implementing Continuous Quality Improvement models.
 Mentors need to be trained how to use existing data sources/reports to inform their mentoring interventions. They can then teach their nurse mentees how to effectively utilize data to improve patient care.
 Mentors should provide regular feedback to their mentees, supervisors and stakeholders. Similarly, mentors should receive regular feedback from these parties.
 Local and national government bodies should be involved early in the process of designing and implementing a mentoring program
 There is a need to improve support health center management skills since the lack of management skills affects mentoring and training outcomes. Training health center managers could sustain improvements brought about through clinical mentoring (Rowe et al. 2010).
 Nurse attrition rates and lack of motivation have been identified as challenges to implementing mentoring programs at health centres. The WHO proposes the following measures to address this challenge: recognition schemes, performance management, training and professional development, leadership, participation mechanisms, intra-organizational communication processes

Attached resource:
  • Building Nurse Mentoring Programs focused on Quality Improvement_Summary (download, 32.5 KB)

    Summary: I wanted to thank all participants for your fantastic contributions to this panel discussion over the past week. I hope this exchange continues—there is much we can continue to learn from one another! Below, I’ve summarized some highlights from the discussion so far and some additional thoughts from my own research on this topic.

    In Rwanda, as in many resource-limited settings, the majority of primary care is delivered at health centers staffed by nurses. Delivering quality care is often limited by both facility challenges and the performance of health providers. Implementing nurse mentoring and quality improvement initiatives is an important strategy to improve care, particularly in sub-Saharan Africa where patient care is being shifted from physicians to nurses, especially in HIV care and treatment (Kanchanachitra et al. 2011).

    Partners In Health, in collaboration with the Rwandan Ministry of Health, launched the Mentorship and Enhanced Supervision at Health centers (MESH) Program in Kirehe and Southern Kayonza districts in 2010. While early results show promising benefits of this intervention, we have faced many challenges in implementing and growing this program. During this five day online discussion, experts in the domains of clinical mentoring and quality improvement have shared their experiences and reflections on mentoring activities, M&E data utilization for effective mentoring, mentor selection and training, and ongoing support for mentors.

    Highlights:

     Mentoring contributes to nurses’ professional development by teaching skills in new areas and encouraging growth. Mentoring has the potential to sustainably contribute to high-quality clinical care (WHO 2005).
     A mentoring approach that leads to improved quality of care must focus on both individuals through side-by-side teaching and on systems through supportive supervision.
     In addition to the tailored clinical training, mentors need to receive hands-on training in supportive supervision techniques, approaches to adult learning, and implementing Continuous Quality Improvement models.
     Mentors need to be trained how to use existing data sources/reports to inform their mentoring interventions. They can then teach their nurse mentees how to effectively utilize data to improve patient care.
     Mentors should provide regular feedback to their mentees, supervisors and stakeholders. Similarly, mentors should receive regular feedback from these parties.
     Local and national government bodies should be involved early in the process of designing and implementing a mentoring program
     There is a need to improve support health center management skills since the lack of management skills affects mentoring and training outcomes. Training health center managers could sustain improvements brought about through clinical mentoring (Rowe et al. 2010).
     Nurse attrition rates and lack of motivation have been identified as challenges to implementing mentoring programs at health centres. The WHO proposes the following measures to address this challenge: recognition schemes, performance management, training and professional development, leadership, participation mechanisms, intra-organizational communication processes

    Source: Partners In Health - PIH

    Keywords: mentoring, quality improvement

Tess Panizales, DNP, MSN, RN Replied at 1:59 PM, 7 Oct 2011

Sorry to have missed this wonderful and timely discussion. I consider mentoring as an improvement process by itself - having said that, we empower the other nurse/s to make a difference in their career and workplace. Nurses, allied health workers entrusted to us are in the crossroads to make this happen and for us who have skills have the responsibility to take this mentorship across the spectrum of nursing and to transfer the knowledge to help improve patient care delivery. Kindly keep me in the loop for related activities on this aspect.

Richard Reckmeyer Replied at 4:11 AM, 10 Oct 2011

Great discussion. In what ways, if any, has oral health been integrated into MESH?

Richard T. Reckmeyer, DDS, MBA
Executive Director
Rural Rwanda Dental

LORENZO DORR Replied at 3:31 AM, 11 Jul 2012

This topic is very thought provoking and an essential coponent of health system strenthening.

I am a Physician Assistant. I work for Merlin Liberia at a project site in the south-eastern province of Grand Gedeh County in rural Liberia as Field Medical Coordinator. In retrospect of our work over the years supporting the Minstry of Health through the County Health Team, there has been seroius challenges in the area of capacity buliding with regard to result based management, a term one may interchangeably use for value based delivery care. Kindly allow me to share with you some experiences.
While formal trainings are good, particularly when rolling out new ideals/ or methods/protocols, and which involves, most often groups of staff, it has not proven worhty of the cost attached to the exercise. It may be fair to say that it lacks value. Contextually speaking, experience has show over time the idea of formal training has been viewed by health workers as income generating avenue and not a parameter for leanring new skills or building on what they already have or know.
While there are associated advantages, there are also gross disadvantages which I would like to caputure in my reply. However, points propounded in this text does not in any way mean the idea is totally unacceptable, wrong or inappropriate.

1. It is very expensive- whenever staff are taken away from their duty posts to another place for training, transportation is re-embursed, logging cost is provided and meals are also rovided for the duration of the training.
2. A human resource gap is created in service delivery particularly when the training innvolves skilled staff and the beneficiaries are the one that suffer
3. Knowledge /skilled gained becomes individual property and not the institution's property. Staff trained keeps the knowledge and does not shared with other team members thus creats capacity gap

Contrastingly, on-the-job training, coaching and mentoring of staff is very essential and accrue many benefits for the mentor and mentored.
1. The exercse is supportive.
2. It allows for the building of personal relationship with the each other
3. It allows for mutual discussion in an atmosphere of mutual respect
4. It provide the staff the opportunity to ask personal questions that he or she might rather not ask in group discussion
5. It affords the mentor the opportunity to discover the strenght and weakness of the staff being mentored
6. It also generate collective decision to work on the weakness with the mentored taking lead.

4. Mentoring is diffrent from teach or coaching. Mentorship involves personal relationship with the mentored. In order to develop good mentors, they must be transcend the idea that they are teachers, they are trained to support. To support, one must cheerish the people's knowledge and skills and build on it. To be a mentor for another, you must be accepted and not inpose yourself and therefore there is need for mutual trust.

Anatole Manzi Replied at 10:14 AM, 16 Jul 2012

Thank you so much Lorenzo for sharing your thoughts on clinical mentoring as an essential component of health system strengthening.
In my role leading mentoring program, I have realized that it constitutes both a quality improvements process and a catalyzer of partnership with Ministry of health or public sector in general.
I do have the same view about your three limitations of didactic trainings (costly, worsening existing human resource gaps, promoting more individual property than institution’s property)
In addition to your points, the effectiveness of these trainings is limited by the fact that traditional learning methods (especially ppt presentations) remain the most used rather than encouraging active participation.
Another limitation is related to translation of the theoretical package into practice which is always hard especially because the didactic training context always differs from the real/regular working environment while mentoring gives a room to present both the ideally and an alternative option.
Quality health care will remain only a concept if we don’t invest much effort including reaching people and providing onsite mentoring.

Kind regards,